End Organ Damage In HypertensionDARB.pptx

HTN
AF
CVA
END ORGAN DAMAGE

1. End Organ Damage In Hypertension Dr Ihab suliman Sept 2022

2. Treatment In the Morning or Evening: The TIME Study Results A large randomised study of 21,104 subjects with treated high BP to find out if taking tablets in the evening is better than in the morning Funded by the British Heart Foundation and BIHS Prof Tom MacDonald, University of Dundee, UK 25 th August 2022

3. Our study findings Taking prescribed BP tablets in the evening was no better or worse than taking them in the morning for the prevention of cardiovascular disease. Taking medication in the evening was not harmful. Patients can take their BP medication in either the morning or evening as the timing makes no difference to cardiovascular outcomes.

4. Methods A large decentralised study of patients treated in the UK NHS 21,104 randomised and followed up for over 5 years (longest 9.3 years) Outcome tracked from patients, clinicians and UK NHS hospital databases and death records Independently verified heart attacks, strokes and CV deaths Intention to treat analysis

5. Results –MI, stroke or vascular death

6. Results – other outcomes not different

7. Key messages Taking tablets for high BP in the evening was not different to morning dosing in prevening heart attacks, strokes and vascular deaths Evening dosing was not harmful Patients can take their BP tablets whenever convenient

8. Definitions and epidemiology. End organ damage in HTN

9. Definition Hypertension in adults  (stage 1)  2017 ACC/AHA: persistent  systolic  blood pressure (SBP )  ≥ 130 mm Hg  and/or  diastolic  blood pressure (DBP)  ≥ 80 mm Hg   [1] 2020 International Society of Hypertension (ISH) and 2014 JNC 8: persistent SBP   ≥ 140 mm Hg  and/or DBP  ≥ 90 mm Hg   [2] Hypertension in children  (< 13 years of age)  (stage 1): blood pressure ≥ 95 th percentile  or ≥ 130/80 mm Hg, whichever is lower    Primary hypertension : hypertension with no identifiable cause Secondary hypertension : hypertension caused by an identifiable underlying condition Resistant hypertension : hypertension that remains uncontrolled (≥ 130/80 mm Hg) despite treatment with ≥ 3  antihypertensives  OR requires ≥ 4 medications to be controlled

10. Prevalence Hypertension affects between approximately one-third and one-half of adults in the US.  Primary hypertension : accounts for  ∼ 90%  of cases of hypertension in adults and  prevalence  is increasing in children and adolescents .  Secondary hypertension : accounts for  ∼ 10%  of cases of hypertension in adults  [1] Prevalence  increases with age: Approximately 65–75% of adults develop hypertension by 65–74 years of age.    [11] Rates are highest in  African American individuals , followed by white individuals, and lowest in Asian American and Hispanic individuals.  ∼ 60–87% of overweight  and ∼ 73–95% of  obese  patients are affected.

11. Assessment of the overall cardiovascular risk and Search for target organ damage Brain Cerebrovascular disease transient ischemic attacks ischemic or hemorrhagic stroke vascular dementia Eyes Hypertensive retinopathy Heart Left ventricular dysfunction Left ventricular hypertrophy Coronary artery disease myocardial infarction angina pectoris congestive heart failure Kidney Chronic kidney disease hypertensive nephropathy (GFR < 60 ml/min/1.73 m2) albuminuria Arteries Peripheral artery disease intermittent claudication ankle brachial index < 0.9

12. Effect of Long-Term Modest Reductions in CV Risk Factors Emberson et al. Eur Heart J. 2004;25:484-491. 10% Reduction in BP 10% Reduction in Total-C + 45% Reduction in CVD =

13. Routine Laboratory Tests Preliminary Investigations of patients with hypertension Urinalysis Blood chemistry (potassium, sodium and creatinine) Fasting glucose Fasting or Non Fasting lipid profile Standard 12-leads ECG Optional tests Urinary albumin excretion or albumin/creatinine ratio Limited Echo for LVH

14. The classic manifestations of hypertensive end organ damage include the following: vascular and hemorrhagic stroke, retinopathy, coronary heart disease/myocardial infarction and heart failure, proteinuria and renal failure and in the vasculature, atherosclerotic change including the development of stenoses and aneurysms

15. Hypertensive Emergencies : Definition A rapid decompensation of vital organ function secondary to an inapropriately elevated BP Require lowering of BP within 1 hour to decrease morbidity Not determined by a BP level, but rather the imminent compromise of vital organ function

16. Hypertensive Emergencies CNS - Hypertensive encephalopathy CVS Acute myocardial ischemia Acute cardiogenic pulmonary edema Acute aortic dissection Post-op vascular surgery Renal - Acute renal failure Eclampsia Catechol excess- Pheochrom, Drugs

17. Hypertensive Emergencies High BP WITHOUT acute end-organ dysfunction IS NOT a hypertensive emergency “Hypertensive Pseudoemergency”

18. Schmieder, R E End Organ Damage In Hypertension Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

19. Echocardiography 2013 ESH/ESC Guidelines. J Hypertens 2013

20. Echocardiography should be considered in hypertensive patients in different clinical contexts and with different purposes: in hypertensive patients at moderate total CV risk, it may refine the risk evaluation by detecting LVH undetected by ECG in hypertensive patients with ECG evidence of LVH it may more precisely assess the hypertrophy quantitatively and define its geometry and risk in hypertensive patients with cardiac symptoms, it may help to diagnose underlying disease . 2013 ESH/ESC Guidelines. J Hypertens 2013 Cardiac Damage

21. Schmieder, R E End Organ Damage In Hypertension Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

22. Schmieder, R E End Organ Damage In Hypertension Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

23. Schmieder, R E End Organ Damage In Hypertension Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

24. Atherosclerosis and Vascular Stiffness Ng et al. Am J Physiol Renal Physiol 2011 Wikipedia.org

25. Vascular Stiffness and Mortality Relative Risk of Cardiovascular Mortality According to PWV and Cardiovascular Risk Factors: Univariate Analysis Parameters OR Lower 95% CI Higher 95% CI P PWV, 5 m/s 2.35 1.76 3.14 <0.0001 Previous CVD, yes/no 14.81 7.98 27.47 <0.0001 Age, 10 y 2.32 1.78 3.01 <0.0001 PP, 10 mm Hg 1.53 1.31 1.80 <0.0001 SBP, 10 mm Hg 1.26 1.12 1.42 <0.001 Diabetes, yes/no 4.23 1.96 9.15 <0.001 Laurent S et al. Hypertension 2001