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Prof. Dr. Sarma VSN Rachakonda

Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FICP, FIMSA, FRCP (G), FCCP & FACP (USA) Adjunct Professor Tamilnadu Dr. MGR Medical University Sr. Consultant Physician & Cardio-metabolic Specialist Honorary National Professor of Medicine, CGP. www.drsarma.in.

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Prof. Dr. Sarma VSN Rachakonda

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  1. Prof. Dr. Sarma VSN Rachakonda M.D., M.Sc., (Canada), FCGP, FICP, FIMSA, FRCP (G), FCCP & FACP (USA) Adjunct Professor Tamilnadu Dr. MGR Medical University Sr. Consultant Physician & Cardio-metabolic Specialist Honorary National Professor of Medicine, CGP www.drsarma.in

  2. Hypertension High lights A COMPREHENSIVE APPROACH What is new and imperative in Hypertension Based on the latest recommendations of JNC VII, ISH, ESH, WHO, NICE, HWG

  3. Globally Renowned HT Societies • JNC VII – Joint National Committee on HT, USA • ISH – WHO International Society on HT • AHA – American Heart Association, USA • ACC – American College of Cardiologist • BHS – British Hypertension Society • NIHLB – National Inst. Heart Lung & Blood vessels • EHS – European Hypertension Society • CHS – Canadian Hypertension Society • NKF – National Kidney Foundation, USA • AKA – American Kidney Association, USA • HWG – Hypertension Writing Group, USA

  4. Many Avoidable HT Deaths ! On April 12, 1945, US President Franklin D. Roosevelt died of cerebral hemorrhage, a consequence of HT. It was a devastating illness for him. By current standards, President Roosevelt’s death was unnecessary. President Roosevelt was never treated with Anti-hypertensive drugs. Modern treatment would have controlled his BP and prolonged his life. Arch Int Med, Sept, 23,1996 . . . so also of many others!

  5. Friends, Let Us Reflect in Us • How many of us routinely check blood pressure at each clinic visit • How many of us screen asymptomatic patients for hypertension • How many of us are focused on evaluating for target organ damage (TOD) • How many of us look for ‘Co-Thieves’ like DM, Lipids, MS, CAD, CKD • How many us offer correct combination of treatment for HT • How many of us insist on continued therapy and follow up • How many of us educate of Total Lifestyle Change (TLC) • How many of us achieve ‘Goal Blood Pressure’ • By doing all of the above, do we know how much good we do!! • If negligent, Almighty is taking note and will sure punish us!!

  6. Indian Statistics • Currently, CVD is more common in India and China as compared to all economically developed countries in the world added together.1 • Compared to 2000, the number of years of productive life lost to CVD will have increased in 2030 by only 20% in USA, whereas for India, the figure is 95%.1 • For India, hypertension is projected to increase from 16.3% to 19.4% between 1995 and 2025.1 1. International cardiovascular disease statistics. Am Heart Assoc. 2004.

  7. The New Paradigm of CVD CVD

  8. Integrated Approach A Paradigm Shift in Management • Clustering of two or more risk factors (RFs) was found to be associated with cardiovascular disease. Individual Risk Factor Approach vs. More Integrated Strategies INTERHEART study showed that sum of smoking, dyslipidemia, arterial hypertension and diabetes mellitus was responsible for about 90% of the risk of acute myocardial infarction. Volpe M. J Hum Hypertens. 2008;22(2):154157. 

  9. CMR and CVD Paradigm

  10. 1 75 % 2 3 25 % COST Percent of CV Events v/s Cost EVENTS

  11. Cardio Metabolic Continuum REGRESS Targetorgandamage Asymptomatic CVD PREVENT RETARD Newriskfactors Atherosclerosis Targetorgandamage Symptomatic Risk factors Cardiometabolic risk Death CVD

  12. Cardio Metabolic Continuum REGRESS Target organ damage Asymptomatic CVD PREVENT RETARD New risk factors Target organ damage Atherosclerosis Symptomatic Risk factors Cardiometabolic risk CVD Death

  13. The Truth is HYPERTENSION What we record as B.P. It is only a marker of the bigger problem Hypertension is a multi-organ systemic disease The Problem is Hypertension is asymptomatic in 85% of cases

  14. The Truth is How to be wise in HT? It is wrong To consider Hypertension as an isolated disease Hypertension, DM, Dyslipidemia, Obesity often coexist They are the 4 pallbearers to the grave of CHD, CVD For all of them Primary and secondary prevention by TLC is the answer Afflicted with one, must be screened for all other thieves

  15. Where are we moving ?

  16. Hypertension Approach: JNC 7 vs. HWG The Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Giles TD, et al. J ClinHypertens. 2005;7(9).

  17. Hypertension Approach: JNC 7 vs. HWG CV risk factors and target organ damage are not the components of classification of blood pressure in JNC 7. The Seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Giles TD, et al. J ClinHypertens. 2005;7(9).

  18. The Truth is Treatment Goal Goal BP Keep B.P. < 140/90 mm Hg in each patient This may be revised to 120/80 may be ? 110/70 MRFIT’s cut off values are 115/75 mm Hg It is essential to keep the B.P at or below the goal But, It also matters how the goal B.P. is achieved !

  19. As per JNC VII and ISH (WHO) 2004 What is normal B.P ? What is pre hypertension ? Definitions As per JNC VII and ISH (WHO) 2004 Normal SBP < 120 and DBP < 80 Pre HT SBP 120 to 139 mm Hg DBP 80 to 99 mm Hg

  20. What is stage 1 HT ? What is stage 2 HT ? Definitions Stage 1 SBP 140 to 159 DBP 90 to 99 Stage 2 SBP 160 and more DBP 100 and more

  21. Are the values same for Diabetics , CKD? Definitions No, for DM, IHD and CKD the criteria are more stringent The cut off values are 10 mm lower Stage 1 SBP 130 to 149 DBP 80 to 89 Stage 2 SBP 150 and more DBP 90 and more

  22. 25 DM 20 non-DM 15 Events/1000pt-years 10 5 0 <90 <85 <80 Target diastolic BP Hypertension Optimal Treatment (HOT) Study Reduction in CV events p=0.005 (DM) Lancet 1998; 351: 1755–62

  23. What is this rule of halves in HT ? Rule of Halves • For every 800 adults in the community • 400 are HT (either ↑ SBP or ↑ DBP or both) • Of them only 200 are diagnosed HT • Of them only 100 are started on treatment • Of them only 50 are on correct drug • Of them in only 25 the goal B.P. is attained • Means 25 ÷ 400 = 6% only have goal BP

  24. Under control (40%) (7.5% of the total hypertensives) Hypertensives (22%) Uncontrolled hypertension (60%) Normotensives (78%) How many are really Dx. and Rx.ed ?? Diagnosed HT Under treatment (50%) Un Rx. HT 37% 63% Undiagnosed HT A study from Europe on 23,339 patients

  25. What is ISH ? – What percentage of 65+ aged have ISH ? Which is more harmful – ↑ SBP or DBP ? Why is ISH important ? Isolated Systolic Hypertension

  26. Relative prevalence of SBP and DBP 40 + yrs ISH S&DHT DHT Normal

  27. R R for CVD - SBP and DBP

  28. ISH is universal after 65+ Persons who are normo-tensive at age 55 have a 90% lifetime risk for developing HTN.

  29. 20 Stroke 15 Myocardial Infarction 10 5 0 HT- RR of stroke and MI Normotensives Hypertensives 5 Year Risk (%) 40 80 240 280 20 60 220 260 0 100 200 300 140 180 120 160 Systolic Blood Pressure (mmHg) Brown, M.J. Lancet 2000; 355: 659 - 660

  30. Is SBP more dangerous or DBP ?

  31. Practice Points for Using WHO/ISH Scoring System http://www.who.int/cardiovascular_diseases/guidelines/Chart_predictions/en/index.htm Accessed on: 21 March 2013.

  32. What is ISH ? – SBP 140+ , DBP < 90 What percentage of 65+ aged have ISH ? More than 90% Which is more harmful – ↑ SBP or DBP ? Of course ↑ SBP Why is ISH important ? Because of ↑↑ CVA and CHD mortality Isolated Systolic Hypertension

  33. Do you think we can control most of the patients of hypertension with – One drug Two drugs Three drugs Can’t control For adequate control of B.P. In most of the patients of hypertension Two drugs are required for adequate control More so if the initial BP is 20/10 above the goal

  34. Gone are the days of monotherapy It is the era of combination therapy Why is it so? Today’s Paradigm

  35. What are the so called CHD risk factors ? What are known as CHD risk equivalents ? What is Framingham risk score ? CVD Risk Factors

  36. Dr.Sarma@works Global Risk Profile and HT 25)

  37. HT combined with other CHD RF Framingham offspring study, subjects aged 17 – 84

  38. What are the so called CHD risk factors ? List discussed in previous slide What are known as CHD risk equivalents ? DM, PVD, CVA, Nephropathy, Retinopathy What is Framingham 10 CHD risk estimate ? 10 yearCHD risk estimate based on age, sex, smoking, TC, HDL, SBP, Rx. for HT CVD Risk Factors

  39. Why is there TOD in HT ? What are the organs targeted for damage ? What is the basis of TOD ? What tests we need to do to assess HT ? Target Organ Damage

  40. Diseases Attributable to Hypertension Stroke Coronary heart disease Heart failure Cerebral hemorrhage Myocardial infarction Left ventricular hypertrophy Hypertension Chronic kidney failure Aortic aneurysm Hypertensive encephalopathy Retinopathy All Vascular Peripheral vascular disease Adapted from: Arch Intern Med 1996; 156:1926-1935.

  41. Target Organ Damage (TOD) • Heart • Left ventricular hypertrophy (LVH) • Angina or prior myocardial infarction (CHD) • Prior Coronary revascularization PTCA or CABG • Heart failure (Systolic / Diastolic dysfunction) • Brain • CVA Stroke or Transient Ischemic Attack (TIA) • Kidney : Chronic kidney disease and CRF • Vessels : Peripheral arterial disease PVD • Eyes : Hypertensive Retinopathy

  42. Dr.Sarma@works Atherosclerosis – Time line

  43. Endothelial NO Balance NO

  44. Target Organ Damage - Assessment • Routine Tests • Electrocardiogram, Echocardiography (desirable) • Urinalysis for proteinuria, Microalbuminuria • Blood glucose (F and PP), and Hematocrit • Serum Na and K, Creatinine or GFR, Calcium • Lipid Profile complete, Eye examination, ABI • Optional tests • X-Ray Chest PA • 24 hr. urine albumin excretion or ACR • More extensive testing is notgenerally indicated

  45. Why is there TOD in HT ? It is a disease of blood vessels. What are the organs targeted for damage ? Heart, brain, kidney, eye, peripheral vessel What is the basis of TOD ? ED, Arterial stiffness and Atherosclerosis What tests we need to do to assess TOD ? List discussed Target Organ Damage

  46. Paradigm Shift in HT Therapy It is not just ↓B.P. TODAY we must strive to • Alter the modifiable risk factors • Keep the SBP < 140 and DBP < 90 • Prevent or halt or reduce TOD – • LVH, CHD, CHF, CVA, CRF, PVD & Retino. • Prevent or control DM (as HT + DM is hazardous) • Prevent or control Dyslipidemia (Endothelial Dysf.) • Reduce morbidity and mortality • Improve QUALY – Quality Adjusted Life Years

  47. What is single most imp. predictor of CHD, HF, Death ? What time course of HT to LVH to LVF to death ? Can LVH be regressed at all ? Will drugs help to regress LVH and ↓TOD ? How important is Micro-albuminuria ? Target Organ Damage

  48. Dr.Sarma@works Transverse Section of HEART - LVH 10 mm 25 mm

  49. Dr.Sarma@works Echocardiography of Heart - LVH

  50. ECG and Left Ventricular Hypertrophy

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