1. An evidence-based approach to Hypertension

3. Hypertension: The global epidemic

4. Hypertension: Leading cause of death Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360. Attributable Mortality (In millions) High mortality, developing region Lower mortality, developing region Developed region 0 8 7 6 5 4 3 2 1 High blood pressure Tobacco High cholesterol Unsafe sex High BMI Physical inactivity Alcohol Indoor smoke from solid fuels Iron deficiency Underweight

5. Hypertension prevalence world-wide % Reuters Business Insight – Healthcare – 2004 (USA, JAP, FRA, GER, ITALY, SPAIN, UK)

6. Hypertension prevalence world-wide Billions + 60% 2000 2025

7. Hypertension prevalence world-wide WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004. Italy 38% Spain 47% England 42% Germany 55% Canada 27% U.S.A. 28% Sweden 38%

8. Hypertension control world-wide Finland 21% Italy 9-23% Spain 5-16% France 27% England 6-10% Scotland 18% Germany 8-23% Canada 16-17% U.S.A. 29-31% Sweden 6% BP<140/90 35-64 years WHO Report 2004; 2. Wolf-Maier K et al. Hypertension 2004.

9. Hypertension Awareness, Treatment and Control: US 1976 - 2000 JNC-VII. Hypertension. 2003;42:1206–1252

10. Awareness, treatment and control JNC-VII. Hypertension. 2003;42:1206–1252

12. Blood Pressure and risk of Stroke Mortality MRFIT trial. Arch Intern Med 1992; 152:56-64

13. Blood Pressure and risk of CAD Mortality MRFIT trial . Arch Intern Med 1992; 152:56-64

14. Estimated Cumulative Incidence of Morbid Events in Untreated and Treated Hypertensive Patients *Including events such as hemorrhages, uncontrolled heart failure, diastolic blood pressure above specified limits, and cardiac, central nervous system, and renal events Veterans Administration Cooperative Study Group JAMA 1970;213(7):1143-1152

15. Classification and Management

16. BP Classification JNC-VII. Hypertension. 2003;42:1206–1252

17. BP Classification 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.

18. BP threshold with different types of measurement 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.

19. Risk Stratification 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.

20. When to initiate antihypertensive treatment? 2007 ESC/ESH Guidelines for the management of Arterial Hypertension. J Hypertens. 2007;25:1105-1187.

22. SBP or DBP?

23. SBP or DBP ?

24. SBP increases with age Franklin SS et al. Circulation. 1997;96:308-315.

25. Are people with elevated SBP always elderly? NHANNES III >50 years 79.7% 45.1% 40-50 years

26. SBP is most predictive of cardiovascular events MRFIT trial. Arch Intern Med 1992; 152:56-64

27. SBP is most predictive of stroke Borghi c et al. J Hypertens. 2002;20:1737-1742.

28. SBP control, difficult to achieve J Hypertens 2002;20:1461-1464.

29. Hypertension control in European countries Erdine S. J Hypertens. 2000;18:1348-1349.

31. Guidelines Recommendation

34. Benefits of treating SBP J Hypertens 2003;21:1983-1992 SBP Distributions Before Intervention After Intervention Reduction in BP JNC 7 report, Hypertension. 2003; 42: 1206-1252. Reduction in SBP mmHg 2 3 5 % Reduction in Mortality Stroke CHD Total – 6 –4 –3 – 8 –5 –4 – 14 –9 –7

36. Diuretics in the Guidelines

37. JNC VII algorithm for HT treatment JNC-VII. Hypertension. 2003;42:1206–1252

39. 2006 NICE / BHS algorithm for HT treatment

42. Diuretic antihypertensives: Support of recent trials

44. SHEP morbidity and mortality for non diabetics Curb Dj, et al. JAMA.1996;276(23):1886-1892

45. SHEP morbidity and mortality for diabetics Curb Dj, et al. JAMA.1996;276(23):1886-1892

48. (Thiazide-type diuretic vs ACEi and CCB - 33,357 hypertensives patients) ALLHAT JAMA 2002;288:2981-2997 ALLHAT

49. (Thiazide-type diuretic vs ACEi and CCB - 33,357 hypertensives patients) 2. ALLHAT JAMA 2002;288:2981-2997 1. Appel LJ. JAMA. 2002;288:3039-3042. ALLHAT

50. Diuretics clearly reduce strokes High-dose diuretic and low-dose diuretic, both reduced the incidence of stroke ( -51%, -34% ). Psaty BM et al. JAMA. 1997;277:739-745.

51. Diuretics clearly reduce CHD Low-dose diuretic reduced the incidence of CHD ( -28% ). Psaty BM et al. JAMA. 1997;277:739-745.

52. Diuretics clearly reduce mortality Low-dose diuretic reduced the incidence of Total mortality ( -10% ). Psaty BM et al. JAMA. 1997;277:739-745.

53. Diuretics clearly reduce CV death High-dose and low-dose diuretic therapy both significantly reduced cardiovascular mortality( -22% ,-24% ). Psaty BM et al. JAMA. 1997;277:739-745.

54. Diuretics versus β -blockers Trials in elderly: Diuretics or  -Blockers Diuretics  -Blockers

56. Conclusion

57. Diuretics: The cornerstone of hypertension treatment 1. Chobanian AV, Bakris GL, Black HR, et al. (JNC-7). Hypertension. 2003;42:1206-1252. 2. WHO, ISH writing group statement on management of hypertension. J Hypertens. 2003;21:1983-1992 They enhance the antihypertensive efficacy of all other antihypertensive drugs

58. Conclusion 1. The ALLHAT study JAMA. 2002; 288: 2981-2997 2. JNC - VII Report, JAMA , 2003;289:2560-2572

59. THANK YOU