فيصل الناصر - Prof faisal hypertension presentation1 4

Hypertension the Silent KillerEpidemiology

Prof Faisal A Alnasir FRCGP, MICGP, FFPH, PhD

President, Family & Community Medicine Council Arab Board Chairman, Department of Family & Community Medicine

Arabian Gulf University

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Hypertension

• Common • Non Communicable disease• Inevitable• Preventable• Serious complication

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WHO estimated that high blood pressure

causes one in every eight deaths, making

hypertension the third leading killer in the world.

Globally, there are one billion hypertensives and

four million people die annually as a direct result

of it.

Hussein A. GezairyRegional Director for the Eastern Mediterranean

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Size of the problem1-World wide

• In 2010, 1.2 billion people were expected to be suffering from hypertension worldwide

Sixth report of the Joint National Committee on prevention,1997 • Expected to increase to 1.56 billion by 2025

International Society of Hypertension • Its prevalence from 20% to 30% of the adult population.

Alwan A 1993

• Incidence In USA between 14% to 40% in 35 to 64 years. WHO 2002

• Prevalence in Canada 17.3%. Most patients had untreated hypertension (68.6%), and only 15.8% had blood pressure treated and controlled.

Petrella et al 2007

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Size of the problem

2-In the Eastern Mediterranean Region

• The average prevalence of hypertension 26% and it affects

approximately 125 million individuals.

• Each year, there are several million new cases of

hypertension and more of pre-hypertension

Report on the regional consultation on hypertension UAE, 2003

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Size of the problem

In Bahrain

National Non-communicable Diseases Risk Factors Survey 2007

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Size of the problem

In Bahrain


In Lebanon

•23.1% are hypertensive

•Prevalence increases with age

•Occurs more in the less educated and unemployed

•Prevalence increases significantly with an increase in

body mass index particularly in female patients

•Only14.7% exercised daily R A Tohme, A R Jurjus, A Estephan 2005

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Size of the problem

In Saudi Arabia:The prevalence range from 4% to 15%.

Abolfotouh MA et al.

It may reach as high as 20.4% for systolic hypertension and 25.9% for diastolic hypertension.

Al-Nozha MM et al.

In south-western 11.1%. Abolfotouh MA et al.

In Jeddah, the hypertensive were 22.6%.Elkalifa Am et al.2011

In the UAE:Hypertension has become one of the leading public health problems

In Sudan

of 6-12y children:

4.9% were pre-hypertensive and

4.9% were hypertensive

Salman Z, et al 2010

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Size of the problem

It has been estimated that individuals who are

normotensive at the age 55 years have a 90% lifetime risk for developing hypertension.

EMR0 Technical Publications

Blood pressure is under control in less than 20% of patients with hypertension in many countries

A joint CINDI/EuroPharm Forum project WHO

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Awareness of Hypertension

Although the prevalence of high blood pressure is high, there is a low awareness rate (Up To 70% are unaware)

Alwan A1993


Faisal Alnasir, 2004

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In Egypt only 37.5% of hypertensives were aware of Having it.

In United States, Chile, and Cub, 32%, 37%, and 39% of the people were not aware.

Pan American Health

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Advantage of Controlling Hypertension

•A 5-6 mmHg reduction in diastolic BP reduces stroke by 40%. Joint National Committee on Detection, 1992

•lowering by 5-6mmHg can reduce mortality from cerebrovascular disease by 35%-40%, from ischemic heart disease by 15% 20%

and reduction in all deaths from cardiovascular causes by 23%.

Psaty, et al 1997

• 3 mmHg decrease in systolic BP reduces annual mortality from stroke, coronary heart diseases and all other causes by 8%, 5% and 4%.

Whelton PK, 1994

•The chances of mortality from CVD in old hypertensive people when taking anti hypertensive medications is decreased by 34%.

MacMahon, 1993

Advantage of Controlling Hypertension

The first long-term data from a high-blood-

pressure study, the

Systolic Hypertension in the Elderly Program

(SHEP), show that each month of chlorthalidone-

based therapy was associated with

approximately one day of extension in life, free

from cardiovascular death.

The main findings are that after 22 years of

follow-up, when about 60% of the participants in

SHEP were dead, we saw a prolonged life

expectancy in those who took the active

treatment for 4.5 years. Dr John B Kostis Journal of the American Medical Association 2011

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Economic Impact

The economic burden of chronic NCDs can be analyzed on two levels.

•First, the effects of macroeconomic policies on opportunities for prevention in different

population groups

•Second, the cost and overall efficiency of interventions must be evaluated in terms of

effectiveness and health gains for the population at large.

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Economic Impact

Direct Cost:Including prescribing medicines, inpatient visits, outpatient visits, emergency room visits, office-based medical provider visits, home health visits, and other medical expenses

Sanjeev Balu, 2001

Indirect Cost:Productivity loss ($300 per eligible employee per year)

absence & short term disability Goetzel (2004), the only study in the U.S.

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Economic Impact

•Poor are disproportionately affected •more vulnerable •Prevalence 6 time more in uneducated•Medication cost up to US$ 100 per month •further poverty

•Cost to Health Services•USA total cost of CVD is 2% of the gross domestic product• direct medical costs estimated at nearly $55.0 billion for the year 2001

Sanjeev Balu, 2001

•Canada 21% of all diseases costs are due to CVD (US$12 billion/Year) direct cost is $3,072 per person per year, and indirect cost is $854

Guijing Wang,2008

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Economic Impact

In Alkhobar the total direct cost of hypertension

care for patients registered in the primary health

care represented 6.32% of the estimated cost of

treating the expected number of patients. Al-Shahri 1998

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Prevention

Primary prevention is the most cost-effective

approach to containing the emerging

hypertension epidemic.Hussein AlGezairy

Regional Director for WHO

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Prevention

Incidence of hypertension was reduced by 20% to

50% if primary prevention were implemented Stamler 1991

For the developing countries prevention of hypertension should be the goal.

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Prevention

Life style Modification:

•perform aerobic exercise•maintain a healthy body weight •follow a healthy diet •restrict salt intake•stress management•limit alcohol consumption

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ModificationRecommendationApproximate systolic BP reduction

Weight reduction Maintenance of normal body weight 5–20 mmHg/10 kg

healthy eating planConsumption a diet rich in vegetables, fruits, and

low-fat dairy products with a reduced content of saturated and total fat

8–14 mm Hg

Dietary sodiumReduction dietary sodium intake to no more than

2.4 g sodium

2–8 mmHg

Physical activityEngagement in regular aerobic

physical activity at least 30

minutes daily, most days of the

week

4–9mmHg

Recommended lifestyle modifications

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Life style Modification

• Weight reduction

Every 1 kilogram of weight loss lower blood pressure by

1.6/1.1 mmHgKhatib et al. EMR0 Technical Publications

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Prevalence of overweight and obesity among some countries of the Eastern Mediterranean Region (WHO.2004)

CountryOverweight/obesity (%) Males Females

Saudi Arabia64.070.0

Lebanon60.053.0

Islamic Republic of Iran57.067.7

Bahrain56.479.0

Jordan46.043.7

Egypt43.841.0

Libyan Arab Jamahiriya42.574.9

Oman40.543.5

Morocco37.221.7

United Arab Emirates25.539.9

Tunisia13.141.9

Kuwait7956

In Bahrain


In Sudan

of 6-12y children:

45 (14.8%) were overweight; 32 (10.5%) were obese

Salman Z et al 2010

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• Eating habits

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• Physical activity Exercise lowers systolic and diastolic blood pressure by 5-10 mmHg

Arakawa

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• Physical activity


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• Sodium moderation

Reducing dietary sodium intake to no more than 100 mEq/L

) 2.4 g sodium or 6 g sodium chloride ,(reduces the blood

pressure by an average of 4–6 mmHg .Khatib et al. EMR0 Technical Publications

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• Diabetes (In Bahrain)


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• Diabetes (In Bahrain)

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• Tobacco (In Bahrain)


-Lipids

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• Lipids (In Bahrain)


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• Cocoa ingestion 100g/day of chocolate drink reduces the systolic BP and diastolic BP Taubert et al 2007

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Blood Pressure Pooled Change (mm Hg) P

Cocoa

Systolic -4.7 .002

Diastolic -2.8.006

Tea

Systolic 0.4 .63

Diastolic -0.6 .38

Change in Blood Pressure reduction between cocoa & Tea

Taubert et al 2007

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Taubert et al 2007

“The magnitude of the hypotensive effects of cocoa is in the range that is usually achieved with monotherapy of β-blockers or angiotensin-converting enzyme inhibitors”

Chocolate and Coronary Heart Disease: A Systematic Review

This article reviews current evidence on the effects of cocoa/chocolate on

clinical and subclinical coronary heart disease (CHD), CHD risk factors,

and potential biologic mechanisms.

The high content of polyphenols and flavonoids present in cocoa has

been reported to play an important protective role in the development of

CHD.

Although studies have demonstrated beneficial effects of chocolate on

endothelial function, blood pressure, serum lipids, insulin resistance, and

platelet function, it is unclear whether chocolate consumption influences

the risk of CHD. Khawaja O et al Current Atherosclerosis Reports, Volume 13 / September 2011

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Measurement of Blood Pressure

The "white-coat" effect

Prevalence of white coat hypertension was 3.6% overall and 12.8% in hypertensive patients. Marquez Contreras et al. 2006

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Hypertension Control

Very poor control of hypertension world wide

•In Egypt 23.9% were receiving treatment & 8% controlled

Ibrahim et al.

•In Canada 15.8% had blood pressure treated and controlled

Petrella et al, 2007 •In Saudi Arabia, 76 % were receiving treatment, but only

20% were found controlledAbolfotouh et al,

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•Seated in a quiet room •Arm muscles relaxed •Cubital fossa at heart level •Avoid tight sleeves •Suitable size Cuff to be used•Repeat if BP > 140/90•Measurement on both arms •Mercury sphygmomanometers are most reliable

Goodman and Gilman's1993

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Management

Good management of hypertension is central to any

strategy formulated to control hypertension at the

community level. Randomized trials of drugs that

lower and control blood pressure clearly show a

reduction in mortality and morbidity.Hussein A. Gezairy

Regional Director for the Eastern Mediterranean

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Management

2 mmHg reduction in systolic blood pressure

is likely to reduce the annual mortality from

stroke, coronary heart disease and all other

causes by 6%, 4% and 3%, respectively

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Conclusion

Hypertension is a serious problem that could

be called "the silent killer". Its prevalence is

very high especially in the GCC countries.

Effective efforts ought to be taken in order to

prevent, prevent, prevent, prevent then diagnose and treat it.

A Wife is a Wife, no matter who

THE HELL you are!!

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Thank you

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Recommended Classification of Hypertension

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Classification of Hypertension

Normal blood pressure for adults is defined as systolic blood pressure below 140 mmHg and diastolic blood pressure below 90 mmHg

Protocol and Guidelines A joint CINDI/EuroPharm Forum project WHO

• Mild • Moderate • Severe

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CategorySystolic BP (mmHg)Diastolic BP (mmHg)

Optimal< 120< 80

Normal < 130< 85

High-normal130–13985–89

Grade 1 hypertension (mild)140–15990–99

Subgroup: borderline140–14990–94

Grade 2 hypertension (moderate)160–179100–109

Grade 3 hypertension (severe)≥ 180≥ 110

Isolated systolic hypertension≥ 140< 90

Subgroup: borderline140–149< 90

Operational classification of hypertension by blood pressure level

European Society of Hypertension 2003

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EMR0 Technical Publications Series 29 Clinical guidelines

BP classification

Systolic BP (mmHg)

Diastolic BP (mmHg)

Normal <120and<80

Prehypertension120–139or80–89

Stage 1 hypertension

140–159or90–99

Stage 2 hypertension

≥160or≥100

classification that is suggested by the EMRO for adult aged > 18 years

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Classification according to the extent of organ damage

•hypertension with no other cardiovascular risk factors and no target organ damage

•hypertension with other cardiovascular risk factors

•hypertension with evidence of target organ damage

•hypertension with other cardiovascular risk factors and evidence of target organ damage.

Ala Din Alwan WHO, 1996, CINDI/EUROPHARM Forum WHO

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Clinical assessment of people with hypertension

Objectives

•to confirm a persistent elevation of blood pressure•to assess the overall cardiovascular risk•to evaluate existing organ damage or concomitant disease•to search for possible causes of the hypertension

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Causes of hypertension

•Primary hypertension (95% of cases)

•Secondary hypertension

*Renal *Drugs

*Endocrine *Coarctation of the aorta and aortitis

*Pregnancy-induced hypertension

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The possibility of secondary hypertension

•young age•family history of renal disease •evidence of renal disease•hypertension due to drugs •episodes of sweating, headache, anxiety (phaeochromocytoma)•episodes of muscle weakness and tetany (hyperaldosteronism(

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Laboratory investigations

•urine analysis •plasma creatinine and/or blood urea nitrogen•plasma potassium•random blood glucose•serum cholesterol•heamatocrit •electrocardiogram.•lipids lipoprotein cholesterol•plasma uric acid•chest X-ray•echocardiography.

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High BP: DBP≥90 and/orSBP≥ 140 mmHg

Hypertension confirmed Hypertension not confirmed

SBP 140-180 mmHg DBP 90-105 mmHgBP <140/90

Low CV riskHigh CV risk

DBP 90-95 mm HgSBP 140-160 mmHg

DBP ≥95 mmHgSBP ≥160 mmHg

Repeated measurements

General assessment and evaluation of Check again in CV risk and nonpharmacological six months Therapy for 4 weeks*

Reinforce nonpharmacological Therapy for 3-6 months

Follow up Follow up Start drug therapy Start drug therapy

Guidelines for the diagnosis and management of hypertension

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• Physical activity Exercise lowers systolic and diastolic blood pressure by 5-10 mmHg

Arakawa

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Of course being a doctor

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Economic Impact

“Since hypertension is associated with cardiovascular disease and diabetes, its

management and control is potentially costly".

Dr Hussein AlGezairy regional director, WHO

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Hypertension the Silent Killer

Prof Faisal A Alnasir FRCGP,MICGP,Phd

President, Family & Community Medicine Council Arab Board

Arabian Gulf University

Qatar Primary Health Care-20081st International Conference, in Partnership with the WHO

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Health & Medicine

فيصل الناصر - Prof faisal hypertension presentation1 4