Transcript Hypertension & Cardiovascular Risk Factors

Hypertension &
Cardiovascular Risk Factors
Final Year Cardiology Teaching
2003-4
Outline
• Global burden of cardiovascular disease
• Epidemiology of cardiovascular disease
• Hypertension
– Epidemiology
– Clinical features
– Investigation
• Cardiovascular risk assessment
The Global Burden of Disease
The scope of the problem
Leading Causes of Death and Disability (DALY’s)
1990
Rank
Cause
2020
% Rank
Cause
%
1
Lower respiratory infections
8.2
1
Ischemic heart disease
5.9
2
Diarrhoeal diseases
7.2
2
Major depression
5.7
3
Perinatal conditions
6.7
3
Road traffic accidents
5.1
4
Major depression
3.7
4
Cerebrovascular disease
4.4
5
Ischemic heart disease
3.4
5
COPD
4.2
6
Cerebrovascular disease
2.8
6
Lower respiratory infections
3.1
7
Tuberculosis
2.8
7
Tuberculosis
3.0
8
Measles
2.7
8
War
3.0
9
Road traffic accidents
2.5
9
Diarrhoeal diseases
2.7
10 Congenital abnormalities
2.4
10 HIV
2.6
Global Burden of Disease Study, 1996
Mortality due to leading global risk factors
*
**
*
World Health Report 2002
Cardiovascular risk factors
Blood pressure
Lipids
Diabetes
Smoking
BP and relative risk of stroke and CHD
Stroke
CHD
4.00
4.00
2.00
2.00
1.00
1.00
0.50
0.50
0.25
0.25
123
76
136
84
148
91
162
98
175
105
Approximate mean usual BP
123
76
136 148
84
91
162 175
98 105
Approximate mean usual BP
Brit Med Bull 1994;50:272-98
Average annual rate/ 10,000
Blood Pressure and Risk of Congestive Heart Failure:
the Framingham Study
140
120
100
80
Normotensive
BP <140/90 mmHg
60
Hypertensive
BP >160/95 mmHg
40
20
0
35-44
45-54
55-64
65-74
Age at examination
Kannel et al. 1972
Incidence / 100,000 person years
Systolic BP as a risk factor for renal failure
100
80
60
White men 300,645
African-American men 20,222
40
20
0
< 117
117-123
124-130
131-140
> 140
Systolic BP, mmHg
MRFIT ‘screenees’ Klag MJ, JAMA ‘97; 277: 1293
Cholesterol and risk of CHD & cardiovascular death
4.00
Coronary Heart Disease
Cardiovascular Death
(51652 participants, 310 events)
(9 studies, 49296 participants, 938 events)
4.00
(51652 participants, 310 events)
Relative Risk
Relative Risk
2.00
1.00
2.00
1.00
0.50
0.50
0.25
0.25
4.0
4.5
5.0
5.5
6.0
Approximate mean usual cholesterol (mmol/l)
4.0
4.5
5.0
5.5
6.0
Approximate mean usual cholesterol (mmol/l)
Eastern Stroke & Coronary Heart Disease Project
Relative risk
Association between cholesterol and ischemic stroke
4.0
4.5
5.0
5.5
6.0
Approximate mean usual cholesterol concentration (mmol/L)
Asia Pacific Cohort Studies Collaboration
Worldwide Prevalence of Diabetes
1997
160
140
120
millions
100
80
60
40
20
0
Developed
Developing
World
Risks of death in diabetics and non-diabetics
6
5
4
Non-diabetics
Diabetics
3
2
1
All cause
Non-CVD
All CVD
Other CVD
CHF
CHD
Stroke
0
Asia-Pacific Cohort Studies Collaboration
Smoking
Cumulative deaths (in millions)
Premature Deaths From Tobacco Use
350
300
250
Preventable if adults quit
(halving global cigarette
consumption by 2020)
200
150
Preventable if young
adults do not start
(halving global uptake by
2020)
100
50
Other premature deaths
from tobacco-related
causes
0
2000-2024
1
2025-2049
2
Years
The World Health Report, 1999: Making a Difference
Blood Pressure
or
Hypertension?
Hypertension and alcohol
C. Lian, French army physician, 1915
30
% hypertensive
25
20
15
10
5
0
Sobres
Moyens Buveurs Grands Buveurs
Sobres
Moyens buveurs:
Grands buveurs:
Tres grands buveurs:
Tres Grands
Buveurs
<1 litre wine/ day
1-1.5 litres wine/ day
2-2.5 litres wine/ day
3 litres wine/ day + 4-6 aperitifs
Blood Pressure
or
Hypertension?
The ‘normal’ distribution of diastolic BP within a population
% of screened population
20
15
10
5
0
50
60
70
80
90
100
Diastolic BP, mmHg
110 120
130
Hypertension: a practical definition
That level of blood pressure at
which investigation and treatment
do less harm than good
Rose
Assessment of the
Hypertensive Patient
Hypertension risk factors
Weight
Family history
Salt, Alcohol,Stress
Concurrent conditions
Clues to 2o HT
Asthma
Gout
Pregnancy
Symptoms
Drugs
Signs
History
+
Examination
Other CV risk factors
Target organ damage
Lipids
Smoking
Diabetes
Exercise
Heart
Brain
Eyes
Kidneys
Investigations
• Urine
• Blood
• ECG
? Specialised investigations
•
•
•
•
•
•
Renal USS
24-hour ABPM
Echocardiography
Angiography
Hormone assays
CT / MRI scanning
Indications for further investigations
•
•
•
•
•
•
•
•
Clinical features of an underlying cause
Early onset (< 30 y)
Rapid progression
Proteinuria, haematuria, glycosuria
Severe hypertension, difficult to control
Vascular disease: peripheral, coronary, carotid
Heart failure, ‘flash’ pulmonary oedema
Lack of nocturnal dip on ABPM
Secondary causes of hypertension…
…. comprise a
small proportion
of overall cases,
probably < 5%
The Heinz guide to hypertension
Renal artery stenosis
Pyelonephritis
Obstruct nephropathy
Vesico-ureteric reflux
Ask-Upmark kidney
Renal dysplasia
Renin JGA tumor
Glomerulonephritis
Polycystic disease
Analgesic kidney
Systemic sclerosis
ITT purpura
Haemolytic uremic
1o Aldosteronism
Cushing’s syndrome
Phaeochromocytoma
DOC excess
Cong adrenal h’plasia
Gluc remediable
Diabetes
Amyloidosis
Carbenoxalone
Obstruct sleep apnoea
Alcohol
MAO-I inhibitors
Pre-eclampsia
Liquorice
Sympathomimetics
Chronic renal failure
Poliomyelitis
11- OH-St dehyd def
Porphyria
Acromegaly
Aortic coarctation
 intracranial pressure
Oral contraceptive
Endothelinoma
Lead poisoning
Corticosteroids
Secondary causes of hypertension
Renal artery stenosis
Secondary causes of hypertension
Polycystic kidney
Phaeochromocytoma
Phaeochromocytoma
MIBG scan
Target Organ Damage
&
Complications of Hypertension
Target organ damage: left ventricular hypertrophy
Target organ damage: hypertensive retinopathy
Grade 4 hypertensive retinopathy
Complications of hypertension
Intra-cerebral
haemorrhage
Myocardial infarction in
hypertrophied left ventricle
Management of Hypertension
Non-pharmacological/ lifestyle
Pharmacological
Non-pharmacological interventions
Measures that lower blood pressure:





 weight
 salt intake
 alcohol consumption
 physical exercise
 fruit & vegetable consumption
Measures to reduce cardiovascular risk:




Stop smoking
 saturated fat,  poly- & mono-unsaturates
 oily fish consumption
 total fat intake
BHS Guidelines 1999
The Mediterranean Diet
BP lowering treatment and cardiovascular risk
1200
Non-fatal events
Fatal events
1000
T
800
T=treatment
C=control
C
T
C
600
400
T
T
C
C
200
% reduction
in odds
Stroke
CHD
38%
SD 4
16%
SD 4
All vascular
deaths
All other
deaths
Brit Med Bull 1994;50:272-98
Drug treatment of hypertension
Diuretic
Calcium-channel
blocker
Beta-blocker


ACE-inhibitor
Angiotensin receptor
blocker
(Alpha-blocker)
Most hypertensives will need  2 drugs to control BP
Drug combinations may be synergistic
How to choose anti-hypertensive therapy
ACE inhibitor (AII antagonist)
or
-blocker
Calcium antagonist
C
A
B
Diuretic
One drug:
Younger, non-black A or B
Older, black
C or D
Two drugs:
(A or B) + (C or D)
Three drugs: (A or B) + C + D
D
Target blood pressure
< 140/90 mmHg
…. except in those with diabetes or
chronic renal disease
< 130/80 mmHg
Cholesterol & cardiovascular
disease
“Large randomised trials demonstrate lowering LDLcholesterol by 1 mmol/l reduces non-fatal MI and fatal CHD by
about 25% ( about half the the effect predicted from
epidemiological studies for a similar reduction in long term
cholesterol lowering in people without vascular disease ) “
Collins 2002
With greater reductions in cholesterol there are
correspondingly larger reductions in CHD endpoints.
Landmark Statin Trials:
LDL-C Levels vs Events at 5 Years
Follow-up
Percentage with CHD event
4S-P
25
20
4S-S
HPSh-P
LIPID-P
CARE-P
15
HPSh-S
10
5
0
LIPID-S
WOSCOPS-P
CARE-S
HPSl-S
ASCOT-P*
ASCOT-S* AFCAPS-S
2.3 (90)
Secondary
prevention
Primary
prevention
Simvastatin
Pravastatin
2.8 (110)
3.4 (130)
HPSl-P
WOSCOPS-S
Atorvastatin
AFCAPS-P
3.9 (150) 4.4 (170)
LDL-C, mmol/L (mg/dL)
S=statin treated; P=placebo treated
* Extrapolated to 5 Years
Modified from Kastelein JJP. Atherosclerosis. 1999;143(suppl 1):S17-S21.
Lovastatin
4.9 (190) 5.4 (210)