Presentation on theme: "William B. Kannel, MD, FACC Former Director, Framingham Heart Study"— Presentation transcript:
1 William B. Kannel, MD, FACC Former Director, Framingham Heart Study Epidemiologic and Clinical Significance of Incremental Changes in Blood PressureWilliam B. Kannel, MD, FACCProfessor of Medicine and Public Health Boston University School of MedicineFormer Director, Framingham Heart Study
2 Hypertension Is a Major Treatable Risk Factor for Cardiovascular Disease Powerful independent risk factor for CHD, stroke, PAD, and heart failureRelationship with risk is continuous and gradedBenefits of blood pressure reduction with pharmacologic treatment are incremental and continuousCHD = Coronary heart disease.PAD = Peripheral arterial disease.
3 Coronary Heart Disease Risk by Major Risk Factors 5Coronary Heart Disease Risk by Major Risk FactorsFramingham Study—36-yr Follow-upElevated Hypertension Diabetes Smoking cholesterolRisk ratio35-64 yr 1.9** 1.8* 2.0** 2.2** 1.5** 3.7** 1.5** 1.165-94 yr ** 1.6** 1.9** 1.6* 2.1***p < 0.01; **p < Kannel WB. Framingham Heart Study.
4 Risk for Cardiovascular Events by Diastolic Blood Pressure Framingham StudyPatients aged 35 to 64 yr, initially free of CVD; 38-yr follow-upKannel WB. Framingham Heart Study.
5 Risk for Cardiovascular Events by Systolic Blood Pressure Framingham StudyPatients aged 35 to 64 yr, initially free of CVD; 38-yr follow-upKannel WB. Framingham Heart Study.
6 Relative Risks of Stroke and Coronary Heart Disease† 5Relative Risks of Stroke and Coronary Heart Disease†StrokeCHD7 prospective observational studies:843 events9 prospective observational studies:4,856 events4.004.002.002.001.001.00Relative risk of strokeRelative risk of CHD0.500.500.250.257684919810576849198105Approximate 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;
7 5Reducing 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:
8 Observational studies,† mm Hg Drug treatment trials,†† mm Hg Incremental Reduction in Diastolic Blood Pressure Lowers Coronary Heart Disease and Stroke RiskObservational studies,† mm HgDrug 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:††Adapted from Hebert PR, et al. Arch Intern Med. 1993;153:†††Estimated risk reduction.
9 Advantage of Additional BP Reduction: NNTT to Prevent 1 Stroke Event† Framingham average Reduction in DBP NNTT risk/10 yr5 - 6 mm Hg Average risk 28 38% High risk†† 15 46%7.5 mm Hg Average risk 20 38% High risk†† %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.
10 Reduction in Systolic Blood Pressure Lowers Coronary Heart Disease and Stroke Risks SHEP† Syst-Eur††Baseline BP, mm Hg 170/77 184/85BP reduction, mm Hg 11/3 10/4-5†SHEP. JAMA. 1991;265: ††Staessen JA, et al. Lancet. 1997;350:
11 US Adults With Hypertension Unmet Medical Need Percent†AwareTreatedControlled††NHANES III (Phase 2) (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.
12 Physician Practices Treating Hypertension Hypertension, particularly ISH, seldom treated to recommended goalNo increase in medication at 75% of visits despite continued BP elevationDrugs rarely up-titrated; reluctance to include additional drugsTherefore, more effective monotherapy drugs could facilitate attaining recommended treatment goalsISH = Isolated systolic hypertension.Coppola WG, et al. J Hum Hypertens. 1997;11:Berlowitz DR, et al. N Engl J Med. 1998;339:
13 Conclusions: Importance of Incremental Blood Pressure Reduction Hypertension is a major treatable risk factor for CVD including CHD, stroke, PAD, and heart failureIncremental blood pressure reduction is meaningful from a public health perspectiveBenefits of blood pressure reduction with pharmacologic treatment are incremental and continuousCompelling need for clinicians to use the more effective BP-reducing drugs to achieve recommended treatment goals in individual patients