PRACTICAL APPROACHES

TO HYPERTENSION
DR MOHAMMAD NASIM
SENIOR GP CONSULTANT
BADRUDDIN MEDICAL GROUP

FACTS
The number of adults around the world
living with hypertension has nearly doubled
since 1975, from 594 million to over 1.1
billion in 2015, a large study shows.
THE LANCET ONLINE,NOV.15,2016

The number of people living with

hypertension is predicted to be 1.56
billion worldwide by the year 2025.

FACTS
First heart attack: About 7 of every 10
people having their first heart attack have
high blood pressure. ...
First stroke: About 8 of every 10 people
having their first stroke have high blood
pressure.

FACTS
Congestive heart failure:About 7 of every
10 people with congestive heart failure
have high blood pressure.
Kidney diseaseis also a major risk factor
for high blood pressure.

 In the US, around 75 million(32%) people have

hypertension, with more people dying of
hypertension-related cardiovascular disease than
from the next three deadliest diseases combined.
In 2011-2012 in the US, about a third of all people
over the age of 20 years had hypertension,
based on high blood pressure assessments
and the number of people taking antihypertensive
medications

 Approximately16 million people in the

UK(25%)kloltytrrhavehighbloodpressure.
30 per cent of womenand32 per cent of
menhavehighbloodpressure.
Uptotheageof64therearehigher rates of
menwithhighbloodpressurethanwomen.
Amongwomen,levelsofhighblood
pressure increase as income decreases.

 Approximately62,000 unnecessary deathsfrom

strokeandheartattacksoccurduetopoorblood
pressurecontrolinUK.
Approximatelyone thirdofpeoplewithhighblood
pressuredo not know that they have it.
Morethan90 per cent of peoplewithhighblood
pressurewhoarereceivingtreatmentare not
controlledto140/90mmHg.
Most peoplewithhighbloodpressurewhoneedto
takemedications,willneed to take two or moreto
ensurethattheirbloodpressureislowereddownto
atargetof140/85mmHg.

 People with hypertension are more likely

to develop complications of diabetes.
HYPERTENSION is called the Silent
Killer" because it often has no warning
signs or symptoms, and many people do
not realize they have it; that is why it's
important to get blood pressure checked
regularly.

 More than360,000American deaths in

2013 included hypertension as a primary or
contributing cause.That is almost1,000
deaths each day.

FACTS(CONTD)
Control of hypertension has become a key national priority
in the US as part of the Million Hearts initiative from the
Department of Health and Human Services, which aims to
prevent 1 million heart attacks and strokes in the US by
2017.
A relatively small reduction in BP may affect the
incidence of cardiovascular disease on a
population basis. A decrease in BP of 2 mm

Hg reduces the risk of stroke by 15% and

the risk of coronary artery disease by 6%
in a given population

FACTS(CONTD)
The increasing prevalence of the condition
is blamed on lifestyle and dietary factors,
such as physical inactivity, alcohol and
tobacco use, and a diet high in sodium
(usually from processed and fatty foods)

KEY FINDINGS OF THE STUDY

PUBLISHED IN THE
LANCET,NOV.15,2016

Canada, the United Kingdom, Australia,

the United States, Peru, South Korea, and
Singapore had the lowest proportion of
adults living with raised blood pressure in
2015 (below or around 1 in 8 women and
1 in 5 men).

 More than a third of men in several central

and eastern European countries, including
Croatia, Latvia, Lithuania, Hungary, and
Slovenia, have high blood pressure, and
about a third of women living in most
countries in West Africa (eg, Niger, Chad,
and Mali) have high blood pressure.

 In 2015, over half (590 million) of adults with

high blood pressure lived in East, Southeast,
and South Asia, of whom 199 million lived in
India and 226 million in China.
In 2015, systolic blood pressure levels were
lowest in South Korea and Canada, at about
118 mmHg for men and 111 mmHg for women.
Men had higher blood pressure than women in
most world regions in 2015.

THE REAL TRUTH

HYPERTENSION IS
EASY TO DIAGNOSE
BUT DIFFICULT TO
TREAT.

EASY TO DIAGNOSE
Normal blood pressure is below 120 systolic and below 80 diastolic,
Prehypertension -- 120-139 systolic or 80-89 diastolic,
Stage 1 hypertension - 140-159 systolic or 90-99 diastolic
Stage 2 hypertension - 160 or higher systolic or 100 or higher
diastolic.
Hypertensive crisis -blood pressure is
above 180 systolic or above 110 diastolic.

DIFFICULT TO TREAT
WHY?
DIFFICULT TO CLASSIFY WHETHER IT IS PRIMARY OR SECONDARY HTNALTHOUGH
PRIMARY HYPERTENSION IS MUCH MORE COMMON THAN SECONDARY HYPERTENSION,BUT
WE HAVE TO DIFFERENTIATE BETWEEN THEM BECAUSE SECONDARY HYPERTENSION IS
MOSTLY CURABLE..
HYPERTENSION ,EVEN NEWLY DIAGNOSED CASES,HAVE COMPLICATIONS EITHER HIDDEN
OR OBVIOUS----WE HAVE TO SEARCH THESE COMPLICATIONS BEFORE THE TREATMENT.
PATIENTS WITH HYPERTENSION MAY HAVE SOME OTHER ASSOCIATED DISEASES LIKE
DIABETES MELLITUS,THYROID DISORDERS OR OTHER ENDOCRINE
DISORDERS,DYSLIPIDEMIA,KIDNEY DISEASES,CARDIAC DISEASES ,RESPIRATORY
DISEASES,OPHTHALMIC DISEASES ETC ---WE HAVE NOT ONLY TO KEEP THESE ASSOCIATED
DISEASES INTO CONSIDERATION WHILE TREATING THE CASE OF HYPERTENSION,BUT WE
HAVE TO EVALUATE THE TREATMENT OF THESE DISEASES ALSO BECAUSE THESE DISEASES
ARE DIRECTLY OR INDIRECTLY GOING TO AFFECT OUR TREATMENT OF HYPERTENSION.
THE FUTURE COMPLICATIONS OF HYPERTENSION HAVE TO KEEP IN OUR MIND BEFORE
STARTING THE TREATMENT

WHAT COMPLICATIONS OR ASSOCIATED

DISEASES ARE IMPORTANT TO US
Diabetes (both due to renal complications and nerve damage)
Renal disease
Pheochromocytoma

Cushing syndrome (which can be caused by use of corticosteroid drugs)

Congenital adrenal hyperplasia
Hyperthyroidism.Hyperparathyroidism (which affects calcium and phosphorous levels)
Pregnancy
Sleep apnea
Obesity.

Dyslipidemia

CARDIAC COMPLICATIONS
Cardiac involvement in hypertension
manifests as LVH, left atrial
enlargement, aortic root dilatation,
atrial and ventricular arrhythmias,
systolic and diastolic heart failure,
and ischemic heart disease

Anteroposterior x-ray from a 28-year

old woman who presented with
congestive heart failure secondary to
her chronic hypertension, or high
blood pressure. The enlarged cardiac
silhouette on this image is due to
congestive heart failure due to the
effects of chronic high blood pressure
on the left ventricle. The heart then
becomes enlarged, and fluid

BASIC LAB INVESTIGATIONS

FOR NEWLY DIAGNOSED
CASES OF HYPERTENSION
urinalysis; fastingblood glucoseor
A1c;hematocrit;serum sodium,
potassium,creatinine(estimated or
measured glomerular filtration rate
[GFR]), and calcium; and lipid profile

Assessment of suspected secondary causes

Condition

Screening Test

Chronic kidney disease

Estimated glomerular filtration rate

Coarctation of the aorta

Computed tomography
angiography

Cushing syndrome; other

states of glucocorticoid
excess (eg, chronic steroid
therapy

Dexamethasone suppression test

Drug-induced/drug-related
hypertension*

Drug screening

Pheochromocytoma

24-hour urinary metanephrine and

normetanephrine

Primary aldosteronism,
other states of
mineralocorticoid excess

24-hour urinary aldosterone level,

specific mineralocorticoid tests

Renovascular hypertension

Doppler flow ultrasonography,

magnetic resonance angiography,
computed tomography angiography

Sleep apnea

Sleep study with oxygen saturation

(screening would also include the
Epworth Sleepiness Scale [ESS])

Thyroid/parathyroid disease

Thyroid stimulating hormone level,

serum parathyroid hormone level

REASONS TO DO THESE
INVESTIGATIONS

Presence of end-organ disease

Possible causes of hypertension
Cardiovascular risk factors
Baseline values for judging
biochemical effects of therapy

THE MOST MPORTANT AND

MOST DIFFICULT ASPECT OF
TREATMENT

TO CHANGE THE
LIFE STYLE OF THE
PATIENT

WHAT LIFESTYLE CHANGES WE

HAVE TO DO..

AGE,RACE,FAMILY HISTORY AND

SEX ARE NON MODIFIABLE RISK
FACTORS,BUT WHAT ABOUT
OTHER RISK FACTORS THAT WE
CAN MODIFY BY CHANGING THE
LIFE STYLE OF THE PATIENT.

MODIFIABLE RISK FACTORS

INCREASED BODY WEIGHT/OBESITY

PHYSICAL INACTIVITY
SMOKING
STRESS AND STRAIN
DIETARY HABITS
ALCOHOL INTAKE

HYPERTENSIONA MODIFIABLE
RISK FACTOR
Hypertension,itself, is the most important
modifiable risk factor for coronary heart
disease , stroke , congestive heart failure,
end-stage renal disease, and peripheral
vascular disease. Therefore, health care
professionals must not only identify and
treat patients with hypertension but also
promote a healthy lifestyle and preventive
strategies to decrease the prevalence of
hypertension in the general population

PATHOPHYSIOLOGY OF
HYPERTENSION
Regulation of normal blood pressure
(BP) is a complex process. Arterial BP
is a product of cardiac output and
peripheral vascular resistance. The
factors affecting cardiac output
include sodium intake, renal function,
and mineralocorticoids; the inotropic
effects occur via extracellular fluid
volume augmentation and an
increase in heart rate and

PATHOPYSIOLOGY (CONTD)
Peripheral vascular resistance is
dependent upon the sympathetic
nervous system, humoral factors,
and local autoregulation. The
sympathetic nervous system
produces its effects via the
vasoconstrictor alpha effect or the
vasodilator beta effect.

The JNC 8 recommendations

In patients aged 60 years or older, initiate
therapy in those with systolic BP levels at
150 mm Hg or greater or whose diastolic
BP levels are 90 mm Hg or greater; treat
to below these thresholds.
In patients younger than 60 years as well
as those older than 18 years with either
chronic kidney disease (CKD) or diabetes,
the BP treatment initiation and goals
should be 140/90 mm Hg

The JNC 8 recommendations(contd)

In nonblack hypertensive patients, begin
treatment with either a thiazide-type
diuretic, CCB, ACE inhibitor, or ARB
In hypertensive black patients, initiate
therapy with a thiazide-type diuretic or
CCB
Regardless of race or diabetes status, in
patients 18 years or older with CKD, initial
or add-on therapy should consist of an ACE
inhibitor or ARB

The JNC 8 recommendations(contd)

Do not use an ACE inhibitor in conjunction with an
ARB in the same patient
If a patient's goal BP is not achieved within 1 month
of treatment, increase the dose of the initial agent
or add an agent from another of the recommended
drug classes; if 2-drug therapy is unsuccessful for
reaching the target BP, add a third agent from the
recommended drug classes
In patients whose goal BP cannot be reached with 3
agents from the recommended drug classes, use
agents from other drug classes and/or refer the
patients to a hypertension specialist

Collaborative AHA/ACC/CDC
advisory recommendations
BP: Recommended goal of 139/89 mm Hg or less
Stage 1 hypertension (systolic BP 140-159 mm Hg
or diastolic BP 90-99 mm Hg): Can be treated with
lifestyle modifications and, if needed, a thiazide
diuretic
Stage 2 hypertension (systolic BP >160 mm Hg or
diastolic BP >100 mm Hg): Can be treated with a
combination of a thiazide diuretic and an ACE
inhibitor, an angiotensin receptor blocker, or a
calcium channel blocker
Patients who fail to achieve BP goals: Medication
doses can be increased and/or a drug from a
different class can be added to treatment

Joint ESH and ESC guidelines(contd)

In patients younger than 80 years, the systolic BP
target should be 140 to 150 mm Hg, but
physicians can go lower than 140 mm Hg if the
patient is fit and healthy; the same advice applies
to octogenarianshowever, the patient's mental
capacity and physical heath should also be
considered if targeting to less than 140 mm Hg
Patients with diabetes should be treated to below
85 mm Hg diastolic BP
Salt intake should be limited to approximately 5 to
6 g per day

Joint ESH and ESC guidelines(contd)

Body-mass index (BMI) should be reduced

to 25 kg/m2and waist circumferences
should be reduced to less than 102 cm in
men and less than 88 cm in women
Ambulatory BP monitoring (ABPM) should
be incorporated into the assessment of risk
Effective combination therapies include
thiazide diuretics with ACE inhibitors, ARBs
or calcium-channel antagonists, ; or,
calcium-channel antagonists with ARBs or
ACE inhibitors.

Joint ESH and ESC guidelines

Dual renin-angiotensin system
blockade (i.e. ,ACE inhibitors, ARBs,
and direct renin inhibitorsaliskiren/Tekturna) is not
recommended because of the risks of
hyperkalemia, low BP, and kidney
failure
Although additional data is needed,
renal denervation is a promising
therapy in the treatment of resistant

FUTURE TREATMENT
Recent studies with bilateral

radiofrequency renal nerve

ablation have shown a significant
reduction of blood pressure in drugresistant patients.Similar reductions
in blood pressure have shown

bilateral carotid artery

stimulation in the same
populations.

Hypertension remains the first cause of

death

7 million deaths

Can You Imagine

FA
ST

STRON
G

Super
ior

More over strong BP

reduction and BP control,
COVERSYL also has a
unique protection package.

Trial

Active treatment

ADVANCE 1

Risk reduction versus control

Renal events

CV death

All-cause death

perindopril/indapamide

IDNT 2

irbesartan

RENAAL 3

losartan

na

ONTARGET 4

telmisartan/ramipril

TRANSCEND 5

telmisartan

DIRECT 6

candesartan

ROADMAP 7

olmesartan

8
3. Brenner BM, et al. N Engl J Med.
2001;345:861-869. 4. Mann JF, et al. Lancet 2008;372:547-553.
benazepril/amlodipine
ACCOMPLISH
+
5. Mann JF, et al. Ann Intern Med. 2009;151:1-10. 6. Bilous R, et al. Ann Intern Med. 2009;151:11-20.

1. Patel A, et al. Lancet. 2007;370:829-840. 2. Lewis EJ, et al. N Engl J Med. 2001;345:851-860.
7. Haller H, et al. N Engl J Med. 2011;364:907-917. 8. Bakris GL. Lancet 2010;375:1173-1181.

WHEN

MATTE

The 2013 ESH/ESC guidelines recommends

for
Diabetic hypertensive patients
a target BP of

140/85 mm Hg

Excess cardiovascular risk in

diabetic patients is attributable to
coexistent hypertension
Participants with hypertension at the time of
diabetes diagnosis had higher rates of all-cause
mortality and cardiovascular disease than did
people with diabetes without hypertension
All-cause
mortality
Cardiovascul
ar disease
event

Ferrannini E, Cushman WC. Lancet. 2012;380(9841):601-610.

+72%
+57%
For internal use

Achieving BP control in hypertensive

patients with diabetes is A Big

Challenge
n=919
ABPM recordings
T2DM patients with treated hypertension

2015

85%

of hypertensive patients with diabetes have

uncontrolled hypertension

41%

Despite this,
remained on unchanged
antihypertensive therapy

1. Mengden T et al. ABSTRACT/POSTER, ESC 2015.

For internal use

If
If 140
140 is
is your
your
goal,
goal, BiBipreterax
preterax is
is
your
your
BEST
BEST

Rapid BP Reduction

Perindopril / Indapamide
Effecti
Effective
ve
Blood Pressure Reduction

1.
2.
3.
4.

PellaD.High Blood Press Cardiovasc Prev. 2011;18:107-113.

FarsangC;PICASSOinvestigators. Blood Press.2013;22(Suppl1):3-10.
KarpovYu.A,etal;.J Hypertens. 2013;31(e-SupplA).
NetchessovaTA,ShepelkevichAP,GorbatTV,LazarevaIV;NIKAStudyGroup.High Blood Press Cardiovasc Prev.ePubaheadofprint.

Bi-Preterax provides MORE

27 mm Hg blood pressure reduction

BiPreterax
FarsangC.Inpress.

Bi-Preterax ensures effective BP

reduction ADAPTED to the severity of
your HT-patients with diabetes

n= 2762 hypertensive patients with

diabetes

Farsang C et al; PICASSO investigators. Adv in Therapy. 2014;31:333-344.

Bi-Preterax
10 Patients

NORMALIZES 9 Out of

9/1
0
*Control rate for systolic (<140 mm Hg) and diastolic blood pressure (<90 mm Hg)
1.
2.
3.
4.

PellaD.High Blood Press Cardiovasc Prev. 2011;18:107-113.

FarsangC;PICASSOinvestigators. Blood Press.2013;22(Suppl1):3-10.
KarpovYu.A,etal;.J Hypertens. 2013;31(e-SupplA).
NetchessovaTA,ShepelkevichAP,GorbatTV,LazarevaIV;NIKAStudyGroup.High Blood Press Cardiovasc Prev.ePubaheadofprint.

Both Components Provide

24-H EFFICACY

1.MyersMG,etal.Can J Cardiol.1996;12:1191-1196.2.MorganT,AndersonA,etal.Clin Exp Pharmacol Physiol.1992;19:61-65.3.

MallionJM,AsmarR,BoutelantS,etal.JCardiovasc Pharmacol.1998;32:673-678.4.PerticoneF,PuglieseF,CeravoloR,MattioliPL.
Cardiology.1994;85:36-46.5.McCarronD,etal.Clin Cardiol.1991;14:737-742.6.ZannadF,MatzingerA,LarchJ.Am J Hypertens.
1996;9:633-643. 7. Lacourcire Y, Poirier L, Lefebvre J, et al. Am J Hypertens.1995;8:1154-1159. 8. Song JC, White CM.
Pharmacotherapy.2000;20:130-139.

SUPERIORITY OVER COARBs

Bi Preterax SUPERIOR to other

RAASi in controlling Diabetic
hypertensive patients

HIGHER Control Rate

STRONGER BP Control than ARB

76
Clinical Drug Invest 2002: 22 (8): 553-560

Indapamide is significantly more effective

than HCTZ at reducing blood pressure
Additional BP efficacity of Indapamide vs HCTZ
Systematic review and meta-analysis; 10 head-to-head Randomized Clinical Trials comparing HCTZ-indapamide
and HCTZ-chlortalidone at commonly used doses n=883

HCTZ

SBP mm
Hg

CTD

54%

INDAPAMIDE

HCTZ =
Hydrochlorothiazide

CTD = Chlorthalidone
-5.1 mm Hg, (95% CI, 8.7 to 1.6), P=0.004

1. Roush et al. Hypertension. 2015;65(5):1041-1046.

SAFETY PROFILE

Perindopril/Indapamide
is highly appreciated
Tolerability rated
good or very
good by:
Patients: 98%
Doctors: 99%

NetchessovaTA,ShepelkevichAP,GorbatTV,LazarevaIV;NIKAStudyGroup.High Blood Press Cardiovasc Prev.ePubaheadofprint.

Perindopril/Indapamide Improves
the Patients Metabolic Profile

Indapamide:
The Diuretic Providing The Best
Protection

1. Ambrosioni E, Safar M, Degautec J-P, et al. J Hypertens. 1998;16:1677-1684. 2. Akram J, Sheikh UE, Mahmood M, et al. Curr
Med Res Opin. 2007;23:2929-2936. 3. Gaciong Z, Symonides B. Expert Opin Pharmacother. 2010;11:2579-2597. 4. Beckett NS,
Peters R, Fletcher AE, et al. N Engl J Med. 2008;358:1887-1898. 5. Gosse P, Sheridan DJ, Zannad F, et al. J Hypertens.
2000;18:1465-1475.6.MarreM,GarciaJ,KokotF,etal.J Hypertens. 2004;22:1613-1622.

Indapamide Should Be Used

In Preference To Hydrochlorothiazide

NationalClinicalGuidelineCentreUK.Hypertensiontheclinicalmanagementofprimaryhypertensioninadults.August2011.

Your reference treatment for

hypertensive patients with diabetes

Effective
blood
pressure
reduction
Life-saving
benefits
Optimal
tolerability
profile

4 Endorsed By
guidelines

Perindopril / Indapamide ensures effective

blood pressure reduction, which is adapted
to the severity of patients with diabetes
Bi Preterax controls 9 patients with diabetes
out of 10

Perindopril / Indapamide significantly

reduces total mortality by 9% and
cardiovascular mortality by 12% over 10
years

Perindopril / Indapamide improves the

metabolic profile of patients with diabetes
with a Tolerability acknowledged by doctors
and patients

Perindopril / Indapamide is the ADA 2015

reference treatment for Diabetic
hypertensive patients.

Conclusion
Bi preterax provides Powerful BP
reduction

-45/-21

mmHg SBP/DBP.
Rapid BP control.
Renal protection
Cardio vascular protection.
Total mortality reduction.
ARBs are not equal to ACEi

Saves Lives

86