Kolkata Final API 2010
Transcript of Kolkata Final API 2010
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Managing Hypertension
Beyond BP ControlRajeev Gupta, MD PhD FACC
Fortis Escorts Hospital, Jaipur 302017 &Rajasthan University of Health Sciences, Jaipur 302023 India
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20.3
16.9
9.3
8
6.7
9.9
6.4 6.25.4
7.1 7.1
4.75.4
65.2
4.5
0
5
10
15
20
25
Cardiovascular COPD Diarrhea Perinatal Respiratory TB Cancers Injuries
M ale F emale
Major Causes of Death in India: All AgesMillion Death Study 2001-2003
Million Death Study 2009
Analysis of cause of deaths in 1.1 million households and 113,692 personsin all the Indian States
%
CVDs caused 1.7-2.0 million deaths annually
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Cardiovascular Mortality in Different
Indian States: Million Death Study
Males Females
Mony P, et al. 2009https://tspace.library.utoronto.ca/bitstream/1807/18899/3/Mony_Prem%20kumar_200911_MSc_Thesis.pdf
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Burden of Risk FactorsMajor Population-wide Cardiovascular Risk
Factors
WHO. Global Health Risks. 2009
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Kaplan & Opie. Lancet 2006; 367:168-176Danaei G, et al. PLoS Med 2009; 6:e1000058
Hypertension: A Major Cardiovascular Risk Factor
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Risk Factors for AMI in South AsiansINTERHEART Study. Population Attributable Risks %
46.8
37.5
19.3
11.8
37.7
16.1
27.4
-4.6
21.4
36.2
23.9
12.5
33.3
19.6
25.2
15.8
12.2
45.9
-10
0
10
20
30
40
50
ApoB/ApoA1
Smoking
Hyperten
sion
Diabetes
HighWHR
Psychos
ocial
Exercise
Alcoh
ol
Fruits/Veg
South Asians
Others
Joshi PP, et al. JAMA 2007; 297:286-94
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Ten Risk Factors for StrokeINTERSTROKE Study: Population Attributable Risk
21.4
26.1
17.3
29.4
7.9
1.1 1.1
8.5
35.2
73.6
9.5
26.124.1
27.6
14.6
3.5
45.2
0
10
2030
40
50
60
70
Hypertension
Smoking
High
WHR
Diet
risk
Physical
Diabetes
Highalcohol
Psycho
Cardiac
ApoA/ApoB
Ischemic
Hemorrhage
ODonnel M, et al. Lancet 2010; 376:112-23
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1.9
0.5
3.6
0.4
5.6
2.6
3.8
4.1
3.4
1.6
7.1
2.42.6
4.3
0.3
5.4
0
1
2
3
4
5
6
7
8
1955 1965 1975 1985 1995 2005
Years
Delhi
Bombay
HaryanaHaryana
Rajasthan Rajasthan
U.P.
Punjab
Chandigarh
U.P.
Maharashtra
Rajasthan
Maharashtra
Himachal
Orissa
Orissa
Increasing Hypertension in IndiaRural populations: BP >160/95
r2=0.19
Percent
Prevalence
Gupta R, et al. J Human Hypertens 1996; 10:465-472
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1.2
4.2
3.1
4.3
6.4
15.5
14.1
10.911.6
13.1
9.2
0
2
4
6
8
10
12
14
16
18
1945 1955 1965 1975 1985 1995
Years
Calcutta
Kanpur
Bombay
Agra
Railways
Rohtak
Bombay
Ludhiana
Jaipur
Delhi
Jaipur
IncreasingHypertension in IndiaUrban populations: BP >160/95
r2=0.70
Percent
Prevalence
Gupta R, et al. J Hum Hypertension 1996;10:465-472
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29
44
31
34
25
3638
45
41
38
42
33
20
30
40
50
60
1993 1995 1997 1999 2001 2003 2005 2007
M en W omen
Jaipur
Mumbai
Delhi
Chennai
Jaipur
Mumbai
Jaipur
Recent Studies on Hypertension in IndiaUrban populations: BP >140/90
r2=0.37
Percent
Preval
ence
Gupta R. J Human Hypertens 2004; 18:73-78
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Risk Factor Trends in Urban RajasthanJaipur Heart Watch Studies 1992-2006
Gupta R, et al. Heart 2008; 94:16-26
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Lifetime Risk of HypertensionFramingham Heart Study
Vasan et al. JAMA 2002; 287:1003-10
Hypertension: The Neglected Disease of 21st Century
Lancet 2009
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.. Control of blood pressure is nolonger disputed & is supported by
most impressive evidence basemedicine in past and even today
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SBP Distribution & Mortality
Whelton PK et al. JAMA 2002; 288: 1882-8
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Cardiovascular Benefits of Reducing BP
0.36
0.490.43
0.38
0. 5 0 .5
0.43
0.54 0.530.5
0.60.64
0.67 0.670.7
0
0.2
0.4
0.6
0.8
1
40-49 50-59 60-69 70-79 80-89
S troke IHD V ascul ar
0.35
0.470.43
0.34
0.520.48
0.4
0.56
0.49 0.48
0.62 0.610.63
0.7 0.71
0
0.2
0.4
0.6
0.8
1
40-49 50-59 60-69 70-79 80-89
S tr ok e IHD V as c ular
Systolic BP
Diastolic BP
Hazard
ratio
Reduction of usual systolic BP (upper panel) and diastolic BP (lower panel) is associated
with a lower hazard ratios (hazard ratio
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Blood Pressure Goals & CVD Prevention
Goals: Reduce and preserve normal blood pressure
Increase rates of BP control
Promoters:
Physical activity, healthy diet, good medical care,medication, health insurance, diabetes control, weight loss.
Healthy food environments, stable income and workingconditions, health promotion and education
Barriers: Physical inactivity, high salt high fat diet, obesity, diabetes,
stress, lack of medical care, medication cost, tobacco use.
Lack of access to medical care, medications, and
recreation. Unemployment. Social stressors, social conflict.Centers Disease Control, USA 2007
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Lifestyle Modification Interventions
Modification SBP reduction (range)
Weight reduction 520 mmHg/10 kg weight loss
Adopt DASH eating plan 814 mmHg
Dietary sodium reduction 28 mmHg
Physical activity 49 mmHg
Moderation of alcoholconsumption
24 mmHg
Kaplan & Opie. Lancet 2006; 367:168-176
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Goals of Therapy: JNC-7 & BHS-4
Reduce CVD (CHD, stroke, diabetes, CHF) and
renal morbidity and mortality.
Treat to BP
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Beyond BP Control: Questions in
Hypertension Management
1. Are there drug-specific benefitsbeyond BP lowering?
2. Are we trying to prevent end pointsor the disease process?
3. Most effective therapeutic strategyto reduce overall CVD risk burden.
4. Improving adherence to therapy.
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Which is Better: ACEIs vs CCBs
William
s,B.JAmColl
Cardiol
2005;45:813-8
27
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Why are ACE Inhibitors Better?Benefits Beyond BP Control
Improvement in endothelial function
Reduction in oxidative stress
Decrease in vascular inflammation and adhesion
molecules
Inhibition of mitogenesis
Regression of atherosclerotic plaques and LVH
superior to older agents Inhibition of proteinuria superior to older agents
Reduction in new onset diabetes
Improvement in fibrinolysis
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Evidence Based Molecules for HypertensionABCD Rule: British NICE Guidelines 2006
Younger 55 yr or Black
Step 1 A Mono C or D
Step 2 A + C or D Two A + C or D
Step 3 A + C + D Multi drug A + C + D
Step 4 andResistant HTN
Add: either beta-blocker, alpha-blockeror spironolactone orother diuretic
Multi drugAdd: either beta-blocker,alpha-blocker orspironolactone or otherdiuretic
A= ACEI orARB
B= beta-blocker C= CCB D= Diuretic (THZ)
British NICE Guidelines. 2006
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Issues in High BP Management
1. Are there drug-specific benefits beyond
BP lowering?
2. Are we trying to prevent end points orthe disease process?
3. Most effective therapeutic strategy to
reduce overall CVD risk burden.4. Improving adherence to therapy.
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26% 25%
8%
Adapted fromKannel WB. Am J Hypertens. 2000;13:3S-10S.
Men Women
2 RFs
3 RFs
1 RF
NoAdditional
RFs 4 orMore RFs
27% 24%
12%
2 RFs
3 RFs
1 RF
NoAdditional
RFs 4 orMore RFs
>50% of Hypertension Occurs in Presence of 2 or More Risk Factors
CV Risk Factor Clustering With Hypertension
Framingham Offspring Study, Aged 18 to 74 Years
19% 22% 17% 20%
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Risk of CHD in Mild Hypertension by
Intensity of Associated Risk Factors
SBP 150-160 mm Hg + + + + + +
TC 240-262 mg/dL + + + + +
HDL-C 33-35 mg/dL + + + +
Diabetes + + +
Cigarette smoking + +
ECG-LVH +
42
36
30
24
18
12
6
0
46
1014
21
40
10-Yea r
Probability
of
Ev
ent
(%)
Kannel WB. Am J Hypertens. 2000;13:3S-10S.
Risk Factors
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The Polypill Concept
Majority of cardiovascular events occur in subjects withnormal risk factor levels.
To target prevention of intermediate and hard cardiovascularend-points in short- and long-term it is essential to shift the riskfactor continuum to lower levels.
Multiple risk factor interventions required to reduce acuteevents. Blood cholesterol and BP control is crucial.
Original polypill:
3 anti-hypertensives (diuretics, enalapril, atenolol)
Statin, aspirin and folic acid. Revised formulations
Clinical concernsLaw & Wald. BMJ 2002; 324:1570-6
Wald & Law. BMJ 2003; 326:1419-22
Combination Pharmacotherapy Working Group. Ann Intern Med 2005; 143:593-99
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Polypill Concept: Phase II Trial
TIPS. Lancet 2009; 373:1341-51.
Blood Pressure Lowering in
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Blood Pressure Lowering in
TIPS
TIPS. Lancet 2009; 373:1341-51.
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Beyond BP Control: Statins
Cholesterol Lowering Trialists Collaboration. Lancet 2005;366:1267-78
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Benefits of Statins in Hypertension
Pleiotropic effects Anti-inflammatory
Anti-oxidant
Anti-mitotic
Anti-atherosclerotic
Vasculoprotective effects Endothelial function
Vasodilatory mechanisms Protective interleukins
Others
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Lipid Lowering in TIPS
TIPS. Lancet 2009; 373:1341-51.
B d BP C l
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Beyond BP ControlAspirin in Primary Prevention
Antithrombotic Trialists Collaboration. Lancet 2009;373:1849-60
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Beyond BP Control: Folic Acid
Miller ER, et al. Am J Cardiol 2010;106:517-27
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Polypill: Projected Benefits for CHD & Stroke
TIPS. Lancet 2009; 373:1341-51.
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Issues in High BP Management
1. Are there drug-specific benefitsbeyond BP lowering?
2. Are we trying to prevent end pointsor the disease process?
3. Most effective therapeutic strategy
to reduce overall CVD risk burden.4. Improving adherence to therapy.
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Prevalence, Awareness, Treatment and Control of
Hypertension in Indian WomenMulticentric DST Study (4 urban, 5 rural sites; n=4608)
46.2
28.6
0
5
10
15
20
25
30
35
40
45
50
Prevalence Awareness Treatment Control
Urban Rural
56.8
24.6
35.7
46.5 28.310.2
Gupta R, Pandey RM, Misra A, et al. 2011
The Rule of Thirds (1/3)
%
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Hypertension Prevalence, Awareness, Treatment
and Control Status in IndiaParsi Community Study, Bombay (n=2879)
0
5
10
15
20
25
30
35
40
Prevalence Awareness Treatment Control
Bharucha & Kuruvilla. BMC Pub Health 2003; 3:e1
36.4%
51.5%
63.6%13.6%
Treatment
Gap, 36.4%
Compliance
Gap, 86.4%
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Determinants of Poor BP Control in India
Compliance with treatment** (Odds ratio 6.1,CI 3.9-12.6)
Life stress (life event score, 4 vs. 1)**
Smoking
Alcohol intake High body mass index
Others Age, gender
Educational status
Occupation
Marital status
Socioeconomic status
Joshi PP, et al. J Hum Hypertens 1996; 10:299-303** significant
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Compliance with BP Medicines in UK
Practice
Vrijens et al. BMJ 2008;336:1114-7
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Contributing Factors for Noncompliance
Misunderstandings about the medicationregimen
Complexity of the medication regimen
Adverse side effects
Concerns about taking medications
Patientphysician relationship
Financial and social reasons
Thrall et al; J Human Hypertens 2004; 18:596-8
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Strategies to Improve Compliance
Pharmacological therapy in hypertension Simplifying the medication regimen
Appropriate drug selection dependent on patientcharacteristics
Improved patientphysician communication Appropriate education
Behavioral strategiesfor example, self-monitoringof BP, diary, memory cues, rewards
Social supportfor example, family, health-careworkers, physicians
Continual monitoring of patient compliance by thephysician
Thrall et al; J Human Hypertens 2004; 18:596-8
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ABCDE Algorithm in HypertensionOur modification
Younger 50 yr
Step 1 A or B (if sympathetichyperactivity)
Mono A and/or C
Step 2 A (or B) + C or D orboth
Two Add D
Step 3 A or B, C and/or D, addE
Multidrug
A and C, and/or D, add Bor E
Concomitant
therapies
Statins Statins
A= ACE inhibitors/angiotensin receptor blockers; B= beta blockers;
C= calcium channel blockers; D= diuretics;
E= extra drugs (central adrenergic agonists, direct vasodilators, alpha blockers, etc)
Gupta & Guptha. Ind J Med Res 2011; In press.
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Improving Management in Primary Care
Integrated approach to prevention and management. Public policies are important, eg, tobacco control,
salt.
Opportunistic case finding for risk factorassessment, early disease detection, and
identification of high risk status
Combination of pharmacological and psychosocial
interventions, in a stepped care fashion needed.
Long term follow-up with regular monitoring, and
promoting adherence to treatment.
Beaglehole R, et al. Lancet 2008; 372:940-9
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Conclusions Hypertension is highly prevalent in India. There is
low awareness, treatment and control status.
Treatment is best achieved with combination of
lifestyle measures and drugs.
Two-drug combination is best option for BP control.
Global CVD risk reduction is required to prevent
events in all patients with hypertension.
Addition of statins (and NOT aspirin or folic acid) toconventional BP therapy is useful for risk reduction.
Compliance and adherence to treatment is a
major issue.
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1.18
2.04
2.58
1.59
0.5
1
1.5
2
2.5
1990 2000 2010 2020
No. in Millions
Million Death Study
1.9025-30%
GBD 1997 Projections
THANKS