epidemiology of hypertension - university of california ... of htn franklin feb 2012.pdf · agenda:...

Epidemiology of Hypertension

Stanley S. Franklin, MD, FACP, FACC

Clinical Professor of MedicineUniversity of California at IrvineAssociate Medical DirectorUCI Heart Disease Prevention ProgramIrvine, California

Agenda: epidemiology of hypertension

1 BP measurement

2 Defining hypertension

3 Important public health problem

4 Global risk assessment

5 Intervention trials

6 Management strategies

7 Barriers to treatment

8 Prevention strategies

1 BP measurement

2 Defining hypertension

3 Important public health problem

4 Global risk assessment

5 Intervention trials

6 Management strategies

7 Barriers to treatment

8 Prevention strategies

1. How to measureblood pressure?

Nokolai Korotkoff, 1905

Ascultatory method ofblood pressure measurement

S:\SLIDES\2005\V\ASH_Rsnt-HTN-Shortr_OS.ppt

• Measurement error

• Small number of readings

• White coat effect

• No measure of the diurnal changes of BP

Auscultatory clinic/ office errors:

Presenter

Presentation Notes

Although the traditional method of BP measurement in the clinic has provided a wealth of useful information about the importance of hypertension and its treatment, there are serious limitations to the method as commonly used in clinical practice. Out-of-office monitoring can overcome all of these.

BP Measurement Techniques

Method Brief Description

In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

Ambulatory BP monitoring Indicated for evaluation of “white-coat” HTN. Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.

135/85 Ambulatory Pressure

140/90

Clinic Pressure Sustained

HypertensionWhite Coat Hypertension

True Normotension

Masked Hypertension

24-hour ambulatory monitoring (ABM)

Presenter

Presentation Notes

Classification of blood pressure status using a combination of clinic and ambulatory measurement.

Self-Measurement of BP

Provides information useful for:1. assessing response to antihypertensive Rx2. improving adherence with therapy 3. evaluating white-coat HTN & masked HTN

Home BP is more strongly related to target organ damage and has better prognostic accuracy than office BP.

150/90140/85130/80

(>135/85)(<135/85) Day-time ambulatory BP

AHA/ASH Scientific Statment

Presenter

Presentation Notes

----- Meeting Notes (3/16/11 19:49) ----- Indeed, because of the high rate of misclassification of BP status by conventional clinic or office recordings, the AHA and ASH recommended this schemma for evaluation patients for possible antihypertensive treatment with predominently using home BP recording. When done correctly, home BP assessment will identify masked HTN and separate true white-coat HTN from persons with sustained white-coat effect. Unfortunately, few RCTs recruit subjects using home or ABP.

2. Defining Hypertension:

(a) By the numbers?≥95 DBP160/95140/90130/85

>120/80

“A number at which the benefits of intervention exceed those of inaction”

2098 Franklin #11

CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment*

*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressureLewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

CV mortality

risk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105

Presenter

Presentation Notes

Slide Summary According to a meta-analysis of over 60 prospective studies, the risk of cardiovascular mortality doubles with each rise of 20 mm Hg in systolic blood pressure (BP) and 10 mm Hg in diastolic BP. Background In a meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline, the researchers found that between the ages of 40-69 years, each incremental rise of 20 mm Hg systolic BP and 10 mm Hg diastolic BP was associated with a twofold increase in death rates from ischemic heart disease and other vascular disease. The researchers also noted that when attempting to predict vascular mortality risk from a single BP measurement, the average of systolic and diastolic BP was “slightly more informative” than either alone, and that pulse pressure was “much less informative.” The seventh report Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) notes this study result as yet more information linking hypertension to high risk for cardiovascular events. Lewington S, Clarke R, Qizilbash H, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2003;361:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

2098 Franklin #12

JNC Reclassification of BP Based on Risk

Source for JNC VI: Arch Intern Med. 1997;157:2413-2446.Adapted with permission from Chobanian AV et al. Hypertension. 2003;42:1206-1252.

JNC VIJNC VISBP

(mm Hg)SBP

(mm Hg)DBP

(mm Hg)DBP

(mm Hg)SBP

(mm Hg)SBP

(mm Hg)DBP

(mm Hg)DBP

(mm Hg)

Optimal Normal80 <120<120 and 80andNormal

Hi-normalPrehypertension

120-129

130-139120-139

80-84

or 85-89

and80-89or

Stage 1

HypertensionStage 1140-159 140-15990-99or 90-99or

Stage 2

Stage 3Stage 2

160-179

≥180≥160

100-109or

≥110or≥100or

CategoryCategory CategoryCategoryJNC 7JNC 7

Presenter

Presentation Notes

This slide shows the changes in classification of blood pressure from JNC VI to JNC 7.1,2 “Optimal” blood pressure in JNC VI became “normal” in JNC 7, while “normal” and “borderline” blood pressures in JNC VI were combined as “prehypertension” in JNC 7.1,2 Stage 1 hypertension remained constant from JNC VI to JNC 7.1,2 However, JNC 7 grouped JNC VI Stage 2 and Stage 3 hypertension into one stage (Stage 2).1,2 This change reflected the fact that the approach to patient management for both former categories is similar.1

BP CategoryBP Category PrevalencePrevalence

NormalNormal 38%38%

PrehypertensionPrehypertension 31%31%

HypertensionHypertension 31%31%

Prevalence of Blood Pressure Categories in US Adults ≥20 Years of Age

(NHANES 1999-2000)

Prevalence of Blood Pressure Categories Prevalence of Blood Pressure Categories in US Adults in US Adults ≥≥20 Years of Age 20 Years of Age

(NHANES 1999(NHANES 1999--2000)2000)

Greenland, Croft, Greenland, Croft, MensahMensah (CDC). Arch Intern Med. 2004;164:2113f(CDC). Arch Intern Med. 2004;164:2113f

Risk Pyramid: SBP and CHD Mortality for Men Screened in MRFIT

Adapted from Stamler J et al. Arch Intern Med. 1993;153:598-615.Hypertension Control. WHO Technical Reports Series, 1996. No. 862.

SBP (mm Hg) Excess CHD deaths (%) Men (%)

180 7.2 0.9 170-179 6.8 1.2 160-169 10.1 2.7 150-159 19.5 6.2 140-149 23.4 12.8

130-139 20.7 22.8 120-129 9.9 28.4 110-119 1.3 19.0 <110 0.0 6.1

High BP

Defining Hypertension:

(b) By hemodynamic mechanism?

Increased peripheral vascular resistance

versus

Increased large artery stiffness

The Arterial Pulse Wave

75

125

Pres

sure

(mm

Hg)

Systolic Systolic pressurepressure

Diastolic Diastolic pressurepressure

Mean pressureMean pressure

Diastolic decay Diastolic decay curvecurve

DicroticDicrotic notchnotch(aortic valve closes)(aortic valve closes)

Time

Pulse Pulse pressurepressure

= 1/3 SBP + 2/3 DBP

Hemodynamic Components of BP

MAP - STEADY COMPONENT (due to CO and SVR)

• PP – PULSATILE COMPONENT (due to LV ejection

and elastic artery stiffness)

• SBP – rises with increased resistance and stiffness

• DBP – rises with increased resistance and decreases

with increased stiffness

Elzinga G, Westerhof N. Circ Res 1973;32:178-186. Yano, et al. Basic Res Cardiol 1997;92:115-122.Berne RM, Levy MN. Cardiovascular Physiology 1992:135-151.

160/80

‘Isolated systolic hypertension’

Arterial stiffening

Large arteries

Pulse Pressure

160/110

‘Essential hypertension’

Increased resistance

Small arteries

MAP

Defining Hypertension:

(c) By subtype?

IDH, SDH, ISH

Age Distribution of Hypertensives in US Population (NHANES III and the 1991 Census)

3.7

9.5

13

21.3

23.7

19.2

9.6

0

5

10

15

20

25

30

18-29 30-39 40-49 50-59 60-69 70-79 80+

Hyp

erte

nsiv

esW

ithin

Age

Gro

up (%

)

Franklin SS. J Hypertension. 1999;17(suppl 5):S29-S36.

Age Groups (y)

47.4 million 47.4 million hypertensiveshypertensives26.0% of US 26.0% of US populationpopulation

26% 74%

<40 40-49 50-59 60-69 70-79 80+Age (y)

17% 16% 16% 20% 20% 11%

Distribution of Hypertension Subtype in the Untreated Distribution of Hypertension Subtype in the Untreated Hypertensive Population by Age Hypertensive Population by Age (NHANES III)(NHANES III)

ISH (SBP 140 mm Hg and DBP <90 mm Hg) SDH (SBP 140 mm Hg and DBP 90 mm Hg)IDH (SBP <140 mm Hg and DBP 90 mm Hg)

0

20

40

60

80

100

Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age.Franklin et al. Hypertension. 2001;37: 869-874.

Frequency of hypertension

subtypes in all untreated

hypertensives(%)

} Diastolic Hypertension

An Analysis of NHANES III Blood Pressure DataSummary: Hypertensives fall into one of two

categories:

1. A smaller (26%), younger (age 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH)

2. A larger (74%), older (age 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH).

Summary: Hypertensives fall into one of two categories:

1. A smaller (26%), younger (age 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH)

2. A larger (74%), older (age 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH).

Franklin et al. Hypertension 2001;37: 869-874

Residual Lifetime Risk for Hypertension From Age 55

Vasan RS et al. JAMA. 2002;287:1003-1010.

Individuals who are normotensive at age 55 have a 90% lifetime risk of developing hypertension

Ris

k fo

r Hyp

erte

nsio

n (%

)

Time (Years)10 15 20 25

0

20

40

60

80

100

52

8391

7256

88 9378

WomenMen

Presenter

Presentation Notes

Key data cited by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a basis for reclassification of blood pressure came from the Framingham Heart Study.1 Framingham Heart Study investigators reported that individuals who are normotensive at age 55 or 65 have a 90% residual lifetime risk of developing hypertension if they survive to age 80 to 85.2

Vasan, R. S. Hypertension 2009;54:454-456

Evolution of BP over the life course and constellation of factors influencing BP

2098 Franklin #25

3. Why is hypertension considered a major Public health problem in the United States?

Firstly, hypertension is very common In the adult population

50

65

0

20

40

60

80

100

1988-1994 1999-2000

National Health and Nutrition Survey (NHANES)

Increased Prevalence of Hypertension in the United States from 1988-1994 (NHANES III) to 1999-2000

NHANES

Increased Prevalence of Hypertension in the United Increased Prevalence of Hypertension in the United States from 1988States from 1988--1994 (NHANES III) to 19991994 (NHANES III) to 1999--2000 2000

NHANESNHANES

Fields, et al. Hypertension. 2004;44:398f

Popu

latio

n W

ith

Hyp

erte

nsio

n (m

illio

ns)

30% increase, p<.00130% increase, p<.001

Nearly 1 in 3 Adults (31%) in the US Has Hypertension

2098 Franklin #27

Trends in Prevalence of Hypertension in the US Population, by Race/Ethnicity,1988-2000

0

5

10

15

20

25

30

35

Prev

alen

ce (%

)

Non-Hispanic White Non-Hispanic Black Mexican American

1988-19911991-19941999-2000

*p<0.01, **p<0.001,compared to Non-Hispanic Whites within given time period; no significant trends across time periods within gender; analyses are age-adjusted to 2000 US population. Data from Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988- 2000. JAMA 2003; 290: 199-206.

** ****

* *

Chobanian A. N Engl J Med 2009;361:878-887

Hypertension Paradox: Changes in the Prevalence and Control ofHypertension in the United States (1988-2004)

Rate of control:27% to 35%

Presenter

Presentation Notes

Figure 3. Changes in the Prevalence and Control of Hypertension in the United States (1988-2004). The total number of persons with uncontrolled hypertension has increased from 37 million to 42 million during the past two decades, even though the rate of control has increased from 27% to 35% during the same period. Data are from Chobanian et al.12 and Cutler et al.41

Colors of Salt

• White• Black• Red• Yellow• Green• Brown• Clear

• Table salt• Soy sauce• Catsup• Mustard• Pickles• Soups & gravies• Saline

The connection between salt, obesity, hypertension and CVD mortality• During the past 25 years salt intake has

increased by 1/3 to 150-170 mmol/day (3.5 to 4.0 g sodium/day).

• This has contributed to the growing obesity epidemic and increased prevalence of hypertension by causing increased intake of high-calorie soft drinks containing corn sugar

• Recent studies suggests that a decrease of 50 mmol/day below the current level (a reduction of 1/3) would decrease BP by 4.0/2.5 mm Hg in hypertensives and reduce CVD mortality in the US by more than 100,000/yr.

• During the past 25 years salt intake has increased by 1/3 to 150-170 mmol/day (3.5 to 4.0 g sodium/day).

• This has contributed to the growing obesity epidemic and increased prevalence of hypertension by causing increased intake of high-calorie soft drinks containing corn sugar

• Recent studies suggests that a decrease of 50 mmol/day below the current level (a reduction of 1/3) would decrease BP by 4.0/2.5 mm Hg in hypertensives and reduce CVD mortality in the US by more than 100,000/yr.

Secondly, hypertension is associated with considerable

cardiovascular risk.


2098 Franklin #33

Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors

EzzatiEzzati et al. et al. Lancet.Lancet. 2002;360:13472002;360:1347--1360.1360.Attributable Mortality Attributable Mortality

(In thousands; total 55,861,000)(In thousands; total 55,861,000)

High mortality, developing regionHigh mortality, developing regionLower mortality, developing regionLower mortality, developing regionDeveloped regionDeveloped region

00 8000800070007000600060005000500040004000300030002000200010001000

High blood pressureHigh blood pressure

TobaccoTobacco

High cholesterolHigh cholesterol

Unsafe sexUnsafe sex

High BMIHigh BMI

Physical inactivityPhysical inactivity

AlcoholAlcohol

Indoor smoke from solid fuelsIndoor smoke from solid fuels

Iron deficiencyIron deficiency

UnderweightUnderweight

Presenter

Presentation Notes

The Comparative Risk Assessment module of the World Health Organization (WHO)’s Global Burden of Disease 2000 study performed a systematic assessment of changes in population health that would result from modifying exposure to environmental and physiological health risk factors. The methodology used to determine the attributable mortality and attributable burden of disease due to each risk factor was a counterfactual analysis in which the contribution of 1 or a group of risk factors is estimated by comparing the current disease burden with the magnitude that would be expected in an alternative scenario characterized by a theoretical minimal exposure. In the case of high BP and cholesterol, the theoretical minimal exposures were levels of 115 mm Hg and �3.8 mmol/L, respectively. This analysis of the contribution of 26 selected risk factors to global disease burden found that high BP was the leading cause of mortality in both developing regions and developed regions of the world. The study looked at the impact of risk factors on mortality. High mortality, developing regions such as many countries in Africa and Southeast Asia. Lower mortality, developing regions such as Latin America and countries in the Western Pacific. Developed regions including Europe, Japan, and North America. In high mortality, developing regions, the leading causes of death were reported to be childhood and maternal undernutrition, including being underweight. However, despite the large contribution of communicable, maternal, perinatal, and nutritional conditions and their underlying risk factors to disease burden in the high mortality, developing regions, the “industrialized” risks of high BP, tobacco, and blood cholesterol levels also resulted in significant loss of life in these regions. Across developed regions, high BP, tobacco use, alcohol, high cholesterol, and high body mass index (BMI) were reported to be consistently the leading causes of loss of life.

Is it a true risk factor or a risk marker?

A true risk factor is suspected of being causative of the disease process.

A risk marker is associated with the disease process without being in the causal pathway.

TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease HF = heart failure. Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22.

Retinopathy Renal failurePeripheral vascular

disease

Complications of Hypertension:

LVH, CHD, HF

TIA, stroke

Hypertension Hypertension is a risk factoris a risk factor

Presenter

Presentation Notes

Hypertension is an important contributing risk factor for end-organ damage and subsequent increases in morbidity and mortality. The goal in treating hypertension is to prevent cardiovascular and renal complications. Even small elevations above optimal blood pressure (BP) values (<120/80 mm Hg) increase the likelihood of developing hypertension (BP ≥140/90 mm Hg) and incurring target-organ damage. Chronic elevations of BP lead to target-organ damage and the development of cardiovascular and renal diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, left-ventricular hypertrophy, and renal failure. Signs of target-organ damage herald a poorer prognosis and may present in the heart, blood vessels, kidneys, brain, or eyes. Later consequences include cardiac, cerebrovascular, vascular, and renal morbidities and death. Because of the complex nature of hypertension, it is not surprising that single antihypertensive agents normalize BP for less than a majority of hypertensive patients. Reference Cushman WC. J Clin Hypertens. 2003;5(suppl):14-22.

Elevated pulse pressure, an indirect (but important) measure of increased vascular stiffness Elevated pulse pressure, an indirect (but important) measure of increased vascular stiffness

Associated with:• Cardiac complications:

LVH

Atrial fibrillation

Systolic and diastolic dysfunction

Heart failure

• Large artery complications:

Myocardial infarction

Stroke

• Microvascular complications:

White matter lesions, cognitive impairment, dementia

Renal disease

2098 Franklin #37

:“Diabesity”

Association of Systolic BP and CV Death in Type 2 Diabetes

0

25

50

75

100

125

150

175

200

225

250

<120 120–139 140–159 160–179 180–199 200

Without diabetesWith diabetes

CV

mor

talit

y ra

te/

10,0

00 p

erso

n-y

Systolic BP (mm Hg)Stamler et al. Diabetes Care. 1993;16:434.

Presenter

Presentation Notes

Increasing degrees of systolic hypertension contribute to increased mortality. In diabetes, age-adjusted CV mortality rates at any given level of systolic blood pressure (BP) exceed �the mortality rates in the nondiabetic population. This study cohort consisted of 361,661 men aged 35 to 57 years who were potential participants at the initial screening visit of the Multiple Risk Factor Intervention Trial (MRFIT). Among those screened, 5625 men reported being treated at that time for diabetes.

Stages of Chronic Kidney Disease

Stage Description GFRmL/min/1.73 m2

1 Kidney damage with normal or increased GFR

≥

90

2 Kidney damage with mild decreased GFR

60-89

3 Moderate decreased GFR 30-59

4 Severe decreased GFR 15-29

5 Kidney failure < 15 (or dialysis)

Proteinuria Is an Independent Risk Factor for Mortality in Type 2 Diabetes

1.0

0.9

0.8

0.7

0.6

0.50 1 2 3 4 5 6

Years

Sur

viva

l(a

ll-ca

use

mor

talit

y)

Normoalbuminuria(n=191)

Microalbuminuria(n=86)

Macroalbuminuria(n=51)

P<0.01, normo- vs micro- and macroalbuminuria.P<0.05, micro- vs macroalbuminuria.

Gall et al. Diabetes. 1995;44:1303.

Presenter

Presentation Notes

Proteinuria, a window into blood vessel integrity, predicts poor survival. The impact of micro- and macroalbuminuria on mortality was evaluated prospectively in �328 white patients with type 2 diabetes who were followed for 5 years. Patients in the 3 �study groups included those with normoalbuminuria (109 men and 82 women with albumin excretion rates [AER] <30 mg/24 h), microalbuminuria (50 men and 36 women with AER 30 �to 299 mg/24 h), and macroalbuminuria (43 men and 8 women with AER 300 mg/24 h). �The mean age at entry was 54 (SD ± 9) years. From 1987 until January 1993 (or until death), 8% of patients with normoalbuminuria, �20% of patients with microalbuminuria, and 35% of patients with macroalbuminuria died (predominantly from CV disease [CVD]; P<0.01 [normo- vs micro- and macroalbuminuria] �and P<0.05 [micro- vs macroalbuminuria]). The researchers concluded that abnormal elevated urinary albumin excretion (UAE) increased all-cause (mainly CV) mortality risk in type 2 diabetes.

Diabetes: The Most Common Cause of ESRD

United States Renal Data System. Annual data report. 2000.

Primary Diagnosis for Patients Who Start Dialysis

Diabetes50.1%

Hypertension27%

Glomerulonephriti s13%

Other10% No. of patients

Projection95% CI

1984 1988 1992 1996 2000 2004 20080

100

200

300

400

500

600

700

r2=99.8%243,524

281,355520,240

No.

of d

ialy

sis

patie

nts

(thou

sand

s)

ESRD in the USA 2002

↓ Mortality from MI & stroke over past 30 years ↑ Life expectancy contributed to ↑ ESRD Currently in USA > 300,000 patients on dialysis The cost exceeds $ 60,000 per patient per year Twenty one billion $ projected cost in 2002 First year mortality ~ 20% ~ 50% of deaths are cardiac (USRDS)

Life Expectancy for Selected U.S. Populations

0

5

10

15

20

25

30

35

Age 49 Age 59

U.S.Prostate cancerColon cancerESRDLung cancer

USRDS 1993 Annual Data Report

USRDS 1993 Annual Data Report

Expe

cted

rem

ainin

g ye

ars

Presenter

Presentation Notes

We’re going to be talking about clinical outcomes in patients with ESRD, and I like to show this because the first time I saw this slide, the dramatic reduction in life expectancy that ESRD patients face really hit home. Here’s the general population, patients with prostate and colon cancer, and well…at least we beat lung cancer. ESRD patients have a life expectancy that is between 17 and 33% of the general population. And we know that in large part this is due to cardiovascular deaths.

Thirdly, there is considerablereduction in cardiovascular riskwith effective lowering of blood

pressure with therapy.


35%-40%

20%-25%

>50%

Average reduction in events

(%)

–60

–50

–40

–30

–20

–10

0Stroke

Myocardialinfarction Heart failure

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events

Fourthly, there is insufficientawareness, treatment andcontrol of hypertension.


01020304050607080

Hypertension Awareness, Treatment, and Control: US 1976 to 2000*

NHANES III NHANES III (Phase 2) (Phase 2) 19911991--19941994

NHANES III NHANES III (Phase 1) (Phase 1) 19881988--19911991

51%51%

73%73% 68%68%

31%31%

55%55% 54%54%

10%10%

29%29% 27%27%

% A

dults

% A

dults

NHANES II NHANES II 19761976--19801980

NHANES NHANES 19991999--20002000

70%70%

59%59%

34%34%

Healthy PeopleHealthy People 2000/2010 2000/2010 Control Control Target = 50%Target = 50%

ControlControl

AwarenessAwareness

TreatedTreated

ChobanianChobanian et al. et al. JAMAJAMA. 2003;289:2560. 2003;289:2560--2572.2572.

Presenter

Presentation Notes

Awareness, treatment, and control rates of hypertension improved from the 1976-1980 NHANES II to the 1988-1991 NHANES III, phase 1. Awareness increased from 51% to 73%, treatment rate from 31% to 55%, and control rates from 10% to 29%. However, from the first phase of NHANES III (1988-1991) to the second phase (1991-1994); there was a plateauing of awareness, treatment, and control rates, as seen in this slide. In the most recent NHANES survey (1999-2000), rates of awareness, treatment, and control had increased again. Therefore, relative to 1976-1980, realization of the importance of BP has been on the rise. The present control rate of 34%, however, is still significantly short of the 2000/2010 goal of 50%. Definitions: With hypertension = systolic BP 140 or diastolic BP 90 mm Hg, or taking medication Aware hypertension = with hypertension and told by doctor Treated hypertension = taking hypertension medication Control hypertension = taking hypertension medication and systolic BP <140 and diastolic BP <90 mm Hg. Percentages are over population with hypertension (denominator).

4. Global Risk Assessment

Risk Factor Clustering With Hypertension

Risk Factor Clustering With Hypertension

Risk factor clustering with hypertension, ages 18–74 years. Framingham offspring.

Kannel WB. Am J Hypertens. 2000.

0 1 2 3

5

0

10

15

20

25

30MenWomen

17%19%

26% 27% 25% 24%22%

20%

8%12%

≥4

Risk Factors

(%)

Number of Risk Factors

BP is a risk marker for “The Metabolic Syndrome”

*Diagnosis is established when ≥3 of these risk factors are present.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

NCEPNCEP--ATP III Definition: ATP III Definition: ≥≥3 of the Following*3 of the Following*• Men: >102 cm (>40 in)• Women: >88 cm (>35 in)

Fasting glucose

• ≥130/≥85 mmHg (risk marker)

Blood pressure

HDL-C

• ≥150 mg/dLTriglycerides

Abdominal obesity (waist circumference)

• Men: <40 mg/dL• Women: <50 mg/dL

• ≥100 mg/dL

Presenter

Presentation Notes

Like patients with diabetes, patients with the metabolic syndrome are at increased risk for CHD. Both diseases are associated with insulin resistance, a condition in which the normal actions of insulin are impaired. As with diabetes, obesity—particularly central, or abdominal, obesity—and a sedentary lifestyle are RFs for the development of insulin resistance. Moreover, patients with the metabolic syndrome have a higher risk of developing overt diabetes than do subjects without this condition. The clinical criteria used to identify patients with metabolic syndrome recommended by the National Cholesterol Education Program (NCEP) are shown on this slide. The diagnosis is established when 3 or more of these RFs are present. The presence of the metabolic syndrome substantially enhances the risk of CHD at any given low-density–lipoprotein cholesterol (LDL-C) level. Because the correlation between abdominal obesity and other metabolic syndrome RFs is stronger than the correlation between BMI and these RFs, the measurement of waist circumference is recommended as a simple method to identify the weight component of the metabolic syndrome. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. Lakka H-M et al. JAMA. 2002;288:2709-2716.

Other CVD Risk Factors: JNC 7

Physical inactivity

Cigarette smoking

Age (older than 55 for men, 65 for women)

Family history of premature CVD (men under age 55 or women under age 65)

*Components of the metabolic syndrome in blue ChobanianChobanian et al. et al. JAMAJAMA. 2003;289:2560. 2003;289:2560--25722572

700

600

500

400

300

200

100

8 Ye

ar P

roba

bilit

y Pe

r 1,0

00

Systolic BP: Cholesterol: Glucose Intol.: Cigaretes:ECG-LVH:

105 >>> 185185000

105 >>> 185335000

105 >>> 185335+00

105 >>> 185335++0

105 >>> 185335+++

Kannel, 1983

Framingham Heart Study (1983)Framingham Heart Study (1983)CV Risk ProfileCV Risk Profile

703

459

326

210

46

Presenter

Presentation Notes

Framingham Study (1983) From the Framingham study, cardiovascular risk increased as you increase blood pressure. The risk also increased as the number of risk factors increased, including high cholesterol, glucose intolerance, smoking, and ECG-LVH. Kannel WB, 1983

Expert Panel on Detection, Evaluation, and Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Treatment of High Blood Cholesterol in Adults. JAMAJAMA. 2001;285:2486. 2001;285:2486--2497.2497.

Age, yAge, y PointsPoints2020--3434 --993535--3939 --444040--4444 004545--4949 335050--5454 665555--5959 88604604 10106565--6969 11117070--7474 12127575--7979 1313

11

22

55

TotalTotal AgeAge AgeAge AgeAge AgeAge AgeAge CholesterolCholesterol 2020--3939 4040--4949 5050--5959 6060--6969 7070--7979

<160<160 00 00 00 00 00 160160--199199 44 33 22 11 00 200200--239239 77 55 11 33 00 240240--279279 99 66 44 22 11

280280 1111 88 55 33 11

AgeAge AgeAge AgeAge AgeAge AgeAge 2020--3939 4040--4949 5050--5959 6060--6969 7070--7979

HDL mg/HDL mg/dLdL PointsPoints

6060 --11 5050--5959 00 4040--4949 11

<40<40 22

Systolic BPSystolic BP IfIf IfIf mm Hgmm Hg UntreatedUntreated TreatedTreated

<120<120 00 00 120120--129129 00 11 130130--139139 11 22 140140--159159 11 22 160160 22 33

Point TotalPoint Total 1010--Year Risk, %Year Risk, %<0<0 <1<1

00 11 11 11 22 11 33 11 44 11 55 22 66 22 77 33 88 44 99 55

1010 66 1111 88 1212 1010 1313 1212 1414 1616 1515 2020 1616 2525

1717 3030

66

ATP-III: Framingham Point Scores Estimate of 10-Year Risk for Men

NonsmokerNonsmoker 00 00 00 00 00 SmokerSmoker 88 55 33 11 11

44

33

Presenter

Presentation Notes

Global risk assessment is the first step in CV risk management, and the intensity of risk-reduction therapy is based on the patient’s degree of absolute risk for CV events. This is because it is now understood that the impact of moderate elevations in several risk factors on CV morbidity and mortality is equivalent to large elevations in a single risk factor. The absolute global risk is determined by The Framingham Point Scores, which quantify the 10-year risk for developing CHD. The Framingham Point Scores for men and women take into account 6 risk factors—age (1), total serum cholesterol level (2), systolic BP and hypertension treatment status (3), serum HDL-C (4), and smoking status (5). Each risk factor is assigned a point value according to the Framingham Point Scores, and these values may be different for men and women. The 10-year risk for MI and coronary death measured in percent is estimated from the sum of the points (6). Point scores for men are shown here.

56

Advice from Woody Allen

“If I knew I would live this long I would have taken better care of myself”

“ Sudden Death is nature’s way of telling you to slow down”

“If I knew I would live this long I would have taken better care of myself”

“ Sudden Death is nature’s way of telling you to slow down”

_________________________________________________ _____

_________________________________________________ _____

_______________________________________________________ _____

5. Intervention Trials

•“Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.”

• “Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.”

Paul Dudley White, 1931 Textbook of Cardiology.

MesserliMesserli, F. H. , F. H. N N EnglEngl J MedJ Med 19951995

Hypertension Intervention Trials: 1959- 1970

Trial Severity of Hypertension

CV events/yr. In CTRL Group

CV events/yr: CTRL vs Ther. Group

Harrington, et al (1959)

Malignant Hypertension

90% Mortality 90% vs 50% (Mortality / Yr)

VA Coop. Study (1967)

Severe (DBP 115 mmHg) 187/121

29% 10:1 (1.5 Yr.)


Moderate (DBP 105-114 mmHg) 165/105

5.5% 3.5:1 (4.5 Yr.)

Trial Severity of Hypertension

CV events/yr. In CTRL Group

CV events/yr: CTRL vs Ther. Group

Harrington, et al (1959)

Malignant Hypertension

90% Mortality 90% vs 50% (Mortality / Yr)


Severe (DBP 115 mmHg) 187/121

29% 10:1 (1.5 Yr.)


Moderate (DBP 105-114 mmHg) 165/105

5.5% 3.5:1 (4.5 Yr.)

TOMHSTOMHS VA VA MONORxMONORx

CONVINCECONVINCE ALLHAT ALLHAT ANBP2ANBP2

LIFELIFE

HAPPHYHAPPHY MAPHYMAPHY

INSIGHTINSIGHTNORDILNORDIL

CAPPPCAPPP STOPSTOP--22

VALUEVALUE ASCOTASCOT

ACCOMPLISHACCOMPLISH

Clinical Trials in Hypertension

HR Black, 2003.HR Black, 2003.

1960s1960s 1970s1970s 1980s1980s 19901990--19951995 19961996--19991999 20002000 20012001--20032003 20042004--20082008

Should we treat Should we treat diastolic HBP?diastolic HBP?

What is the What is the best way to best way to treat HBP?treat HBP?

Should we treat Should we treat DBP in older DBP in older

persons?persons?

What is theWhat is thegoal of goal of

treatment?treatment?

Should we Should we treat ISH in treat ISH in

older older persons?persons?

Can we Can we prevent prevent

hypertension?hypertension?

VA VA Cooperative Cooperative

StudiesStudiesMRCMRC--11

ANHBPANHBP--11

EWPHEEWPHE

MRCMRC--22STOPSTOP--11

SCOPESCOPEHDFPHDFP HOTHOT

UKPDSUKPDS

SystSyst--EurEur SystSyst--ChinaChinaSHEPSHEP TROPHYTROPHY

Presenter

Presentation Notes

Large-scale clinical trials have addressed a number of questions about the treatment of hypertension. The earliest trials, such as the VA Cooperative Studies, MRC1 and ANHBP 1, investigated whether to treat diastolic hypertension. Determining the goal of treatment was the question addressed by HDFP, HOT, and UKPDS, later trials. Whether to treat diastolic BP elevation in older patients was investigated in the EWPHE, MRC, STOP, and SCOPE studies. Whether to treat systolic BP elevation in older patients was answered by SHEP, Syst-Eur and Syst-China. Many trials have addressed the question “What is the best way to treat HBP?,” starting with HAPPHY, MAPHY, TOMHS, and the VA study, and more recently extending to INSIGHT, NORDIL, ALLHAT, ANBP2, CONVINCE, and LIFE. Trials under way are also investigating the best way to treat high BP (HBP)—VALUE, ACCOMPLISH—and whether we can prevent hypertension—TROPHY.

SHEP Trial: Design

• N: 4736; 43% male• Age: >60• BP: SBP 160-219 and DBP <90• Design: Placebo control, double blind• Active Rx: Chlorthalidone (atenolol as step 2)

• SBP difference: 12 mm Hg• Duration: 4.5 years

• N: 4736; 43% male• Age: >60• BP: SBP 160-219 and DBP <90• Design: Placebo control, double blind• Active Rx: Chlorthalidone (atenolol as step 2)

• SBP difference: 12 mm Hg• Duration: 4.5 years

JAMA 1991;265:3255

SHEP Trial: Cardiovascular Disease Endpoints

JAMA 1991;265:3255

HR 95% CI P value

All stroke - 34% 0.46 - 0.95 0.025

Total mortality - 28% 0.59 - 0.88 0.001

Fatal stroke - 45% 0.33 - 0.93 0.021

Cardiovascular mortality

- 27% 0.55-0.97 0.029

Heart failure - 72% 0.17-0.48 <0.001

Cardiovascular events - 37% 0.51-0.71 <0.001

HYVET Results All Outcomes

Per Protocol

Beckett N. N Engl J Med. 2008;358: epub. March 31, 2008.

6. Management of Hypertension

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

National Heart, Lung, and Blood Institute

National High Blood Pressure Education Program

JNC 7: Appropriate BP Targets

• For both CVD and kidney disease, systolic BP is far more important than diastolic BP

• Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease)

• Only a small fraction of hypertensives are achieving appropriate BP control

• Multiple antihypertensive agents are needed for most patients

• Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD.

• For both CVD and kidney disease, systolic BP is far more important than diastolic BP

• Systolic BP should be <140 mm Hg in all patients, and ideally between 120-130 mm Hg in patients with complications (diabetes, heart failure, kidney disease)

• Only a small fraction of hypertensives are achieving appropriate BP control

• Multiple antihypertensive agents are needed for most patients

• Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered pre-hypertensive who require health-promoting lifestyle modifications to prevent CVD.

Presenter

Presentation Notes

In summary, the key messages regarding BP targets for clinicians treating patients with diabetes and hypertension are as follows:

JNC 7: Considerations for older persons with hypertension

This population has the lowest rates of BP control and the greatest absolute benefit with effective therapy.

Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.

More than two-thirds of people over 65 have HTN, i.e. ISH (Isolated systolic hypertension).

JNC 7: Considerations for special populations with hypertension

• Treatment generally similar for all demographic groups

• Socioeconomic factors and lifestyle important barriers to BP control

• Prevalence, severity of hypertension increased in blacks

• Treatment generally similar for all demographic groups

• Socioeconomic factors and lifestyle important barriers to BP control

• Prevalence, severity of hypertension increased in blacks

JNC 7. JAMA. 2003;289:2560-2672.

Presenter

Presentation Notes

The treatment of hypertension is generally similar across all demographic groups. Socioeconomic factors and lifestyle are important barriers to BP control in minority populations. The prevalence, severity, and impact of hypertension are increased in blacks, who also demonstrate a reduced BP response to certain types of antihypertensive monotherapy.

Intervention

Exercise

Weight reduction

Alcohol intake reduction

Sodium intake reduction

DASH diet

Intervention

Exercise

Weight reduction

Alcohol intake reduction

Sodium intake reduction

DASH diet

Lifestyle Interventions for Prevention or Treatment of Hypertension

Blood Pressure Effect

5-10 mm Hg (>30 min >3x/wk)

1-2 mm Hg/Kg

1 mm Hg/drink/d

2-3 mm Hg/40 mmol/d

3-10 mm Hg

Blood Pressure Effect

5-10 mm Hg (>30 min >3x/wk)

1-2 mm Hg/Kg

1 mm Hg/drink/d

2-3 mm Hg/40 mmol/d

3-10 mm Hg Adapted from Cushman et al. Endocrine Practice 1997;3:106 & Sacks, et al. NEJM 2001;334:3

Sacks F and Campos H. N Engl J Med 2010;362:2102-2112

Sodium Reduction, the DASH Diet, and Changes in Systolic Blood Pressure

Presenter

Presentation Notes

Figure 2. Sodium Reduction, the DASH Diet, and Changes in Systolic Blood Pressure. The figure shows the additive beneficial effects of the DASH diet and reduced intake of sodium on systolic blood pressure in patients with mild hypertension who were older than 45 years of age. The participants were a subgroup of those in the study of the effects of the DASH diet and reductions in dietary sodium,53 who were randomly assigned to follow a DASH diet (33 participants) or a typical U.S. diet (37 participants) for 90 days. During that period, each group consumed three versions of the diet adjusted for daily sodium content. The participants in each group consumed each of the sodium-adjusted diets for 30 days in a crossover design; body weight was held constant. The two downward-sloping arrows on the left depict the effect of intermediate sodium intake as compared with higher sodium intake, and the two downward-sloping arrows on the right depict the effect of lower sodium intake as compared with intermediate sodium intake. The dotted lines show the effect of the DASH diet as compared with the typical U.S. diet at each level of dietary sodium. Numbers shown represent the mean changes with 95% confidence intervals. Adapted from Bray et al.54

Sacks F and Campos H. N Engl J Med 2010;362:2102-2112

Effects of a Low-Sodium DASH Diet on Systolic Blood Pressure with Increasing Age

Presenter

Presentation Notes

Figure 3. Effects of a Low-Sodium DASH Diet on Systolic Blood Pressure with Increasing Age. A total of 412 participants were randomly assigned to follow a DASH diet (208 participants) or a typical U.S. diet (control group, 204 participants) for 90 days. During that period, each group consumed three versions of the diet adjusted for daily sodium content: high (3.5 g), intermediate (2.3 g), and low (1.2 g). The participants in each group consumed each of the sodium-adjusted diets for 30 days in a crossover design; body weight was held constant. Mean ({+/-}SD) systolic blood pressure is depicted for the DASH group during the period of low sodium intake and for the control group during the period of high sodium intake, according to age, at the end of the 30-day period; there were 45 to 58 participants per group in each of the four age ranges shown. The slope for the control group during the period of high sodium intake was 0.3 mm Hg per year, spanning 30 years. The slope for the DASH-diet group during the period of low sodium intake was 0 mm Hg per year. I bars denote 95% confidence intervals. Data are from Sacks et al.53

We modified the four basic food groups

Lifestyle Treatment Measures

Nonpharmacologic treatments are used for:

Lowering blood pressure

Reducing need for antihypertensive agents Minimizing associated risk factors

Primary prevention of hypertension

19721972 19731973 19761976 19801980 19841984 19881988 19931993 19971997 20032003

Development of Hypertension Guidelines: the JNCs and Drug Therapy

NHBPEPNHBPEPSTARTSSTARTS

EarliestEarliest GuidelinesGuidelines

28 drugs28 drugs DBP DBP 105105 DiureticsDiuretics

JNC IJNC I

43 drugs43 drugs

diuretics,diuretics, --blockersblockers

AddedAdded

JNC IIIJNC III

JNC IIJNC II

34 drugs34 drugsDiureticsDiuretics

JNC IVJNC IV

50 drugs50 drugsACEI, ACEI, CAsCAs

addedadded

JNC VIJNC VI

84 drugs84 drugs7 options7 options

LowLow--dosedose

JNCsJNCs II--7.7.

68 drugs68 drugsDiuretics/Diuretics/--blockersblockers

JNC VJNC V JNC 7JNC 7

> 125 drugs> 125 drugsDiureticsDiuretics

Presenter

Presentation Notes

Since its inception in 1972, the National High Blood Pressure Education Program (NCEP) has overseen the publication of 7 Joint National Committee Reports. During that time, the drug classes available to treat hypertension have expanded from diuretics to include -blockers, angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), and angiotensin-receptor blockers (ARBs). The number of drugs available to treat hypertension has increased from 28 to more than 125.

Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug ChoicesInitial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed

With Compelling Indications

With Compelling Indications

Lifestyle ModificationsLifestyle Modifications

Not at Goal Blood Pressure

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved

Consider consultation with hypertension specialist

Optimize dosages or add additional drugs until goal blood pressure is achieved

Consider consultation with hypertension specialist

Stage 2 Hypertension (SBP >160 or DBP >100 mm Hg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 2 Hypertension (SBP >160 or DBP >100 mm Hg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg)

Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB,

or combination

Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg)

Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB,

or combination

Without Compelling Indications

Without Compelling Indications

JNC 7 Algorithm for Treatment of Hypertension

ChobanianChobanian et al. et al. JAMAJAMA. 2003;289:2560. 2003;289:2560--2572.2572.

Presenter

Presentation Notes

As recommended by JNC 7, hypertension treatment should start with lifestyle modifications. If the patient is not at goal BP of <140/90 mm Hg (<130/80 mm Hg for those with diabetes or chronic kidney disease), pharmacologic therapy should be initiated. Initial drug choices for patients without compelling indications should be a thiazide diuretic for most patients with stage 1 hypertension. Typically, combination therapy with 2 drugs is required for stage 2 hypertension. When use of a single drug fails to achieve the BP goal, addition of a second drug from a different class should be initiated. A 2-drug combination usually consists of a thiazide-type diuretic plus an ACEI, an ARB, a -blocker, or a CCB. Specific antihypertensives are designated for compelling indications (ie, HF, post-MI, high coronary artery disease [CAD] risk, diabetes, etc.). If a patient is still not at goal BP following the treatment algorithm, optimize the patient’s dosages or add additional drugs until goal BP is achieved. Also consider consulting with a hypertension specialist.

Number of Medications to Achieve Goal BP in 5 Trials of DM &/or Renal Disease

3.8

3.3

3.6

2.8

2.7

0 1 2 3 4

AASK (<92 mm Hg MAP)

HOT (<80 mm Hg DBP)

MDRD (<92 mm Hg MAP)

ABCD (< 75 mm Hg DBP)

UKPDS (<150/85 mm Hg)

Number of BP Meds

3.8

3.3

3.6

2.8

2.7

0 1 2 3 4

AASK (<92 mm Hg MAP)

HOT (<80 mm Hg DBP)

MDRD (<92 mm Hg MAP)

ABCD (< 75 mm Hg DBP)

UKPDS (<150/85 mm Hg)

Number of BP Meds

BakrisBakris. . J J ClinClin HypertensHypertens 1999;1:1411999;1:141--77

7. Barriers to Treatment

Barriers to Controlling Hypertension

Healthcare System

Patients Providers

Presenter

Presentation Notes

In a global effort, patients, providers, and the healthcare system must make their contributions to get hypertension to goal.

Is this true?

The Initial Confrontation of the HTN Problem

• Upon making a diagnosis of HTN, tell patient the BP reading and what it should be (provide a written copy).

• Prepare patient for the probable necessity for polypharmacy to control BP with a minimum of side effects

• Advise Home BP measurement (135/85 mmHg is considered to be hypertensive).

• Upon making a diagnosis of HTN, tell patient the BP reading and what it should be (provide a written copy).

• Prepare patient for the probable necessity for polypharmacy to control BP with a minimum of side effects

• Advise Home BP measurement (135/85 mmHg is considered to be hypertensive).

Table 28. JNC 7 Report. Hypertension. 2003;42(6):1240.

8. Prevention Strategy:

General Population StrategyVersus

Targeted Intensive Strategy

Life’s Simple 7

Primordial PreventionGet activeControl cholesterolEat betterManage blood pressureLose weightReduce blood sugarStop smoking

AHA 2010

IntermediateLesion

Primordial, primary and secondary Primordial, primary and secondary prevention of atherosclerotic diseaseprevention of atherosclerotic disease

FoamCells

FattyStreak Atheroma

FibrousPlaque

ComplicatedLesion/Rupture

From First Decade From Third Decade From Fourth Decade

Growth of the Lipid CoreSmooth

Muscle and Collagen

Thrombosis

Endothelial Dysfunction

Nilsson PM, Lurbe E, Laurent S, J Hypertens 2008;26:1049-1057

Presenter

Presentation Notes

Key Points/Summary: Degeneration of healthy endothelium via the pathogenesis of atherosclerosis occurs slowly over decades. It appears to begin with a subtle form of endothelial injury that alters function. Foam cells are the earliest sign of endothelial dysfunction. They are macrophages that contain oxidized LDL-C and are most frequent in infants and children. Foam cells may then infiltrate the vessel, progressing to a fatty streak. As the lesion progresses to an intermediate lesion, small pools of extracellular lipid form within the smooth muscle layers, disrupting the intimal lining of the vessel. Progression to an advanced lesion occurs when the accumulated lipid, cells, and other components of the plaque disrupt the artery wall. This lesion is termed an atheroma. Once the plaque becomes fibrous, it is primed to rupture. This type of advanced lesion can be found from the fourth decade of life onward. The endothelium itself appears to participate in some of this remodeling through secretion of specific compounds. Citation: Butler R, McDonald TM, Struthers AD, Morris AD. The clinical implications of diabetic heart disease. Euro Heart J 1998;19:1617-1627.

Natural history of CVD: a 3-act tragedy

• First act: Introduces the main characters

-- Risk factors (primordial prevention).

• Second act: Takes place over decades

-- Villains attack the arterial walls

(Primary prevention)

• Third act: Can be tragically brief

-- plaque rupture & arterial thrombosis

-- patient survives (2ndary prevention)

• First act: Introduces the main characters

-- Risk factors (primordial prevention).

• Second act: Takes place over decades

-- Villains attack the arterial walls

(Primary prevention)

• Third act: Can be tragically brief

-- plaque rupture & arterial thrombosis

-- patient survives (2ndary prevention)

Sniderman AD. Lancet 2008;371:1547-1549

Total CV prediction: an elusive goal ?

Lifetime risks of CV disease• Optimal RF: cholesterol <180 mg/dl, BP <120/80

mm Hg, non-smoker, no diabetes

• Not optimal RF: cholesterol 180-199 mg/dl, SBP 120-139 mm Hg, DBP 80-89 mm Hg

• Elevated RF: Cholesterol 200-239 mg/dl, SBP 140-159 mm Hg, DBP 90-99 mm Hg

• Major RF: Cholesterol ≥

240 mg/dl, BP ≥ 160/100 mm Hg, current smoker, + diabetes

• Optimal RF: cholesterol <180 mg/dl, BP <120/80 mm Hg, non-smoker, no diabetes

• Not optimal RF: cholesterol 180-199 mg/dl, SBP 120-139 mm Hg, DBP 80-89 mm Hg

• Elevated RF: Cholesterol 200-239 mg/dl, SBP 140-159 mm Hg, DBP 90-99 mm Hg

• Major RF: Cholesterol ≥

240 mg/dl, BP ≥ 160/100 mm Hg, current smoker, + diabetes

Berry JD et al. N Engl J Med 2012;366:321-329

Lifetime Risk of Death from Cardiovascular Disease among Black Men and White Men at 55 Years of Age, According to the Aggregate Burden of Risk Factors and Adjusted for

Competing Risks of Death.


Presenter

Presentation Notes

Figure 1 Lifetime Risk of Death from Cardiovascular Disease among Black Men and White Men at 55 Years of Age, According to the Aggregate Burden of Risk Factors and Adjusted for Competing Risks of Death. The risk-factor profile was considered optimal when a participant had a total cholesterol level of less than 180 mg per deciliter (4.7 mmol per liter) and untreated blood pressure of less than 120 mm Hg systolic and less than 80 mm Hg diastolic, was a nonsmoker, and did not have diabetes. It was considered not to be optimal for nonsmokers without diabetes who had a total cholesterol level of 180 to 199 mg per deciliter or untreated systolic blood pressure of 120 to 139 mm Hg or untreated diastolic blood pressure of 80 to 89 mm Hg. Levels of risk factors were viewed as elevated for nonsmokers without diabetes who had a total cholesterol level of 200 to 239 mg per deciliter (5.17 to 6.18 mmol per liter) or untreated systolic blood pressure of 140 to 159 mm Hg or untreated diastolic blood pressure of 90 to 99 mm Hg. Major risk factors were defined as current smoking, diabetes, treatment for hypercholesterolemia, an untreated total cholesterol level of at least 240 mg per deciliter (6.21 mmol per liter), and treatment for hypertension, untreated systolic blood pressure of at least 160 mm Hg, or untreated diastolic blood pressure of at least 100 mm Hg. The data were derived from the 17 studies in the pooled cohort; data from the Multiple Risk Factor Intervention Trial were not included.

Lifetime risks of CV disease• Risk factor burden related to lifetime CVD risk

• RFs: HTN, cholesterol, smoking, DM

• Consistent across race and birth cohorts

• RFs differences affect racial risk differentially

• Primordial prevention is 3-5X > primary prevention in decreasing lifetime CVD risk.

• Risk factor burden related to lifetime CVD risk

• RFs: HTN, cholesterol, smoking, DM

• Consistent across race and birth cohorts

• RFs differences affect racial risk differentially

• Primordial prevention is 3-5X > primary prevention in decreasing lifetime CVD risk.


• Epidemiology Summary:– Increasing prevalence; world wide problem– Blood pressure as a moving target– ↑ PVR in the young, ↑ stiffness in the elderly– Predominantly isolated systolic hypertension– Consider special populations at increased risk– Hypertension as a part of absolute global CV risk– Population vs. high risk approaches for prevention

• Epidemiology Summary:– Increasing prevalence; world wide problem– Blood pressure as a moving target– ↑ PVR in the young, ↑ stiffness in the elderly– Predominantly isolated systolic hypertension– Consider special populations at increased risk– Hypertension as a part of absolute global CV risk– Population vs. high risk approaches for prevention

epidemiology of hypertension - university of california ... of htn franklin feb 2012.pdf · agenda:...

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