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PGS TS Châu Ngọc Hoa Bộ môn Nội - ĐHYD Tp HCM

TĂNG HUYẾT ÁP Khuyến cáo và ứng dụng lâm sàng. PGS TS Châu Ngọc Hoa Bộ môn Nội - ĐHYD Tp HCM. Hypertension is the leading risk factor for CVD globally About 17% of global mortality can be attributed to HT.

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PGS TS Châu Ngọc Hoa Bộ môn Nội - ĐHYD Tp HCM

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  1. TĂNG HUYẾT ÁP Khuyến cáo và ứng dụng lâm sàng PGS TS ChâuNgọc Hoa BộmônNội- ĐHYD Tp HCM

  2. Hypertensionistheleadingrisk factorforCVDglobally About17%ofglobal mortalitycanbe attributedtoHT WorldHealthOrganisation.Globalatlasoncardiovasculardiseasepreventionandcontrol.2011 Availableat:http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/index.html

  3. WorldwidePrevalenceofHypertensionin males(A)&females(B)≥25years B A 5

  4. •192,441participantswithhypertension •29.9%receivedHTNtreatment •10.3%achievedHTNcontrol Inthebestperformingcountries,treatment coveragereachedupto80%andcontrolrates justless<70%.Butinsomecountriescontrol wasaslowas<30% Lancet.2019Jul18.pii:S0140-6736(19)30955-9 Lancet.2019Jul18.pii:S0140-6736(19)31145-6 6

  5. WhatTheWorldNeedstoDo ToreachtheSDG3.4targetofa1/3reductionoftheriskofdeathamongpeopleages30 -69 Intervention Tobaccocontrol* Sodiumreduction* Prevention,detection,andtreatmentof cervical*,liver,colon,andothercancers Treatmentofhypertension* Reductionofindoorairpollution Artificialtransfatelimination Reductionofharmfulalcoholuse* TOTAL CVD *WHO“BestBuy”forNCDprevention Note:somelivessavedmaybecountedtwice Estimatedpotentialreductionin riskofdeathfromselectedNCDs ages30-69 15.0% 5.5% 5.0% 4.8% 3.3% 1.9% 0.9% 36.4% 27.2% AdaptedfromResolvetoSaveLives Targetpercentreductionto achieveSDG3.4 50% 30% 27%overall 50%hypertensioncontrol 25% 100% 20%

  6. Prevalenceofhypertension Lowincomecountries aremainlyaffected 1outof5adults arelivingwithhypertension 70%ofhypertensivepatients areolderthan65yearsold In40years,thenumberofadultswith hypertensionhasnearlydoubled 1.http://www.who.int/features/qa/82/en2.SANDabstractN°169fromtheBEACHprogram:Hypertension,comorbidityandbloodpressurecontrol.Sydney:FMRCUniversityof Sydney.2011ISSN1444-9072c20113.WozniakGetal.HypertensionControlCascade:AFrameworktoImproveHypertension.JClinHypertens.2015:18(3):1-8c2015

  7. Hypertension “Therearefewstoriesinthehistoryof medicinethatarefilledwithmoreerrors ormisconceptionsthanthestoryof hypertensionanditstreatment.” ProfMarvinMoser(1925-2015) YaleUniversitySchoolofMedicine

  8. NonpharmacologicalInterventions WheltonPK,etal.JAmCollCardiol.2017.

  9. SURPRISING TRENDS FROM THE FRONT LINES • •90% ofcardiologistshadnoorminimal nutrition education during fellowship training • Only 8% had a “solid nutrition education” that they considered “adequate” DevriesS,AgatstonA,AggarwalM,AspryKE,EsselstynCB,Kris-EthertonP,MillerM,O'KeefeJH,RosE,RzeszutAK, WhiteBA,WilliamsKA,FreemanAM.ADeficiencyofNutritionEducationandPracticeinCardiology.AmJMed.2017 May24.

  10. CVDPreventionGuidelines

  11. GetYour30 •Adultsshouldaimfor150minutesperweekofaccumulatedmoderate- intensityphysicalactivityor75minutesperweekofvigorous-intensity physicalactivity. •Aimfor30minutesdaytokeepitsimple! •Getridofthesedentarybehavior •Ifunabletohittargets,doyourbest!Theguidelinesarefavorable towardsANYactivity,thoughtargetsshouldbestrivenfor!

  12. ASCVDRiskEstimationtoGuide theManagementofHypertension: TheTimeHasCome TyJ.Gluckman,MD,FACC,FAHA MedicalDirector,CenterforCardiovascular Analytics,ResearchandDataScience(CARDS) ProvidenceHeartInstitute ProvidenceSt.JosephHealth Portland,Oregon

  13. 2017ACC/AHAHypertensionGuideline ManagementofBPinAdults Stage2HTN SBP>140 OR DBP>90 ElevatedBP SBP120-129 AND DBP<80 Stage1HTN SBP130-139 OR DBP80-89 Nonpharmacologictherapy NormalBP SBP<120 AND DBP<80 Promoteoptimal lifestylehabits ASCVDor 10-year risk>10% Yes No AddBP- lowering therapy BP-lowering therapynot needed WheltonP,etal.JACC2018;71(19):e127-248.

  14. What’snewin2018? OfficeBloodPressureThresholdsforDrugTreatmentofHypertension* Aged65-80yrs BPThreshold ≥140/90mmHg I A VeryHighCVRisk Treatment may be  considered when BP ≥130/85mmHg II B Aged18-65yrs BPThreshold ≥140/90mmHg I A Aged>80yrs BPThreshold SBP ≥160mmHg I A *Lifestyle Interventions recommended for all when BP is high-normal (BP≥130/85mmHg) 2018 ESC/ESH Guidelines for the management of arterial hypertension European Heart Journal (2018) doi:10.1093/eurheartj/ehy339  Journal of Hypertension (2018) doi:10.1097/HJH.0000000000001940 8 www.escardio.org/guidelines

  15. Table 5. 10-year CV risk categories (SCORE system) People with any of the following: Documented CVD, either clinical or unequivocal on imaging. •Clinical CVD includes; acute myocardial infarction, acute  coronary syndrome, coronary or other arterial  revascularization, stroke, TIA, aortic aneurysm, PAD. •Unequivocal documented CVD on imaging includes: significant  plaque (i.e. ≥ 50% stenosis) on angiography or ultrasound. It  does not include increase in carotid intima-media thickness. Diabetes mellitus with target organ damage, e.g. proteinuria or  a with a major risk factor such as grade 3 hypertension or  hypercholesterolaemia.  Severe CKD (eGFR < 30 mL/min/1.73 m2). A calculated 10-year SCORE of ≥ 10%. 2018 ESC/ESH Guidelines for the management of arterial hypertension European Heart Journal (2018) doi:10.1093/eurheartj/ehy339 Very high-risk www.escardio.org/guidelines 9

  16. Table 5. 10-year CV risk categories (SCORE system) People with any of the following: Marked elevation of a single risk factor, particularly cholesterol  > 8 mmol/L (> 310 mg/dL) e.g. familial hypercholesterolaemia,  grade 3 hypertension  (BP ≥ 180/110 mmHg). High-risk www.escardio.org/guidelines Most other people with diabetes mellitus (except some young  people with type 1 diabetes mellitus and without major risk  factors, that may be moderate risk). Hypertensive LVH. Moderate CKD eGFR 30–59 mL/min/1.73 m2). A calculated 10-year SCORE of 5–10%. 2018 ESC/ESH Guidelines for the management of arterial hypertension European Heart Journal (2018) doi:10.1093/eurheartj/ehy339 10

  17. WaystoAssessCardiovascularRisk CardiovascularEndPoints RiskScore Revas c M I Stroke Card Fail TIA A P U A CHD Death Stroke Death TotalCHDEvents,including Revascularization TotalCHDEvents HardCHD Events HardASCVDEvents HardASCVDEvents, includingCardiacFailure GoffDCetal.JAmCollCardiol2014;63:2935-2959

  18. We are not treating numbers, we are treating patients! We are not treating numbers, we are treating patients!  Edward D. Freis, MD

  19. •Bloodpressuretargetsshouldbeappliedintheappropriateclinical•Bloodpressuretargetsshouldbeappliedintheappropriateclinical contextandonapatientby-patientbasis. •Inclinicalpractice,onesizedoesnotalwaysfitall,asspecialcases exist. •Treatingnumbersratherthanpatientsmayresultinunbalanced patientcare.Theoptimalapproachtobloodpressuremanagement reliesonacomprehensiveriskfactorassessmentandshared decision-makingwiththepatientbeforesettingspecificblood pressuretargets.

  20. Changingparadigminhypertension management PrecisiontargetBPand combinationtherapy– apreferredapproach forselectedsubgroup Specialindicationsin selectedgroupfor targetanddrugclasses Universalidealdrugs UniversalBPtarget

  21. Stroke is the most devastating complication for older hypertensive patients Age-specific incidence rates of stroke and acute myocardial infarction (MI) in women1 Age-specific incidence rates of stroke and acute myocardial infarction (MI) in men1 1. Gentil A et al. J NeurolNeurosurgPsychiatry. 2009;80:1006-1010.)

  22. ChangesinoveralldiseaseburdeninChina: Strokebecomesthefirstcauseofdeath ØResearchersfromtheChineseCenterforDiseaseControlandPrevention,the UniversityofWashingtonHealthIndexandEvaluationInstitute,andother institutionshaveconductedacomprehensiveassessmentofthediseaseburdenin China(1990-2010). ØStudieshaveshownthat,unliketheworld's235deathcauses,ischemicdiseaseisthe firstcauseofdeathinChina. China'stopthreefataldiseasesin2010 Stroke （1700000） CHD （948700） COPD （934000） COPD=chronicobstructivepulmonarydisease. GonghuanYang,etal.Lancet2013;381:1987–2015.

  23. Strokepatientswithhighratesofhypertension (ChinaNationalStrokeRegistry) Historyofstrokeandcomorbidityrate Coronaryheart disease Hyperlipidemia Hypertension Paststrokehistory Combineddiabetes Atrialfibrillation Thestatisticalresultswereobtainedfromatotalof21,902strokepatientsfrom132 hospitalsacrossthecountry(includingall31provincialadministrativeunitsincluding HongKong)fromCNSR(ChinaNationalStrokeRegistry)2007.9-2008.8.Amongthem,63. 2%werehypertensive. 27 WangY,etal.IntJStroke.2011Aug;6(4):355-61.

  24. Đột quị: tỉlệtửvongrất cao tạiViệt Nam 32% Valery L. Feigin, Bo Norrving, George A. Mensah; Global Burden of Stroke;Circ Res. 2017;120:439-448n

  25. 2016: STROKE IS IN TOP 3 REASONOF MORTALITY IN VIETNAM 200.000 cases/year 100.000 died • 80 mils VND if have surgery • 10 mils VND internal treatment for inpatients • 3 – 5 kinds of drugs for outpatients • 90% pts have after-effect • Be paralysed, Diminish capacity, Depression… • 1/3 will have recurrent stroke in 5 years.

  26. ImpactofSpecificBP-loweringTreatmentsversusalternative classonMajorCardiovascularOutcomes&Mortality JustifiesthefocusoftreatmentonACE-IorARB,CCBorDiuretic EttehadD,etal.Lancet2016;387:957-967

  27. THA Người Cao Tuổi ESC/ESH 2018

  28. BPLoweringDrugsinthePreventionofCVD RRestimatesofCHDeventsandstrokein46drugcomparisontrialscomparing eachofthefiveclassesofBPloweringdrugwithanyotherclassofdrug LawMRetal.BMJ2009;338:b1665

  29. THA + Bệnhlítrênlâmsàng THA + Tổnthương cơquanđích Tiền THA Sốthuốc Renin huyếttương SỰ TIẾN TRIỂN CỦA TĂNG HUYẾT ÁP Trẻhơn Già hơn • Giảm GFR • Giữmuối • Tăngcunglượngtim • Cứngđộngmạch – THA tâmthu • Co mạch • tăngkhánglựcngoại vi • táicấutrúcmạchmáu • hoạthóahệ RAAS & SNS C: chẹncanxi D: lợitiểu (loại thiazide-like) A: ứcchếhệ RAAS B: chẹn beta B. Williams. Lancet 2006

  30. Reduction of Stroke in Elderly HYVET SHEP Syst-EUR 0 10 20 Reduction (%) -36% 30 -30% 40 -42% JAMA 1991, Lancet 1997, NEJM 2008

  31. Amountofsaltintakebycountry forages20+,averageofbothsexes,in2010. Sodium(mg/day) Saltequivalent(g/day) PowlesJ.etal.BMJOpen2013;3:e003733 EnshuHospital,Hamamatsu,Japan

  32. USSodiumIntake •USAverage3400mg/d •Target<1500mg/d FromAntmanEMetal.Circulation2014;129:e660-e679

  33. Saltintakereducedby1.4g/dayintheUK between2000and2011 9.5g/day 8.1g/day atleast9,000deathsaverted

  34. To stay on a low salt diet is feasible,  if you either… have the ascetism  of a religious zealot  (Pickering 1948) get whipped  periodically (Kempner 1997) are an inmate In Federal Prison (Jones et al. 2018)

  35. Characteristics of hypertension inAsians High prevalence and low controlrates High sodium and low potassiumintakes High night-time BP and low dipping Wang JG and Li Y. Curr Hypertens Rep 2012;14:410-415.

  36. …Diureticshaveremainedthecornerstoneof antihypertensivetreatmentsinceatleastthe firstJointNationalCommittee(JNC)reportin 1977[412]andthefirstWHOreportin1978 [413],andstill,in2003,theywereclassifiedas theonlyfirst-choicedrugbywhichtostart treatment,inboththeJNC-7[264]andthe WHO/InternationalSocietyofHypertension Guidelines[55,264]. …Ithasalsobeenarguedthatdiureticssuch aschlorthalidoneorindapamideshouldbe usedinpreferencetoconventionalthiazide diuretics,suchashydrochlorothiazide[271]. …D:Ifdiuretictreatmentistobeinitiatedor changed,offeraThiazide-likeDiureticslike Chlortalidone(12.5-25mgoncedaily)or Indapamide(1.5modified-releaseor2.5once daily)inpreferencetoaconventionalthiazide diureticsuchasBendroflumethiazideor Hydrocholorothiazide.

  37. Lợi tiểu: bằng chứng với Indapamide 1. Beckett NS, Peters R, Fletcher AE, etal.N Engl J Med. 2008;358:1887-1898. 2. PROGRESS CollaborativeGroup. Lancet. 2001;358:1033-1041. 3. Patel A, Group AC, MacMahon S, etal.Lancet. 2007;370:829-840.

  38. RelativeRiskofTreatmentDiscontinuationaccordingtotheDrug InitiallyPrescribedwithinAnyGivenClass ACEInhibitors ARB’S CCB’s Drug Discontinuers Drug Discontinuers Drug Discontinuers 448/1629 354/1325 79/375 729/4116 805/4915 426/2842 121/604 230/1736 119/993 2007/17302 7019/73492 2975/32611 1076/15444 5145/81530 Captopril Moexipril Spirapril Fosinopril Quinapril Benazepril Trandolapril Delapril Cilazapril Lisinopril Enalapril Perindopril Zofenopril Ramipril Nicardipine Diltiazem Nisoldipine Verapamil Nifedipine Felodipine Lacidipine Amlodipine Nitrendipine Isradipine Manidipine Lercanidipine Barnidipine Losartan Eprosartan Telmisartan Irbesartan Candesartan Valsartan Olmesartan 1325/13063 226/2945 902/12579 1412/19712 943/14007 1446/21789 2584/44212 269/523 1774/4460 45/29 1651/5838 2504/12266 562/3474 757/5052 3942/29695 25/198 13/106 445/4196 1534/15859 63/12348 510 Riskofdiscontinuation 510 Riskofdiscontinuation 510 Riskofdiscontinuation 01 15 01 15 01 15 Diuretics AntisympatheticAgents BetaBlockers Discontinuers Drug Drug Discontinuers Drug Discontinuers Clonidine Terazosin Doxazosin Moxonidine Methyldopa 774/1794 57/222 2099/9698 177/1326 9/91 Pindolol Propranolol Carvedilol Sotalol Bisoprolol Metoprolol Timolol Acebutolol Atenolol Labetalol Nebivolol Betaxolol Celiprolol 5/126 386/2202 1940/7707 1026/4125 3808/17017 1823/8190 15/87 31/209 4687/34518 3/24 2918/27221 5/79 3/66 Torasemide Spironolactone Furosemide Canrenone K-canrenoate Hydrochlorothiazide Chlorthalidone Indapamide 2713/6002 859/1912 2799/9142 569/2375 572/3266 42/243 83/494 691/4800 01 15 01 15 01 15 510 Riskofdiscontinuation 510 Riskofdiscontinuation 510 Riskofdiscontinuation ManciaGetal,JHypertens2010

  39. Thiazide(-Like)Diuretics *TwiceaspotentinloweringBPonmg-per-mgbasisasHCTZ. Goodman&Gilman'sThePharmacologicalBasisofTherapeutics,12e.2011 Pharmacotherapy:APathophysiologicApproach,9e.2014

  40. EarlyCardiovascularProtectionbyinitialtwo-drugsinglepillcombinationEarlyCardiovascularProtectionbyinitialtwo-drugsinglepillcombination versusmonotherapyinhypertension N=37,078monotherapy N=7,456SPC 2,212CVeventsat1year Theeffectofstartingtreatmentwitha SPCversusMonotherapyon1year riskofCVoutcomes Highdimensionalpropensityscorematched in2212patientswitheventsat1year HealthcareutilizationDatabase|Lombardi,Italy ReaF,etal.EurHeartJ,2018

  41. Phốihợpchẹncalci/lợitiểu thiazide giảmđộtquỵhiệuquảhơn vs cácphốihợpkhác Risk ratios for stroke comparing treatment with combination CCB/thiazide-like diuretic vs other combinations CCB, calcium channel blocker; CI, confidence interval, Diu, diuretic; RR, risk ratio. 1. Rimoldi SF et al. J Clin Hypertens. 2015;17:193-199.

  42. Evidence-basedcombinationtherapy RAS blockade Diuretic CCB

  43. FactorsthatcancontributetoBPreduction outcome Comorbiditiesandoverallriskofdeath Demography Age Lifeexpectancy Concomitantdrugs Sex Race Outcome Additionalfactors BPvariability Adherence Sideeffects

  44. WhichDrug(s)? ARB Betablocker CCB ACEI Diuretic

  45. RightDrugforRightPerson

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