Nur Samsu

Division of Nephrology and Hypertension

2014

Treatment of Hypertension

Initial Evaluation

1. Confirm diagnosis (Repeat

readings, home BP, ABP)

2. Screen for secondary causes

3. Estimate CV risk status

4. Assess Target Organ Damage

5. Co-morbid conditions

Common problems in BP

measurement

Wrong cuff size

Excess pressure of

stethoscope

Patient arm at the wrong level

White coat effect

Auscultatory Gap (silent gap)

Risk Factors of Clinical Events

BP level

Calculated CV risk (estimated from factors

such as age, gender, smoking history etc.)

Presence of target organ damage

Presence of established CV disease

Concomitant disease associated with CV risk

(e.g. diabetes or CKD)

FRAMINGHAM RISK CALCULATOR

Blood Pressure and Cardiovascular Risk:

ESHESC Guidelines

Other RF,

OD or

disease

BP (mmHg)

Normal SBP 120129 or DBP 8084

High normal SBP 130139 or DBP 8589

Grade 1 SBP 140159 or DBP 9099

Grade 2 SBP 160179

or DBP 100109

Grade 3 SBP 180

or DBP 110

No other RF Average risk Average risk Low added

risk

Moderate

added risk

High added

risk

12 RF Low added

risk

Low added

risk

Moderate

added risk

Moderate

added risk

Very high

added risk

3 RF, MS,

OD or

diabetes

Moderate

added risk

High added

risk

High added

risk

High added

risk

Very high

added risk

Established

CV or renal

disease

Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

Very high

added risk

MS = metabolic syndrome

OD = subclinical organ damage

RF = risk factors Reproduced from the Task Force of ESHESC. J Hypertens 2007;25:110587

Copyright 2007, with permission from Lippincott Williams and Wilkins

Hypertension Syndrome!!

Its More Than Just Blood Pressure

Decreased Arterial

Compliance Endothelial Dysfunction

Abnormal Glucose

Metabolism

Neurohormonal Dysfunction

Renal-Function Changes

Blood-Clotting Mechanism

Changes

Obesity

Abnormal Insulin

Metabolism

LV Hypertrophy and Dysfunction

Accelerated Atherogenesis

Abnormal Lipid Metabolism

Hypertension

Kannel WB. JAMA. 1996;275:1571-1576. Weber MA et al. J Hum Hypertens. 1991;5:417-423. Dzau VJ et al. J Cardiovasc Pharmacol. 1993;21(suppl 1):S1-S5.

Co-morbid conditions

More Than 80% of Hypertensive Patients Have Additional Comorbidities

>50% have 2 or more comorbidities

Men

Kannel WB. Am J Hypertens. 2000:13:3S-10S.

Comorbidities:

Obesity Glucose intolerance Hyperinsulinemia Reduced HDL-C Elevated LDL-C Elevated TG LVH

Four 8%

Three 22%

Two 25%

One 26%

None 19%

Women

Four 12%

Three 20%

Two 24%

One 27%

None 17%

Hypertension Management Algorithm

ESH-ESC 2013

Mancia et al. Eur Heart J 2013;34(28):2159-219

Diabetes or CKD

present

General population

(no diabetes or CKD)

Nonblack Black

Adult aged 18 years with hypertension

Implement lifestyle interventions (continue throughout management)

Set BP goal and initiate BP lowering-medication based on age,

diabetes, and CKD

Age 60 years

SBP

11

Condition Target

SBP and DBP mmHg

Isolated systolic hypertension

Age > 80 years

Indications for Pharmacotherapy

Strongly consider prescription if:

Average DBP > 90 mmHg and:

Hypertensive with Target-organ damage or

Independent cardiovascular risk factors

Elevated systolic BP

Cigarette smoking

Abnormal lipid profile

Strong family history of premature CV disease

Truncal obesity

Sedentary Lifestyle

Average DBP > 80 mmHg in a patient with diabetes or

CKD CHEP 2013

Individualized treatment

Compelling indications: Ischemic Heart Disease

Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

Left Ventricular Systolic Dysfunction

Cerebrovascular Disease

Left Ventricular Hypertrophy

Non Diabetic Chronic Kidney Disease

Renovascular Disease

Smoking

Diabetes Mellitus With Nephropathy

Without Nephropathy

Global Vascular Protection for Hypertensive Patients Statins if 3 or more additional cardiovascular risks

Aspirin once blood pressure is controlled CHEP 2013

Factors affecting choice of

antihypertensive drug

The Foundation of a Modern Blood

Pressure Treatment Regimen

BP lowering Structural

regression

Metabolic

benefits

CVD

Protection

Reno

Protection

Tolerability

Combination Therapy

Choosing the right antihypertensive

Condition Preferred drugs Other drugs that can

be used

Drugs to be

avoided

Asthma CCBs a-blockers/ARB/Diuretics/

ACE-i

b-blockers

Diabetes

mellitus

a-blockers/ACE-i/

ARB

CCBs Diuretics/

b-blockers

High

cholesterol

levels

a-blockers ACE-i/ARB/ CCB b-blockers/

Diuretics

Elderly

patients

CCBs b-blockers/ACE-i/

ARB/a- blockers

BPH a- blockers

b-blockers/ ACE-i/ ARB/

Diuretics/ CCBs