High risk hypertensive patient

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By Essam Mahfouz, MD Professor of Cardiology Mansoura University High Risk Hypertensive Patient

Definition: : 

Definition: High risk hypertensive patient means : Hypertensive patient with evidence of atherosclerosis ( coronary, cerebral, or peripheral). Or with one or more atherosclerotic risk factors. Or with target organ damage (cardiac, renal, eye or cerebral affection.

26.3 of the Egyptian adults(25-95 Year) have hypertension : 

26.3 of the Egyptian adults(25-95 Year) have hypertension 62.5% 13.5% 16% 8% Egyptian National Hypertension Project

Blood Pressure Classification : 

Blood Pressure Classification JNC7, 2003

ESC GUIDELINES 2007Definitions & classifications : 

ESC GUIDELINES 2007Definitions & classifications

Target Organ Damage : 

Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy JNC7, JAMA,2003

Patient Evaluation : 

Patient Evaluation Evaluation of patients with documented HTN has three objectives: Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. Reveal identifiable causes of high BP. Assess the presence or absence of target organ damage and CVD. JNC7, JAMA,2003

Routine and optional laboratory tests : 

Routine and optional laboratory tests

Investigation for Renovascular Hypertension : 

Investigation for Renovascular Hypertension

Clinical Risk Factors for Stratification of Patients With Hypertension : 

Clinical Risk Factors for Stratification of Patients With Hypertension Heart diseases Stroke or transient ischemic attack Nephropathy Peripheral arterial disease Retinopathy

Search for target organ damage : 

Search for target organ damage Cerebrovascular disease - transient ischemic attacks - ischemic or hemorrhagic stroke - vascular dementia Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease - myocardial infarction - angina pectoris - congestive heart failure Chronic kidney disease - hypertensive nephropathy (GFR < 60 ml/min/1.73 m2) - albuminuria Peripheral artery disease - intermittent claudication III. Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors : 

Cardiovascular Risk Factors Presence of Risk Factors Increasing age Male gender Smoking Family history of premature cardiovascular disease (age< 55 in men and < 65 in women) Dyslipidemia Sedentary lifestyle Unhealthy eating Abdominal obesity CV Risk Factors that may alter thresholds and targets in the treatment of HTN III. Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors : 

Cardiovascular Risk Factors Presence of Diabetes Presence of Target Organ Damage Microalbuminuria or proteinuria Left ventricular hypertrophy Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2) Presence of atherosclerotic vascular disease Previous stroke or TIA CHD Peripheral arterial disease CV Risk Factors that may alter thresholds and targets in the treatment of HTN III. Assessment of the overall cardiovascular risk

High/Very high risk subjects : 

High/Very high risk subjects BP > 180 mmHg systolic and/or >110 mmHg diastolic Systolic BP > 160 mmHg with low diastolic BP < 70 mmHg Diabetes mellitus Metabolic syndrome >3 cardiovascular risk factors

High/Very high risk subjects : 

High/Very high risk subjects One or more of the following subclinical organ damages: Electrocardiographic (particularly with strain) or echocardiographic (particularly concentric) left ventricular hypertrophy Ultrasound evidence of carotid artery wall thickening or plaque Increased arterial stiffness Moderate increase in serum creatinine Reduced estimated glomerular filtration rate or creatinine clearance Microalbuminuria or proteinuria Established cardiovascular or renal disease

ESC Guidelines 2007: Risk stratification : 

ESC Guidelines 2007: Risk stratification

Benefits of Lowering BP : 

Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50% JNC7, JAMA,2003

Benefits of Lowering BP : 

Benefits of Lowering BP In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated. JNC7, JAMA,2003

Aim of Antihypertensive Therapy : 

Aim of Antihypertensive Therapy To prevent the cardiovascular complications of hypertension (stroke, acute myocardial infarction, congestive heart failure) not just to lower an elevated blood pressure.

Lifestyle Modifications : 

For Prevention and Management Lifestyle Modifications Lose weight if overweight Limit alcohol intake Increase aerobic physical activity Reduce sodium intake Maintain adequate intake of potassium Maintain adequate intake of calcium and magnesium Stop smoking Reduce dietary saturated fat and cholesterol For Overall and Cardiovascular Health

Pharmacologic Treatment : 

Pharmacologic Treatment Decreases cardiovascular morbidity and mortality based on randomized controlled trials. Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

Pharmacological therapy : 

Pharmacological therapy With which group of drugs to start treatment? Monotherapy or combination ? What is the target BP to be reached ? Secondary HTN must be excluded especially in young age Patient compliance is an important issue

Special Considerationsin Selecting Drug Therapy : 

Special Considerationsin Selecting Drug Therapy Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions Economic considerations

ESC guidelines 2007Treatment and Risk : 

ESC guidelines 2007Treatment and Risk

AHA Position statement for CAD prevention and treatment in HTN : 

AHA Position statement for CAD prevention and treatment in HTN Rosendorff et al Circulation 2007

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This is a meta-analysis of 9 trials of atenolol in HTN; 4 trials Vs Placebo(6826 patients) and 5 trials Vs other drugs (17,671 patients) The authors cast doubt on atenolol as a suitable drug for hypertensive patients and challenge its use as a reference drug in outcome trials in HTN

Outcome data of atenolol Vs placebo trials : 

Outcome data of atenolol Vs placebo trials All cause mortality CV Mortality Myocardial infarction Stroke 0.5 0.7 1.0 1.5 2.0 Atenolol is better placebo is better RR & 95% CI Carlberg et al Lancet 2004 1.01(0.89- 1.15) 0.99(0.83- 1.18) 0.99(0.83- 1.19) 0.85(0.72- 1.01)

Outcome data of atenolol Vs other anti HTN drugs : 

Outcome data of atenolol Vs other anti HTN drugs All cause mortality CV Mortality Myocardial infarction Stroke 0.5 0.7 1.0 1.5 2.0 Atenolol is better Comparator is better RR & 95% CI Carlberg et al Lancet 2004 RR & 95% CI 1.13(0.97- 1.33) 1.16(1.0- 1.34) 1.04(0.89- 1.20) 1.30(1.12- 1.50)

ASCOT-BPLA : 

ASCOT-BPLA Prospective randomized controlled MC trial 19,257 patient 40-79 y with 3 or more risk factors in 2 treatment arms (amlodopine + perindopril Vs atenolol + bendroflumethiazide) The study were stopped prematurely due the marked benefit of amlodopine perindopril regimen Also, the development of incident DM was less in the amlodopine based arm (HR 0.7, 95% CI= 0.63-0.78, P< 0.0001) Dahlof et.al. Lancet 2005

ESH 2007 Guidelines: B-Blockers : 

ESH 2007 Guidelines: B-Blockers The benefit of b-blockers compared with that of other antihypertensive agents has recently been questioned on the basis of the results of two large randomized trials, the LIFE study and the ASCOT study, both of which showed superiority of an ARB and, respectively, a calcium antagonist over therapy initiated by a b-blocker as far as stroke (LIFE) or stroke and mortality (ASCOT) were concerned. These two large trials have strongly influenced a recent meta-analysis (Lindholm et.al. Lancet 2005) which concluded that b-blocker initiated therapy is inferior to others in stroke prevention, but not in prevention of myocardial infarction and reduction in mortality.

Algorithm for treatment : 

Algorithm for treatment Not at goal blood pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Lifestyle modifications Initial drug choices Without compelling indications Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 hypertension (SBP >160 or DBP >100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) With compelling indications Drugs for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Not at goal blood pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist JNC7, JAMA,2003

Drug selection for newly diagnosed HTN : 

Drug selection for newly diagnosed HTN NICE (national institute of health and clinical excellence) Guidelines 2006

Selection of anti-HTN drugs : 

Selection of anti-HTN drugs

ESH Guidelines 2007: Drug combinations : 

ESH Guidelines 2007: Drug combinations

HOT - Rate of Major CV Events According to Randomized Groups : 

HOT - Rate of Major CV Events According to Randomized Groups BP goal mmHg p for trend<0.005 p for trend> 0.5 Hansson et al., Lancet 1998 0 5 10 15 20 25 30 All n=18790 Diabetic n=1501 Rate/1000 person-years <90 <85 <80

Causes for InadequateResponse to Drug Therapy : 

Causes for InadequateResponse to Drug Therapy Pseudoresistance Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension

Take home message : 

Take home message Hypertension is a common health problem allover the world In spite the great effort of HTN societies, the %age of controlled HTN patients still low High risk HTN patients are an important sector that needs aggressive control of BP in order to avoid CV morbidity and mortality Use of specific groups of antihypertensive agents that proved effective in large clinical trials is mandatory in this situation All efforts must be used to reach the target BP in those high risk patients whatever the No. of drugs used.

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Thank you