Mid claviculer
Prevalence of hypertension
21%
43%
22%
43%
22%
21%
13%
NHANES
III
(Phase I)
1988-91
73.0%
NHANES
III
(Phase II)
1991-94
Awareness
51.0%
68.4%
Treated
31.0%
55.0%
53.6%
Controlled
10.0%
29.0%
27.6%
Failure to treat to
target
MD Reluctance
Accurate blood pressure
measurements
Secondary Causes
Sleep apnea
Renal vascular HTN
Endocrine causes
Chronic renal failure
Rx Drugs (NSAIDS, steroids)
White-coat HTN
Stroke
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy
Hypertension
Hypertensive
encephalopathy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
All
Vascular
30
24.4
25
20
18.6
15
11.9
10
9.9
10.0
9.3
5
0
90 mmHg
85 mmHg
80 mmHg
Stroke
Microvascular
disease
Deterioration in
visual acuity
24% P<0.005
32% P<0.05
37% P<0.01
Tight control (n=758)
Less tight control (n=390)
44% P<0.05
47% P<0.005
BMJ 1998;317:703713
BP targets
Strngt : ktat,kras
Initial Assessment
Target organ damage
Overall cardiovascular risk
Rule out secondary and often curable
causes
Eyes
Kidneys
Arteries
Hypertension
Age
Smoking
Dyslipidemia
Diabetes
Family history
Obesity
Adapted from: JNC VI. Arch Intern Med 1997;157: 2413-46
Normal
SBP 120129
DBP 80-84
High
normal
SBP 130139
DBP 85-89
Grade 1
SBP140159
DBP 9099
Grade 2
SBP 160179
DBP 100109
Grade 3
SBP >
180
DBP >
110
Average
risk
Average
risk
Low
added
risk
Moderate
added risk
High
added
risk
1 2 risk factors
Low added
risk
Low added
risk
Moderate
added
risk
Moderate
added risk
Very high
added
risk
High
added risk
High
added
risk
High
added risk
Very high
added
risk
ACC
Very high
added risk
Very high
added
risk
Very high
added rsik
Very
added
risk
High
added risk
2003 ESH-ESC
14
Effectively reduces BP
No adverse effects
Affordable
Clinical Practice:
Most people with hypertension are treated with monotherapy
Clinical Evidence:
Most people in clinical trials are treated with combination
therapy
HOT(Hyp.Optimal.Treatment): percentage of
patients requiring combination therapy to
achieve target DBP
Target DBP group
90 mmHg
85 mmHg
26.1%
31.7%
37.1%
62.9%
80 mmHg
68.3%
73.9%
Combination therapy
Monotherapy
The lower the target DBP, the greater the need for combination therapy
HOT:Hypertesion Optimal Treatment
Drug Action
- vasodilatation
RAS Activation
SNS Activation
-Vasoconstriction
- Sodium retention
RAS = renin-angiotensin system
SNS = sympathetic nervous system
Thiazide
Natriuretic
Lowers Blood
Pressure
Activates
Renin Angiotensin
System
24
Thiazide
Diuretics
Excrete Potassium
Combination
Prevents hypokalaemia of thiazide therapy
Limits hyperkalaemia of RAS(renin angt sys) blockade
25
26
27
28
100
80
80
60
60
Traditional
40
40
20
20
0
Dose
Efficacy (%)
Freedom from
side effects (%)
29
Man Int Veld AJ. J Hypert, 1997
30
31
Lifestyle
Modification
Without Compelling
Indication
With Compelling
Indication
Encourage
Prehypertension
120-139/80-89 mm Hg
Yes
No drug indicated
Stage 1 hypertension
140-159/90-99 mm Hg
Yes
Thiazide-type diuretics
for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Stage 2 hypertension
160/100 mm Hg
Yes
33
34
Easy as ABCD
A = ACE-Inhibitor or Angiotensin Receptor Blocker
B = - Blocker
C = Calcium Channel Blocker
D = Diuretic (thiazide)
Adapted from : Better blood pressure control: how to combine drugs
Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org
35
A or B
C or D
Inhibit the
Renin-Angiotensin
System
More Effective
In Younger
More Effective
In Older
36
1.
Younger
Or Diabetes
( 55yrs)
Older
(55yrs)
or Black
A or B
C or D
2.
A or (B) + C or D
3.
A or (B) + C + D
4.
A or (B) + C + D + other
Adapted from : Better blood pressure control: how to combine drugs
Journal of Human Hypertension (2003) 17, 81-86 www.bhsoc.org
38
Recommended Combinations
1. ACE inhibitors / AIIRA
2. ACE inhibitors / AIIRA
3. ACE inhibitors / AIIRA
4. Beta-Blockers
5. Beta-Blockers
Diuretics
Calcium antagonists
Beta-blockers
(Special condition)
Diuretics
Calcium Antagonists
39
SUMMARY
COMBINATION THERAPY IN HTN
MANAGEMENT IS LOGIC AND EVIDENCE
BASED
MAXIMIZE EFFECT, MINIMIZE SIDE
EFFECT
COMBINATION THERAPY IN HTN
INCREASE COMPLIANCE
THE END