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Hypertension update Which guideline to follow?


Hypertension update Which guideline to follow? Dr Sunita Dodani Department of Family Medicine Aga Khan University Karachi, Pakistan February 23,2003 – PowerPoint PPT presentation

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Title: Hypertension update Which guideline to follow?

Hypertension updateWhich guideline to follow? 
  • Dr Sunita DodaniDepartment of Family
    MedicineAga Khan UniversityKarachi,
    PakistanFebruary 23,2003

Presentation outline
  • World Wide Epidemic Some Figures
  • Epidemiological Transition Hypertension
  • Data From Developing Countries
  • EMRO Work
  • Statistics From Pakistan NHSP
  • Hypertension Guidelines
  • Currently available guidelines
  • Similarities in guidelines
  • Differences in guidelines

Presentation outline
  • Hypertension Guidelines (Contd)
  • Still Unanswered Questions
  • What is needed in Pakistan
  • Epidemiologic research
  • Which guideline to follow?
  • JNC VI guideline (1994)
  • Risk stratification

Worldwide Epidemic Some Figures
  • affect all ages, but primarily occurs in adults.
  • 20 prevalence,approximately 690m people have
    hypertension world wide
  • major risk factor for stroke, coronary heart
    disease and kidney failure
  • 30 of deaths worldwide (15 million) are due to
    cardiovascular diseases
  • 5 million deaths / year worldwide due to strokes
    alone, with another 30 million suffering from its
    disabling effects.
  • (Geneva, Switzerland November 15-16, 1999)

Epidemiological Transition Hypertension 
  • Developing countries experiencing rapid health
    transition, escalating relative and absolute
    burdens of CVD
  • Determinants of transition
  • a) demographic (increased life expectancy)
  • b) lifestyle changes
  • c) urbanization, industrialization and

Epidemiological Transition Hypertension
  • In developing countries ,steady increase in
    hypertension prevalence over the last 50 years,
    more in urban than in rural areas
    (WHO report 2002)
  • WHO Regions

World regions according to WHO

Eastern Mediterranean region (EMR)
  • (Jordan, Iran, Srilanka, Pakistan, Egypt Oman,
    Saudi Arabia , Bangladesh etc)
  • Paucity of large, authentic, epidemiological
  • Limited data available in the form of small
  • Majority of studies done have shortcomings
  • differing examination techniques differing
    diagnostic criteria
  • screening blood pressure values used

The studies are not representative of the
total population Limited to single centers or
single community
EMR (cont'd)
  • Majority of third world countries lack
  • sufficient national estimates of the
  • prevalence of hypertension
  • In developing countries ,steady increase
  • in hypertension prevalence over the last 50
  • years, more in urban than in rural areas

EMR. Some prevalence figures
  • Saudi Arabia 10-15
  • (EMRO bulletin 2001)
  • Riyadh city 15.4 (27 unaware)
  • Bangladesh (gt 70 yrs) 65
  • (multi center trail, hypertension study
    group, 2000)
  • Egypt (national estimates) 26
  • gt 70 yrs 56.6
  • (Ibrahim MM , Cairo university Egypt,
  • Iran(population based) 18
  • (Sarraf-Zadegan N, East Mediterr
    Health J 1999)

Hypertension figures in Pakistan
  • National Health Survey of Pakistan
  • 1990-1994
  • Some data available, some in re-analysis phase
  • 10.8 million hypertensives (pop 91m,1991)
  • 5.5 million men
  • 5.3 million women
  • 12 million hypertensives (pop 130m,1998)
  • 17.9 (? 15 yrs)
  • 21.5.. Urban
  • 16.2.. Rural

Hypertension figures in Pakistan
  • NHSP ( 1990-1994)
  • 58 (? 65 yrs females)
  • 1 in every 3 Pakistanis (gt45 yrs)
  • Prevalence is lower in females than males at
    younger ages, but exceed after 35-44 yrs of age
  • (This cross over is at later age in US
  • gt3 of the hypertensive patients have BP
    controlled to the conventional recommendations of
    under 140/ 90 mmHg

Hypertension figures in Pakistan
  • Prevalence of hypertension (PMRC)
  • Rural

Hypertension figures in Pakistan
  • Prevalence of hypertension (PMRC)

Early detection,awareness treatment
  • (Need for guidelines)
  • help to limit the subjective element in decision
    making assist clinicians to provide better care
  • define the best clinical decisions and the
    minimal level of acceptable care in order to
    ensure appropriate quality
  • formulated based upon the evidence collected from
    available literature, and agreement among experts
    in areas where literature is deficient

Hypertension Guidelines
  • Several guidelines for the management of
    hypertension were published in the last few years
  • Many were recent revisions and updated versions
    of old ones, modified according to new evidence
    from clinical trials
  • Provided answers to many clinical questions. a)
    Isolated systolic hypertension in the
  • elderly is dangerous should be
  • treated
  • b) aggressive lowering of blood pressure is
  • required in patients with risk

Hypertension Guidelines
  • JNC VI 1994
  • Hypertension Detection and Follow-up Program
  • WHO/ISH 1999
  • British hypertension Society 1999
  • Medical Research Council (MRC)
  • Canadian Cardiac Society 1999
  • Local
  • Pakistan hypertension league 1998
  • (First Report of National Task Force)

Hypertension Guidelines
  • These four major guidelines are based on the
    strong evidence from almost the same literature
    and the large randomized mega trials, they agree
    and disagree on a number of important issues

Hypertension Guidelines
  • These guidelines agree on many aspects
  • 1. All guidelines agree upon the definition of
  • 2. The type of routine tests needed for the
    evaluation of hypertensive patients
  • 3. The need for global risk assessment the
    target blood pressure
  • 4. The importance of life style modification
  • 5. Individualization of antihypertensive therapy
  • 6. Need for indefinite follow-up

Hypertension Guidelines
  • Differences in the guidelines

Hypertension Guidelines
  • Still Unanswered Questions
  • how to avoid over treatment of patients at very
    low risk?
  • what is the best simple approach for accurate
    cardiovascular risk assessment?
  • Decisions to initiate therapy are based on the
    absolute cardiovascular risk profile of the
    hypertensive patient
  • ? risk assessment are based on the Framingham
  • ? risk scoring equations are incomplete
  • ? do not account for racial and genetic

Hypertension Guidelines
  • Still Unanswered Questions
  • management of patients with uncomplicated mild
  • ? duration period of observation
  • ? the number of office visits
  • ? blood pressure measurements
  • ? the average blood pressure threshold during
    the period of monitoring
  • role of ambulatory blood pressure is not settled
  • how to adjust for racial, genetic, geographic,
    age gender and socioeconomic differences

Hypertension Guidelines
  • Still Unanswered Questions
  • optimal blood pressure reduction
  • ? what is the desired level of blood pressure
  • ? It is not necessarily the same level in all
  • individuals.
  • ? Race, age and gender may influence our target
  • blood pressure.
  • ? We might need more aggressive reduction in
  • blood pressure in special groups, e.g.,
  • blacks and patients with end-organ damage.

Hypertension Guidelines
  • Population dataPriorities in Epidemiologic
  • define the magnitude of the hypertension problem
    in Pakistan with evidenced based data
  • prevalence among different age groups, geographic
    areas, socioeconomic classes and the influence of
    factors like gender, ethnicity
  • Its risk factors e.g. Obesity, excessive salt
    intake, alcohol intake, psychosocial stress, low
    levels of education, poor SES, should be
    recognized examined

Hypertension Guidelines
  • Epidemiologic research
  • the type and prevalence of hypertensive
    cardiovascular complications. might be influenced
    by environment, race and other demographic
  • identify the susceptible groups which are most
    vulnerable to complications
  • How close are these complications related to the
    level of blood pressure and what are the other
    mechanisms involved
  • develop methods to improve detection and control
    of hypertension

Hypertension Guidelines
  • which guideline to follow?
  • Considering several meta analysis
  • outcome data from major clinical trial
  • strongest outcome data support the JNC VI

Hypertension Guidelines
Table 1 Classification of Blood Pressure
(mm Hg)
(mm Hg)
Normal Values of Blood Pressure
less than 120
less than 80
less than 85
less than 130
High normal
130 - 139
85 - 89
Stages of Hypertension
140 - 159
90 - 99
Stage 1
Stage 2
100 - 109
160 - 179
Stage 3
180 or higher
110 or higher

Hypertension Guidelines
  • Risk factors stratification
  • In populations in individual patients, the
    benefit from antihypertensive treatment is
    determined by the absolute cardiovascular risk
  • Blood pressure by itself is a very weak predictor
    of risk or benefit from treatment
  • simple but accurate risk assessment tools for
    estimating cardiovascular risk, similar to that
    in the New Zealand guidelines

Hypertension Guidelines
  • Presentation available at
  • http//www.pitt.edu/super1
  • http//www.pitt.edu/super1/pakistan/pakistan.htm

Presentation references
  • Ramsay LE. Williams B, Johnston GD, et al.
    Guidelines for management of hypertension report
    from the third working party of the British
    Hypertension Society. J Hum Hypertens 1000
  • Fieldman RD, Campbell N, Larochell P. Burgess ED,
    et al. 1999 Canadian recommendations for the
    management of hypertension CMAJ 1999 161 (12
    suppl) S1-S17
  • Joint National Committee on Prevention,
    Detection, Evaluation, and treatment of High
    Blood Pressure. The Sixth report. Arch Intern Med
    1997 1572413-2446.

Presentation references
  • Carretero OA. Oparil S. Essential hypertension
    Part II treatment. Circulation 2000
  • Reddy KS. Implementation of international
    guidelines on hypertension the Indian
    experience.Clin Exp Hypertens. 1999 Jul-Aug21
  • OBrien E. Critical appraisal of the JNC VI,
    WHO/ISH and BHS guidelines for essential
    hypertension.Expert Opin Pharmacother. 2000

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