Sir, today we would like to have your views regarding hypertension management. The recent guidelines which came, they are not talking about any classification. JNC 7 has talked about pre hypertension, stage I, stage II. So, does pre hypertension still exist in clinical factors?
Yeah,in JNC 7, the people started talking about the pre hypertension which designated the blood pressure range of 120 to 139 systolic and 80 to 89 diastolic. In fact, that correlates with the normal and high normal blood pressure of European Society guidelines and in fact no, that has been practiced in many countries as a pre hypertension because one that, was actually propagated as a message in United States and that was not accepted in European Society of Cardiology as well as European Society of Hypertension but Indians have our own guidelines.However, Indian hypertension guidelines in fact consistently reports only about high normal and normal blood pressurewhich actually if we just add these two that comes under the table of pre hypertension. The so-called JNC 8 is not JNC 8 which has recently published last year actually does not mention anything about the pre hypertension but American Society of Hypertension still would like to leave it to us to retain this terminology as pre hypertension, but personally I feel that the term has to be retained and that has got some valid information because many times we tend to forget about the range of blood pressure for normal or high normal or optimal blood pressure which is getting propagated even by Indian guidelines. I think it is better to remember a simple information that is on pre hypertension 120 to 139 systolic and 80 to 89 diastolic is considered as a pre hypertension.
Do you recommend any intervention in these patients?
Normally, we do not recommend pharmacotherapy.There are some few studies which had started using this ARB particularly the candesartan which was found to be useful in treating pre hypertension. That prevented incident hypertension following therapy when compared to people who did not receive ARB, but that does not mean that we should initiate treatment. Because if you just consider treatment for this group of patients, even our country will not tolerate this issue because more than 180 million people are suffering from pre hypertension when compared to people who are already suffering from hypertension. That becomes a big burden on the nation. I think we should only promote the therapeutic lifestyle changes by restricting salt intake and then improving the physical activity and reduction of overweight and obesity and smoking cessation will all help in the sort of bringing it down.
What percentage of these patients will eventually lend up into hypertension?
Actually, studies are not very clear to tell us the exact percentage of patients who jump into stage I hypertension. It all depends on the underlying problems if the patient is overweight and the patient has got other features of metabolic syndrome is the one who is going to get these problems or a patient who got a tendency to develop diabetes with a strong family history is the one who is going to develop incidental hypertension quickly or the patient who has been having an indulgence in high salt intake are those people who are likely to get into these problems of stage I hypertension following pre hypertension.
So, recent guidelines have created a lot of controversies regarding when to start therapy based on age of the patients. Some guidelines say 140/90 but more than 60 years, it is 150/90. So, what is your take on that?
I think the last guidelines which were considered to be the JNC 8. Actually strictly speaking it is not JNC 8. It has been only a recommendation because NHLVA actually came out of these guidelines development and started giving the message that it is not JNC 8 and those so called 150/90 and 140/90, I think we need to be very, very careful in this sort of classification. Because recent studies have shown clearly that people who are having a blood. pressure between 140 to 149 systolic had got more cardiovascular risk and even mortality had gone up in this kind of group. I think we should be very careful in advising people to go and treat only people above the age of 60 are 150/90 or about the age of 80 as to keep it around 160. I think that is not the current approach. What we have been categorizing until JNC 7 and what had been propagated as a message from nice guidelines, I think still was good. I would probably consider 140/90 is a cutoff value beyond which we need to treat the patient. If the patient is a diabetic probably 140/80 is the cutoff value as per the recommendation of American Diabetes Association and that is the one which is being practiced now in our country also. Till that time probably we are all trying to get worried about diabetic patients are the CKD patients that we need to keep the levels less than 130/80 but now that we are very clear about the morbidity and mortality benefit are not much between this 130 and 140 The idea is to keep only ideal way of tackling patients with hypertension in people with diabetes and CKD between 140 and 80.
The guidelines have bracketed four major classes as equal, diuretics, ACE inhibitors, ARBs and CCBs. They do not recommend any specific drug in starting the therapy. So, is it same practiced in India as well?
In fact, no. The study that was published on the name of ALLHAT study which is considered to be a overview study because it involved more than 42,000 patients which had gone to prove that the diuretics chlorthalidone is almost equal to the amlodipine as well as the lisinopril. In that particular study almost equal benefit was seen and in prevention of stroke, in prevention of heart failure, in prevention of causes of mortality, and that is the one which change the view of all the guideline developers to consider that almost all drugs are equal. It is not so, we need to probably pick up these drugs which had got a lot of evidence in certain tough population, for example, if the diabetic patients suffer from hypertension the choice of the drug would be only ACE inhibitor and ARB. If ACE inhibitor is not tolerated, we will go for ARB, but I would like to concentrate on one important issue, type I diabetic patient, the ACI are the best drugs to be used because you have lots and lots of evidence to say that it is very efficacious in type 1 diabetic with hypertension, where as in type 2 diabetes, you have lot of evidence mainly for ARBs. So, if you use ARBs probably it reduces the proteinuria much more effectively when compared to ACE inhibitors. I think ARBs are the better drugs for treatment of type II diabetes, ACI are better drugs for the type I diabetes. For general population in whom we are seeing blood pressure as the most important situation where we need intervention probably you can choose either ACI or ARB but if we look at the control of blood pressure, it is almost equal, but if we look at the left ventricular hypertrophy regression, the left ventricular must coming down only with the usage of ARB. The next drug will be CCB. The third drug will be the ACI and the fourth drug will be the diuretic and the last one is a beta blocker and that study had stimulated my interest to choose only ARB is the first drug.
Where do you keep beta blocker in the current treatment algorithm?
In fact, beta blockers had been actually witnessing a lot of problems we have seen, the Lindell and group when they published the meta analysis and they started bombarding the usage of beta blockers particularly the atenolol group of drugs and the study has cost study which had evaluated the efficacy of amlodipine +/- perindopril compared to atenolol plus bendroflumethiazide had come out to the data showing that far far superior this combination of ACE inhibitor plus the amlodipine had done wonders in this group of patients particularly the primary outcome, the secondary outcome, the tertiary problems or the post-drug analysis, all those events were actually in favor of only the combination of amlodipine +/- perindopril and not with atenolol or with the thiazide group of diuretics. In fact now that had stimulated a lot of interest to go for another study called CAFE study where it is a sub study which had evaluated these group of patients in whom the central aortic pressure was measured. The central aortic pressure had definitely shown that there is an improvement only with ACE inhibitor and CCB combination and nothing with the atenolol plus thiazide group diuretic combination that was showing the incidence of stroke comes down remarkably in this combination that incident of new onset diabetes is much more in atenolol and thiazide group of drugs and thereby giving us the good information that beta blockers probably will not find a place in the routine practice of pretreating hypertension but I would like to reserve beta blocker mainly for secondary prevention strategy, not as a primary prevention strategy in the management of hypertension. We will need to probably selecting those group of people in who have excess sympathetic drive or people who have arrhythmias, people who have problems of angina, or people who have already suffered from myocardial infarction or in people in whom there is a congestive cardiac failure, in those situations, I think there is a good evidence to say that 10:00 beta blockers will definitely play a role. Even there probably if I am allowed to do an extra work, I would prefer to use another antihypertensive drug rather than depending only on beta blockers because the excess dosage of beta blockers will do harm more than bringing down the blood pressure.
In a recently published pure study, they said that low-income countries, the most commonly used drug is beta blockers and India was one of the participants in the low-income group. So how do we justify this is not in line to what is happening?
I think that has to be revised because people who started talking about it, they can hold to the polycab where they had introduced this atenolol as a drug, one of the drugs with statin and all. I am not in any way against the poly pill therapy or poly pharmacy instead of giving multiple pills, you combine everything and give it for primary prevention or the secondary prevention. Of course, we need to now concentrate only on secondary prevention in our country which is considered still a low-income country. I think the atenolol has to be removed from that particular poly pill and one has to advocate poly pill therapy with some other drug non-atenolol drug will be a better option rather than concentrating on atenolol. Pure study had repeatedly convinced people that that should be a combination of drugs, but that combination need not to be atenolol. It should be any other beta blocker if that is really required for secondary prevention.
Thanks a lot Sir. Thanks for joining us and sharing your views on management of hypertension. Thank you.