William B. Kannel, MD, FACC Former Director, Framingham Heart Study

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Presentation transcript:

William B. Kannel, MD, FACC Former Director, Framingham Heart Study Epidemiologic and Clinical Significance of Incremental Changes in Blood Pressure William B. Kannel, MD, FACC Professor of Medicine and Public Health Boston University School of Medicine Former Director, Framingham Heart Study

Hypertension Is a Major Treatable Risk Factor for Cardiovascular Disease Powerful independent risk factor for CHD, stroke, PAD, and heart failure Relationship with risk is continuous and graded Benefits of blood pressure reduction with pharmacologic treatment are incremental and continuous CHD = Coronary heart disease. PAD = Peripheral arterial disease.

Coronary Heart Disease Risk by Major Risk Factors 5 Coronary Heart Disease Risk by Major Risk Factors Framingham Study—36-yr Follow-up Elevated Hypertension Diabetes Smoking cholesterol Risk ratio 35-64 yr 1.9** 1.8* 2.0** 2.2** 1.5** 3.7** 1.5** 1.1 65-94 yr 1.2 2.0** 1.6** 1.9** 1.6* 2.1** 1.0 1.2 *p < 0.01; **p < 0.001. Kannel WB. Framingham Heart Study.

Risk for Cardiovascular Events by Diastolic Blood Pressure Framingham Study Patients aged 35 to 64 yr, initially free of CVD; 38-yr follow-up Kannel WB. Framingham Heart Study.

Risk for Cardiovascular Events by Systolic Blood Pressure Framingham Study Patients aged 35 to 64 yr, initially free of CVD; 38-yr follow-up Kannel WB. Framingham Heart Study.

Relative Risks of Stroke and Coronary Heart Disease† 5 Relative Risks of Stroke and Coronary Heart Disease† Stroke CHD 7 prospective observational studies: 843 events 9 prospective observational studies: 4,856 events 4.00 4.00 2.00 2.00 1.00 1.00 Relative risk of stroke Relative risk of CHD 0.50 0.50 0.25 0.25 76 84 91 98 105 76 84 91 98 105 Approximate mean usual DBP, mm Hg †420,000 patients for CHD, 405,500 patients for stroke, 10-yr mean follow-up period. MacMahon et al. Lancet. 1990;335;765-774.

5 Reducing Diastolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risk† †420,000 patients for CHD, 405,500 patients for stroke, 843 strokes, 4,856 CHD events, 10-yr mean follow-up period. MacMahon S, et al. Lancet. 1990;335:765-774.

Observational studies,† mm Hg Drug treatment trials,†† mm Hg Incremental Reduction in Diastolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risk Observational studies,† mm Hg Drug treatment trials,†† mm Hg –2 –5 to –6 –7.5 –2††† –5 to –6 –7.5††† †Data from MacMahon S, et al. Lancet. 1990;335:765-774. ††Adapted from Hebert PR, et al. Arch Intern Med. 1993;153:578-581. †††Estimated risk reduction.

Advantage of Additional BP Reduction: NNTT to Prevent 1 Stroke Event† Framingham average Reduction in DBP NNTT risk/10 yr 5 - 6 mm Hg Average risk 28 38% High risk†† 15 46% 7.5 mm Hg Average risk 20 38% High risk†† 9 46% NNTT = Number needed to treat. †Men aged 60 to 69 yr. ††Smoker, SBP 150 mm Hg, CVD, HDL < 40 mg/dL, cholesterol > 260 mg/dL. Kannel WB. Framingham Heart Study.

Reduction in Systolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risks SHEP† Syst-Eur†† Baseline BP, mm Hg 170/77 184/85 BP reduction, mm Hg 11/3 10/4-5 †SHEP. JAMA. 1991;265:3255-3264. ††Staessen JA, et al. Lancet. 1997;350:757-764.

US Adults With Hypertension Unmet Medical Need Percent† Aware Treated Controlled†† NHANES III (Phase 2) 1991-1994 (JNC VI). Estimated 50 million adults with hypertension in the US. †Percent = Proportions based on persons with hypertension in the survey. ††BP < 140/90 mm Hg.

Physician Practices Treating Hypertension Hypertension, particularly ISH, seldom treated to recommended goal No increase in medication at 75% of visits despite continued BP elevation Drugs rarely up-titrated; reluctance to include additional drugs Therefore, more effective monotherapy drugs could facilitate attaining recommended treatment goals ISH = Isolated systolic hypertension. Coppola WG, et al. J Hum Hypertens. 1997;11:185-191. Berlowitz DR, et al. N Engl J Med. 1998;339:1957-1963.

Conclusions: Importance of Incremental Blood Pressure Reduction Hypertension is a major treatable risk factor for CVD including CHD, stroke, PAD, and heart failure Incremental blood pressure reduction is meaningful from a public health perspective Benefits of blood pressure reduction with pharmacologic treatment are incremental and continuous Compelling need for clinicians to use the more effective BP-reducing drugs to achieve recommended treatment goals in individual patients