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Fac.of Med.UII. jogjaSlide 2: Anatomi Pembuluh Darah Jantung APEKS:SIC V Mid claviculerThe World Health Organization (WHO) estimates that 20% of the world’s current adult population has hypertension : The World Health Organization (WHO) estimates that 20% of the world’s current adult population has hypertension Prevalence of hypertensionAwareness, Treatment and Control of High Blood Pressure in Canada: Awareness, Treatment and Control of High Blood Pressure in Canada Patients unaware of their high blood pressure 43% Aware but not treated and not controlled 22% Treated but not controlled 21% Treated and controlled 13% Joffres et al. Am J Hypertens 2001; 14(11):1099-1105 4 3 % 22 % 2 1 % 1 3 %Trends in the awareness, treatment and control of hypertension in the U.S.: Trends in the awareness, treatment and control of hypertension in the U.S. Awareness 51.0% 73.0% 68.4% Treated 31.0% 55.0% 53.6% Controlled 10.0% 29.0% 27.6% NHANES II 1976-80 NHANES III (Phase I) 1988-91 NHANES III (Phase II) 1991-94 Controlled BP = SBP <140 mmHg and DBP <90 mmHg Adapted from Burt et al. 1995Causes of Resistant Hypertension: Causes of Resistant Hypertension Efficacy of medications Patient compliance: Side effects (-) Convenience Lack of symptoms Patient education Cost Failure to treat to target MD Reluctance Accurate blood pressure measurements Secondary Causes Sleep apnea Renal vascular HTN Endocrine causes Chronic renal failure Rx Drugs (NSAIDS, steroids) White-coat HTN Relctnce: enggan Rstant : mlawan complcekrelaanghdyDiseases Attributable to Hypertension: Diseases Attributable to Hypertension Hypertension Heart failure Stroke Coronary heart disease Myocardial infarction Left ventricular hypertrophy Aortic aneurysm Retinopathy Peripheral vascular disease Hypertensive encephalopathy Chronic kidney failure Cerebral hemorrhage All Vascular Adapted from: Dustan et al. Arch Intern Med 1996; 156:1926-1935Hypertension Optimal Treatment (HOT) study: Hypertension Optimal Treatment (HOT) study 9.9 10.0 9.3 24.4 18.6 11.9 0 5 10 15 20 25 30 90 mmHg 85 mmHg 80 mmHg Target DBP group Major CV events per 1000 patient years All patients ( n =18 790) Diabetics ( n =1501) Lancet 1998;351:1755–1762 Intensive BP-lowering decreases cardiovascular risk in patients with hypertension, especially among those with diabetesUKPDS: relative risk reduction with tight versus less tight blood pressure control: UKPDS: relative risk reduction with tight versus less tight blood pressure control Any diabetes-related endpoint Diabetes-related deaths Stroke Microvascular disease –24% P <0.005 –32% P <0.05 –44% P <0.05 –37% P <0.01 Tight control ( n= 758) Less tight control ( n =390) Deterioration in visual acuity –47% P <0.005 BMJ 1998;317:703–713 Tight BP control decreases morbidity and mortality in patients with diabetesBP targets: BP targets BP targets in guidelines are becoming more stringent Coexistent cardiovascular risk factor profile is important Strngt : ktat,krasInitial Assessment: Initial Assessment Target organ damage Overall cardiovascular risk Rule out secondary and often curable causesComponents of Risk Stratification Target Organ Damage/Clinical Cardiovascular Disease: Target end-organs should be assessed by history and physical examination Components of Risk Stratification Target Organ Damage/Clinical Cardiovascular Disease Brain Heart Kidneys Eyes Arteries Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46Components of Risk Stratification Major Cardiovascular Risk Factors: Components of Risk Stratification Major Cardiovascular Risk Factors Hypertension Age Smoking Dyslipidemia Diabetes Family history Obesity > 45 years Male > 55 years Female (Postmenopausal) CAD <65 Female CAD <55 Male Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46Stratification of risk to quantity prognosis: 14 Stratification of risk to quantity prognosis Other risk factor and disease history Normal SBP 120-129 DBP 80-84 High normal SBP 130-139 DBP 85-89 Grade 1 SBP140-159 DBP 90-99 Grade 2 SBP 160-179 DBP 100-109 Grade 3 SBP > 180 DBP > 110 No other risk factors Average risk Average risk Low added risk Moderate added risk High added risk 1 – 2 risk factors Low added risk Low added risk Moderate added risk Moderate added risk Very high added risk 3 or more risk factors or TOD or DM Moderate added risk High added risk High added risk High added risk Very high added risk ACC High added risk Very high added risk Very high added risk Very high added rsik Very added risk Blood pressure (mm Hg) 2003 ESH-ESCThe ideal antihypertensive agent: Effectively reduces BP Maintains BP control over 24 h with once-a-day dosing Effective in all hypertensive patients No adverse effects No negative metabolic side effects Affordable The ideal antihypertensive agentSlide 16: Persistent use of monotherapy Obsession with “first line therapy” Poor recognition of the importance and efficacy of combination therapy Lack of advice on most appropriate drugs to use in combination Reasons for Undertreatment of HypertensionSlide 17: BP monotherapy: BP fall <10% Statin therapy: Cholesterol fall 30-40% Reasons for Undertreatment Of Hypertension “Antihypertensive monotherapy is not very effective”Slide 19: Clinical Practice: Most people with hypertension are treated with monotherapy Clinical Evidence: Most people in clinical trials are treated with combination therapy Improving Blood Pressure ControlHOT(Hyp.Optimal.Treatment): percentage of patients requiring combination therapy to achieve target DBP: HOT(Hyp.Optimal.Treatment): percentage of patients requiring combination therapy to achieve target DBP 90 mmHg 37.1% 62.9% 85 mmHg 31.7% 68.3% 80 mmHg 26.1% 73.9% Combination therapy Monotherapy Target DBP group The lower the target DBP, the greater the need for combination therapy HOT:Hypertesion Optimal TreatmentSlide 21: Combining Antihypertensive Medications is Logical and Evidence-basedAdvantages of combination therapy: Advantages of combination therapy Additive antihypertensive efficacy (due to complementary mechanisms of action) Higher patient response rates Simple titration and dosing schedules Maintained or improved tolerability Improved patient compliance Cost effectiveSlide 23: Drug Action - vasodilatation RAS Activation SNS Activation Vasoconstriction Sodium retention RAS = renin-angiotensin system SNS = sympathetic nervous system Combination Therapy for Hypertension Concept of CounteregulationSlide 24: 24 Thiazide Lowers Blood Pressure Natriuretic Activates Renin Angiotensin System Reduces antihypertensive effect Combination Therapy for Hypertension CounteregulationSlide 25: 25 Reduce Adverse Effects of Drug Therapy: ACE inhibition or Angiotensin Receptor Blockers Retain potassium(K) Thiazide Diuretics Excrete Potassium Combination Prevents hypokalaemia of thiazide therapy Limits hyperkalaemia of RAS(renin angt sys) blockade Combination Therapy for HypertensionSlide 26: 26Slide 27: 27Slide 28: 28WHAT IS THE IDEAL WAY OF CONTROLLING BP? The new therapeutic window in hypertension: 29 WHAT IS THE IDEAL WAY OF CONTROLLING BP? The new therapeutic window in hypertension 100 80 60 40 20 0 100 80 60 40 20 0 Efficacy (%) Freedom from side effects (%) Dose Man In’t Veld AJ. J Hypert, 1997 IDEAL treatment TraditionalSlide 30: 30Slide 31: 31Slide 32: 32 ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker; CCB, = calcium channel blocker. Chobanian AV et al. JAMA. 2003;289:2560-2572. Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE-I, ARB, BB, CCB) as needed BP Classification Lifestyle Modification Initial Drug Therapy Without Compelling Indication With Compelling Indication Normal <120/80 mm Hg Prehypertension 120-139/80-89 mm Hg Stage 1 hypertension 140-159/90-99 mm Hg Stage 2 hypertension 160/100 mm Hg Encourage Yes Yes Yes No drug indicated Drug(s) for the compelling indications Thiazide-type diuretics for most; may consider ACE-I, ARB, BB, CCB, or combination 2-drug combination for most (usually thiazide-type diuretic and ACE-I, ARB, BB, or CCB) JNC VII: Management of Hypertension by Blood Pressure ClassificationSlide 33: 33 BP target of <140/90 mm Hg for patients with uncomplicated hypertension without compelling indications BP target of <130/80 mm Hg for patients with diabetes Combinations of 2 or more drugs are usually needed to achieve target BP goal BP target of <130/80 mm Hg for patients with chronic renal disease* Combinations of 3 or more drugs are often needed to reach target BP goal *Chronic kidney disease = GFR <60 mL/min per 1.73 m 2 or presence of albuminuria (>300 mg/d or 200 mg/g creatinine). Chobanian AV et al. JAMA. 2003;289:2560-2572. American Diabetes Association. Diabetes Care. 2003;26(Suppl 1):S33-S50. Guidelines Committee. J Hypertens. 2003;21:1011-1053. Target BP and Compelling IndicationsSlide 34: 34 Most patients with hypertension will require 2 or more antihypertensive drugs to achieve BP goals According to baseline BP and presence or absence of complications, therapy can be initiated either with a low dose of a single agent or with a low-dose combination of 2 agents When BP is >20/10 mm Hg above goal, consideration should be given to initiating 2 drugs, either as separate prescriptions or in fixed-dose combinations, one of which should be a thiazide-type diuretic Chobanian AV et al. JAMA. 2003;289:2560-2572. Guidelines Committee. J Hypertens. 2003;21:1011-1053. JNC VII & ESH/ESC 2003: Treatment ConsiderationsSlide 35: 35 Easy as ABC D A = ACE-Inhibitor or Angiotensin Receptor Blocker B = - Blocker C = Calcium Channel Blocker D = Diuretic (thiazide) Adapted from : ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org Combining Antihypertensive MedicationsSlide 36: 36 A or B Inhibit the Renin-Angiotensin System C or D Do not inhibit the Renin-Angiotensin System More Effective In Younger More Effective In Older Adapted from : ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org Combining Antihypertensive MedicationsSlide 37: Younger Or Diabetes ( 55yrs) Older ( 55yrs) or Black A or B C or D 1. A or (B) + C or D 2. A or (B) + C + D 3. A or (B) + C + D + other 4. Adapted from : ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.orgSlide 38: 38Recommended Combinations: 39 Recommended Combinations 1. ACE inhibitors / AIIRA Diuretics 2. ACE inhibitors / AIIRA Calcium antagonists 3. ACE inhibitors / AIIRA Beta-blockers (Special condition) 4. Beta-Blockers Diuretics 5. Beta-Blockers Calcium AntagonistsSUMMARY: SUMMARY COMBINATION THERAPY IN HTN MANAGEMENT IS LOGIC AND EVIDENCE BASED MAXIMIZE EFFECT, MINIMIZE SIDE EFFECT COMBINATION THERAPY IN HTN INCREASE COMPLIANCE THE ENDSlide 41: Thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.