Hypertension And Coronary Artery Diseases

The impact of hypertension as a risk factor for coronary artery disease. A look at data from Kuwait Dr. Rashed J. Al-Hamdan Al-Jahra Hospital, Kuwait

M.D. FRCPC

Hypertension - Backgrounds • Hypertension is defined as the elevation of arterial pressure above 140 mmHg systolic and 90 mmHg diastolic. • Pulse pressure ( PP ) equals the systolic pressure minus the diastolic pressure. • It is proportional to stroke volume and inversely proportional to the compliance of the aorta.

Hypertension - Backgrounds • PP in healthy adults, sitting position, is about 40 mmHg. PP increases with exercise due to increased stroke volume. • PP values of 50-55 mmHg have been suggested ARBITATRLY with no evidence from the literature to support this. • PP may be used to identify elderly pts with systolic hypertension who are at high risk.

Definition and Classification of Hypertension - ESH Category

Systolic mmHg

Diastolic mmHg

Optimal

< 120

and

< 80

Normal

120 – 129

and / or

80 - 84

High Normal

130 – 139

and / or

85 - 89

Grade 1 Hypt.

140 – 159

and / or

90 - 99

Grade 2 Hypt.

160 – 169

and / or

100 - 109

Grade 3 Hypt.

≥ 180

and / or

≥ 110

Isolated Syt. Hypt.

≥ 140

and

< 90

Definition and Classification of Hypertension – JNC7

Why the Difference between the ESH and the JNC-7 • In the Framingham data, the high normal group was different from the normal group in terms of the risk of developing hypertension, so there is no need to join them. • The choice for intervention in the high normal group depends on other factors like age and other co-morbidities and not only on the numbers.

Why the Difference between the ESH and the JNC-7 • The term “Pre-Hypertension” may create a big confusion to the lay person leading to anxiety and to un-necessary battery of tests and investigations to further over burden the health system.

Hypertension and CAD • Data from observational studies involving more than 1 million individuals have indicated that death from both IHD and stroke increases progressively and linearly from levels as low as 115 mmHg SBP and 75 mmHg DBP upward. • For every 20 mmHg systolic or 10 mmHg diastolic increase, there is a doubling of mortality from both IHD and stroke.

Hypertension and CAD • Data obtained from the Framingham Heart Study have indicated that BP values between 130–139/85–89 mmHg are associated with a more than twofold increase in relative risk from cardiovascular disease CVD as compared with those with BP levels <120/80 mmHg.

Hypertension and IHD Mortality

Hypertension and CVA Mortality

Hypertension and CAD • The treatment of hypertension is the focus of treatment in the JNC-7. • Hypertension is, on the other hand, part of the global cardiovascular risk that needs to be addressed. • This has been based on the fact that only a minority of hypertensives have only hypertension as their CVD risk factor.

Hypertension and CAD • Moreover, hypertension as a risk factor is known to potentiate the in a synergistic manner the deleterious effects of other CVD risk factors like DM and dyslipidemia. • Furthermore, hypertensives with more global risk should be treated in a different more aggressive manner as a part of the global CVD risk.

Hypertension and CAD

Hypertension and CAD

Hypertension and CAD

Hypertension and CAD • The emphasis in the ESH-ESC 2007 guidelines is laid upon the prompt treatment of the condition rather than on the choice of the agent. • Several computerized methods have been developed to estimate the global CVD risk in patients with hypertension.

Hypertension and CAD • The problem with these methods is that they are mostly based on the data from the Framingham registry. • The population in the Framingham studies does NOT represent the diverse ethnicities in the European nor in the Middle Eastern countries.

Hypertension and CAD • Given that, we have no clear model to represent our population’s estimated risk for developing a coronary artery episode or of cardiovascular deaths. • We know that our population is younger, have less co-morbidities, have more diabetes especially type II, are more likely to be smokers.

Hypertension and CAD • These facts have been reflected in the data obtained from various observational studies as well as of registries in the Middle East. • They also have been reflected in the mortality rates observed in some registries, e.g. the KACS where the mortality from MI was as low as 3.3% compared with 6% in the GRACE registry.

Hypertension Data from Kuwait

Hypertension – General Data about Kuwait • Total population: 2,687,000 • Gross national income per capita (PPP international $): 24,010 • Life expectancy at birth m/f (years): 77/ 79 • Healthy life expectancy at birth m/f (years, 2002): 67/67

Hypertension – General Data about Kuwait • Probability of dying under five (per 1 000 live births): 12 • Probability of dying between 15 and 60 years m/f (per 1 000 population): 71/54 • Total expenditure on health per capita (Intl $, 2004): 538 • Total expenditure on health as % of GDP (2004): 2.8

Hypertension – Data from Kuwait • A nationwide survey examined the issue of obesity through calculation of the BMI.

Hypertension – Data from Kuwait

Hypertension – Data from Kuwait • Prof Abdella in 1996 examined the prevalence of DM and associated risk factors in Kuwait.

Hypertension – Data from Kuwait

Diastolic BP _ Abdella et al 1998

Hypertension – Data from Kuwait

Diastolic BP _ Abdella et al 1998

Hypertension – Data from Kuwait

Jackson et al; 2001

Hypertension – Data from Kuwait • Al-Owaish et all conducted a prevalence study of hypertension in Kuwait in 1999. • Hypertensives and non-hypertensives were compared according to age, sex, and other CVD risk factors. • It was found that out of more than 2800 Kuwaitis studied, 26.3% were hypertensives ( 28.3%males and 22.9% females ).

Hypertension – Data from Kuwait •

No significant association was found between the presence of hypertension and any of the following variables: (b) family history of hypertension, (c) previous history of cardiovascular disease (c) smoking. • However, there was an evident association with obesity.

Hypertension – Data from Kuwait

El-Reshaid Kamel et al; Saudi Journal of Kidney Diseases and Transplantations,1999.

Hypertension – Data from Kuwait

Comparison between 1989 and 1997 with regards to causes of hospital admissions, for adult (>20 years) Kuwaiti patients. El-Reshaid Kamel et al; Saudi Journal of Kidney Diseases and Transplantations,1999.

Hypertension – Data from Kuwait

Comparison between 1989 and 1997 with regards to cardiovascular causes of death, in Kuwaiti patients. El-Reshaid Kamel et al; Saudi Journal of Kidney Diseases and Transplantations,1999.

Hypertension – Data from Kuwait • Non-adherence to preventive and therapeutic lifestyle recommendations among patients at high risk of CVD is more prevalent than previously thought. • A prospective study by M. Serour published in the Br J Gen Pract. to look at Kuwaiti patients, both males and females, who have DM and or Hypertension, from 6 family practice centers in Kuwait.

Hypertension – Data from Kuwait • A sample of 334 patients was collected. • From the study sample, 63.5% reported that they were not adhering to any diet regimen, 64.4% were not participating in regular exercise, and 90.4% were overweight and obese.

Hypertension – Data from Kuwait • The main barriers to adherence to diet were: 1- Unwillingness (48.6%), 2- Difficulty adhering to a diet different from that of the rest of the family (30.2%), and 3- Social gatherings (13.7%).

Hypertension – Data from Kuwait • The main barriers to adherence to exercise were: 1- Lack of time (39.0%), 2- Coexisting diseases (35.6%), and 3- Adverse weather conditions (27.8%).

Hypertension – Data from Kuwait • Factors interfering with adherence to lifestyle measures were: 1- Traditional Kuwaiti food (79.9%), 2- Stress (70.7%), 3- High consumption of fast food (54.5%), 4- High frequency of social gatherings (59.6%), 5- Abundance of maids (54.1%), and 6- Excessive use of cars (83.8%).

Hypertension – Data from Kuwait • Most of the studies available are small observational or small cross sectional studies that do not serve well the purpose of generating an accurate estimate of the size of the problem. • A correspondence to the journal of hypertension in 2005 by Dr. Jafar Al-Said regarding the issue of the prevalence of hypertension in the Gulf States drew the following results.

Hypertension – Data from Kuwait • Kuwait, Iraq and Qatar had NO published data about the prevalence of hypertension. • A meta analysis of the available data showed that on average, 4% of the population in the remaining 5 states are older than 65 years of age. • Also, on average, the life expectancy for citizens of these states is around 70 years

Hypertension – Data from Kuwait

Hypertension – Data from Kuwait • Dr. Al-Said did NOT find any significant correlation between hypertension and any of the studied parameters explaining its rate of occurrence.

Hypertension and CAD in Kuwait • The results of the “Kuwait Registry of Acute Coronary Syndrome” by Prof. M. Zubaid et al. are published. • The KACS registry was conducted in the period between 2003-2004 over a period of 6 months. • The registry was conducted in all 6 major hospitals in Kuwait and included most of the patients with the final diagnosis (ACS).

Hypertension and CAD in Kuwait The distribution of ACS (discharge diagnosis) 2130 patients

39.2%

UA 835

STEMI 673

31.6%

NSTEMI 524 BBB/Uncertain_98

4.6%

24.6%

Hypertension and CAD in Kuwait (n=2130) No. Age (mean ± SD)

% 56 ± 12

Sex Male Female

1617 513

76 24

Risk factors Current smoker Known Type 1 DM Known Type 2 DM Known HTN Known hyperlipidemia Family history

859 41 990 1052 742 379

40 2 47 49 35 18

LVF at presentation Past IHD

404 1060

19 50

Hypertension and CAD in Kuwait Diabetics

Non Diabetics

N=1034

N=1102

n Age yrs (mean±SD)

%

n

60 ± 11

P Value %

52 ± 12

< 0.001

Male Sex

669

64.7

953

86.5

< 0.001

Previous MI

330

31.9

257

23.3

< 0.001

Known hypertension

678

65.6

34

< 0.001

Known high

475

45.9

24.4

< 0.001

cholesterol

302

29.2

51

< 0.001

Current smoking

280

27.1

124

11.3

< 0.001

LVF on admission

38

3.7

19

1.7

< 0.001

In-hospital mortality

375 269 562

Medications in KACS STEMI N=680 n

%

NSTEMI N=524 n %

BBB/ uncertain N=98 n %

n

UA N=835 %

Aspirin

673

99.0

499

95.2

90

91.8

796

95.3

Plavix

15

2.2

33

6.3

6

6.1

96

11.5

I.V. Heparin

630

92.6

438

83.6

62

63.3

610

73.1

LMWH

33

4.9

62

11.8

21

21.4

155

18.6

Aggrastat

4

0.6

24

4.6

1

1.0

9

1.1

B Blocker

492

72.3

327

62.4

48

49.0

611

73.2

ACE-I

309

45.4

248

47.3

48

49.0

382

45.7

Nitrates

516

75.9

469

89.5

88

89.8

768

92.0

Diuretics

76

11.2

175

33.4

44

44.9

205

24.6

Inotropes

36

5.3

21

4.0

9

9.2

6

0.7

Ca Blocker

22

3.2

89

17.0

18

18.4

175

21.0

Antiarrythmics

36

5.3

36

6.9

10

10.2

22

2.6

Statin

473

69.6

400

76.3

70

71.4

607

72.7

Ezetrol

0

0

1

0.2

0

0

1

0.1

Other cholesterol

16

2.4

12

2.3

7

7.1

27

3.2

Digoxin

10

1.5

33

6.3

8

8.2

29

3.5

Hypertension and CAD in Kuwait • When it comes to the ethnic groups living in the Middle East region, data becomes even more scarce. • One study comparing AMI patients and their risk factors in Arabs and South Asians living in Kuwait was conducted in Kuwait by Suresh et. al. published in the Indian Heart Journal in 2002.

Hypertension and CAD in Kuwait • The study was a retrospective study looking at admissions to the CCU in a big teaching hospital over a 3 years period. • Taking into consideration the number of population of each respective ethnic group in that area, the study looked at the rate of admissions and the prevalence of risk factors stratified by age groups.

Hypertension and CAD in Kuwait • Between September 1997 and August 2000, a total of 866 Arabs and 277 South Asian men were admitted to the CCU in Mubarak hospital with the diagnosis of MI. • It was found that the rate of admission for the entire patient population was two-fold higher among Arabs as compared with South Asians (6.7/1000 population and 3.3/1000, respectively).

Hypertension and CAD in Kuwait • They found that DM was present in 453 Arabs (52.3%) and 109 South Asians (39.4%) (p<0.001) of those >25 years. • Also, hypertension was recorded in 247 Arabs (28.5%) and 57 South Asians (20.6%) (p<0.01). • In those < 55 years of age, DM was present in 202 Arabs (44.5%) and 80 South Asians (35.4%) (p<0.05).

Hypertension and CAD in Kuwait • Furthermore, smoking was recorded in 353 Arabs (77.8%) and 160 South Asians (70.8%) (not significant). • Hypercholesterolemia was present in 182 (40.1%) and 88 (39%), respectively (not significant).

Hypertension and CAD in Kuwait • They concluded that among men >55 and <75 years of age, Arabs had a higher rate of admission with acute myocardial infarction compared with men of South Asian origin. • Also, that the incidence of diabetes and hypertension was significantly higher among Arabs in this age group.

Hypertension and CAD in Kuwait • They also concluded that in younger patients (<55 years), the rate of AMI was not different between the two groups; however, diabetes was present more often among Arabs. • Moreover, smoking rate was found to be very high in both groups and was an important risk factor for both Arab and South Asian men living in the Middle East.

Hypertension and CAD in Kuwait • The situation in the Arabic countries is largely unknown. • We have data from very few countries regarding the weight of the problem. • Yet, we do not have enough data to create our own normogram regarding the prospected risk of developing CAD for our Arab population who are different from the Western European population.

Hypertension – Data from Kuwait

Hypertension and CAD in Kuwait

What do we know as of now about the treatment of hypertension?

General Outline Points • Subclinical organ damage is of great importance and should be sought carefully. • Subclinical organ damage can serve as pointer to the overall cardiac risk.

General Outline Points - Heart • ECG should be part of the routine used in evaluating any hypertensive patient. One should look for signs of LV hypertrophy, strain patterns, ischemia and arrhythmia. • Echocardiography is useful to further study the LV pattern of hypertrophy as well as the diastolic function.

General Outline Points Kidneys • Signs of hypertension effects on the kidneys include a worsening of the renal function as well as microalbuminuria. • Estimated glomerular filtration rate and or estimated creatinine clearance are to be routinely applied. • Urine dip stick for protein and if negative urine spot for microalbumin are also considered to be of routine use also.

General Outline Points – Blood Vessels • Carotid arteries ultrasound to detect intimal thickening to be done when detection of asymptomatic atherosclerotic disease is deemed useful. • Ankle-brachial index is useful for the diagnosis of peripheral arterial disease. • Pulse wave velocity to detect arterial stiffening as a cause of isolated systolic hypertension in the elderly.

General Outline Points Fundoscopy • Fundal exam is indicated only in severe hypertension. • Hemorrhages, exudates and papilledema present only in severe hypertension are associated with an increased CVD risk.

General Outline Points - CNS • Infarcts, lacunar and large, are not infrequent in hypertensive patients. • The problem would be to identify patients with mild problems without the overburden it entails to use advanced tests like MRIs. • Cognitive testing especially in the elderly can help in selecting candidates for such tests.

General Outline Points – Treatment Regimens • Many trials to investigate the best antihypertensive agent have been conducted. • Many of these trials have been included in numerous meta-analysis. • The overall number of patients included in these post hoc analysis is HUGE. • There are many lessons to be learned.

General Outline Points – Treatment Regimens • Antihypertensive treatment leads to significant reduction in cardiovascular morbidity and mortality. • Antihypertensive treatment does not lead to the same significant reduction in all causes mortality. • Benefits of treatment extends to all age groups including the elderly patient with isolated systolic hypertension.

General Outline Points – Treatment Regimens • The proportional cardiovascular risk reduction is similar in men and women. • The benefits of treatment includes all ethnic groups, including Asians and Hispanics. • Antihypertensive medications reduce cause specific events more in the CNS territory (Strokes) than in the CVS (MI’s).

General Outline Points – Treatment Regimens • The beneficial effects of antihypertensive medications have been found regardless of the agent used to initiate treatment, whether it was a thiazide diuretic, a BB, a CCB or an ACE-I.

General Outline Points – Treatment Regimens • Due to ethical issues, there is going to be NO MORE TRIALS comparing an antihypertensive drug to a placebo. • Instead what is considered as a placebo is now in fact a group of patients on a different antihypertensive agent than the study medication.

General Outline Points – Treatment Regimens

General Outline Points – Treatment Regimens

General Outline Points – Treatment Regimens

General Outline Points – Treatment Regimens

General Outline Points – Treatment Regimens