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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