1. Hypertension: is it all about the numbers?
Edward e chung
Dm, facp, fccp, facc, fesc, flmi
11th annual international conference on nephrology and hypertension
January 2019

2. Preamble Globally, over 1 billion people have hypertension
As populations age and adopt more sedentary lifestyles,
the worldwide prevalence of hypertension will continue to rise towards 1.5 billion by 2025
Elevated BP is the leading global contributor to premature death, accounting for almost
10 million deaths in 2015, 4.9 million due to ischaemic heart disease and 3.5 million due to stroke.
Hypertension is also a major risk factor for heart failure, AF, CKD,
PAD, and cognitive decline.

3. Definition – JNC 7
Hypertension is a sustained elevation of blood pressure at or above 140/90 measured on 3 separate occasions
Pre-hypertension is a BP between 130/85 and 139/89

5. 2018 ESC-ESH Guidelines for the Management of Arterial Hypertension
2018 ESC/ESH Hypertension Guidelines 1
2018 ESC-ESH Guidelines for the Management of Arterial Hypertension
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

6. Classification of office BP and definitions of hypertension grade
2018 ESC/ESH Hypertension Guidelines 11
Classification of office BP and definitions of hypertension grade
Category
Systolic (mmHg)
Diastolic (mmHg)
Optimal
< 120
and
< 80
Normal
120–129
and/or
80–84
High normal
130–139
85–89
Grade 1 hypertension
140–159
90–99
Grade 2 hypertension
160–179
100–109
Grade 3 hypertension
≥ 180
≥ 110
Isolated systolic hypertension
≥ 140
< 90
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

7. JNC 8 Recommendations 2014
In people over the age of 60, blood pressure target should be below 150/90 mmHg. Pharmacological therapy should be started if blood pressure is above this value.
If a patient achieves a blood pressure target lower than 150/90 and even lower than 140/90 mmHg, but tolerates this blood pressure and the medication without side-effects, no change is needed. In other words, there is no need to reduce medication dose to allow the blood pressure to go up.

8. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults
© American College of Cardiology Foundation and American Heart Association, Inc.

10. The Burden of CVD Risk in Jamaica
JAMAICA HEALTH AND LIFESTYLE SURVEY II
( )
Rainford Wilks
ACPJ 12/09/2009

11. Changes in CNCD Prevalence: 2000-2008
Disease Condition
JHLS-2000
JHLSII-2008
Diabetes Mellitus
7.2 ( )
7.9 ( )
Hypertension*
20.9 ( )
25.2 ( )
Pre-hypertension
29.9 ( )
35.3 ( )
High Cholesterol
14.6 ( )
11.7 ( )
*P< 0.05

12. Changes in Awareness, Treatment & Control Levels (%) Listed CNCDs
Disease Condition
JHLS
2000
JHLSII
2008
Hypertension
Aware
Treatment
Control
41.3( ) 
42.0 ( )
36.4( )
50.7( )
40.0( )
41.4( )
Diabetes
66.8( )
67.4( )
36.0( )
76.1( )
71.5( )
43.9( )

13. Summary
Hypertension, obesity and high cholesterol occur in one in every five persons
1 in 10 persons have diabetes mellitus
Hypertension, diabetes and high cholesterol increase in older persons while obesity peaks in middle age

14. JAMAICA HEALTH AND LIFESTYLE SURVEY III (2016 -2017)
Hypertension
Jnc 7 AND ESC
Acc/aha 2017
Prevalence of HTN
Rural
Urban
Pre Hypertension
33.8% (M-31.7% vs F-35.8%)
35.2%
33%
34.0% (M-43.0% vs F-25.7%)
57.6% (M-58.3% vs F-57.0%)

15. Secular trends in Prevalence of HTN (Jnc 7 AND esc cLASSIFICATION)
2000 – 2001 – 20.9%
2007 – 2008 – 25.2%
2017 – %

17. ‘High-normal’ BP is Not Benign in Women …
Framingham data
Women
2.5-fold greater risk†
High- normal
High-normal = 130–139/85-89 mmHg
Normal = 120–129/80-84 mmHg
Optimal = < 120/< 80 mmHg
Cumulative incidence of cardiovascular (CV) events* (%)
Normal
The category of pre-hypertension was created on the basis of new data, such as that from the Framingham study, which demonstrate a substantially increased risk of CVD in persons with BP below usual goals of 130–139/85–89 mmHg, a category previously referred to as high-normal
In 6859 individuals free from hypertension and CVD at baseline, the 10-year cumulative incidence of a first CV event among women was 4.4% in subjects with BP of /85-89 mmHg and 2.8% in those with BP of 120–129/80–84 mmHg (normal). This corresponded to a hazard ratio of 2.5 (adjusted for concomitant CV risk factors), P <0.001 for comparison across categories
Optimal
Time (years)
*CV death, MI, stroke, heart failure
†Adjusted for concomitant CV risk factors
Vasan et al. N Engl J Med 2001;345:1291–7

18. Cumulative incidence of cardiovascular (CV) events* (%)
…or in Men
Framingham data
High- normal
Men
1.6-fold greater risk†
High-normal = 130–139/85-89 mmHg
Normal = 120–129/80-84 mmHg
Optimal = < 120/< 80 mmHg
Normal
Cumulative incidence of cardiovascular (CV) events* (%)
Optimal
The category of pre-hypertension was created on the basis of new data, such as that from the Framingham study, which demonstrate a substantially increased risk of CVD in persons with BP below usual goals of 130–139/85–89 mmHg, a category previously referred to as high-normal
In 6859 individuals free from hypertension and CVD at baseline, the 10-year cumulative incidence of a first CV event among women was 4.4% in subjects with BP of /85-89 mmHg and 2.8% in those with BP of 120–129/80–84 mmHg (normal). This corresponded to a hazard ratio of 2.5 (adjusted for concomitant CV risk factors), P <0.001 for comparison across categories
*CV death, MI, stroke, heart failure
†Adjusted for concomitant CV risk factors
Time (years)
Vasan et al. N Engl J Med 2001;345:1291–7

19. Systolic BP/Diastolic BP (mmHg)
Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increment in Systolic/Diastolic Blood Pressure*
CV mortality risk 8
8X risk 6 4
4X risk
For individuals aged 4069 years, each increment in systolic BP of 20 mmHg or diastolic BP of 10 mmHg doubles the risk of cardiovascular disease (stroke, ischemic heart disease, other vascular diseases) across the entire BP range.
Benefits are therefore to be gained from lowering BP in terms of reduced risk of cardiovascular mortality.
Reference
Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13. 2
2X risk
1X risk
115/75
135/85
155/95
175/105
Systolic BP/Diastolic BP (mmHg)
*Individuals aged 40–69 years
Lewington et al. Lancet 2002;360:1903–13

20. 2 mmHg decrease in mean SBP
Blood Pressure Reduction of 2 mmHg Decreases the Risk of Cardiovascular Events by 7–10%
Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
7% reduction in risk of ischaemic heart disease mortality
2 mmHg decrease in mean SBP
Trials have shown that BP lowering can produce rapid reductions in cardiovascular disease risk. In fact, even a 2 mmHg decrease in systolic BP would result in about a 7% lower mortality risk from ischemic heart disease and a 10% lower mortality risk from stroke.
Reference
Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.
10% reduction in risk of stroke mortality
Lewington et al. Lancet 2002;360:1903–13

21. SBP is a Stronger Predictor of Cardiovascular Mortality Than DBP
48.3
CAD death rate per 10,000 person-years
37.4
80.6
31.0
34.7
43.8
25.5
23.8
24.6
38.1
20.6
16.9
25.3
13.9
25.2
10.3
11.8
12.8
24.9
100+
12.6
8.8
90-99
Data from the Multiple Risk Factor Intervention Trial (MRFIT) of 316,099 men were analyzed to assess the influence of BP and other risk factors on death from coronary artery disease (CAD)
Differences in death rates due to CAD among diastolic BP categories for each systolic BP category were small, particularly for patients with diastolic BP <90 mmHg. However, a strong risk gradient was evident for systolic BP for each diastolic BP category
A strong graded relationship between systolic BP >110 mmHg and diastolic BP >70 mmHg and CAD mortality was discerned. Systolic BP was a stronger predictor of death due to CAD than diastolic BP in all age groups. The investigators emphasized that their findings, together with the results of clinical trials, offered strong support for intensified efforts to control SBP
11.8
8.5
160+
80-89
9.2
75-79
Diastolic BP (mmHg)
70-74
< 70
< 120
Systolic BP (mmHg)
MRFIT = Multiple Risk Factor Intervention Trial
CAD = coronary artery disease
Neaton et al. Arch Intern Med 1992;152:56–64

22. 2018 ESC/ESH Hypertension Guidelines22
Definitions of hypertension according to office, ambulatory, and home BP levels
Category
Systolic (mmHg)
Diastolic (mmHg)
Office BP
≥ 140
and/or
≥ 90
Ambulatory BP
Daytime (or awake) mean
≥ 135
≥ 85
Night-time (or asleep) mean
≥ 120
≥ 70
24-h mean
≥ 130
≥ 80
Home BP mean
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

24. 2018 ESC/ESH Hypertension Guidelines
Classification of hypertension stages according to BP levels, presence of CV risk factors, HMOD, or comorbidities
Hypertension disease staging
Other risk factors, HMOD, or disease
BP (mmHg) grading
High-normal SBP 130−139
DBP 85−89
Grade 1
SBP 140−159
DBP 90−99
Grade 2
SBP 160−179
DBP 100−109
Grade 3
SBP ≥ 180
DBP ≥ 110
Stage 1
(uncomplicated)
No other risk factors
Low risk
Moderate risk
High risk
1 or 2 risk factors
Moderate to high risk
≥ 3 risk factors
Low to moderate risk
Stage 2 (asymptomatic disease)
HMOD, CKD grade 3, or diabetes mellitus without organ damage
Moderate to high risk
High to very high risk
Stage 3 (establishe d disease)
Established CVD, CKD grade ≥ 4, or diabetes mellitus with organ damage
Very high risk
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

25. CVD Risk Factors Common in Patients With Hypertension
Modifiable Risk Factors*
Relatively Fixed Risk Factors†
Current cigarette smoking, secondhand smoking
Diabetes mellitus
Dyslipidemia/hypercholesterolemia
Overweight/obesity
Physical inactivity/low fitness
Unhealthy diet
CKD
Family history
Increased age
Low socioeconomic/educational status
Male sex
Obstructive sleep apnea
Psychosocial stress
*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through the use of current intervention techniques, may not reduce CVD risk (psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.

27. SPRINT Trial – NIH 2015
Landmark NIH study shows intensive blood pressure management may save lives
Demonstrated that more intensive management of high blood pressure, below a commonly recommended blood pressure target, significantly reduces rates of cardiovascular disease, and lowers risk of death in a group of adults 50 years and older with high blood pressure.

28. SPRINT Trial – NIH 2015
The intervention in this trial, which carefully adjusts the amount or type of blood pressure medication to achieve a target systolic pressure of 120 millimeters of mercury (mm Hg), reduced rates of cardiovascular events, such as heart attack and heart failure, as well as stroke, by almost a third and the risk of death by almost a quarter, as compared to the target systolic pressure of 140 mm Hg.

29. SPRINT Primary Outcome Cumulative Hazard
Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89)
Standard
(319 events)
Intensive
(243 events)
During Trial (median follow-up = 3.26 years)
Number Needed to Treat (NNT)
to prevent a primary outcome = 61
Number of
Participants

30. All-cause Mortality Cumulative Hazard
Hazard Ratio = 0.73 (95% CI: 0.60 to 0.90)
Standard
(210 deaths)
Adapt from Figure 2B in the N Engl J Med manuscript
Intensive
(155 deaths)
During Trial (median follow-up = 3.26 years)
Number Needed to Treat (NNT)
to Prevent a death = 90
Include NNT
Number of
Participants
Intensive

31. ACC/AHA BP Goal for Patients With Hypertension
COR
LOE
Recommendations for BP Goal for Patients With Hypertension I
SBP:
B-RSR
For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher a BP target of less than 130/80 mm Hg is recommended.
DBP:
C-EO
IIb
B-NR
For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable.

32. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy
COR
LOE
Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy* I
C-EO
Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target.
IIa
Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.

33. Recommendations for Treatment of Hypertension in Older Persons
Age-Related Issues
COR
LOE
Recommendations for Treatment of Hypertension in Older Persons I A
Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age) with an average SBP of 130 mm Hg or higher.
IIa
C-EO
For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs.

38. CVD + HTN = FATAL COMBINATION
Cardiovascular Disease (CVD) is the leading cause of death and disability
Hypertension is the most powerful risk factor of CV Mortality and Morbidity
Dual Treatment Goal of Hypertension:
Control of Blood Pressure
Provide best possible CVD Risk Reduction and Protection

39. Guidelines implementation
Guidelines are intended to define practices, meeting the needs of patients in most, but not all circumstances
Guidelines should not replace clinical judgement

40. Is it all about the Numbers?
YES
CVD mortality increases as the systolic pressures rises above normal NO
CVD risk assessment is important in determining when drug therapy should be implemented at lower systolic pressures

42. Summary of office BP thresholds for treatment
2018 ESC/ESH Hypertension Guidelines 59
Summary of office BP thresholds for treatment
Age group
Office SBP treatment threshold (mmHg)
Office DBP treatment threshold (mmHg)
Hypertension
+ Diabetes
+ CKD
+ CAD
+ Stroke/TIA
18−65 years
≥ 140
≥ 90
65−79 years
≥ 80 years
≥ 160
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

43. Summary of office BP thresholds for treatment
2018 ESC/ESH Hypertension Guidelines 60
Summary of office BP thresholds for treatment
Age
18-65 years
Age
65-79 years
Age
≥ 80 years
Very high risk factors
≥ 140/90 mmHg
≥ 140/90 mmHg
≥ 160/90 mmHg
≥ 135/85 mmHg can be considered IA IA IA
IIbA
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

44. Office BP treatment target range
2018 ESC/ESH Hypertension Guidelines 76
Office BP treatment target range
Age group
Office SBP treatment target ranges (mmHg)
Office DBP treatment target range (mmHg)
Hypertension
+ Diabetes
+ CKD
+ CAD
+ Stroke/TIA
18−65 years
Target to 130
or lower if tolerated Not < 120
Target to
< 140 to 130
if tolerated
70-79
65−79 years
≥ 80 years
Office DBP treatment target range(mmHg)
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39:

45. Office BP treatment target range
2018 ESC/ESH Hypertension Guidelines 77
Office BP treatment target range
Age
18-65 years
Age
>65-79 years*
Age
≥ 80 years*
First SBP <140 mmHg
Aim for SBP 130 mmHg or lower if tolerated
DBP <80-70 mmHg
Do not go <120/70 mmHg
First SBP <140 mmHg
Aim for SBP 130 mmHg
First SBP <140 mmHg
Aim for SBP 130 mmHg
DBP <80-70 mmHg
Do not go <130/70 mmHg
DBP <80-70 mmHg
Do not go <130/70 mmHg IA IA IA
* Consider frailty/independence/tolerability of treatment
Williams, Mancia et al., J Hypertens 2018;36: and Eur Heart J 2018;39: