The Global Burden of Disease The scale of the problem.
-
date post
22-Dec-2015 -
Category
Documents
-
view
218 -
download
2
Transcript of The Global Burden of Disease The scale of the problem.
![Page 1: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/1.jpg)
The Global Burden of Disease
The scale of the problem
![Page 2: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/2.jpg)
Leading Causes of Death and Disability (DALY’s)
Rank Cause % Rank Cause %
1 Lower respiratory infections 8.2 1 Ischemic heart disease 5.9
2 Diarrhoeal diseases 7.2 2 Major depression 5.7
3 Perinatal conditions 6.7 3 Road traffic accidents 5.1
4 Major depression 3.7 4 Cerebrovascular disease 4.4
5 Ischemic heart disease 3.4 5 COPD 4.2
6 Cerebrovascular disease 2.8 6 Lower respiratory infections 3.1
7 Tuberculosis 2.8 7 Tuberculosis 3.0
8 Measles 2.7 8 War 3.0
9 Road traffic accidents 2.5 9 Diarrhoeal diseases 2.7
10 Congenital abnormalities 2.4 10 HIV 2.6
1990 2020
Global Burden of Disease Study, 1996
![Page 3: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/3.jpg)
*
**
*
World Health Report 2002
Mortality due to leading global risk factors
![Page 4: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/4.jpg)
![Page 5: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/5.jpg)
Prevalence of ‘Hypertension’ by different cut points
0
5
10
15
20
50 60 70 80 90 100 110 120 130
Diastolic BP, mmHg
% o
f sc
reen
ed p
opul
atio
n
90 = 25.3%
95 = 14.5%
100 = 8.4%
105 = 4.7%
110 = 2.9%
115 = 1.4%
![Page 6: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/6.jpg)
![Page 7: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/7.jpg)
British Hypertension Society Guidelines for hypertension management 2004
(BHS-IV): summary
Bryan Williams, Neil R Poulter, Morris J Brown, Mark Davies, Gordon T McInnes, John F Potter, Peter S Sever, Simon McG Thom; the BHS guidelines working party, for the British Hypertension Society
BMJ Volume 328 13 March 2004 634-640.
![Page 8: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/8.jpg)
BHS Guidelines
DefinitionsMeasurement
Risk assessmentEvaluation of hypertensive patients
Thresholds for interventionTreatment goals
Lifestyle measuresChoice of therapy
Meta-analysis of trials ABCD rule
Aspirin and statinsFollow up and implementation
![Page 9: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/9.jpg)
Classification of blood pressure levels of the British Hypertension Society
Category Systolic blood pressure
(mmHg)
Diastolic blood pressure
(mmHg)
Blood Pressure
Optimal <120 <80
Normal <130 <85
High normal 130-139 85-89
Hypertension
Grade 1 (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) >180 >110
Isolated systolic hypertension
Grade 1 140-159 <90
Grade 2 >160 <90
![Page 10: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/10.jpg)
Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device
• Use of properly maintain, calibrated, and validated device
• Measure sitting blood pressure routinely: standing blood pressure should be recorded at least at the initial estimation in elderly or diabetic patients
• Remove tight clothing, support arm at heart level, ensure arm relaxed and avoid talking during the measurement procedure
• Use of cuff of appropriate size
Continued
![Page 11: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/11.jpg)
• Lower mercury column slowly (2mm per second)
• Read blood pressure to the nearest 2 mm Hg
• Measure diastolic blood pressure as disappearance of sounds (phase V)
• Take the mean of at least two readings, more recordings are needed if marked differences between initial measurements are found
• Do not treat on the basis of an isolated reading
Blood pressure measurement by standard mercury sphygmomanometer or semiautomated device
![Page 12: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/12.jpg)
Potential indications for the use of ambulatory blood pressure monitoring
• Unusual variability of blood pressure
• Possible white coat hypertension
• Informing equivocal treatment decisions
• Evaluation of nocturnal hypertension
• Evaluation of drug resistant hypertension
• Determining the efficacy of drug treatment over 24 hours
• Diagnosis and treatment of hypertension in pregnancy
• Evaluation of symptomatic hypotension
![Page 13: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/13.jpg)
Cardiovascular risk assessment
![Page 14: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/14.jpg)
![Page 15: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/15.jpg)
Lifestyle measures
• Maintain normal weight for adults (body mass index 20-25kg/m2)
• Reduce salt intake to < 100mmol/day (<6g NaCI or < 2.4 g Na+/day)
• Limit alcohol consumption to < 3 units/day for men and < 2 units/day for women)
• Regular physical exercise (brisk walking rather than weightlifting) for > 30 minutes per day, ideally on most days of the week but at least on three days of the week.
• Consume at least five portions/day of fresh fruit and vegetables
• Reduce the intake of total and saturated fat
![Page 16: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/16.jpg)
Thresholds and treatment for antihypertensive drug treatment
• Drug treatment should be started in all patients with sustained systolic blood pressures > 160mmHg or sustained diastolic blood pressures > 100mmHg despite non-pharmacological measures (A)
• Drug treatment is also indicated in patients with sustained systolic blood pressures 140-159mmHg or diastolic blood pressures 90-99mmHg if target organ damage is present, or there is evidence of established cardiovascular disease or diabetes, or if there is a 10 year cardiovascular disease risk of > 20% (B)
continued
![Page 17: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/17.jpg)
Thresholds and treatment for antihypertensive drug treatment
• For most patients a target of < 140mmHg systolic blood pressure and <85mmHg diastolic blood pressure recommended (B). For patients with diabetes, renal impairment or established cardiovascular disease a lower target of < 130/80mmHg is recommended
![Page 18: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/18.jpg)
180/110 160-179100-109
140-159 90-99
130-139 80-89
<130/85
160/100 140-159 90-99
<140/90
ReassessYearly
Re-measurein 5 years
Treat
Treat
Initial Blood Pressure
SEE NEXT SLIDE
![Page 19: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/19.jpg)
140-159 90-99
Target organ damage orCVS complications or Diabetes or CV event risk 2%/year[>20% over 10 yrs ]
No target organ damageand
No CVS complicationsand
No diabetesand
CV event risk < 2%/year[<20% over 10 yrs ]
Treat Observe Reassess CV risk yearly
![Page 20: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/20.jpg)
Drug treatment of hypertension
Diuretic
Beta-blocker
Calcium-channel blocker
ACE-inhibitor
(Alpha-blocker)
Angiotensin receptorblocker
Most hypertensives will need 2 drugs to control BP
Drug combinations may be synergistic
![Page 21: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/21.jpg)
STROKEComparisons of different active treatments
RR (95% CI) Favours first listed
Favours second listed
0.5 1.0 2.0Relative Risk
BP difference(mm Hg)
1.09 (1.00,1.18) ACE vs. D/BB
0.93 (0.86,1.01) CA vs. D/BB
1.12 (1.01,1.25) ACE vs. CA
2/0
1/0
1/1
![Page 22: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/22.jpg)
CORONARY HEART DISEASEComparisons of different active treatments
RR (95% CI)
Favours first listed
Favours second listed
BP difference(mm Hg)
0.5 1.0 2.0Relative Risk
0.96 (0.88,1.05)
1.01 (0.94,1.08)
0.98 (0.91,1.05)
ACE vs. CA
CA vs. D/BB
ACE vs. D/BB 2/0
1/0
1/1
![Page 23: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/23.jpg)
HEART FAILUREComparisons of different active treatments
RR (95% CI)
Favours first listed
Favours second listed
BP difference(mm Hg)
0.5 1.0 2.0Relative Risk
1.07 (0.96,1.19)
ACE vs. CA
CA vs. D/BB
ACE vs. D/BB
1.33 (1.21,1.47)
0.82 (0.73,0.92)
2/0
1/0
1/1
![Page 24: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/24.jpg)
MAJOR CARDIOVASCULAR EVENTS Comparisons of different active treatments
RR (95% CI)
Favours first listed
Favours second listed
BP difference(mm Hg)
0.5 1.0 2.0Relative Risk
ACE vs. CA
CA vs. D/BB
ACE vs. D/BB
0.97 (0.92,1.03)
1.04 (0.99,1.08)
1.02 (0.98,1.07)2/0
1/0
1/1
![Page 25: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/25.jpg)
ALLHAT Design
High riskHypertensive
Patients42,515
Randomize
AmlodipineChlorthalidoneDoxazosinLisinopril
10,362 eligible forLipid lowering
Not eligible forLipid lowering
Randomize
Pravastatin Usual CareStudy completion January
2003
![Page 26: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/26.jpg)
ALLHAT Primary Endpoint: CHD Death and Nonfatal MI
Relative Risk (95% Relative Risk (95% CI)CI)
FavorsFavorsChlorthalidoneChlorthalidone
Amlodipine 0.98 (0.90-1.07)Amlodipine 0.98 (0.90-1.07)
0.70.7 1.31.3
Lisinopril 0.99 (0.91-1.08)Lisinopril 0.99 (0.91-1.08)
Favors AmlodipineFavors AmlodipineFavors LisinoprilFavors Lisinopril
ALLHAT Collaborative Research Group. ALLHAT Collaborative Research Group. JAMAJAMA. 2002;288:2981-2997.. 2002;288:2981-2997.
![Page 27: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/27.jpg)
High-riskHypertensive
High-riskHypertensive
Eligible forLipid Lowering
Atorvastatin10 mg
Atorvastatin10 mg
PlaceboPlacebo
Randomize DB
ASCOT: PROBE Design
Randomized
Amlodipine Perindopril
Doxazosin GITs
Atenolol Bendrofluazide Doxazosin GITs
Not Eligible forLipid Lowering
Expected Mean Follow-up: 5 Yrs
Fatal CHD + Non-Fatal MI
Expected Mean Follow-up: 5 Yrs
Fatal CHD + Non-Fatal MI
19342
10305
![Page 28: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/28.jpg)
0
1
2
3
4
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Years
Cu
mu
lati
ve
Inc
ide
nc
e (
%)
36% reduction
HR = 0.64 (0.50-0.83)
Atorvastatin 10 mg Number of events 100
Placebo Number of events 154
p=0.0005
ASCOT study: Effect of atorvastatin on CHD
![Page 29: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/29.jpg)
ASCOT study: Effect of atorvastatin on stroke
0
1
2
3
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
Years
Cu
mu
lati
ve
Inc
ide
nc
e (
%)
27% rreduction
HR = 0.73 (0.56-0.96) p=0.0236
Atorvastatin 10 mg Number of events 89
Placebo Number of events 121
![Page 30: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/30.jpg)
The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs
Younger (e.g.<55yr)and Non-Black
Older (e.g.55yr) or Black
Step 1
Step 2
Step 3
Step 4Resistant Hypertension
Add: either -blocker or spironolactone or other diuretic
A: ACE Inhibitor or angiotensin receptor blocker B: - blockerC: Calcium Channel Blocker D: Diuretic (thiazide)
A (or B*)
A (or B*)
A (or B*) C or D
C or D +
+ +C D
Adapted from: ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 8186
* Combination therapy involving B and D may induce more new onset diabetes compared with other combination therapies
![Page 31: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/31.jpg)
Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
![Page 32: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/32.jpg)
% of hypertensives with controlled BP
USA1
27%
England2
6%
<140/90 mm Hg
Canada3
16%
Australia4
19%
Zaire4
2.5%
India4
9%
Scotland4
17.5%
Spain4
20%
Finland4
20.5%
<160/95 mm Hg
Adapted from Mancia, 1997
![Page 33: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/33.jpg)
Other medication for hypertensive patients
Primary prevention
(1) Aspirin: use 75mg daily if patient is aged >50 years with blood pressure controlled to <150/90mmHg and; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies cardiovascular disease risk chart)
(2) Statin: use sufficient doses to reach targets if patient aged up to at least 80 years, with a 10 year risk of cardiovascular disease of >20% (measured by using the new Joint British Societies risk chart) and with total cholesterol concentration >3.5mmol/l
(3) Vitamins – no benefit shown, do not prescribe
![Page 34: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/34.jpg)
Secondary prevention (including patients with type 2 diabetes)
(1) Aspirin: use for all patients contraindicated
(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration >3.5mmol/l
(3) Vitamins – no benefits shown, do not prescribe
![Page 35: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/35.jpg)
Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg
![Page 36: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/36.jpg)
Age- and gender adjusted hypertension control by country (35-64 years); 140/90 mmHg
Impact of structured algorithm
![Page 37: The Global Burden of Disease The scale of the problem.](https://reader035.fdocuments.in/reader035/viewer/2022062516/56649d775503460f94a588c7/html5/thumbnails/37.jpg)