790 likes | 1.14k Views
Lebanese Society of Family Medicine 5 th Annual Conference Chronic Disease: An Update Hypertension Guidelines and Practice. Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular Medicine American University of Beirut- Medical Center
E N D
Lebanese Society of Family Medicine5th Annual ConferenceChronic Disease: An UpdateHypertensionGuidelines and Practice Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular Medicine American University of Beirut- Medical Center Venue: Crown Plaza Hotel Hamra-Beirut-lebanon Date: Saturday, Nov 11, 2006
Hypertension guidelines published in 2003 (JNC VII and ESH/ESC/generally still valid • In light of recent findings initiation of process of changing guidelines.
Hypertension major risk for • Cardiovascular events • Myocardial infarction • Heart failure • Stroke • Renal failure • Impaired quality of life • Impaired cognitive function • Memory loss • Dementia • Sexual dysfunction • Decreased general well being. • BP reduction associated with • Reduction in cardiovascular events • Improvement in quality of life
Reduction of cardiovascular events by active antihypertensive treatment.
-12-4-5 About mmHg Benefits of Lowering BP by Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
Despite evidence that BP control associated with reduction in risk of cardiovascular events, hypertension control remains poor.
Systolic BP vs Diastolic BP
Systolic hypertensionrecently recognized as more important than diastolic hypertension: - Cardiovascular risk factor - Therapeutic decision making in older subjects
SBP, rather than DBP, of greater importance in long-term risk of CVD in middle aged patients. • CVD risk associated with DBP dependent on • SBP level • Low CVD risk/similar to Normotension in SBP<140 even when DBP> 90 mm Hg • Increased CVD risk with SBP>140/DBP<90 mm Hg
Predictive Power of Systolic Blood Pressure on Overall Cardiovascular Outcomes Systolic Blood Pressure Diastolic Blood Pressure DBP (mm Hg) SBP(mm Hg) <140 <90 Total Mortality 140-159 90-99 160-179 ≥100 ≥180 0.5 0.5 2 1 1.5 2.5 2.5 1 1.5 2 Relative Risk Relative Risk Prognosis better Prognosis worse Prognosis better Prognosis worse <140 <90 Cardio-vascular Mortality 140-159 90-99 160-179 ≥100 ≥180 0.5 1 1.5 2 2.5 2.5 1 1.5 0.5 2 Relative Risk Relative Risk Alli C et al. Arch Intern Med. 1999;159:1205-1212.
SBP, rather than DBP, of greater importance in long-term risk of CVD in middle aged patients. • CVD risk associated with DBP dependent on • SBP level • Low CVD risk/similar to Normotension in SBP<140 even when DBP> 90 mm Hg • Increased CVD risk with SBP>140/DBP<90 mm Hg
Relation between SBP and DBP and risk of cardiovascular disease
Compelling evidence that benefits of hypertension reduction related primarily to extent of SBP reduction not to DBP reduction
SBP < 140 mmHg In Uncomplicated Essential Hypertension
SBP < 130 mmHg In High Risk Hypertensive Patients (Diabetes or Chronic Kidney Disease)
Difficulty in Achieving Goal SBP In Contrast to DBP
mmHg Rates of Achieved Goal SBP and DBP with Antihypertensive Treatment.LlOYD JONES (FRAMINGHAM HEART STUDY) Hypertension 2000; 36: 594-599
Normotension (True / Persistent) • Prehypertension • White coat hypertension • Masked hypertension. • Hypertension (True / Sustained)
Definition • SBP / DBP = 120-139 / 80-89 mmHg Prognostic significance • Progression to hypertension • Cardiovascular events
Increasing increments of blood pressure are associated with increasing risk of cardiovascular mortality. mm Hg mm Hg mm Hg mm Hg mm Hg
Progression Rates to Hypertension in Non-Hypertensive Participants in Framingham Study
Definition • SBP/DBP = 120-139/80-89 mmHg Prognostic Significance • Progression to hypertension • Cardiovascular events Therapy • Lifestyle modification • Antihypertensive medications in patients with • Diabetes Mellitus • Chronic Kidney Disease
Definition • Normal office/clinic BP levels and elevated home / ambulatory BP levels. Prevalence • 10-15% of population (children, adolescent, adults) • Tendency to decrease with age. Prognostic Significance • Increased risk for: • Progression to sustained hypertension • Target organ involvement • Cardiovascular morbidity/mortality.
Relation between office, home, ambulatory blood pressures and cardiovascular / all cause mortality in various BP patients.
Predisposing Factors • Obesity, especially android obesity • Strong family history of hypertension at an early age. Characteristic Clinical Features • Rapid pulse rate • Elevated nocturnal BP levels. Diagnostic Procedure • Ambulatory BP monitoring • Home BP measurement Treatment • Lifestyle modification • Pharmacologic treatment in high CV risk individuals
Groups Blood Pressure Levels Blood Pressure Patterns Diagnostic Procedures
Blood Pressure Patterns Definition, Risk of CV Events, Therapy
Protein excretionin the urine is a strong predictor of cardiovascular disease in middle-aged men and women. Independent from effects of various well recognized CV risk factors
Relative prognostic value of microalbuminuriain type 2 Diabetes 10.02 10 8 6.52 6 Mortality from CHD (odds ratio) 4 3.20 2.32 2 0 Microalbuminuria Smoking Diastolic BP Cholesterol Eastman RC, Keen H. Lancet 1997;350(Suppl 1):29–32.
Microalbuminuria 1.59 CAD 1.51 Diabetes 1.42 1.4 Creatinine 1.4 mg/dL Male 1.20 WHR (0.1) 1.13 Age (1y) 1.03 Ramipril 0.79 Hazard Ratio Multivariate Hazard Ratios forPrimary Outcome in HOPE 2 0 1 HOPE Study Investigators. N Engl J Med 2000;342:145-53.
Classification (Conventional)
NormoalbuminuriaMicroalbuminuriaMacroalbuminuria (Proteinuria)NormoalbuminuriaMicroalbuminuriaMacroalbuminuria (Proteinuria)
Increased urinary albumin excretion (UAE) not detected by routine urinalysis (urinary strips detect UAE levels greater than 300mg/D) • Special strips available • Quantitative assessment: • 24 hours urine collection • Timed overnight urinary collection • SPOT urine albumin/creatinine in first morning urine sample (best accurate/practical method). • Special techniques required
Detected by routine urinalysis strips. • Regular 24hr urine collection for Proteinuria.
Threshold Levels for Urinary Albumin Excretion Rates in Various Categories