HT guideline management97
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Management in HypertensionMunchukorn Leelatanon, MD
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ContentsLifestyle interventionsCriteria for starting antihypertensive drug
treatmentBlood pressure targetsPatients education and adherence to drug
treatment
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Reference
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Lifestyle interventions Weight reduction Diet and exercise Relaxation Reduce alcohol
consumption and stop smoking
Discourage excessive consumption of caffeine
Low sodium diet
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Weight reductionWeight circumference
Men < 90 cm Women < 80 cm
BMI 22.5 – 25 kg/m2
OrlistatBariatic surgery
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Diet control Mediterranean dietDASH diet
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Low salt diet< 2,300 mg/day
NaCl <6g/day
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Moderate alcohol consumptionMen 2 drink (20-30g/day)Women 1 drink (10-20g/day)
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Stop smokingNicotine replacement therapyBupropionVarenicline Motivational interview
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ExercisePreventing cardiovascular
disease
50-70% max HR
70-85% max HR
Maximum HR = 220 - age
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Effectiveness of lifestyle modification
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Criteria for starting antihypertensive drug treatmentJNC 8
Age ≥ 60 years BP ≥ 150/90 mmHg
Age < 60 years BP ≥ 140/90 mmHg
Diabetes BP ≥ 140/90 mmHg
CKD BP ≥ 140/90 mmHg
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SBP ≥ 160 mmHg or DBP ≥100 mmHg
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Criteria for starting antihypertensive drug treatmentNICE guideline
Age < 80 years old with stage 1 HT with target organ damage established cardiovascular disease renal disease Diabetes 10-year cardiovascular risk equivalent to 20% or
greater. Any age with stage 2 HT
BP ≥ 140/90 at clinicOr
BP ≥ 135/85 at home
BP ≥ 160/100 at clinic
OrBP ≥ 150/95 at
home
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Choosing antihypertensive drug treatmentOffer drugs taken only once a dayPrescribe non-proprietary drugs where these
are appropriate and minimise cost.Do not combine ACEI and ARB
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Treatment steps for hypertension
1
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SBP >160 mmHg and/orDBP >100 mmHg
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2
3
4
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Treatment steps for hypertension
Beta-blockers may be considered in younger people :
•intolerance or contraindication to ACEI and ARB or
•women of child-bearing potential or
•increased sympathetic drive
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If a CCB is not suitable•Edema •intolerance•evidence of heart failure•high risk of heart failure
offer a thiazide-like diuretic. (Chlortalidone or indapamide)
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If a CCB is not suitable•offer a thiazide-like diuretic. (Chlortalidone or indapamide)
For black people of African or Caribbean family origin, •ARB in preference to an ACE inhibitor in combination with CCB
If initiated with a beta-blocker and a second drug is required•CCB is better than a thiazide-like diuretic to reduce risk of developing diabetes
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If clinic BP > 140/90 mmHg after optimal or best tolerated doses of an •ACE inhibitor or an ARB plus a •CCB plus a •diuretic
Resistant HT •consider adding a fourth antihypertensive drug and/or seeking expert advice.
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If serum K ≤ 4.5 mmol/l •low-dose spironolactone (25 mg once daily)
If serum K > 4.5 mmol/l •higher-dose thiazide-like diuretic
If further diuretic therapy is not tolerated, or is contraindicated or ineffective, •consider an alpha- or beta-blocker.
Monitor •serum Na •Serum K •renal function within 1 month & repeat as required thereafter.
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Blood pressure targets< 80 years
Clinic BP < 140/90 mmHg Home BP < 135/85 mmHg
≥ 80 years Clinic BP < 150/90 mmHg Home BP < 145/85 mmHg
JNC 8 (2014)< 60 years
BP < 140/90 mmHg ≥ 60 years
BP < 150/90 mmHg
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Antihypertensive drugs Beta-blockers Diuretics Calcium antagonists Angiotensin-converting enzyme inhibitors Angiotensin receptor blockers Renin inhibitors Alpha blockers Vasodilators
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RE Jackson, MC Bellamy, antihypertensive drugs, BJA education, 14 January 2015 http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku061
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Calcium channel blocker
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Renin inhibitors
ACE inhibitors
ARB
Aldosterone
antagonists
SE: hyperkalemia, hypotension
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http://my-lifespan.com/coverex.html
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Renin inhibitors
Aliskiren Great use if combine with
HCTZ or ARB
Cough, Angioedema
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Diuretics
FurosemideBumetanid
e
Thiazide-- HCTZThiazide like -- Indapamide-- Chlortalidone
Epithelial sodium channel blockers-- Amiloride-- Triamterene
Aldosterone antagonist-- Spinorolactone-- Eplerenone
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Thiazide VS thiazide like diuretics
Rik H.G. Olde E, Wijnanda JF, Bas VB, Lizzy MB, Liffert V, Bert-JH. Effects of Thiazide-Type and Thiazide-Like Diuretics on Cardiovascular Events and Mortality, American Heart Association,2015.
TL diuretics resulted in a 12% additional risk reduction for cardiovascular events (P=0.049) and a 21% additional risk reduction for heart failure (P=0.023) when compared with TT diuretics.
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Beta-blockers
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Alpha blockers Doxazosin Prazosin Terazosin
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Vasodilators
Hydralazine Minoxidil
Sodium nitroprusside
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Contraindications
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White coat hypertensionWithout additional risk factors
Lifestyle changes only + close F/U
With a higher CV risk because of metabolic derangements or asymptomatic OD drug treatment + addition to lifestyle changes
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Masked hypertensionLifestyle modification + antihypertensive drug
treatment
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Isolated systolic hypertensionStart with diuretics or DHP or CCB
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ElderlyPatients with SBP ≥160 mmHg
Reduce SBP to 140 – 150 mmHg In fit elderly patients <80 years old
Start drug at SBP values ≥140 mmHg Target SBP <140 mmHg if treatment is well tolerated.
All hypertensive agents are recommended and can be used in the elderly,
Diuretics and CCB may be preferred in isolated systolic hypertension.
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DiabetesStart drug treatment when SBP is ≥140 mmHg. SBP goal <140 mmHgDBP goal <85 mmHg. All classes of antihypertensive agents are
recommended RAS blockers may be preferred, especially in
the presence of proteinuria or microalbuminuria.
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CKDLowering SBP to <140 mmHg If overt proteinuria is present, SBP values <130
mmHg RAS blockers are more effective in reducing
albuminuria than other antihypertensive agentsCombination of two RAS blockers is not
recommendedAldosterone antagonists is not recommended
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Stroke or TIADon’t start drug in first week after acute stroke
Clinical judgement should be used in very high SBP
Start drug treatment even SBP is in the 140–159 mmHg
SBP goal of <140 mmHg ]Drug of choice : ACE inhibitors, diuretics
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Coronary heart diseaseSBP goal <140 mmHg Recent myocardial infarction beta-blockers
are recommendedDiuretics, beta-blockers, ACE inhibitors,
angiotensin receptor blockers, and/or mineralocorticoid receptor antagonists are recommended in patients with heart failure or severe LV dysfunction to reduce mortality and hospitalization.
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Resistant hypertension Resistance to treatment when lifestyle modification + 3
antihypertensive drugs (include diuretics) fail to reach goal of SBP < 140 mmHg, DBP < 90 mmHg
Consider stopping all current drugs and restart with a simpler treatment regimen under close medical supervision
Mineralocorticoid receptor antagonists (amiloride) and alpha-1-blocker (doxazosin) should be considered
Invasive procedures renal denervation and baroreceptor stimulation
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Renovascular hypertension RAS blockers cannot be used in bilateral
renal artery stenosis or in unilateral artery stenosis with evidence of functional importance by ultrasound examinations or scintigraphy.
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Primary aldosteronism the treatment of choice is unilateral
laparoscopic adrenalectomy mineralocorticoid receptor antagonists is
indicated in patients with bilateral adrenal disease (idiopathic adrenal hyperplasia and bilateral adenoma
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Pregnancy Start when BP ≥140/90 mmHg with
Gestational hypertension (with or without proteinuria) Pre-existing hypertension with the superimposition of
gestational hypertension Hypertension with asymptomatic OD or symptoms at any
time during pregnancy
Methyldopa, labetalol and nifedipine Beta-blockers and diuretics should be used with caution ACE inhibitors, ARBs, renin inhibitors are contraindated
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JNC8
NICE
ESC
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