Hypertension Guidelines: International; African,?Kenyan

Transcription

1 Hypertension Guidelines: International; African,?Kenyan Elijah N. Ogola University of Nairobi Kenya Cardiac Society Symposium 24 th 25 th February 2017 Eldoret

2 Outline Background Overview of international guidelines WHF Roadmap PASCAR roadmap Kenyan guidelines Conclusion

3 Global Burden of Disease Due to Risk Factors by disease type: 2010 CV & Circulato ry Lancet 2012

4 Hypertension is a global public health issue Worldwide prevalence of hypertension in adults is estimated at ~40% 1 Hypertension is responsible for approximately 13% of all deaths and 3.7% of total disability adjusted life years 2 Lifetime risk of CV disease at 30 years of age is 63.3% in patients with hypertension, compared with 46.1% in normotensive individuals 3 High BP is the primary cause of CV death 4 High blood pressure 40.6 Smoking Poor diet Insufficient physical activity Abnormal blood glucose levels BP, blood pressure; CV, cardiovascular Adjusted estimated population attributable fraction for CV death (%) 4 1 WHO. A global brief on Hypertension. Silent killer, global public health crisis Available at: prevalence_text/en/; 2 WHO. Global Status Report on Non communicable diseases Available at: 3 Rapsomaniki et al. Lancet 2014;383: ; 4 Go et al. Circulation 2013;127:143 52

5 Global burden of disease, DALYS for SSA 2010

6 In the present systematic review of data from 33 surveys involving over participants, we found a pooled prevalence of hypertension of 30% 27% of people with hypertension were aware of their hypertensive status 18% were receiving treatment 7% had controlled blood pressure Hypert. Patients Aware Treated Controlled Sub Saharan Africa Ataklte et al, Hypertension. 2015;65:

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9 Cardiovascular Mortality Risk Doubles with Each 20/10 mmhg Increment in Systolic/Diastolic BP* Cardiovascular mortality risk 8 6 8X risk X risk 2X risk 4X risk 115/75 135/85 155/95 175/105 Systolic BP/Diastolic BP (mmhg) *Individuals aged years Lewington et al. Lancet 2002;360:

10 Long term Anti HTN Therapy Significantly CV Events 0 Stroke Myocardial infarction Heart failure Average reduction in events (%) % 25% % 40% N= 201,566 >50% Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2000;355:

11 Blood pressure reduction of 2 mmhg decreases the risk of cardiovascular events by 7 10% 2 mmhg decrease in mean SBP 7% reduction in risk of ischemic heart disease mortality 10% reduction in risk of stroke mortality Meta analysis of 61 prospective, observational studies 1 million adults 12.7 million person years SBP: systolic blood pressure Lewington et al. Lancet 2002;360:

12 Guidelines, Guidelines ESH/ESC ISH/ASH NICE JNC ISHIB etc,etc Flurry of New Guidelines in 2013 (NICE 2011)

13 So why an African or National Guideline?

14 Management of hypertension: the issues Measurement Classification Investigations Risk assessment Non pharmacological measures Treatment thresholds Drug therapy 1 st line sequencing beyond BP Treatment targets Concomitant therapy

15 Summary of the Trial Gaps: 1. Does the use of HBPM/ABPM/Central BP/BPV add value to management & if so what thresholds/targets 2. Thresholds young low CV risk (HOPE 3) elderly white coat 3. Targets SHOT (SPRINT) subgroups 4. Resistant H/T Step 4 (PATHWAY 2) Devices 5. Others A Fib n., Risk Assessment, TOD as surrogate, lifestyle 6. Optimal Therapy by ethnic group

16 Recommended 2 drug combinations of antihypertensive drugs NICE ESH ESC ASH ISH JNC8 A + C A + C Black Black A + D* A + C C + D C + D A +D C + D Non black A + C A + D Non black A + C A + D C + D : A = ACE inhibitor or angiotensin receptor blocker : C = Calcium channel blocker *: D = Diuretic (including thiazides or thiazide like/type)

17 A more fundamental defect of the western guidelines is being clinic centric, not paying due attention to health systems and the totality of the environment.

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22 Basis for The African Roadmap Burden of hypertension Political recognition 2004 AU meeting resolution Need for a comprehensive, system wide approach Customization of the WHF roadmap

23 Roadblocks Health system related Healthcare worker related Patient/public related

24 With courtesy of Dr Anastase DZUDIE on behalf of the PASCAR task force on hypertension

25 The 10 Pillars Detection programmes Funding Simple guidelines Monitoring Integration Task shifting Drugs and equipment Universal access Research Population level Interventions (primordial)

26 Kenyan guidelines?

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