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Avoiding End Organ Damage

Avoiding End Organ Damage. DR. SHAHBAZ AHMED KURESHI MBBS, MCPS, D. CARD, D. Med.Sc, FACC, FAHA, FACP, FPAMS Consultant Cardiologist, Head Department of Cardiology and Nuclear Cardiology, Federal Government Services Hospital, Islamabad. Destination <120/80 Lower is Better !.

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Avoiding End Organ Damage

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  1. Avoiding End Organ Damage DR. SHAHBAZ AHMED KURESHI MBBS, MCPS, D. CARD, D. Med.Sc, FACC, FAHA, FACP, FPAMS Consultant Cardiologist, Head Department of Cardiology and Nuclear Cardiology, Federal Government Services Hospital, Islamabad

  2. Destination <120/80Lower is Better !

  3. Worldwide, hypertension is responsible for 62% of strokes1 49% of heart attacks1 Hypertension is the third leading risk factor for disease Causes 7.1 million premature deaths each year1 4.5% of global burden of disease1 Hypertension represents a high burden on healthcare expenditure In 2004, the direct and indirect cost of high blood pressurein the US was $55.5 billion; drug costs accounted for $21 billion2 Hypertension Represents a Significant Burden on Healthcare Thus, hypertension management is a public health priority 1. WHO, 2002; 2. AHA, 2004

  4. National Health Survey • Circulatory diseases account for over 100,000 deaths a year or 12% of all cause mortality . • Overall 18% of adults in Pakistan suffer from HBP, 21.5% in urban areas and 16.2% in rural areas. • One in every 3 adults over age 45 suffer from hypertension. • Very few Pakistanis with hypertension (<3%) have their B.P controlled. PROCOR: 7/25/99 The National Health Survey in Pakistan published in 1998 by (PMRC) 1

  5. Potentially Preventable Causes of Death

  6. BP and increasing age Kearney et al, Lancet 2005

  7. Prevalence of hypertension is high Prevalence of hypertension in people aged 20 years and older 2000 Prevalence of hypertension (%) 2025 Kearney PM et al.,Lancet. 2005;365:217-223.

  8. Factors Necessary to Assess the Risk or Target Organ Damage ESH-ESC guidelines, 2003, J Hypertens

  9. Hypertension is a leading cause for cardiovascular morbidity Men Women Men Women Men Women Men Women 36-Year Follow-up in Patients Aged 35-64 Years1,2 Peripheral Arterial Disease Heart Failure Coronary Disease Stroke 50 45.4 40 Normotensive Hypertensive Biennial Age-Adjusted Rate per 1,000 30 22.7 21.3 20 13.9 12.4 9.9 9.5 7.3 10 6.2 6.3 5.0 3.5 3.3 2.4 2.1 2.0 0 1. Kannel W.B. et al., JAMA 1996; 275: 1571-1576 2. Kannel W.B. et al., J Hum Hypertens 2000; 14: 83-90

  10. Prehypertension Normal 120-129/80-84 mm Hg Optimal <120/80 mm Hg High normal 130-139/85-89 mm Hg Men Women 14 P<.001 10 12 P<.001 8 10 Cumulative Incidence (%) 8 6 6 4 4 2 2 0 0 0 2 4 6 8 10 12 14 0 2 4 6 8 10 12 14 Time (years) Time (years) High-Normal BP and CVD Risk Vasan et al. N Engl J Med. 2001

  11. a b Age at risk: Age at risk: 256 128 64 32 16 8 4 2 1 256 128 64 32 16 8 4 2 1 80–89 years 80–89 years 70–79 years 70–79 years 60–69 years 60–69 years 50–59 years 50–59 years Ischaemic heart disease mortality (floating absolute risk and 95% CI) Ischaemic heart disease mortality (floating absolute risk and 95% CI) 40–49 years 40–49 years 70 80 90 100 110 120 140 160 180 Usual DBP (mmHg) Usual SBP (mmHg) Blood pressure, heart disease and age correlate closely Relationship between (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP) and ischaemic heart disease mortality in one million individuals in the general population.CI, confidence interval. Lewington S et al. Lancet. 2002; 360:1903-1913.

  12. CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment* 8 7 6 5 CVmortalityrisk 4 3 2 1 0 115/75 135/85 155/95 175/105 SBP/DBP (mm Hg) *Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

  13. Absolute Risk Of Coronary Artery Disease And Stroke Mortality

  14. Curvilinear Relation Of Blood Pressure And Cardiovascular Risk

  15. Geographical Variation In Hypertension Prevalence In Population Of African And European Ancestry

  16. Age- Dependent Changes In Systolic and Diastolic Blood Pressure In USA

  17. Vascular Remodeling Of Small And Large Arteries

  18. The Renin- Angiotensin- Aldosterone System

  19. Schematic Representation Of The Central Role Played By Angiotensin 1 Receptor (AT1R)

  20. Superiority Of Ambulatory Over Office Blood Pressure Measurements

  21. 24-Hour Ambulatory Blood Pressure Recording

  22. Relation Between Systolic Blood Pressure And The Rate Of Progression Of Coronary Atheroma

  23. Blood Pressure Risk Stratification (ESH/ESC 2007) Mancia G et al., J Hypertens 2007;25:1105–87

  24. Blood pressure reductions of as little as 2 mmHg reduce the risk of cardiovascular events by up to 10%1 Meta-analysis of 61 prospective, observational studies One million adults 12.7 million person-years 7% reduction in risk of ischemic heart disease mortality 2 mmHg decrease in mean systolic blood pressure 10% reduction in risk of stroke mortality 1. Lewington S et al. Lancet. 2002;360:1903–1913.

  25. Effective blood pressure control reduces cardiovascular morbidity and mortality Systolic–diastolic hypertension Isolated systolic hypertension Fatal and non-fatal events Fatal and non-fatal events Mortality Mortality 10 AllCauses AllCauses CV Non CV CV Non CV Stroke CHD Stroke CHD 0 NS NS -10 Relative Risk Reduction (%) 0.02 <0.01 <0.01 -20 <0.001 0.01 <0.001 -30 <0.001 -40 ESH/ESC guidelines consider systolic values of <139 mmHg and diastolic values of <89 mmHg to be normal <0.001 Event reduction in patients on active antihypertensive treatment vs placebo or no treatment CHD: coronary heart disease; CV: cardiovascular -50 Cifkova R, et al. J Hypertens. 2003;21:1011–1053.

  26. Relations Between Achieved Blood Pressure Control And Declines In Glomerular Filtration Rate

  27. Absolute Benefits For The Prevention Of Fatal Nonfatal Cardiovascular Events

  28. Odds Ratio For Cardiovascular Events And Systolic Blood Pressure

  29. Trials Comparing The Effect On Primary End Point Of Treatment Based On Different Antihypertensive Drugs

  30. Antihypertensive Therapy: Number of Agents Required to Achieve BP Goal UKPDS (<85 mm Hg, diastolic) MDRD (<92 mm Hg, MAP) HOT (<80 mm Hg, diastolic) AASK (<92 mm Hg, MAP) RENAAL (<140/90 mm Hg) IDNT (135/85 mm Hg) 1 2 3 4 Number of BP Medications Bakris et al. Am J Kidney Dis. 2000;36:646-661; Bakris et al. Arch Intern Med. 2003;163:1555-1565; Lewis et al. N Engl J Med. 2001;345:851-860.

  31. An Algorithm For The decision To Manage Patients With Different Average Blood Pressure Levels

  32. Algorithm For Therapy Of Hypertension

  33. What qualities do you want to see in an effective Anti Hypertensive agent? • Get patients to BP goal • Provides 24 hour BP control • Has good tolerability • Has ‘added’ protection

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  38. Conclusion In patients with MI complicated by heart failure, left ventricular dysfunction or both: Valsartan is as effective as a proven dose of captopril in reducing the risk of: Death CV death or nonfatal MI or heart failure admission Combining valsartan with a proven dose of captopril produced no further reduction in mortality—and more adverse drug events. Implications: In these patients, valsartan is a clinically effective alternative to an ACE inhibitor.

  39. Cardiovascular morbidity and mortality Treatment Enables Retardation of the Progression of Renal Disease Prevention Protection Benedict study IRMA 2 MARVAL IDNT RENAAL MicroalbuminuriaMacroalbuminuriaESRD Early stageLate stage Terminal stage Severity of renal disease

  40. Conclusions • In type 2 diabetic pts with microalbuminuria arterial BP was reduced to the same extent in the valsartan and amlodipine groups • AER was significantly reduced in the valsartan group compared with the amlodipine group. • Significantly more pts regressed to normoalbuminuria in the valsartan group • The effect of valsartan on AER was similar in both the normotensive and hypertensive subgroups

  41. “First do no harm”

  42. The Mechanisms By Which Chronic Diuretic Therapy May Lead TO Various Complications

  43. Theoretical Therapeutic And Toxic Logarithmic And Linear Dose Response Curve

  44. Classification Of Beta- Adrenoreceptor Blockers On The Basic Of Cardioselectivity And Intrinsic Sympathomimetic Activity

  45. Worldwide blood pressure control rates in treated hypertensive patients are low Germany 33.6 Canada 41.0 Japan* 55.7 England 29.2 Greece 49.5 USA 53.1 China 28.8 Taiwan 18.0 Turkey 19.8 Mexico 21.8 Egypt 33.5 South Africa* 47.6 Kearney P.M. et al., J Hypertens 2004; 22: 11–19; * Data for men only

  46. Simplified Schematic View Of The Adrenergic Nerve

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