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Candra Wibowo
Nephrology Division, Medical School of Trisakti University Jakarta
RENAL REGISTRY CENTER
JNC 7, 2002
Publication of many new observ. studies & clinical trials Need new, clear & concise guideline useful Need simply classification JNC 6 reports were not being used to max benefit
CVD events
Risk CVD begins at 115/75 mmHg 40-70 yrs : 20/10 mmHg at beginning 115/75 mmHg have 2 x > 50 yrs : systolic > 140 mmHg much more important than diastolic 55 yrs w/ normotensi 90% lifetime risk for developing HPT HPT continuous, consistent & independent of heart attack, heart failure, stroke, kidney dis. PRE HYPERTENSION : ( 2x) risk progression to hypertension should be health promotion life style modifications STAGE 2 & 3 STAGE 2 : simply & prognosis 2 = 3
RENAL REGISTRY CENTER
ESC/ESH, 2003
1. Flexible approach to def & treat 2. Goal is reduction BP long term CVD risk 3. Pre hypertension pts anxious & intrusive lifestyle changes, medical visits & lab. test 4. Pre hypertension looking at idea the whole life was a pre-death experience
The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)
RENAL REGISTRY CENTER
Systolic
<120 120129 130139 140159 160179 >180 >140 and and/or and/or and/or and/or and/or and
Diastolic
<80 8084 8589 9099 100109 >110 <90
Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressure values in the ranges indicated,provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication of total cardiovascular risk.
Systolic
<120 120129 130139 140159 160179 >180 >140 and and/or and/or and/or and/or and/or and
Diastolic
<80 8084 8589 9099 100109 >110 <90
Isolated systolic hypertension should be graded (1 ,2,3) according to systolic blood pressurevalues in the ranges indicated, provided that diastolic values are <90 mmHg. Grades 1 , 2and 3 correspond to classication in mild, moderate and severe hypertension, respectively. These terms have been now omitted to avoid confusion with quantication of total cardiovascular risk.
Borderline hypertens
Grade I (mild) Grade 2 (moderate) Grade 3 (severe)
140 - 149 90 94
140 - 159 90 99 160 - 179 100 109 180 110
140 - 159 90 - 99
160 100
Stage I
Stage II
>140
> 140
< 90
< 90
>140
< 90
TREATMENT OF HYPERTENSION
Life style modification Not at Goal BP (<140/90 mmHg for those with DM or CKD) Initial drug choices Hypertension without compelling indications Hypertension with compelling indications
Stage 1 Thiazide type diuretics Consider ACE-I, ARB, BB, CCB or combination
Dietary
Dietary Sodium
Fresh Fruits Vegetables Low Fat dairy products Low fat diet in accordance with the DASH diet
Restrict to target range of 65-100 mmol/day (Most of the salt in food is hidden and
comes from processed food)
Dietary Potassium
If required, daily dietary intake >80 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html
Physical Activity
Should be prescribed to reduce blood pressure F I T T
Frequency - Four or more days per week Intensity Time Type - Moderate - 30-60 minutes Dynamic exercise - Walking, jogging - Cycling - Non-competitive swimming
For patients who are prescribed pharmacological therapy: exercise should be prescribed as adjunctive therapy
RENAL REGISTRY CENTER
Alcohol
Low risk alcohol consumption
0-2 drinks/day Men: maximum of 14 drinks/week Women: maximum of 9 drinks/week
1 drink = one beer, or 1 glass of wine or 1 ounce of 40% spirit
Stress Management
Stress management
Hypertensive patients in whom stress appears to be an important issue Behaviour Modification Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed
Weight Loss
Hypertensive and all patients BMI over 25 for hypertension - Encourage weight reduction - Healthy BMI: 18.5-24.9 kg/m2 Waist Circumference < 102 cm (90 cm in Asia Pacific) for men < 88 cm (80 cm in Asia Pacific) for women
For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification.
Recommendation
Maintain normal body weight (BMI 18.5-24.9) Consume a diet rich in fruits, vegetables & low fat dairy products with a reduced content of saturated & total fat Reduce dietary sodium intake to no more than 100 mEq/L (2.4 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week) Limit consumption to no more than 2 drinks per day (1 oz or 30 ml ethanol, eg, 24 oz beer, 10 oz wine or 3 oz 80 proof whiskey) in most men and no more than 1 drink per day in women and lighter weight persons
2-8 mmHg
4-9 mmHg
2-4 mmHg
Change
- 100 mmol/day - 4.5 kg - 2.7 drinks/day 3 times/week
SBP/DBP
-5.8 / -2.5 -7.2 / -5.9 -4.6 / -2.3 -7.4 / -5.8
Dietary patterns
DASH diet
-11.4 / -5.5
* 1- Exercise and Hypertension. Medicine & Science in Sports & Exercise. 36(3):533-553, March 2004. 2- Result of aggregate and metaanalyses of short term trials. Miller ER et al. J Clin Hyper 1999: Nov/Dec:191-8.
Summary
Intervention
Sodium restriction Weight loss Waist Circumference Alcohol restriction Exercise Dietary patterns Smoking cessation
Target
65-100 mmol/day BMI <25 kg/m2 < 102 (90) cm for men < 88 (80)cm for women Less or equal to 2 drinks/day at least 4 times/week DASH diet Smoke free environment
130/80 mmHg
130/80 mmHg
Proteinuria
Diabetes mellitus
K/DOQI NKF, 2002
Target (mmHg)
< 140/90
Nonpharmacologic
Low salt diet, exercise
Pharmacologic treatment
Beta blockers Diuretics
With proteinuria (> 1 g/dl) With proteinuria (< 1 g/dl) Without proteinuria
With HD With PD
ACE Inh, ARB (diuretics) ACE Inh, ARB (diuretics) ACE Inh, ARB (diuretics)
All agents, except diuretics All agents, except diuretics ACE Inh, ARB, CCB (diuretics) ACE Inh, ARB, CCB (diuretics)
K/DOQI NKF, 2002
ESRD
RRT
MULTIPLE RISKS FACTORS INTERVENTION STRATEGY TO SLOW THE PROGRESSION OF RENAL DISEASE
INTERVENTION Control BP ACE-I / AII RB therapy Control glucose (DM) Protein intake intervention
LEVEL I
LEVEL II
LEVEL III
UKPDS
ABCD MDRT HOT AASK
DBP <85
DBP <75 MAP <92 DBP <80 MAP <92 1 4 2 3 No. Antihypertension agents
YES
Individualized Treatment (with compelling indications)
Thiazide
ACE-I
ARB
Longacting CCB
Betablocker*
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
RENAL REGISTRY CENTER
Thiazide diuretic
Long-acting calcium channel blocker*
Thiazide diuretic
ACE-I
ARB
Long-acting CCB
Betablocker*
CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?
Dual Combination
Thiazide diuretic
ARB
CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?
Thiazide diuretic
ARB
CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?
Dual combination
Compelling indications: Smoking 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
Diabetes Mellitus With Diabetic Nephropathy Without Diabetic Nephropathy Global Vascular Protection for Hypertensive Patients Statins Aspirin
RENAL REGISTRY CENTER
Smoking
Beta-blocker
The benefits of treating smokers with beta-blockers remain uncertain in the absence of a specific indications like angina or post-MI
Stable angina
Treatment of Hypertension in Pts with Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Recent myocardial infarction
If beta-blocker contraindicated or not effective YES Long-acting DHP CCB (Amlodipine, Felodipine)
If additional therapy is needed: Diuretic* for CHF class III-IV: Aldosterone Antagonist If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination
Beta-blockers used in clinical were bisoprolol, carvedilol and metoprolol. Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a physician experienced in heart failure management particularly for NYHA Class III-IV patients
Stroke TIA
Renal disease
Caution in the use of ACE-I/ARB in bilateral renal artery stenosis or unilateral disease with solitary kidney
Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with: uncontrolled hypertension despite therapy with three or more drugs, or deteriorating renal function, or bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney), or recurrent episodes of flash pulmonary edema.
RENAL REGISTRY CENTER
Diabetes
without Nephropathy
Systolicdiastolic Hypertension Isolated Systolic Hypertension
ACE-I or ARB
IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE Cardioselective BB or Long-acting CCB or Thiazide diuretic
If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired RENAL REGISTRY CENTER
* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol More than 3 drugs may be needed to reach target values for diabetic patients RENAL REGISTRY CENTER
Diabetes
without Nephropathy
COMBINATION : ADD Cardioselective BB or Long-acting CCB or Thiazide diuretic, or an ACE-I with an ARB (or vice versa) More than 3 drugs may be needed to reach target values for diabetic patients If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired
Summary I
Regarding the treatment of hypertension, the recommendations endorse: Individualizing therapy consider concomitant risk factors and/or concurrent diseases (i.e., diabetes, CVD, renal disease) Treating to target BP treat aggressively to achieve individualized targets
Summary II
Regarding the treatment of hypertension, the recommendations endorse: Lifestyle modification alone if effective to reach the goal value or in combination with pharmacological treatment
Summary III
Regarding the treatment of hypertension, the recommendations endorse: Using combination therapy the addition of medications in combination to achieve BP targets is preferred over maximal dose titration or serially switching drugs Promoting adherence a multi-faceted approach should be used to improve adherence with both non pharmacological and pharmacological strategies
Summary IV
Hypertension is a major factor responsible for progression of atherosclerotic disease. Therefore, a comprehensive treatment of hypertension should aim at CV risk reduction strategies, including management of all associated risk factors.