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- December 1, 2008 |
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"Hypertension: Where We Have Been and Where We Are Going"Prof. George L. Bakris (biography)
English - 2006-11-11 - 33 minutes
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Summary :
With the growing epidemic of obesity and the associated increase in the prevalence of diabetes and kidney disease comes an accompanying increase in the incidence of hypertension. Thus, the future portends more cardiovascular events associated with these conditions. This presentation is an overview of where we have been and where we are going with respect to control of hypertension.
It is clear from population studies, such as the Framingham study, as well as recent meta-analyses, such as that from the Oxford Blood Pressure Trialists group, along with the reformulation of the definition of hypertension by the American Society of Hypertension, that risk for cardiovascular events starts at a blood pressure of 115/75 mm Hg. Moreover, even patients who are “normotensive” at age 55 have a 90% chance of becoming hypertensive during their lifetime. Therefore, earlier intervention to attenuate the rise in blood pressure is an important consideration for such individuals. Clearly, lifestyle modifications such as low-sodium, high-potassium diets, weight-loss diets and the like have all shown benefits relating to blood-pressure reduction or an attenuated rise in pressure over periods of 6 to 18 months. Unfortunately, these studies all demonstrate high recidivism rates, with effects rarely lasting more than 1 to 2 years. The TROPHY trial attempted to demonstrate prevention of hypertension by pharmacologic intervention. Although this study did not provide the answer for prevention of hypertension, it does offer another potential way to alter the natural history of the disease and reduce the overall “pressure load” to the vessels for a longer time period than placebo. Moreover, it is unclear whether agents from other classes also could have produced the same results. It is clear from the experimental design of this study that development of hypertension was delayed but not prevented. However, given the linear association between risk for cardiovascular events such as stroke and level of blood pressure, this may be good enough. Therefore, although this study does not advocate early pharmacologic treatment of prehypertension and certainly did not prevent its development, it does make the point that intervention with a class of agents that have placebo-like side effects could provide a reasonable alternative in those patients who may have tried and failed lifestyle intervention.
Ultimately, it is important to learn an individual’s global risk for cardiovascular disease, regardless of their blood pressure level. It is clear from all studies published to date that African Americans, patients with diabetes, and patients with obesity/metabolic syndrome are at much higher risk than the general population for cardiovascular events, irrespective of blood pressure level. In other words, the curve for events seems to be shifted to the left so that at a given blood pressure level, a higher cardiovascular event rate is noted in those who are African American or have obesity/diabetes. Current guidelines have changed the focus from treatment of individual risk factors to treatment of persons with high global risk. This shift implies that prehypertension should be explored in conjunction with other risk factors or 13 manifestations of vascular disease. Most people with prehypertension have at least 1 additional risk factor.
Recent studies have also identified single nucleotide polymorphisms associated with salt sensitivity and blood-pressure elevations. Although a uniform standard to define salt sensitivity is needed, it has been shown in a variety of settings that African Americans and patients with obesity and/or diabetes are much more likely to have a salt-sensitive component to their blood pressure. Thus, future preventive strategies should consider not only the demographic data (age, sex, and race or ethnic group) but the gene/proteomic profiles of such patients to identify those who are at much higher cardiovascular disease risk and intervene in a more focused way to prevent cardiovascular events.
Learning objectives :
After viewing this presentation the participant will be able to discuss:
- Trends in the prevalence of hypertension
- Hypertension awareness, treatment and control
- JNC and HWG blood pressure classifications
- Prevalence of prehypertension
- Cardiovascular disease risk factors/markers
- Findings from the TROPHY trial
Bibliographic references :
Beeks, Esther; Kessels, Alfons GH; Kroon, Abraham A; van der Klauw, Melanie M; de Leeuw, Peter W Genetic predisposition to salt-sensitivity: a systematic review. Journal of Hypertension. 22(7):1243-1249, July 2004.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW,Materson BJ, Oparil S, Wright JT Jr, Roccella EJ; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education
Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560-72.
European Society of Hypertension-European Society of Cardiology Guidelines Committee. 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension [published corrections appear in J Hypertens. 2003;21:2203-2204 and J Hypertens.2004;22:435]. J Hypertens. 2003;21:1011-1053.
Kshirsagar AV, Carpenter M, Bang H, Wyatt SB, Colindres RE. Blood Pressure Usually Considered Normal Is Associated with an Elevated Risk of Cardiovascular Disease Am J Med. 2006 Feb;119(2):133-41.
Lewington S, Clarke R, Qizilbash N, Peto R, Collins R; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies Lancet. 2002 Dec 14;360(9349):1903-13.
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