1. Update on hypertension complications and HTN management
Prof. Vang Chu MD., PhD., FAsCC, FACC, FESC
Director of the Lao-Luxembourg Heart Centre
President of the Lao Cardiac Society

2. Lecture Contents Burden of hypertension and its complications
Update on hypertension management

3. Lecture Contents
Burden of hypertension and its complications

4. Causation pathway for NCD

5. Fact: Four types of NCDs account for most deaths in most low-and middle-income countries

6. Proportional mortality (% of total deaths, all ages, both sexes) in Lao PDR in 2014
World Health Organization - Noncommunicable Diseases (NCD) Country Profiles, 2014

7. NONCOMMUNICABLE DISEASES
Risk Factors and NCD
NONCOMMUNICABLE DISEASES
RISK FACTORS
CVD
Stroke
Cancer
CRD
Diabetes
age 
heredity
unhealthy diet and excessive energy intake
physical inactivity
tobacco smoking
alcohol
raised blood pressure
raised blood glucose
abnormal blood lipids
overweight/ obesity
Source: WHO. (2003). STEPS: A framework for surveillance. Geneva, Switzerland. 7

8. Ranking of 10 selected risk factors of cause of death
World Health Organization – Hypertension: Silent killer, global public health crisis, 2013

9. The Burden of hypertension
Globally cardiovascular disease accounts for approximately 17 million deaths a year, nearly one third of the total (1).
Of these, complications of hypertension account for 9.4 million deaths worldwide every year (2).
Hypertension is responsible for
45% of deaths due to heart disease;
51% of deaths due to stroke.
Causes of Death 2008 [online database]. Geneva, World Health Organization
(http ://
2. Lim SS, Vos T, Flaxman AD, Danaei G, et al A comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, : a systematic analysis for the Global Burden of Disease Study Lancet.
2012 ; 380 (9859) :

10. Age-standardized prevalence of raised blood pressure in adults aged 25+ years, comparable country estimates, WPR, 2010
Raised blood pressure
High-income
LMIC and unclassified
Note: Raised blood pressure is defined as systolic blood pressure of ≥140 mmHg and/or diastolic blood pressure of ≥90 mmHg, or using medication to lower blood pressure.
Source: WHO Global Status Report on Noncommunicable Diseases 2010 10

11. Percentage of respondents with treated and/or controlled of raised blood pressure among those with raised blood pressure or currently on medication for raised blood pressure (Males=988, Females=1,528)
Source: Lao National STEP Survey on NCD risk Factors, 2013

13. Causes of Hospitalization in the Department of Cardiology of the LLHC in Mahosot Hospital from to 2004 (n=1808)
Saytouki et al, 2007

14. Is the current hospital admission due to hypertension complications
Is the current hospital admission due to hypertension complications ? (n= 329)
Yang N & Vang C, 2013

15. Types of Complications (251/329)
Yang N & Vang C, 2013

16. Causes of CVD Death Detected in the Department of Cardiology of the Mahosot Hospital from 1999 to (n= 177)
Vang C & Khamtan A, 2004

17. CHD and Stroke Can be Prevented with Hypertension Control

18. Lecture Contents
Update on hypertension management

19. World Heart Day 2013: Hypertension- A silent killer, global public health crisis

20. Definitions and classification of office blood pressure levels (mmHg)a (2013 ASH and ESC guideline on HTN)

21. ACC HTN Guideline (JNC VII)

22. Counseling for Life Style Modification
Weight reduction
Exercise regularly
Moderate alcohol intake
Tobacco smoking cessation
Stress management
Healthy Diet (low salt, low fat and low sugar food intake and eat fruits and vegetables)

23. Salk Intake in Lao PDR Salt Intake in Vientiane Capital City
Mean Salt (sodium chloride) intake is 6.4 g/day;
Mean sodium intake is 2.5 g/day.
Lao source of salt
From salty condiments: salt, soy sauce, fish sauce, fermented fish and MSG or Knor;
From processed foods: instant noodles, salty egg, salty fish and salty meat.
WHO recommendation for salt intake < 5 g/day or
< 2g/day of sodium;
Recommendations of the study: Sodium reduction intervention is needed to reduce high salt intake among population for the control and prevention of hypertension and cardio-vascular diseases
Sengchanh Kounnavong et al. Salt intake in sub-samples of the population of Vientiane capital city, Lao PDR, 2013

24. Salt is one of the causes of Hypertension
Blood Pressure = Cardiac Output (CO) X Peripheral Resistance (PR)
Hypertension = Increased CO and/or Increased PR
Functional
contraction
Structural
hypertrophy
Preload
Contractility
Venous
contraction
Fluid
volume
Cell membrane
alteration
Renin
angiotensin
excess
Sympathetic
nervous
over-activity
Decreased
filtration
surface
Renal
sodium
retention
Hyperinsu
linemia
Excess
sodium
intake
Endothelium
derived
factor
Genetic
alteration
Genetic
alteration
Obesity
Stress

25. Absolute Cardiovascular Mortality Attributed to Sodium Consumption of More than 2.0 g per Day in 2010, According to Nation.
Figure 3 Absolute Cardiovascular Mortality Attributed to Sodium Consumption of More than 2.0 g per Day in 2010, According to Nation. The scale is based on the number of deaths from cardiovascular causes (per 1 million persons) in 2010 that were attributed to sodium consumption of more than 2.0 g per day.
Total CVD death for Laos/100,000
Male= 467.9; Female=392.8
Lao Mean sodium intake= 2.5 g/day
The scale is based on the number of deaths from cardiovascular causes (per 1 million persons) in 2010 that were attributed to sodium consumption of more than 2.0 g per day.
Mozaffarian D et al. N Engl J Med 2014;371:

26. Effects of Reduced Sodium Intake on Systolic Blood Pressure
the effect of reduced sodium intake on systolic blood pressure was linear (P<0.001)
The solid line represents the central estimate,
and the dotted lines the 95% confidence intervals [CIs].
The model is based on inverse-variance–weighted, restricted-cubic-spline regression adjusted for age, race, and the presence or absence of hypertension.
Mozaffarian D et al. N Engl J Med 2014;371:

27. Less salt please! Worldwide salt intake is 10g/day
WHO’s recommendation for salt intake is
< 5 g/day or < 1 teaspoon /day

28. Initiation of lifestyle changes and antihypertensive drug treatment.

29. Drugs to be preferred in specific conditions

32. Possible combinations of classes of antihypertensive drugs.

33. Suggestion for useful antihypertensive drugs combination
Angiotensin Receptor Blockers
No ACE-I and ARB
Combination allowed
Calcium
Chanel
Blockers
Thiazide
Diuretic
ONTARGET study: Ramipril + telmisartan leads to
Hyper Kalaemia
Hypotension
ESRD and renal death
ACE-Inhibitors

34. Beta Blockers indication
Stable angina
Previous MI
Atrial fibrillation, Ventricular rate control
Heart failure
Excitation by sympathetic nerve
(e.g. Hyperthyroidism, anxiety neurosis)

35. Evidence-Based dosing antihypertensive drugs
Paul A et al. JNC VIII, 2014;

36. Take Home Messages
Cardiovascular diseases is the leading cause of mortality worldwide
Cardiovascular diseases: Prevention is better than care
Hypertension is the most common cardiovascular disease that you have to learn how to manage it appropriately

37. Thank you for your attention
Any Questions ?

38. More Information available in:
United Nations General Assembly resolution 66/2 (
Global Action Plan for the Prevention and Control of Noncommunicable Diseases ( ) Appendix 3/Corr.1
2013 ESH/ESC Guidelines for the management of arterial hypertension. European Heart Journal 2013; 10:
Paul A et al Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) (
ONTARGET Investigators. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 2008;358:1547–1559.