2) Update แนวทางการรักษาโรคความดันโลหิตสูง_นพ.อภิชาต (1)

Hypertension Guidelines in
Primary Practice

Apichard Sukonthasarn MD. FACP. FRCP T
Professor of Cardiovascular Medicine

Deputy Director & Head of Medicine Bangkok Hospital Chiang Mai
President of Thai Hypertension Society

The Rationale for Reduction of Elevated Blood Pressure

1 The frequency of CVD and death is directly related to the height of BP
2 The BP rises most in those whose BP are already high
3 Vascular damages is less where the BP is lower
4 Lowering BP protects the vascular system
5 Antihypertensive therapy reduces CVD and death

Stroke Mortality in Each Decade of Age vs. Usual BP
at the Start of That Decade

A: Systolic blood pressure B: Diastolic blood pressure

Age at risk: Age at risk:
256 80-89 256 80-89

years years
128 70-79 128 70-79

years years
64 60-69 64 60-69

years years
32 50-59 32 50-59

years years
16 16

8 8

4 4

2 2

1 1
Stroke mortality
(floating absolute risk and 95% CI)

Stroke mortality
(floating absolute risk and 95% CI)

120 140 160 180 70 80 90 100 110
Usual Systolic blood Usual Diastolic blood
pressure (mmHg) pressure (mmHg)
Lancet 2002;360:1903-13.

IHD Mortality in Each Decade of Age vs. Usual BP at
the Start of That Decade

A: Systolic blood pressure B: Diastolic blood pressure

Age at risk: Age at risk:
256 80-89 256 80-89

years years
128 70-79 128 70-79

years years
64 60-69 64 60-69

years years
32 50-59 32 50-59

years years
16 16

8 40-49
8 years
4
4
2
2
1
Stroke mortality 1
(floating absolute risk and 95% CI)

Stroke mortality
(floating absolute risk and 95% CI)

120 140 160 180 70 80 90 100 110
Usual Systolic blood Usual Diastolic blood
pressure (mmHg) pressure (mmHg)
Lancet 2002;360:1903-13.

Blood Pressure and CVD Death in the Asia Pacific

4.0 Asia Australasia

Hazard ratio and 95% CI 2.0

1.0

0.5 Total stroke
100% Ischemic heart disease
Other cardiovascular
% of events75%
J Hypertens 2003;21:707-716
50%

25%

0%

110 120 130 140 150 160 170 110 120 130 140 150 160 170

Usual systolic blood pressure (mmHg)

Asia Pacific Cohort Studies Collaboration.

Asia Pacific Cohort Studies Collaboration

Fatal Hazard ratio 1.8 Asian Hazard ratio 1.8 Caucasian
and
nonfatal 1.5 1.5
CHD
1.2 1.2
Stroke
1.0 P int. <0.001 1.0 P int. <0.001
0.9 0.9
5 10 15 5 10 15 <65 years
123 SBP (mmHg) 123 SBP (mmHg) 65+ years

Hazard ratio 1.8 Hazard ratio 1.8

2.0 Asian 2.0 Caucasian

1.5 P int. <0.001 1.5 P int. <0.001

1.2 5 10 15 1.2 5 10 15
1.0 SBP (mmHg) 1.0 SBP (mmHg)
0.9 0.9

123 123

Hypertension 2007;50:991-997.

Effects of BP on the Risk of Total CVD

Australia and New Zealand Hazard ratio Events
(95% CI)
Prehypertension 1117
Isolated diastolic hypertension 1.11 (0.97-1.27) 133
Isolated systolic hypertension 1.40 (1.12-1.74) 1698
Systolic-diastolic hypertension 1.45 (1.27-1.65) 1445
2.12 (1.85-2.42)
Asia 2205
Prehypertension 1.55 (1.41-1.70) 553
Isolated diastolic hypertension 2.12 (1.84-2.44)
Isolated systolic hypertension 2.68 (2.39-3.00) 1330
Systolic-diastolic hypertension 4.51 (4.11-4.96) 2957

0.5 12 4 8
Hazard ratio

Asia Pacific Cohort Studies Collaboration Hypertension 2012;59:1118-

Causes of Death in Thai Population

One CVD Death in Every 5 Minutes

IHD Death in Thailand: 2010-15

Stroke Death in Thailand: 2010-15

Factors Contributive to Hypertension and
CVD in Asia

HOPE Asia .J Clin Hypertens. 2019;00:1–13. https://doi.org/10.1111/jch.13733.

ฐานข้อมูล OP/IP/OP-AE Individual สปสช. (ไตรมาศ 3-4, 1-2 ปี งบประมาณ 2559-2560)

%

Thai National Health Examination Survey NHES V

Hypertension in Thailand 2017

23% controlled

Risk factors

Confidence
Adherence

Quality

Continuing for Rx : those who had contact with health facility at least twice in the year
Controlled : those with last two consecutive BP readings <140/90

No data reported from Bangkok; No data from private sector

Risk Factors of Hypertension

What Do We Expected From Guidelines ?

1. They should be based on Up-to-Date, solid
scientific evidences.

2. Only Hard Endpoints considered valuable ?
3. Treatment should be cost effective.
4. Treatment should be available for All.
5. Giving Clear and practical messages.
6. Solve Problems.

Guideline Definitions of Hypertension

BP Category ACC/AHA 2017 ESC/ESH 2018 NICE 2019 ISH 2020
(mmHg)
Normal <120 120–129 <140 <130
SBP <80 80–84 <90 <85
DBP
Elevated 120–129 130–139 ∗ 130–139
SBP <80 85–89 ∗ 85–89
DBP
Hypertension 130–139 140–159 140–179 140–159
Stage I 80–89 90–99 90–119 90–99
SBP
DBP ≥140 160–179 ≥180 ≥160
Stage II ≥90 100–109 ≥120 ≥100
SBP
DBP ∗ ≥180 ∗ ∗
Stage III ≥110 ∗ ∗
SBP
DBP

Classification of the Severity of Hypertension
in Adults Aged 18 years and Older

Category SBP and DBP
(mmHg) and/or (mmHg)
Optimal and/or
Normal < 120 and/or < 80
High normal 120-129 and/or 80-84
Grade 1 Hypertension 130-139 and/or
Grade 2Hypertension 140-159 85-89
Grade 3 Hypertension 160-179 and 90-99
Isolated systolic 100-109
hypertension (ISH) ≥ 180 ≥ 110
≥ 140 < 90

SBP = systolic blood pressure, DBP = diastolic blood pressure

Defining Hypertension

Defining by Numbers

140/90 ?

“A number at which the benefits of intervention
exceed those of inaction”

Long-Term Antihypertensive Therapy

Significantly Reduces CV Events

Stroke Myocardial Heart failure
0 infarction

–10

Average –20 20%-25%
reduction –30
in events (%) –40

–50 35%-40%

–60 >50%

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

The Syst-China trial

Rate per 1000 patient-years 40 Placebo
Active-treatment group
35
39%

20 P=0.003
28.4

25

20 39%
P=0.03

17.4 58% 32%
P=0.02 P=0.021
15 15.2
105 9.4 6.9 8.0
5.4

0 Total 2.9

All CV Stroke Cardiac

Mortality

J Hypertens 1998;16:1823-1829.

1. 6,859 participants in the Framingham Heart
Study

2. Initially free of hypertension and CV disease
3. Mean follow-up 11.1 years, 75,980 person-years

N Engl J Med 2001;345:1291-7.

Impact of
High-Normal BP
on the Risk of CVD

( CVD death, MI, stroke, HF )

N Engl J Med 2001;345:1291-7.

Original Article

A Randomized Trial of Intensive versus Standard Blood-
Pressure Control

The SPRINT Research Group

N Engl J Med
Volume 373(22):2103-2116

November 26, 2015

Study Overview

• Patients at increased cardiovascular risk but
without diabetes were assigned to intensive
treatment of systolic BP (target, <120 mm Hg)
or standard treatment (target, <140 mm Hg).

• A median of 3.26 years follow-up.

SPRINT: Selected Baseline Characteristics

Mean age Total
N=9361
≥75 years 68 years

Female 28%
36%
White 58%
30%
African-American 11%
20%
Hispanic 24%

Prior CVD 91%
1.8
Mean 10-year Framingham CVD
risk 140/78
Taking antihypertensive meds

Mean number of antihypertensive
meds
Mean Baseline BP, mm Hg

Primary Outcome ( CVD Death, MI, HF ) and all-cause Death .

The SPRINT Research Group. N Engl J Med
2015;373:2103-2116

SBP in the Two Treatment Groups over the Course of the Trial.

The SPRINT Research Group. N Engl J Med 2015;373:2103-2116

The Heart Outcomes Prevention
Evaluation (HOPE– 3) Trial

Eva Lonn, Jackie Bosch, Salim Yusuf

For the HOPE-3 Investigators

Population Health Research Institute, (PHRI)

McMaster University and Hamilton Health Sciences, Hamilton,

Canada

Unrestricted grants from the Canadian Institutes of Health Research and
AstraZeneca

Aspects of HOPE-3

• BP lowering trial with wide range of BP entry
criteria ( mean entry BP 138/82. 38%HT,
22%treated )

• Cholesterol lowering treatment based on risk
opposed to baseline LDL or HDL measurement

• Diverse population

4

Cumulative Hazard Rates CV Death, MI, Stroke, Cardiac Arrest,
Revascularization, Heart Failure
0.04 0.06 0.08 0.10
HR (95% CI) = 0.95 (0.81-1.11)
P-value = 0.51

BP difference 6/3 mmHg
Placebo

Candesartan + HCTZ

FDC 16/12.5 mg

0.02

0.0 0 1 2 34 5 6 7

No. at Risk 6356 6272 6200 Years 4969 2076 522 14
6349 6270 6198 6103 5968 4970 2075 488
Cand + HCTZ 6096 5967

Placebo

Prespecified Subgroups:
By Thirds of SBP

CV Death, MI, Stroke, Cardiac Arrest, Revasc, HF

SBP Placebo HR (95% CI) P Trend

Cutoffs Mean Diff Event Rate%

≤131.5 122 6.1 3.5 1.25 (0.92-1.70) 0.009
1.02 (0.77-1.34)
131.6-143.5 138 5.6 4.6 0.76 (0.60-0.96)

>143.5 154 5.8 7.5

0.5 1.0 2.0

Candesartan + HCTZ Better Placebo Better

17

Blood Pressure Measurement
How to Gain Patient’s Confidence ?



The Good Old Days

Insert-arm BP Monitor System

False Positive
False Negative

Automated BP Measurement

False Positive
False Negative

ไม่ดม่ื ชาหรือกาแฟ และไม่สูบบหุ ร่ี กอ่ นทาํ การ หอ้ งเงยี บสงบ
วัด 30 นาที ไม่มีเสยี งดงั รบกวน

น่ังบนเกา้ อมี้ ีพนักพงิ งดการพูดคุยระหว่างวัด
หลังตรง วางแขนไว้บนพนื้ เรยี บ

ให้ arm cuff อยู่ระดบั เดยี วกบั หวั ใจ
ไม่เกรง็ แขนและไม่กาํ มอื
ขณะวัดความดนั โลหติ

เทา้ วางราบกับพนื้
ไม่ไขว่หา้ ง









Cardiovascular Mortality Risk Doubles with Each 20/10 mmHg Increment in
Systolic/Diastolic BP*

Cardiovascular mortality risk 8X
8 risk

6

4 4X
risk
2
2X
1X risk risk

0 135/85 155/95 175/105
115/75

Systolic BP/Diastolic BP (mmHg)

*Individuals aged 40–69 years Lewington et al. Lancet 2002;360:1903–13

Consequences of Hypertension1-4

Hypertension Brain Stroke, dementia
Heart
Kidney MI, heart failure,
sudden death

End-stage
renal disease

1. Weir et al. Am J Hypertens 1999;12:205S-213S. 2. Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed.
1999:1629-1648. 3. Francis CK. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:175-176.
4. Hershey LA. In: Izzo JL Jr, Black HR, eds. Hypertension Primer: The Essentials of High Blood Pressure. 2nd ed. 1999:188-189.

46

Blood Pressure Reduction of 2 mmHg Decreases the Risk of
Cardiovascular Events by 7–10%

 Meta-analysis of 61 prospective, observational studies

 1 million adults

 12.7 million person-years

2 mmHg decrease 7% reduction in risk of
in mean SBP ischaemic heart
disease mortality

10% reduction in risk of
stroke mortality

Lewington et al. Lancet 2002;360:1903–13

Benefits of Lowering BP

Stroke incidence Average Percent Reduction
Myocardial infarction 35–40%
Heart failure 20–25%
50%

Mpoepaunlabtliooond18pryeesasrusroefiangteheorUoSlder

150 Men 150 Women
Systolic
pressure blood Systolic blood
pressure
130 Blacks
Whites 130
110 Mexican Americans
Blacks
80 110 Whites

Mexican Americans

80

70 Diastolic blood 70 Diastolic blood
pressure pressure
18-29
18-29 30-39 40-49 50-59 60-69 70-79 > 80 30-39 40-49 50-59 60-69 70-79 > 80
Age, y
Age, y

NHANES III survey 1988-1991.

ISH Becomes More Prevalent with Increasing Age

(The Korean National Health and Nutrition Survey 2001)

40 ISH

30 SDH
IDH
Percent
20

10

0 20-29 30-39 40-49 50-59 60-69 >70
Age (years)
Hypertens Res 2015;38:227-236.