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HYPERTENSION IN INDIA Dr. A. Muruganathan President - API Dr. M. Chenniappan Trichy Medical Writer

On the Occasion of World Hypertension Day... An API Initiative to upgrade knowledge of Practising physicians throughout India

Why ?

Educate Empower Easy learning Enjoyable learning Evaluate ownself 9912064435

The theme for World Hypertension Day 2013 is “Healthy Heart Beat - Healthy Blood Pressure”. Considering the fact that atrial fibrillation – arrhythmias is very common in people with hypertension, especially among older patients, the WHL executive board felt that it is important to improve the public awareness about atrial fibrillation – arrhythmias. In order to make it easier for the public to understand they have used the simple terminology – Heart Beat.

The objectives of the World Hypertension League are to promote the detection, control and prevention of arterial hypertension in populations. The World Hypertension League is a federation of leagues, societies, and other national bodies devoted to this goal. Bringing together and stimulating organizations committed to the control of hypertension is the goal of the WHL. The WHL is a division of the International Society of Hypertension (ISH), and is in official relations with the World Health Organization (WHO).

Benefit of Interventions Over 5 Years Lowering systolic BP 4 mm Hg: -12.5 cardiovascular events / 200 patients Lowering LDL cholesterol 1 mmol/L -8.2 cardiovascular events / 200 patients Lowering HbA1c 0.9 % -2.9 cardiovascular events / 200 patients

Prevalence1 Nearly 1 billion adults (more than a quarter of the world’s population) had hypertension in 2000, and this is predicted to increase to 1.56 billion by 2025. The prevalence of hypertension varies considerably from one region of India to another. In India, 23.10% men and 22.60% women over 25 years old suffer from hypertension, says the World Health Organization’s global health statistics 2012’ released in May, 2012. 1. Indian J Med Res 128, December 2008, pp 688-690

Prevalence Recent (2012) studies show that for every known person with hypertension in India, there may possibly be 2 persons with either undiagnosed hypertension or prehypertension. With over 139 million patients, India accounts for 15% of world’s uncontrolled hypertension patients.

Prevalence In terms of attributable deaths, the leading behavioral and physiological risk factors globally are raised blood pressure (to which 13% of global deaths are attributed), followed by tobacco use (9%), raised blood glucose (6%), physical inactivity (6%) and being overweight or obese (5%). It has been estimated that raised blood pressure causes 51% of stroke deaths and 45% of coronary heart disease deaths.

Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 1000 2000 3000 4000 5000 6000 7000 8000 Attributable Mortality (In thousands; total 55,861,000) Ezzati et al. Lancet. 2002;360:1347-1360.

Prevalence Only 1 in 5 hypertensive women were on treatment and less than 4% are controlled. Majority of hypertensive still remain undetected & the control of hypertension is also inadequate. But, despite all this, the good news is that the prevalence of hypertension in India is low as compared to world figures and India fares better than other countries in the South-East Asia Region (SEAR). SEAR’s average is - 25.40% in men & 24.20 in women.

Among the High Blood Pressure patients only one third are aware of the disease. Out of this only one third come for treatment. Out of this only one third of patients are under control.

An Analysis of NHANES III Blood Pressure Data Summary: Hypertensives fall into one of two categories: 1. A smaller (26%), younger (age < 50 years), predominantly male (63%) with diastolic hypertension out of proportion to systolic hypertension (primarily IDH and SDH) 2. A larger (74%), older (age ≥ 50 years), predominantly female (58%) with systolic hypertension out of proportion to diastolic hypertension (primarily ISH). Franklin et al. Hypertension 2001;37: 869-874

Pre-hypertension Pre-hypertension is defined as a systolic blood pressure reading between 120 and 139 and a diastolic blood pressure of 80 to 89. Nearly 50 % people have Pre Hypertension, accordingly to one study, 50 % of people above 50 years have high blood pressure. The category of pre-hypertension, was introduced to emphasize that persons whose blood pressure is >120/80 mm Hg are likely to progress to definite hypertension. It was also hoped that doctors will encourage persons with pre- hypertension to begin lifestyle modifications to prevent its progression to hypertension.

Members of the Association of Physicians of India (API) are planning to conduct screening camps and patient education regarding hypertension, complications and management with the help of IMA throughout the country. API is also interested to conduct updates for practicing physicians regarding the newer methods and updates about hypertension throughout the country directly and through web.

The Medical content of all 3 Modules has been written by Dr. M The Medical content of all 3 Modules has been written by Dr.M.Chenniappan (Trichy) The Panelist representing respective Regions and Key Members of API will review & give their suggestions on the Modules before it is uploaded in the www.apiindia.org site. Sessions on Modules 2 & 3 will be facilitated by respective Panelist/KOLs in respective Bimonthly period A book on Diabetic Hypertension will be released with the input & support of API Key Members & Panelists and will be presented to registered Drs for E-Hypertension Academy

Lifestyle Modification MODULE-1 Basics, Diagnosis and Lifestyle Modification

1: INTRODUCTION AND BASICS Introduction to hypertension e academics Epidemiology of hypertension in India – Incidence, Awareness , Control Etiopathogenesis of hypertension Classification

2: DIAGNOSIS OF HYPERTENSION Clinical examination in hypertension Measurement of blood pressure Ambulatory BP monitoring Laboratory investigation in hypertension Imaging in hypertension

3: NONPHARMACOLOGICAL APPROACH TO HYPERTENSION Goals and risk stratification Diet and hypertension Salt and hypertension Exercise and other lifestyle modifications

MODULE-2 Management of Hypertension

1: PHARMACOLOGICAL TREATMENT OF HYPERTENSION (Part 1) Classification of antihypertensive and their mechanism of action Selection of initial drugs in uncomplicated hypertension Selection of drugs according to compelling indications

2: PHARMACOLOGICAL TREATMENT OF HYPERTENSION (Part 2) Combination therapy Difficult to control hypertension and resistant hypertension – Approach Treatment of acute severe hypertension

3: INTERVENTIONAL THERAPY IN HYPERTENSION Renal artery Angioplasty Renal sympathetic denervation Baroreceptor stimulation Surgical approach to hypertension

MODULE-3 Target Organs and Special Situations

1: HYPERTENSION AND HEART Various cardiovascular changes in hypertension Hypertension and CAD Hypertension and HF (REF, PEF) Hypertension and atherosclerosis – vascular aging Cardiovascular emergencies in hypertension.

2: HYPERTENSION IN SPECIAL SITUATION Hypertension in extremes of age Hypertension and kidney Hypertension and lung disease Hypertension and CVA Pregnancy and Hypertension

3: EVIDENCE Important trials in Hypertension Meta analysis in Hypertension API – Indian hypertension guidelines

Patient Based Interactive Module (Optional) Patient Based Interactive Module

THE GOOD NEWS

reduction in cardiovascular risk with effective lowering of blood There is considerable reduction in cardiovascular risk with effective lowering of blood pressure with therapy.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events Myocardial Stroke infarction Heart failure –10 –20 Average reduction in events (%) –30 20%-25% –40 35%-40% –50 >50% –60 Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

On Completion of all 3 Module Test, Practising Physician will be given “ Certificate of Participation from the house of API”

MODULE-1 1 B Hypertension in India

Diseases Attributable to Hypertension Gangrene of the Lower Extremities Heart Failure Left Ventricular Hypertrophy Myocardial Infarction Hypertensive Encephalopathy Aortic Aneurysm Blindness Chronic Kidney Failure Stroke Preeclampsia/Eclampsia Cerebral Hemorrhage Coronary Heart Disease Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935

Attributable Mortality (In thousands; total 55,861,000) Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Lower mortality, developing region Developed region Alcohol Indoor smoke from solid fuels Iron deficiency 1000 2000 3000 4000 5000 6000 7000 8000 Attributable Mortality (In thousands; total 55,861,000) Ezzati et al. Lancet. 2002;360:1347-1360.

Hypertension in India (1/2) Cardiovascular diseases caused 2.3 million deaths in India in the year 1990; Projected to double by the year 2020 Hypertension directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India Strong correlation between changing lifestyle factors and increase in hypertension in India The nature of genetic contribution and gene-environment interaction in accelerating the hypertension epidemic in India needs more studies Gupta R. J Hum Hypertens 2004;18:73-78

Hypertension in India (2/2) In India, hypertension is present in 25% urban and 10% rural subjects At an underestimate, there are 31.5 million hypertensives in rural and 34 million in urban populations A total of 70% of these would be Stage I hypertension (systolic BP 140-159 and/or diastolic BP 90-99 mmHg) Recent reports show that borderline hypertension (systolic BP 130-139 and/or diastolic BP 85-89 mmHg) and Stage I hypertension carry a significant cardiovascular risk Gupta R. J Hum Hypertens 2004;18:73-78

Risk Attributable due to Hypertension in India http://www.whoindia.org/SCN/AssBOD/08-Hypertension.pdf Accessed on 27th May 2010

Prevalence studies in India R Gupta :Journal of Human Hypertension (2004) 18, 73–78

Recent studies R Gupta :Journal of Human Hypertension (2004) 18, 73–78

R Gupta :Journal of Human Hypertension (2004) 18, 73–78

National Heath and Nutrition Survey, Percent TRENDS IN AWARENESS, TREATMENT AND CONTROL OF HIGH BLOOD PRESSURE 1976-2000 National Heath and Nutrition Survey, Percent 1976-80 1988-91 1991-94 1999-2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34 In India and surrounding countries, awareness level is ≤ 45%. Only 50% of these are on treatment and BP control rates are very poor.

Trends in BP Control in India (1/2) % of uncontrolled hypertensive patients Only 27.3% patients had both SBP and DBP under control Survey in hypertensive patients (n=3402) receiving antihypertensive medications Hathial M. J Indian Med Assoc. 2007; 105 (7): 401-2, 404, 410.

% of hypertensive patients achieving BP goal Trends in BP Control in India (2/2) % of hypertensive patients achieving BP goal Study conducted in Chennai, of the treated hypertensive patients (n=154), only 45.9% of patients had their BP under control (i.e. <140/90 mm Hg). Similar analysis done in diabetic hypertension patients (n=149) showed that of the patients that were treated for hypertension, only 51.1% had their blood pressure under control. Mohan V et al. JAPI 2007; 55: 326-32.

Control of Hypertension in Indian population Undiagnosed hypertension 67.2% Diagnosed hypertension 32.8% Treated hypertension 29.2% Untreated hypertension 70.8% Hypertensive 20% Normotensive 80% Controlled hypertension Uncontrolled hypertension …only 15.4% of total hypertensive group have blood pressure controlled Mohan:J Assoc Physicians India, 2007 May;55:326-32

END OF MODULE-1 1B