Promising Practices Related To The Prevention, Control and Treatment of Hypertension David J. Hyman, MD, MPH Professor of Medicine and Family & Community Medicine Baylor College of Medicine President elect - Texas Chapter of the American Society of Hypertension

Problems Hypertension is an extremely important Risk factor for heart disease, stroke, Renal failure, CHF and all the complications of diabetes Population BP has stopped going down About 35% of people with hypertension are still unaware of it About 35% of people being treated for hypertension are not controlled to target

Age Standardized Prevalence of Hypertension in the United States National Health and Nutrition Survey (NHANES) (1999-2002) Non-Hispanic Mexican- African- white American American 27.4% 25.1 % 40.5%

Prevalence of Hypertension in the United States* The prevalence of hypertension in a representative sample from the National Health and Nutritional Examination Survey (NHANES 19992000) reveals that approximately 28.4% of the United States adult population has hypertension and that the prevalence of hypertension increases sharply with advancing age. The NHANES 19992000 survey was conducted in the United States among a representative sample (n=4,531) of adult, noninstitutionalized, nonpregnant civilians with the goals of 1) estimating the prevalence of selected diseases and risk factors; 2) estimating population reference distributions of certain health parameters; 3) documenting and investigating reasons for secular trends in selected diseases and risk factors; 4) contributing to an understanding of disease etiology; and 5) investigating the natural history of selected diseases. References: National High Blood Pressure Education Program Coordinating Board. The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1997;157:2413-2446. Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: a rising tide. Hypertension. 2004;44:398-404. † Age *Based on NHANES 19992000 data. Hypertension is defined as blood pressure 140/90 mmHg or antihypertensive treatment. †Low reliability due to large relative error. Fields et al. Hypertension. 2004:44;398-404.

Hypertension Control in U.S. - NHANES % of Treated Controlled 30 % of Treated Controlled 43 % of Treated Controlled 51 % of Treated Controlled 64 % of Treated Controlled 65 Ong, Hypertension 2007

Primary Prevention of Hypertension via food supply sodium reduction: A growing international trend that TEXAS should join 1.3 gm average daily decrease will prevent 5mm/HG rise in BP with age and save 150,000 lives year - Most sodium is in processed food - Individual action is extremely difficult - Commercial alternatives exist - Food supply interventions are occurring around the world Dickinson, AMA council of scientific affairs, archives IM 2007

International Efforts England Department of Health and Food standards agency goal 2.4 gm sodium by 2010 50 food manufactures have signed on and begun to reduce Ireland Pressuring food industry New Zealand / Australia Strict labeling Industry pressure to reduce sodium has reduced Sodium in breads, cereals, margarine France Goal 20% reduction in 5 years Finland National focus since 1970s Sodium decrease from 4700 to 3300 Population decrease in blood pressure

30% of Hypertensives Unaware!

Of the unaware hypertensives… Mexican Americans are very over represented But 90 % of Unaware have insurance 80% have a usual source of care 75% had a BP measurement in the last year 96% had a BP measurement in the last 4 years Mean age 58 Mean BP 148/83 Hyman NEJM 2001

Implication: New screening programs needed Hispanics Low utilizers Education programs needed for health providers and public on appropriate reaction to “mild” BP elevations New technologies and paradigms for BP measurement may be needed.

Improving control in treated patients Continue public and physician education Appreciate limits on scientific data on achieving goals Educate on the availability of low cost drugs

Hypertension Treatment by Drug Class CCBs ß-Blocker ACE Inhibitors Diuretics ARBs IMS Health NDTI, 1978-2002

Cost of market leaders Norvasc $84 month Valsartan $74 month What you can get for $ 4 per month from Walmart (web 9/07) ACE Benezepril 10-40 Lisinopril 10-20 B blocker Metoprolol (BID) Atenelol Carvedilol (BID) Thiazides* Clonidine* Lovastatin 10,20 Pravastatin 10-40

Big pharma can’t make any $ on BP Drugs… If BP drugs are cheap… Big pharma can’t make any $ on BP Drugs… If big pharma controls the flow of medical information… and big pharma looses interest in Hypertension… The public health community will have to keep blood pressure control on the agenda by our selves!! The population will suffer if we don’t.