New (1999) WHO-ISH Definitions and Classification of BP Levels CategorySystolic BPDiastolic BP(mm...
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New (1999) WHO-ISH Definitionsand Classification of BP Levels
Category Systolic BP Diastolic BP(mm Hg) (mm Hg)
Optimal BP <120 <80Normal BP <130 <85High-Normal 130-139 85-89
Grade 1 Hypertension (mild) 140-159 90-99 Subgroup: Borderline 140-149 90-94Grade 2 Hypertension (moderate) 160-179 100-109Grade 3 Hypertension (severe) >180 >110
Isolated Systolic Hypertension >140 <90 Subgroup: Borderline 140-149 <90
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What is the Goalof the Practice Guidelines?
To lower blood pressure (BP) and other risk factors in order to reduce the risk of cardiovascular disease (CVD)
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Why is Hypertension Management Needed? (1)
• 600 million hypertensives in the world
• 3 million die annually as a direct result of hypertension
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Why is Hypertension Management Needed? (2)
The Rule of Halves• Only 1/2 have been diagnosed
• Only 1/2 of those diagnosed have been treated
• Only 1/2 of those treated are adequately controlled
• Thus, only 12.5% overall are adequately controlled
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Why BP <130/85 mm Hgand Not <140/90 mm Hg? (1)
• The relationship between CV risk and BP is continuous
• Today, more than 50% of all hypertensives have BP >160/90 mm Hg and 75% have BP >140/90
• The major determinant of the risk reduction conferred by antihypertensive therapy is the BP level attained
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Why BP <130/85 mm Hgand Not <140/90 mm Hg? (2)
• In diabetics, there is a clear benefit of lowering BP <85 mm Hg
• The HOT Study showed that lowering BP < 85 mm Hg did not increase CV risk
• The goal should be to attain normal BP (<130/85 mm Hg)
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What is High Blood Pressure?
• BP levels are continuously related to the risk of CVD
• Definition of hypertension or raised BP is arbitrary
• Even within the normotensive range, people with the lowest BP levels have the lowest rates of CVD
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Relative Risk of CHD and Stroke in Relation to Patient’s Usual Diastolic BP
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Clinical Evaluation - What Should Be Done?
• Confirm elevation of BP
• Exclude or identify secondary causes of hypertension
• Determine presence of target organ damage and quantify extent
• Search for other CV risk factors and clinical conditions that may influence prognosis and treatment
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Multiple BP Measurements Recommended
Because BP is characterized by large spontaneous variations, diagnosis should be based on multiple BP measurements taken on several separate occasions
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Minimum RoutineInvestigations
Clinical and family history
Full physical examination as described in medical textbooks
Laboratory investigations, including:– urinalyses for blood, protein, and glucose– microscopic examination of the urine– blood chemistry for potassium, creatinine, fasting glucose,
and total cholesterol
Electrocardiography (ECG)
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“Isolated” Office Hypertension
In some patients office BP is persistently elevated whereas daytime BP outside clinic environment is not. Continuing debate whether “isolated” office hypertension (“white coat hypertension”) is an innocent phenomenon or carries an increased risk of CVD
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Ambulatory BP Monitoring
BP values obtained by home measurement or ambulatory monitoring are several mm Hg lower than office measurement
Average 24 hour or home BP values around 125/80 mm Hg = office BP 140/90 mm Hg
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Which Factors Influence Prognosis? (1)
Decisions should not be made on BP alone, but also on presence of other risk factors, target organ damage, and
concomitant diseases, as well as on other aspects of patients’ personal, medical, social, economic, ethnic, and
cultural characteristics
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• Risk factors of CVD
I. Used for risk stratificationII. Other factors adversely influencing
prognosis
• Target organ damage (TOD)
• Associated clinical conditions (ACC)
Which Factors Influence Prognosis? (2)
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Which Factors Influence Prognosis? (3)
I. Used for risk stratification• Levels of systolic and diastolic blood
pressure (Grades 1-3)• Men >55 years• Women >65 years• Smoking• Total cholesterol >6.5 mmol/L (250 mg/dl)• Diabetes• Family history of premature
cardiovascular disease
Risk factors for CVD
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Which Factors Influence Prognosis? (4)
II.Other factors adversely influencing prognosis• Reduced HDL cholesterol• Raised LDL cholesterol• Microalbuminuria in diabetes• Impared glucose tolerance• Obesity• Sedentary lifestyle• Raised fibrinogen• High risk socioeconomic group• High risk ethnic group• High risk geographic region
Risk factors for CVD
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Which Factors Influence Prognosis? (5)
Target organ damage (TOD)• Left ventricular hypertrophy (electrocardiogram,
echocardiogram, or radiogram)
• Proteinuria and/or slight elevation of plasma creatinine concentration 106-177 mmol/L (1.2-2.0 mg/dl)
• Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac, and femoral arteries, aorta)
• Generalised or focal narrowing of the retinal arteries
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Which Factors Influence Prognosis? (6)
Associated clinical conditions (ACC)
Cerebrovascular disease• Ischaemic stroke• Cerebral haemorrhage• Transient ischaemic attack (TIA)
Heart disease• Myocardial infarction• Angina pectoris• Coronary revascularisation• Congestive heart failure
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Which Factors Influence Prognosis? (7)
Associated clinical conditions (ACC)Renal disease
• Diabetic nephropathy• Renal failure, plasma creatinine concentration
>177 mmol/L (>2.0 mg/dl)Vascular disease
• Dissecting aneurysm• Symptomatic arterial disease
Advanced hypertensive retinopathy• Haemorrhages or exudates• Papilloedema
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Stratifying Risk - Quantifying Prognosis
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Effects of Antihypertensive Treatment in Randomised Controlled Trials
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Initiate lifestyle measures wherever appropriate in all patients, including those
who require drug treatment
• Smoking cessation
• Weight reduction
• Moderation of alcohol consumption
• Reduction of salt intake
• Increased physical activity
Management Strategy
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Principles of Drug Treatment (1)
• Use a low dose of one drug to initiate therapy
• If good response and tolerability but inadequate control increase the dose of the first drug
• If little response or poor tolerability change to another drug class
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Principles of Drug Treatment (2)
• It is often preferrable to add a small dose of a second drug rather than increase the dose of the first drug
• Use long-acting drugs providing 24-hour efficacy on a once daily basis. Improves adherence to therapy and minimizes BP variability.
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Principles of Drug Treatment (3)
There are six maindrug classes used worldwide - diuretics, beta-blockers, ACE
inhibitors, calcium antagonists, alpha blockers, and angiotensin
II antagonists.
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Principles of Drug Treatment (4)
All 6 classes are suitable for the initiation and maintenance of BP lowering therapy, but the choice
of drugs will be influenced by cost and by many factors for special groups
of patients. In some parts of the world, reserpine and methyldopa are
also used frequently.
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Indications
Compelling PossibleHeart failure Diabetes
Elderly patients
Systolic hypertension
Diu
reti
cs
Contraindications
Compelling PossibleGout Dyslipidaemia
Sexually active
males
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IndicationsCompelling Possible
Angina Heart failure
After myocardial infarct Pregnancy
Tachyarrhythmias DiabetesContraindications
Compelling Possible
Asthma and Dyslipidaemia
Chronic obstructive Athletes and
Pulmonary disease Physically active
Heart block (AV 2,3) Patients
Peripheral
vascular disease
Beta
-Blo
ckers
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IndicationsCompelling PossibleAngina Peripheral
Elderly patients Vascular disease
Systolic hypertension
Calc
ium
Anta
gonis
ts
Contraindications
Compelling PossibleHeart block (AV 2,3) Heart failure** verapamil or diltiazem
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IndicationsCompelling Possible
Heart failure
Left ventricular dysfunct
After myocardial infarct
Diabetic nephropathy
ContraindicationsCompelling Possible
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
AC
E Inhib
itors
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ACE inhibitors:Mech. of eff.: inhibition of the conversion of AT I onto AT II, degradation of bradykine,
decrease of PVR and slight venodilatation vasokonstriction ATII, secretion of aldosterone -natriuresis regression of hypertrophia of left ventricle and vessel’s wall
heart insufficiency - mortality rate 20-30 %
glom. pressure - proteinuria during DM nephropatia
- cardioprotective, vasoprotective and renoprotective eff.
AE: hypotension after initial dose, renal impairment (acute renal insufficiency, hyperkalaemia, dry cough, angioedema
short acting: captoprile - three times a day
medium term: enalaprile - twice a day
long acting: perindoprile, lisinoprile, quinaprile, ramiprile, spiraprile, trandolaprile
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Indications
Compelling Possible
Prostatic Hypertrophy Glucose intolerance
Dyslipidaemia
Contraindications
Compelling Possible
Orthostatic
hypotension
Alp
ha-B
lock
ers
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- blockersCentral acting - 2, I1 rec. - decrease of sympatic influence
clonidine - 2,I1-agonist - renal hypertension, !sedation, dyssomnia
methyldopa, guanfacine - 2-rec.
moxonidine, rilmenidine - imidazolin I1 rec. reserpine -depletion of catecholamines - only in combination - NÚ!!!
Combined - urapidile - block of postsyn. 1-rec., activation of 5-HT1Arec. in CNS
Peripheral -blockers 1 - prazosine, doxazosine, metazosine, terazosine
1+2 - phentolamine - th. of feochromocytoma + - labetalol, carvedilol
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Indications
Compelling Possible
ACE-I cough Heart failure
ContraindicationsCompelling Possible
Pregnancy
Bilateral renal
Artery stenosis
Hyperkalaemia
Ang
iote
nsi
n II
Anta
gonis
ts
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Antagonists of AT II:
Antagonists of AT II block of AT1 rec., regression of hypertr. LV, renoprotective eff. In AE of ACEI losartan, valsartan, irbesartan, telmisartan,……
Direct vasodilat. eff.: hydralazines (endralazine, dihydralazine), minoxidil, sodium nitroprusside reflex. tachycardia - in combination with -blockers and diuretics
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Combination Therapy (1)
In most patients, appropriate combination therapy produces BP
reductions that are twice as great as those obtained with monotherapy.
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Combination Therapy (2)Effective drug combinations to treat hypertension are:
• diuretic and beta-blocker• diuretic and ACE inhibitor (or Angiotensin II
antagonist)• calcium antagonist (dihydropyridine) and
beta-blocker• calcium antagonist and ACE inhibitor• alpha-blocker and beta-blocker
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Other Drugs to Consider in Hypertension
• Aspirin
• Cholesterol lowering therapy
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Treatment Goal
The goal of antihypertensive treatment should be to achieve “optimal” or “normal” BP in young, middle-aged, or diabetic subjects (below 130/85 mm Hg), and at least “high-
normal” BP in elderly patients (below 140/90 mm Hg)
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How should hypertensionduring pregnancy be defined?
Hypertension in pregnancy usually defined as:
pre-existing chronic hypertension de novo diagnosed, gestational hypertension or
pre-eclampsia pre-eclampsia superimposed on chronic
hypertension
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Antihypertensive drugsmost widely used acutely
during pregnancy
• Nifedipine
• Labetalol
• Hydralazine
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• Beta-blockers:oxprenolol, pindolol, labetalol
atenolol, however, is associated with fetal growth retardation when used long-term throughout pregnancy
• Methyldopa
• Prazosin, hydralazine, nifedipine, and isradipine
Antihypertensive drugsmost widely used chronically
during pregnancy
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Drugs most widelyavoided during pregnancy
• ACE inhibitors (associated with possible adverse fetal effects)
• Angiotensin ll antagonists (effects may be similar to ACE inhibitors)
• Diuretics used infrequently because of concerns of reducing already compromised plasma volume
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Hypertensionin Type-2 Diabetics (1)
• Diabetes and hypertension are multiplicative risk factors for CVD
• Absence of hypertension in diabetes is associated with a better long-term survival
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Hypertensionin Type-2 Diabetics (2)
• Progressive decline in glomerular function can be slowed with antihypertensive treatment
• Similar lifestyle measures are recommended for hypertension and diabetes
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Hypertensionin Type-2 Diabetics (3)
Good evidence for reductionin CVD events in diabetic patients treated
with antihypertensivedrugs, including diuretics,
and more recently, beta-blockersand ACE inhibitors
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Hypertensionin Type-2 Diabetics (4)
The goal of antihypertensive treatment in Type-2 diabetics should be to achieve
“optimal” or “normal” BP (that is below 130/85 mm Hg)