2007 Hypertension as a Public Health Risk January, 2007.
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2007
Hypertensionas a Public
Health Risk
January, 2007
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2007 Canadian Hypertension Education Program Recommendations2
Proportion of deaths attributable to leading risk factors worldwide (2000)
Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360.
Attributable Mortality (In millions; total 55,861,000)
High mortality, developing regionLower mortality, developing regionDeveloped region
0 87654321
High blood pressure
Tobacco
High cholesterol
Unsafe sex
High BMI
Physical inactivity
Alcohol
Indoor smoke from solid fuels
Iron deficiency
Underweight
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2007 Canadian Hypertension Education Program Recommendations3
Hypertension is a significant risk factor for:– cerebrovascular disease– coronary artery disease– congestive heart failure– renal failure– peripheral vascular disease– dementia– atrial fibrillation
Hypertension as a Risk Factor
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2007 Canadian Hypertension Education Program Recommendations4
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.
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2007 Canadian Hypertension Education Program Recommendations5
Classification of Hypertension
Category Systolic DiastolicOptimal <120 and / or <80Normal <130 and / or <85High-Normal 130-139 and / or 85-89Grade 1 (mild hypertension ) 140-159 and / or 90-99Grade 2 (moderate hypertension) 160-179 and / or 100-109Grade 3 (severe hypertension) 180 and / or 110Isolated Systolic Hypertension (ISH)
140 and / or <90
The category pertains to the highest risk blood pressure
*ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17:151-85.
(Pre Hypertension) 120-139 / 80-89
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2007 Canadian Hypertension Education Program Recommendations6
Blood Pressure and Risk of Stroke Mortality
Lancet 2002;360: 1903-13
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2007 Canadian Hypertension Education Program Recommendations7
Blood Pressure and Risk of IHD Mortality
Lancet 2002;360: 1903-13
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2007 Canadian Hypertension Education Program Recommendations8
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)
20.610.3 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
37.448.3
Neaton et al. Arch Intern Med 1992; 152:56-64.
Effect of SBP and DBP onAge-Adjusted CAD Mortality: MRFIT
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2007 Canadian Hypertension Education Program Recommendations9
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)
(121-129)
(< 120)
mmHg
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2007 Canadian Hypertension Education Program Recommendations10
The Concept of Masked Hypertension
From Pickering, Hypertension 1992
Office SBP mmHg
Ambu
lato
ry S
BP m
mHg
Truehypertensive
TrueNormotensive White Coat HTN
Masked HTN
White Coat HTNTrueNormotensive
Masked HTNTruehypertensive
200
180
160
140
120
100100 120 140 160 180 200
135
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2007 Canadian Hypertension Education Program Recommendations11
The Prognosis of Masked HypertensionPrevalence is approximately 10% in hypertensive patients.
05
101520253035
Normal23/685
White coat24/656
Uncontrolled41/462
Masked236/3125
Bobrie et al. JAMA 2004;291:1342-9
CV
eve
nts
per 1
000
patie
nt-y
ear CV Events
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2007 Canadian Hypertension Education Program Recommendations12
Cumulative hazard for stroke in 3 groups of subjects: Normotensive, White-Coat Hypertension, and Ambulatory
hypertension
Verdecchia, P et al. Short- and Long-Term Incidence of Stroke in White-Coat Hypertension. Hypertension. 45(2):203-208, February 2005.
Time to stroke (years)
0 1 2 3 1615141312114 105 6 7 8 9
Cum
ulat
ive
haza
rd o
f str
oke
(%)
0
1
2
3
4
5
6
7
8White-coat hypertension
p = 0.0013
Normotensivegroup
Ambulatoryhypertension
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2007 Canadian Hypertension Education Program Recommendations13
Benefits of Treating Hypertension
• Younger than 60– reduces the risk of stroke by 42%– reduces the risk of coronary event by 14%
• Older than 60– reduces overall mortality by 20% – reduces cardiovascular mortality by 33%– reduces incidence of stroke by 40%– reduces coronary artery disease by 15%
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2007 Canadian Hypertension Education Program Recommendations14
Correlation Between Reduction in SBP and Stroke or MI
Staessen et al. Lancet 2001;358:1305-15.
Stroke Myocardial Infarction
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2007 Canadian Hypertension Education Program Recommendations15
Correlation Between Reduction in SBP and Cardiovascular Mortality or Events
Cardiovascular mortality Cardiovascular events
Staessen et al. Lancet 2001;358:1305-15.
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2007 Canadian Hypertension Education Program Recommendations16
Benefits of Treating to Target
• Older than 60 with isolated systolic hypertension(SBP 160 mm Hg and DBP <90 mm Hg)
– 36% reduction in the risk of stroke– 25% reduction in the risk of coronary events
Ref: adapted from SHEP, SYST-EUR, STONE studies.
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2007 Canadian Hypertension Education Program Recommendations17
Effect of Long-Term Modest Reductions in CV Risk Factors
Emberson et al. Eur Heart J. 2004;25:484-491.
10% Reduction
in BP
10% Reductionin Total-C+
45% Reduction
in CVD=
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2007 Canadian Hypertension Education Program Recommendations18
Evaluating the Impact of Different Strategies for CV Prevention on CV Risk Reduction.
Treating hypertension and other risk factors.
Adapted from Emberson et al. Eur Heart J. 2004;25:484-491.
Pred
icte
d R
educ
tion
in
Maj
or C
VD (%
)
Treatment Based on TC
(statin)
Treatment Based on BP(β-blocker,
diuretic)
Treatment Based on Overall Absolute Risk
(ASA, statin, ACEI, β-blocker, diuretic)
-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
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2007 Canadian Hypertension Education Program Recommendations19
22% of Canadians 18-70 years of age have hypertension50% of Canadians >65 years of age have hypertension
Joffres et al. Am J Hyper 2001;14:1099 –1105
21%13%
43%22%
Hypertensive patients who are treated
but BP uncontrolled
Hypertensive patientswho are treated
and BP controlled
Hypertensive patients who are unaware
Patients who are awarebut remain untreatedand BP uncontrolled
9%
Diabetic patientswho are treated and
BP controlled
The Challenge In Canada
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2007 Canadian Hypertension Education Program Recommendations20
Results of a survey on awareness on hypertension (Canada 2002)
67% of aware hypertensive patients believe that their BP was their own primary responsibility
Two thirds of these patients stated that high BP was not a serious concern.
Thus the mandate to improve public awareness of the consequences of hypertension is clear.
R. Petrella MD, Perspective in Cardiology, March 2002.
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2007 Canadian Hypertension Education Program Recommendations21
The Canadian Hypertension Education Program Objectives
• Develop evidence-based recommendations for the management of hypertension
• Implement recommendations• Evaluate impact of the program
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2007 Canadian Hypertension Education Program Recommendations22
Leading diagnoses resulting in visits to physician offices in Canada
Mill
ion
visi
ts/y
ear
0
5
10
15
20
25
Hyp
erte
nsio
n
Dep
ress
ion
Dep
ress
ion
Dia
bete
sD
iabe
tes
Rou
tine
med
ical
R
outin
e m
edic
al
exam
sex
ams
Acu
te re
spira
tory
Acu
te re
spira
tory
trac
t inf
ectio
ntr
act i
nfec
tion
Source: IMS HEALTH Canada 2002. http://www.imshealthcanada.com/
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2007 Canadian Hypertension Education Program Recommendations23
Changes in diagnosis of hypertension in Canada
Post 1999 compared to pre 1999
• Doubling of the rate of diagnosis of hypertension
• Closing of the gender gap
Hypertension 2006;48:853-60
Hypertension Diagnosis by Gender
10
15
20
1992 1994 1996 1998 2000 2002 2004
Year
Perc
enta
ge o
f Pop
ulat
ion
Females
Males &FemalesMales
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2007 Canadian Hypertension Education Program Recommendations24
Changes in the treatment of hypertension
Post 1999 compared to pre 1999
• Doubling of the rate of treatment of hypertension
• Closing of the gender gap
Hypertension 2006;48:853-60
Hypertension Treatrment by Gender
5
10
15
20
1992 1994 1996 1998 2000 2002 2004
Year
Perc
entage
of P
opulation
Females
Males & Females
Males
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2007 Canadian Hypertension Education Program Recommendations25
Changes in the proportion of thosediagnosed that are not treated
Post 1999 compared to pre 1999
• Marked decrease in proportion of aware hypertensives that are untreated
• Closing of the gender gap.
Hypertension 2006;48:853-60
Hypertensives who were Aware but not treated by Gender
10
20
30
40
1992 1994 1996 1998 2000 2002 2004
Year
Perc
entage
of P
opulation
Females
Males &FemalesMales
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2007 Canadian Hypertension Education Program Recommendations26
2007 Canadian Recommendations for the Management of Hypertension
A slide kit for medical education can be downloaded from:
http://www.hypertension.ca