1. Hypertension in Malaysia
Assoc. Prof. Dr. Rashidi Ahmad
MD(USM), MMed(EM)(USM),FADUSM,
AM(Mal), Clinical Fellow (Cardio)(NHI)
School of Medical Sciences, USM, KB, Kelantan

2. Objectives
Understanding hypertension
Magnitude of hypertension in
Malaysia
Best clinical practice
(antihypertensive agents)

3. Definition
Confirmed/based on the average of 2 or more readings
taken at 2 or more visits to the doctor.

4. CUFF:
Width should at least be 40% of the
circumference of the arm

5. SITTING ARM SUPPORT IN
STANDING
KOROTKOFF PHASE:
SBP 1 CLEAR TAPPING SOUNDS
FIRST APPEAR
DBP 5 THE DISAPPEARANCE OF
SOUND

6. Important rules
Check BP both arms – coarctation of
aorta, arterial anomaly
Lying & standing – postural drop in
elderly, diabetics
Beware of auscultatory gap

7. Pathophysiology

9. Keep thinking of secondary causes
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and
Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

14. IHD mortality versus blood pressure

16. O’Donnell, et al. J Hypertension, 1998; 16: 3

17. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%

21. Magnitude of HPT
Affects about 50 million people in the US and
approximately 1 billion worldwide.
Prevalence increases with age: individuals
who are normotensive at age 55 still face a
90% lifetime risk of developing HPT.
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003;289:2560-72.
Residual lifetime risk for developing hypertension in middle-aged women and men:
The Framingham Heart Study. JAMA 2002;287:1003-10.

22. Chan
1997: 10%
Lim,et al
1991: 13.8%
Prevalence rates from Srinavas, et al
Different years and 1998: 25.6%
Different populations Nawawi
2002: 31.2%
Liew, et al.
1997: 42.8%

23. Hypertension in Malaysia
Prevalence: 25.7%.
Men vs women - 26.3% vs 25.0%.
1 in 4 adults aged 25-64 years had HPT.
Known hypertensives: 1.4 million
Newly diagnosed:1.7 million.
Chinese (31.0%), Malays (23.4%) and
Indians (21.6%).

24. Prevalence of HPT by sex and race amongst Malaysian residents
aged ≥ 18 years in 2006 (N=33,976)
Sex, % (95% CI)
Age (Years)
Male Female Both sexes
All races 33.3 (31.6, 32.8) 31.0 (30.3, 31.7) 32.2 (31.6, 32.8)
Malay 33.7 (32.5, 34.8) 34.1 (33.1, 35.1) 33.9 (33.1 34.7)
Chinese 35.0 (33.2, 36.8) 29.8 (28.2, 31.4) 32.4 (31.1, 33.8)
Indians 30.9 (28.2, 33.8) 27.8 (25.6, 30.1) 29.4 (27.5,31.2)
Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)
Bumi Sarawak 35.6 (31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

25. Prevalence of HPT by sex and race amongst Malaysian
residents aged ≥ 30 years in 2006 (N=24,796)
Sex, % (95% CI)
Age (Years)
Male Female Both sexes
All races 41.7 (40.7, 42.8) 43.4 (42.5, 44.4) 42.6 (41.8, 43.3)
Malay 45.8 (44.4, 47.1) 51.2 (50.0, 52.4) 45.4 (44.3, 46.4)
Chinese 47.4 (45.4, 49.4) 42.3 (40.4, 44.3) 40.6 (39.0, 42.1)
Indians 44.1 (40.8, 47.4) 42.7 (39.9, 45.5) 40.0 (37.7, 42.3)
Bumi Sabah 36.0 (33.0, 39.1) 26.4 (24.1, 28.8) 31.1 (29.2, 33.2)
Bumi Sarawak 35.6 ( 31.0,40.4) 33.3 (29.5,37.3) 34.4 (31.0,38.1)

26. Rural vs Urban
Rural 36.9% ( 35.9, 38.0)
Urban 29.3% ( 28.5, 30.0)

27. The Malaysian Rule
All hypertensives
64% 36% Aware
12% 88% Treated
74% 26% controlled

28. The ‘Malaysian Rule’
100 All hypertensives
64 36 Aware
69 31 Treated
92 8 Controlled

29. Overall BP Control by ethnicity
Indian 12.2% ( 10.0,14.7)
Chinese 11.5% ( 10.1,12.9)
Malays 7.0% ( 6.4,7.7)

30. Comparison with NHMS 11 ( > 30 years )
1996 2006
Prevalence 33% 43%
Aware 33 % 36%
Diagnosed & Rx 23% 88%
Rx and controlled 26% 26%
Overall control 6% 8%

31. Hypertension Control in the
Asia Pacific Region
Prev Aware Treat Control
Thailand (2003-4) 22.2% 28.6% 23.7% 8.6%
China 2002 18.8% 30.2% 24.7% 6.1%
Korea 2001 22.9% 30.2% 22.9% 10.7%
Malaysia 2006 32.2% 35.8% 31% 8.2%
USA 2004 29.9% 66.5% 53.7% 33.1%

33. Clinical Aspects – Current Status
( IHM MOH 2006 )
National Essential Hypertension Audit
- rates of control
Hospital with specialist 31.2%
Hospital without specialist 26.6%
Clinics with FMS/ MO 28.8%
Clinics without FMS/MO 26.9%

34. Clinical Aspects – Current Status
( IHM MOH 2006 )
National Essential Hypertension Audit
- rates of control by ethnicity
Malay 24.3%
Indian 30.8%
Chinese 37.6%
Others 30.8%

35. Clinical Aspects – Current Status
( IHM MOH 2006 )
National Essential Hypertension Audit
- rates of control by age
30-39 19.4%
40-49 27.1%
50-59 29.1%
>60 29.2%

36. Points to ponder!
Patients’ non compliance
Doctors not sure when to treat and what
the treatment goals are
Doctors not using the right drug/drugs
Patients has undiagnosed secondary
hypertension or complications of
hypertension which makes optimum
control difficult

37. What are the better ways to
manage hypertensive patients
in Malaysia?

38. Risk Stratification
Co-existing Condition No RF TOD TOC Previous MI
No TOD or or or
No TOC RF (1 – 2) RF (≥ 3) Previous stroke
BP Levels No TOC or or
(mmHg) Clinical Diabetes
atherosclerosis
SBP 120 – 139 and/or Low Medium High Very high
DBP 80 – 89
SBP 140 – 159 and/or Low Medium High Very high
DBP 90 – 99
SBP 160 – 179 and/or Medium High Very high Very high
DBP 100 – 109
SBP 180 – 209 and/or High Very high Very high Very high
DBP 110 – 119
SBP ≥ 210 and/or Very high Very high Very high Very high
DBP ≥ 120
Risk Level Risk of Major CV Event in 10 years Management
Low < 10% Lifestyle changes
Medium 10 – 20% Drug treatment and lifestyle changes
High 20 – 30% Drug treatment and lifestyle changes
Very high > 30% Drug treatment and lifestyle changes

39. First line therapy
NICE / BHS
ACEi / ARB/ diuretics/ CCB
ESH/ESC
ACEi /ARB/diuretics/CCB/Beta blockers
WHO/ISH
Low dose diuretics/ ACEi/CCB
MSH
ACEi / ARB/diuretics/CCB
Chinese
ACEi /ARB/diuretics/CCB/Beta blockers

40. Choice of anti-hypertensive drugs in patients
with concomitant conditions
Concomitant disease Diuretics β- ACEIs CCBs Peripheral ARBs
blockers α-blockers
Diabetes mellitus + +/- +++ + +/- ++
(without nephropathy)
Diabetes mellitus (with ++ +/- +++ ++* +/- +++
nephropathy)
Gout +/- + + + + +
Dyslipidaemia +/- +/- + + + +
Coronary heart disease + +++ +++ ++ + +
Heart failure +++ +++# +++ +@ + +++
Asthma + - + + + +
Peripheral vascular + +/- + + + +
disease
Non-diabetic renal ++ + +++ +* + ++
impairment
Renal artery stenosis + + ++$ + + ++$
Elderly with no co-morbid +++ + + +++ +/- +
conditions
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice
+/- Use with care
- Contraindicated
* Only non-dihydropyridine CCB
# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated
@ Current evidence available for amlodipine and felodipine only
$ Contraindicated in bilateral renal artery stenosis

42. ESH/ESC Guidelines 2007
monotherapy vs combination therapy
Mild BP elevation Choose between Marked BP elevation
Low / moderate CV risk High / very high CV risk
Conventional BP target Lower BP target
Single agent Two-drug combination
at low dose at low dose
If goal BP not achieved
Previous agent Switch to different agent Previous combination Add a third drug
at full dose at low dose at full dose at low dose
If goal BP not achieved
Two-to three-drug Full dose Two-three-drug combination
combination at full dose monotherapy at full dose
ESH/ESC Guidelines 2007 J Hypertens. 2007;25:1105-1187

43. Newly diagnosed, uncomplicated patients with
hypertension with no compelling indication
First line monotherapy
Blockers of the renin system ( ACEi, ARB )
Calcium channel blockers
Diuretics

44. WHO/ISH
JNC-6
Effects of diuretics and ß-blockers on
cardiovascular mortality
Treatment Treatment
Better Worse
Drug Dose No. RR (95% CI)
Diuretics High 11 0.78 (0.62-0.97)
Diuretics Low 4 0.76 (0.65-0.89)
ß-blockers 4 0.89 (0.76-1.05)
0.4 0.7 1.0
RR (95% CI)

46. Combination therapy
BP >160/90 mmHg
Include diuretics as part of combination
therapy (ACEI + Diuretic)
Consider fixed dose combination if
compliance is an issue

47. Malaysian Untreated Hypertensives
(Acta Cardiol. 1999;54:277-282 )
NT HT
SBP * 120 (112-130) 169(160- 180)
DBP* 80 ( 78-82 ) 100 ( 100-110 )
MAP * 94 ( 91-97 ) 123 ( 119-130 )
PWV* 8.8 (8.3- 9.6) 11.7(10.9- 12.9 )
Our population most likely needs combination antihypertensive agents

48. Malaysian Untreated Hypertensives
( Asia Pacific J Pharmacol ; 1997 :89-95 )
NT HT
Se Na * 142.18 +0.78 146.83+2.30
UNaV * 140.58+ 15.65 100.55+17.28
Se i Ca* 1.25 + 0.01 1.17+0.01
PRA 0.89+0.19 0.79+0.2
PRC 3.09+0.74 4.23+1.43
Se Aldo 275+21.51 257 + 16.22
“Malaysian hypertensives are salt retainers “
“ Malaysian hypertensives are normoreninaemic hypertensives “

49. Effective Combinations in Malaysia
- Retrospective Review of Record
( Asia Pac J Pharmacol.; 2001:17-24 )
Diuretics No Diuretics
( n=100 ) ( n=100 )
SBP * 140 +2 151+3
DBP * 85+1 88+1
dSBP * 30+3 21+3
dDBP 13+2 13+2

50. Effective Combinations in Malaysia
Diuretics No Diuretics
Controlled 66% 38%
p < 0.0001

51. What predicts BP control ?
By univariate analysis
Odds p
Statin on admission 2.53 0.000
Presence of IHD 2.21 0.001
Diuretics on admission 2.12 0.002
ACE I on admission 1.97 0.006
> 2 drugs 1.92 0.007

52. What predicts BP control ?
By multivariate analysis
Odds p
Statin on admission 1.79 0.030
Diuretics on admission 1.77 0.033

53. The Raub
Heart Study
Prevalence of Hypertension,
Diabetes and Obesity
1993 1998
Males
Hypertension 26.2 30.6
Diabetes 4.4 4.7
Obesity 3.1 5.2
Overweight 17.7 30.9
Females
Hypertension 29.4 31.7
Diabetes 3.5 7.5
Obesity 10.5 12.3
Overweight 25.3 31.1

54. Blood pressure and vascular risk in diabetes
Best evidence: 2000
UK Prospective Diabetes Study

55. UKPDS
SBP
UK Prospective Diabetes Study

56. Blood pressure reduction
165 Placebo
Perindopril-Indapamide Average BP
155 during follow-up
Mean Blood Pressure (mmHg)
145 Systolic 140.3 mmHg
135 134.7 mmHg
125 ∆ 5.6 mmHg (95% CI 5.2-6.0); p<0.001
115
105
95
85
Diastolic
75 77.0 mmHg
∆ 2.2 mmHg (95% CI 2.0-2.4); p<0.001 74.8 mmHg
65
R 6 12 18 24 30 36 42 48 54 60
Follow-up (Months)

57. All-cause mortality
10
Placebo
Perindopril-Indapamide
COVERSYL PLUS
Cumulative incidence (%)
14%
5
Relative risk reduction
14%: 95% CI 2-25%
p=0.025
0
0 6 12 18 24 30 36 42 48 54 60
Follow-up (months)

58. Conclusion
Hypertension is getting more prevalent in
Malaysia
Awareness and control rates are still poor
Understanding the profile of our patients is
important for optimum management

59. A typical Malaysian Hypertensive
- Back to Reality !
Diagnosed late
Has other concomitant cardiovascular
risk factors
Has complications of hypertension
including target organ damage and target
organ complications
BP not optimally controlled
We have more works to do?

60. Thank You for Your
Attention !