A Common Link Between

Hypertension and
Cardiovascular Disease

Kasan Wongdjaja
SMF. Penyakit Dalam
RSU. Dr. Moch. Ansari Saleh Banjarmasin
 Hypertension
is The Most Important Preventable Cause
of Premature death

The Benefits of Antihypertensive Drugs

For Prevention of CV Mortality & Morbidity
Are Well Established

Lancet 2002;360:1347-60
 Germany 6.6-13.1%

Bulgary 1,1% Japan 20% Canada 13%

Greece 27%
England 21%

USA 25-29%

Korea 4,7%
Mexico 2,3%
France 16,1-18,5%
Indonesia 817%

Taiwan 2-5% Brazil 21.7%

Spain 25.7-35%
China 1.2-4.1%
South Africa 14,8%

PREVALENSI HIPERTENSI
 Update in hypertension
Global mortality 2000: impact of hypertension
and other health risk factors
High blood pressure (BP)
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
High-mortality, developing region
Alcohol Low-mortality, developing region
Indoor smoke from fuels Developed region
Iron deficiency
0 1000 2000 3000 4000 5000 6000 7000 8000
Attributable mortality
(In thousands; total 55,861,000)

Adapted from Ezzati et al, Lancet, 2002.

 Prevalence of Hypertension
Hypertension is one of the most frequent clinical discorders.
prevalence of hypertension (%)

70
SBP > 140 mm Hg 65
60 64
DBP > 90 mm Hg
50 54

40 44

30
20 21
10 4 11
0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Pathogenesis of Hypertension
Excess sodium Reduced Stress Genetic Endothelium Obesity
intake Nephron number Alteration derived factors
Renal Decreased Sympatheti Renin
Sodium Filtration c Angiotensin
retension surface nervous Excess
overactivit Cell membrane Hyperinsulinemia
y alteration
Fluid Volume Venous
Constriction

Preload Contractility Functional ConstrictionStructural Hypertrophy

Blood Pressure = Cardiac Output (CO) X Peripheral Resistance (PR)

Hypertension Increased CO and/or Increased PR
Autoregulation

Kaplan NM, Clinical Hypertension 7th ed. 2002; 63

 Endothelial Dysfunction and Cardiovascular Disease

CHF Reocclusion
Vasospasm
Thrombosis and coronary/cerebral
coagulopathies Hypertension

Diabetic Endothelial
Angiopathies dysfunction Reperfusion Injury

Hyperlipidemia Peripheral Artery

disease
Atherosclerosis

Immune Reaction Inflammatory Disease

J Cardiovasc Pharmacol, Vol 22 (Suppl.4), 1993

 THE CARDIOVASCULAR CONTINUUM
Myocardial Sudden Death
infarction
Coronary Arrhythmia &
thrombosis loss of muscle

Myocardial Remodelling
ischaemia
Ventricular
CAD dilatation
STROKE
Atherosclerosis Congestive
LVH heart failure

Risk factors Death

smoking, HYPERTENSION,
cholesterol, diabetes
 Hypertension
Left Ventricle Hypertrophy (LVH)

Myocardial Impaired Impaired Ventricular

ischemia contractility LV filling dysrhythmias

Myocardial Congestive Congestive Ventricle

Infarction Heart failure Heart failure fibrillation

Death
 Left Ventricular Hypertrophy
(Normal Hypertension) ( Cardiac Hypertrophy) ( Cardiac Dilation)

Pressure is applied to Dilated Image

myocardium Contractile function is
reduced by dilation of
cardiac cavities

Dilated Image
Fibrosis
Enlarged myocardium
Heart Disease
in Hypertension
A Normal human heart of 350 g in weight from a 35 years old man male.

Olivetti,G., et.al. Cardiovascular Research 45 (2000)

An Hypertrophied human heart of 850 g in weight from a 40 year old
hypertensive male.

Olivetti,G., et.al. Cardiovascular Research 45 (2000)

The Aim of Treatment for
Hypertension

Prevention or to decrease
Myocardial infarction
Heart failure
Cerebro Vascular Desease
Aorta disease
Pheriperal Vascular disease
End Stage Renal Disease
Complication of Hypertension (1)
Hypertensive complication;
Accelerated malignant hypertension
Encephalopathy
Cerebral hemorrhage
Left ventricular hypertrophy
Congestive heart failure
Renal insufficiency
Aortic dissection
Complication of Hypertension (2)

Atherosclerotic complication;
Cerebral hemorrhage
Myocardial infarction
Coronary artery disease
Claudication syndromes
 Control of Blood Pressure and
Antihypertensive Sites of Action
BP is controlled
via changes in
Sympathetic
Cardiac output Stimulation
Vasomotor tone
Plasma volume 1 3

Sympathetic Heart
Stimulation

Postcapillary Venules 1 -Blockers

12 (Capacitance Vessels) 1-Blockers
Sympathetic
Stimulation Precapillary Arteriole 2 Vasodilators
(Resistance Vessels)
1 3 ACE Inhibitors
Renin 12 AT1-RA
4 Activates
Angiotensin
3 Sympathetic 4 Diuretics
Activates
3 Stimulation
Kidney Aldosterone
 Percentages of Patients whose
Hypertension is Controlled

< 140/90 mmHg < 160/95 mmHg

USA Canada Finland Spain Australia
16 20.5 20 19
27

England France Germany Scotland India

6 9
24 22.5 17.5

> 65 years

USA: JNC VI. Arch Intern Med 1997 Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998 Adapted from G. Mancia / L. Ruilope
 Hypertension

How to manage?
 JNC BP Classification : DBP
130

125 Stage 4
Severe Severe Severe
120 Stage 3 Stage 2
Hyper-
tensive
115 Stage 3

110 Moderate Moderate Moderate

DBP
( mmHg ) 105 Stage 2 Stage 2

100
Consider
Mild Mild Mild
therapy
95 Stage 1 Stage 1 Stage 1

90
High High High High
Normal Normal Normal Normal Prehyper
85
tension
Normal Normal Normal Normal
80
Optimal Optimal Normal

JNC I JNC II JNC III JNC IV JNC V JNC VI JNC VII

JNC I. JAMA. 1977;237:255-261 JNC IV. Arch Intern Med. 1988;148:1023-1038

JNC II. Arch Intern Med. 1980;140:1280-1285 JNC V. Arch Intern Med. 1993;153:154-183
JNC III. Arch Intern Med. 1984;144:1047-1057 JNC VI. Arch Intern Med. 1997;157:2413-2466
 JNC BP Classification : SBP
220
Stage 4
210

200 Stage 3
Stage 3
190 Stage 2
ISH ISH

180

SBP 170 Stage 2 Stage 2

( mmHg )
160

150 Borderline Borderline Stage 1 Stage 1 Stage 1

140
High High
No recommendations normal normal Prehyper
130 For SBP in JNC I tension
Or JNC II Normal Normal
120 Normal

110
Optimal Optimal Normal

JNC I JNC II JNC III JNC IV JNC V JNC VI JNC VII

JNC I. JAMA. 1977;237:255-261 JNC IV. Arch Intern Med. 1988;148:1023-1038
JNC II. Arch Intern Med. 1980;140:1280-1285 JNC V. Arch Intern Med. 1993;153:154-183
JNC III. Arch Intern Med. 1984;144:1047-1057 JNC VI. Arch Intern Med. 1997;157:2413-2466
 RULE OF HALVES

Only HALF of all hypertensive patients are AWARE

Only HALF of those aware are TREATED
Only HALF of those treated have their BP CONTROLLED
= 50% x 50% x 50%
In Indonesia
Only: ... % x 50% X 50% X 50% affordto pay treatment
 Important messages for the
management of Hypertension

Assess the risk

Treat to target
Lifestyle
Combination therapy
Pharmacotherapy

Compliance
ASSESS THE RISK
 Diabetes?
Chronic kidney disease?
Stroke?
High coronary disease risk?
Heart failure?
Post myocardial infarction?

NO YES

Treatment in the
Individualized
absence of specific
treatment
indication
TREAT TO TARGET
 JNC VII: Classification of blood pressure

Blood pressure Systolic BP Diastolic BP

classification (mm Hg) (mm Hg)

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1
140-159 or 90-99
hypertension
Stage 2
>160 or >100
hypertension

The JNC VII. JAMA 2003;289:2560-72

 BLOOD PRESSURE CONTROL

GOAL

Less than 140/90 mm Hg

or
Less than 130/80 mm Hg
(diabetes)
or
Less than 125/75 mm Hg
(protein uria >1g/day)
1999 WHO/ISH Hypertension Guidelines. J Hypertens 1999;17:151-183
ADA Position Statement. Diabetes Care 2002;25:S33-S49
LIFESTYLE MODIFICATION
Lifestyle Recommendations for Hypertension

Healthy diet:
High in fresh fruits, vegetables and low fat
dairy products, low in saturated fat and salt

Regular physical activity:

optimum 45-60 minutes of moderate
cardiorespiratory activity 4-5/week
Reduction in alcohol consumption
in those who drink excessively (<2 drinks/ day)

Weight loss (> 5 Kg)

in those who are over weight (BMI>25)

Smoke free environment

2003 Canadian Hypertension Education Program Recommendations.

PHARMACOTHERAPY
 Profile of an Ideal Combination
Antihypertensive Product

Scientific rationale and complimentary mechanisms of action

Simple pharmacokinetics profiles
Maintains 24-hr BP control
Placebo-like tolerability
Superior to existing monotherapies
Work independent of special population status
Effect beyond BP reduction

Cardilogy
Treatment Algorithm for Adults with Systolic-Diastolic
Hypertension without another compelling indication

TARGET <140/90 mmHg

INITIAL TREATMENT AND MONOTHERAPY

Lifestyle modification
therapy

Long-acting Beta-
Thiazide ACE-I ARB
DHP-CCB blocker

Alpha-blocker
as initial
monotherapy

2003 Canadian Hypertension Education Program Recommendations.

COMPLIANCE
 Recommendations for Improving Adherence to
Antihypertensive Prescription

Adherence can be improved by a multi-pronged

approach
Simplify medication regimens to once daily dosing
Tailor pill-taking to fit patients daily habits
Encourage greater patient
responsibility/autonomy in monitoring their BP
management (including monitoring)
Educate patients and patients families about their
disease/treatment regimens
2003 Canadian Hypertension Education Program Recommendations.
 Additional suggestions for improving adherence to
antihypertensive prescription

Ask about side effects and record any that occur

Tailor pill taking into a usual daily routine (same
time/place/situation)
Simplify drug and lifestyle regime
Ensure regime is affordable
Involve family and friends in lifestyle and medication
adherence
Maintain regular BP follow-up
Consider self measurement of blood pressure

2003 Canadian Hypertension Education Program Recommendations.

 CONCLUSION
Regarding the treatment of hypertension,
the recommendations endorse:

Lifestyle modification (alone if effective to reach

the goal value)

Individualizing therapy

Treating to target BP

Using combination therapy

Promoting adherence