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Hypertension as a Public Health Risk

Hypertension as a Public Health Risk. January, 2007. High blood pressure. Tobacco. High cholesterol. Underweight. Unsafe sex. High BMI. Physical inactivity. High mortality, developing region Lower mortality, developing region Developed region. Alcohol. Indoor smoke from solid fuels.

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Hypertension as a Public Health Risk

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  1. Hypertensionas a PublicHealth Risk January, 2007

  2. High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 0 1 2 3 4 5 6 7 8 Attributable Mortality (In millions; total 55,861,000) Proportion of deaths attributable to leading risk factors worldwide (2000) Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360.

  3. Hypertension as a Risk Factor Hypertension is a significant risk factor for: • cerebrovascular disease • coronary artery disease • congestive heart failure • renal failure • peripheral vascular disease • dementia • atrial fibrillation

  4. Men Women 150 150 130 130 PP PP 110 110 80 80 70 70 30-39 40-49 50-59 60-69 70-79 30-39 40-49 50-59 60-69 70-79 80 80 Age Age Blood Pressure Distribution in the Population According to Age PP=Pulse Pressure. Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13

  5. Classification of Hypertension (Pre Hypertension) 120-139 / 80-89 The category pertains to the highest risk blood pressure *ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.

  6. Blood Pressure and Risk of Stroke Mortality Lancet 2002;360: 1903-13

  7. Blood Pressure and Risk of IHD Mortality Lancet 2002;360: 1903-13

  8. CAD Death Rate per 10,000 Person-years 80.6 48.3 43.8 38.1 37.4 34.7 31.0 25.3 25.8 25.2 24.9 24.6 23.8 160+ 16.9 13.9 12.6 12.8 11.8 20.6 140-159 10.3 11.8 8.8 8.5 9.2 120-139 Systolic BP (mmHg) <120 100+ 90-99 80-89 75-79 70-74 <70 Diastolic BP (mmHg) Neaton et al. Arch Intern Med 1992; 152:56-64. Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT

  9. Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE mmHg (130-139) (121-129) (< 120) N Engl J Med 2001;345:1291-7

  10. True hypertensive Masked HTN 135 True Normotensive White Coat HTN The Concept of Masked Hypertension 200 180 True hypertensive Masked HTN 160 Ambulatory SBP mmHg 140 True Normotensive 120 White Coat HTN 100 100 120 140 160 180 200 Office SBP mmHg From Pickering, Hypertension 1992

  11. The Prognosis of Masked Hypertension Prevalence is approximately 10% in hypertensive patients. 35 CV Events 30 25 20 CV events per 1000 patient-year 15 10 5 0 Normal White coat Uncontrolled Masked 23/685 24/656 41/462 236/3125 Bobrie et al. JAMA 2004;291:1342-9

  12. Cumulative hazard for stroke in 3 groups of subjects: Normotensive, White-Coat Hypertension, and Ambulatory hypertension 8 Ambulatory hypertension White-coat hypertension 7 6 Normotensive group 5 Cumulative hazard of stroke (%) 4 3 2 p = 0.0013 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Time to stroke (years) Verdecchia, P et al. Short- and Long-Term Incidence of Stroke in White-Coat Hypertension. Hypertension. 45(2):203-208, February 2005.

  13. Benefits of Treating Hypertension • Younger than 60 • reduces the risk of stroke by 42% • reduces the risk of coronary event by 14% • Older than 60 • reduces overall mortality by 20% • reduces cardiovascular mortality by 33% • reduces incidence of stroke by 40% • reduces coronary artery disease by 15%

  14. Stroke Myocardial Infarction Staessen et al. Lancet 2001;358:1305-15. Correlation Between Reduction in SBP and Stroke or MI

  15. Cardiovascular mortality Cardiovascular events Staessen et al. Lancet 2001;358:1305-15. Correlation Between Reduction in SBP and Cardiovascular Mortality or Events

  16. Benefits of Treating to Target • Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP <90 mm Hg) • 36% reduction in the risk of stroke • 25% reduction in the risk of coronary events Ref: adapted from SHEP, SYST-EUR, STONE studies.

  17. 45% Reductionin CVD 10% Reductionin BP + 10% Reductionin Total-C = Effect of Long-Term Modest Reductions in CV Risk Factors Emberson et al. Eur Heart J. 2004;25:484-491.

  18. Treatment Based on BP(β-blocker, diuretic) Treatment Based on Overall Absolute Risk(ASA, statin, ACEI, β-blocker, diuretic) Treatment Based on TC (statin) 0 -5 -6 -6 -10 -8 -9 -10 -12 -15 Predicted Reduction in Major CVD (%) -17 -20 Treatment thresholds -25 Top 10% -30 -28 Top 20% -35 Top 30% -37 -40 Evaluating the Impact of Different Strategies for CV Prevention on CV Risk Reduction. Treating hypertension and other risk factors. Adapted from Emberson et al. Eur Heart J. 2004;25:484-491.

  19. Hypertensive patients who are treated and BP controlled Hypertensive patients who are treated but BP uncontrolled 13% 9% 21% Diabetic patients who are treated and BP controlled 43% 22% Patients who are aware but remain untreated and BP uncontrolled Hypertensive patients who are unaware Joffres et al. Am J Hyper 2001;14:1099 –1105 The Challenge In Canada 22% of Canadians 18-70 years of age have hypertension 50% of Canadians >65 years of age have hypertension

  20. Results of a survey on awareness on hypertension (Canada 2002) 67% of aware hypertensive patients believe that their BP was their own primary responsibility Two thirds of these patients stated that high BP was not a serious concern. Thus the mandate to improve public awareness of the consequences of hypertension is clear. R. Petrella MD, Perspective in Cardiology, March 2002.

  21. The Canadian Hypertension Education Program Objectives • Develop evidence-based recommendations for the management of hypertension • Implement recommendations • Evaluate impact of the program

  22. Leading diagnoses resulting in visits to physician offices in Canada 25 20 15 Routine medical exams Depression Acute respiratory tract infection Million visits/year Diabetes Hypertension 10 5 0 Source: IMS HEALTH Canada 2002. http://www.imshealthcanada.com/

  23. Changes in diagnosis of hypertension in Canada Post 1999 compared to pre 1999 • Doubling of the rate of diagnosis of hypertension • Closing of the gender gap Hypertension 2006;48:853-60

  24. Changes in the treatment of hypertension Post 1999 compared to pre 1999 • Doubling of the rate of treatment of hypertension • Closing of the gender gap Hypertension 2006;48:853-60

  25. Changes in the proportion of thosediagnosed that are not treated Post 1999 compared to pre 1999 • Marked decrease in proportion of aware hypertensives that are untreated • Closing of the gender gap. Hypertension 2006;48:853-60

  26. 2007 Canadian Recommendations for the Management of Hypertension A slide kit for medical education can be downloaded from: http://www.hypertension.ca

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