Hypertension update Which guideline to follow?

1. Hypertension updateWhich guideline to follow? Dr Sunita DodaniDepartment of Family MedicineAga Khan UniversityKarachi, PakistanFebruary 23,2003

2. Presentation outline • World Wide Epidemic: Some Figures • Epidemiological Transition & Hypertension • Data From Developing Countries • EMRO Work • Statistics From Pakistan: NHSP • Hypertension Guidelines • Currently available guidelines • Similarities in guidelines • Differences in guidelines

3. Presentation outline • Hypertension Guidelines (Cont’d) • Still Unanswered Questions • What is needed in Pakistan • Epidemiologic research • Which guideline to follow? • JNC VI guideline (1994) • Risk stratification

4. Worldwide Epidemic: Some Figures • affect all ages, but primarily occurs in adults. • 20% prevalence,approximately 690m people have hypertension world wide • major risk factor for stroke, coronary heart disease and kidney failure • 30% of deaths worldwide (15 million) are due to cardiovascular diseases • 5 million deaths / year worldwide due to strokes alone, with another 30 million suffering from its disabling effects. (Geneva, Switzerland November 15-16, 1999)

5. Epidemiological Transition & Hypertension • Developing countries experiencing rapid health transition, escalating relative and absolute burdens of CVD • Determinants of transition a)demographic (increased life expectancy) b)lifestyle changes c)urbanization, industrialization and globalization

6. Epidemiological Transition & Hypertension (Cont’d) • In developing countries ,steady increase in hypertension prevalence over the last 50 years, more in urban than in rural areas(WHO report 2002) WHO Regions

7. World regions according to WHO

8. Eastern Mediterranean region (EMR) (Jordan, Iran, Srilanka, Pakistan, Egypt Oman, Saudi Arabia , Bangladesh etc) • Paucity of large, authentic, epidemiological studies • Limited data available in the form of small studies • Majority of studies done have shortcomings differing examination techniquesdiffering diagnostic criteria screening blood pressure values used

9. The studies are not representative of the total population Limited to single centers or single community EMR (cont'd…) • Majority of third world countries lack sufficient national estimates of the prevalence of hypertension • In developing countries ,steady increase in hypertension prevalence over the last 50 years, more in urban than in rural areas

10. EMR…. Some prevalence figures • Saudi Arabia 10-15% (EMRO bulletin 2001) Riyadh city 15.4% (27% unaware) • Bangladesh (> 70 yrs) 65% (multi center trail, hypertension study group, 2000) • Egypt (national estimates) 26% > 70 yrs 56.6% (Ibrahim MM , Cairo university Egypt, 1998) • Iran(population based) 18% (Sarraf-Zadegan N, East Mediterr Health J 1999)

11. Hypertension figures in Pakistan National Health Survey of Pakistan 1990-1994 • Some data available, some in re-analysis phase • 10.8 million hypertensives(pop 91m,1991) 5.5 million men 5.3 million women • 12 million hypertensives(pop 130m,1998) • 17.9% ( 15 yrs) 21.5%………….. Urban 16.2%………….. Rural

12. Hypertension figures in Pakistan NHSP ( 1990-1994) • 58%( 65 yrs females) • 1 in every 3 Pakistanis (>45 yrs) • Prevalence is lower in females than males at younger ages, but exceed after 35-44 yrs of age (This cross over is at later age in US population) • >3% of the hypertensive patients have BP controlled to the conventional recommendations of under 140/ 90 mmHg

13. Hypertension figures in Pakistan Prevalence of hypertension (PMRC) Rural Female Male

14. Hypertension figures in Pakistan Prevalence of hypertension (PMRC) URBAN Female Male

15. Early detection,awareness & treatment (Need for guidelines) • help to limit the subjective element in decision making & assist clinicians to provide better care • define the best clinical decisions and the minimal level of acceptable care in order to ensure appropriate quality • formulated based upon the evidence collected from available literature, and agreement among experts in areas where literature is deficient

16. Hypertension Guidelines • Several guidelines for the management of hypertension were published in the last few years • Many were recent revisions and updated versions of old ones, modified according to new evidence from clinical trials • Provided answers to many clinical questions.a)Isolated systolic hypertension in the elderly is dangerous & should be treated b)aggressive lowering of blood pressure is required in patients with risk factors

17. Hypertension Guidelines JNC VI 1994 {Hypertension Detection and Follow-up Program (HDFP)} WHO/ISH 1999 British hypertension Society 1999 {Medical Research Council (MRC)} Canadian Cardiac Society 1999 Local Pakistan hypertension league 1998 (First Report of National Task Force)

18. Hypertension Guidelines • These four major guidelines are based on the strong evidence from almost the same literature and the large randomized mega trials, they agree and disagree on a number of important issues

19. Hypertension Guidelines These guidelines agree on many aspects 1.All guidelines agree upon the definition of hypertension. 2. The type of routine tests needed for the evaluation of hypertensive patients 3. The need for global risk assessment & the target blood pressure 4. The importance of life style modification 5. Individualization of antihypertensive therapy 6. Need for indefinite follow-up

20. JNC VI 1994 WHO/ISH 1999 BHS 1999 1.Drug therapy in mild hypertensives if BP remains  140/90 after non pharmacological treatment Continuing monitoring without medication for subjects without other risk factors if pressures are not greater than 150/95 mm H Add drug therapy if BP is greater than 160/90 2.Recommend diuretics or B-blocker as initial drug therapy all classes of medication are suitable initial therapy, despite the lack of morbidity and mortality data Diuretics as first line therapy Hypertension Guidelines Differences in the guidelines

21. Hypertension Guidelines Still Unanswered Questions • how to avoid over treatment of patients at very low risk? • what is the best simple approach for accurate cardiovascular risk assessment? Decisions to initiate therapy are based on the absolute cardiovascular risk profile of the hypertensive patient ? risk assessment are based on the Framingham data ? risk scoring equations are incomplete & complicated ?do not account for racial and genetic differences.

22. Hypertension Guidelines Still Unanswered Questions • management of patients with uncomplicated mild hypertension ? duration period of observation ? the number of office visits ? blood pressure measurements ? the average blood pressure threshold during the period of monitoring • role of ambulatory blood pressure is not settled • how to adjust for racial, genetic, geographic, age gender and socioeconomic differences

23. Hypertension Guidelines Still Unanswered Questions • optimal blood pressure reduction ? what is the desired level of blood pressure ? It is not necessarily the same level in all individuals. ? Race, age and gender may influence our target blood pressure. ? We might need more aggressive reduction in blood pressure in special groups, e.g., diabetics, blacks and patients with end-organ damage.

24. Hypertension Guidelines Population data:Priorities in Epidemiologic research • define the magnitude of the hypertension problem in Pakistan with evidenced based data • prevalence among different age groups, geographic areas, socioeconomic classes and the influence of factors like gender, ethnicity • Its risk factors e.g. Obesity, excessive salt intake, alcohol intake, psychosocial stress, low levels of education, poor SES, should be recognized & examined

25. Hypertension Guidelines Epidemiologic research • the type and prevalence of hypertensive cardiovascular complications. might be influenced by environment, race and other demographic characteristics • identify the susceptible groups which are most vulnerable to complications • How close are these complications related to the level of blood pressure and what are the other mechanisms involved • develop methods to improve detection and control of hypertension

26. Hypertension Guidelines which guideline to follow? • Considering several meta analysis • outcome data from major clinical trial strongest outcome data support the JNC VI recommendations

27. Hypertension Guidelines Table 1 – Classification of Blood Pressure* Diastolic Systolic Category (mm Hg) (mm Hg) Normal Values of Blood Pressure** Optimal less than 120 less than 80 Normal less than 85 less than 130 High normal 130 - 139 85 - 89 Stages of Hypertension** (Mild) 140 - 159 90 - 99 Stage 1 Stage 2 (Moderate) 100 - 109 160 - 179 Stage 3 (Severe) 180 or higher 110 or higher *

28. Hypertension Guidelines Risk factors stratification • In populations & in individual patients, the benefit from antihypertensive treatment is determined by the absolute cardiovascular risk • Blood pressure by itself is a very weak predictor of risk or benefit from treatment • simple but accurate risk assessment tools for estimating cardiovascular risk, similar to that in the New Zealand guidelines

29. Hypertension Guidelines Presentation available at http://www.pitt.edu/~super1 & http://www.pitt.edu/~super1/pakistan/pakistan.htm

30. Presentation references • Ramsay LE. Williams B, Johnston GD, et al. Guidelines for management of hypertension: report from the third working party of the British Hypertension Society. J Hum Hypertens 1000; 13:569-592. • Fieldman RD, Campbell N, Larochell P. Burgess ED, et al. 1999 Canadian recommendations for the management of hypertension CMAJ 1999; 161 (12 suppl): S1-S17 • Joint National Committee on Prevention, Detection, Evaluation, and treatment of High Blood Pressure. The Sixth report. Arch Intern Med 1997; 157:2413-2446.

31. Presentation references • Carretero OA. Oparil S. Essential hypertension Part II: treatment. Circulation 2000; 101:446-453. • Reddy KS. Implementation of international guidelines on hypertension: the Indian experience.Clin Exp Hypertens. 1999 Jul-Aug;21 (5-6):693-701. • O’Brien E. Critical appraisal of the JNC VI, WHO/ISH and BHS guidelines for essential hypertension.Expert Opin Pharmacother. 2000 May;1(4):675-82.

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