Addressing Challenges in

Hypertension in Asia:

Blood Pressure Variability and CVD?

Anwar Santoso
Dept. of Cardiology – Faculty of Medicine; Universitas Indonesia
National Cardiovascular Centre – Harapan Kita Hospital
Jakarta - Indonesia
 BACKGROUND

• Hypertension is a major risk factor for CVD

• Strict BP control effective approach to prevent CVD.

• Recently, 2017 AHA/ACC guideline  140/90 to 130/80

mmHg

• ABPM and HBPM recommended for HTN management

• Prevalence of masked uncontrolled HTN, morning surge

HTN, nocturnal HTN higher and blood pressure
variability (BPV) in Asians than Westerners
 Intima-media thickness and BP class
in Flores islands - Indonesia

Pasha SM, et al. J Hypertens 2011; 29(11); Gupta S, et al. J Rural Tropical Public Health 2011; 10: 29
Rahajeng E, et al Maj Kedokteran Indon 2009; 59: 580-8
 Methods
• The Indonesia MMM17 cross-sectional survey
• We recruited 292 sites in all 34 provinces of Indonesia
• Convenient sampling technique
• BP measurement and criteria for HTN  the MMM
protocol
• 45% using digital BP devices
• 69,307 people screened with three BP readings
Widyantoro B, ….Santoso A. Eur Heart J 2019; 21 (Suppl): D63 – D65
Differences in mean BP according to BMI adjusted for age, sex and
anti HTN medication: Indonesia May Measurement Month 2018

Widyantoro B, ….Santoso A. Eur Heart J 2019; 21 (Suppl): D63 – D65

 Differences in mean BP according to individual characteristics adjusted for
age, sex and anti HTN medication: Indonesia May Measurement Month 2018

Widyantoro B, ….Santoso A. Eur Heart J 2019; 21 (Suppl): D63 – D65

Patient perceptions of HTN consequences in
Asian

Rahman ARA, et.al. As Pac Fam Med 2015: 14(2).

Differences in mean BP according to day of the week adjusted for
age, sex and anti HTN medication: Indonesia May Measurement
Month 2018

Day to Day Variability

Widyantoro B, ….Santoso A. Eur Heart J 2019; 21 (Suppl): D63 – D65

 Methods
• A prospective, multicenter, non-interventional trial 
Asian countries and regions
• Px aged > 20 years with HTN having stable dose anti
HTN
• Validated-automatic HBPM (Omron HEM-7130-AP, Kyoto
®
)
• BP measurements 15 days HBPM period
• The HOPE Asia Network consensus

Kario K, et al. J of Clin Hypertension 2018; 20: 1686.

Distribution of BP control status on different clinic & Home BP
thresholds
in the Asia BP@Home Study (n = 1441)

Kario K, et al. J of Clin Hypertension 2018; 20: 1686.

Country/regional differences in BP control
status

Kario K, et al. J of Clin Hypertension 2018; 20: 1686.

Country/regional differences in measures of
BPV

Kario K, et al. J of Clin Hypertension 2018; 20: 1686.

Standardized Association of BPV with Coronary Atheroma
Progression

Calrk-III D, et al. JAMA Cardiol April 10, 2019; doi: 10.1001/jamacardio.2019.0751

MACCE Among Patients stratified Across Quartiles of SBP
Variability

Calrk-III D, et al. JAMA Cardiol April 10, 2019; doi: 10.1001/jamacardio.2019.0751

Major Determinants of BP in Essential HTN

Carey RM, et.al. J Am Coll Cardiol 2018: 72(23).

RR for an absolute 10% increase in Central AIx and CV
outcomes - death

Vlachopoulus C, et.al. Eur H J 2010: 31: 1865 - 71.

Effect of CV Drugs on Central Aortic Pressure

Messerli FH, et.al. J Am Coll Cardiol 2016: 68(7).

 Effects of losartan vs. candesartan in reducing
cardiovascular events in hypertension
‘Real Life’ registry study designed to see if there are
CVD risk differences between losartan and candesartan
in patients with hypertension (with no known CVD)
72 Primary Care centres in Sweden
Patients prescribed losartan or candesartan
between 1999-2007
24,943 patients of which 14,100 were
diagnosed with hypertension
Patients linked to Swedish national
hospitalisation and death register
Primary composite endpoint: CVD morbidity,
CVD mortality and elective coronary
revascularisation procedures

Kjeldsen SE et al. J Hum Hypertens 2009. Advance online publication 5th November 2009
Real Life - Results
Primary composite endpoint
3
5 losartan
3
0
candesartan Primary Endpoint:
2
Cumulative
incidence

5
2 676 CVD events fo
0
1 losartan
5
1 Adjusted risk reduction 14.4%
0 p=0.0062 575 CVD events fo
5 Unadjusted risk reduction 20.6%
p<0.0001 candesartan
0
0 6
1 1 2 3 3 4 4 5 6 6 7 7 8 9 9 Adjusted HR 0.86
2 8 4 0 6 2 8 4 0 6 2 8 4 0 6
Number at Time (months) (p=0.0062)
risk
Los.6771581245483913318825912090173814581169925 715 526 385 259 183 95
Can.73296291486040913385274222421875158013021021794 592 436 257 152 78

Individual Components
Heart Failure (HR 0.64; p=0.0004)
Cardiac Arrhythmias (HR 0.80; p=0.0330)
PAD (HR 0.61; p=0.0140)
Other endpoints not significantly different
Kjeldsen SE et al. J Hum Hypertens 2009. Advance online publication 5th November 2009
 Additional treatment with thiazides was
needed with losartan1
– In order to achieve a similar level of BP control (mean of 145/85 mmHg),
20% more patients receiving losartan required additional treatment with a
thiazide diuretic compared to those receiving candesartan

Concomitant thiazides during 8 years of follow up

90
losartan
80 candesartan
Thiazides* (%)

70
60
50
40
30
20
10
0
1 2 3 4 6 7 8 9
Index
2 4 6 8 0 2 4 6
Time (months)

* Thiazides (ATC C03A A, C03A B, C09D A01, C09D A06)

sen SE et al. J Hum Hypertens 2009 advance online publication; doi:10.1038/jhh.2009.77
Mancia G, et.al. Eur Heart J 2018: 00: 1 - 98. doi: 10.1093/eurheartj/ehj339
Cardiovascular Risk and Antihypertensive Treatment
Classification of Office BP and definitions of
Hypertension

Mancia G, et.al. Eur Heart J 2018: 00: 1 - 98. doi: 10.1093/eurheartj/ehj339

Drug-treatment strategy for HTN and Coronary Artery Disease
Effect of RAS Inhibition on Occurrence of Atrial
Fibrillation

Schneider MP, et.al. J Am Coll Cardiol 2010; 55 (21): doi: 10.1016/j.jack.2010.01.043

Drug-treatment strategy for HTN and Atrial Fibrillation
Drug-treatment strategy for HTN and HFrEF
 SUMMARY
• ABPM and HBPM should be applied in health practice
as proven in Asian region

• Pharmacological treatment and life-style management

should be done in considering ’10-year CV risk
assessment’

• RAS inhibitors and CCB combination proved to give

most clinical benefits in CVD outcomes and renal
outcomes in HTN, particularly in diabetics HTN

• Candesartan is still in the armamentarium