The Global Burden of Disease
The scale 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
*
Prevalence of ‘Hypertension’ by different cut points
% of screened population
20
 90 = 25.3%
 95 = 14.5%
 100 = 8.4%
 105 = 4.7%
 110 = 2.9%
 115 = 1.4%
15
10
5
0
50
60
70
80
90
100
Diastolic BP, mmHg
110
120 130
British Hypertension Society Guidelines
for hypertension management 2004
(BHS-IV): summary
Bryan Williams, Neil R Poulter, Morris J Brown, Mark
Davies, Gordon T McInnes, John F Potter, Peter S
Sever, Simon McG Thom; the BHS guidelines working
party, for the British Hypertension Society
BMJ Volume 328 13 March 2004 634-640.
BHS Guidelines
Definitions
Measurement
Risk assessment
Evaluation of hypertensive patients
Thresholds for intervention
Treatment goals
Lifestyle measures
Choice of therapy
Meta-analysis of trials
ABCD rule
Aspirin and statins
Follow up and implementation
Classification of blood pressure levels of the
British Hypertension Society
Category
Systolic blood pressure
(mmHg)
Diastolic blood pressure
(mmHg)
Blood Pressure
Optimal
<120
<80
Normal
<130
<85
130-139
85-89
Grade 1 (mild)
140-159
90-99
Grade 2 (moderate)
160-179
100-109
>180
>110
Grade 1
140-159
<90
Grade 2
>160
<90
High normal
Hypertension
Grade 3 (severe)
Isolated systolic
hypertension
Blood pressure measurement by standard mercury
sphygmomanometer or semiautomated device
• Use of properly maintain, calibrated, and validated device
• Measure sitting blood pressure routinely: standing blood
pressure should be recorded at least at the initial
estimation in elderly or diabetic patients
• Remove tight clothing, support arm at heart level, ensure
arm relaxed and avoid talking during the measurement
procedure
• Use of cuff of appropriate size
Continued
Blood pressure measurement by standard mercury
sphygmomanometer or semiautomated device
• Lower mercury column slowly (2mm per second)
• Read blood pressure to the nearest 2 mm Hg
• Measure diastolic blood pressure as disappearance of
sounds (phase V)
• Take the mean of at least two readings, more recordings are
needed if marked differences between initial measurements
are found
• Do not treat on the basis of an isolated reading
Potential indications for the use of
ambulatory blood pressure monitoring
•
Unusual variability of blood pressure
•
Possible white coat hypertension
•
Informing equivocal treatment decisions
•
Evaluation of nocturnal hypertension
•
Evaluation of drug resistant hypertension
•
Determining the efficacy of drug treatment over 24 hours
•
Diagnosis and treatment of hypertension in pregnancy
•
Evaluation of symptomatic hypotension
Cardiovascular risk assessment
Lifestyle measures
• Maintain normal weight for adults (body mass index 20-25kg/m2)
• Reduce salt intake to < 100mmol/day (<6g NaCI or < 2.4 g
Na+/day)
• Limit alcohol consumption to < 3 units/day for men and < 2
units/day for women)
• Regular physical exercise (brisk walking rather than weightlifting)
for > 30 minutes per day, ideally on most days of the week but at
least on three days of the week.
• Consume at least five portions/day of fresh fruit and vegetables
• Reduce the intake of total and saturated fat
Thresholds and treatment for
antihypertensive drug treatment
• Drug treatment should be started in all patients with
sustained systolic blood pressures > 160mmHg or
sustained diastolic blood pressures > 100mmHg
despite non-pharmacological measures (A)
• Drug treatment is also indicated in patients with
sustained systolic blood pressures 140-159mmHg or
diastolic blood pressures 90-99mmHg if target organ
damage is present, or there is evidence of established
cardiovascular disease or diabetes, or if there is a 10
year cardiovascular disease risk of > 20% (B)
continued
Thresholds and treatment for
antihypertensive drug treatment
• For most patients a target of < 140mmHg systolic
blood pressure and <85mmHg diastolic blood
pressure recommended (B). For patients with
diabetes, renal impairment or established
cardiovascular disease a lower target of <
130/80mmHg is recommended
Initial Blood Pressure
 180/110
160-179
100-109
160/100
Treat
130-139
80-89
140-159
90-99
140-159
90-99
<130/85
<140/90
Reassess
Yearly
Treat
SEE NEXT SLIDE
Re-measure
in 5 years
140159
90-99
Target organ damage
or
CVS complications
or
Diabetes
or
CV event risk  2%/year
[>20% over 10 yrs ]
Treat
No target organ damage
and
No CVS complications
and
No diabetes
and
CV event risk < 2%/year
[<20% over 10 yrs ]
Observe
Reassess CV risk yearly
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
STROKE
Comparisons of different active treatments
BP
difference
(mm Hg)
Favours
Favours
first listed second listed
RR (95% CI)
ACE vs. D/BB
2/0
1.09 (1.00,1.18)
CA vs. D/BB
1/0
0.93 (0.86,1.01)
ACE vs. CA
1/1
1.12 (1.01,1.25)
0.5
1.0
Relative Risk
2.0
CORONARY HEART DISEASE
Comparisons of different active treatments
BP
difference
(mm Hg)
Favours
Favours
first listed second listed
RR (95% CI)
ACE vs. D/BB 2/0
0.98 (0.91,1.05)
CA vs. D/BB
1/0
1.01 (0.94,1.08)
ACE vs. CA
1/1
0.96 (0.88,1.05)
0.5
1.0
Relative Risk
2.0
HEART FAILURE
Comparisons of different active treatments
BP
difference
(mm Hg)
Favours
Favours
first listed second listed
RR (95% CI)
ACE vs. D/BB 2/0
1.07 (0.96,1.19)
CA vs. D/BB
1/0
1.33 (1.21,1.47)
ACE vs. CA
1/1
0.82 (0.73,0.92)
0.5
1.0
Relative Risk
2.0
MAJOR CARDIOVASCULAR EVENTS
Comparisons of different active treatments
BP
difference
(mm Hg)
Favours
first listed
Favours
second listed
RR (95% CI)
ACE vs. D/BB
2/0
1.02 (0.98,1.07)
CA vs. D/BB
1/0
1.04 (0.99,1.08)
ACE vs. CA
1/1
0.97 (0.92,1.03)
0.5
1.0
Relative Risk
2.0
ALLHAT Design
High risk
Hypertensive
Patients
42,515
Amlodipine
Chlorthalidone
Doxazosin
Lisinopril
Randomize
10,362 eligible for
Lipid lowering
Not eligible for
Lipid lowering
Randomize
Pravastatin
Usual Care
Study completion January
2003
ALLHAT Primary Endpoint:
CHD Death and Nonfatal MI
Relative Risk (95%
CI)
Amlodipine 0.98 (0.90-1.07)
Lisinopril 0.99 (0.91-1.08)
0.7
1.3
Favors Amlodipine
Favors
Favors Lisinopril Chlorthalidone
ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.
ASCOT: PROBE Design
19342
High-risk
Hypertensive
10305
Randomized
Eligible for
Lipid Lowering
Amlodipine 
Perindopril 
Doxazosin GITs
Atenolol 
Bendrofluazide 
Doxazosin GITs
Not Eligible for
Lipid Lowering
Randomize
DB
Atorvastatin
10 mg
Placebo
Expected Mean Follow-up: 5 Yrs
Fatal CHD + Non-Fatal MI
ASCOT study: Effect of atorvastatin on CHD
Cumulative Incidence (%)
4
Atorvastatin 10 mg
Number of events
100
Placebo
Number of events
154
36% reduction
3
2
1
HR = 0.64 (0.50-0.83)
0
0.0
0.5
1.0
1.5
2.0
Years
2.5
3.0
3.5
p=0.0005
ASCOT study: Effect of atorvastatin on stroke
Cumulative Incidence (%)
3
Atorvastatin 10 mg
Number of events
89
Placebo
Number of events
121
27% rreduction
2
1
HR = 0.73 (0.56-0.96)
0
0.0
0.5
1.0
1.5
2.0
Years
2.5
3.0
3.5
p=0.0236
The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs
Step 1
Step 2
Younger (e.g.<55yr)
and Non-Black
Older (e.g.55yr)
or Black
A (or B*)
C or D
A (or B*)
Step 3
A (or B*)
Step 4
Resistant
Hypertension
+
+
C
C or D
+
D
Add: either -blocker or spironolactone or other diuretic
A: ACE Inhibitor or angiotensin receptor blocker
C: Calcium Channel Blocker
B: b - blocker
D: Diuretic (thiazide)
* Combination therapy involving B and D may induce more new onset diabetes compared with other combination therapies
Adapted from: ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 8186
Compelling and possible indications, contraindications, and cautions for the
major classes of antihypertensive drugs
% of hypertensives with controlled BP
<160/95 mm Hg
<140/90 mm Hg
USA1
27%
England2
6%
Canada3
16%
Finland4
20.5%
Scotland4
17.5%
Spain4
Australia4
20%
19%
India4
9%
Zaire4
2.5%
Adapted from Mancia, 1997
Other medication for hypertensive patients
Primary prevention
(1) Aspirin: use 75mg daily if patient is aged >50 years with blood
pressure controlled to <150/90mmHg and; target organ damage,
diabetes mellitus, or 10 year risk of cardiovascular disease of
>20% (measured by using the new Joint British Societies
cardiovascular disease risk chart)
(2) Statin: use sufficient doses to reach targets if patient aged up to
at least 80 years, with a 10 year risk of cardiovascular disease of
>20% (measured by using the new Joint British Societies risk
chart) and with total cholesterol concentration >3.5mmol/l
(3) Vitamins – no benefit shown, do not prescribe
Secondary prevention (including patients
with type 2 diabetes)
(1)
Aspirin: use for all patients contraindicated
(2) Statin: use sufficient doses to reach targets if
patient is aged up to at least 80 years with a total
cholesterol concentration >3.5mmol/l
(3)
Vitamins – no benefits shown, do not prescribe
Age- and gender adjusted hypertension control by country
(35-64 years); 140/90 mmHg
Age- and gender adjusted hypertension control by country (35-64
years); 140/90 mmHg
Impact of structured algorithm