Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Benefits of hypertension control
1. Benefits of Hypertension Control:
What Levels ? Which Drugs ?
Dr. Akshay Mehta
Nanavati Superspeciality Hospital
Asian Heart Institute
2.
3. Mr X is 64 yr old with BP of 148/84 since last 6
months despite all life style measures. He has no
other RF, CVD or TOD. His brother had a stroke at
age 73 yrs. Should one start drug Rx ?
A. No, as per JNC VIII panel report
B. Yes, as per other guidelines
C. Leave it to the patient
4. Hypertension Guidelines 2011- 2014
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood pressure
(in mm Hg)
NICE
2011
ESH/
ESC 2013
2014 Hypertension
guidelines, US “JNC
8”
ASH /ISH
2014
Indian Guidelines -2013
Definition of
Hypertension
≥140/90
and daytime
ABPM (or home
BP)
≥135/85
≥140/90 Not addressed ≥140/90 > 140/90 mm Hg
Blood pressure
targets
< 140/90 <140/90 < 60 y. <140/90 <140/90 (young and middle aged)
<140/90
≥ 80 y. Elderly < 80 y. ≥ 80 y. Elderly 140 – 145/90
< 150/90 SBP 140-150 ≥ 60 y. <150/90 < 150/90
SBP <140 in fit
patients
Elderly ≥ 80 y.
SBP 140-150
Blood Pressure
target in patients
with diabetes
mellitus
Not
addresse
d
< 140/85 <140 /90 <140/90 <140/80
5. Published Online Journal of American Medical Association 18th Nov, 2013
• New relaxed drug Rx goals:
BP < 150/90 if age 60+ years
BP < 140/90 if age < 60 years
The panel originally appointed by the NHLBI to review the
evidence on treatment of hypertension
6. If you were to wake up in the
morning and had to have either a
stroke or a heart attack, which one
of the 2 would you like to have?
9. So for b/w age 60yrs & 80yrs, stopping at
SBP 150 goal is not a good idea
• If you want to prevent stroke
• If you want to protect the >60 population, a large
high risk group most likely to be protected with goal
below 140 mm Hg SBP
• Major trials show benefit with goal BP around 143
which is nearer 140 than 150
• Going to 140 mm Hg is safe
10. Problems with JNC VIII panel report
• Not sanctioned by the NHLBI
• The panel’s report is now published in JAMA as a
stand-alone document
• Prior guidelines based on the totality of evidence,
including observational studies, RCTs, and meta-
analyses, as well as expert opinion
• JNC VIII panel depended only on specific RCTs which
showed lack of definitive benefit for goal of 140
• But paradoxical that for young pts goal maintained at
140 despite NO evidence of benefit from RCT
11.
12. A target of <150/90 mm Hg is recommended
for patients >80 if it can be done safely
13. JNC VIII panel - Corollary
Recommendation
• In the general population aged ≥60 years, if
pharmacologic treatment for high BP results in
lower achieved SBP (eg, <140 mm Hg) and
treatment is well tolerated and without
adverse effects on health or quality of life,
treatment does not need to be adjusted.
14. JNC VIII Panel
Goals for CKD & Diabetes
• In the population aged ≥18 years with chronic kidney
disease (CKD), initiate pharmacologic treatment to
lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and
treat to goal SBP <140 mm Hg and goal DBP <90 mm
Hg
• In the population aged ≥18 years with diabetes,
initiate pharmacologic treatment to lower BP at SBP
≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal
SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert
Opinion – Grade E)
16. ]able 1. Key studies on blood pressure targets in patients with chronic kidney disease
MDRD study REIN-2 AASK
Year of publication 1994 2005 2010
No. individuals included 840 338 1094
Cause of CKD Nondiabetic Nondiabetic 'Hypertensive'
Baseline kidney 33 (low BP target) 36 (low BP target) 46 (low BP target)
function (ml/min) 32 (usual BP target) 34 (usual BP target) 45 (usual BP target)
Proteinuria at baseline 390 mg/day (low BP target) 2.8 g/day (low BP target) 80 mg/day (low BP target)
310 mg/day (usual BP target) 2.9 g/day (usual BP target) 80 mg/day (usual BP target)
Target BP (mmHg) Low BP: MAP≤92 (≈125/75) Low BP:<130/80 Low BP: MAP≤92 (≈125/75)
Usual BP: MAP≤107 (≈140/90) Usual BP: DBP<90
Usual BP: MAP≤102–107 (the latter
≈140/90)
Primary endpoint Rate of change in GFR ESRD
Combination of doubling of serum
creatinine, ESRD, and death
18. Superiority of ambulatory BP for predicting
CV death
Syst-Eur Study(Systolic hypertension in Europe Study)
Staessen JA et al. JAMA 1999;282:539-46
0.00
0.04
0.08
0.12
0.16
0.20
90 110 130 150 170 190 210 230
Systolic blood pressure (mmHg)
2-yearsincidenceof
cardiovascularendpoints
Nighttime
24-h
Daytime
Conventional
19. Other Goals to look at :
More goals, better results !
• Out of office BP :
-Nocturnal BP & Dip
-BP variability –including morning surge
-Masked hypertn
• Rate of BP control
• Lower limits of BP goals- J curve ?
• Central aortic BP
• Pulse wave velocity
20.
21. What are the lower limits ?
Is there a J curve ?
22. • No direct evidence
• Evidence from observational and post hoc analysis of trials
like INVEST, HYVET, ON TARGET etc :
• 1. No J shaped relationship between systolic BP and
adverse events
• 2. " " " b/w BP and other organs such as
brain, kidney etc
26. There could be a J shaped relationship between DBP and
cardiac events (MI) in elderly, having LVH and/or coronary
heart disease (esp non revascularized), and wide pulse
pressure. The critical DBP is 60 mm Hg.
28. Ambulatory BP targets :
Heart Foundation
• • Daytime and night-time ABP “loads”* should be <20% above
normal values.
• Mean day-time and night-time (sleep) ABP measurements
should differ by >10%.
30. All the following factors determine
choice of initial drugs in hypertension
except :
A. Age
B. Gender *
C. Race
D. Presence of comorbid conditions
E. BMI (obesity)
31. Best drug(s) to initiate treatment with,
in the young (<55)
• ACEI/ARB
• BB
• CCB
• D
37. √ ×
• Migraine
• Asthma
• Prostatism
• Gout
• Acute CVA
BB
CCB (NDHP) BB
αBB
ARB Diu
ACEI, BB, D Short
actg
DHPCCB
38. Drugs which activate the renin-angiotensin-aldosterone system
(green) make it more susceptible to the action of drugs which
suppress the system (shown in red).
How to combine drugs ?
40. Which is a better combination with
ACE I/ ARB ?
• CCB
• Diu
41. ACCOMPLISH TRIAL
Cumulativeeventrate
HR (95% CI): 0.80 (0.72, 0.90)
20% Risk Reduction
Time to 1st CV morbidity/mortality (days)
p = 0
ACEI + HCTZ
ACEI + CCB
650
526
.0002
INTERIM RESULTS Mar 08
42. ‘ACCOMPLISH’ SUBANALYSIS
Fat versus the thin !
• in patients treated with hydrochlorothiazide and benazepril,
there was a 69% higher risk in the lean patients as compared
to obese
• in people treated with amlodipine, this phenomenon not seen
• in lean pts, amlodipine was better and reduced the risk of
cardiovascular death 38%, total stroke by 40%, and MI by
more than 50%
• In obese patients diuretics - OK
44. When to Initiate Rx with Beta blockers?
• women of child-bearing potential
• people with evidence of increased
sympathetic drive.
• Co morbid conditions requiring BB
If BB alone not effective add
CCB or D ?
45. Best drug to reduce nocturnal BP
• ACEI/ARB
• BB
• CCB
• Diuretic √
46. Best drug to reduce BP variability
• ACEI/ARB
• BB
• CCB √
• D
48. Hypertension Guidelines 2011- 2014
Lindholm LH, Carlberg B. HT News 2014, Opus 35
Blood pressure
(in mm Hg)
NICE 2011 ESH/
ESC 2013
2014 Hypertension
guidelines, US “JNC
8”
ASH /ISH
2014
Indian Guidelines -2013
Definition of
Hypertension
≥140/90 and
daytime ABPM (or
home
BP) ≥135/85
≥140/90 Not addressed ≥140/90 > 140/90 mm Hg
Blood pressure
targets
< 140/90 <140/90 < 60 y. <140/90 <140/90 (young and middle aged)
<140/90
≥ 80 y. Elderly < 80 y. ≥ 80 y. Elderly 140 – 145/90
< 150/90 SBP 140-150 ≥ 60 y. <150/90 < 150/90
SBP <140 in fit
patients
Elderly ≥ 80 y.
SBP 140-150
Blood Pressure
target in patients
with diabetes
mellitus
Not
addressed
< 140/85 <140 /90 <140/90 <140/80
Initiate drug
therapy with two
drugs
Not mentioned In patients
with
markedly
elevated BP
≥160/100 ≥160/100 > 160/100
49. All the following are sound
combination of drugs except ?
A. ACEI +CCB
B. CCB+BB
C. ARB + Diu
D. ACEI + ARB
50. Indian Hypertn Guidelines 2013
BP Goals :
• 140/90 mm Hg in the young and middle aged
• 140/80 mm Hg in diabetic patients
• 130/85 mm Hg in pts who have survived stroke
• 140-145/90 in elderly patients
• Treatment of hypertension even in > 80 has been showed to
be beneficial and has been recommended.
• A J shaped curve does exist specially for non revascularised
CAD patients and caution has been advocated in trying to
lower blood pressure to low target levels specially in these
patients.
51. Indian Hypertn Guidelines 2013
• Which drugs :
• Beta-blockers not first line agents and now recommended as
agents for use only in young or in hypertensives with specific
indications.
• Diuretics are now considered at par with of ACEI’s or ARB’s
and CCB and not
• as preferred agents as in previous guidelines.
• Chlorthalidone is now available and shown to be better than
Hydrochlorothiazide and its usage is to be preferred.
52. Indian Hypertn Guidelines 2013
• Which Drugs
• When blood pressure is high by more than 20/10 mm of Hg
systolic and diastolic it is now recommended to start with a
combination of drugs.
• Certain combinations have been shown to be better than
others in recent trials. (Specially ACEI’s/ARB’s +CCB’s)
53.
54. Take home messages :
• BP Goal : Office BP < 140/90 in all except age 80 &
above
• Other Goals – more benefits : Out of office BP (esp
noct BP, dip, variability, masked hypertn etc)
• Initiate Rx accrdg to age and co morbid conditions
• Use physiologically sound combinations
• Avoid severe diastolic hypotension esp in non
revascularized CAD pts
Notas del editor
Not wanting a stroke is a strong reason to stick to goal of 140 b/w 60 and 80 age
Adjusted risk of outcome events by achieved systolic blood pressure, divided in to deciles (grey bars). The shallow nadir of the J-curve is spread over several deciles and occurred around 130 mmHg SBP for all outcomes except stroke. The reference value for the hazard ratio applies to SBP 121 mmHg. Reproduced with permission from Sleight et al.1
Achieved systolic blood pressure (SBP) values and reductions in cardiovascular (CV) events in trials of antihypertensive treatment in diabetics. Achieved SBP values are indicated in the histograms (yellow, less intensive treatment; brown, more intensive treatment) with ordinates on the left. % CV event (cardiovascular deaths, non-fatal myocardial infarctions, and strokes) reductions are indicated by the filled circles with ordinates on the right. Reductions are those reported in the original article, or calculated approximations when the combined cardiovascular outcome as specified above was not used in the original report. Data from the following trials are included: S.Eur.DM, Systolic Hypertension in Europe, diabetic subgroup;21 SHEP DM, Systolic Hypertension in the Elderly Program, diabetic subgroup;22 UKPDS, United Kingdom Prospective Diabetes Study;7 HOT DM, Hypertension Optimal Treatment, diabetic subgroup;6 HOPE, Microalbuminuria, cardiovascular and Renal Outcomes in the Heart Outcomes Prevention Evaluation;23 ADV = ADVANCE, Action in Diabetes and Vascular disease, Preterax and Diamicron-MR Controlled Evaluation;5 ABCD, Appropriate Blood pressure Control in Diabetes (HT, hypertensive subgroup;24 NT, normotensive subgroup25); ACRD = ACCORD, Action to Control Cardiovascular Risk in Diabetes.11 Modified from Zanchetti et al.12
