1. to

2. HYPERTENSION IN INDIA Dr. A. Muruganathan President - API
Dr. M. Chenniappan
Trichy
Medical Writer

3. On the Occasion of World Hypertension Day...
An API Initiative to upgrade knowledge of Practising physicians throughout India

4. Why ?

5. Educate
Empower
Easy learning
Enjoyable learning
Evaluate ownself

6. The theme for World Hypertension Day 2013 is “Healthy Heart Beat - Healthy Blood Pressure”.
Considering the fact that atrial fibrillation – arrhythmias is very common in people with hypertension, especially among older patients, the WHL executive board felt that it is important to improve the public awareness about atrial fibrillation – arrhythmias. In order to make it easier for the public to understand they have used the simple terminology – Heart Beat.

7. The objectives of the World Hypertension League are to promote the detection, control and prevention of arterial hypertension in populations.
The World Hypertension League is a federation of leagues, societies, and other national bodies devoted to this goal. Bringing together and stimulating organizations committed to the control of hypertension is the goal of the WHL.
The WHL is a division of the International Society of Hypertension (ISH), and is in official relations with the World Health Organization (WHO).

8. Benefit of Interventions Over 5 Years
Lowering systolic BP 4 mm Hg: cardiovascular events / 200 patients
Lowering LDL cholesterol 1 mmol/L cardiovascular events / 200 patients
Lowering HbA1c 0.9 % cardiovascular events / 200 patients

9. Prevalence1
Nearly 1 billion adults (more than a quarter of the world’s population) had hypertension in 2000, and this is predicted to increase to 1.56 billion by 2025.
The prevalence of hypertension varies considerably from one region of India to another.
In India, 23.10% men and 22.60% women over 25 years old suffer from hypertension, says the World Health Organization’s global health statistics 2012’ released in May,
1. Indian J Med Res 128, December 2008, pp

10. Prevalence
Recent (2012) studies show that for every known person with hypertension in India, there may possibly be 2 persons with either undiagnosed hypertension or prehypertension.
With over 139 million patients, India accounts for 15% of world’s uncontrolled hypertension patients.

11. Prevalence
In terms of attributable deaths, the leading behavioral and physiological risk factors globally are raised blood pressure (to which 13% of global deaths are attributed), followed by tobacco use (9%), raised blood glucose (6%), physical inactivity (6%) and being overweight or obese (5%).
It has been estimated that raised blood pressure causes 51% of stroke deaths and 45% of coronary heart disease deaths.

12. Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors
High blood pressure
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
High mortality, developing region
Lower mortality, developing region
Developed region
Alcohol
Indoor smoke from solid fuels
Iron deficiency
1000
2000
3000
4000
5000
6000
7000
8000
Attributable Mortality (In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:

13. Prevalence
Only 1 in 5 hypertensive women were on treatment and less than 4% are controlled.
Majority of hypertensive still remain undetected & the control of hypertension is also inadequate.
But, despite all this, the good news is that the prevalence of hypertension in India is low as compared to world figures and India fares better than other countries in the South-East Asia Region (SEAR).
SEAR’s average is % in men & in women.

14. Among the High Blood Pressure patients only one third are aware of the disease.
Out of this only one third come for treatment.
Out of this only one third of patients are under control.

15. An Analysis of NHANES III
Blood Pressure Data Summary: Hypertensives fall into one of two categories:
1. A smaller (26%), younger (age < 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH)
2. A larger (74%), older (age ≥ 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH).
Franklin et al. Hypertension 2001;37:

16. Pre-hypertension
Pre-hypertension is defined as a systolic blood pressure reading between 120 and 139 and a diastolic blood pressure of 80 to 89.
Nearly 50 % people have Pre Hypertension, accordingly to one study, 50 % of people above 50 years have high blood pressure.
The category of pre-hypertension, was introduced to emphasize that persons whose blood pressure is >120/80 mm Hg are likely to progress to definite hypertension.
It was also hoped that doctors will encourage persons with pre- hypertension to begin lifestyle modifications to prevent its progression to hypertension.

17. Members of the Association of Physicians of India (API) are planning to conduct screening camps and patient education regarding hypertension, complications and management with the help of IMA throughout the country.
API is also interested to conduct updates for practicing physicians regarding the newer methods and updates about hypertension throughout the country directly and through web.

18. The Medical content of all 3 Modules has been written by Dr. M
The Medical content of all 3 Modules has been written by Dr.M.Chenniappan (Trichy)
The Panelist representing respective Regions and Key Members of API will review & give their suggestions on the Modules before it is uploaded in the site.
Sessions on Modules 2 & 3 will be facilitated by respective Panelist/KOLs in respective Bimonthly period
A book on Diabetic Hypertension will be released with the input & support of API Key Members & Panelists and will be presented to registered Drs for E-Hypertension Academy

19. Lifestyle Modification
MODULE-1
Basics, Diagnosis and
Lifestyle Modification

20. 1: INTRODUCTION AND BASICS
Introduction to hypertension e academics
Epidemiology of hypertension in India – Incidence, Awareness , Control
Etiopathogenesis of hypertension
Classification

21. 2: DIAGNOSIS OF HYPERTENSION
Clinical examination in hypertension
Measurement of blood pressure
Ambulatory BP monitoring
Laboratory investigation in hypertension
Imaging in hypertension

22. 3: NONPHARMACOLOGICAL APPROACH TO HYPERTENSION
Goals and risk stratification
Diet and hypertension
Salt and hypertension
Exercise and other lifestyle modifications

23. MODULE-2
Management of
Hypertension

24. 1: PHARMACOLOGICAL TREATMENT OF HYPERTENSION (Part 1)
Classification of antihypertensive and their mechanism of action
Selection of initial drugs in uncomplicated hypertension
Selection of drugs according to compelling indications

25. 2: PHARMACOLOGICAL TREATMENT OF HYPERTENSION (Part 2)
Combination therapy
Difficult to control hypertension and resistant hypertension – Approach
Treatment of acute severe hypertension

26. 3: INTERVENTIONAL THERAPY IN HYPERTENSION
Renal artery Angioplasty
Renal sympathetic denervation
Baroreceptor stimulation
Surgical approach to hypertension

27. MODULE-3
Target Organs and
Special Situations

28. 1: HYPERTENSION AND HEART
Various cardiovascular changes in hypertension
Hypertension and CAD
Hypertension and HF (REF, PEF)
Hypertension and atherosclerosis – vascular aging
Cardiovascular emergencies in hypertension.

29. 2: HYPERTENSION IN SPECIAL SITUATION
Hypertension in extremes of age
Hypertension and kidney
Hypertension and lung disease
Hypertension and CVA
Pregnancy and Hypertension

30. 3: EVIDENCE Important trials in Hypertension
Meta analysis in Hypertension
API – Indian hypertension guidelines

31. Patient Based Interactive Module
(Optional)
Patient Based Interactive Module

32. THE GOOD NEWS

33. reduction in cardiovascular risk with effective lowering of blood
There is considerable
reduction in cardiovascular risk
with effective lowering of blood
pressure with therapy.

34. Long-Term Antihypertensive Therapy Significantly Reduces CV Events
Myocardial
Stroke
infarction
Heart failure
–10
–20
Average reduction in events (%)
–30
20%-25%
–40
35%-40%
–50
>50%
–60
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:

35. On Completion of all 3 Module Test, Practising Physician will be given
“ Certificate of Participation from the house of API”

36. MODULE-1
1 B
Hypertension in India

37. Diseases Attributable to Hypertension
Gangrene of the Lower Extremities
Heart Failure
Left Ventricular Hypertrophy
Myocardial Infarction
Hypertensive Encephalopathy
Aortic Aneurysm
Blindness
Chronic Kidney Failure
Stroke
Preeclampsia/Eclampsia
Cerebral Hemorrhage
Coronary Heart Disease
Adapted from Dustan HP et al. Arch Intern Med. 1996; 156:

38. Attributable Mortality (In thousands; total 55,861,000)
Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors
High blood pressure
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
High mortality, developing region
Lower mortality, developing region
Developed region
Alcohol
Indoor smoke from solid fuels
Iron deficiency
1000
2000
3000
4000
5000
6000
7000
8000
Attributable Mortality (In thousands; total 55,861,000)
Ezzati et al. Lancet. 2002;360:

39. Hypertension in India (1/2)
Cardiovascular diseases caused 2.3 million deaths in India in the year 1990; Projected to double by the year 2020
Hypertension directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India
Strong correlation between changing lifestyle factors and increase in hypertension in India
The nature of genetic contribution and gene-environment interaction in accelerating the hypertension epidemic in India needs more studies
Gupta R. J Hum Hypertens 2004;18:73-78

40. Hypertension in India (2/2)
In India, hypertension is present in 25% urban and 10% rural subjects
At an underestimate, there are 31.5 million hypertensives in rural and 34 million in urban populations
A total of 70% of these would be Stage I hypertension (systolic BP and/or diastolic BP mmHg)
Recent reports show that borderline hypertension (systolic BP and/or diastolic BP mmHg) and Stage I hypertension carry a significant cardiovascular risk
Gupta R. J Hum Hypertens 2004;18:73-78

41. Risk Attributable due to Hypertension in India
Accessed on 27th May 2010

42. Prevalence studies in India
R Gupta :Journal of Human Hypertension (2004) 18, 73–78

43. Recent studies
R Gupta :Journal of Human Hypertension (2004) 18, 73–78

44. R Gupta :Journal of Human Hypertension (2004) 18, 73–78

45. National Heath and Nutrition Survey, Percent
TRENDS IN AWARENESS, TREATMENT AND CONTROL OF HIGH BLOOD PRESSURE
National Heath and Nutrition Survey, Percent
Awareness 51 73 68 70
Treatment 31 55 54 59
Control 10 29 27 34
In India and surrounding countries, awareness level is ≤ 45%.
Only 50% of these are on treatment and BP control rates are very poor.

46. Trends in BP Control in India (1/2)
% of uncontrolled hypertensive patients
Only 27.3% patients had both SBP and DBP under control
Survey in hypertensive patients (n=3402) receiving antihypertensive medications
Hathial M. J Indian Med Assoc. 2007; 105 (7): 401-2, 404, 410.

47. % of hypertensive patients achieving BP goal
Trends in BP Control in India (2/2)
% of hypertensive patients achieving BP goal
Study conducted in Chennai, of the treated hypertensive patients (n=154), only 45.9% of patients had their BP under control (i.e. <140/90 mm Hg).
Similar analysis done in diabetic hypertension patients (n=149) showed that of the patients that were treated for hypertension, only 51.1% had their blood pressure under control.
Mohan V et al. JAPI 2007; 55:

48. Control of Hypertension in Indian population
Undiagnosed hypertension 67.2%
Diagnosed hypertension
32.8%
Treated hypertension
29.2%
Untreated hypertension
70.8%
Hypertensive
20%
Normotensive
80%
Controlled hypertension
Uncontrolled hypertension
…only 15.4% of total hypertensive group have blood pressure controlled
Mohan:J Assoc Physicians India, 2007 May;55:326-32

49. END OF MODULE-1 1B