hypertension treatment and management

7/26/2019 Hypertension Treatment and Management

1/15

HYPERTENSION TREATMENT AND

MANAGEMENT

Wahyu Widjanarko MD


2/15

Algorithm for Hypertension Treatment

Recommend lifestyle modification

If not a goal, is BP < 20 / 10 mmHg above goal?

The seven report of JNC on prevention detection, evaluation, and treatment of high BP

YE !"

#ono $% conside& combination $%

ta&get BP ac'ieved ?

YE !"

(ontin)ed $%

inc&ease dose medication add additional agent


3/15

JNC VII

*ey massage +

oal anti H$! $% is &ed)ced (- and &enal mo&bidity and mo&tality, foc)s

t'e BP.

P&e H$! BP 1201, 3BP 4045, lifestyle modification to 6&event t'e

6&ogessive BP and (- disease.

7ncom6licated H$! t'ia8ide alone o& combination.

In 'ig' &is9 condition :(E in'ibito&, :RB, beta bloc9e&, and ((B.


4/15

Drug class recommendation forcompeling indication based on various

clinical trials

H; + di)&etic, Beta bloc9e&, :(E in'ibito&, :RB, :ldoste&on

antagonist

Post #I + beta bloc9e&, :(E in'ibito&, aldoste&on

antagonist.

(:3 + di)&etic, beta bloc9e&, :(E in'ibito&, ((B.

3iabetes + di)&etic, beta bloc9e&, :(E in'ibito&, :RB, ((B.

(*3 + :(E in'ibito&, :RB.

Rec)&&ent st&o9e 6&evention + di)&etic, :(E in'ibito&.


5/15

Single agent or multi agenttreatment approach ?

:(E I!HIBI$"R

((B bloc9e&

= bloc9e& :RB

di)&etic


6/15

Treatment of HTN in adults withdiabetes

)ide line + >!( -II

:me&ican 3iabetes :ssociation:3:5 2011

Evidence &evie

H$! as a &is9 facto& fo& com6lication of diabetes

7*P3 e6idemiological st)dy,eac' 10 mmHg

&ed)ction in mean BP &ed)ction

12 @ any com6lication

1A @ of deat'

11 @ #I

12 @ mic&ovasc)la& com6lication


7/15

Evidence for target levels of ! in ptsdiabetes

$y6e 1 diabetes ne6'&o6at'y H$! $y6e 2 diabetes, one of a g&o)6 &elated

ca&dio metabolic facto&s

In gene&al 6ts diabetes ty6e 1 o& 2 H$!'ave s'on clinical im6&ovement it' A

anti H$! agents

>!( -II and 2011 :3: &ecommended BP

cont&ol be cont&oled < 10/40 mmHg,6&ima&ily to 6&event o& loe& t'e &is9 of

6&og&ession ne6'&o6at'y ER3


8/15

Evidence for non drug management ofHTN

3:H diete&y management

Ceig't &ed)ction

Dimitation inta9e sodi)m mo9ing cessation

#ode&ate intensity 6'ysical activity


9/15

Evidence for drug therap" of HTN

#)lti6le clinical t&ials s)ggest A class

anti H$! d&)gs 6&ovide t'e same

deg&ee of (- 6&otection fo& t'e same

level of BP cont&ol !"R3ID, $"P2, I!IH$ and

:DDH:$ concl)de t'e&e e&e no

diffe&ences in 6&ima&y o)tcome fo& t'e Aclass anti H$! agents


10/15

Evidence for drug therap" of HTN

#ost st)dy 'ave s'on s)6e&io&ity of

:(E in'ibito& o& :RB ove& ((B

If cannot tole&ate one class of d&)g,

t'e ot'e& s'o)ld be t&ied

$'ia8ide indicated fo& 6ts it'

estimated ;R 0 ml/mmol/1,m2,

if less t'an 0 loo6 di)&etic is

indicated


11/15

Some trials of #CE inhibitor for HTNin $iabetes

7:R3 :(E in'ibito& combined it'

((B 'ave &es)lt &ed)ce BP 'ave favo&able

metabolic effect 6&otein)&ia ;R

:("#PDIH H"PE st)dy

(:PP t&ial

;:(E$ :B(3

HEP


12/15

Some trials of #% for HTN indiabetes

!:"Y: HE:R$ $73Y simila& clinical

o)tcome valsa&tan vs amlodi6in fo& H$! d&)g

t% in diabetes 5

"!$:RE$ telmisa&tan alone o& it' &ami6&il5 !*; *3"FI )idelines :(E in'ibito& mo&e

effective t'an ot'e& anti H$! in sloing

6&og&ession of 9idney disease in H$! 6ts ty6e

1 diabetes, :RB mo&e effective in H$! 6ts ty6e2 diabetes 5

DI;E, -:D7E, #E3I(:


13/15

%ecommendation on initial t&and goals for adult HTN

diabetes pts : G level evidence 6ts diabetes s'o)ld be t&eated to 3BP

< 40 mmHg

Pts it' BP 10 G 1 mmHg o& 3BP

404 mmHg lifestyle t% alone fo& ma%

of mont', if not ac'ieved 6'a&maco

t% 6ts it' BP /1J0 o& 3BP/ 0

d&)g t% add life style t%


14/15

Initial d&)g t% + :(E in'ibito&, :RB, Beta

bloc9e& o& di)&etic

H$! it' mic&o o& clinical alb)min)&ia

:(E in'ibito& o& :RB

Pts ove& AA y& it' o& /o H$!, b)t (-&is9 facto&s :(E in'ibito& (-

event


15/15

E&pert consensus

If :(E in'ibito& o& :RB a&e )sed c'ec9

R; and se&)m *

Elde&ly BP s'o)ld be loe&ed g&ad)ally

Pts not ac'ieving ta&get BP on t'&ee

d&)gs o& com6licated &efe&&ed to

s6ecialist

hypertension treatment and management

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