ueda 2016 hypertension & diabetes - gamila nasr

EGYPT IN FEW WORDS ……..

Current Age Demographics in Egypt

Age Demographics in Egypt 2050

Life expectancy in Egypt in males and females

HYPERTENSION & DIABETES

(NEW GUIDELINES).

Prof. GAMELA NASR , MD

Professor of Cardiology Suez Canal University ,

Consultant in Suez Canal Authority - National Insurance & Sporting Hospitals

Master of Medical Education Holland-SCU , Diploma of E Teaching NORWAY

Member of American Society of Clinical Nutrition

Trainer in Diploma for Clinical Nutrition in AUC and National Institute for

Nutrition

2010-2005

2010-2016

اللجان

العليا

موتمرات ودولية

محلية وعالميةالدراسات

العلياخدمة المجتمع

النشر المحلي

التدريسالتعليم الطبيوالدولىالمراحل

النمو العلمىةالتعليميخدمة

المرضىالمشروعات

التحكيم

2000-1995

2005-2000

CAREER Gantt Chart

1987-MAY 1995

True or false …..

• Hypertension is a common co morbidity with diabetes.

• Diabetes morbidity and mortality are mainly due to cardiovascular causes.

• No general consensus of which drug to use in diabetic hypertensive patients.

• Improvement in diabetic hypertensive outcome is dependant on how low is BP.

• The target BP in diabetic hypertensive patients is <130/80 mmHg.

• RAAS blockers are recommended by all guidelines in management of

hypertension in diabetics.

Agenda

• What is common in Diabetes and Hypertension? What is the

link?

• Why Hypertension is important?

• Why Diabetes is important?

• Management: What do literature and guidelines recommend?

Agenda

• What is common in Diabetes and Hypertension? What is the link?




What is common in Hypertension and Diabetes?

◦ Prevalent

◦ Morbidity

◦ Mortality

◦ Resistant

◦ Preventable

◦ Treatable

◦ Curable

Hypertension& type II DM: >40% @ age 45 years up to 60% @ age 75 years.

Agenda

• Diabetes and Hypertension, any link ?!




0

10

20

30

40

50

Lebanon KuwaitOmanQatar EgyptBahrain SaudiArabia

TurkeyUAE

PREVALENCE OF HYPERTENSION IN THE MIDDLE EAST

Hypertension is defined as systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg

Raised Blood Pressure, 2008. WHO website. http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/blood_pressure_prevalence/atlas.html. Accessed March 26, 2011.

43.7% 42.7% 41.4% 41.4% 40.4%38.9% 38.4% 38.1%

36.1%

Pre

vale

nce

, %

Why hypertension is important?

• One third (35%) of all adults have high blood pressure

o 53% aged 55–64

o 66% aged 65–74

o 76% aged 75+

• Each 10/5 mmHg reduction in BP associated with:

o 40% lower risk of stroke death

o 30% lower risk of other vascular mortality

• Strong correlation between hypertension and CV mortality

CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment

*Individuals aged 40-69 years, starting at BP 115/75 mm Hg.Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC VII. JAMA. 2003.

CVmortality

risk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

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

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Benefits of Lowering BP

Agenda





Why Diabetes is Important?

• The prevalence of diabetes worldwide is estimated to be 4.4% in 2030.

• The number diabetics is projected to rise from 171 to 536 millions in

2030.

• The prevalence of diabetes is higher in men than women.

• Diabetes is expected to be the 7th leading cause of death worldwide by

2020.

Global status report on non-communicable diseases 2010. Geneva, WHO, 2011.

Clinical Impact of Diabetes Mellitus

Diabetes

Leading cause

of amputation

of LL (PAD)

Leading cause

of new cases

of ESRD

2-4 fold

increase in CV

Mortality

Leading cause

of new cases

of blindness

40

1513 13

10

4 5

0

10

20

30

40

50

Causes of Death in People With Diabetes

of Diabetic Patients Deaths are from CV Causes65%

0

0.05

0.1

0.15

0.2

0.25

Even

t ra

te

Months6 9 153 18 2112

RR=2.88 (2.37-3.49)

24

RR=1.99 (1.52-2.60)

RR=1.71 (1.44-2.04)

RR=1.00

Diabetes/CVD (n=1,148)

No Diabetes/CVD (n=3,503)

Diabetes/No CVD (n=569)

No Diabetes/No CVD (n=2,796)

OASIS Study Mortality by Diabetes and CVD Status

Malmberg K, et al. Circulation. 2000;102:1014-1019.

OASIS=Organization to Assess Strategies for Ischemic Syndromes

CVD=cardiovascular disease.

aThis analysis by Stamler et al included a cohort of 342,815 men aged 35 to 57 years who did not have diabetes, and a cohort of 5,163 men who did have diabetes at baseline. The health status of study participants was followed through an average of 12 years.

1. Stamler J et al. Diabetes Care. 1993;16(2):434–444.

Combined Impact of Hypertension and Diabetes on CVD Death Rate in Men1,a

0

50

100

150

200

250

300

≥200180–199160–179140–159120–139<120

Systolic Blood Pressure, mmHg

CV

D D

eat

h R

ate

, p

er

10

,00

0 p

ers

on

-ye

ars

Without diabetes

With diabetes

Why Hypertension and DM are dangerous combination

MI=myocardial infarction; CHD=coronary heart disease; LVH=left ventricular hypertrophy; ESRD=end-stage renal disease; PAD=peripheral artery disease.

1. Mancia G et al. J Hypertens. 2007;25(6):1105–1187. 2. Chobanian AV et al. Hypertension. 2003;42:1206–1252. 3. Spence JD. Hypertension. 2004;44:20–21. 4. Cerasola G et al. J Nephrol. 2008;21:368–373. 5. Cerasola G et al. J Hum Hypertens. 2010;24:44–50.

39

Proteinuria, renal failure, ESRD

MI, CHD, LVH, AF, HF, sudden cardiac death

Hemorrhage, stroke, dementia

PAD

Retinopathy

Agenda





75% of diabetic complications are attributed to hypertension

70% of diabetic patients die of cardiovascular disease

60% of patients require >2 antihypertensive agents to achieve tight control

Treatment of hypertension in patients with diabetes reduces:

Total mortality, MI, stroke, retinopathy and progressive renal failure

Management of Hypertension in Diabetes patients

JNC VIII

• Recommendation 5: In population >18 years with DM, initiate pharmacologic treatment to lower

BP at SBP 140mmHg or DBP 90 mmHg and treat to a goal SBP <140 mmHg and goal DBP <90

mmHg. (Expert Opinion –Grade E)

• Recommendation 6: In general nonblack population, including those with DM, initial

antihypertensive treatment should include a thiazide-type diuretic, CCBs, ACEI, or ARB.

(Moderate Recommendation– Grade B)

• Recommendation 7: In general black population, including those with DM, initial

antihypertensive treatment should include a thiazide-type diuretic or CCB. (for black patients with

DM: Weak Recommendation – Grade C)

• Recommendation 8: In population >18 years with CKD, initial antihypertensive treatment should

include ACEI or ARB to improve kidney outcomes. (Mod. Recommendation – Grade B).

JNC 7 Algorithm for the Treatment of Hypertension

*Compelling IndicationsHeart failurePost-MIHigh coronary artery disease riskDiabetesChronic kidney diseaseRecurrent stroke prevention

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mm Hg for those with diabetes or chronic kidney

disease)

Initial Drug Choices

Drug(s) for compelling indications*

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

Lifestyle Modifications

Stage 2 Hypertension

(SBP >160 or DBP >100 mmHg) 2-drug combination for most

(usually thiazide-type diuretic, ACEI, or ARB, or BB, or CCB).

Stage 1 Hypertension

(SBP 140–159/ DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI,

ARB, BB, CCB, or combination.

Without Compelling Indications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

With Compelling Indications

Chobanian AV et al. JAMA. 2003;289:2560–2572.

2013 Oct;31(10):1925-38.

ESH/ESC 2013 One Goal For All

2013 ESH/ESC Guidelines for the management of arterial hypertension

ARBs in ESH/ESC Treatment Guidelines

1. Mancia G et al. J Hypertens. 2007;25(6):1105–1187.

ACEInhibitors Diuretics

β-Blockers CCBs ARBs

LVH

Asymptomatic atherosclerosis

Microalbuminuria

Renal dysfunction

Previous stroke

Previous myocardial infarction

Heart failure

Recurrent atrial fibrillation

ESRD/proteinuria

Metabolic syndrome

Diabetes mellitus

ISH (elderly)

ACE inhibitor or ARB

Aged <55 years

Aged ≥55 years orblack person of African orCaribbean family originof any age

CCB

ACE inhibitor or ARB + CCB

ACE inhibitor or ARB + CCB + thiazide-like diuretic

ACE inhibitor or ARB + CCB + thiazide-like diuretic +consider further diuretic or α- or β-blocker

NICE (British) Hypertension Guidelines’ Treatment Algorithm

18

NICE Guidelines

(updated 26th Nov 2013)

Managing blood pressure in type 2 diabetes

http://pathways.nice.org.uk/pathways/diabetes


Managing blood pressure in type 2 diabetes



Egyptian Hypertension Guidelines 2014

The diagnostic cutoff for the diagnosis

of hypertension is lower in people with

diabetes (140/90 mmHg) than those

without diabetes or low risk patients

(150/95 mmHg).

Prevalence of hypertension is 1.5-fold

higher in diabetic patients relative to

non-diabetic patients.

Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

WithNephropathy, CVD or CV risk factors

ACE Inhibitor or ARB

Diabetes

Withoutthe above

1. ACE Inhibitor or ARB or

2. Thiazide diureticor DHP-CCB

• Monitor K and Cr. carefully in patients with CKD prescribed an ACEI or ARB.

• Combination ACEI & ARB are not recommended in the absence of proteinuria

• More than 3 drugs may be needed to reach target values

Combination of 2 first line

drugs may be considered

as initial therapy if SBP is

>20 mmHg or DBP >10

mmHg above target

> 2-drug combinations

Pharmacotherapy for Hypertension in Patients with Diabetes

Hypertension, Diabetes and Pregnancy

• In a pregnancy complicated by DM & hypertension, target BP goals is 130/80

mmHg.

• Lower blood pressure levels may be associated with impaired fetal growth.

• ACEi and ARBs are contraindicated, as they cause fetal damage.

• Effective and safe antihypertensive drugs include: methyldopa, labetalol,

diltiazem, clonidine, and prazosin.

• Chronic diuretic use during pregnancy is associated with restricted maternal

plasma volume, which may reduce uteroplacental perfusion.

Agenda





• Why RAAS blockade in Diabetic hypertensive patients?

Angiotensin II

Vasoconstriction

Aldosterone

Secretion

Direct Renal

Sodium Retention

↑ Thirst

ADH Release

↑ Cardiac

Contractility

Sympathetic Activation

Cardiac & Vascular

Hypertrophy

All known physiologic effects are mediated

by the angiotensin II type 1 receptor

RAAS Blockade in Hypertensive diabetic patients

• This review article reviewed 63 RCT trials with 36 917 participants,

including 2400 deaths, 766 patients required dialysis& 1099 patients

whose s.Cr. level had doubled.

• RAAS Blockers, alone or in combination, significantly reduced mortality

and doubling of serum creatinine levels.

RAAS Blockers, ARBs, in Hypertension Diabetic Patients

Reduced risk of CV events (MI, HF, stroke).

Slower rate of deterioration in renal function.

Lower CV and all-cause mortality risk.

Take-Home Message

• Diabetes& Hypertension are dangerous combination

• RCTs support the general consensus & guidelines that RAAS Blockade, including

ARBs, is a class of choice as monotherapy or in combination in hypertensive

diabetic patients.

Lower all-cause & CV mortality.

Reduced risk of CV events (MI & HF).

Slower rate of deterioration in renal function.

• ?/

•?

“The first wealth is health." Ralph Waldo Emerson

ueda 2016 hypertension & diabetes - gamila nasr

Health & Medicine