ESSENTIAL HYPERTENSION

DEFINITION

• Essential, primary, or idiopathic hypertension is defined as high BP in which secondary causes or mendelian (monogenic) forms are not present

• High BP – repeatedly measured BP exceeding 140/90 mmHg, i.e. a systolic BP above 140 and/or diastolic BP above 90

Aetiology of Hypertension

• Primary – 90-95% of cases – also termed “essential” of “idiopathic”

• Secondary – about 5% of cases– Renal or renovascular disease– Endocrine disease

• Phaeochomocytoma• Cusings syndrome• Conn’s syndrome• Acromegaly and hypothyroidism

– Coarctation of the aorta– Iatrogenic

• Hormonal / oral contraceptive• NSAIDs

Definitions and classifications of BP levels

2003 ESH/ESC guidelines for the management of arterial hypertension

Definitions and classifications of BP levels

JNC 7th Report on Prevention, Detection, Evaluation and Treatment of High Blood Pressure

WHO Classification of Hypertension (1993)

• Stage I – no evident signs of target organ damage

• Stage II – presence of at least one of the following signs of target organ damage:

Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography) Retina: generalized or focal narrowing of retinal arteries Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:

Heart: angina pectoris, myocardial infarction, heart failure Brain: stroke, TIA, vascular dementia Retina: haemorrhages, exudates, papilloedema Kidney: renal insufficiency (creatinine>2mg/ml) Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial disease

Adapted from WHO/ISH Recommendations on Hypertension. Journal of Hypertension 2003, Vol 21 No 6

Blood pressure (mmHg)

Other risk factors and

disease history

NormalSBP 120-129 or

DBP 80-84

High normalSBP 130-139 or DBP 85-89

Grade 1SBP 140-159 or DBP 90-99

Grade 2SBP 160-179 or DBP 100-109

Grade 3SBP ≥180 or DBP ≥110

I. No other risk factors

Average risk Average riskLow added

riskModerate added risk

High added risk

II. 1-2 risk factors

Low added risk

Low added risk

Moderate added risk

Moderate added risk

Very high added risk

III. ≥3 risk factors or target organ damage or diabetes

Moderate added risk

High added risk

High added risk

High added risk

Very high added risk

IV. Associated clinical conditions

High added risk

Very high added risk

Very high added risk

Very high added risk

Very high added risk

DEFINITION

The “New Definition” of hypertension must include overall risk (ND Kaplan, MD, 2005 ASH meeting)

EPIDEMIOLOGY

• Treatment Approaches:• Lifestyle• Pharmacological

Swales JD (ed.) Textbook of hypertension. Oxford: Blackwell Scientific Publishers. © 1994, 22–36

EPIDEMIOLOGY

Burt et al., Hypertension 1995;25:305–13.

Trends in awareness, treatment, and control of high blood pressure in adults aged 18-74*

Multiple interactions in the pathogenesis of hypertension

MAJOR RISK FACTORS

• Age• Genetics and family history• Family and personal history of hyperlipidaemia• Family and personal history of diabetes• Cigarette smoking• Environment (stress, sedentary lifestyle)• Weight• Dietary habits (high alcohol intake, high

sodium intake, low potassium intake)• Race• Personality

Search for exogenous potentially modifiable factors that can induce/aggravate hypertension• Salt• Excessive Alcohol• Recreational drugs (e.g. cocaine)• Non-steroidal anti-inflammatory drugs• Oral contraceptive pill• Corticosteroids• Anabolic steroids• Erythropoietin• Calcineurin inhibitors (cyclosporin, tacrolimus)• Ephedrine /pseudo-ephedrine• Licorice• Sleep apnea

DiagnosisDiagnostic procedures are aimed at:1. Establishing BP levels2. Identifying secondary causes of hypertension3. Evaluating the overall CV risk by searching for other

risk factors, target organ damage, concomitant diseases or accompanying clinical conditions.

The diagnostic procedures comprise:1. Repeated BP measurements2. Medical history3. Physical examination4. Laboratory and instrumental investigations

Procedures for Blood Pressure Measurement

Blood Pressure Assessment

Medical History1. Duration and previous level of high BP

2. Indications of secondary hypertension Family history of renal disease (polycystic kidney) Renal disease, UTI, haematuria, analgesic abuse (parenchymal renal

disease) Drug/substance intake: oral contraceptives, liquorice, nasal drops,

cocaine, steroids, NSAID’s, erythropoietin, cyclosporin Episodes of sweating, headache, anxiety, palpitation

(phaeochromocytoma) Episodes of muscle weakness (aldosteronism)

3. Risk factors

4. Symptoms of organ damage

5. Previous antihypertensive therapy (drugs used, efficacy, adverse effects)

6. Personal, family, environmental factors

Symptoms of organ damage

Heart: palpitations, chest pain, shortness of breath, swollen ankles

Brain and eyes: headaches, vertigo, impaired vision, TIA’s, sensory or motor deficit

Kidney: thirst, polyuria, nocturia, haematuria

Peripheral arteries: cold extremities, intermittent claudication

Signs of organ damage

Brain: murmurs over neck arteries, motor or sensory deficits

Eyes: funduscopic abnormalities

Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, peripheral oedema

Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesions

Physical examination for secondary hypertension and organ damage

Signs suggesting secondary hypertension

Features of Cushing syndrome Skin stigmata of neurofibromatosis (phaeochromocytoma) Palpation of enlarged kidneys ( polycystic kidney) Auscultation of abdominal murmurs (renovascular hypertension) Auscultation of precordial chest murmurs (aortic coarctation or

aortic disease) Diminished and delayed femoral pulse and reduced femoral BP

(aortic coarctation or aortic disease)

White coat effect (Office-induced blood pressure elevation)

Further assessusing

24-h ambulatoryblood pressure

monitoring

If office BP measurementis elevated and Home BP

is normal

Daytime average BP over 135/85 mm Hg should be considered elevated

A drop in nocturnal BP of <10% is associated with increased risk of CV events

WHO Classification of Hypertension (1993)

• Stage I – no evident signs of target organ damage

• Stage II – presence of at least one of the following signs of target organ damage:

Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography)

Retina: generalized or focal narrowing of retinal arteries Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:

Heart: angina pectoris, myocardial infarction, heart failure Brain: stroke, TIA, vascular dementia Retina: haemorrhages, exudates, papilloedema Kidney: renal insufficiency (creatinine>2mg/ml) Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial disease

Search for target organ damage: LVH

Search for target organ damage: LVH

Sokolow-Lyons >35 mm (SV1+RV5-6)

Cornell (RavL+SV3): F: >20mm, M: >24-28 mm

Search for target organ damage: LVH

WHO Classification of Hypertension (1993)

• Stage I – no evident signs of target organ damage

• Stage II – presence of at least one of the following signs of target organ damage:

Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography)

Retina: generalized or focal narrowing of retinal arteries

Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:

Heart: angina pectoris, myocardial infarction, heart failure Brain: stroke, TIA, vascular dementia

Retina: haemorrhages, exudates, papilloedema Kidney: renal insufficiency (creatinine>2mg/ml) Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial disease

Search for target organ damage: funduscopy

Example of moderate hypertensive retinopathy:

Arteriovenous nicking (black arrows) and cotton-wool spots (white arrows)

Example of mild hypertensive retinopathy:

Arteriovenous nicking (black arrow) and focal narrowing (white arrow)

Example of malignant hypertensive retinopathy:

Multiple cotton-wool spots (white arrows), retinal haemorrhages (black arrows), and swelling of the optic disc are visible

WHO Classification of Hypertension (1993)

• Stage I – no evident signs of target organ damage

• Stage II – presence of at least one of the following signs of target organ damage:

Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography) Retina: generalized or focal narrowing of retinal arteries

Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l)

Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:

Heart: angina pectoris, myocardial infarction, heart failure Brain: stroke, TIA, vascular dementia Retina: haemorrhages, exudates, papilloedema

Kidney: renal insufficiency (creatinine>2mg/ml) Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial disease

Search for target organ damage: kidney

The diagnosis of hypertension-induced renal damage is based on the finding of

an elevated value of serum creatinine (>/=133 µmol/l (1.5 mg/dl) in men and 124 µmol/l (1.4 mg/dl) in women, or

by the finding of estimated creatinine clearance values below 60-70 ml/min

WHO Classification of Hypertension (1993)

• Stage I – no evident signs of target organ damage

• Stage II – presence of at least one of the following signs of target organ damage:

Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography) Retina: generalized or focal narrowing of retinal arteries Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l)

Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:

Heart: angina pectoris, myocardial infarction, heart failure Brain: stroke, TIA, vascular dementia Retina: haemorrhages, exudates, papilloedema Kidney: renal insufficiency (creatinine>2mg/ml) Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial disease

Search for target organ damage: vessels

IMT>/=0.9 mm

Plaques

Routine Laboratory Tests

1. Urinalysis

2. Complete blood count

3. Blood chemistry (potassium, sodium and creatinine)

4. Fasting glucose

5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides

6. Standard 12-leads ECG

Investigation of all patients with hypertension

Recommended Tests

• Echocardiogram• Carotid (femoral) ultrasound• C-reactive protein• Microalbuminuria (essential test in diabetics)• Quantitative proteinuria (if dipstick test is

positive)• Funduscopy (in severe hypertension)

Screening for Hyperaldosteronism

• Spontaneous hypokalemia (<3.5 mmol/L)

• Profound diuretic-induced hypokalemia (<3.0 mmol/L)

• Hypertension refractory to treatment with 3 or more drugs

• Incidental adrenal adenomas.

Should be considered for patients with the following characteristics:

Screening for Hyperaldosteronism

Screening for hyperaldosteronism should include plasma aldosterone and plasma renin activity- measured in morning samples- taken from patients in a sitting position after resting at least 15 minutes.

Aldosterone antagonists, ARBs, beta-blockers and clonidine should be discontinued prior to testing.

A positive screening test should lead to referral or further testing.

Screening for Pheochromocytoma

• Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy;

• Hypertension and symptoms suggestive of catecholamine excess (two or more of headaches, palpitations, sweating, etc);

• Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;

• Incidentally discovered adrenal mass;

• Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease. 

Should be considered for patients with the following characteristics:

Screening for Pheochromocytoma

• Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine

• Assessment of urinary VMA is inadequate

Blood Pressure Threshold Values for Initiation of Pharmacological Treatment of Hypertension

Condition Initiation

SBP / DBP mmHg

Diastolic ± systolic hypertension 140/90

Isolated systolic hypertension 160

Diabetes 130/80

Renal disease (130/80)

Proteinuria >1 g/day (125/75)

Lifestyle Recommendations for the Treatment of Hypertension

1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet

2. Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week or more

3. Reduction in alcohol consumption in those who drink excessively4. Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25)5. Waist Circumference

< 102 cm for men< 88 cm for women

6. In individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day

7. Smoke free environment

Lifestyle Recommendations for Hypertension: Dietary

• Fresh Fruits• Vegetables• Low Fat dairy

products• Low fat diet in

accordance with the DASH diet

http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html

Dietary SodiumRestrict to target range of 65-100

mmol/day(Most of the salt in food is hidden and

comes from processed food)

Dietary PotassiumIf required, daily dietary

intake >80 mmol

Calcium supplementationNo conclusive studies for hypertension

Magnesium supplementationNo conclusive studies for hypertension

Lifestyle Recommendations for Hypertension: Physical Activity

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Should be prescribed to reduce blood pressure

Type Dynamic exercise- Walking, jogging- Cycling- Non-competitive swimming

Time - 30-60 minutes

Intensity - Moderate

Frequency - Four or more days per weekF

I

T

T

Lifestyle Recommendations for Hypertension: Alcohol

Low risk alcohol consumption

• Women: maximum of 9 drinks/week

• Men: maximum of 14 drinks/week

• 0-2 drinks/day

1 drink = one beer, or 1 glass of wine or 1 ounce of 40% spirit

Lifestyle Recommendations for Hypertension: Stress Management

Hypertensive patientsin whom stress appears to be an important issue

Individualized cognitive behavioral interventions are more likely to be effective when relaxation techniques are employed

Stress management

Behaviour Modification

Lifestyle Recommendations for Hypertension: Weight Loss

Hypertensive and all patientsBMI over 25 for hypertension- Encourage weight reduction- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference< 102 cm for men< 88 cm 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.

Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults

Intervention Change SBP/DBP

Sodium intake - 100 mmol/day -5.8 / -2.5

Weight - 4.5 kg -7.2 / -5.9

Alcohol intake - 2.7 drinks/day -4.6 / -2.3

Exercise* 3 times/week -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.

Lifestyle Therapies in Hypertensive Adults: Summary

Intervention Target

Sodium restriction 65-100 mmol/day

Weight lossWaist Circumference

BMI <25 kg/m2

< 102 cm for men< 88 cm for women

Alcohol restriction Less or equal to 2 drinks/day

Exercise at least 4 times/week

Dietary patterns DASH diet

Smoking cessation Smoke free environment

Indications for Pharmacotherapy

Strongly consider prescription if:• Average DBP equal or over 90 mmHg and:

• Hypertensive Target-organ damage (or CVD) 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 equal or over 80 mmHg in a patient with diabetes

Treatment of Adults with Systolic-Diastolic Hypertension without Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

* Not indicated as first line therapy over 60

Beta-blocker*

Long-actingCCB

Thiazide ACE-I ARB

Lifestyle modificationtherapy

TARGET <140 mm Hg systolic and < 90 mmHg diastolic

Considerations Regarding the Choiceof First-Line Therapy

• Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent

• ACE-I are not recommended (as monotherapy) for black patients without another compelling indication

• Beta adrenergic blockers are not recommended for patients over 60 years without another compelling indication

Combination Therapy for Systolic-Diastolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or lifestyle?• White coat effect?• Resistant Hypertension?

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).

2. Triple or Quadruple Therapy

1. Dual Combination Therapy

If partial response to monotherapy

Summary: Treatment of Hypertension without Other Compelling Indications

* Not indicated as first line therapy over 60

CONSIDER

•Nonadherence?•Secondary HTN?•Interfering drugs

or lifestyle?•White coat effect?

Dual Combination

Triple or Quadruple Therapy

Lifestyle modificationtherapy

Thiazidediuretic ACE-I Long-acting

CCBBeta-

blocker* ARB

TARGET <140 mm Hg systolic and < 90 mmHg diastolic

Useful Combinations

INDICATIONS FOR INDIVIDUAL DRUG CLASSES

Treatment of Hypertension in Patients with

Ischemic Heart Disease

• Caution should be exercised when combining a non DHP-CCB and a beta-blocker• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem)

1. Beta-blocker2. Long-acting CCBStable angina

ACE-I are recommended in ALL patients with established CAD

Short-actingnifedipine

Treatment of Hypertensionin Patients with Recent ST Segment Elevation-MIor non-ST Segment Elevation-MI

Long-actingDHP CCB

(Amlodipine, Felodipine)

Beta-blocker and ACE-I

Recentmyocardialinfarction

Heart Failure

?

NO

YES

Long-acting CCB

If beta-blocker contraindicated or not effective

Treatment of Hypertension with Left Ventricular Systolic Dysfunction

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

If additional therapy is needed:• Diuretic* • for CHF class III-IV: Aldosterone Antagonist

Systoliccardiac

Dysfunction• ACE-I• if ACE-I intolerant: ARB

If ACE-I and ARB are contraindicated: Hydralazine and Isosorbide dinitrate in combination

If additional antihypertensive therapy is needed: • ACE-I / ARB Combination • Long-acting DHP-CCB (Amlodipine or Felodipine)

Non dihydropyridine

CCB

and Beta-Blocker

Treatment of Hypertensionfor Patients with Cerebrovascular Disease

Strongly consider blood pressure reductionin all patients after the acute phase of non disabling stroke or TIA .

An ACE-I / diuretic combination is

preferred

StrokeTIA

Treatment of Hypertension in Patients with Left Ventricular Hypertrophy

Vasodilators:Hydralazine, Minoxidil Can

Increase LVH

Left ventricular

hypertrophy

Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.

- ACE-I- ARB,- CCB- Diuretic- BB (below age 60)*

Treatment of Hypertension in Patients with with Non Diabetic chronic kidney disease

Renal disease

ACE-I/ARB: Bilateral renal artery stenosis

1. ACE-I2. Alternate if ACE-I not tolerated: ARB

Combination with other agents

Additive therapy: Thiazide diuretic.Alternate: If volume overload: loop diuretic

Target BP: Nondiabetic: < 130 mmHg systolic and

< 80 mmHg diastolic

Proteinuria: > 1 g/day: < 125 / 75 mmHg

Treatment of Hypertension in association with Renovascular Disease

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.

Does not imply specific treatment choice

Renovascular disease

Caution in the use of ACE-I/ARB in Bilateral renal artery stenosis or unilateral disease with solitary kidney

Treatment of Hypertension for Patients

with Diabetes Mellitus

Treatment of Hypertension for Patients with Diabetes Mellitus

Threshold ≥ 130/80 mmHg and TARGET < 130 mmHg systolic and < 80 mmHg diastolic

withNephropathy

Urinary albumin excretion rate equal or over 30 mg/dayDiabetes

withoutNephropathy

IsolatedSystolic

Hypertension

Systolic- diastolic

Hypertension

Urinary albumin excretion rate less than 30 mg/day

Treatment of Systolic-Diastolic Hypertension without Diabetic Nephropathy

ACE-Inhibitor or

ARB or

Thiazide diuretic

IF ACE-I and ARB and Thiazide are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB* or• Long-acting CCB

More than 3 drugs may be needed to reach target values for diabetic patients

Urinary albumin excretion rate less than 30 mg/day

* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol

Combination of first line agents

Addition of one or more of:

Cardioselective BB orLong-acting CCB

Diabeteswithout

Nephropathy

WithSystolic diastolic

Hypertension

Threshold ≥ 130/80 mmHg and

TARGET < 130 mmHg systolic and < 80 mmHg diastolic

Treatment of Hypertension in Association with Diabetic Nephropathy

Urinary albumin excretion rate over 30 mg/day

TARGET < 127/75 mmHg when proteinuria >1g/day is present

If Creatinine over 150 µmol/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

DIABETESwith

Nephropathy

ACE Inhibitoror ARB

IF ACE-I and ARB are contraindicated or not tolerated, SUBSTITUTE• Cardioselective BB or• Long-acting CCB or• Thiazide diuretic

Addition of one or more ofThiazide diuretic orLong-acting CCB

3 - 4 drugs combination may be needed

Threshold ≥ 130/80 mmHg and TARGET < 130 mmHg systolic and < 80 mmHg diastolic

Treatment of Hypertension for Patients with Diabetes Mellitus: Summary

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/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

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

COMBINATION : ADD• Cardioselective BB or• Long-acting CCB or• Thiazide diuretic, or• an ACE-I with an ARB (or vice versa)

Diabetes

withNephropathy

Combination

Effective 2-drug combination

ACE Inhibitoror ARB

ACE-Inhibitor or ARB or Thiazide diuretic

withoutNephropathy

Treatment of Hypertension for Patients Who Use Tobacco

The benefits of treating smokers with beta-blockers

remain uncertain in the absence of a specific indications like angina or post-MI

Smoking Beta-blocker

Global Vascular Protection for Patients with Hypertension

Vascular Protection for Hypertensive Patients: Statins

Statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 cardiovascular risks such as :

• Male• 55 y or older• Smoking• Type 2 Diabetes• Total-C/HDL-C ratio of 6 or

higher• Premature Family History of CV

disease

• Previous Stroke or TIA• LVH• ECG abnormalities• Microalbuminuria or Proteinuria• Peripheral Vascular Disease

ASCOT-LLA Lancet 2003;361:1149-58

Vascular Protection for Hypertensive Patients : ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.