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HYPERTENSION IN INDIA
Dr. A. Muruganathan
President - API
Dr. M. Chenniappan
Trichy
Medical Writer
On the Occasion of
World Hypertension Day...
An API Initiative to upgrade knowledge of Practising
physicians throughout India
Why
?
• Educate
• Empower
• Easy learning
• Enjoyable learning
• Evaluate ownself
• 9912064435
• The theme for World Hypertension Day 2013 is “Healthy
Heart Beat - Healthy Blood Pressure”.
• Considering the fact that atrial fibrillation – arrhythmias is
very common in people with hypertension, especially
among older patients, the WHL executive board felt that it
is important to improve the public awareness about atrial
fibrillation – arrhythmias. In order to make it easier for the
public to understand they have used the simple
terminology – Heart Beat.
• The objectives of the World Hypertension League are to
promote the detection, control and prevention of arterial
hypertension in populations.
• The World Hypertension League is a federation of leagues,
societies, and other national bodies devoted to this goal.
Bringing together and stimulating organizations committed
to the control of hypertension is the goal of the WHL.
• The WHL is a division of the International Society of
Hypertension (ISH), and is in official relations with the World
Health Organization (WHO).
Benefit of Interventions Over 5 Years
• Lowering systolic BP 4 mm Hg:
-12.5 cardiovascular events / 200 patients
• Lowering LDL cholesterol 1 mmol/L
-8.2 cardiovascular events / 200 patients
• Lowering HbA1c 0.9 %
-2.9 cardiovascular events / 200 patients
Prevalence1
• Nearly 1 billion adults (more than a quarter of the world’s
population) had hypertension in 2000, and this is predicted
to increase to 1.56 billion by 2025.
• The prevalence of hypertension varies considerably from
one region of India to another.
• In India, 23.10% men and 22.60% women over 25 years old
suffer from hypertension, says the World Health
Organization’s global health statistics 2012’ released in May,
2012.
1. Indian J Med Res 128, December 2008, pp 688-690
Prevalence
• Recent (2012) studies show that for every known person
with hypertension in India, there may possibly be 2 persons
with either undiagnosed hypertension or prehypertension.
• With over 139 million patients, India accounts for 15% of
world’s uncontrolled hypertension patients.
Prevalence
• In terms of attributable deaths, the leading behavioral and
physiological risk factors globally are raised blood pressure
(to which 13% of global deaths are attributed), followed by
tobacco use (9%), raised blood glucose (6%), physical
inactivity (6%) and being overweight or obese (5%).
• It has been estimated that raised blood pressure causes 51%
of stroke deaths and 45% of coronary heart disease deaths.
Global Mortality 2000: Impact of
Hypertension and Other Health Risk Factors
High mortality, developing region
Lower mortality, developing region
Developed region
0
1000 2000 3000 4000 5000 6000 7000 8000
Attributable Mortality
(In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:1347-1360.
Prevalence
• Only 1 in 5 hypertensive women were on treatment and less
than 4% are controlled.
• Majority of hypertensive still remain undetected & the
control of hypertension is also inadequate.
• But, despite all this, the good news is that the prevalence of
hypertension in India is low as compared to world figures
and India fares better than other countries in the South-East
Asia Region (SEAR).
• SEAR’s average is
- 25.40% in men & 24.20 in women.
• Among the High Blood Pressure patients only one third are
aware of the disease.
• Out of this only one third come for treatment.
• Out of this only one third of patients are under control.
An Analysis of NHANES III
Blood Pressure Data Summary:
Hypertensives fall into one of two categories:
1. A smaller (26%), younger (age < 50 years), predominantly
male (63%) with diastolic hypertension out of proportion to
systolic hypertension (primarily IDH and SDH)
2. A larger (74%), older (age ≥ 50 years), predominantly female
(58%) with systolic hypertension out of proportion to
diastolic hypertension (primarily ISH).
Franklin et al. Hypertension 2001;37: 869-874
Pre-hypertension
• Pre-hypertension is defined as a systolic blood pressure reading
between 120 and 139 and a diastolic blood pressure of 80 to 89.
• Nearly 50 % people have Pre Hypertension, accordingly to one
study, 50 % of people above 50 years have high blood pressure.
• The category of pre-hypertension, was introduced to emphasize
that persons whose blood pressure is >120/80 mm Hg are likely
to progress to definite hypertension.
• It was also hoped that doctors will encourage persons with prehypertension to begin lifestyle modifications to prevent its
progression to hypertension.
• Members of the Association of Physicians of India (API) are
planning to conduct screening camps and patient education
regarding hypertension, complications and management with the
help of IMA throughout the country.
• API is also interested to conduct updates for practicing
physicians regarding the newer methods and updates about
hypertension throughout the country directly and through
web.
• The Medical content of all 3 Modules has been written by
Dr.M.Chenniappan (Trichy)
• The Panelist representing respective Regions and Key Members
of API will review & give their suggestions on the Modules before
it is uploaded in the www.apiindia.org site.
• Sessions on Modules 2 & 3 will be facilitated by respective
Panelist/KOLs in respective Bimonthly period
• A book on Diabetic Hypertension will be released with the input
& support of API Key Members & Panelists and will be presented
to registered Drs for E-Hypertension Academy
MODULE-1
Basics, Diagnosis and
Lifestyle Modification
1: INTRODUCTION AND BASICS
• Introduction to hypertension e academics
• Epidemiology of hypertension in India – Incidence,
Awareness , Control
• Etiopathogenesis of hypertension
• Classification
2: DIAGNOSIS OF HYPERTENSION
• Clinical examination in hypertension
• Measurement of blood pressure
• Ambulatory BP monitoring
• Laboratory investigation in hypertension
• Imaging in hypertension
3: NONPHARMACOLOGICAL APPROACH
TO HYPERTENSION
• Goals and risk stratification
• Diet and hypertension
• Salt and hypertension
• Exercise and other lifestyle modifications
MODULE-2
Management of
Hypertension
1: PHARMACOLOGICAL TREATMENT OF
HYPERTENSION (Part 1)
• Classification of antihypertensive and their mechanism of
action
• Selection of initial drugs in uncomplicated hypertension
• Selection of drugs according to compelling indications
2: PHARMACOLOGICAL TREATMENT OF
HYPERTENSION (Part 2)
• Combination therapy
• Difficult to control hypertension and resistant hypertension
– Approach
• Treatment of acute severe hypertension
3: INTERVENTIONAL THERAPY IN
HYPERTENSION
• Renal artery Angioplasty
• Renal sympathetic denervation
• Baroreceptor stimulation
• Surgical approach to hypertension
MODULE-3
Target Organs and
Special Situations
1: HYPERTENSION AND HEART
• Various cardiovascular changes in hypertension
• Hypertension and CAD
• Hypertension and HF (REF, PEF)
• Hypertension and atherosclerosis – vascular aging
• Cardiovascular emergencies in hypertension.
2: HYPERTENSION IN SPECIAL SITUATION
• Hypertension in extremes of age
• Hypertension and kidney
• Hypertension and lung disease
• Hypertension and CVA
• Pregnancy and Hypertension
3: EVIDENCE
• Important trials in Hypertension
• Meta analysis in Hypertension
• API – Indian hypertension guidelines
MODULE-4
(Optional)
Patient Based Interactive Module
THE GOOD NEWS
There is considerable
reduction in cardiovascular risk
with effective lowering of blood
pressure with therapy.
Average reduction in events (%)
Long-Term Antihypertensive Therapy
Significantly Reduces CV Events
Stroke
Myocardial
infarction
Heart failure
0
–10
–20
–30
20%-25%
–40
–50
35%-40%
–60
Blood Pressure Lowering Treatment Trialists’ Collaboration.
Lancet. 2000;355:1955-1964.
>50%
On Completion of all 3 Module Test, Practising Physician will be given
“ Certificate of Participation from the house of API”
MODULE-1
1B
Hypertension in India
Diseases Attributable to Hypertension
Gangrene of the
Lower Extremities
Heart
Failure
Left Ventricular
Hypertrophy Myocardial
Infarction
Hypertensive
Encephalopathy
Aortic
Aneurysm
HYPERTENSION
Coronary Heart
Disease
Blindness
Chronic
Kidney
Failure
Adapted from Dustan HP et al. Arch Intern
Med. 1996; 156: 1926-1935
Stroke
Cerebral
Preeclampsia/E Hemorrhage
clampsia
Global Mortality 2000: Impact of
Hypertension and Other Health Risk Factors
High mortality, developing region
Lower mortality, developing region
Developed region
0
1000 2000 3000 4000 5000 6000 7000 8000
Attributable Mortality
(In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:1347-1360.
Hypertension in India (1/2)
• Cardiovascular diseases caused 2.3 million deaths in India in
the year 1990; Projected to double by the year 2020
• Hypertension directly responsible for 57% of all stroke
deaths and 24% of all coronary heart disease deaths in India
• Strong correlation between changing lifestyle factors and
increase in hypertension in India
• The nature of genetic contribution and gene-environment
interaction in accelerating the hypertension epidemic in
India needs more studies
Gupta R. J Hum Hypertens 2004;18:73-78
Hypertension in India (2/2)
• In India, hypertension is present in 25% urban and 10% rural
subjects
• At an underestimate, there are 31.5 million hypertensives in
rural and 34 million in urban populations
• A total of 70% of these would be Stage I hypertension
(systolic BP 140-159 and/or diastolic BP 90-99 mmHg)
• Recent reports show that borderline hypertension (systolic
BP 130-139 and/or diastolic BP 85-89 mmHg) and Stage I
hypertension carry a significant cardiovascular risk
Gupta R. J Hum Hypertens 2004;18:73-78
Risk Attributable due to Hypertension
in India
http://www.whoindia.org/SCN/AssBOD/08Hypertension.pdf Accessed on 27th May 2010
Prevalence studies in India
R Gupta :Journal of Human Hypertension (2004)
18, 73–78
Recent studies
R Gupta :Journal of Human Hypertension (2004)
18, 73–78
R Gupta :Journal of Human Hypertension (2004)
18, 73–78
TRENDS IN AWARENESS, TREATMENT AND
CONTROL OF HIGH BLOOD PRESSURE 1976-2000
National Heath and Nutrition Survey, Percent
1976-80
1988-91
1991-94
1999-2000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
• In India and surrounding countries, awareness level is ≤ 45%.
• Only 50% of these are on treatment and BP control rates are
very poor.
Trends in BP Control in India (1/2)
% of uncontrolled
hypertensive patients
100
81.1
80
70.5
76.2
60
36.9
40
20
0
Hypertension (n=3402)
Uncontrolled Systolic BP
Diabetic Hypertension
(n=1435)
Uncontrolled Diastolic BP
Only 27.3% patients had both SBP and DBP under control
Survey in hypertensive patients (n=3402) receiving antihypertensive medications
Hathial M. J Indian Med Assoc. 2007; 105 (7): 4012, 404, 410.
% of hypertensive
patients achieving BP goal
Trends in BP Control in India (2/2)
55
51.1
50
45.9
45
40
Hypertension (n=154)
Diabetic Hypertension
(n=149)
Study conducted in Chennai, of the treated hypertensive patients (n=154), only
45.9% of patients had their BP under control (i.e. <140/90 mm Hg).
Similar analysis done in diabetic hypertension patients (n=149) showed that of the
patients that were treated for hypertension, only 51.1% had their blood pressure
under control.
Mohan V et al. JAPI 2007; 55: 326-32.
Control of Hypertension in Indian population
Normotensive
80%
Controlled hypertension
Treated hypertension 29.2%
Diagnosed hypertension
29.2%
32.8%
Hypertensive
20%
Untreated hypertension
70.8%
Uncontrolled hypertension
70.8%
Undiagnosed hypertension
67.2%
…only 15.4% of total hypertensive group have blood pressure controlled
Mohan:J Assoc Physicians India, 2007
May;55:326-32
END OF MODULE-1
1B