Hypertension update Which guideline to follow by rsr13049


									  Hypertension update
Which guideline to follow?

        Dr Sunita Dodani
  Department of Family Medicine
      Aga Khan University
        Karachi, Pakistan
        February 23,2003
   Presentation outline
 World Wide Epidemic: Some Figures
 Epidemiological Transition &
 Data From Developing Countries
 EMRO Work
 Statistics From Pakistan: NHSP
 Hypertension Guidelines
   Currently available guidelines
   Similarities in guidelines
   Differences in guidelines
    Presentation outline
 Hypertension Guidelines        (Cont’d)
   Still Unanswered Questions
   What is needed in Pakistan
   Epidemiologic research
   Which guideline to follow?
   JNC VI guideline (1994)
   Risk stratification
Worldwide Epidemic: Some Figures
 affect all ages, but primarily occurs in adults.
 20% prevalence,approximately 690m
  people have hypertension world wide
 major risk factor for stroke, coronary heart
  disease and kidney failure
 30% of deaths worldwide (15 million) are
  due to cardiovascular diseases
 5 million deaths / year worldwide due to
  strokes alone, with another 30 million
  suffering from its disabling effects.
             (Geneva, Switzerland November 15-16, 1999)
Epidemiological Transition &
Developing countries experiencing
 rapid health transition, escalating
 relative and absolute burdens of CVD
Determinants of transition
 a) demographic (increased life
 b) lifestyle changes
 c) urbanization, industrialization and
Epidemiological Transition &
  Hypertension     (Cont’d)

In developing countries ,steady
 increase in hypertension
 prevalence over the last 50 years,
 more in urban than in rural areas
                     (WHO report 2002)

          WHO Regions
World regions according to WHO

  Eastern Mediterranean region
   (Jordan, Iran, Srilanka, Pakistan, Egypt
     Oman, Saudi Arabia , Bangladesh etc)
 Paucity of large, authentic,
  epidemiological studies
 Limited data available in the form of small
 Majority of studies done have
          differing examination techniques
          differing diagnostic criteria
          screening blood pressure values used
   EMR                             (cont'd…)
 The studies are not representative of the
  total population
  Limited to single centers or single

Majority of third world countries lack
  sufficient national estimates of the
  prevalence of hypertension

In developing countries ,steady increase
 in hypertension prevalence over the last 50
 years, more in urban than in rural areas
EMR…. Some prevalence figures
 Saudi Arabia                           10-15%
                                       (EMRO bulletin 2001)

     Riyadh city 15.4% (27% unaware)
 Bangladesh (> 70 yrs)     65%
          (multi center trail, hypertension study group, 2000)

 Egypt (national estimates)             26%
               > 70 yrs                  56.6%
                   (Ibrahim MM , Cairo university Egypt, 1998)

 Iran(population based)                 18%
              (Sarraf-Zadegan N, East Mediterr Health J 1999)
  Hypertension figures in Pakistan
      National Health Survey of Pakistan
 Some data available, some in re-analysis phase
 10.8 million hypertensives      (pop 91m,1991)
           5.5 million men
           5.3 million women
 12 million hypertensives        (pop 130m,1998)
 17.9% ( 15 yrs)
     21.5%………….. Urban
     16.2%………….. Rural
Hypertension figures in Pakistan
            NHSP ( 1990-1994)
 58% ( 65 yrs females)
 1 in every 3 Pakistanis (>45 yrs)
 Prevalence is lower in females than
  males at younger ages, but exceed after
  35-44 yrs of age
 (This cross over is at later age in US population)
 >3% of the hypertensive patients have
 BP controlled to the conventional
 recommendations of under 140/ 90
Hypertension figures in Pakistan
Prevalence of hypertension (PMRC)




 20                       Male

      15-24   25-34   35-44    45-64   65+
Hypertension figures in Pakistan
Prevalence of hypertension (PMRC)


  30                               Male


       15-24   25-34    35-44    45-64    65+
   Early detection,awareness &
           (Need for guidelines)
 help to limit the subjective element in
  decision making & assist clinicians to
  provide better care
 define the best clinical decisions and the
  minimal level of acceptable care in order
  to ensure appropriate quality
 formulated based upon the evidence
  collected from available literature, and
  agreement among experts in areas where
  literature is deficient
         Hypertension Guidelines
 Several guidelines for the management of
  hypertension were published in the last few
 Many were recent revisions and updated
  versions of old ones, modified according to
  new evidence from clinical trials
 Provided answers to many clinical
  questions.    a) Isolated systolic hypertension in
          elderly is dangerous & should be
        b) aggressive lowering of blood pressure is
          required in patients with risk factors
     Hypertension Guidelines
JNC VI                                       1994
{Hypertension Detection and Follow-up Program (HDFP)}
WHO/ISH                                      1999
British hypertension Society                 1999
{Medical Research Council (MRC)}

Canadian Cardiac Society                     1999

Pakistan hypertension league                 1998
(First Report of National Task Force)
 Hypertension Guidelines

These four major guidelines are
 based on the strong evidence from
 almost the same literature and the
 large randomized mega trials, they
 agree and disagree on a number of
 important issues
     Hypertension Guidelines
These guidelines agree on many aspects
1. All guidelines agree upon the definition of
2. The type of routine tests needed for the
  evaluation of hypertensive patients
3. The need for global risk assessment & the
  target blood pressure
4. The importance of life style modification
5. Individualization of antihypertensive
6. Need for indefinite follow-up
        Hypertension Guidelines
 Differences in the guidelines
JNC VI 1994            WHO/ISH 1999               BHS 1999
1. Drug therapy      Continuing monitoring Add drug therapy
in mild              without medication for if BP is greater
hypertensives if     subjects without other than 160/90
BP remains          risk factors if pressures
140/90 after non     are not greater than
pharmacological      150/95 mm H               Diuretics as first
treatment             all classes of           line therapy
2. Recommend          medication are
diuretics or B-       suitable initial
blocker as initial    therapy, despite the
drug therapy          lack of morbidity
                      and mortality data
    Hypertension Guidelines
Still Unanswered Questions
 how to avoid over treatment of patients at very low
 what is the best simple approach for accurate
  cardiovascular risk assessment?
      Decisions to initiate therapy are based on the absolute
  cardiovascular risk profile of the hypertensive patient
  ? risk assessment are based on the Framingham
  ? risk scoring equations are incomplete &
  ? do not account for racial and genetic differences.
Hypertension Guidelines
Still Unanswered Questions
 management of patients with uncomplicated
  mild hypertension
      ? duration period of observation
      ? the number of office visits
      ? blood pressure measurements
      ? the average blood pressure threshold during the
       period of monitoring
 role of ambulatory blood pressure is not
 how to adjust for racial, genetic, geographic,
  age gender and socioeconomic differences
   Hypertension Guidelines
Still Unanswered Questions
 optimal blood pressure reduction
 ? what is the desired level of blood pressure
 ? It is not necessarily the same level in all
 ? Race, age and gender may influence our target
   blood pressure.
 ? We might need more aggressive reduction in
   blood pressure in special groups, e.g., diabetics,
   blacks and patients with end-organ damage.
    Hypertension Guidelines
      Population data:Priorities in
         Epidemiologic research
 define the magnitude of the hypertension
  problem in Pakistan with evidenced based data
 prevalence among different age groups,
  geographic areas, socioeconomic classes and
  the influence of factors like gender, ethnicity
 Its risk factors e.g. Obesity, excessive salt
  intake, alcohol intake, psychosocial stress, low
  levels of education, poor SES, should be
  recognized & examined
  Hypertension Guidelines
Epidemiologic research
 the type and prevalence of hypertensive
  cardiovascular complications. might be
  influenced by environment, race and other
  demographic characteristics
 identify the susceptible groups which are
  most vulnerable to complications
 How close are these complications related
  to the level of blood pressure and what are
  the other mechanisms involved
 develop methods to improve detection and
  control of hypertension
     Hypertension Guidelines

      which guideline to follow?
Considering several meta analysis
outcome data from major clinical trial

strongest outcome data support the JNC
          VI recommendations
         Hypertension Guidelines
    Table 1 – Classification of Blood Pressure*
                Systolic         Diastolic
   Category     (mm Hg)           (mm Hg)
          Normal Values of Blood Pressure**
   Optimal   less than 120    less than 80

    Normal       less than 130    less than 85

  High normal 130 - 139        85 - 89
            Stages of Hypertension**
Stage 1 (Mild)     140 - 159       90 - 99
Stage 2 (Moderate) 160 - 179     100 - 109
Stage 3 (Severe) 180 or higher   110 or higher
    Hypertension Guidelines
      Risk factors stratification
 In populations & in individual patients,
  the benefit from antihypertensive
  treatment is determined by the absolute
  cardiovascular risk
 Blood pressure by itself is a very weak
  predictor of risk or benefit from
 simple but accurate risk assessment
  tools for estimating cardiovascular risk,
  similar to that in the New Zealand
     Hypertension Guidelines

        Presentation available at

       Presentation references
1. Ramsay LE. Williams B, Johnston GD, et al.
   Guidelines for management of hypertension:
   report from the third working party of the
   British Hypertension Society. J Hum Hypertens
   1000; 13:569-592.

1. Fieldman RD, Campbell N, Larochell P. Burgess
   ED, et al. 1999 Canadian recommendations for
   the management of hypertension CMAJ 1999;
   161 (12 suppl): S1-S17

1.   Joint National Committee on Prevention,
     Detection, Evaluation, and treatment of High
     Blood Pressure. The Sixth report. Arch Intern
     Med 1997; 157:2413-2446.
      Presentation references
• Carretero OA. Oparil S. Essential hypertension
  Part II: treatment. Circulation 2000;

• Reddy KS. Implementation of international
  guidelines on hypertension: the Indian
  Clin Exp Hypertens. 1999 Jul-Aug;21

• O’Brien E. Critical appraisal of the JNC VI,
  WHO/ISH and BHS guidelines for essential
  Expert Opin Pharmacother. 2000

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