Treatment of Hypertension

Nur Samsu
Division of Nephrology and Hypertension
2014

Initial Evaluation
1.

2.

3.
4.
5.

Confirm diagnosis (Repeat

readings, home BP, ABP)
Screen for secondary causes
Estimate CV risk status
Assess Target Organ Damage
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
BP (mmHg)
Other RF,
OD or
disease

Normal

High normal

Grade 1

Grade 2

SBP 120129
or DBP 8084

SBP 130139
or DBP 8589

SBP 140159
or DBP 9099

SBP 160179
or DBP 100109

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

Grade 3

Reproduced from the Task Force of ESHESC. J Hypertens 2007;25:110587

Copyright 2007, with permission from Lippincott Williams and Wilkins

Co-morbid conditions
Hypertension Syndrome!!
Its More Than Just Blood Pressure
Obesity

Decreased
Arterial
Compliance

Endothelial
Dysfunction
Abnormal
Glucose
Metabolism

Abnormal Lipid
Metabolism

Hypertension

Accelerated
Atherogenesis
LV Hypertrophy
and Dysfunction

Abnormal
Insulin
Metabolism

Neurohormonal
Dysfunction

Renal-Function
Changes
Blood-Clotting
Mechanism
Changes

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.

More Than 80% of Hypertensive Patients Have

Additional Comorbidities
Men

None
19%

Women

Four
8%
Three
22%

One
26%

Two
25%

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

None
17%

Four
12%
Three
20%

One
27%
Two
24%

>50% have 2 or more comorbidities

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

Hypertension Management Algorithm

ESH-ESC 2013

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

Management Algorithm of Hypertension

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
General population Diabetes or CKD
(no diabetes or CKD)
present

Age 60 years

Age < 60 years

All ages Diabetes

present , No CKD

SBP <150 mm Hg
DBP <90 mm Hg

SBP <140 mm Hg
DBP <90 mm Hg

SBP <140 mm Hg
DBP <90 mm Hg

Nonblack

Initiate thiazide-type diuretic

or ACEI or ARB or CCB,
alone or in combination a

All ages CKD

present with or
without diabetes

SBP <140 mm Hg
DBP <90 mm Hg
All Races

Black

Initiate thiazide-type
diuretic or CCB, alone or
in combination

Initiate ACEI or ARB,

alone or in combination
with other drug class a

Select a drug treatment titration strategy

A. Maximize first medication before adding second or
B. Add second medication before reaching maximum dose of first medication or
C. Start with 2 medication classes separately or as fixed-dose combination.
2014 Guideline for Management of High Blood Pressure JNC 8

Goals of Therapy
Condition

Target
SBP and DBP mmHg

Isolated systolic hypertension

Age > 80 years

<140
< 150

Systolic/Diastolic Hypertension
Systolic BP
Diastolic BP

<140
<90

Diabetes
Systolic
Diastolic

<130
<80
11

CHEP 2013

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

Factors affecting choice of

antihypertensive drug
Individualized treatment
Compelling indications:

Diabetes Mellitus

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
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

The Foundation of a Modern Blood

Pressure Treatment Regimen
BP lowering
CVD
Protection

Structural
regression
Reno
Protection

Metabolic
benefits
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