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PRIMARY HYPERTENSIONAkhmad JalaludinsyahOverviewEssential hypertension refers to high blood pressure with no identifiable cause.

Blood PressureBP = CO x PVRPeripheral Vascular Resistance Inherent stiffness of arterial wall Vasodilation- Beta-2 adrenergic innervation- Nitric oxide c-AMP Vasoconstriction- Alpha-1 adrenergic innervation- Circulating catecholamines- Angiotensin IIAetiology of HypertensionPrimary hypertension (90-95% of cases)Secondary hypertension* Renal* DrugsHormonal / oral contraceptiveNSAIDs* EndocrinePhaeochromocytomaCusings syndromeConns syndromeAcromegaly and hypothyroidism* Coarctation of the aorta and aortitis* Pregnancy-induced hypertensionPathogenesis of Hypertension

Kaplan. Clinical Hypertension. 2006Hypertension Pathophysiology Three teories: 1. Inability of the kidneys to excrete sodium, resulting in natriuretic factors such as Atrial Natriuretic Factor being secreted to promote salt excretion with the side-effect of raising total peripheral resistance. 2. An overactive renin / angiotensin system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension. 3. An overactive Sympathetic nervous system, leading to increased stress responses. 2013 ESH/ESC Guidelines for the management of arterial hypertension

European Heart JournalAdvance Access published June 14, 2013ESH ESC HT guidelinesWhats new for 2013(1) Epidemiological data on hypertension and BP control in Europe.(2) Strengthening of the prognostic value of home blood pressure monitoring (HBPM) and of its role for diagnosis and management of hypertension, next to ambulatory blood pressure monitoring (ABPM).(3) Update of the prognostic significance of night-time BP, white-coat hypertension and masked hypertension.(4) Re-emphasis on integration of BP, cardiovascular (CV) risk factors, asymptomatic organ damage (OD) and clinical complications for total CV risk assessment.(5) Update of the prognostic significance of asymptomatic OD, including heart, blood vessels, kidney, eye and brain. (6) Reconsideration of the risk of overweight and target body mass index (BMI) in hypertension.(7) Hypertension in young people.(8) Initiation of antihypertensive treatment. More evidence-based criteria and no drug treatment of high normal BP.(9) Target BP for treatment. More evidence-based criteria and unified target systolic blood pressure (SBP) (inc. CV events: OSA, DM, CKD

Search for asymptomatic organ damageEKG in all HT patients (I, B)Stress EKG if chest pain (I, C)Serum Cr & eGFR, urine protein (dipstick), microalbuminuria (spot) in all HT patients (I,B)Difficult-to-control HT: fundoscopy (IIa, C)ABI (IIa, C)When to start Anti-HT RxBP 140/90 after lifestyle change (I, B)BP 160/100: start drug promptly (I, A)Elderly: SPB 160 mmHg (I,A)Not recommend anti-HT drug for High normal BP (130-139 / 85-89 mmHg) (III, A)ISH in young patient, but should close F/U with lifestyle change (III, A)

2007Elderly: start drug if BP 140/90DM, CKD, CVD: start drug if BP > 130 / 85 Initiation of lifestyle changes and antihypertensive drug treatment.

Risk Fx: male, age 55 (M) 65 (F), smoking, dyslipidemia, IFG, abnormal OGTT, obesity, abdominal obesity, FHx premature CVD < 55 yr (M), < 65 yr (F)Unified target SBP < 140 mmHg in both lower, higher CV riskDM: high to very high riskRisk: Low Moderate High Very highInitiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated. Colours are as in Figure 1. Consult Section 6.6 for evidence that, in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg. In the high normal BP range, drug treatment should be considered in the presence of a raised out-of-office BP (masked hypertension). Consult section 4.2.4 for lack of evidence in favour of drug treatment in young individuals with isolated systolic hypertension.BP targetSBP < 140 mmHgDM (I,B) Low-moderate CV risk (I,A) Previous stroke/TIA, CHD, CKD (IIa)Elderly < 80 yr: SPB keep 140-150 mmHg (I, A)Elderly > 80 yr: 140-150 mmHg if good physical and mental condition (I, B)DBP < 90 mmHg for allExcept DM: DBP < 85 mmHg

Lifestyle change (I,A for all)Salt restriction 5-6 gm/day Moderate alcohol intake: not more than 20-30 gm/d (M), 10-20 gm/d (F)Increased fruits, vegetablesReduce weight to BMI of 25 kg/m2, waist circumference < 102 cm (M), < 88 cm (F) Regular exercise 30 min/day, 5 days/wkStop smoking1 drink

Moderate drinking: no more than two drinks a day for men and no more than one drink a day for women.

* One drink = 0.6 fluid oz. = 13.7 gm of alcohol 28

New

Drug choice / treatment strategyStart / maintain, monotherapy / combination Diuretics, BB, CCB, ACEI, ARB all suitable & recommended (I, A).Some drugs should be preferred in specific conditions (IIa, C).Markedly high baseline BP or high CV risk: start two-drug combination may be considered (IIb, C).

Main benefit of drug: to reduce BP. Most patients need 2 drugs to achieve target BP.Monotherapy vs. drug combination strategies to achieve target BP. Moving from a less intensive to a more intensive therapeutic strategy should be done whenever BP target is not achieved.

Monotherapy vs. drug combination strategies to achieve target BP. Moving from a less intensive to a more intensive therapeutic strategy should be done whenever BP target is not achieved.Combination of 2 antagonists of RAS: not recommended and should be discouraged (III, A).Combinations of 2 drugs at fixed doses in single tablet may be recommended and favored (IIb, B).

Possible combinations of classes of antihypertensive drugs.

Only DHP-CCB should normally be combined with beta-blockersThiazide + BB: increased new-onset DMGreen continuous lines: preferred combinations; Green dashed line: useful combination (with some limitations); Black dashed lines: possible but less well-tested combinations; Red continuous line: not recommended combination.Possible combinations of classes of antihypertensive drugs. Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination. Although verapamil and diltiazem are sometimes used with a beta-blocker to improve ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium antagonists should normally be combined with beta-blockers.

White-coat & masked HTWhite-coat HT, no risk Fx: lifestyle change & close F/U (IIa, C)White-coat HT + high CV risk or TOD: consider drug Rx (IIb, C)Masked HT: lifestyle change + drug Rx (IIa, C)

ElderlyAge < 80 yr: may consider start drug when SBP 140 mmHg & target < 140 if tolerated (IIb, C) Age > 80 yr: 140-150 mmHg if good physical and mental condition (I, B).When reach > 80 yr: consider to continue drug if well-tolerated (IIa, C)Frail elderly: depend on clinicians judgement (I, C)

All drugs are recommended and can be used (I, A)Diuretics & CCB: preferred in isolated systolic HT (I, A).Start drug when SBP 160 mmHg: -> aim SBP 140-150 mmHg (I, A)Pregnant womenIf BP > 160/110 mmHg, treatment is recommended (I, C).Consider drug Rx (IIb, C) BP 150/95mmHg, or BP 140/90 mmHg + TOD Methyldopa, labetolol, nifedipine preferred (IIa, B)Pre-eclampsia: IV labetolol or nitroprusside (IIa, B)

DMStart drug Rx when SPB 140 mmHg (I, A).Target SBP < 140/85 mmHg (I, A).All classes of drugs are recommended and can be used (I, A). RAS blockers preferred, especially if having proteinuria / microalbuminuria (I, A).

Metabolic syndromeStart drug Rx if 140/90 mmHg (I, B). Target BP < 140/90 mmHg (I, B).Lifestyle changes, particularly weight loss and exercise (I, B).RAS blockers and CCB should be preferred (IIa, C).BB* and thiazides: only as add-on Rx (IIa, C).

* Newer vasodilating BB (carvedilol, nebivolol): affect insulin sensitivity LESS than metoprolol. Nebivolol not worsen glucose tolerance when added to HCTZ.HT with nephropathyTarget SBP < 140 mmHg (IIa, B).Overt proteinuria: target SBP < 130 mmHg may be considered (IIb, B).RAS blockers indicated for HT with over proteinuria or microalbuminuria (I, A).Recommend combining RAS blockers with other anti-HT drugs to achieve target BP (I, A).Combining two RAS blockers is not recommended (III, A).Aldosterone antagonists not recommened in CKD (III, C).Atherosclerosis, arteriosclerosis, peripheral artery diseaseTarget BP < 140/90 mmHg.Carotid atherosclerosis: CCB, ACEI (IIa, B).PAD: BB may be considered. Their use does not appear to be associated with worsening of PAD symptoms (IIIb, A).Resistant HTMR antagonist, amiloride, doxazosin should be considered.If drugs are ineffective: renal denervation and baroreceptor stimulation may be considered (IIb, C) (only by experienced operators at restricted HT centers).Summary: ESH ESC 2013Diagnosis of HTOffice BP 140/90ABPM (daytime) or HBPM 130/85When to start RxBP 140/90 after lifestyle change 160/100 start promptlyElderly SBP 160Initial medicationACEI, ARB, CCB, BB, Thiazides all suitable and recommendedWhen to start 2 drug combinationMarked BP elevationHigh/very high CV riskTarget BPSBP < 140 for all * 140-150 for elderly < 80 yr < 130 for overt proteinuria ** DBP < 90 mmHg for all < 85 mmHg for DMSBP < 140 recommended in DM should be considered in CHD, previous stroke/TIA, CKD/DKD SPB < 130 may be considered in overt proteinuria Compelling indicationsLVH: ACEI/ARB, CCBMicroalbuminuria: ACEI/ARBDM: ACEI/ARBMetS: ACEI/ARB, CCBPrev stroke: any drug effectively lower BPPrev MI: BB, ACEI/ARBESRD/proteinuria: ACEI/ARBPAD: ACEI, CCBISH (elderly): Diuretic, CCBPreferred combinationThiazide + ACEI or ARB or CCBCCB + ACEI or ARBNot recommendedACEI + ARB combinationSummary: ESH ESC 2013ExcesssodiumintakeReducednephronnumberStressGeneticalterationObesityEndotheliumderivedfactorsRenalsodiumretentionDecreasedfiltrationsurfaceSympatheticnervousoveractivityRenin-angiotensinexcessCellmembranealterationHyper-insulinemiaIncreasedfluidvolumeVenousconstrictionIncreasedpreloadIncreasedcontractabilityFunctionalconstrictionStructuralhypertrophyBLOOD PRESSURE = CARDIAC OUTPUTHypertension = Increased Cardiac OutputPERIPHERAL RESISTANCEIncreased Peripheral Resistancexand/orautoregulation