hypertension

t . Samavat MD,Cadiologist,MPH

Head of prevention and control of CVD disease

office Ministry of heath

RECOMMENDATIONS FOR

HYPERTENSION DIAGNOSIS, ASSESSMENT, AND TREATMENT

Definition of hypertension

Hypertension is sustained elevation of resting systolic BP

(≥140mmhg),diastolic BP(≥90mmhg),or both.

Two type of hypertension was categorized:

-Primary HTN ,that hemodynamics and physiologic

components vary indicating that primary HTN have no a

single cause but multiple factors involved in sustaining

elevated BP.

-secondary HTN cause include renal parenchyma

disease,renovascular diseas,pheochromacytoma,cushing,

Hyper and hypothyroidism, alcohol consumption,coarctaion

Of aorta, adrenal disease.

Key Messages for the Management of Hypertension

1. All adults should have their blood pressure assessed at all appropriate clinical visits.

2. Optimum management of the hypertensive patient requires assessment and communication of overall cardiovascular risk.

3. Home BP monitoring is an important tool in self-monitoring and self-management.

4. Treat to target.

5. Lifestyle modifications are effective in preventing hypertension, treating hypertension and reducing cardiovascular risk.

6. Combinations of both lifestyle changes and drugs are generally necessary to achieve target blood pressures.

7. Focus on adherence.

Reversible Risk Factors for Developing Hypertension

• Obesity

• Poor dietary habits

• High sodium intake

• Sedentary lifestyle

• High alcohol consumption

Prevalence of Hypertension

of those age 15 to 39

of those age 40 to 59

of those age 60 to 70

21.8%

Number of

adults + 15

suffering from

hypertension

…have hypertension.

3.3%

21.8

%

52.4

%

Staging of hypertension for office blood pressure determination

DIASTOLIC

(PRESSURE(mmhg

SYSTOLIC

mmhg))PRESSURE

HYPERTENSION

STAGE

<80 <120 Normal

80-89 120-139 Pre hypertension

90-99 140-159 Stage1 hypertension

≥100 ≥160 Stage2 hypertension

Definition of HTN by office and out-of-office BP level

Office BP ≥140 and/or ≥90

Home BP ≥135 and/or ≥85

Amb BP

Daytime(or awake) ≥135 and/or ≥85

Nighttime(or sleep( ≥120 and/or ≥70

24 hour ≥130 and/or ≥80

category Systolic

BP(mmhg)

DdiastolicBP(m

mhg)

High Risk of Developing Hypertension in Those with pre hypertension

• pre hypertensive Individuals are at high risk of progression to overt hypertension.

• Annual follow-up of patients with pre -hypertension is recommended.

Blood Pressure Assessment: Patient preparation and posture

1.Standardized Preparation:

2.Patient

3.No acute anxiety, stress or pain.

4.No caffeine, smoking or nicotine in the preceding 30 minutes.

5.No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops).

6.Bladder and bowel comfortable.

7.No tight clothing on arm or forearm.

8.Quiet room with comfortable temperature

9.Rest for at least 5 minutes before measurement

10.Patient should stay silent prior and during the procedure.

Blood Pressure Assessment: Patient preparation and posture

Standardized technique:

Posture

• The patient should be

calmly seated with his or

her back well supported

and arm supported at the

level of the heart.

• His or her feet should

touch the floor and legs

should not be crossed.

Blood Pressure Assessment: Patient position

X

Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up

BP: 140-179 / 90-109

ABPM (If available) Clinic BPM Home BPM (If available)

Yes

Hypertension Visit 2

Target Organ Damage

or Diabetes

or BP >180/110?

Hypertension Visit 1

BP Measurement,

History and Physical

examination

Hypertensive

Urgency /

Emergency

Diagnosis

of HTN

No

Elevated Out of the

Office BP

measurement

Elevated Random

Office BP

Measurement

Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up

*Consider home

blood pressure

measurement for

follow-up readings,

to assess for the

presence of

masked

hypertension or

white coat effect

and to enhance

adherence.

Symptoms, severe hypertension, intolerance to anti-hypertensive treatment

or target organ damage

Are BP readings below target during 2 consecutive visits?

Non pharmacological treatment

With or without pharmacological treatment

Diagnosis of hypertension

Follow-up at 3-6

month intervals *

No Yes

Yes

More frequent visits *

Visits every 1 to 2

months*

No

BP: 140-179 / 90-109

ABPM (If available)

Diagnosis

of HTN

Awake BP

>135 SBP or

>85 DBP or

24-hour

>130 SBP or

>80 DBP

Awake BP

<135/85

and

24-hour

<130/80

Continue to

follow-up

Clinic BPM

Diagnosis

of HTN

Hypertension visit 3

>160 SBP or

>100 DBP

>140 SBP or

>90 DBP

< 140 / 90

Diagnosis

of HTN

Continue to

follow-up

<160 / 100

Hypertension visit 4-5

ABPM or HBPM

or

Home BPM

>135 SBP or

>85 DBP

< 135/85

Diagnosis

of HTN

Continue to

follow-up

Patients with high normal blood pressure (office SBP

130-139 and/or DBP 85-89) should be followed annually.

Repeat Home BPM

If

< 135/85

or

Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up

A assessment of the Overall Cardiovascular Risk

• Search for exogenous potentially modifiable factors that can induce/aggravate hypertension

• Prescription Drugs:

• NSAIDs, including coxibs

• Corticosteroids and anabolic steroids

• Oral contraceptive and sex hormones

• Vasoconstricting/sympathomimetic decongestants

• Calcineurin inhibitors (cyclosporin, tacrolimus)

• Erythropoietin and analogues

• Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs

• Midodrine

• Other:

• Licorice root

• Stimulants including cocaine

• Salt

• Excessive alcohol use

Assessment of the Overall Cardiovascular Risk Search for target organ damage

• Cerebrovascular disease 50% • transient ischemic attack

• ischemic or hemorrhagic stroke

• vascular dementia

• Hypertensive retinopathy

• Left ventricular dysfunction

• Left ventricular hypertrophy 30% of hypertensive patients by Echo

• Coronary artery disease • Ischemic heart disease more than 50%

• myocardial infarction

• congestive heart failure(the most common cause is HTN)

• Chronic kidney disease • hypertensive nephropathy

(GFR < 60 ml/min/1.73 m2)

• albuminuria

• Peripheral artery disease • intermittent claudication

• ankle brachial index < 0.9

Assessment of the Overall Cardiovascular Risk

• Over 90% of hypertensive have other cardiovascular risks

• Assess and manage hypertensive patients for

dyslipidemia, dysglycemia (e.g. impaired fasting glucose,

diabetes) abdominal obesity, unhealthy eating and

physical inactivity

Routine Laboratory Tests

Preliminary Investigations of patients with hypertension 1. Urinalysis

2. Blood chemistry (potassium, sodium and creatinine)

3. Fasting glucose and/or glycated hemoglobin (A1c)

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

5. Standard 12-leads ECG

Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes

Routine Laboratory Tests

Follow-up investigations of patients with hypertension

• During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation.

• Diabetes develops in 1-3%/year of those with drug treated hypertension. The risk is higher in those treated with a diuretic or beta blocker, in the obese, sedentary, with higher fasting glucose and who have unhealthy eating patterns. Assess for diabetes more frequently in these patients.

The Role of Echocardiography

• Echocardiography is useful for:

• Assessment of left ventricular dysfunction

and the presence of left ventricular

hypertrophy

• Echocardiography is not useful for routine

evaluation of hypertensive patients

The Role of Echocardiography

• Echocardiography is useful for:

• Assessment of left ventricular dysfunction

and the presence of left ventricular

hypertrophy

• Echocardiography is not useful for routine

evaluation of hypertensive patients

Treatment Algorithm for Isolated Systolic Hypertension without

Other Compelling Indications

INITIAL TREATMENT AND MONOTHERAPY

Thiazide

diuretic

Long-acting

DHP CCB

Lifestyle modification

therapy

ARB

TARGET <140 mmHg (< 150 mmHg if age > 60 years)

Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications

IF BLOOD PRESSURE IS NOT

CONTROLLED CONSIDER

• No adherence

• Secondary HTN

• Interfering drugs or lifestyle

• White coat effect

If blood pressure is still not controlled, or there are adverse effects,

other classes of antihypertensive drugs may be combined (such as

alpha blockers or centrally acting agents).

2. Triple or Quadruple Therapy

1. Add-on Therapy

If partial response to monotherapy

Drug Combinations

When combining drugs, use first-line therapies.

• Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects. Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication

• Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended

Drug Combinations

• Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block.

• Monitor serum creatinine and potassium when combining K sparing diuretics (such as aldosterone antagonists), ACE inhibitors and/or angiotensin receptor blockers.

• If a diuretic is not used as first or second line therapy, triple therapy should include a diuretic, when not contraindicated.

Choice of Pharmacological Treatment for Hypertension

Individualized treatment

• Compelling indications: – Ischemic Heart Disease

– Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI

– Left Ventricular Systolic Dysfunction

– Cerebrovascular Disease nicardipine labetolol .nitroproside Left Ventricular Hypertrophy

– Non Diabetic Chronic Kidney Disease

– Renovascular Disease

– Smoking

• Diabetes Mellitus – With Nephropathy ARB but NO amlodipine

– Without Nephropathy

• Global Vascular Protection for Hypertensive Patients – Statins if 3 or more additional cardiovascular risks

– Aspirin once blood pressure is controlled

Vascular Protection for Hypertensive Patients: Statins

In addition to current recommendations on management of

dyslipidemia, statins are recommended in high-risk

hypertensive patients with established atherosclerotic disease

or with at least 3 of the following criteria:

• Male

• Age 55 or older

• Smoking

• Total-C/HDL-C ratio of 6

mmol/L or higher

• Family History of Premature

CV disease

• LVH

• ECG abnormalities

• Microalbuminuria or Proteinuria

Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence

• Secondary HTN

• Interfering drugs or

lifestyle

• White coat effect

Thiazide

diuretic

Long-acting

DHP CCB

Dual therapy

Triple therapy

Lifestyle modification

therapy

ARB

TARGET <140 mmHg, < 150 mmHg for age > 60years

*If blood pressure is still not

controlled, or there are adverse

effects, other classes of

antihypertensive drugs may be

combined (such as ACE

inhibitors, alpha blockers,

centrally acting agents, or

nondihydropyridine calcium

channel blocker).

Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications

CONSIDER

• Nonadherence

• Secondary HTN

• Interfering drugs or

lifestyle

• White coat effect

Dual Combination

Triple or Quadruple

Therapy

Lifestyle modification

Thiazide diuretic

ACEI Long-acting

CCB

TARGET <140/90 mmHg

ARB

*Not indicated as first

line therapy over 60 y

Initial therapy

A combination of 2 first line drugs may

be considered as initial therapy if the

blood pressure is >20 mmHg systolic

or >10 mmHg diastolic above target

Beta- blocker*