Promising Practices Related To The Promising Practices Related To The Prevention, Control and Treatment of Prevention, Control and Treatment of HypertensionHypertension

David J. Hyman, MD, MPHDavid J. Hyman, MD, MPHProfessor of Medicine andFamily & Community MedicineBaylor College of Medicine

President elect - Texas Chapter of the American Society of Hypertension

ProblemsProblems

■ Hypertension is an extremely important Risk factor for heart disease, stroke, Renal failure, CHF and all the complications of diabetes

■ Population BP has stopped going down

■ About 35% of people with hypertension are still unaware of it

■ About 35% of people being treated for hypertension are not controlled to target

Non-Hispanic Mexican- African- white American American

27.4% 25.1 % 40.5%

Age Standardized Prevalence of Age Standardized Prevalence of Hypertension in the United StatesHypertension in the United States

National Health and Nutrition Survey (NHANES) (1999-2002)

6%

16%

31%

48%

65%

78%

0%

20%

40%

60%

80%

100%

18-34 35-44 45-54 55-64 65-74 75+

†

Prevalence of HypertensionPrevalence of Hypertensionin the United States*in the United States*

*Based on NHANES 19992000 data. Hypertension is defined as blood pressure 140/90 mmHg or antihypertensive treatment.†Low reliability due to large relative error.

Fields et al. Hypertension. 2004:44;398-404.

Hyp

ert

en

sio

nP

revale

nce

Age

% of Treated Controlled 64

1976 - 1980

18

1049

23

Unaware

Aware - Untreated

Treated - Controlled

Treated & Uncontrolled

Hypertension Control in U.S. - NHANES1991 - 1994

15.822.67

32.828.73

1999 - 2000

15.725.5

37

21.8

2001 - 2002

12.5

32.4

37.5

17.6

2003 - 2004

12.234.3

33.519.4

Ong, Hypertension 2007

% of Treated Controlled 30

% of Treated Controlled 65

% of Treated Controlled 43 % of Treated Controlled 51

Primary Prevention of Hypertension Primary Prevention of Hypertension via food supply sodium reduction:via food supply sodium reduction:

■ A growing international trend that TEXAS should join

■ 1.3 gm average daily decrease will prevent 5mm/HG rise in BP with age and save 150,000 lives year

- Most sodium is in processed food - Individual action is extremely difficult - Commercial alternatives exist - Food supply interventions are occurring around the world

-Dickinson, AMA council of scientific affairs, archives IM 2007

England Department of Health and Food standards agency goal 2.4 gm

sodium by 201050 food manufactures have signed on and begun to reduce

IrelandPressuring food industry

New Zealand / AustraliaStrict labelingIndustry pressure to reduce sodium has reducedSodium in breads, cereals, margarine

FranceGoal 20% reduction in 5 years

FinlandNational focus since 1970sSodium decrease from 4700 to 3300Population decrease in blood pressure

International EffortsInternational Efforts

30% of Hypertensives Unaware!30% of Hypertensives Unaware!

Of the unaware hypertensives…Of the unaware hypertensives…

■ Mexican Americans are very over represented

But

■ 90 % of Unaware have insurance■ 80% have a usual source of care■ 75% had a BP measurement in the last year■ 96% had a BP measurement in the last 4 years■ Mean age 58■ Mean BP 148/83

Hyman NEJM 2001

Implication:Implication:

■ New screening programs needed

Hispanics Low utilizers

■ Education programs needed for health providers and public on appropriate reaction to “mild” BP elevations

■ New technologies and paradigms for BP measurement may be needed.

Improving control in treated patientsImproving control in treated patients

■ Continue public and physician education

■ Appreciate limits on scientific data on achieving goals

■ Educate on the availability of low cost drugs

Hypertension Treatment Hypertension Treatment by Drug Classby Drug Class

0

10

20

30

40

50

60

1978 1981 1984 1987 1990 1993 1996 1999 2002Year

% o

f T

reate

d P

ati

en

ts o

n M

ed

icati

on

Calcium Channel BlockersBeta BlockersDiureticsACE InhibitorsARBs

CCBCCBss

ß-Blockerß-Blocker

ACEACE InhibitorsInhibitors

DiureticsDiuretics

ARBARBss

IMS Health NDTI, 1978-2002

Cost of market leadersCost of market leadersNorvasc $84 month

Valsartan $74 month

What you can get for $ 4 per month from Walmart (web 9/07)

ACE Benezepril 10-40 Lisinopril 10-20

B blocker Metoprolol (BID) Atenelol Carvedilol (BID)

Thiazides*Clonidine*

Lovastatin 10,20Pravastatin 10-40

If BP drugs are cheap…Big pharma can’t make any $ on BP Drugs…

If big pharma controls the flow of medical information…and big pharma looses interest in Hypertension…

The public health community will have to keep blood pressure control on the agenda by our selves!!

The population will suffer if we don’t.