hypertension and cardiovascular disease

This seminar depicts the present problem and situation of hypertension and ischemic diseases in India. The present and proposed strategy to combat such situation.

1. EPIDEMIOLOGY AND RECENT ADVANCES IN HYPERTENSION AND CORONARY ARTERY DISEASE By Abhishek Agarwal

2. Introduction Cardiovascular Diseases Leading cause of death World Wide. Cardiovascular diseases counts for over 17.5 million deaths in 2012. Over 3 quarters of CVD deaths are from low and middle income countries. Most cardiovascular diseases are preventable. 2

3. DEFINITION OF CARDIOVASCULAR DISEASES Cardiovascular diseases are the diseases of the Heart, Vascular Supply of Brain and diseases of blood vessels. WHO 3

4. TYPES OF CARDIOVASCULAR DISEASES CORONARY HEART DISEASE STROKE HYPERTENSION RHEUMATIC HEART DISEASE 4

5. CARDIOMYOPATHY MYOCARDITIS OTHERS TYPES OF CARDIOVASCULAR DISEASES 5

6. HYPERTENSION EPIDEMIOLOGY AND RECENT ADVANCES

7. HYPERTENSION: A MODERN DAY EPIDEMIC 7 W illiam Harvey (1578 – 1657) Understanding of cardiovascular system

8. BLOOD PRESSURE MEASUREMENT STEPHEN HALES (1733) FIRST INVASIVE WAY TO MEASURE BLOOD PRESSURE 8

9. SPHYGMOMANOMETER Scipione Riva Rocci (1896) 1 st Cuff based Sphygmomanometer was used 9

10. KROTKOFF SOUND NIKOLAI KROTKOFF (1905) KROTKOFF SOUND 10

11. HYPERTENSION: A GLOBAL PUBLIC HEALTH PROBLEM 11 10 million deaths SOURCE: WHO

12. WHO FACT SHEET FOR HYPERTENSION Globally, nearly one billion people have high blood pressure (hypertension); of these, two-thirds are in developing countries. Hypertension is one of the most important causes of premature death worldwide and the problem is growing; in 2025, an estimated 1.56 billion adults will be living with hypertension. 12

13. CHANGING TRENDS OF HYPERTENSION 13 SOURCE: WHO GLOBAL BURDEN OF DISEASE, 2017

14. HYPERTENSION AND RULE OF HALVES (WOMEN) 14 SOURCE: NFHS 4

15. HYPERTENSION: WHO DEFINITION Hypertension, also known as high or raised blood pressure, is a condition in which the blood vessels have persistently raised pressure. 15

16. BP CATEGORY SYSTOLIC BP DIASTOLIC BP NORMAL < 120 mm Hg < 80 mm Hg ELEVATED 120 – 139 mm Hg < 80 mm Hg HYPERTENTION STAGE 1 140 – 159 mm Hg 80 – 89 mm Hg HYPERTENSION STAGE 2 ≥ 160 mm Hg ≥ 90 mm Hg 16 HYPERTENSION CLASSIFICATION IN ADULTS : WHO / JNC 8

17. DEFINITION USED IN NFHS 4 17 An individual is classified as having hypertension if he/she has a systolic blood pressure level greater than or equal to 140 mmHg, or a diastolic blood pressure greater than or equal to 90 mmHg, he/she is currently taking antihypertensive medication to lower his/her blood pressure.

18. BP CATEGORY SYSTOLIC BP DIASTOLIC BP NORMAL < 120 mm Hg < 80 mm Hg ELEVATED 120 – 139 mm Hg < 80 mm Hg HYPERTENSION STAGE 1 140 – 159 mm Hg 80 – 89 mm Hg HYPERTENSION STAGE 2 160 - 179 mm Hg ≥ 90 mm Hg HYPERTENSION STAGE 3 ≥ 180 mm Hg ≥ 90 mm Hg 18 HYPERTENSION CLASSIFICATION IN ADULTS : NFHS 4

19. HYPERTENSION CLASSIFICATION IN ADULTS : AHA (Nov: 2017) BP CATEGORY SYSTOLIC BP DIASTOLIC BP NORMAL < 120 mm Hg < 80 mm Hg ELEVATED 120 – 129 mm Hg < 80 mm Hg HYPERTENSION STAGE 1 130 – 159 mm Hg 80 – 89 mm Hg HYPERTENSION STAGE 2 ≥ 160 mm Hg ≥ 90 mm Hg 19

20. PATHOPHYSIOLOGY OF HYPERTENSION 20 NaCl

21. CAUSES OF HYPERTENSION 21 PRIMARY (94%) SECONDARY (6%) RENAL (4%) ENDOCRINE (1%) OTHER (1%)

22. RISK FACTORS 22

23. RISK FACTORS 23

24. PREVALENCE OF HYPERTENSION IN AGE 15 – 49 YEARS 24 SOURCE: NFHS 4

25. HYPERTENSION BURDEN : ACCORDING TO DALY’S CONTRIBUTED ACCORDING TO AGE AND SEX 25 SOURCE: WHO GLOBAL BURDEN OF DISEASE, 2017

26. HYPERTENSION AND SOCIO ECONOMIC STATUS 26 SOURCE: NFHS 4

27. 27 HYPERTENSION AND NUTRITIONAL STATUS SOURCE: NFHS 4

28. HYPERTENSION AND RURAL URBAN COMPARISON 28 12 % 10.4 % SOURCE: NFHS 4

29. CLINICAL FEATURES OF HYPERTENSION 29 Hypertension is regarded as silent killer. Without sign and symptoms it can cause nose bleeding, early morning headache, irregular heartbeats, buzzing in the ear.

30. Severe Hypertension 30

31. PREVENTION OF HYPERTENSION PRIMARY POPULATION STRATEGY HIGH RISK STRATEGY SECONDARY EARLY CASE DETECTION TREATMENT PATIENT COMPLIANCE 31

32. POPULATION STRATEGY 32

33. DASH DIET 33 1500 MG / DAY DASH DIET D: DIETARY A: APPROACH TO S: STOP H: HYPERTENSION

34. PHYSICAL ACTIVITY 34 WHO RECOMMENDATIONS ON PHYSICAL ACTIVITY FOR HEALTH AGE TYPE OF ACTIVITY TIME 5 – 17 YEARS MODERATE TO VIGROUS INTENSITY 60 MIN / DAY 18-64 YEARS MODERATE INTENSITY 150 MIN / WEEK VIGROUS INTENSITY 75 MIN / WEEK ≥ 65 YEARS MODERATE INTENSITY 150 MIN / WEEK MODERATE + VIGROUS INTENSITY 75 MIN / WEEK

35. WEIGHT REDUCTION 35 9.2 kg 6.3 / 3.1 mmHg Source: Harrison 18 th edition

36. LIFESTYLE MODIFICATION TO MANAGE HYPERTENSION MODIFICATIONS RECOMMENDATIONS APPROXIMATE SYSTOLIC BP WEIGHT REDUCTION BMI (18.5 – 24.9) 5 – 20 mm Hg DASH DIET HIGH FIBER DIET 8 – 14 mm Hg DIETARY SODIUM REDUCTION < 6 g/day 2 – 8 mm Hg PHYSICAL ACTIVITY AT LEAST FOR 30 MIN / DAY 4 – 9 mm Hg MODERATE ALCHOHAL CONSUMPTION < 2 DRINKS PER DAY ( < 60ml ethanol) 2 – 4 mm Hg 36

37. HIGH RISK STRATEGY To prevent the attainment of levels of blood pressure at which the institution of treatment would be considered 37

38. TRACKING OF BLOOD PRESSURE 38

39. SECONDARY PREVENTION : EARLY CASE DETECTION 39 SCREENING NO FOLLOW UP HEALTH CHECK UP AT EVERY CONTACT WITH HEALTH SERVICE

40. 40 SECONDARY PREVENTION : TREATMENT CAUSE TREATMENT HYPERTENSION < 140 / 90

41. The extent to which patient behavior coincides with clinical prescription 41 SECONDARY PREVENTION : PATIENT COMPLIANCE

42. ENCOURAGEMENTS FROM JAPAN 42 MORTALITY DUE TO HYPERTENSIVE DISORDERS REDUCED BY 85%

43. WORLD HYPERTENSION DAY 43

44. May M easurement Month The purpose: Promote public awareness of hypertension and to encourage citizens of all countries to prevent and control this silent killer, the modern epidemic 44

45. Ischemic heart disease Coronary heart disease

46. Definition WHO defined ischemic heart diseases as:- “ Impairment of heart function due to inadequate blood flow to heart compared to its needs, caused by obstructive changes in the coronary circulation to the heart” 46

47. FACTS OF ISCHAEMIC HEART DISEASE Coronary artery diseases are contributing 7.4 million deaths across the world. Prevalence of coronary artery disease in India is as high as 3.7 %. 47

48. CHD A DISEASE OF URBAN INDIA ?? 6.4 % PREVALENCE OF CHD 2.5 % PREVALENCE OF CHD NATIONAL HEALTH PROFILE, 2010 3.7 % PREVALENCE OF CHD 48

49. Risk factors for coronary heart disease

50. Risk factors introduction Over 300 risk factors have been associated with coronary heart disease and stroke. The major established risk factors meet the following criteria: 50

51. Modifiable Risk factors High blood pressure Abnormal B lood Lipids Tobacco use Physical inactivity Obesity Unhealthy diet Diabetes Mellitus 51

52. Other modifiable risk factors Low socio economic status Mental ill Health Phycho social Stress Alcohol use Use of Certain Medications Lipo Protein A Left Ventricular Hypertrophy 52

53. Non Modifiable R isk F actors Advancing Age Ethnicity and Race Genetic or hereditary Gender 53

54. Prevention of coronary heart disease

55. Primordial prevention

56. Primordial prevention Population strategy Comprehensive tobacco control policies 56

57. Primordial prevention Population strategy T axation to reduce the intake of foods that are high in fat, sugar and salt 57

58. Primordial Prevention Population strategy B uilding walking and cycle paths to increase physical activity 58

59. Primordial Prevention Population strategy S trategies to reduce harmful use of alcohol 59

60. Primordial Prevention Population strategy P roviding healthy school meals to children 60

61. Primary prevention Treatment of risk factors

62. HIGH RISK GROUPS BENEFITS OF TARGETTING HIGH RISK GROUPS: SYSTOLIC BLOOD PRESSURE REDUCE 10 -15 mmhg DIASTOLIC BLOOD PRESSURE REDUCE 5 – 8 mmhg REDUCE BLOOD CHOLESTEROL BY 20% 50 % MORTALITY CAN BE REDUCED 62

63. SYSTOLIC BP > 150 mmhg DIASTOLIC BP > 90 mmhg SERUM CHOLESTROL > 5mmol/L DRUGS CAN REDUCE MORTALITY UPTO 25% IMPACT OF DRUGS IN HIGH RISK GROUPS 63

64. WHO RISK PREDICTION CHART 64

65. WHO RISK PREDICTION CHART 65

66. PREVENTION OF CARDIOVASCULAR DISEASES ACCORDING TO INDIVIDUAL TOTAL RISK 10 YEAR RISK OF CARDIOVASCULAR EVENT 20 % - 30 % INDIVIDUALS IN THIS CATEGORY ARE AT VERY HIGH RISK OF FATAL OR NON FATAL VASCULAR EVENTS. MONITOR RISK PROFILE EVERY 3 – 6 MONTHS 10 YEAR RISK OF CARDIOVASCULAR EVENT > 30 % INDIVIDUALS IN THIS CATEGORY ARE AT HIGH RISK OF FATAL OR NON FATAL VASCULAR EVENTS. MONITOR RISK PROFILE EVERY 3 – 6 MONTHS 66

67. PREVENTION OF CARDIOVASCULAR DISEASES ACCORDING TO INDIVIDUAL TOTAL RISK 10 YEAR RISK OF CARDIOVASCULAR EVENT < 10 % INDIVIDUALS IN THIS CATEGORY ARE AT MODERATE RISK OF FATAL OR NON FATAL VASCULAR EVENTS. MONITOR RISK PROFILE EVERY 6 - 12 MONTHS 10 YEAR RISK OF CARDIOVASCULAR EVENT 10 - 20 % INDIVIDUALS IN THIS CATEGORY ARE AT LOW RISK CONSERVATIVE MANAGEMENT FOCUSSING ON LIFE STYLE MODIFICATIONS IS SUGGESTED 67

68. Primary prevention Specific interventions Dietary changes Less than 100mg / 1000 kcal per day Intake of complex carbohydrates Less than 5gm daily 68

69. Primary prevention Specific interventions Smoking Cessation NATIONAL TOBACCO CESSATION QUIT HELP LINE 1800-22-77-87 69

70. Primary prevention Specific interventions BLOOD PRESSURE CONTROL PRUDENT DIET LOW SALT DIET INCREASE PHYSICAL ACTIVITY AVOIDANCE OF ALCHOHAL 70

71. Primary prevention Specific interventions DRUG MANAGEMENT STATINS / LIPID LOWERING DRUGS ANTI HYPERTENSIVES ORAL HYPOGYLECMICS 71

72. Secondary prevention Early diagnosis and treatment

73. HELP !!!! Is this chest pain a cardiac pain or a general gastritis ??? Should I call for help??? 73

74. Clinical Features Angina pectoris Dull aching Not sharp and superficial Heaviness is felt Elephant sitting on chest Radiating to the left arm, neck, epigastrium. Dyspnea Labored breathing Dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea Other features Edema Cough Hemoptysis 74

75. Secondary prevention Early diagnosis and treatment TREATMENT Per cutaneous interventions (PCI) Coronary Artery Bypass Graft (CABG) 75

76. Secondary Prevention Early diagnosis and treatment DRUGS LOW DOSE ASPIRIN STATINS BETA BLOCKERS ACE INHIBITORS 76

77. RISK FACTOR INTERVENTION TRIALS 77

78. Who surveillance of non communicable diseases

79. WHO STEPS APPROACH FOR SURVEILLANCE OF NON COMMUNICABLE DISEASES 79

80. 80

81. GLOBAL ACTION PLAN 2013 - 20 81

82. Sustainable Development Goals And Non Communicable Diseases 82

83. National program for prevention and control of cancer, diabetes, cardiovascular disease and stroke NPCDCS

84. Reasons for I ncreasing Burden of C ardio V ascular Diseases in India 84

85. OBJECTIVES 85

86. Strategies 86

87. Services at Sub - Centre OPPORTUNISTIC SCREENING AND HEALTH PROMOTION FOR PERSONS ABOVE 30 YEARS BY ANM 87

88. Services at Community Health Centre 88

89. SERVICES AT DISTRICT HOSPITAL 89

90. SERVICES AT STATE / CENTRAL LEVEL 90

91. CONCLUSION 91 Cardiovascular diseases are the leading cause of death world wide with over 17.5 million deaths. Hypertension is one the leading cause for ischemic and cerebrovascular diseases and most of the population is unaware of this problem. Ischemic heart disease constituting 7 million deaths is declared as the modern day epidemic.

92. CONCLUSION To combat this high burden of hypertension WHO and Ministry of Health and Family Welfare has launched strategies like global action plan for NCD’s and NPCDCS with targets set so as to meet Sustainable development goals by 2030. 92

93. references Park’s textbook of preventive and social medicine; 24 th Edition, Bhanot Publication. Global strategy for the prevention and control of non-communicable diseases; by WHO Director General; March 2000 WHO global action plan for the prevention and control of Non Communicable diseases; 2013 – 2020 WHO Fact sheet on Hypertension and Cardiovascular Diseases; May 2017 NPCDCS Operational Guidelines, 2016; Ministry of Health and family welfare WHO Steps approach for Non communicable diseases 93

94. 94 Eat healthy to remain healthy…

95. GLOBAL DISTRIBUTION OF CAUSE OF DEATH DUE TO NCD 95

96. 96

97. 97

98. Deaths due to ncd’s 17.5 million deaths 19 million deaths 98

99. Prevalence of risk factors in India and changing trends from 2010 - 2014 99

100. hypertension Global status report on NCD, 2014 100

101. Tobacco smoking Global status report on NCD, 2014 101

102. Inadequate physical activity Global status report on NCD, 2014 102

103. Mean bmi Global status report on NCD, 2014 103

104. Overweight Global status report on NCD, 2014 104

105. obesity Global status report on NCD, 2014 105

106. Diabetes mellitus Global status report on NCD, 2014 106

107. Prevalence of risk factors in uttar pradesh 107

108. 108

109. Prevalence of risk factors in meerut 109

110. 110

111. Global status report on NCD, 2014 111

112. Secondary Prevention Early diagnosis and treatment SMOKING CESSATION, PHYSICAL ACTIVITY & DIET 112