Hypertension in Malaysia

Assoc. Prof. Dr. Rashidi Ahmad

MD(USM), MMed(EM)(USM),FADUSM,

AM(Mal), Clinical Fellow (Cardio)(NHI)

School of Medical Sciences, USM, KB, Kelantan

Objectives

Understanding hypertension

Magnitude of hypertension in Malaysia

Best clinical practice (antihypertensive agents)

Definition

Confirmed/based on the average of 2 or more readings taken at 2 or more visits to the doctor.

CUFF:Width should at least be 40% of the

circumference of the arm

ARM SUPPORT IN STANDING

SITTING

KOROTKOFF PHASE:

1 CLEAR TAPPING SOUNDS FIRST APPEAR

5 THE DISAPPEARANCE OF SOUND

SBP

DBP

Important rules

Check BP both arms – coarctation of aorta, arterial anomaly

Lying & standing – postural drop in elderly, diabetics

Beware of auscultatory gap

Pathophysiology

Keep thinking of secondary causes

Sleep apneaDrug-induced or related causes

Chronic kidney diseasePrimary aldosteronismRenovascular disease

Chronic steroid therapy and Cushing’s syndromePheochromocytoma

Coarctation of the aortaThyroid or parathyroid disease

IHD mortality versus blood pressure

O’Donnell, et al. J Hypertension, 1998; 16: 3

Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Magnitude of HPT

Affects about 50 million people in the US and approximately 1 billion worldwide.

Prevalence increases with age: individuals who are normotensive at age 55 still face a

90% lifetime risk of developing HPT.

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72.

Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002;287:1003-10.

Lim,et al1991: 13.8%

Srinavas, et al1998: 25.6%

Liew, et al.1997: 42.8%

Nawawi2002: 31.2%

Chan1997: 10%

Prevalence rates fromDifferent years and

Different populations

Hypertension in Malaysia

Prevalence: 25.7%.

Men vs women - 26.3% vs 25.0%.

1 in 4 adults aged 25-64 years had HPT.

Known hypertensives: 1.4 million

Newly diagnosed:1.7 million.

Chinese (31.0%), Malays (23.4%) and Indians (21.6%).

Prevalence of HPT by sex and race amongst Malaysian residentsaged ≥ 18 years in 2006 (N=33,976)

Sex, % (95% CI)Age (Years)

Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)

Bumi Sarawak 35.6 (31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

Male Female Both sexes

All races 33.3 (31.6, 32.8) 31.0 (30.3, 31.7) 32.2 (31.6, 32.8)

Malay 33.7 (32.5, 34.8) 34.1 (33.1, 35.1) 33.9 (33.1 34.7)

Chinese 35.0 (33.2, 36.8) 29.8 (28.2, 31.4) 32.4 (31.1, 33.8)

Indians 30.9 (28.2, 33.8) 27.8 (25.6, 30.1) 29.4 (27.5,31.2)

Prevalence of HPT by sex and race amongst Malaysian residents aged ≥ 30 years in 2006 (N=24,796)

Sex, % (95% CI)Age (Years)

Indians 44.1 (40.8, 47.4) 42.7 (39.9, 45.5) 40.0 (37.7, 42.3)

Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)

Bumi Sarawak 35.6 ( 31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

Male Female Both sexes

All races 41.7 (40.7, 42.8) 43.4 (42.5, 44.4) 42.6 (41.8, 43.3)

Malay 45.8 (44.4, 47.1) 51.2 (50.0, 52.4) 45.4 (44.3, 46.4)

Chinese 47.4 (45.4, 49.4) 42.3 (40.4, 44.3) 40.6 (39.0, 42.1)

Rural vs Urban

Rural 36.9% ( 35.9, 38.0)

Urban 29.3% ( 28.5, 30.0)

The Malaysian Rule

All hypertensives

64% 36% Aware

12% 88% Treated

74% 26% controlled

The ‘Malaysian Rule’

100 All hypertensives

64 36 Aware

69 31 Treated

92 8 Controlled

Overall BP Control by ethnicity

Indian 12.2% ( 10.0,14.7)

Chinese 11.5% ( 10.1,12.9)

Malays 7.0% ( 6.4,7.7)

Comparison with NHMS 11 ( > 30 years )

1996 2006

Prevalence 33% 43%

Aware 33 % 36%

Diagnosed & Rx 23% 88%

Rx and controlled 26% 26%

Overall control 6% 8 %

Hypertension Control in the Asia Pacific Region

Prev Aware Treat Control

Thailand (2003-4) 22.2% 28.6% 23.7% 8.6%

China 2002 18.8% 30.2% 24.7% 6.1%

Korea 2001 22.9% 30.2% 22.9% 10.7%

Malaysia 2006 32.2% 35.8% 31% 8.2%

USA 2004 29.9% 66.5% 53.7% 33.1%

Clinical Aspects – Current Status ( IHM MOH 2006 )

National Essential Hypertension Audit - rates of control

Hospital with specialist 31.2%Hospital without specialist 26.6%Clinics with FMS/ MO 28.8%Clinics without FMS/MO 26.9%

Clinical Aspects – Current Status ( IHM MOH 2006 )

National Essential Hypertension Audit- rates of control by ethnicity

Malay 24.3%Indian 30.8% Chinese 37.6%Others 30.8%

Clinical Aspects – Current Status ( IHM MOH 2006 )

National Essential Hypertension Audit - rates of control by age

30-39 19.4%40-49 27.1%50-59 29.1%>60 29.2%

Points to ponder!

Patients’ non compliance

Doctors not sure when to treat and what

the treatment goals are

Doctors not using the right drug/drugs

Patients has undiagnosed secondary hypertension or complications of hypertension which makes optimum control difficult

What are the better ways to

manage hypertensive patients

in Malaysia?

Co-existing Condition

BP Levels(mmHg)

No RFNo TODNo TOC

TODor

RF (1 – 2)No TOC

TOCor

RF (≥ 3)or

Clinical atherosclerosis

Previous MIor

Previous strokeor

Diabetes

SBP 120 – 139 and/or DBP 80 – 89

Low Medium High Very high

SBP 140 – 159 and/or DBP 90 – 99

Low Medium High Very high

SBP 160 – 179 and/orDBP 100 – 109

Medium High Very high Very high

SBP 180 – 209 and/orDBP 110 – 119

High Very high Very high Very high

SBP ≥ 210 and/orDBP ≥ 120

Very high Very high Very high Very high

Risk Level Risk of Major CV Event in 10 years Management

Low < 10% Lifestyle changes

Medium 10 – 20% Drug treatment and lifestyle changes

High 20 – 30% Drug treatment and lifestyle changes

Very high > 30% Drug treatment and lifestyle changes

Risk Stratification

First line therapy

NICE / BHS ACEi / ARB/ diuretics/ CCB

ESH/ESC ACEi /ARB/diuretics/CCB/Beta blockers

WHO/ISH Low dose diuretics/ ACEi/CCB

MSH ACEi / ARB/diuretics/CCB

Chinese ACEi /ARB/diuretics/CCB/Beta blockers

Choice of anti-hypertensive drugs in patients with concomitant conditions

Concomitant disease Diuretics β-blockers

ACEIs CCBs Peripheralα-blockers

ARBs

Diabetes mellitus (without nephropathy)

+ +/- +++ + +/- ++

Diabetes mellitus (with nephropathy)

++ +/- +++ ++* +/- +++

Gout +/- + + + + +

Dyslipidaemia +/- +/- + + + +

Coronary heart disease + +++ +++ ++ + +

Heart failure +++ +++# +++ +@ + +++

Asthma + - + + + +

Peripheral vascular disease

+ +/- + + + +

Non-diabetic renal impairment

++ + +++ +* + ++

Renal artery stenosis + + ++$ + + ++$

Elderly with no co-morbid conditions

+++ + + +++ +/- +

The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice+/- Use with care- Contraindicated* Only non-dihydropyridine CCB# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated@ Current evidence available for amlodipine and felodipine only$ Contraindicated in bilateral renal artery stenosis

ESH/ESC Guidelines 2007monotherapy vs combination therapy

ESH/ESC Guidelines 2007 ESH/ESC Guidelines 2007 J HypertensJ Hypertens. 2007;25:1105. 2007;25:1105--11871187

Single agentSingle agentat low doseat low dose

TwoTwo--drug combinationdrug combinationat low doseat low dose

If goal BP not achievedIf goal BP not achieved

If goal BP not achievedIf goal BP not achieved

Previous agentPrevious agentat full doseat full dose

Switch to different agentSwitch to different agentat low doseat low dose

Previous combinationPrevious combinationat full doseat full dose

Add a third drugAdd a third drugat low doseat low dose

TwoTwo--to threeto three--drugdrugcombination at full dosecombination at full dose

Full doseFull dosemonotherapymonotherapy

TwoTwo--threethree--drug combinationdrug combinationat full doseat full dose

Mild BP elevationMild BP elevationLow / moderate CV riskLow / moderate CV riskConventional BP targetConventional BP target

Marked BP elevationMarked BP elevationHigh / very high CV riskHigh / very high CV riskLower BP targetLower BP target

Choose betweenChoose between

Newly diagnosed, uncomplicated patients with hypertension with no compelling indication

First line monotherapy

Blockers of the renin system ( ACEi, ARB )

Calcium channel blockers

Diuretics

WHO/ISH JNC-6

Effects of diuretics and ß-blockers on cardiovascular mortality

Treatment Treatment Better Worse

Drug Dose No. RR (95% CI)

0.4 0.7 1.0 RR (95% CI)

Diuretics High 11 0.78 (0.62-0.97)

Diuretics Low 4 0.76 (0.65-0.89)

ß-blockers 4 0.89 (0.76-1.05)

Combination therapy

BP >160/90 mmHg

Include diuretics as part of combination therapy (ACEI + Diuretic)

Consider fixed dose combination if compliance is an issue

Malaysian Untreated Hypertensives(Acta Cardiol. 1999;54:277-282 )

NT HT

SBP * 120 (112-130) 169(160- 180)DBP* 80 ( 78-82 ) 100 ( 100-110 )MAP * 94 ( 91-97 ) 123 ( 119-130 ) PWV* 8.8 (8.3- 9.6) 11.7(10.9- 12.9 )

Our population most likely needs combination antihypertensive agents

Malaysian Untreated Hypertensives( Asia Pacific J Pharmacol ; 1997 :89-95 )

NT HT

Se Na * 142.18 +0.78 146.83+2.30

UNaV * 140.58+ 15.65 100.55+17.28

Se i Ca* 1.25 + 0.01 1.17+0.01

PRA 0.89+0.19 0.79+0.2

PRC 3.09+0.74 4.23+1.43

Se Aldo 275+21.51 257 + 16.22

“Malaysian hypertensives are salt retainers “

“ Malaysian hypertensives are normoreninaemic hypertensives “

Effective Combinations in Malaysia- Retrospective Review of Record

( Asia Pac J Pharmacol.; 2001:17-24 )

Diuretics No Diuretics( n=100 ) ( n=100 )

SBP * 140 +2 151+3DBP * 85+1 88+1 dSBP * 30+3 21+3 dDBP 13+2 13+2

Effective Combinations in Malaysia

Diuretics No Diuretics

Controlled 66% 38%

p < 0.0001

What predicts BP control ?

By univariate analysisOdds p

Statin on admission 2.53 0.000Presence of IHD 2.21 0.001Diuretics on admission 2.12 0.002ACE I on admission 1.97 0.006

> 2 drugs 1.92 0.007

What predicts BP control ?

By multivariate analysis

Odds p

Statin on admission 1.79 0.030

Diuretics on admission 1.77 0.033

The Raub Heart Study

Prevalence of Hypertension, Diabetes and Obesity

1993 1998MalesHypertension 26.2 30.6Diabetes 4.4 4.7Obesity 3.1 5.2Overweight 17.7 30.9FemalesHypertension 29.4 31.7Diabetes 3.5 7.5Obesity 10.5 12.3Overweight 25.3 31.1

Blood pressure and vascular risk in diabetes Best evidence: 2000

UK Prospective Diabetes Study

UKPDS

SBP

UK Prospective Diabetes Study

Blood pressure reduction

165

∆ 2.2 mmHg (95% CI 2.0-2.4); p<0.001

∆ 5.6 mmHg (95% CI 5.2-6.0); p<0.001

Diastolic

Systolic

PlaceboPerindopril-Indapamide

Mea

n B

lood

Pre

ssur

e (m

mH

g)

65

75

85

95

105

115

125

135

145

155

R 6 12 18 24 30 36 42 48 54 60

140.3 mmHg134.7 mmHg

Average BP during follow-up

77.0 mmHg74.8 mmHg

Follow-up (Months)

All-cause mortality

0

10

0 6 12 18 24 30 36 42 48 54 60

PlaceboPerindopril-Indapamide

COVERSYL PLUS

Relative risk reduction 14%: 95% CI 2-25%

p=0.025

5

14%

Cu m

ula t

ive

inci

d enc

e (%

)

Follow-up (months)

Conclusion

Hypertension is getting more prevalent in Malaysia

Awareness and control rates are still poor

Understanding the profile of our patients is important for optimum management

A typical Malaysian Hypertensive- Back to Reality !

Diagnosed late

Has other concomitant cardiovascular risk factors

Has complications of hypertension including target organ damage and target organ complications

BP not optimally controlled

We have more works to do?

Thank You for Your Attention !