Download Hypertension

Hypertension
An 2006’ update on how to choose
and prescript the best medications
for our patients
Dr. Wong Bun Lap Bernard
Definition and classification of
hypertension: ESH/ESC 2003
Hypertension is defined as blood pressure ≥140/90 mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Optimal
<120
<80
Normal
120120-129
8080-84
High normal
130130-139
8585-89
Grade 1 hypertension (mild)
140140-159
9090-99
Grade 2 hypertension
(moderate)
160160-179
100100-109
Grade 3 hypertension (severe)
≥180
≥110
Isolated systolic hypertension
≥140
<90
When a patient’s systolic and diastolic blood pressures fall into different
categories, the higher category should apply
ESH/ESC Guidelines 2003
J Hypertens 2003;21:1011-1053
1
Definition and classification of
hypertension: JNC VII
Hypertension is defined as blood pressure ≥140/90
mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
<120
and <80
Prehypertension
120120-139
or 8080-89
Stage 1 hypertension
140140-159
or 9090-99
Stage 2 hypertension
≥160
or ≥100
Normal
JNC VII. JAMA 2003;289:2560-2572
Definition and classification of
hypertension: WHO/ISH 1999/2003
Hypertension is defined as blood pressure ≥140/90 mmHg
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Optimal
<120
<80
Normal
<130
<85
HighHigh-normal
130130-139
8585-89
Grade 1 hypertension (mild)
Subgroup: borderline
140140-159
140140-149
or 9090-99
9090-94
Grade 2 hypertension
(moderate)
160160-179
or 100100-109
Grade 3 hypertension
(severe)
≥180
or ≥110
≥140
140140-149
<90
<90
Isolated systolic
hypertension
Subgroup: borderline
When a patient’s systolic and diastolic blood pressures fall
into different categories, the higher category should apply
2003 WHO/ISH Statement on Hypertension.
J Hypertens 2003;21:1983-1992; 1999 WHO/ISH Guidelines for the
Management of Hypertension. J Hypertens 1999;17:151-183
2
Prevalence of hypertension*:
North America and Europe
80
Men
Women
Total
70
Prevalence (%)
60
50
40
30
20
10
Fi
nl
an
d
G
er
m
an
y
Ita
* BP ≥140/90 mmHg or treatment with antihypertensive medication
Sp
ai
n
ly
Sw
ed
en
En
gl
an
d
Un
ite
d
Eu
ro
pe
St
at
es
C
an
ad
a
0
Wolf-Maier K, et al. JAMA 2003;289:2363-2369
Prevalence of hypertension: Asia
Th
6)
ai
la
nd
Ph
(1
99
ilip
1)
pi
ne
s
(1
In
99
do
9)
ne
si
In
a
di
(1
a
(M
99
4)
um
ba
i,
Ja
19
pa
99
n
)
(1
99
295
)
(1
99
8)
(1
99
ys
ia
al
a
M
Si
ng
a
po
r
e
ng
(1
99
7
4)
(1
99
g
Ko
iw
an
H
on
0/
20
Ta
(2
00
na
C
hi
)
Men
Women
Total
01
)
Prevalence (%)
80
70
60
50
40
30
20
10
0
Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol
1997;24:987-988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al.
Singapore Med J 2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
3
Millimetres matter …
“A 2-mmHg reduction in DBP
would
result in … a 6% reduction in
the risk of
CHD and a 15% reduction in the
risk of
stroke and TIAs”
DBP, diastolic blood pressure; CHD, coronary heart
disease;
TIA, transient ischaemic attack
Cook NR, et al. Arch Intern Med 1995;155:701-709
Millimetres matter …
“For individuals 4040-70 years of age,
each increment of 20 mmHg in systolic
BP or
10 mmHg in diastolic BP doubles the
risk
of CVD across the entire BP range from
115/75 to 185/115 mmHg”
BP, blood pressure; CVD, cardiovascular disease
JNC VII. JAMA 2003;289:2560-2572
4
Hypertension control rates around the
world
<140/90 mmHg
United States
France
Canada
Italy
Egypt
England
Korea
(%)
27
24
22
9
8
6
5
<160/95 mmHg
Germany
Finland
Spain
Australia
Scotland
India
Zaire
(%)
23
21
20
19
18
9
3
3
2
China
Poland
JNC VI. Arch Intern Med 1997;157:2413-2446; Joffres MR, et al. Am J Hypertens 1997;10:1097-1102;
Colhoun HM, et al. J Hypertens 1998;16:747-752; Chamotin B, et al. Am J Hypertens 1998;11:759-762;
Marques-Vidal P, et al. J Hum Hypertens 1997;11:213-220
National Health and Nutrition
Examination Survey (NHANES)
Trends in awareness, treatment and control of
high blood pressure in adults aged 18-74*
II
(1976(1976-80)
III
(Phase 1
19881988-91)
III
(Phase 2
19911991-94)
199919992000
Awareness
51%
73%
68%
70%
Treatment
31%
55%
54%
59%
Control†
10%
29%
27%
34%
* High blood pressure defined as SBP ≥140 mmHg or
DBP ≥90 mmHg or taking antihypertensive medication
† SBP <140 mmHg and DBP <90 mmHg
Unpublished data for 1999–
1999–2000 compiled by M.
Wolz,
Wolz, National Heart, Lung and Blood Institute:
JNC VI
5
Goals of treatment: ESH/ESC 2003
Achieve maximum reduction in total
cardiovascular risk
Treat all reversible risk factors and
associated clinical conditions in addition
to treating raised blood pressure
Target blood pressure <140/90 mmHg
and to lower values, if tolerated
For diabetics, target blood pressure is
<130/80 mmHg
ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053
Goals of treatment: JNC VII
The SBP and DBP targets are
<140/90 mmHg
The primary focus should be on
achieving the SBP goal
In patients with hypertension and
diabetes or renal disease, the BP
goal is <130/80 mmHg
SBP, systolic blood pressure; DBP, diastolic blood pressure;
BP, blood pressure
JNC VII. JAMA 2003;289:2560-2572
6
Goals of treatment: WHO/ISH 2003
In hypertensive patients at low to
medium risk*, the SBP goal is
<140 mmHg
In hypertensive patients at high
risk*, a target of <130/80 mmHg
is appropriate
* Risk of developing a major cardiovascular event (fatal and nonfatal stroke, and
myocardial infarction)
SBP, systolic blood pressure
2003 WHO/ISH statement on hypertension. J Hypertens 2003;21:1983-1992
2 Important Directions
1.
2.
Life-Style Management
Medical Therapy
7
Life-Style Management
A to E
A – Alcohol moderation
B – Benign emotion
C – Cigarettes
D - Diet
E – Exercise
Medical Therapy
2 points worth to remember on starting
AntiAnti-HT medications :
1.
When SBP ≥ 140 &/or DBP ≥ 90 mmHg
2.
Detailed discussion with patient and their
family on (preferably with booklets)
•
•
•
Definition of hypertension
Complications & prognosis of hypertension
The choices, cost, benefit, potential sidesideeffects & the importance of compliance on
medications
8
8 Considerations on
Anti - HT Medications
1.
2.
3.
4.
5.
6.
7.
8.
Compelling Indications
QD 24 Hours smooth release
Single tablet
Small doses combination
Combination pills
Side effects
Start Slow – no need to be too hurry
Cost - a real life efficient free market
Factors influencing BP control
Efficacy
+
Adverse effects
+
Convenience
9
Hypertension treatment strategy:
ESH/ESC 2003
Consider:
Untreated BP level
Presence or absence of TOD and risk factors
Choose between:
Two-drug combination
at low dose
Single agent
at low dose
If goal BP not achieved
Previous agent
at full dose
Switch to different
agent at low dose
Previous combination
at full dose
Add a third drug
at low dose
If goal BP not achieved
Two- to three-drug
combination
Three-drug combination
at effective doses
Full-dose
monotherapy
BP, blood pressure; TOD, target organ damage
ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053
Hypertension treatment strategy: JNC
VII
Lifestyle modifications
Not at goal blood pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes or chronic kidney disease)
Initial drug choices
Without compelling
indications
Stage 1 hypertension
(SBP 140-159 or DBP
90-99 mmHg)
Thiazide-type diuretics
for most. May consider
ACE-I, ARB, BB, CCB
or combination
Stage 2 hypertension
(SBP ≥160 or DBP ≥100 mmHg)
Two-drug combination for
most (usually thiazide-type
diuretic and ACE-I or
ARB, or BB, or CCB)
With compelling
indications
Drug(s) for the
compelling indications
Other antihypertensive
Drugs (diuretics, ACE-I,
ARB, BB, CCB) as needed
Not at blood pressure goal
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
JNC VII. JAMA 2003;289:2560-2572
10
The BHS recommendations for combining
blood pressure-lowering drugs
Older (eg ≥55 years)
or black
Younger (eg <55 years)
and non-black
Step 1
A
Step 2
C or D
A
Step 3
A
Step 4
Resistant
hypertension
+
+
C
C or D
+
D
Add: further diuretic, alpha-blocker or beta-blocker
A: ACE inhibitor or ARB
C: Calcium-channel blocker
B: Beta-blocker
D: Diuretic (thiazide)
NICE (National Institute for Health and Clinical Excellence)
Clinical guideline June 2006’，
4 Major Classes of Medications
A to D
ABCD-
ACEI/ARB, Alpha-Blocker
Beta-Blockers
Calcium Channel Blockers
Diuretics
11
A - ACEI
ACEI
Acertil (Perindopril) 2-8mg
Tritace (Ramipril)
2.5-10mg
Zestril (Lisinopril)
5-20mg
QD
QD
QD
A - ARB
ARB
Aprovel
Blopress
Cozaar
Diovan
Olmetec
Micardis
(Irbesartan)
Irbesartan)
(Candesartan)
Candesartan)
(Losartan)
Losartan)
(Valsartan)
Valsartan)
(Olmesartan)
Olmesartan)
(Telmisartan)
Telmisartan)
7575-300mg
4-16mg
2525-100mg
4040-160mg
2020-40mg
4040-80mg
QD
QD
QD
QD
QD
QD
12
A- Alpha Blockers
Cardura XL (Doxazosin) 4 – 8mg QD
B - Beta-blockers
Betaloc Zok (Metoprolol)
Metoprolol)
Concor
(Bisoprolol)
Bisoprolol)
Dilatrend
(Carvedilol)
Carvedilol)
2525-200mg QD
1.251.25-10mgQD
3.1253.125-25mg BD
13
C – Calcium Channel Blockers
(dihydropyridine group)
Norvasc (Amlodipine)2.5-10mg
Plendil (Felodipine) 2.5- 10mg
QD
QD
D - Diuretics
Natrilix SR (Indapamide)1.5mg QD
14
Combination Pills
A + D ACEI + Diuretics
Predonium
• Acertil (Perindopril)
Perindopril) 2mg + Natrilix
(Indapamide)
Indapamide) 0.625mg
Combination Pills
A+D
ARB + Diuretics (hydrochlorothiazide)
Co-Approvel 150 /300 + 12.5
Blopress Plus 8 + 12.5
Co-Diovan 80/160 + 12.5
Hyzaar 50/100,
Hyzaar Forte 12.5/25
Micardis Plus 40 + 12.5
15
Combination Pills
B+D
Beta-Blocker + Diuretics (hydrochlorothiazide)
Lodoz (Bisoprolol)2.5mg/6.25mg
Betaloc Comp (Metoprolol)
Metoprolol)
100mg/12.5mg
Combination Pills
B+C
Beta-blocker+Calcium Channel Blocker
Logimax
Betaloc Zok (Metoprolol) 50mg +
Plendil (Felodipine) 5mg
16
NICE June 2006’
Beta-blocker –no longer a routine
initial therapy
• Less effective in the reduction of CVA
• Less effective in reducing the risk of
diabetes
NICE June 2006’
BetaBeta-blocker:
No longer a routine initial HT drug
Only for Patients intolerance to ACEI/ARB
Avoid the addition of diuretic to betabeta-blocker increase the risk of DM development
• When withdrawing a betabeta-blocker, step down
the dose gradually
• BetaBeta-blocker should not be withdrawn in
•
•
•
Symptomatic angina
Old MI
17
A fine Sunday afternoon
wake-up
Word of Wisdom
Whatever
THE MIND OF MAN
can
CONCIEVE
and
BELIEVE
it can
ACHIEVE
~ Napoleon Hill ( 18831883-1970 )
Q&A
1. According to WHO/ISH 2003, ESC
2003, NICE 2006, the optimal BP is
SBP < 120 and DBP < 80mmHg.
True or False
18
Q&A
2. According to the WHO/ISH 2003,
ESC 2003, NICE 2006 guidelines, we
can consider anti-hypertensive
medications when the SBP is ≥ 140
and/or DBP ≥ 90mmHg
True or False
Q&A
3. According to the NICE 2006
guidelines, beta-blocker is no
longer a first line medication
True or False
19
Q&A
4. According to the NICE 2006
guidelines, ACEI/ARB are the firstline medications for younger patients
(<55 years old) and CCB/Diuretics
are the first line medications for (≥55
years old) older patients.
True or False
Q&A
5. Detailed discussion with patient and their
family on
Definition of hypertension
• Complications & prognosis of hypertension
• The choices, cost, benefit, potential sidesideeffects & the importance of compliance on
medications
is the most important key to success
True or False
20
Q&A
Questions 1 5
Answers: All True
21