A.ht & Downstream Effects

HT & Downstream Effects What to look for in an outpatient clinic
Kriengkrai Hengrussamee MD. Central Chest Institute Nonthaburi, Thailand kk_hm2000@yahoo.com

1 HT & Downstream effects&OPD
Hypertension,the global
major health
problem Downstream effects of HT What to look for in an outpatient clinic
HT & Downstream effects&OPD
THE CARDIOVASCULAR CONTINUUM

Tissue injury
In-hospital management of HF-KK
Maladaptive remodeling
Pathological remodelling
Vascular disease
MI,stroke, glomerular ischemia
LVH,LVE, glomerulosclerosis
Constriction,inflammation, Hypertrophy,hyperplasia, atherogenesis,thrombosis
Target-organ dysfunction
HF,nepropathy
Endothelial dysfunction DM,HT & IR
End-stage organ failure

Death
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The prevalence of HT in adult ~30-40%
In-hospital management of HF-KK
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Headlines
Hypertension,the global major health
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Definition
Downstream effect
= Relating to or happening at a later stage in a process HT and downstream effect =HT and its complication or target organ damage
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Downstream Effects of HT
Subclinical/Asymptomatic
CVD (LVH) CVA (Increase carotid IMT) Renal diseases (MAU/AU/CKD) PAD (abnormal ABI)
Clinical/Symptomatic
CVD (HTCVD,CAD,CHF) CVA Renal diseases PAD
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Healthy artery vs. Artery in HT (Atherosclerosis)
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HT is a significant risk factor for:

cerebrovascular
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disease coronary artery disease congestive heart failure renal failure peripheral vascular disease dementia HT & Downstream effects&OPD atrial fibrillation
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A Thai ADHERE comparison to Europe (in press)

Figure 3: Aetiology and co-morbidity
70 60
% of patients
50 40 30 20 10 Coronary Artery Disease A-fib/flutter Hypertension Diabetes
Thai ADHERE RiksSvikt EHFS I EHFS II
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Learn more from ADHERE
Causes of HF in THAI (THF registry)
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management of CHF 2008
What to look for in an outpatient HT clinic
Subclinical
CVD (LVH) CVA (Increase carotid IMT) Renal diseases (MAU/AU/CKD) PAD (abnormal ABI)
Clininical
CVD CVA Renal diseases PAD
Comobidities & Other CV risk factors

DM Dyslipidemia Cigarette smoking Mets
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ESC CVD Prevention
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ESC CVD Prevention 2012
LIFE Study Change in Cornell Voltage Duration Product and Sokolow-Lyon

Change from baseline (%) 0 -2 -4 -6 -8 -10 -12 -14 -16 -18
HT B, & Downstream effects&OPD et al. Lancet. 2002;359:995-1003. 32 Dahlof Reprinted with permission from Elsevier Science. www.hypertensiononline. org
Cornell Product
Sokolow-Lyon
P<0.0001
Losartan Atenolol
P<0.0001
HT & LVH
ACEI or ARB induce regression of
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LVH decreases adverse cardiovascular events and improves overall survival. When modifying medications in hypertensive patients, it is important to remember that the treatment of LVH is not synonymous with blood pressure control.
Carotid B-Mode Ultrasonography

Measurement of intimal medial thickness Non-invasive, inexpensive, no radiation
Well-established as an indicator of cardiovascular risk from epidemiologic studies

Published clinical trials on utility of carotid IMT as measure of progression of atherosclerosis and effects of therapy Accuracy of assessments depends on experience of those interpreting scans
ACCF/AHA 2010 Guideline: CIMT measurement may be reasonable for CV risk assessment in asymptomatic adults at intermediate risk (Class IIa-B)
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Cardiovascular Health Study: Combined intimal-medial thickness predicts total MI and stroke
Cardiovascular Health Study (CHS) (aged 65+): MI or stroke rate 25% over 7 years in those at highest quintile of combined IMT (OLeary et al. 1999)
CVA TIA/RIND/Ischemic stroke
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HT & Downstream effects&OPD From abnormal ABI to PAD
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ABI and Total Mortalty (ABI Collaboration, JAMA 2008)
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Definitions of abnormalities in albumin excretion

Category
Normal Microalbuminuri a Clinical albuminuria 24 hour collection (mg/24h) Timed collection (g/min) Spot collection (g/mg Cr)
< 30 30-299 300
< 20 20-199 200
< 30 30-299 300
Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 should be abnormal before considering diagnostic threshold positive False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria.
Relative Importance of MAU
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Early CKD in HT
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LATE CKD in HT

HT & Downstream effects&OPD 56
Hypertensive Retinopathy
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Assessment of HT Patients
Confirm Diagnosis
Loof for Secondary Causes
Detect HT Target Organ Damage& CVD
Cardiovascular risk calculation

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BENEFITS OF LOWERING BP (12/6 mmHg)

Stroke 35-40% MI 20-25% CCF 50% Stage 1 with 1 risk factor, SBP 12 mmHg for 10 years prevents 1 death for 11 treated Stage 1 plus TOD only 9 patients
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Risk Factors 1
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Risk Factors 2
ESC HT CVD Prevention 2012 & Downstream effects&OPD
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Risk Factors 3
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Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increase in Systolic/Diastolic BP*
Cardiovascular mortality risk 8
6
4 2 0
1X risk
8X risk
4X risk 2X risk 135/85 155/95 175/105 Systolic BP/Diastolic BP (mmHg)
115/75
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*Individuals aged 4069 years
Lewington et al. Lancet 2002;360:190313
Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increment in Systolic/Diastolic BP*
Cardiovascular mortality risk 8
6
4 2
1X risk
The closer to target the less reliable to office BP becomes
8X risk
Benefit not established
Benefit
4X risk
2X risk
115/75
135/85
155/95
175/105
Systolic BP/Diastolic BP (mmHg)

*Individuals aged 4069 years
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Lewington et al. Lancet 2002;360:190313
CV Risk in Men With Hypertension Rises With Other Additional CV Risk Factors
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ECG-LVH Smoking
10-Year % Probability of Event
36 30 24 18 12 6 0 4
Systolic BP 150-160
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Smoking
Diabetes HDL-C 33-35
14 10 6
Cholesterol 240-262 Systolic BP 150-160
Diabetes HDL-C 33-35 Cholesterol 240-262 Systolic BP 150-160 Cholesterol 240-262 Systolic BP 150-160
Diabetes HDL-C 33-35 Cholesterol 240-262 Systolic BP 150-160
HDL-C 33-35
Cholesterol 240-262 Systolic BP 150-160
A combination of high BP and high serum cholesterol increases the risk of CHD, especially in men
Adapted from Kannel. Am J Hypertens. 2000;13:3S-10S.
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Table 5. Reynolds Risk Score Applied to Population of U.S. Men.
Tattersall MC, Gangnon RE, Karmali KN, Keevil JG (2012) Women Up, Men Down: The Clinical Impact of Replacing the Framingham Risk Score with the Reynolds Risk Score in the United States Population. PLoS ONE 7(9): e44347. doi:10.1371/journal.pone.0044347 HT & Downstream effects&OPD 76 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0044347
A cohort of patients with high risk for cardiovascular events : CORE Thailand)
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Patients characteristics
N=4981(%) CV risk factors DM 3157 (63.4)
HT
Dyslipidemia Smoking (current) CKD FHx of premature athero
4131 (82.9)
4261 (85.5) 292 (5.9) 981 (19.7) 406 (8.2)
Patients characteristics
N=4981(%)
Chronic stable angina Myocardial infarction Unstable angina Stroke (ischemic) Transient ischemic attack Aortic dissection
646 1209 308 299 59 10 43
(13%) (24.3%) (6.2%) (6.0%) (1.2%) (0.2%) (0.9%)
Peripheral vascular disease Percutaneous coronary intervention (PCI)

Coronary artery bypass graft (CABG) Aortic surgery Peripheral artery angioplasty Peripheral artery bypass surgery Amputation of ischemic limbs Carotid stenting
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1312
238 13 17 4 6 7 1
(26.3%)
(4.8%) (0.3%) (0.3%) (0.1%) (0.1%) (0.1%) (0%)
Carotid endarterectomy
HT Managemnet
Awareness
Treatment
Control
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Undertreatment of Risk Factors in Patients Worldwide*1

Patients not achieving target (% of regional population)1
Patients not achieving target (%)
100 80
60 65 56 52 56 44 28 43 34 24 15 9 48 43 43 64
60
40
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North America Latin America Western Europe Eastern Europe Middle East Asia Australia Japan
40 20 0 Elevated blood pressure (140/90 mm Hg)
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21 15 13 7
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Elevated cholesterol (200 mg/dL)
Continued smoking (5 cigarettes/d)
*Data shown may differ slightly from published abstracts owing to a subsequent database lock. 1. Bhatt DL et al, on behalf of the REACH Registry Investigators. JAMA 2006; 295(2): 180-189.
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Hypertension,the global
major health
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Diseases Attributable to Hypertension

Coronary heart disease Myocardial infarction Left ventricular hypertrophy Stroke
Heart failure
Cerebral hemorrhage
Hypertension
Chronic kidney failure Hypertensive encephalopathy
Aortic aneurysm Retinopathy Peripheral vascular disease
All Vascular
Adapted from: Arch Intern Med 1996; 156:1926-1935.
HT& Target Organ Damage

Atherosclerosis Vasoconstriction Carotid IMT & bruit Vascular hypertrophy Endothelial dysfunction Ankle brachial index LV hypertrophy Fibrosis Remodeling Apoptosis GFR Proteinuria ALdosterone release Glomerular sclerosis
Stroke Hypertension Death Heart failure MI
HT
Renal failure
Adapted from Willenheirrer et al. Eur Heart J 1999,20:997; Jahlof. J Hum Hypertens.1995;9(suppl6):S37;Daugherty et al. J Clin Invest 2000; 105:1605; Fynrquist et al. J Hum Hypertens. 1995; 9(suppl5): S19Bcoz and Baker. Heart Fail Rev. 1998; 3: 125; Beers and Berkow, eds. The Merck Manual of DiagnosisAnd HT Exp & Downstream effects&OPD Therapy; Nephrol 1996;4(suppl1):34; Fogo. Am J idney Dis. 2000;36:179. 91 Andersor.
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How to approach HT patients?

History
Clinical signs & symptoms

Lab;
Urine strip test for blood and protein Blood electrolytes and creatinine, and eGFR Blood glucose & lipid (LDL-C, TG,HDL) Serum total and HDL cholesterol CXR 12 lead ECG UA, MAU, renal function test (eGFR)
Important Aspects of the Physical Examination in the Hypertensive Patient

Accurate measurement of blood pressure General appearance: distribution of body fat, skin
lesions, muscle strength, alertness Fundoscopy Neck: palpation and auscultation of carotids, thyroid Heart: size, rhythm, sounds Lungs: rhonchi, rales Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses Extremities: peripheral pulses, edema Neurologic assessment
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Clinical Signs of LV Dysfunction

Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displace ment Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion
rales
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Investigation of all patients with hypertension: 1. Urinalysis 2. Complete blood cell count 3. Blood chemistry (potassium, sodium and creatinine) 4. Fasting glucose 5. Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides 6. Standard 12 ECG 7. CXR
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Target Organ damage detection

Left ventricular hypertrophy
(ECG: Sokolow-Lyons>38 mm Echo ; LVMI ; M 125,F 110 g/m2) Vascular ultrasound Carotid IMT 0.9 mm or positive atherosclerotic plaque Microalbuminuria (30-300 mg/24 h; albumin-creatinine ratio M 22,W 31 mg/g) Slight increase in serum creatinine (M1.3-1.5 , W 1.2-1.4 mg/dl)
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The Heart Association of Thailand under the Royal Patronage of H.M. the King
www.apsc2013.org
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HT & Downstream Effects What to look for in an outpatient clinic

Kriengkrai Hengrussamee MD. Central Chest Institute Nonthaburi, Thailand kk_hm2000@yahoo.com

problem Downstream effects of HT What to look for in an outpatient clinic

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

THE CARDIOVASCULAR CONTINUUM

In-hospital management of HF-KK

MI,stroke, glomerular ischemia

Constriction,inflammation, Hypertrophy,hyperplasia, atherogenesis,thrombosis

Endothelial dysfunction DM,HT & IR

End-stage organ failure

The prevalence of HT in adult ~30-40%

HT & Downstream effects&OPD

In-hospital management of HF-KK

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

problem Downstream effects of HT What to look for in an outpatient clinic

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

Healthy artery vs. Artery in HT (Atherosclerosis)

HT & Downstream effects&OPD

HT is a significant risk factor for:

HT & Downstream effects&OPD

HT & Downstream effects&OPD

A Thai ADHERE comparison to Europe (in press)

50 40 30 20 10 Coronary Artery Disease A-fib/flutter Hypertension Diabetes

Thai ADHERE RiksSvikt EHFS I EHFS II

Learn more from ADHERE

Causes of HF in THAI (THF registry)

management of CHF 2008

What to look for in an outpatient HT clinic

Comobidities & Other CV risk factors

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

ESC CVD Prevention

HT & Downstream effects&OPD

ESC CVD Prevention 2012

LIFE Study Change in Cornell Voltage Duration Product and Sokolow-Lyon

Carotid B-Mode Ultrasonography

Well-established as an indicator of cardiovascular risk from epidemiologic studies

HT & Downstream effects&OPD

HT & Downstream effects&OPD

CVA TIA/RIND/Ischemic stroke

HT & Downstream effects&OPD

ESC CVD Prevention 201239

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD From abnormal ABI to PAD

ABI and Total Mortalty (ABI Collaboration, JAMA 2008)

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

HT & Downstream effects&OPD

Definitions of abnormalities in albumin excretion

< 30 30-299 300

< 20 20-199 200

< 30 30-299 300

A.ht & Downstream Effects

A.ht & Downstream Effects