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APEKS:SIC V
Mid claviculer
Prevalence of hypertension
43%
22%
21%
13%
NHANES III
(Phase I)
1988-91
NHANES III
(Phase II)
1991-94
Awareness
51.0%
73.0%
68.4%
Treated
31.0%
55.0%
53.6%
Controlled
10.0%
29.0%
27.6%
Efficacy of
medications
Patient compliance:
Side effects
Convenience
Lack of symptoms
Patient education
Cost
Failure to treat to
target
MD Reluctance
Accurate blood pressure
measurements
Relctnce: enggan
Rstant : mlawan
Secondary Causes
Sleep apnea
Renal vascular HTN
Endocrine causes
Chronic renal failure
Rx Drugs (NSAIDS, steroids)
White-coat HTN
Pseudo-hypertension
Vasoactive substances
(non-Rx)
Stroke
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy
Hypertension
Hypertensive
encephalopathy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
All
Vascular
30
24.4
25
20
18.6
15
11.9
10
9.9
10.0
9.3
5
0
90 mmHg
85 mmHg
80 mmHg
Lancet 1998;351:17551762
Stroke
Microvascular
disease
Deterioration in
visual acuity
24% P<0.005
32% P<0.05
37% P<0.01
Tight control (n=758)
Less tight control (n=390)
44% P<0.05
47% P<0.005
BMJ 1998;317:703713
BP targets
Strngt : ktat,kras
Initial Assessment
Target organ damage
Overall cardiovascular risk
Rule out secondary and often curable
causes
Brain
Heart
Eyes
Kidneys
Arteries
Hypertension
Age
Smoking
Dyslipidemia
Diabetes
Family history
Obesity
Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46
Normal
SBP 120129
DBP 80-84
High normal
SBP 130139
DBP 85-89
Grade 1
SBP140159
DBP 90-99
Grade 2
SBP 160179
DBP 100109
Grade 3
SBP > 180
DBP >
110
Average
risk
Average
risk
Low added
risk
Moderate
added risk
High
added risk
1 2 risk factors
Low added
risk
Low added
risk
Moderate
added risk
Moderate
added risk
Very high
added risk
Moderate
added risk
High added
risk
High added
risk
High added
risk
Very high
added risk
ACC
High added
risk
Very high
added risk
Very high
added risk
Very high
added rsik
Very
added risk
14
2003 ESH-ESC
Effectively reduces BP
No adverse effects
Affordable
Clinical Practice:
Most people with hypertension are treated with monotherapy
Clinical Evidence:
Most people in clinical trials are treated with combination
therapy
85 mmHg
26.1%
31.7%
37.1%
62.9%
80 mmHg
68.3%
73.9%
Combination therapy
Monotherapy
The lower the target DBP, the greater the need for combination therapy
HOT:Hypertesion Optimal Treatment
Drug Action
- vasodilatation
RAS Activation
SNS Activation
-Vasoconstriction
- Sodium retention
RAS = renin-angiotensin system
SNS = sympathetic nervous system
Thiazide
Natriuretic
Lowers Blood
Pressure
Activates
Renin Angiotensin
System
24
Thiazide
Diuretics
Retain potassium
Excrete Potassium
Combination
Prevents hypokalaemia of thiazide therapy
Limits hyperkalaemia of RAS(r angt sys) blockade
25
26
27
28
100
80
80
60
60
Traditional
40
40
20
20
0
Dose
Efficacy (%)
Freedom from
side effects (%)
29
Man Int Veld AJ. J Hypert, 1997
30
31
BP Classification
Normal
<120/80 mm Hg
Lifestyle
Modification
Without Compelling
Indication
With Compelling
Indication
Encourage
Prehypertension
120-139/80-89 mm Hg
Yes
No drug indicated
Stage 1 hypertension
140-159/90-99 mm Hg
Yes
Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Stage 2 hypertension
160/100 mm Hg
Yes
33
34
Easy as ABC D
A = ACE-Inhibitor or Angiotensin Receptor Blocker
B = - Blocker
C = Calcium Channel Blocker
D = Diuretic (thiazide)
Adapted from : Better blood pressure control: how to combine drugs
Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org
35
A or B
C or D
Inhibit the
Renin-Angiotensin
System
More Effective
In Younger
More Effective
In Older
36
1.
Younger
Or Diabetes
( 55yrs)
Older
(55yrs)
or Black
A or B
C or D
2.
A or (B) + C or D
3.
A or (B) + C + D
4.
A or (B) + C + D + other
Adapted from : Better blood pressure control: how to combine drugs
Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org
38
Recommended Combinations
1. ACE inhibitors / AIIRA
2. ACE inhibitors / AIIRA
3. ACE inhibitors / AIIRA
4. Beta-Blockers
5. Beta-Blockers
Diuretics
Calcium antagonists
Beta-blockers
(Special condition)
Diuretics
Calcium Antagonists
39
SUMMARY
COMBINATION THERAPY IN HTN
MANAGEMENT IS LOGIC AND
EVIDENCE BASED
MAXIMIZE EFFECT, MINIMIZE SIDE
EFFECT
COMBINATION THERAPY IN HTN
INCREASE COMPLIANCE
THE END