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1、1,Improving Blood Pressure Treatment in the Community: Implications of the JNC7 Recommendations and ALLHAT Results Nathan D. Wong, PhD, FACC Professor and Director Heart Disease Prevention Program University of California, Irvine,2,Peripheral vascular disease, Morbidity Disability,Renal disease,CAD,
2、CHF LVH,Stroke,Hypertension,National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.,Hypertension: A Significant CV and Renal Disease Risk Factor,3,Nearly 1 in 3 adults (31%) in the US has hypertension,Fields LE et al. Hypertension. 2004;44:398-404.,Hypertensi
3、on: How Big Is the Problem?,At Least 65 Million Americans Require Treatment for Hypertension,4,Risk of Cardiovascular Events by Hypertensive Status,36-Year Follow-up in Patients Aged 35-64 Years,9.5,3.3,2.4,5.0,2.0,3.5,2.1,45.4,21.3,12.4,6.2,9.9,7.3,13.9,6.3,22.7,0,10,20,30,40,50,Normotensive,Hypert
4、ensive,Coronary Disease,Stroke,Peripheral Arterial Disease,Cardiac Failure,Biennial Age-Adjusted Rate per 1,000,Reprinted with permission from Kannel WB. JAMA. 1996;275:1571-1576.,5,SBP-Associated Risks: MRFIT,Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.,SBP versus DBP in Risk of C
5、HD Mortality,Diastolic BP (mm Hg),Systolic BP (mm Hg),CHD Death Rate,100+,9099,8089,7579,7074,70,120,120139,140159,160+,48.3,20.6,10.3,11.8,8.8,8.5,9.2,23.8,16.9,13.9,12.8,12.6,11.8,31.0,25.5,24.6,25.3,25.2,24.9,37.4,34.7,43.8,38.1,80.6,40,40-49,50-59,60-69,70-79,80+,Age (y),17%,16%,16%,20%,20%,11%,
6、Distribution of Hypertension Subtype in the untreated Hypertensive Population in NHANES III by Age,Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age.Franklin et al. Hypertension 2001;37: 869-874.,Frequency of hypertension subtypes in all untreated
7、hypertensives(%),7,Disease Relative Risk Kidney failure (ESRD) 2.8 Stroke 2.7 Heart failure 1.5 Peripheral vascular disease 1.8 Myocardial infarction* =1.6 Coronary artery disease 1.5,ESRD = end-stage renal disease; SBP 165 mm Hg. *Men only. Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S; Pe
8、rry HM Jr et al. Hypertension. 1995;25(part 1):587-594; Klag MJ et al. N Engl J Med. 1996;334:13-18; Nielsen WB et al. Ugeskr Laeger. 1996;158:3779-3783; Neaton JD et al. Arch Intern Med. 1992;152:56-64.,Elevated SBP Alone Is Associated With Increased Risk of Cardiovascular and Renal Disease,8,9,Pre
9、valence, Awareness, Treatment, and Control of Hypertension in US Adults 2003-2004 (Ong et al., Hypertension 2007; 49: 69-75),10,Prevalence (%) of HTN in US Adults, by Disease Status (Wong et al, Arch Intern Med 2007, in press),*P0.01 when compared to No-Disease Group,*,*,*,*,*,*,*,Mean age (y): 53.5
10、 59.3 54.8 60.5 76.1 65.9 68.2 69.3 67.2,*,11,Treatment (%) of HTN in US Adults, by Disease Status (Wong et al., Arch Intern Med 2007, in press),*P0.05, *P0.01 when compared to No-Disease group Treatment is in persons with HTN,*,*,*,*,12,Control (all treated) (%) of HTN in US Adults, by Disease Stat
11、us (Wong et al., Arch Intern Med 2007, in press),*P0.05*P0.01 when compared to No-Disease Group Control is in persons with HTN defined as BP 140/90 If DM and CKD is based on BP130/80 control is *35.3% and *23.2%, respectively. If MetS is based on BP130/85 control is *46.7%,*,*,*,*,13,Minimum BP dist
12、ance from goal of 140/90 in parenthesis, even with DM & CKD *p0.05 *p0.01 compared to no disease,Mean BP and Distance to Goal Among HTN Pts Not at Goal (Wong et al., Arch Intern Med 2007, in press),14,Blood Pressure Classification,15,4-Year Progression To Hypertension: The Framingham Heart Study,(12
13、0/80 mm Hg),(130/85 mm Hg),(130-139/85-89 mm Hg),Vasan, et al. Lancet 2001;358:1682-86,Participants age 36 and older,HOT Study: Significant Benefit From Intensive Treatment in the Diabetic Subgroup,Hansson L et al. Lancet. 1998;351:1755-1762.,0,5,10,15,20,25,90,85,80,Major cardiovascular events/1,00
14、0 patient-years,p=0.005 for trend,mm Hg,Target Diastolic Blood Pressure,17,Benefits of Lowering BP,Average Percent ReductionStroke incidence 3540% Myocardial infarction 2025% Heart failure 50%,TROPHY Study ACC 2006: Even lowering BP in those with pre-HTN appears to reduce incidence of new HTN by up
15、to 60%,18,19,Preventable CHD Events from Control of Hypertension in US Adults (Wong et al., Am Heart J 2003; 145: 888-95),PAR% = population attributable risk (proportion of CHD events preventable), NNT = number needed to treat to prevent 1 CHD event ; 0.01 comparing men and women for PAR%,20,Randomi
16、zed Design of ALLHAT,High-risk hypertensive patients,Consent / Randomize (42,418),Amlodipine Chlorthalidone Doxazosin Lisinopril,Eligible for lipid-lowering,Not eligible for lipid-lowering,Consent / Randomize (10,355),Pravastatin Usual care,Follow for CHD and other outcomes until death or end of study (up to 8 yr).,
