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Congress Report: 20th Annual Scientific Meeting of the Egyptian Hypertension Society (EHS)

Congress Report: 20th Annual Scientific Meeting of the Egyptian Hypertension Society (EHS)
  • Cardiometabolic
  • Hypertension

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Publication

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blood pressure targets
SPRINT

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Practical

The Egyptian Hypertension Society meeting this year celebrated the 25th anniversary of the Egyptian National Hypertension Project (ENHP). This was the first study of this kind in the developing world, and identified the prevalence of cardiovascular risk factors and hypertensive complications among Egyptians for the first time, on a national level. Other presentations at the meeting covered imaging in hypertension and controversies in hypertension, including how to care for difficult to treat patients, the elderly and those with comorbidities.


Highlights of the meeting included ‘Hypertension and cardiovascular disease’ presented by Professor Vasilios Papadimitriou (Georgetown University, Washington, USA).  Professor Papadimitriou explained that the prevalence of hypertension worldwide is 40% in adults aged 25-55 years, and is only controlled in 40% of those adults – a situation that is not satisfactory. 

According to the ACE study,1 the prevalence of hypertension in the Middle East in those aged >60 years is 72.7%, of which only 19% are controlled.

There is a linear relationship between systolic blood pressure and mortality from stroke and ischaemic heart disease, which increases with patient age. In addition, the benefits of reducing blood pressure are present for all grades of hypertension and the reduction in the relative risk of stroke and coronary heart disease depend on the degree of blood pressure reduction more than the type of medication used.

The issues in hypertension guidelines that are still controversial, were highlighted, such as:

  • No clear guidance on when to start treatment
  • Target blood pressure values are under debate
  • Sometimes recommendations are conflicting
  • Recommendations have gone from “the lower the better” to “the earlier the better”
  • Accepting higher levels of blood pressure

Professor Paul Whelton (Tulane University School of Medicine, Louisiana, USA), in his presentation on ‘Pharmacological and nonpharmacological intervention to prevent high blood pressure’ suggested that the best way to prevent hypertension is by environmental and genetic modulation. According to Professor Whelton, hypertension is highly prevalent worldwide, and high blood pressure in the only factor that kills more people than tobacco.

            There are four major questions that should be answered for the proper management of hypertension:

  • What is the best therapeutic regimen?       
  • At what level of blood pressure should treatment start?              
  • What should treatment be based on?
  • What is the target level of blood pressure to be reached?

Nonpharmacological management is the cornerstone of hypertension prevention and four key questions should be answered in this regard:            

  • What environmental factors cause high blood pressure?
  • Are there effective interventions to influence these factors favourably? 
  • Are they safe and acceptable?            
  • Can they be maintained over prolonged periods of time?    

Nonpharmacological interventions include:            

  • Dietary help to lose weight, reduce sodium intake, increase potassium intake, generally to adopt a healthy diet (eg DASH2)  
  • Avoidance or modest intake of alcohol
  • Increase physical activity

Pharmacological interventions, including claims that low dose drug therapy can delay or prevent the occurrence of hypertension, as seen in the TROPHY3 and PREVER4 trials, but there is less enthusiasm for this approach.

Finally, strategies for prevention of hypertension should include intensive blood pressure reduction strategies targeted at those at highest risk of hypertension (Targeted Intensive Strategy) or a less intensive blood pressure reduction strategy targeted to the general population (General Population Strategy).

 

The controversial and topical subject of intensive treatment of hypertension was tackled by Professor Paul Whelton (Tulane University School of Medicine, Louisiana, USA) in his presentation ‘Lessons learned from the systolic blood pressure interventional trial (SPRINT5)’.

SPRINT is a randomized controlled trial examining the effect of more intensive high blood pressure treatment than is currently recommended. In SPRINT, the intensively-treated group achieved a mean systolic blood pressure of 121.5 mmHg in comparison to 134.6 in the standard treatment group. The results showed a significant reduction in the study’s primary outcome and all-cause mortality in the intensively-treated group. The results were also consistent in the six pre-specified subgroups of interest, including those with chronic kidney disease (where the results showed a modest reduction in glomerular filtration rate in the intensively-treated group), and those with cardiovascular disease. The primary outcome was consistent in frail participants while there was no difference in the rate of serious adverse events between intensively and normally-treated groups. Adverse events with the intensive treatment regime could be avoided by modifying the intensity of the treatment.

SPRINT benefits are consistent with prior experience from randomized clinical trials and consistent with the expected benefits of lowering blood pressure based on cohort experience. The SPRINT study had sufficient power to demonstrate benefit.

Despite claims that the SPRINT study was conducted in a highly selected group of participants, this appears unlikely, as the baseline risk of cardiovascular disease in SPRINT is similar to reports from general practice. There were some concerns that SPRINT blood pressure measurement was more accurate than that used in clinical practice, but all landmark randomized control trials for blood pressure treatments are completed under more favourable conditions. Despite challenges in generalizability, SPRINT provides the best scientific underpinning for practice of evidence-based medicine.

After the SPRINT trial, some of the treatment Guideline recommendations have changed. The Canadian Guidelines (2016)6 have reduced their target blood pressure to <120 mm Hg in high risk patients and the Australian Guidelines (2016)7 state that in a high cardiovascular risk population, a more intensive treatment can be considered, aiming for systolic blood pressure of <120 mmHg. 

Professor Whelton concluded that there is strong evidence that lower is better than higher blood pressure for treatment of hypertension. It is unlikely that the benefits of intensive treatment noted in the SPRINT study can be explain by overestimation of the treatment effect or underestimation of adverse effects. SPRINT provides useful guidance for blood pressure targets during treatment of hypertension, and additional SPRINT-like interventional trials are needed.  


References

  • Alsheikh_Ali AA, et al. PLoS One 2014;9:e102830.
  • Appel LJ, et al. N Engl J Med. 1997;336:1117-24.
  • Williams SA, et al. J Clin Hypertens (Greenwich) 2008;10:436-42.
  • Fuchs FD, et al. J Hypertens. 2016;34:798-806.
  • SPRINT Research Group. N Eng J Med 2015;373:2103-16.
  • Leung AA, et al. Can J Cardiol. 2016;32(5):569-88.  
  • Gabb GM, et al. Med J Aust. 2016;205(2):85-9.

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