hypertension -the latest management
TRANSCRIPT
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Hypertension – The Latest Management
DR AWADHESH KUMAR SHARMAConsultant CardiologyGracian superspeciality HospitalMohali
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Hypertension
Hypertension is the most common condition
in primary care.
1 in 3 patients have hypertension.
Risk factor for MI, CVA, ARF, death.
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Benefits of lowering BP
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Triple paradox
1. Easy to diagnose often remains undetected.
2. Simple to treat often remains untreated.
3. Despite availability of potent drugs, treatment all too often is ineffective.
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Paradigm Shifts in Hypertension Management
1. Controlling it is challenging; All have room for improvement.
2. Focus on BP goal attainment– sooner rather than later.
3. Resort to combination therapy readily.
4. Prevent or reduce target organ damage.
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HTN IN INDIA
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Case
• A 58 year old urban woman with diabetes and dyslipidemia has a BP of 158/94 confirmed on several office visits. Other than obesity, the exam is normal. Labs show normal renal function, well-controlled lipids on atorvastatin and well-controlled diabetes on metformin. Urine micro-albumin is mildly elevated.
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Case Question 1
• What goal BP is most appropriate for this patient?1. <150/90 mmHg
2. <130/80 mmHg
3. <140/90 mmHg
4. <140/80 mmHg
5. <140/85 mmHg
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Case Question 2
• What is the drug of choice to start?1. HCTZ
2. Amlodipine
3. Ramipril
4. Losartan
5. Beta blocker
6. Combination therapy
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What should be the goal BP?
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BP measurements
• Diagnosis of hypertension should be based on at least 3 different BP measurements, taken on 2 separate office visits.
• At least 2 measurements should be obtained once the patient is seated comfortably for at least 5 minutes with the back supported, feet on the floor, arm supported in the horizontal position, and the BP cuff at heart level.
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Classification of BP – JNC 7
Category Systolic (mmHg)
Diastolic (mmHg)
Normal < 120 and < 80
Pre-HTN 120-139 or 80-89
Hypertension
Stage I 140-159 or 90-99
Stage II > 160 or > 100
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Medical Education & Information – for all Media, all Disciplines, from all over the WorldPowered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Definitions and classification of office BP levels (mmHg)*
Category Systolic Diastolic
Optimal <120 and <80
Normal 120–129 and/or 80–84
High normal 130–139 and/or 85–89
Grade 1 hypertension 140–159 and/or 90–99
Grade 2 hypertension 160–179 and/or 100–109
Grade 3 hypertension ≥180 and/or ≥110
Isolated systolic hypertension ≥140 and <90
* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
Hypertension:SBP >140 mmHg ± DBP >90 mmHg
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JNC 8
• 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults– JAMA. 2014;311(5):507-520
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)JAMA. 2014
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JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
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JNC 8: Drug TreatmentThresholds and Goals
• Age > 60 yrs– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg– LOE: Grade A
– Diastolic:• Threshold > 90 mmHg
• Goal < 90 mmHg– LOE: Grade A
Based on trials HYVET,Syst-Eur,SHEP, JATOS,VALISH,andCARDIO-SIS
Recommendation 1
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JNC 8: Drug TreatmentThresholds and Goals
• Age < 60 yrs- Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg– LOE: Grade A for ages 40-59; Grade E for ages 18-
39
– Systolic:• Threshold > 140 mmHg• Goal < 140 mmHg
– LOE: Grade E
(Trials HDFP,Hypertension-StrokeCooperative,MRC,ANBP,andVA Cooperative)
Recommendation 2
Recommendation 3
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JNC 8: Drug TreatmentThresholds and Goals
• Age > 18 yrs with CKD or DM– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg– LOE: Grade E
– Diastolic:• Threshold > 90 mmHg
• Goal < 90 mmHg– LOE: Grade E
Recommendation 4 & 5
Quality evidencefrom3trials(SHEP,Syst-Eur, and UKPDS)
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JNC 8: Initial Drug Choice
• Nonblack, including DM– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B
• Black, including DM– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
Recommendation 6
Recommendation 7
3 federally funded trials (VA Cooperative Trial, HDFP, and SHEP)
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JNC 8: Initial Drug Choice
• Age > 18 yrs with CKD and HTN (regardless of race or diabetes)– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo• Diuretic is an option for initial therapy
Recommendation 8
From trial The AASK study
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JNC 8: Subsequent Management
• Reassess treatment monthly
• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use drugs from other classes– LOE: Grade E
Recommendation 9
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Possible combinations of classes of antihypertensive drugs
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Anti-hypertensive drugs and their usual dosage
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Anti-hypertensive drugs and their usual dosage
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Hypertension
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Medical Education & Information – for all Media, all Disciplines, from all over the WorldPowered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Lifestyle changes for hypertensive patients
* Unless contraindicated. BMI, body mass index.
Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day
Moderate alcohol intake Limit to 20-30 g/day men,10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
BMI goal 25 kg/m2
Waist circumference goal Men: <102 cm (40 in.)*Women: <88 cm (34 in.)*
Exercise goals ≥30 min/day, 5-7 days/week(moderate, dynamic exercise)
Quit smoking
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Management of HTN in specific conditions
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Pregnant women
• If BP > 160/110 mmHg, treatment is recommended (I, C).
• Consider drug Rx (IIb, C) – BP ≥150/95mmHg, or – BP ≥140/90 mmHg + TOD
• Methyldopa, labetolol, nifedipine preferred (IIa, B)
• Pre-eclampsia: IV labetolol or nitroprusside (IIa, B)
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DM
• Start drug Rx when SBP ≥140 mmHg (I, A).
• Target SBP < 140/90 mmHg (I, A).
• All classes of drugs are recommended and
can be used (I, A).
• RAS blockers preferred, especially if having
proteinuria / microalbuminuria (I, A).
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HT with nephropathy
• Target SBP < 140 mmHg (IIa, B).• RAS blockers indicated for HT with overt proteinuria
or microalbuminuria (I, A).• Recommend combining RAS blockers with other
anti-HT drugs to achieve target BP (I, A).• Combining two RAS blockers is not recommended
(III, A).
• Aldosterone antagonists not recommened in CKD (III, C).
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Cerebrovascular disease
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Atherosclerosis, arteriosclerosis, peripheral artery disease
• Target BP < 140/90 mmHg.
• Carotid atherosclerosis: CCB, ACEI (IIa, B).
• PAD: BB may be considered. Their use does
not appear to be associated with worsening
of PAD symptoms (IIIb, A).
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Resistant Hypertension
• Blood pressure remaining above goal (150/90 mm Hg for the overall population and 140/90 mm Hg for those with DM or CKD) in spite of concurrent use of 3 antihypertensive agents of different classes.
• Ideally, 1 of the 3 agents should be a diuretic & all agents should be prescribed at optimal dose amounts.
The JNC 7 report. JAMA 2003; 289: 2560-72.
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Resistant HT
• MR antagonist, amiloride, doxazosin should
be considered.
• If drugs are ineffective: renal denervation and
baroreceptor stimulation may be considered
(IIb, C) (only by experienced operators at
restricted HT centers).
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Conclusion
• Patients with DM & CKD require more aggressive BP control.
• Most patients with hypertension will require two or more antihypertensive medications to control blood pressure.
• The use of combination therapy is appropriate as initial treatment.
• Sustained antihypertensive efficacy may protect against the early morning rise in blood pressure that leads to heightened risk of cardiovascular events.
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