2007 Hypertension as a Public Health Risk January, 2007

2007 Canadian Hypertension Education Program Recommendations 2 Proportion of deaths attributable to leading risk factors worldwide (2000) Ezzati et al. WHO 2000 Report. Lancet. 2002;360: Attributable Mortality (In millions; total 55,861,000) High mortality, developing region Lower mortality, developing region Developed region High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight

2007 Canadian Hypertension Education Program Recommendations 3 Hypertension is a significant risk factor for: –cerebrovascular disease –coronary artery disease –congestive heart failure –renal failure –peripheral vascular disease –dementia –atrial fibrillation Hypertension as a Risk Factor

2007 Canadian Hypertension Education Program Recommendations 4 Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension 1995;25:  Age  Age MenWomen PP Blood Pressure Distribution in the Population According to Age PP=Pulse Pressure.

2007 Canadian Hypertension Education Program Recommendations 5 Classification of Hypertension CategorySystolicDiastolic Optimal <120 and / or <80 Normal <130 and / or <85 High-Normal and / or Grade 1 (mild hypertension ) and / or Grade 2 (moderate hypertension) and / or Grade 3 (severe hypertension)  180 and / or  110 Isolated Systolic Hypertension (ISH)  140 and / or <90 The category pertains to the highest risk blood pressure *ISH=International Society of Hypertension. Chalmers J et al. J Hypertens 1999;17: (Pre Hypertension) / 80-89

2007 Canadian Hypertension Education Program Recommendations 6 Blood Pressure and Risk of Stroke Mortality Lancet 2002;360:

2007 Canadian Hypertension Education Program Recommendations 7 Blood Pressure and Risk of IHD Mortality Lancet 2002;360:

2007 Canadian Hypertension Education Program Recommendations 8 CAD Death Rate per 10,000 Person-years <70 < Diastolic BP (mmHg) Systolic BP (mmHg) Neaton et al. Arch Intern Med 1992; 152: Effect of SBP and DBP on Age-Adjusted CAD Mortality: MRFIT

2007 Canadian Hypertension Education Program Recommendations 9 Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease N Engl J Med 2001;345: CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE ( ) ( ) (< 120) mmHg

2007 Canadian Hypertension Education Program Recommendations 10 The Concept of Masked Hypertension From Pickering, Hypertension 1992 Office SBP mmHg Ambulatory SBP mmHg True hypertensive True Normotensive White Coat HTN Masked HTN White Coat HTN True Normotensive Masked HTN True hypertensive

2007 Canadian Hypertension Education Program Recommendations 11 The Prognosis of Masked Hypertension Prevalence is approximately 10% in hypertensive patients Normal 23/685 White coat 24/656 Uncontrolled 41/462 Masked 236/3125 Bobrie et al. JAMA 2004;291: CV events per 1000 patient-year CV Events

2007 Canadian Hypertension Education Program Recommendations 12 Cumulative hazard for stroke in 3 groups of subjects: Normotensive, White-Coat Hypertension, and Ambulatory hypertension Verdecchia, P et al. Short- and Long-Term Incidence of Stroke in White-Coat Hypertension. Hypertension. 45(2): , February Time to stroke (years) Cumulative hazard of stroke (%) White-coat hypertension p = Normotensive group Ambulatory hypertension

2007 Canadian Hypertension Education Program Recommendations 13 Benefits of Treating Hypertension Younger than 60 –reduces the risk of stroke by 42% –reduces the risk of coronary event by 14% Older than 60 –reduces overall mortality by 20% –reduces cardiovascular mortality by 33% –reduces incidence of stroke by 40% –reduces coronary artery disease by 15%

2007 Canadian Hypertension Education Program Recommendations 14 Correlation Between Reduction in SBP and Stroke or MI Staessen et al. Lancet 2001;358: StrokeMyocardial Infarction

2007 Canadian Hypertension Education Program Recommendations 15 Correlation Between Reduction in SBP and Cardiovascular Mortality or Events Cardiovascular mortalityCardiovascular events Staessen et al. Lancet 2001;358:

2007 Canadian Hypertension Education Program Recommendations 16 Benefits of Treating to Target Older than 60 with isolated systolic hypertension (SBP  160 mm Hg and DBP <90 mm Hg) –36% reduction in the risk of stroke –25% reduction in the risk of coronary events Ref: adapted from SHEP, SYST-EUR, STONE studies.

2007 Canadian Hypertension Education Program Recommendations 17 Effect of Long-Term Modest Reductions in CV Risk Factors Emberson et al. Eur Heart J. 2004;25: % Reduction in BP 10% Reduction in Total-C + 45% Reduction in CVD =

2007 Canadian Hypertension Education Program Recommendations 18 Evaluating the Impact of Different Strategies for CV Prevention on CV Risk Reduction. Treating hypertension and other risk factors. Adapted from Emberson et al. Eur Heart J. 2004;25: Predicted Reduction in Major CVD (%) Treatment Based on TC (statin) Treatment Based on BP (β-blocker, diuretic) Treatment Based on Overall Absolute Risk (ASA, statin, ACEI, β-blocker, diuretic) Top 10% Top 20% Top 30% Treatment thresholds

2007 Canadian Hypertension Education Program Recommendations 19 22% of Canadians years of age have hypertension 50% of Canadians >65 years of age have hypertension Joffres et al. Am J Hyper 2001;14:1099 – % 13% 43% 22% Hypertensive patients who are treated but BP uncontrolled Hypertensive patients who are treated and BP controlled Hypertensive patients who are unaware Patients who are aware but remain untreated and BP uncontrolled 9% Diabetic patients who are treated and BP controlled The Challenge In Canada

2007 Canadian Hypertension Education Program Recommendations 20 Results of a survey on awareness on hypertension (Canada 2002) 67% of aware hypertensive patients believe that their BP was their own primary responsibility Two thirds of these patients stated that high BP was not a serious concern. Thus the mandate to improve public awareness of the consequences of hypertension is clear. R. Petrella MD, Perspective in Cardiology, March 2002.

2007 Canadian Hypertension Education Program Recommendations 21 The Canadian Hypertension Education Program Objectives Develop evidence-based recommendations for the management of hypertension Implement recommendations Evaluate impact of the program

2007 Canadian Hypertension Education Program Recommendations 22 Leading diagnoses resulting in visits to physician offices in Canada Million visits/year Hypertension Depression Diabetes Routine medical exams Acute respiratory tract infection tract infection Source: IMS HEALTH Canada

2007 Canadian Hypertension Education Program Recommendations 23 Changes in diagnosis of hypertension in Canada Post 1999 compared to pre 1999 Doubling of the rate of diagnosis of hypertension Closing of the gender gap Hypertension 2006;48:853-60

2007 Canadian Hypertension Education Program Recommendations 24 Changes in the treatment of hypertension Post 1999 compared to pre 1999 Doubling of the rate of treatment of hypertension Closing of the gender gap Hypertension 2006;48:853-60

2007 Canadian Hypertension Education Program Recommendations 25 Changes in the proportion of those diagnosed that are not treated Post 1999 compared to pre 1999 Marked decrease in proportion of aware hypertensives that are untreated Closing of the gender gap. Hypertension 2006;48:853-60

2007 Canadian Hypertension Education Program Recommendations Canadian Recommendations for the Management of Hypertension A slide kit for medical education can be downloaded from: