Hypertensionas a Public Health Risk

2011 Canadian Hypertension Education Program Recommendations

The full slide set of the 2011 CHEP Recommendations

are available atwww.hypertension.ca

What’s Still Important in 2011

• Keep up to date on the prevention and control of hypertension

• Register for automatic email notification of new hypertension resources for you and your patients, at: www.htnupdate.ca

• Have your patients sign up at www.myBPsite.ca to access latest hypertension resources

Overview

• What is hypertension?

• Age-related blood pressure creep and hypertension is common

• High blood pressure is a significant risk factor for morbidity and mortality

• Hypertension is costly

• Hypertension keeps bad company

• Hypertension can be prevented or delayed

• The complications of hypertension are ameliorated by effective therapy

• Healthy public policies reduce the risk of hypertension

Proportion of Deaths Attributable to Leading Risk Factors Worldwide (2000)

WHO 2000 Report. Lancet. 2002;360:1347-1360.

Attributable Mortality0 87654321

High blood pressure

Tobacco

High cholesterol

Unsafe sex

High BMI

Physical inactivity

Alcohol

Indoor smoke from solid fuels

Iron deficiency

Underweight

Systolic blood pressure greater than 115 mmHg

Hypertension as a Risk Factor

Hypertension is a significant risk factor for:– cerebrovascular disease– coronary artery disease– congestive heart failure– renal failure– peripheral vascular disease– dementia– atrial fibrillation– erectile dysfunction

Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:305-13.

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

70

80

110

130

150

Age

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

70

80

110

130

150

Age

Men Women

PPPP

Blood Pressure Distribution in the Population According to Age

PP=Pulse Pressure.

European Society of Hypertension Classification of Blood Pressure

Category Systolic Diastolic

Optimal <120 and / or <80

Normal <130 and / or <85

High-Normal 130-139 and / or 85-89

Grade 1 (mild hypertension ) 140-159 and / or 90-99

Grade 2 (moderate hypertension) 160-179 and / or 100-109

Grade 3 (severe hypertension) 180 and / or 110

Isolated Systolic Hypertension (ISH) 140 and <90

The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension.

J Hypertens 2007;25:1105-87.

JNC VII (American) Classification of Blood Pressure

Category Systolic Diastolic

Optimal <120 and / or <80

Normal <130 and / or <85

High-Normal 130-139 and / or 85-89

Stage 1 (mild hypertension ) 140-159 and / or 90-99

Stage 2 (moderate to severe hypertension)

160 and / or 100-109

Isolated Systolic Hypertension (ISH) 140 and <90

The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension.

JAMA 2003;289:2560-72.

Blood Pressure and Risk of Stroke Mortality

Lancet 2002;360:1903-13.

Blood Pressure and Risk of Ischemic Heart Disease (IHD) Mortality

Lancet 2002;360: 1903-13.

CAD Death Rate per 10,000 Person-years

100+ 90-99 80-89 75-79 70-74 <70<120

120-139

140-159

160+

Diastolic BP (mmHg)

Systolic BP (mmHg)

20.6

10.3 11.8 8.8 8.5 9.2

11.812.612.813.9

24.6 25.3 25.2 24.9

16.923.8

31.025.8

34.743.8

38.1

80.6

37.4

48.3

Neaton et al. Arch Intern Med 1992; 152:56-64.

Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT

Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease

N Engl J Med 2001;345:1291-7.

Cumulative incidence of cv events in men without hypertension according to baseline blood pressure

(130-139) mmHg

(121-129) mmHg

(< 120) mmHg

The Concept of Masked Hypertension

Derived from Pickering et al. Hypertension 2002: 40: 795-796

Office SBP mmHg

Ho

me/

Am

bu

lato

ry S

BP

mm

Hg

Truehypertensive

TrueNormotensive White Coat HTN

Masked HTN

200

180

160

140

120

100

100 120 140 160 180 200

135

The Prognosis of White Coat and Masked Hypertension

0

0.5

1

1.5

2

2.5

Normal BP White coatHypertension

MaskedHypertension

Hypertension

J Hypertension 2007;25:2193-2198.

Prevalence is approximately 10% of the adult population O

dd

s R

ati

o o

f a

C

ard

iov

as

cu

lar

Ev

en

t

Long term follow-up of Normotensive, White Coat Hypertension, and Ambulatory Hypertension

Hypertension. 2005;45(2):203-208.

Time to stroke (years)

0 1 2 3 1615141312114 105 6 7 8 9

Cu

mu

lati

ve h

azar

d o

f st

roke

(%

)

0

1

2

3

4

5

6

7

8White Coat

Hypertension

p = 0.0013

Normotensivegroup

AmbulatoryHypertension

Benefits of Treating Hypertension

• Younger than 60 (reducing BP 10/5-6 mmHg)

– reduces the risk of stroke by 42%

– reduces the risk of coronary event by 14%

• Older than 60 (reducing BP 15/6 mmHg)

– reduces overall mortality by 15%

– reduces cardiovascular mortality by 36%

– reduces incidence of stroke by 35%

– reduces coronary artery disease by 18%

Lancet 1990;335:827-38.Arch Fam Med 1995;4:943-50.

Benefits of Treating to Target

• Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP <90 mm Hg)– 42% reduction in the risk of stroke

– 26% reduction in the risk of coronary events

Lancet 1997;350:757-64.

Correlation Between Reduction in SBP and Stroke or MI

Staessen et al. Lancet 2001;358:1305-15.

Myocardial InfarctionStroke

Correlation Between Reduction in SBP and Cardiovascular Mortality or Events

Staessen et al. Lancet 2001;358:1305-15.

Cardiovascular mortality Cardiovascular events

Emberson et al. Eur Heart J. 2004;25:484-491.

10% Reduction

in BP

10% Reductionin Total-C+

45% Reduction

in CVD=

90% of Hypertensive Canadians have other Cardiovascular Risk factors

Treating Hypertension and Other Risk Factors

Adapted from Emberson et al. Eur Heart J. 2004;25:484-491.

Pre

dic

ted

Red

uct

ion

in

M

ajo

r C

VD

(%

)

Treatment Based on lipids

(statin)

Treatment Based on BP

Treatment Based on Overall Absolute Risk

(ASA, lipids, BP)

-6 -6

-17

-9 -8

-28

-12-10

-37-40

-35

-30

-25

-20

-15

-10

-5

0

Top 10%

Top 20%

Top 30%

Treatment thresholds

Challenges to Hypertension Management: Public Perceptions

• 44% of people could not identify a normal or a high blood pressure reading

• 80% of people were unaware of the association between hypertension and heart disease

• 63% believed that hypertension was not a serious condition

• 38% of people thought they could control high blood pressure without the help of a health professional

Can J Cardiol 2005;21:589-93.

The Canadian Hypertension Education Program (CHEP)

• Goal– To reduce the burden of cardiovascular disease in Canada

through optimized hypertension management

• Activities– Regularly updated evidence-based recommendations for the

management of hypertension – Knowledge translation and exchange of the

recommendations to support implementation– Regular evaluation and revision of the program – Assessment of patient outcomes

Mill

ion

vis

its/

year

0

5

10

15

20

25

Hyp

erte

nsi

on

Dep

ress

ion

Dia

bet

es

Ro

uti

ne

med

ical

ex

ams

Acu

te r

esp

irat

ory

tra

ct i

nfe

ctio

nSource: IMS HEALTH Canada 2002

Leading Diagnoses Resulting in Visits to Physician Offices in Canada

New Patient Resources for Hypertension Online

• www.hypertension.ca/tools - Download current resources for the prevention and control of hypertension

• www.htnupdate.ca -To keep up to date with the latest evidence and resources

• www.myBPsite.ca - Have your patients sign up to access the latest hypertension resources

• www.lowersodium.ca - Tools and resources for healthcare professionals to use in educating other healthcare professionals, the public or patients about the risks of high dietary sodium in Canada.

• www.sodium101.ca -To access a simple to use demonstration of food sodium content for your patients

• www.heartandstroke.ca/BP -To monitor home blood pressure and encourage self management of lifestyle

• http://www.hypertension.qc.ca/ - Société Québécoise d’hypertension artérielle

• For your patients – ask them to sign up at www.myBPsite.ca for free access to the latest information & resources on HBP

• For health care professionals – sign up at www.htnupdate.ca for automatic updates and on current hypertension educational resources