Hypertension

1. Hypertension In Malaysia

2. Objecilves

3. Table 1 Definit sand classificat: of blood pressure (BP)

levels (mmHg)
Category

Optimal

Normal

Grade 1 hypertension
Grade 2 hypertension
Grade 3 hypertension
Isolated systolic
hypertension

Systolic Diastolic

120
120-129

140-159
160-179
= 180
= 140

6. important rules

7. Excess Reduced
sodium

intake

nephron
number

AN

a a OU
Renal
sodium

retention

Decreased
+<— filtration

surface

Stress Genetic

alteration

y
/ II =

Sympathetic

activity

Renin
nervous over *—® angiotensin
excess

Endothelium
derived

So factors
al
—. TT
Cell Hyper

membrane

—

alteration
N

y

Fluid Venous
volume constriction

Lt]

1 Preload

Blood pressure = Cardiac output

Hypertension Increased CO

y
Ÿ Contractability

constriction

Functional

Ss
Y Ñ _
DK
ALT Su y
hyportrophy

>

Peripheral resistance

Increased PR

t

Autoregulation

insulinaemia

Structural «———

8. Tissue injury
(MI, stroke, renal
insufficiency,
peripheral arterial
insufficiency)

Atherothrombosis and
progressive CV disease Pathological
remodeling

Early tissue dysfunction Target organ damage

Oxidative and End-organ failure
mechanical stress (CHF, ESRD)
Inflammation

Risk factors

9. Keep thinking cf secondary causes

10. Target organ damage (TOD), target organ
complication (TOC), clinical atherosclerosis

‚Organ System

Manifestations

| Cardiac

Left ventricular hypertrophy, coronary
heart disease, heart failure

Cerebrovascular

Transient ischaemic attack

Periperal
vasculature

Absence of one or more major pulse in
extremities (except dorsalis pedis) with or
without intermittent claudication;
aneurysm

Renal

Raised serum creatinine,
microalbuminuria, proteinuria

\ Retinopathy

Haemorrhages or exudates, with or
without papilloedema 7

11. Arterial
Striffness(
hypertrophy

Obesity/
Visceral
adiposity

>

Endothelial
dysfunction

SY Abnormal
glucose
metabolism

Hypertension >
UR u
Increased brachial BPX

Nephropathy

12. The higher the BP, the greater
the risk of stroke and CHD

Stroke CHD
7 prospective 9 prospective
observational studies: observational studies:
843 events 4856 events
Relative risk of stroke Relative risk of CHD
4.00 + 4.00
2.00 t 2.00 LC]
n
1.00 4 1.00 nu
0.50 $ 0.50 o
4 n
0.25 | Baseline DBP category 0.25 | Baseline DBP category
1 2 3 4 «5 1 2 3 4 5

76 84 91 98 105 76 84 91 98 105
Approximate mean usual DBP (mmHg)

MacMahon et al 1990

13. CV mortality risk doubles with TR®PHY
each 20/10 mm Hg BP increment*

CV mortality risk
8

SO = ND & PR um

115/75 135/85 155/95 175/105
Blood pressure (mm Hg)
* Individuals aged 40-70 years, starting at BP 115/75 mm Hg

Lewington et al. Lancet 2002
JNC VII. JAMA 2003

14. IHD mortality versus blood pressure

Ischemic heart disease mortality rate in each decade of age versus usual blood pressure at the
start of that decade

[A] svsrouc BLoco Pressure [E] Dusroux Brooo Pressure

D O0_ AT

140 16 70 so 90 100 no

IHD MORTALITY
(Floating ABSOLUTE RISK AND 95% CI)

x
22

USUAL SYSTOLIC BLOOD Usuat Diasrouic Blood.
PRESSURE (MMHG) Pressure (mmHc)

Age at risk:

mee 50-59 years mn 70-79 years 60-69 years mm 50-59 years mm 40-49 years

JAD, ischemic heart disease
Source: Reprinted with permission from Elsevier. Lewington S, et al. Age-specific relevance of usual blood pressure to vascular
‘mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. (The Lancet 2002:360:1903-13)

15. Ten-year risk for coronary heart disease by systolic blood pressure and

presence of other risk factors
eee SE

60 —

24

10-YEAR RISK or CHD (%)

Cholesterol 180 240 240

HDL so so 35 35 35 35

o 240 240

Smoking No No No Yes Yes

Diabetes No No No No Yes

1H No No No No No

I SBP 120 SBP 180

CHD, coronary heart disease; HDL, high-density lipoprotein; LVH, left ventricular hypertrophy; SBP, systolic
blood pressure

16. 70-
E Men

57.5 56.4
EME Women

60 -
50

BP systolic 0 160 160
| Cholesterol 22 2 260 260
HDL-C 5 5 35 35

Diabetes
| Cigarettes
LVH by ECG

ODonnell, et al. J Hypertension, 1998; 16: 3

18. h
Antihypertensive treatment
reduces cardiovascular events

NE non-fatal events T = treated
Total no. of =
individuals affected = fatal events C = control

1200 1104

1000 964
800
600
400
200

o Stroke Vascular deaths

Reduction in odds: 38% +4 21% +4
2p-value: <0.00001 <0.00001

5 McMahon & Rodgers 1993

19. BP Reductions as Little as 2 mm Hg Reduce
the Risk of CV Events by Up to 10%

e Meta-analysis of 61 prospective, observational studies
e 1 million adults

e 12.7 million person-years
7% reduction

in risk of IHD
2 mm Hg cc mortality

decrease in EX <
mean SBP e 10% reduction
= in risk of
stroke
mortality

Lewington S et al. Lancet 2002;360:1903-1913
BD 2006

20. hits

21. Magnitude of HPT

"Tine Reasearch Pa pat let AL re Gone Far, at ILLA
ara ara Par IS mr LL 1
naa en dia Pp day arar a
"iaa Par oo ru LOL A CDA

22. Prevalence rates from

Different years and
Different populations

23. Hypertension In Malaysia

24. eee ara In TT

26. Rural vs Urban

27. The Malaysian Rule

28. The ‘Malaysian Rule'

29. Overall BP Control by ethnicity

31. Hypertension Control ln the
Asia Pacific Region

Milan 0009 ar oem on a.m

32. World Hypertension Day will be celebrated for the first time today, May 14th
2005
From the Star

A statement from the Malaysian Society of
Hypertension (MSH) said the World Hypertension
League (WHL) had designated May 14, as a day to
emphasise the consequences of hypertension and to

encourage people to monitor their blood pressure.
“Hypertension is highly prevalent in many countries in
the world, including Malaysia. The WHL estimated that
more than 1.5 billion people worldwide suffer from
hypertension, withaply a third of them being treated.
“In Malaysia, onl 6%) of hypertension patients have
their conditaA3' cômfolled,” said MSH president Datuk
Dr Azhari Rosman

33. cl Inical Aspects — Current Status

34. cl Inical Aspects — Current Status

35. cl Inical Aspects — Current Status

36. Points to ponder!

37. What are the better ways to
manage hypertensive patiente
In Malaysia?

38. Co-existing Condition

BP Levels
(mmHg)

TOC
or
RF (23)

or
Clinical
atherosclerosis

Previous MI
or
Previous stroke

or
Diabetes

SBP 120 — 139 and/or
DBP 80 - 89

Low

Medium

High

Very high

SBP 140 - 159 and/or
DBP 90 - 99

Low

Medium

High

Very high

SBP 160 - 179 and/or
DBP 100 - 109

Medium

High

Very high

Very high

SBP 180 — 209 and/or
DBP 110-119

High

Very high

Very high

Very high

SBP > 210 and/or
DBP > 120

Very high

Very high

Very high

Very high

Risk Level

Risk of Major CV Event in 10 years

Management

Low

< 10%

Lifestyle changes

Medium

10 - 20%

Drug treatment and lifestyle changes

High

20 - 30%

Drug treatment and lifestyle changes

Very high

> 30%

Drug treatment and lifestyle changes

39. First line therapy

ACT ara divisa E23

EC MMAR CMS CET Esa bises

low dea Gaveticd ACEYCCO

&CS/ AR Cea e0s

AED CEA basins

40. Concomitant disease | Diuretics B- Peripheral
blockers o-blockers

Diabetes mellitus +/- +/-
(without nephropathy)

Diabetes mellitus (with +/-
nephropathy)

Gout

Dyslipidaemia

Coronary heart disease

Heart failure

Asthma

Peripheral vascular

Non-diabetic renal
impairment

Renal artery stenosis +

Elderly with no co-morbid +/-
conditions

The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice
+/- Use with care

Contraindicated

Only non-dihydropyridine CCB

Metoprolol, bisoprolol, carvedilol - dose needs to be gradually titrated

Current evidence available for amlodipine and felodipine only

Contraindicated in bilateral renal artery stenosis,

41. Blood Pressure Targets

ESH/ESC WHO-ISH BHS IV 2004

Overall <140/90 SBP <140 <140/85

DM DM DM DM
Special renal disease 130/80 renal disease renal disease
Populations <130/80 (lower if CVD CVD

tolerated) <130/80 <130/80

SBP=systolic blood pressure;
DM=diabetes mellitus:
ISH=isolated systolic hypertension;

42. Choose between

Two-to three-drug Fulldose ree-drug combination)
combination at full dose monotherapy at full dose

43. Newly diagnosed, uncampllcaled patenta wltin
hypartarslan with no campsllig Inelleniion

44. WHO/ ISH
JNC-6

45. Choosing drugs for patients newly diagnosed with
hypertension

Younger than | f 55 years or older

Abbreviations:
A or black patients of any age

A = ACE inhibitor 55 years

>
D step

Step 2

Step 3

Consider seeking specialist
advice

46. Combination therapy

47. Malaysian Untreated Hyperiensives
(Rate Our 1E8:4:277-208

[|

48. ) Malaysian Untreated Hyperisnsives
(aia Pant ame; EP EB}

[T |]

49. Effective Gomisinations In Malayala
- Ristrespestvs Review ef Resard
(Jot Fo.) Phase RRR

50. Effective Combinations in Malaysia

51. What predicts BP control ?

844444

52. What predicts BP control ?

53. The Raub
Heart Study

Prevalence of Hypertension,
Diabetes and Obesity

1993 1998
Males
Hypertension 26.2 30.6
Diabetes 4.4 4.7
Obesity 3.1 5.2
Overweight 17.7 30.9
Females

Hypertension 29.4 31.7
Diabetes 35 75
Obesity 10.5 12.3
Overweight 25.3 31.1

54. MJ VOLUME

Less tight control
—— Tight control

Reduction in risk with tight control 24% (95% Cl 8% to 38%)(P = 0.

Fig 5 Kaplan-Meier plots of proportions of patients
lend point, fatal or non-fatal, related to diabetes

56. Blocd pressure reduction

mm

L
140.3 mmHg
134.7 mmHg
77.0 mmHg
74.8 mmHg

58. Conciusion

59. A typical Malaysian Hyperiensive
- Back to Rsallty |

We ewe mane warlen be der