Академический Документы
Профессиональный Документы
Культура Документы
Germany 6.6-13.1%
Bulgary 1,1%
England 21%
Japan 20%
Canada 13%
Greece 27%
USA 25-29%
Korea 4,7%
Mexico 2,3%
France 16,1-18,5%
Taiwan 2-5%
Spain 25.7-35%
China 1.2-4.1%
South Africa 14,8%
Brazil 21.7%
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]
Hypertension in INDONESIA
Based on Survey of Household Health
(SKRT 1995) is 8,3 % per 100 population
Women > men
Based on bordeline hypertension criteria
(140/90-159/94 mmHg), the prevalence is
4,8-18,8%.
Prevalence of Hypertension
70
60
65
70-79
80+
54
50
44
40
30
20
64
21
4
11
18-29
30-39
10
0
age (yrs)
40-49
50-59
60-69
Update in hypertension
Global mortality 2000: impact of hypertension
and other health risk factors
High blood pressure (BP)
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
Alcohol
Developed region
Iron deficiency
0
1000
2000
3000
4000
5000
6000
Attributable mortality
(In thousands; total 55,861,000)
7000
8000
Hypertension
MI
Angina pectoris
Diabetes
LVH
Valvular disease
male
female
1.5
3.0 4.5
Hazard Ratio
7.5
Levy et al JAMA 1996
RULE OF HALF
Hypertensive patients
who are treated
but uncontrolled
25%
12.5%
12.5%
50%
Hypertensive patients
who are unaware
Hypertensive patients
who are treated
and controlled
CONTROLLED HYPERTENSION
< 140/90 mmHg
USA
27
England
6
Canada
16
France
24
Spain
20.5
20
Germany
22.5
Scotland
Australia
19
India
17.5
> 65 years
8x
4x
2x
Impact of High-Normal BP on CV
Disease Risk in Women
12
10
Highnormal
8
Cumulative
Incidence
(%)
6
4
Normal
Optimal
0
0
6
Time (y)
10
12
Impact of High-Normal BP on CV
Disease Risk in Men
16
14
Cumulative
Incidence
(%)
12
Highnormal
10
Normal
8
6
Optimal
4
2
0
0
6
Time (y)
10
12
15
10
5
MI
MI
Stroke
Stroke
0
0
100
200
300
CUMULATIVE INCIDENCE OF HF
IN HYPERTENSIVE PATIENTS
20
Stage 2+ hypertension
15
CHF
Cumulative
Incidence
(%)
10
Stage 1+ hypertension
5
Normal BP
5
10
Years From Baseline Exam
15
Diastolic
Diastolic Blood
Blood Pressure
Pressure
5
5
4
2
1
< 140
mm Hg
mm Hg
140-159 160-179 180-199 200+
< 80
80-89
90-99
100-109
110+
VA Cooperative
Study Group
Control - Placebo
META-ANALYSIS
(LANCET 2000)
35 40 % mean reduction in stroke
20 25 % decrease in MI incidence
> 50 % reduction in CHF
BENEFITS OF BP LOWERING
BENEFITS OF BP LOWERING
Adapted from THE JNC7 REPORT 2003
7.5 mmHg
5-6 mmHg
2 mmHg
-6
-10
-15
-16
-20
-21
-30
-40
-50
-38
CHD
Stroke
-46
12
12 to
to 13
13 mm
mm Hg
Hg Drop
Drop in
in Systolic BP Reduces
4-Year
4-Year Risk
Risk of
of CAD,
CAD, Stroke,
Stroke, Mortality
Mortality
0%
-10%
-13%
P=0.005
-20%
-30%
-40%
-21%
P<0.0001
-25%
P<0.001
-37%
P<0.001
Diastolic
dysfunction
CHF
Hypertension
MI
Death
Systolic
dysfunction
LV
Subclinical
Overt
Normal LV
Structure & Function remodeling LV dysfunction Heart Failure
Time
(decades)
Time
(months)
Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759-1796
Health Status/QOL
Lower
Higher
Impaired
coronary
reserve
Cardiac
arrhythmia
Myocardial
infarction
Sudden
death
Systolic
dysfunction
Congestive
heart failure
Concentric Hypertrophy
Normal
Dilatation
% Change
-Bloq
-5
Diuretics
-8
CCB
-11
ACEi
-12
ARBs
-12 *
Coronary
thrombosis
Myocardial
infarction
Myocardial
ischaemia
CAD
STROKE
Atherosclerosis
LVH
Risk factors
smoking, HYPERTENSION,
cholesterol, diabetes
Sudden Death
Arrhythmia &
loss of muscle
Remodelling
Ventricular
dilatation
Congestive
heart failure
Death
Hypertension
Shear forces
vessel wall thickness
Endothelial injury
Change in gene
expression, cytokines,
growth factors, adhesion
mollecules
Change in lipid
metabolism
Atherosclerosis
Change in Redox
status/
free radicals
BP
BP
Optimal
<120 / <80
<120/<80
Normal
120-129 / 80-84
120-129 /80-84
Prehypertension
High normal
130-139 / 85-89
130-139 / 85-89
Prehypertension
Grade 1 Hypertension
(mild)
140-159 / 90-99
140-159 / 90-99
Stage 1
Hypertension
Grade 2 Hypertension
(moderate)
160-179 /100-109
Grade 3 Hypertension
(severe)
Isolated Systolic
Hypertension
>160 / >100
>140
<90
JNC VII
Bp Classification
Normal
Stage 2
Hypertension
Isolated Systolic
Hypertension
Goals of Therapy
Reduce CVD and renal morbidity and
mortality
JNC VII
Uncomplicated HTN
< 140/90
Hypertension with
diabetes mellitus
< 130/85
< 130/80*
< 130/85
< 125/75
Heart failure
Hypertension with
renal impairment
*National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group.
Normal
High
normal
No other risk
factors
Average
risk
Average
risk
Low
added
risk
3 risk factors,
mets, organ
damage, or
diabetes
Established CV or
renal disease
Grade 1
HT
Grade 2
HT
Grade 3
HT
Low
added
risk
Low
added
risk
Moderate
added
risk
Moderate
added
risk
Moderate
added
risk
Moderate
added
risk
High
added
risk
High
added
risk
High
added
risk
Very high
added risk
Very high
added
risk
Very high
added
risk
Very high
added
risk
Very high
added
risk
Very high
added risk
High
added risk
Very high
added risk
Treatment
Treatment initiation: ESH/ESC 2003
Blood pressure
Other risk factors
and disease
history
Normal
High normal
Grade 1
Grade 2
Grade 3
No other risk
factors
No BP
intervention
No BP
intervention
Lifestyle changes
for several
months, then
drug treatment if
preferred by the
patient and
resources
available
Lifestyle changes
for several
months, then
drug treatment
Immediate drug
treatment and
lifestyle changes
Lifestyle
changes
Lifestyle
changes
Lifestyle changes
for several
months, then
drug treatment
Lifestyle changes
for several
months, then
drug treatment
Immediate drug
treatment and
lifestyle changes
3 or more risk
factors, target
organ damage, or
diabetes
Lifestyle
changes
Drug treatment
and lifestyle
changes
Drug treatment
and lifestyle
changes
Drug treatment
and lifestyle
changes
Immediate drug
treatment and
lifestyle changes
Associated clinical
conditions
Drug
treatment and
lifestyle
changes
Immediate drug
treatment and
lifestyle
changes
Immediate drug
treatment and
lifestyle changes
Immediate drug
treatment and
lifestyle changes
Immediate drug
treatment and
lifestyle changes
SBP*
mmHg
DBP*
mmHg
Lifestyle
modification
<120
and <80
Encourage
Without compelling
indication
Yes
No antihypertensive drug
indicated.
Stage 1
Hypertension
Yes
Stage 2
Hypertension
140159 or 9099
>160
or >100
Yes
With compelling
indications
Drug(s) for
compelling
indications.
Stage 2
HTN (SBP >=160 or DBP
>=100 mmHg)
Two Drug combination
for most (usually thiazidetype diuretic and ACEI, or
ARB, or BB, or CCB
Lifestyle Modifications to
Prevent and Manage Hypertension
Reduce weight
Moderate consumption
of:
alcohol
sodium
saturated fat
cholesterol
Increa
se
physic
al
activity
(JNC VI. Arch Intern Med. 1997)
Avoid
tobacco
Diuretics
Verapamil (1963)
Furosemide (1964)
Beta blockers
Propanolol (1965)
1970
Nifedipin (1975)
CCBs
1-blockers
ACE-inhibitors
Bisoprolol (1988)
Losartan (1995)
1990
AT-antagonists/ARB
Valsartan
2000 ?
BB
ACEI
ACB
CCB
Heart failure
Ald Ant
Post-MI
High coronary
disease risk
Diabetes
Chronic kidney
disease
Class
Coditions
favouring the use
Contraindications
Compelling
Diurretics
(thiazides)
Congestive HF
Elderly hypertensive
ISH
Hypertensive African
Gout
Diuretics (loop)
Renal Insufficiency
Congestive HF
Congestive HF
Post-MI
Renal failure
Hyperkalemia
Beta - blocker
Angina pectooris
Post-MI
Congestive HF (up
titration)
Active patients
Tachyarrythmias
Asthma
COPD
A-V block (grade 2
or 3)
Possible
Pregnancy
Peripheral Vascular D
Glucose intolerance
Athletes and
physically
Dyslipidemia
Coditions favouring
the use
Contraindications
Compelling
Calcium antagonist
(dihydropyridines)
Elderly patients
Isolated SH
Angina pectoris
Peripheral vascular D
Carotid atherosclerosis
Pregnancy
Calcium antagonist
(verapamil, diltiazem)
Angina pectoris
Carotid atherosclerosis
Supraventricular
tachycardia
ACEI
Congestive HF
LV dysfunction
Post-MI
Non-diabetic nephropathy
Type-1 diabetic
nephropathy
Proteinuria
Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis
Possible
Tachyarrythmias
Congestive HF
Coditions favouring
the use
Contraindications
Compelling
ACEI
Congestive HF
LV dysfunction
Post-MI
Non-diabetic nephropathy
Type-1 diabetic nephropathy
Proteinuria
Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis
ARB
Pregnancy
Hyperkalemia
Bilateral renal artery
stenosis
Alfa-blocker
BPH
Hyperlipidemia
Orthostatic
hypotension
Possible
Congestive HF
Clinical event
Previous stroke
Previous MI
Angina pectoris
BB, CA
Heart failure
Atrial fibrillation
Recurrent
Permanent
ARB, ACEI
BB, non-dihydropiridine
CA
Tachyarrhythmias
BB
ESRD/proteinuria
CA
LV dysfunction
ACEI
diuretics, CA
Metabolic syndrome
ACEI, ARB, CA
Diabetes mellitus
ACEI, ARB
Pregnancy
CA, Methyldopa, BB
Black People
diuretic, CA
Glaucoma
BB
ARB
Marked BP elevation
high/very high CV risk
Lover BP target
Single agent at
low dose
Two-drug combination
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 at
full dose
Full dose
monotherapy
Two-three drug
combination at full dose
Diuretics
-blockers
AT1-receptor
blockers
-blockers
AT1-receptor
blockers
1-blockers
Calcium
antagonists
1-blockers
Calcium
antagonists
ACE inhibitors
ACE inhibitors
<55 years
Step 1
Step 2
Step 3
Step 4
C or D
A
or
2006 update
BBs
Depression
Sleep
disorders
Exercise
intolerance
Dyslipidemia
Glucose
intolerance
Impotence
CCB
ACEIs
Edema
Flushing
Headache
Dizziness
GI
disorders
Changes
in heart
rate
Cough
Hyperkalemia
Rash
Angioedema
Hyperkalemia (rare)
Angioedema
ARBs
(Adapted from Hollenberg NK, Higginbotham MB. Therapeutic Options to Preserve Target
Organs. Parsippany, NJ: Applied Clinical Communications; Case 3 of 5)
Thank You