The Global Burden of Disease

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The Global Burden of Disease

• The scale of the problem

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Leading Causes of Death and Disability (DALYs)
1990
2020
Rank Cause Rank Cause
1 Lower respiratory infections 8.2 1 Ischemic
heart disease 5.9 2 Diarrhoeal diseases 7.2 2 Majo
r depression 5.7 3 Perinatal conditions 6.7 3 Road
traffic accidents 5.1 4 Major depression 3.7 4 Ce
rebrovascular disease 4.4 5 Ischemic heart
disease 3.4 5 COPD 4.2 6 Cerebrovascular
disease 2.8 6 Lower respiratory
infections 3.1 7 Tuberculosis 2.8 7 Tuberculosis 3
.0 8 Measles 2.7 8 War 3.0 9 Road traffic
accidents 2.5 9 Diarrhoeal diseases 2.7 10 Congeni
tal abnormalities 2.4 10 HIV 2.6
Global Burden of Disease Study, 1996
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Mortality due to leading global risk factors
World Health Report 2002
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Prevalence of Hypertension by different cut
points
? 90 25.3
? 95 14.5
? 100 8.4
? 105 4.7
of screened population
? 110 2.9
? 115 1.4
50
60
70
80
90
100
110
120
130
Diastolic BP, mmHg
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British Hypertension Society Guidelines for
hypertension management 2004 (BHS-IV) summary

• Bryan Williams, Neil R Poulter, Morris J Brown,
  Mark Davies, Gordon T McInnes, John F Potter,
  Peter S Sever, Simon McG Thom the BHS guidelines
  working party, for the British Hypertension
  Society
• BMJ Volume 328 13 March 2004 634-640.

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BHS Guidelines

• Definitions
• Measurement
• Risk assessment
• Evaluation of hypertensive patients
• Thresholds for intervention
• Treatment goals
• Lifestyle measures
• Choice of therapy
• Meta-analysis of trials
• ABCD rule
• Aspirin and statins
• Follow up and implementation

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Classification of blood pressure levels of the
British Hypertension Society
Category Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
Blood Pressure
Optimal lt120 lt80
Normal lt130 lt85
High normal 130-139 85-89
Hypertension
Grade 1 (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) gt180 gt110
Isolated systolic hypertension
Grade 1 140-159 lt90
Grade 2 gt160 lt90
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Blood pressure measurement by standard mercury
sphygmomanometer or semiautomated device

• Use of properly maintain, calibrated, and
  validated device
• Measure sitting blood pressure routinely
  standing blood pressure should be recorded at
  least at the initial estimation in elderly or
  diabetic patients
• Remove tight clothing, support arm at heart
  level, ensure arm relaxed and avoid talking
  during the measurement procedure
• Use of cuff of appropriate size

Continued
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Blood pressure measurement by standard mercury
sphygmomanometer or semiautomated device

• Lower mercury column slowly (2mm per second)
• Read blood pressure to the nearest 2 mm Hg
• Measure diastolic blood pressure as disappearance
  of sounds (phase V)
• Take the mean of at least two readings, more
  recordings are needed if marked differences
  between initial measurements are found
• Do not treat on the basis of an isolated reading

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Potential indications for the use of ambulatory
blood pressure monitoring

• Unusual variability of blood pressure
• Possible white coat hypertension
• Informing equivocal treatment decisions
• Evaluation of nocturnal hypertension
• Evaluation of drug resistant hypertension
• Determining the efficacy of drug treatment over
  24 hours
• Diagnosis and treatment of hypertension in
  pregnancy
• Evaluation of symptomatic hypotension

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Routine investigations

• Urine strip test for protein and blood
• Serum creatinine and electrolytes
• Blood glucose ideally fasted
• Blood lipid profile ideally fasted for
  consideration of triglycerides
• Electrocardiogram

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Evaluation of hypertensive patients

• Causes of hypertension
• Drugs (non-steroidal anti-inflammatory drugs,
  oral contraceptions, steroids, liquorice,
  sympathomimetics, some cold cures)
• Renal disease (present, past or family history,
  proteinuria or haematuria palpable kidney(s)
  polycystic, hydronephrosis, or neoplasm)
• Renovascular disease (abdominal or loin bruit)
• Phaeochromocytoma (paroxysmal symptoms)
• Conns syndrome (tetany, muscle weakness,
  polyuria, hypokalaemia)
• Coarctation (radio-femoral delay or weak femoral
  pulses)
• Cushings (general appearance)

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Contributory factors

• Overweight
• Excess alcohol (gt 3 units/day for men gt 2
  units/days for women)
• Excess salt intake
• Lack of exercise
• Environmental stress

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Complications of hypertension or target organ
damage

• Stroke, transient ischaemic attack, dementia,
  carotid bruits
• Left ventricular hypertrophy or left ventricular
  strain on electrocardiogram
• Heart failure
• Myocardial infarct, angina, coronary artery
  bypass graft, or angioplasty
• Peripheral vascular disease
• Fundal haemorrhages or exudates, papillodoema
• Proteinuria
• Renal impairment

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Suggested indications for specialist referral

• Urgent treatment needed
• Accelerated hypertension (severe hypertension and
  grade III-IV retinopathy)
• Particularly severe hypertension (gt220/120mmHg)
• Impending complications (for example, transient
  ischaemic attack, left ventricular failure)

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Possible underlying cause

• Any clue in history or examination of a secondary
  cause, such as hypokalaemia with increased or
  high normal plasma sodium (Conns syndrome)
• Elevated serum creatinine
• Proteinuria or haematuria
• Sudden onset or worsening of hypertension
• Resistant to multi-drug regimen (gt 3 drugs)
• Young age (any hypertension lt20 years needing
  treatment lt30 years)

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Therapeutic problems

• Multiple drug intolerance
• Multiple drug contraindications
• Persistent non-adherence or non-compliance

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Special situations

• Unusual blood pressure variability
• Possible white coat hypertension
• Hypertension in pregnancy

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Cardiovascular risk assessment
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Lifestyle measures

• Maintain normal weight for adults (body mass
  index 20-25kg/m2)
• Reduce salt intake to lt 100mmol/day (lt6g NaCI or
  lt 2.4 g Na/day)
• Limit alcohol consumption to lt 3 units/day for
  men and lt 2 units/day for women)
• Regular physical exercise (brisk walking rather
  than weightlifting) for gt 30 minutes per day,
  ideally on most days of the week but at least on
  three days of the week.
• Consume at least five portions/day of fresh fruit
  and vegetables
• Reduce the intake of total and saturated fat

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Thresholds and treatment for antihypertensive
drug treatment

• Drug treatment should be started in all patients
  with sustained systolic blood pressures gt 160mmHg
  or sustained diastolic blood pressures gt 100mmHg
  despite non-pharmacological measures (A)
• Drug treatment is also indicated in patients with
  sustained systolic blood pressures 140-159mmHg or
  diastolic blood pressures 90-99mmHg if target
  organ damage is present, or there is evidence of
  established cardiovascular disease or diabetes,
  or if there is a 10 year cardiovascular disease
  risk of gt 20 (B)

continued
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Thresholds and treatment for antihypertensive
drug treatment

• For most patients a target of lt 140mmHg systolic
  blood pressure and lt85mmHg diastolic blood
  pressure recommended (B). For patients with
  diabetes, renal impairment or established
  cardiovascular disease a lower target of lt
  130/80mmHg is recommended

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Initial Blood Pressure
130-139 80-89
160-179 100-109
140-159 90-99
? 180/110
lt130/85
?160/100
140-159 90-99
lt140/90
Treat
Re-measure in 5 years
Reassess Yearly
Treat
SEE NEXT SLIDE
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140-159 90-99
Target organ damage or CVS
complications or Diabetes
or CV event risk ? 2/year gt20 over
10 yrs
No target organ damage and No CVS
complications and No diabetes and CV event risk
lt 2/year lt20 over 10 yrs
Observe Reassess CV risk yearly
Treat
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Drug treatment of hypertension
Diuretic
ACE-inhibitor
Angiotensin receptor blocker
Calcium-channel blocker
Beta-blocker
(Alpha-blocker)

• Most hypertensives will need ? 2 drugs to control
  BP
• Drug combinations may be synergistic

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STROKEComparisons of different active treatments
BP difference (mm Hg)

Favours second listed
Favours first listed

RR (95 CI)
2/0
1.09 (1.00,1.18)
ACE vs. D/BB
1/0
0.93 (0.86,1.01)
CA vs. D/BB
1/1
1.12 (1.01,1.25)
ACE vs. CA
0.5
1.0
2.0
Relative Risk
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CORONARY HEART DISEASEComparisons of different
active treatments
BP difference (mm Hg)
Favours first listed
Favours second listed


RR (95 CI)
2/0
ACE vs. D/BB
0.98 (0.91,1.05)
1/0
CA vs. D/BB
1.01 (0.94,1.08)
1/1
ACE vs. CA
0.96 (0.88,1.05)
0.5
1.0
2.0
Relative Risk
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HEART FAILUREComparisons of different active
treatments
BP difference (mm Hg)
Favours first listed
Favours second listed


RR (95 CI)
2/0
ACE vs. D/BB
1.07 (0.96,1.19)
1/0
CA vs. D/BB
1.33 (1.21,1.47)
1/1
ACE vs. CA
0.82 (0.73,0.92)
0.5
1.0
2.0
Relative Risk
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MAJOR CARDIOVASCULAR EVENTS Comparisons of
different active treatments
BP difference (mm Hg)
Favours first listed
Favours second listed


RR (95 CI)
2/0
ACE vs. D/BB
1.02 (0.98,1.07)
1/0
CA vs. D/BB
1.04 (0.99,1.08)
ACE vs. CA
1/1
0.97 (0.92,1.03)
0.5
1.0
2.0
Relative Risk
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ALLHAT Design
Amlodipine Chlorthalidone Doxazosin Lisinopril
High risk Hypertensive Patients 42,515
Randomize
10,362 eligible for Lipid lowering
Not eligible for Lipid lowering
Randomize
Study completion January 2003
Pravastatin
Usual Care
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ALLHAT Primary Endpoint CHD Death and Nonfatal
MI
Relative Risk (95 CI)
Amlodipine 0.98 (0.90-1.07)
Lisinopril 0.99 (0.91-1.08)
0.7
1.3
FavorsChlorthalidone
Favors AmlodipineFavors Lisinopril
ALLHAT Collaborative Research Group. JAMA.
20022882981-2997.
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ASCOT PROBE Design
Amlodipine ? Perindopril ? Doxazosin GITs
19342
High-risk Hypertensive
Randomized
Atenolol ? Bendrofluazide ? Doxazosin GITs
Eligible for Lipid Lowering
Not Eligible for Lipid Lowering
10305
Randomize DB
Atorvastatin 10 mg
Placebo
Expected Mean Follow-up 5 Yrs Fatal CHD
Non-Fatal MI
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ASCOT study Effect of atorvastatin on CHD
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ASCOT study Effect of atorvastatin on stroke
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The British Hypertension Society recommendations
for combining Blood Pressure Lowering drugs
Younger (e.g.lt55yr)and Non-Black
Older (e.g.?55yr) or Black
Step 1
A (or B)
C or D
Step 2
A (or B)
C or D

Step 3
A (or B)


C
D
Step 4Resistant Hypertension
Add either ?-blocker or spironolactone or other
diuretic
A ACE Inhibitor or angiotensin receptor
blocker B b - blockerC Calcium Channel
Blocker D Diuretic (thiazide)
Combination therapy involving B and D may
induce more new onset diabetes compared with
other combination therapies
Adapted from Better blood pressure control how
to combine drugs Journal of Human Hypertension
(2003) 17, 81?86
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Compelling and possible indications,
contraindications, and cautions for the major
classes of antihypertensive drugs
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of hypertensives with controlled BP
lt160/95 mm Hg
lt140/90 mm Hg
Australia4
Spain4
Finland4
19
20
20.5
Zaire4
India4
2.5
9
Adapted from Mancia, 1997
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Other medication for hypertensive patients

• Primary prevention
• Aspirin use 75mg daily if patient is aged gt50
  years with blood pressure controlled to
  lt150/90mmHg and target organ damage, diabetes
  mellitus, or 10 year risk of cardiovascular
  disease of gt20 (measured by using the new Joint
  British Societies cardiovascular disease risk
  chart)
• Statin use sufficient doses to reach targets if
  patient aged up to at least 80 years, with a 10
  year risk of cardiovascular disease of gt20
  (measured by using the new Joint British
  Societies risk chart) and with total cholesterol
  concentration gt3.5mmol/l
• Vitamins no benefit shown, do not prescribe

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Secondary prevention (including patients with
type 2 diabetes)

1. Aspirin use for all patients contraindicated
2. Statin use sufficient doses to reach targets if
   patient is aged up to at least 80 years with a
   total cholesterol concentration gt3.5mmol/l
3. Vitamins no benefits shown, do not prescribe

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Large randomised trials demonstrate lowering
LDL- cholesterol by 1 mmol/l reduces non-fatal MI
and fatal CHD by about 25 ( about half the the
effect predicted from epidemiological studies for
a similar reduction in long term cholesterol
lowering in people without vascular disease )
Collins 2002With greater reductions in
cholesterol there are correspondingly larger
reductions in CHD endpoints.
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Heart Protection Study Effect of simvastatin on
major vascular events
30
25
PLACEBO
20
People suffering events ()
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SIMVASTATIN
10
5
0
0
1
2
3
4
5
6
Years of follow-up
5(3)
20(4)
35(5)
46(5)
54(7)
60(18)
Benefit/1000 (SE)
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Age- and gender adjusted hypertension control by
country (35-64 years) 140/90 mmHg
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Age- and gender adjusted hypertension control by
country (35-64 years) 140/90 mmHg
Impact of structured algorithm
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