the southern african hypertension guideline · •overall, cv risk factors – high- > middle-...

THE SOUTHERN AFRICAN

HYPERTENSION GUIDELINE

Brian Rayner,

Division of Hypertension, University of Cape Town

Health Statistics and Informatics

Deaths attributed to 19 leading factors,by country income level, 2004

Lewington et al. Lancet 2002;360:1903–13

Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increment in Systolic/Diastolic BP*

Cardiovascular mortality risk

0

2

4

8

115/75 135/85 155/95 175/105

6

Systolic BP/Diastolic BP (mmHg)

*Individuals aged 40–69 years

2X

risk

4X

risk

8X

risk

1X risk

Figure 5

Source: The Lancet 2014; 383:1899-1911 (DOI:10.1016/S0140-6736(14)60685-1)

Terms and Conditions

http://www.thelancet.com/journals/lancet/article/S0140-6736(14)60685-1/abstract



http://www.thelancet.com/popup?fileName=footer-terms

Bradshaw et al MRC and CDiA 2011

Scope of Problem

Prevalence of Hypertension in SA men

Deaths attributable to high blood pressure in males, South Africa 2000

0

1000

2000

3000

4000

5000

6000

7000

30 - 44 45 - 49 60 - 69 70 - 79 80+

Stroke Hypertensive disease Ischaemic heart disease other cardiovascular

Norman et al. 2007 BOD at the MRC

Principles

Go et al, Effective approach to HT management, Hypertension 2014

Algorithm Development


STROKE

CHD

% reduction / 6 mm Hg fall in

diastolic blood pressure

Epidemiological data

Randomised trials

Epidemiological data

Randomised trials

0 10 20 30 40

50

Results of randomised trials of antihypertensive drug therapy

Collins and Peto,

1994

Awareness, treatment, and control of hypertension

USA

Canada

UK

Germany

Greece

Spain

China

Japan

Taiwan

Mexico

Aware*

Treated†

Controlled#

*Prior diagnosis by health professional †Use of BP medication

#On BP medication, with SBP/DBP<140/90 mm Hg

Proportion of patients (%)

0 20 40 60 80

Figure 6. 4. Adapted from Whelton. J Clin Hypertens. 2004;6:636-642.

Prevalence, awareness, treatment and control in SSA

0

5

10

15

20

25

30

35

prevalence awareness treatment control

%

Pooled data from 33 surveys involving over 110,414 participants of mean age 40 years Adapted, Feven Ataklte et al, Hypertension, 2014

THE GREATEST DANGER TO A MAN

WITH HIGH BLOOD PRESSURE LIES IN

ITS DISCOVERY, BECAUSE SOME FOOL

IS CERTAIN TO LOWER IT

Hay, Editorial, BMJ, 1937

QUOTES OF THE

CENTURY

Kaiser Permanente Model

• Between 2001-2009 number of patients with HT increased from 349,937 to 652763.

• Target BP from 44% to 80%

• In 2011 > 87% reached target


PURE STUDY

• The PURE study enrolled 155,245 subjects between 35 and 70 years old, from both rural and urban areas in 17 countries to assess the influence of cardiovascular risk factors on cardiovascular disease and mortality.

• Overall, CV risk factors – high- > middle- > low-income countries

• Treatment and preventive measures also followed this pattern (p<0.0001).

Yusuf, S, ESC 2013

Fatal CV Events

Yusuf, S, ESC 2013

Key Issues

• Measurement of BP

• Investigations

• Thresholds for diagnosis and intervention

• First line therapy

• How to initiate

• Treatment resistance

#

# Level E evidence

*

OUTCOME OF TREATMENT WITH STAGE 1 HYPERTENSION (3.6/2.4 mmHg)

0.5 1.0 2.0 RR CI Stroke 0.72 0.55-0.94 Coronary heart 0.91 0.74-1.12disease CCF 0.8 0.57-1.12 Total CVS events 0.86 0.74-1.01 CVS death 0.75 0.57-0.98 Total mortality 0.92 0.67-0.92

Adapted Johan Sundstrom, Ann Intenr Med 2014

Favours Treatment Favours control

TARGETS ELDERLY

• In patients > 80 years of age there is solid evidence to initiate treatment at SBP ≥ 160, and lower it between 140-150 provided they are in good mental and physical condition 1 A

• In frail elderly treatment is discretionary 1 C

• Diuretics/CCBs preferred 1 A

Copyright © 2013 Journal of Hypertension. Published

by Lippincott Williams & Wilkins. ESC/ESH 2013

Investigation TOD Secondary cause Risk stratification

Dipsticks urine Yes, usually 1+ protein only

in hypertensive

nephrosclerosis

2+ or more proteinuria

and/or haematuria

suggests kidney disease

Yes

ECG LVH (see ECG criteria) No Yes

creatinine Yes Yes Yes

Echocardiogram# LVH No Yes

K+ No Low K+ may suggest

primary aldosteronism

No

Fasting glucose No no yes

Fasting lipogram No no yes

Urine albumin/creatinine ratio* Yes Yes, if markedly elevated Yes

*mandatory in diabetics, first voided urine specimen, < 3mg – normal, 3-30 microalbuminuria, > 30 macroalbuminuria (spot urines tend to overestimate ratio), # - only if readily available

Mandatory Investigations

>35 – Sokolow-Lyon)

Cornel – (S in V3 + R in aVL + 6 in females) x QRS duration > 2440

Harbinger of death

R in AvL > 11

PATIENT REPORTED HE WALKED

THE DOG REGULARLY

Avoid refined CHO

NICE/SA/JNC/ISHIB GUIDELINES

Diuretics

ARB

CCB

ACEi

Diuretic/CCB preferred in black patients

Diuretic vs other

b Blocker vs other

ACEI vs other

ARB vs other

CCB vs other

1.0 0.7 1.4

0.94 (0.82, 1.09)

1.18 (1.03, 1.36)

1.06 (0.94, 1.20)

0.90 (0.71, 1.13)

0.91 (0.84, 0.98)

favours specified drug favours “other” drug

Relative Risk (95% CI)

SBP DBP

-1.4 0.2

1.4 0.6

0.9 0.4

-0.4 0.1

-0.4 -0.9

Trials Events

15 2255

13 2004

17 2951

7 1643

25 4981

Stroke Events

Relative Risk (95% CI)

D BP (mmHg) Number of

Meta-Analysis of Hypertension Trials: Comparison of Drug Classes

Law et al , BMJ,2009

ASCOT-BPLA Summary of All End Points

Dahlöf B, et al. Lancet. 2005;366:895-906.

Atenolol thiazide better

0.50 0.70 1.00 1.45

Primary Non-fatal MI (incl silent) + fatal CHD

Secondary

Non-fatal MI (exc. Silent) +fatal CHD

Total coronary end point

Total CV event and procedures

All-cause mortality

Cardiovascular mortality

Fatal and non-fatal stroke

Fatal and non-fatal heart failure

Tertiary

Silent MI

Unstable angina

Chronic stable angina

Peripheral arterial disease

Life-threatening arrhythmias

New-onset diabetes mellitus

New-onset renal impairment

2.00

Unadjusted HR (95% CI)

0.90 (0.79-1.02)

0.87 (0.76-1.00)

0.87 (0.79-0.96)

0.84 (0.78-0.90)

0.89 (0.81-0.99)

0.76 (0.65-0.90)

0.77 (0.66-0.89)

0.84 (0.66-1.05)

1.27 (0.80-2.00)

0.68 (0.51-0.92)

0.98 (0.81-1.19)

0.65 (0.52-0.81)

1.07 (0.62-1.85)

0.70 (0.63-.078)

0.85 (0.75-0.97)

0.86 (0.77-0.96)

0.84 (0.76-0.92)

Figure 4. 14. Adapted from ASCOT Dahlöf B, Sever PS, Poulter NR et al; Lancet. 2005;366:895-906.

±

amlodipine ± perindopril better Duration – 5.5 years

2014 Hypertension Guideline JNC-8 Dosing Strategies

1. Start low dose monotherapy and titrate to maximum dose before considering 2nd drug

2. Start low dose monotherapy and add second drug at low dose

3. Start 2 drugs especially if BP > 160/100 mmHg or 20/10 mmHg above goal

SAHS Practice Guidelines, CVJA, in press

BP > 180/110 – see severe hypertension

Re

du

ctio

n in

blo

od

pre

ssu

re (

mm

Hg

)

–11

–21

15 days

–41.9

–23.2

60 days

–63

–29

Stage 3 hypertension (SBP>180 mm Hg)

–29

–16

30 days

–10

0

–20

–30

–40

–50

–60

–70

SBP DBP

n=161

13. Adapted from STRONG. Bahl VK, et al. Am J Cardiovasc Drugs 2009;9:135-142.

BP lowering Efficacy of perindopril and amlodipine combination

n=1 250

….working in Synergy

CCB alone CCB + ACE inhibitor

Precapillary vasodilation => oedema

Venous dilation hence normalising intracapillary pressure

Figure 3. 17. Adapted from Ferrari R. Medical Research and Opinion 2008. 24(12):3543-3557

Compliance and persistence with therapy associated with the use of

an FDC of 2 antihypertensive agents as compared with its

corresponding free-drug combination.

Gupta A K et al. Hypertension 2010;55:399-407 Copyright © American Heart Association

Incidence rates and incidence rate ratios of cardiovascular (CV) events.

Gradman A H et al. Hypertension 2013;61:309-318

Copyright © American Heart Association

A, Kaplan-Meier estimates of achieving target blood pressure (BP) for patients with and

without a cardiovascular (CV) event during the follow-up for all patients.

Gradman A H et al. Hypertension 2013;61:309-318

Copyright © American Heart Association

GUIDELINE CONSENSUS

• Broad consensus for BP thresholds for intervention

• Consensus on BP targets/goals – less aggressive than before

• Much closer agreement on optimal drug treatment (ACE or ARB, CCB, diuretic or all 3)

• Recognition for the wider use of drug combinations for optimal BP control, and earlier initial use of combinations in high risk e.g. > 160/100

• CCB/diuretic for people of African descent

46

SEVERE HYPERTENSION – BP > 180/110

• Asymptomatic severe

– BP > 180/110 mmHg

– No proteinuria, CCF, renal failure or grade 3-4 hpt changes

– Repeat measurements within 1 hour

– Start 2 first line drugs

– Review in 1 week and escalate treatment as needed

– See regularly until controlled

SEVERE HYPERTENSION – BP > 180/110

• Hypertensive urgency – Symptomatic patient e.g. headaches, SOB, oedema

– No proteinuria, CCF, renal failure or

– Admit to hospital and start 2 drugs orally

– Monitor BP, escalate as needed

– Preferably monitor for 48 hours

• Hypertensive Emergency – Encephalopathy, proteinuria, increased creatinine, grade 3-

4 fundal changes, CCF, unstable angina

– Admit to ICU for IVI treatment – labetalol, nitroglycerin

– 25% drop in BP in first 24 hours

>35 – Sokolow-Lyon)

Cornel – (S in V3 + R in aVL + 6 in females) x QRS duration > 2440

Harbinger of death

R in AvL > 11

MALIGNANT HYPERTENSION

BP > 120-130 diastolic

Renal failure

Dipsticks – protein and blood,

Improves with treatment

Resistant Hypertension

• Beta blocker

• Alpha blocker

• Aldosterone antagonist

• Vasodilator e.g. minoxidil

• Centrally acting

• Furosemide twice daily if eGFR < 45mls/min

ASCOT RESULTS BP

Chapman et al, Circulation, 2008

CONCLUSIONS

• Hypertension is major world wide epidemic

• There are substantial differences in awareness, prevalence and control rates, and CV outcomes

• Broad consensus for BP thresholds for intervention

• Consensus on BP targets/goals – less aggressive than before

• Much closer agreement on optimal drug treatment (ACE or ARB, CCB, diuretic or all 3)

• Recognition for the wider use of drug combinations for optimal BP control, and earlier initial use of combinations in high risk e.g. > 160/100

• SAHS guideline is a potential model for Africa

the southern african hypertension guideline · •overall, cv risk factors – high- > middle-...

Documents