1

Goals Of Hypertension Goals Of Hypertension Management in Clinical Practice Management in Clinical Practice

Adel E. Berbari, MD, FAHA, FACP

Professor of Medicine and Physiology

Head Division of Hypertension and Vascular Medicine

World Hypertension League (WHL) MeetingWorld Hypertension League (WHL) Meeting

Head, Division of Hypertension and Vascular Medicine

American University of Beirut- Medical Center

Venue: Fairmont Heliopolis Hotel, Cairo- EgyptDate : Tuesday- April 8, 2008

Role of Physician /Health Care ProviderRole of Physician /Health Care Provider1.1. Lack of appreciation of definition of hypertension Lack of appreciation of definition of hypertension and and

importance of cardiovascular risk factors. importance of cardiovascular risk factors. 2.2. Excessive reliance on monotherapyExcessive reliance on monotherapy

Causes of Poor BP control Rates

3.3. Therapeutic inertiaTherapeutic inertiaReluctance to increase drug dose or to add additional Reluctance to increase drug dose or to add additional antihypertensive agents.antihypertensive agents.

Role of PatientRole of Patient1.1. Non adherence /non compliance with prescribed medicationsNon adherence /non compliance with prescribed medications2.2. Lack of persistenceLack of persistence

C ti ti f f di ti l f ifi dC ti ti f f di ti l f ifi dContinuation of use of medications only for a specified Continuation of use of medications only for a specified time periodtime period

Impact of antihypertensive regimenImpact of antihypertensive regimen1.1. Complexity of treatmentComplexity of treatment2.2. Drug associated side effectsDrug associated side effects3.3. Drug costDrug cost

2

10

12

14

16 R

isk

0

2

4

6

8

Rel

ativ

e

Increasing increments of blood pressure are Increasing increments of blood pressure are associated with increasing risk of cardiovascular associated with increasing risk of cardiovascular

mortality.mortality.

0115/75 135/85 155/95 175/105 195/115mm Hg mm Hgmm Hg mm Hg mm Hg

6

8

10

12

ncid

ence

(%

0

2

4

6

<120/<80 120-129/80-84 130-139/85-89

Cum

ulat

ive

In

SBP

DBP

Impact Impact of High Normal BP on Risk of CV Event Cumulative of High Normal BP on Risk of CV Event Cumulative 10 10 yr Incidence of First Cardiovascular Event According to yr Incidence of First Cardiovascular Event According to

BP Category at baseline BP Category at baseline

((Framingham Heart Study)Framingham Heart Study)

DBPBP Category Optimal Normal High Normal

3

S t li

Age Related Blood Pressure Changes

g)

160

140Males

Systolic

Diastolic

d Pr

essu

re (m

mH

120

100

140Females

Age in years

Blo

o

0 10 20 30 40 50 60 70 80

60

80

In Framingham Heart StudyIn Framingham Heart Study–– Gradual shift from DBP to SBP as Gradual shift from DBP to SBP as

cardiovascular risk predictorscardiovascular risk predictors–– In patients In patients younger than younger than 5050 yearsyears, , DBP major DBP major

predictorpredictor–– In patients In patients 50 50 –– 59 59 yearsyears, , SBP/DBP,SBP/DBP, equal equal

predictor predictor –– In patients In patients 60 60 years and olderyears and older, , coronary heart coronary heart

disease:disease:Positive Correlation with SBPPositive Correlation with SBPInverse Relation with DBP Inverse Relation with DBP

4

20

22

24

92

8883

75

68

DBP

at Baseline

12

14

16

1892

Risk of Death Risk of Death in Control (Untreated) Patients with Systolic (SBP) in Control (Untreated) Patients with Systolic (SBP) at Baseline and at Baseline and Fixed Levels of Diastolic (DBP) Fixed Levels of Diastolic (DBP) in Elderly (in Elderly (7070yrs)yrs)

Patients with Isolated Systolic HypertensionPatients with Isolated Systolic Hypertension

10

160 170 180 190 200 210 220

1.5

2

2.5

Rat

io

SBP

DBP PP

0

0.5

1

Haz

ard

Blood Pressure (mmHg)Adjusted hazard ratios for combined coronary heart disease and

cerebrovascular disease (CHD+CVD) events, SBP:Systolic Blood Pressure, DBP; Diastolic Blood Pressure; PP : Pulse Pressure

5

Systolic hypertension recently recognized as more important than diastolic hypertension:yp

- Cardiovascular risk factor- Therapeutic decision making in older

subjects- Poor hypertension control in 70 % of yp

treated patients due to inability of reaching goal SBP < 140 mmHg

Impact of Serum Chelesterol Levels on Risk of Heart Attacks

30

35

LOW RISK

• No Smoking

Normal

Hypertension

10

15

20

25

30

CH

D R

ISK

(%)

• Normal Glucose Tolerance

• No EKG-LVH195180165150 SB

P

0

5

185 210 235 260 285 310 335Serum Cholesterol (mg/dl)

C 150135120105

S

Data from Framingham study

6

Impact of Serum Cholesterol Levels on Risk of Heart Attacks

35

40 195

180

d Pr

essu

re HIGH RISK• Smoking• Glucose

Hypertension

15

20

25

30

CH

D R

ISK

% 135120

150165

105 Syst

olic

Blo

od Intolerance• EKG-LVH

0

5

10

185 210 235 260 285 310 335Serum cholesterol (mg/dl) Data from Framingham

study

Age 40 Years Age 60 YearsgSBP 180 mmHg

Age 60 Years SBP 120 mmHg

SimilarCardiovascular

Risk

7

35

40

ear

Determinants of CV Events risk during 20 years of successful antihypertensive treatment in middle aged subjects (modified from Alderman)

15

20

25

30

35

er 1

000

pers

ons

/ye

0

5

10

Rat

es p

e

Age >50 PP>60 Smoking Cholesterol DM LVH Heart Stroke> 6.34 Attack

EducationalProvider

Strategies to improve

compliance

Combinational approach to

improve compliance

Parthan et al. Exp Rev Pharmacoeconomics Outcomes Res 2006;6:325–36

BehaviouralAffective

8

ACCOMPLISH: Exceptional ControlRates with ACCOMPLISH: Exceptional ControlRates with Initial Combination TherapyInitial Combination Therapy

80.580

9075.6 71.8

Achieved Control RatesAchieved Control Rates

Con

trol

rate

(%)

Baseline Control Rates

N=8,067

20

30

40

50

60

70

37.6

21 0

44.4N=11,400

65.1

N=3,333

N=1,361

38.6

Jamerson ASH 2007

All Nordic U.S. African American

1021.0

Incidence of serious hypotensive episodes 1.8 % in 12.600 patients

Multiple Antihypertensive Agents are Needed Multiple Antihypertensive Agents are Needed to Reach BP Goalto Reach BP Goal

Trial (SBP achieved)

ASCOT-BPLA (136.9 mmHg)

( )ALLHAT (138 mmHg)IDNT (138 mmHg)

RENAAL (141 mmHg)UKPDS (144 mmHg)

ABCD (132 mmHg)MDRD (132 mmHg)

Average no. of antihypertensive medications1 2 3 4

Reproduced from Am J Med 116(5A), Bakris et al. pp. 30S–8. Copyright © 2004,with permission from Elsevier; Dahlöf et al. Lancet 2005;366:895–906

HOT (138 mmHg)AASK (128 mmHg)

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Advantages of Fixed Versus Free Advantages of Fixed Versus Free Combinations of Two Antihypertensive DrugsCombinations of Two Antihypertensive Drugs

FixedFixed FreeFree

Si li it fSi li it fSimplicity of Simplicity of treatmenttreatment

++ ––

ComplianceCompliance ++ ––

EfficacyEfficacy ++ ++

TolerabilityTolerability +*+* ––

*Lower doses generally used in fixed-dose combinations+ = potential advantage*Lower doses generally used in fixed-dose combinations+ = potential advantage

TolerabilityTolerability ++

PricePrice ++ ––

FlexibilityFlexibility –– ++

Increased Persistence with FixedIncreased Persistence with Fixed--dose dose Combinations Compared with Individual Combinations Compared with Individual

ComponentComponent--based Therapybased Therapy

Fixed-dose combination

19%

54%

combination(Valsartan/HCTZ)

(n=8,150)

Free combination(Valsartan + HCTZ)

(n=561)

p<p<00..00010001

0% 20% 40% 60% 80%

Persistence (defined as patients remaining on treatmentfor a duration of 12 months)

Jackson et al. Value Health Suppl 2006;9:A363

10

Blood Pressure GoalsBlood Pressure Goals

Non diabetic DiabeticChronic kidney disease

(UAE ≥ 1G/D)

Coronary artery disease

< 140/90(or less if tolerated/

achievable

< 125/75< 130/80

Early/ aggressive

Antihypertensive

Delay

Prevent

Reverse

Protection

Futuretreatment.

BP related

Target organ damage

Morbidity

Mortality

Effects of early/aggressive antihypertensive treatment

11

-20

-10

0du

ctio

n (%

)

Primary end pointStrokeMI

-50

-40

-30

Ris

k R

ed All cause mortalityCHF hospitalization

Effect of prompt / better BP control withinEffect of prompt / better BP control within first 6 months of treatment on cardiovascular outcomes (SBP < 140mmHg)

(Value Clinical Trial)

BP ReductionBP Reduction Cardiovascular Cardiovascular ProtectionProtectionProtectionProtection

All classes of All classes of antihypertensive agentsantihypertensive agents

Calcium channel Calcium channel antagonistsantagonists

Angiotensin converting Angiotensin converting enzyme inhibitorsenzyme inhibitors

Angiotensin receptor Angiotensin receptor antagonistsantagonists

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BP ReductionBP Reduction Cardiovascular Cardiovascular ProtectionProtection

All classes ofAll classes of Calcium channelCalcium channelAll classes of All classes of antihypertensive agentsantihypertensive agents

Calcium channel Calcium channel antagonistsantagonists

Angiotensin converting Angiotensin converting enzyme inhibitorsenzyme inhibitors

Angiotensin receptor Angiotensin receptor antagonistsantagonists

RenoprotectionRenoprotectionAngiotensin converting enzyme Angiotensin converting enzyme

inhibitorsinhibitorsAngiotensin receptor Angiotensin receptor

antagonistsantagonists

Antihypertensive Therapy

EffectivePreventionRegression

ManagementAssociated

Control CV

PreventionBP

Reduction

gTarget Organ

Damage

Associated Clinical

Conditions

CVRisk

Factors

New OnsetDiabetes