Respected teachers, colleagues and trainees

Warm welcome you all

• Dr. Rajat SR Biswas, MD• Resident Physician

- Hypertension Basics

- Some recommendations

&

- Some special situations

Hypertension : Problem Magnitude

Hypertension( HTN) is the most common primary diagnosis.

Worldwide prevalence estimates for HTN may be as much as 1

billion.

Prevalance of HTN in Bangladesh from different studies-

14.6% to 19%

Global Mortality 2000: Hypertension is the major risk factor

Adapted from Ezzati et al. Lancet 2002;360:1347-1360.

Attributable mortality in millions (total: 55 861 000)

Developing regions

Developed regions

0 87654321

High BP

Tobacco

High cholesterol

Unsafe sex

High BMI

Physical inactivity

Alcohol

Underweight

7.6 million deaths7.6 million deaths

Systemic hypertension • long-lasting, usually permanent increase of systolic

and diastolic blood pressure

primary (essential) hypertension – unknown cause; usually coincidence of more factors – neural,

hormonal, kidney dysfunction, ...

secondary (symptomatic) hypertension – symptom (sign) of other disease

Isolated systolic hypertension increased systolic blood pressure at normal

or decreased diastolic BPpseudohypertension ← rigid arteries in old

age

“white coat hypertension “ – induced by stress at physical examination

„masked hypertension“ - false finding of normal blood pressure during the examination; opposite of white coat hypertension

Types of Hypertension

• Primary HTN:

• Also known as essential

HTN.

• Accounts for 95% cases of

HTN.

• No universally established

cause known.

• Secondary HTN:

• Less common cause

of HTN ( 5%).

• Secondary to other

potentially rectifiable

causes.

Causes of Secondary HTN

• Common

• Intrinsic renal disease

• Renovascular disease

• Mineralocorticoid

excess (Primary

Aldosteronism)

• Sleep Breathing

disorder

• Uncommon

• Pheochromocytoma

• Glucocorticoid excess

(Cushing’s Syndrome)

• Coarctation of Aorta

• Hyper/hypothyroidism

Secondary hypertension

New Guidelines for Hypertension

National Institute for Health and Clinical Excellence (NICE), 2011

Kidney Disease: Improving Global Outcome (KDIGO), 2012

European Society of Hypertension/European Society of Cardiology,

(ESH/ESC), 2013

American Diabetes Association (ADA), 2014

American Society of Hypertension and the International Society of

Hypertension (ASH/ISH), 2014

Eighth Joint National Committee (JNC8), 2013 - Evidence Based

Guideline

JNC-8 Guideline

The new guidelines emphasize control of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with age- and comorbidity-specific treatment cutoffs.

It also introduce new recommendations designed to promote safer use of angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs).

Comparison of JNC Guidelines

JNC7

Nonsystematic literature review

and expert opinion

Range of study designs

No grading system for

recommendations

Recommendations:

Lifestyle modifications

Initial therapy for HTN

Compelling indications

Addressed secondary HTN

and resistant HTN

JNC8

Systematic review

Randomized, controlled trials

(RCT) only

Graded recommendations

Recommendations:

No specific lifestyle

recommendations

Initial therapy for HTN

Racial, CKD, and diabetic

subgroups addressed

Addressed three key questions

This JNC8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from JNC 7 reasonable.

It offers clinicians an analysis of what is known and not known about BP treatment thresholds, goals, and drug treatment strategies to achieve those goals.

However these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.

Recommendations

Concerning thresholds and goals.

Recommendations 1 -5

General population aged 60 years or older

Recommendation 1

SBP ≥150 mmHg Or

DBP ≥ 90mmHg

Goal of Treatment :

SBP <150 mmHg OR

DBP of < 90mmHg.

Initiate Treatment at :

General population < 60 years

Recommendation 2

Initiate Treatment at : DBP ≥ 90mmHg

Goal of Treatment :

DBP of < 90mmHg.

General population < 60 years

Recommendation 3

SBP ≥ 140 mmHg

Goal of Treatment :

SBP of < 140 mmHg.

Initiate Treatment at :

Population aged 18 years or older with CKD

Recommendation 4

Initiate Treatment at:

SBP ≥ 140 mmHgOr

DBP ≥ 90 mmHg

Goal of Treatment :

SBP < 140 mmHgOr

DBP < 90 mmHg

Population aged 18 years or older with diabetes

Recommendation 5

Initiate Treatment at:

SBP ≥ 140 mmHgOr

DBP ≥ 90 mmHg

Goal of Treatment :

SBP < 140 mmHgOr

DBP < 90 mmHg

Concerning selection of antihypertensive drugs.

Recommendations6,7,8

Recommendation 6

In General nonblack population, including those with diabetes

Initial antihypertensive treatment should include any of the following:

A thiazide-type diuretic Calcium channel blocker (CCB) Angiotensin-converting enzyme inhibitor

(ACEI) or Angiotensin receptor blocker (ARB).

Recommendation 7

In general black population, including those with diabetes:

Initial antihypertensive treatment should include :

Thiazide-type diuretic

CCB.

Recommendation 8

Population aged 18 years or older with CKD and hypertension

Initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes.

This applies to all CKD patients with hypertension regardless of race or diabetes status.

Recommendation 9

The main objective of hypertension treatment is to attain and maintain goal BP.

If goal BP is not reached within a month of treatment: increase the dose of the initial drug OR Add a second drug from one of the classes in

recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB).

The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached.

Opinion for starting & adding drugs

.

Recommendation 9

Recommendation 9 If goal BP cannot be reached with 2 drugs:

Add and titrate a third drug from the list provided.

Do not use an ACEI and an ARB together in the same patient.

If goal BP cannot be reached using the drugs in recommendation 6 because of a contraindication or the need to use more than 3 drugs to reach goal BP: antihypertensive drugs from other classes can be used.

For patients in whom goal BP cannot be attained using the above strategy OR

The management of complicated patients for whom additional clinical consultation is needed.

Referral to a hypertension specialist may be indicated

Recommendation 9

Drug choice in some special situations

Benefits of Treatment

• Reductions in stroke incidence, averaging 35–40

percent

• Reductions in MI, averaging 20–25 percent

• Reductions in HF, averaging >50 percent.

Hypertension in elderly

• Benefit of Rx are much greater in older people than young.

• Commonly isolated systolic hypertension

• Drug of choice:~Thiazide like diuretics~CCBs

Hypertension in young

• Diastolic HTN more common

• 2nd HTN also more common

• Drug of choice:~ ACEIs~ARBs

Hypertension with Heart failure

• Asymptomatic with demonstrable ventricular dysfunction:

~ACEIs~BBs

• Symptomatic ventricular dysfunction OREnd stage heart failure:~Aldosterone blocker with Loop diuretics~ACEIs ~ARBs

• AVOID CCBS

Hypertension with IHDStable angina:

~BBs~CCBs

Acute coronary syndrome:~BBs~ACEIs

Post MIs:~ACEIs~BBs~Aldosterone antagonists

Hypertension with LVF

• Diuretics & ACEIs

• All anti-hypertensive drugs except direct vasodilators eg. Hydralazine

• I/V nitroglycerine in Acute LVF

Hypertension with bradycardia

• Nifidipine & ACEIs preferable

• Avoid :~BBs~Rate limiting CCBs

Hypertension with DM

• Preferable:~ACEIs or ARBs

• Others:~CCBs ~Thiazide~BBs

• Combination of 2 or more drugs preferred

Hypertension with metabolic syndrome

• BBs & Thiazides avoided as they aggravate DM & Dyslipidemia

Hypertensive with CKD

• Favorable drugs:~ACEIs~ARBs * F/U with S. Creatinine level(upto 35% rise acceptable)

• Advanced renal disease: add loop diuretics• A-blockers , CCBs

Hypertension with ischemic strokeNot to lower the BP in 1st

week unless~ Malignant HTN~ Myocardial Ischaemia~ Thrombolytic therapy with BP> 185/110

Recurrent stroke prevention:~ACEIs~Thiazide

Hypertension with hemorrhagic stroke

• Lower the mean arterial BP < 130 mm Hg

• Use non-vasodilating I/V drugs eg. Labetalol, nicardipine, esmolol.

Hypertension in surgical patients• In elective surgery

effective BP control.

• In older pts B-blockers are beneficial.

• Discontinue ACEIs & ARBs 24 prior to non-cardiac surgery.

Hypertension in surgical patients• In urgent surgery I/V

nitroprusside, nicardipine, labetelol.

• Intra-operative coronary ischaemia GTN

• Intra-operative tachycardia BBs.

• Post-operative volume overload frusemide.

Hypertension with OCP

• 2-3 times more in woman taking OCP esp in obese and elderly

• Stop OCP BP returns to normal within few months in most cases

• If BP doesn’t normalize or OCP has to be taken then start anti-HTN drugs

• POP are recommended for hypertensive female.

Hypertension with HRT

• Hypertension is not a contraindication for post menopausal HRT

• Frequent F/U should be advisedc

• Selective Ostrogen receptor modulator are preferred

Pheochromocytoma

• To prepare the patient for surgery, for a minimum of 6 weeks to allow restoration of normal plasma volume.

• The most useful drug is α-blocker phenoxybenzamine (10-20 mg orally 6-8-hourly).

• If α-blockade produces a marked tachycardia, then a β-blocker (e.g. propranolol) or combined α- and β-antagonist (e.g. labetalol) can be added.

• On no account should the β-antagonist be given before the α-antagonist, as it may cause a paradoxical rise in blood pressure due to unopposed α-mediated vasoconstriction.

• During surgery sodium nitroprusside and the short-acting α-antagonist phentolamine are useful in controlling hypertensive episodes which may result from anaesthetic induction or tumour mobilisation.

• Post-operative hypotension may occur and require volume expansion and, very occasionally, noradrenaline (norepinephrine) infusion.

• This is uncommon if the patient has been prepared adequately with phenoxybenzamine

Hypertension with Pregancy

Drugs Comments

Methyldopa Preferred based on long-term followup studiessupporting safety

BBs Reports of intrauterine growth retardation (atenolol)Generally safe

Labetalol Increasingly preferred to methyldopa due to reducedside effects

Hypertension with Pregancy

Drugs Comments

Clonidine Limited data

Calcium antagonists Limited dataNo increase in major teratogenicity with exposure

Diuretics Not first-line agentsProbably safe

ACEIs, angiotensin II receptor antagonists

ContraindicatedReported fetal toxicity and death

Pre-eclampsia

• If delivery is not immediately needed oral methydopa, oral labetalol, BBs & CCBs

• If delivery is immediately needed I/V drugs are indicated eg. I/V Hydralazine I/V labetalol Oral nifedipine (contoversial)

• I/V nitroprusside is rarely used when others failed as risk of fetal cyanide poisoning.

Hypertension in lactating women

• Stage 1 preferably avoid drugs, continue F/U

• Avoid ACEIs & ARBs( Causes adverse neonatal renal effects)

• Avoid Diuretics ( reduces milk volume)

Hypertension in Dyslipidemia

• Preferable drugs:~ ACEIs, ARBs & CCBs

• High doses of Thiazides, Loop diuretics & BBs may transiently increase total cholesterol

Hypertension with Asthma & COPD

• CCBs most preferable• ACEIs safe in most pts• ARBs can be used if cough is troublesome after using

ACEIs

• Contraindicated:~BBs ( except in special circumstances)

Hypertension with liver diseases

• All are safe except methydopa

Hypertension with GOUT

• All the drugs can be used

• All diuretics increase serum uric acid level but rarely induce acute gout, so diuretics should be avoided if possible

Hypertension with BHP

• α-blockers helpful

Hypertension with Psoriasis

• BBs & ACEIs aggravate psoriasis so better to avoid them

Hypertension with raynaud’s phenomenon

• Nifidipine & prostacycline infusions may occasionally be helpful

• Avoid BBs

Hypertension with PVD

• Drug of choice:~ CCBs ~ Vasodilators

• BBs should be avoided

Resistant hypertension

Resistant hypertension is defined as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. Causes: Improper BP measurement

Volume overload Drug-related Drug-induced Associated conditions Potential identifiable cause.

Hypertensive crisis• Hypertensive emergency

• Hypertensive urgency

• Malignant hypertension

Hypertensive emergencies

• Marked BP elevation with acute target organ damage eg.

~Encephalopathy ~MI~Unstable angina ~LVF~Stroke ~Eclampsia~Aortic dissection ~ARF~Retinopathy ~SAH

Treatment of Hypertensive emergency

• Hospitalization• Parenteral drug therapy but can be controlled with oral

drug therapy• Controlled reduction to a level of 150/90 mm Hg over a

period of 24-48 hrs• Rapid uncontrolled reduction of BP may cause coma,

stroke, MI, ARF or death

Drug of choice• Nitroprusside• Nicardipine• Labetalol• Nitroglycerine• hydralazine

Hypertensive urgency

• Markedly elevated BP but without acute target organ damage.

• Don’t require hospitalization.• Combination oral drug therapy• Search for identifiable causes of HTN.• Control over several days to weeks.

Potential favorable effects of anti-HTN

• Thiazide diuretics → ↓ Osteoporosis• BBs → Tachyarrhythmia, AF, Migraine, Thyrotoxicosis,

Essential Tremor, Peri-operative HTN• CCBs → Raynaud's syndrome, Arrhythmias • Alpha-Blockers → Prostatism

Potential unfavorable effects

• Thiazide diuretics → Gout, Hyponatremia• BBs → Asthma, COPD, second & third degree heart

block• ACEIs & ARBs → Pregnancy • ACEIs → Angioedema • Aldosterone antagonist & K+sparing diuretics →

Hyperkalaemia

• Take home messages

• Recommendations of JNC-8

• Choice of drugs in different secondary hypertensions

Thanks