Lebanese Society of Family Medicine 5th Annual Conference Chronic Disease: An Update Hypertension Guidelines and Practic

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Lebanese Society of Family Medicine 5 th Annual Conference Chronic Disease: An Update Hypertension Guidelines and Practice. Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular Medicine American University of Beirut- Medical Center
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Lebanese Society of Family Medicine5th Annual ConferenceChronic Disease: An UpdateHypertensionGuidelines and Practice Adel E. Berbari, MD, FAHA, FACP Professor of Medicine and Physiology Head, Division of Hypertension and Vascular Medicine American University of Beirut- Medical Center Venue: Crown Plaza Hotel Hamra-Beirut-lebanon Date: Saturday, Nov 11, 2006 Introduction
  • Hypertension guidelines published in 2003 (JNC VII and ESH/ESC/generally still valid
  • In light of recent findings initiation of process of changing guidelines.
  • Hypertension major risk for ESH/ESC/generally still valid
  • Cardiovascular events
  • Myocardial infarction
  • Heart failure
  • Stroke
  • Renal failure
  • Impaired quality of life
  • Impaired cognitive function
  • Memory loss
  • Dementia
  • Sexual dysfunction
  • Decreased general well being.
  • BP reduction associated with
  • Reduction in cardiovascular events
  • Improvement in quality of life
  • Reduction of cardiovascular events by active antihypertensive treatment. -12 antihypertensive treatment.-4-5 About mmHg Benefits of Lowering BP by Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% Despite evidence that BP control associated with reduction in risk of cardiovascular events, hypertension control remains poor. Determinants of Poor Hypertension Control in risk of cardiovascular events, Prognostic Importance of Different BP Components in risk of cardiovascular events, Systolic BP in risk of cardiovascular events, vs Diastolic BP Systolic hypertension in risk of cardiovascular events, recently recognized as more important than diastolic hypertension: - Cardiovascular risk factor - Therapeutic decision making in older subjects
  • SBP in risk of cardiovascular events, , rather than DBP, of greater importance in long-term risk of CVD in middle aged patients.
  • CVD risk associated with DBP dependent on
  • SBP level
  • Low CVD risk/similar to Normotension in SBP<140 even when DBP> 90 mm Hg
  • Increased CVD risk with SBP>140/DBP<90 mm Hg
  • Predictive Power of Systolic Blood Pressure on Overall Cardiovascular Outcomes Systolic Blood Pressure Diastolic Blood Pressure DBP (mm Hg) SBP(mm Hg) <140 <90 Total Mortality 140-159 90-99 160-179 ≥100 ≥180 0.5 0.5 2 1 1.5 2.5 2.5 1 1.5 2 Relative Risk Relative Risk Prognosis better Prognosis worse Prognosis better Prognosis worse <140 <90 Cardio-vascular Mortality 140-159 90-99 160-179 ≥100 ≥180 0.5 1 1.5 2 2.5 2.5 1 1.5 0.5 2 Relative Risk Relative Risk Alli C et al. Arch Intern Med. 1999;159:1205-1212.
  • SBP Cardiovascular Outcomes, rather than DBP, of greater importance in long-term risk of CVD in middle aged patients.
  • CVD risk associated with DBP dependent on
  • SBP level
  • Low CVD risk/similar to Normotension in SBP<140 even when DBP> 90 mm Hg
  • Increased CVD risk with SBP>140/DBP<90 mm Hg
  • Relation between SBP and DBP and risk of cardiovascular disease Compelling evidence that benefits of hypertension reduction related primarily to extent of SBP reduction not to DBP reduction Goal SBP Levels related primarily to extent of SBP reduction not to DBP reduction SBP < 140 mmHg related primarily to extent of SBP reduction not to DBP reduction In Uncomplicated Essential Hypertension SBP < 130 mmHg related primarily to extent of SBP reduction not to DBP reduction In High Risk Hypertensive Patients (Diabetes or Chronic Kidney Disease) Difficulty in Achieving Goal related primarily to extent of SBP reduction not to DBP reductionSBP In Contrast to DBP mmHg related primarily to extent of SBP reduction not to DBP reduction Rates of Achieved Goal SBP and DBP with Antihypertensive Treatment.LlOYD JONES (FRAMINGHAM HEART STUDY) Hypertension 2000; 36: 594-599 Blood Pressure Patterns related primarily to extent of SBP reduction not to DBP reduction Classification related primarily to extent of SBP reduction not to DBP reduction
  • Normotension (True / Persistent) related primarily to extent of SBP reduction not to DBP reduction
  • Prehypertension
  • White coat hypertension
  • Masked hypertension.
  • Hypertension (True / Sustained)
  • Prehypertension related primarily to extent of SBP reduction not to DBP reduction Definition related primarily to extent of SBP reduction not to DBP reduction
  • SBP / DBP = 120-139 / 80-89 mmHg Prognostic significance
  • Progression to hypertension
  • Cardiovascular events
  • Increasing increments of blood pressure are associated with increasing risk of cardiovascular mortality. mm Hg mm Hg mm Hg mm Hg mm Hg Progression Rates to Hypertension in increasing risk of cardiovascular mortality.Non-Hypertensive Participants in Framingham Study Definition increasing risk of cardiovascular mortality.
  • SBP/DBP = 120-139/80-89 mmHg Prognostic Significance
  • Progression to hypertension
  • Cardiovascular events Therapy
  • Lifestyle modification
  • Antihypertensive medications in patients with
  • Diabetes Mellitus
  • Chronic Kidney Disease
  • Masked Hypertension increasing risk of cardiovascular mortality.(Reverse White Coat Hypertension) Definition increasing risk of cardiovascular mortality.
  • Normal office/clinic BP levels and elevated home / ambulatory BP levels. Prevalence
  • 10-15% of population (children, adolescent, adults)
  • Tendency to decrease with age. Prognostic Significance
  • Increased risk for:
  • Progression to sustained hypertension
  • Target organ involvement
  • Cardiovascular morbidity/mortality.
  • Relation between office, home, ambulatory blood pressures and cardiovascular / all cause mortality in various BP patients. Predisposing Factors and cardiovascular / all cause mortality in various BP patients.
  • Obesity, especially android obesity
  • Strong family history of hypertension at an early age. Characteristic Clinical Features
  • Rapid pulse rate
  • Elevated nocturnal BP levels. Diagnostic Procedure
  • Ambulatory BP monitoring
  • Home BP measurement Treatment
  • Lifestyle modification
  • Pharmacologic treatment in high CV risk individuals
  • Groups and cardiovascular / all cause mortality in various BP patients. Blood Pressure Levels Blood Pressure Patterns Diagnostic Procedures Blood Pressure Patterns and cardiovascular / all cause mortality in various BP patients. Definition, Risk of CV Events, Therapy Novel and cardiovascular / all cause mortality in various BP patients.Cardiovascular Risk Factors Microalbuminuria and cardiovascular / all cause mortality in various BP patients. Protein excretion and cardiovascular / all cause mortality in various BP patients.in the urine is a strong predictor of cardiovascular disease in middle-aged men and women. Independent from effects of various well recognized CV risk factors Relative prognostic value of microalbuminuria and cardiovascular / all cause mortality in various BP patients.in type 2 Diabetes 10.02 10 8 6.52 6 Mortality from CHD (odds ratio) 4 3.20 2.32 2 0 Microalbuminuria Smoking Diastolic BP Cholesterol Eastman RC, Keen H. Lancet 1997;350(Suppl 1):29–32. Microalbuminuria and cardiovascular / all cause mortality in various BP patients. 1.59 CAD 1.51 Diabetes 1.42 1.4 Creatinine 1.4 mg/dL Male 1.20 WHR (0.1) 1.13 Age (1y) 1.03 Ramipril 0.79 Hazard Ratio Multivariate Hazard Ratios forPrimary Outcome in HOPE 2 0 1 HOPE Study Investigators. N Engl J Med 2000;342:145-53. Classification and cardiovascular / all cause mortality in various BP patients. (Conventional) Normoalbuminuria and cardiovascular / all cause mortality in various BP patients.MicroalbuminuriaMacroalbuminuria (Proteinuria) Definition and cardiovascular / all cause mortality in various BP patients.
  • Increased urinary albumin excretion (UAE) and cardiovascular / all cause mortality in various BP patients.not detected by routine urinalysis (urinary strips detect UAE levels greater than 300mg/D)
  • Special strips available
  • Quantitative assessment:
  • 24 hours urine collection
  • Timed overnight urinary collection
  • SPOT urine albumin/creatinine in first morning urine sample (best accurate/practical method).
  • Special techniques required
  • Macroalbuminuria and cardiovascular / all cause mortality in various BP patients. (Proteinuria)
  • Detected and cardiovascular / all cause mortality in various BP patients. by routine urinalysis strips.
  • Regular 24hr urine collection for Proteinuria.
  • Threshold Levels for and cardiovascular / all cause mortality in various BP patients. Urinary Albumin Excretion Rates in Various Categories Threshold levels for urinary Albumin excretion and cardiovascular / all cause mortality in various BP patients. Timed Collections Spot Collections 24 h Overnight mg/l Alb/Cr Alb/Cr mg/D µg/min mg/mmol mg/g Normal <30 <20 <20 <3 <27 Microalbuminuria 30-300 20-200 20-200 2.5-20M 22-177M 3.5-30F 31-265F Macroalbuminuria >300 >200 >200 >20M >177M (Proteinuria) >30F >265F Alb: albumin Cr: creatinine M: male F: female Microalbuminuria and cardiovascular / all cause mortality in various BP patients. Prevalence and cardiovascular / all cause mortality in various BP patients. Prevalence of microalbuminuria in nondiabetic non hypertensive, hypertensive and diabetic subjects in general population. PREVEND STUDY J INTERN MED 2001;249:519-526. Classification hypertensive, hypertensive and diabetic subjects in general population.
  • Transient hypertensive, hypertensive and diabetic subjects in general population.
  • Persistent
  • Albuminuria Transient Albuminuria hypertensive, hypertensive and diabetic subjects in general population.
  • Decompensated heart failure. hypertensive, hypertensive and diabetic subjects in general population.
  • Strenous exercise.
  • Fever.
  • Urinary tract infection.
  • Postural changes.
  • Sleep apnea.
  • Measurement hypertensive, hypertensive and diabetic subjects in general population. Methods for assessment of urinary albumin excretion hypertensive, hypertensive and diabetic subjects in general population.
  • Timed urine collection
  • 24h urine volume collection
  • Overnight timed urine collection
  • Spot urine sampling
  • Random urine sampling
  • Spot morning (first void) urine collection
  • Precautions In Measurement Of Albuminuria hypertensive, hypertensive and diabetic subjects in general population.
  • Avoid determination in presence of states of hypertensive, hypertensive and diabetic subjects in general population. transient albuminuria.
  • Repeat measurement within 3 months of detection of increased albuminuria due to wide intra-individual day-to-day variation.
  • Most practical approach for detection ofincreased albuminuria in spot albumin/creatinine ratio on first voided urine sample.
  • Treatment hypertensive, hypertensive and diabetic subjects in general population. Antihypertensive Therapy hypertensive, hypertensive and diabetic subjects in general population. General Principles hypertensive, hypertensive and diabetic subjects in general population.
  • BP reduction major determinant of primary prevention of cardiovascular events
  • Beta blockers less effective in prevention of cardiovascular events than Angiotensin receptor blockers, calcium channel blockers, and Thiazide diuretics.
  • Calcium channel blocker-based therapy
  • Less protective in heart failure prevention
  • Slightly more beneficial in stroke prevention
  • Thiazide diuretics
  • drug of first choice in uncomplicated essential hypertension regardless of age/race
  • As effective (even more effective) as other classes in
  • BP reduction
  • Cardiovascular protection
  • No evidence that risk of development of new onset diabetes mellitus associated with increased risk of cardiovascular events
  • Beta Blockers events than Angiotensin receptor blockers, calcium channel blockers, and Thiazide diuretics.
  • Not to be recommended as first line (initiation) therapy in uncomplicated essential hypertension because
  • Suboptimal cardiovascular protection, especially in the elderly, despite BP reduction similar to other antihypertensive agents
  • Greater diabetogenic potential, independent of age
  • Indication in patients with:
  • Augina pectoris
  • Previous myocardial infarction
  • Heart failure
  • Arrhythmias
  • Migraine
  • Recommended First Line (Initiation) Therapy uncomplicated essential hypertension because From National Institute of Health and Clinical Excellence (NICE) and Britsh Hypertension Society (BSH)UPTADE June 2006 Novel Class of Antihypertensive Medications uncomplicated essential hypertension because Renin Inhibitors uncomplicated essential hypertension because Aliskiren uncomplicated essential hypertension because
  • Pharmacological Characteristics uncomplicated essential hypertension because
  • Orally effective, nonpeptide low molecular weight renin inhibitor
  • Very potent / highly specific inhibitor of human renin
  • Suitable for once daily administration because of long terminal half life (25-30 hours)
  • Route of excretion : liver
  • Dose dependent (maximal dose = 300 ml) very effective BP reduction over 24 hrs
  • Low adverse effect profile
  • Minimal drug interactions.
  • Potential advantages over other RAAS blockers
  • Effective reduction in all RAAS components.
  • Pathways Blockade uncomplicated essential hypertension becauseof Renin-Angiotensin-Aldosterone System Angiotensinogen uncomplicated essential hypertension because Renin Aliskiren Angiotensine ACE inhibitors ACE Angiotensin II AT1 receptors AT2 receptors Stimulation Inhibition Angiotensin Receptor Blockers Pathways of Angiotensin II Formation and Sites of Blockade of Renin-Angiotensin System PRA = Plasma Renin Activity uncomplicated essential hypertension because AI = Angiotensin I AII = Angiotensin II Effect of inhibitors of renin-angiotensin-aldosterone system on system components Thank You uncomplicated essential hypertension because
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