Prevalence of hypertension PowerPoint Presentation

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HYPERTENSION SYAIFUL AZMI Subdivision of Nephrology, Faculty of Medicine Andalas University Padang

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Buku pegangan. HARRISON : INTERNAL MEDICINE SUPARTONDO : ILMU OENYAKIT DALAM NORMAN KAPLAN : CLINICAL HYPERTENSION

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Section 1: Definition and Classification of Hypertension

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Definition and classification of hypertension: ESH/ESC 2003 Hypertension is defined as blood pressure 140/90 mmHg ESH/ESC Guidelines 2003 J Hypertens 2003;21:1011-1053 When a patient’s systolic and diastolic blood pressures fall into different categories, the higher category should apply

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Definition and classification of hypertension: JNC VII Hypertension is defined as blood pressure 140/90 mmHg JNC VII. JAMA 2003;289:2560-2572

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Definition and classification of hypertension: WHO/ISH 1999/2003 Hypertension is defined as blood pressure 140/90 mmHg 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 When a patient’s systolic and diastolic blood pressures fall into different categories, the higher category should apply

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Section 2: Prevalence of Hypertension

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Prevalence of hypertension*: North America and Europe 0 10 20 30 40 50 60 70 80 United States Canada Europe Italy Sweden England Spain Finland Germany Prevalence (%) Men Women Total Wolf-Maier K, et al. JAMA 2003;289:2363-2369 * BP 140/90 mmHg or treatment with antihypertensive medication

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Prevalence of hypertension: Asia 0 10 20 30 40 50 60 70 80 China (2000/2001) Taiwan (1994) Hong Kong (1997) Singapore (1998) Malaysia (1996) Thailand (1991) Philippines (1999) Indonesia (1994) India (Mumbai, 1999) Japan (1992-95) Prevalence (%) Men Women Total 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]

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Prevalence of hypertension: Other countries 0 10 20 30 40 50 60 70 80 Ecuador (2000) Colombia (2002) Israel (1996) Prevalence (%) Men Women Total Ordunez P, et al. Pan Am J Public Health 2001;10:226-231; Cubillos-Garzon LA, et al. Am Heart J 2004;147:412-417; Amad S, et al. J Hum Hypertens 1996;10:S31-S33

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TABEL 4 Prevalensi Hipertensi Pada Populasi, Obese, TGT dan DM di SumBar 2005

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Section 3 : Classification of hypertension

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CLASSIFICATION PRIMARY ( ± 90 % ) SECUNDARY ( ± 10 % ) renovascular hypertension renal parenchymal hypertension hypertension with pregnancy pheochromocytoma primary aldosteronemia drug induced or related causes JNC 7 2003, Caplan, clinical hypertension 2002

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Section 4 : Risk factors of Hypertension

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Table Cardiovaskuler risk factors Major Risk Factors Hypertension* Cigarette* (body mass index  30 kg/m2) Physical inactivity Dislipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR < 60 mL/min Age (older than 55 for men, 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65) Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy GFR, glomerular filtration rate * Components of the metabolic syndrome JNC VII 2003

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Risk factors Gender Race Age Family history Cigarette smoking Obesity ( BMI ≥ 30 Kg/m2 )* Physical activity Dyslipidemia* Diabetes Mellitus* Microalbuminuria * componen of metabolic syndrome JNC 7 2003

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Bahaya HIPERTENSI (bila tdk dikendalikan) Kerusakan pada Organ Target Stroke Retinopati (buta) LVH Gagal Jantung PJK Penyakit Ginjal khronik Gagal Ginjal Terminal

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Section 5 : Pathophysiology and Pathogenesis of Hypertension

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PATHOPHYSIOLOGY OF HYPERTENSION Several hypothesis exists of the original pathogenesis of hypertension - Excess Na intake - Renal Na retention - RAS - Stress & sympathetic activity - Peripheral resistance - Endothelial dysfunction - Obesity - Insulin resistance

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Pathogenesis hipertensi ( Kaplan N, 2002 )

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Angiotensinogen Angiotensin I Angiotensin II Ellis ML, et al. Pharmacotherapy 1996;16:849-860; Carey RM, et al. Hypertension 2000;35:155-163 AT1 AT2 Vasoconstriction Aldosterone secretion Catecholamine release Proliferation Hypertrophy Vasodilation Inhibition of cell growth Cell differentiation Injury response Apoptosis BP (-) Renin-angiotensin-aldosterone system Renin Angiotensin- converting enzyme Bradykinin Inactive kinins BP, blood pressure

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Section 6 : Diagnosis of Hypertension

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SYMPTOMS Headache Nocturia Palpitation Dizziness Tinitus Epistaxis Kaplan N , 2002

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PHYSICAL EXAMINATION

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25

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TABLE. IMPORTANT ASPECTS OF THE PHYSICAL EXAMINATION

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LABORATORY TEST ROUTINE LAB WORK UP RISK FACTORS : BLOOD SUGAR, LIPID PROFILE, ELECTROLYTES. LAB OF TARGET ORGAN DEMAGE PLASMA INSULIN, PLASMA RENIN ACTIVITY

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FUNDUSCOPY EXAMINATION : RETINOPATHY CARDIAC ASSESSMENT : LVH, ARYTHMIA CEREBRAL ASSESSMENT : ENCEPHALOPATHY RENAL ASSESSMENT

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Section 7 : Treatment Guidelines

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Table Lifestyle modifications to manage hypertension *† DASH, Dietary Approaches to Stop Hypertension. * For overall cardiovascular risk reduction, stop smoking. † The effects of implementing these modifications are dose and time dependent, and could be greater for some individuals JNC VII 2003

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THE IDEAL ANTIHYPERTENSIVE AGENT Effectively reduces BP Maintains BP control over 24 hours with once-a-day dosing Effective in all hypertensive patients No adverse effects No negative metabolic side effects

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History of antihypertensive drugs 1940’s 1950 1957 1960’s 1970’s 1980’s 1990’s 2000 DHP, dihydropyridine; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker Effectiveness and general tolerability

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AASK MAP <92 Target BP (mmHg) Multiple antihypertensive agents are needed to achieve target BP Number of antihypertensive agents 1 UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 Trial 2 3 4 DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure IDNT SBP <135/DBP <85 ALLHAT SBP <140/DBP <90 Bakris GL, et al. Am J Kidney Dis 2000;36:646-661;Lewis EJ, et al. N Engl J Med 2001;345:851-860;Cushman WC, et al. J Clin Hypertens 2002;4:393-404

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Main classes of antihypertensive drugs Diuretics Inhibit the re absorption of salts and water from kidney tubules into the bloodstream Calcium-channel antagonists Inhibit influx of calcium into cardiac and smooth muscle Beta-blockers Inhibit stimulation of beta-adrenergic receptors Angiotensin-converting enzyme (ACE) inhibitors Inhibit formation of angiotensin II Angiotensin II receptor blockers (ARBs) Inhibit binding of angiotensin II to type 1 angiotensin II receptors

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Clinical trial and guideline basis for compelling indications for individual drug classes RECOMMENDED DRUGS+ COMPELLING INDICATION CLINICAL TRIAL BASIS+ DIURETIC BB ACEI ARB CCB ALDO ANT Heart failure      ACC/AHA Heart Failure Guide- line,40 MERIT-HF, 41 COPERNI- CUS,42 CIBIS,43 SOLVD,44 AIRE,45 TRACE,44 ValHEFT,47 RALES48 Postmyocardial infarction    ACC/AHA post-MI Guideline,49 BHAT,50 SAVE,51 Capricorn,52 EPHESUS,53 High coronary disease risk     ALLHAT,33 HOPE,34 ANBP2,36 LIFE,32 CONVINCE31 Diabetes      NKF-ADA Guideline,31,32 UKPDS,34 ALLHAT33 Chronic Kidney disease   NKF Guideline,22 captopril Trial,55 RENALL,56 IDNT,57 REIN,58 AASK59 Recurrent stroke prevention   PROGRESS35 JNC VII , 2003  Compeling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indications is managed in parallel with the BP + Drug abbreviations; ACEI, angiotensin converting enzyme inhibitor; ARB,angiotensin receptor blicker; Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker ± Conditions for which trials demonstrate benefit of specific classes of antihypertensive drugs.

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Treatment strategy: WHO/ISH 2003 2003 WHO/ISH Statement on Hypertension. J Hypertens 2003;21:1983-1992 DHPCCB, dihydropyridine calcium-channel blocker; ACE-I, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CCB, calcium-channel blocker

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Treatment initiation: JNC VII 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

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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 JNC VII. JAMA 2003;289:2560-2572 SBP, systolic blood pressure; DBP, diastolic blood pressure; BP, blood pressure

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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 With 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) 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. JNC VII. JAMA 2003;289:2560-2572 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

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Circumstances in which ACE Inhibitors and ARBs Should Not Be Used Do Not Use Use with Caution ACE Inhibitor Pregnancy(A) Women not practicing contraception (A) History of angioedema (A) Bilateral renal artery stenosis* Cough due to ACE inhitors (A) Drugs causing hyperkalemia (A) Allergy to ACE or ARB (A) ARB Allergy to ACE inhibitor or ARB (A) Bilateral renal artery stenosis* Pregnancy (C) Drugs causing hyperkalemia (A) Cough dua to ARB (C) Women not practicing contraception (C) Angioedema due to ACE inhibitors (C) K-DOQI AJKD, 2004 * Including renal artery stenosis in the kidney transplant or in a solitary kidney. Letters in parentheses denote strength of recommendations.

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Diuretik : Hati hati pada : - gangguan elektrolit - dislipidemia Beta bloker hati hati pada : - Asma bronkhial / spasme bronkhus - Diabetes melitus

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Terima Kasih