Hypertension; an approach.

AMY
 A definition ?
• The dichotomous separation of “normal” from
“high” blood pressure is artificial, and the
definition of arterial hypertension (i.e., high
blood pressure) has been a moving target.
• A more flexible approach is adopted, stating
that hypertension is the value of blood pressure
above which the benefit of treatment appears
to outweigh the risk.
 Still a dilemma ?
• Provided that you faced a situation in which your
neighbor asked to get his blood pressure
measured. When to say “Sir, you are hypertensive.
Pay attention to your blood pressure.”?
• Two guidelines have been proposed to make the
issue looks easy. One is adopted by The Joint
National Committee (JNC 7) and the other by The
European Society of Cardiology/The European
Society of Hypertension (ESC/ESH)
JNC 7
ESC / ESH
• According to ESC /ESH guidelines:
1. When a patient’s systolic and diastolic blood
pressures fall into different categories the
higher category should apply.
2. The threshold for hypertension (and the need
for drug treatment) should be considered as
flexible based on the level and profile of total
cardiovascular risk.
 Is it easier to categorize my patient now?

• Indeed there are notable differences between

JNC 7 and ESC / ESH guidelines. However, once
the blood pressure of your patient is recorded
above 140/90 you can tell him with
confidence “You are hypertensive.” (The cutoff
point 140/90 is common between both
guidelines)
 Is it that easy ?
• The goal of medicine now is not to diagnose a
patient as “hypertensive” for the sake of
hypertension. Diagnosis of hypertension is a
mean not a goal. A mean to precisely
determine when and what to provide as a
therapy to your patient such that it can
efficiently prevent or delay the devastating
outcomes of hypertension.
 What are the risks of hypertension?
• Sky is the limit for the risks of hypertension:
* Hypertension is nominated “The silent killer”. The
asymptomatic nature of the condition impedes early
detection, which requires regular blood pressure
measurement. Because most cases of hypertension
cannot be cured, blood pressure control requires lifelong
treatment with prescription medication, which is costly
and often causes more symptoms than the underlying
disease process. Effective management requires continuity
of care by a regular and knowledgeable physician as well
as sustained active involvement by an educated patient
* Affecting one quarter of the adult population,
arterial hypertension is the leading cause of death in
the world and the most common cause for an
outpatient visit to a physician; it is the most
recognized treatable risk factor for stroke,
myocardial infarction, heart failure, peripheral
vascular disease, aortic dissection , atrial fibrillation,
and end-stage kidney disease. Despite this
knowledge and unequivocal scientific proof that
treatment of hypertension can prevent many of its
life-altering complications, hypertension remains
untreated or undertreated in the majority of
affected individuals in all countries, including those
with the most advanced systems of medical care.
The blood pressure measurement is between
120/80 & 140/90 ?
• There is a great deal of debate between JNC 7
and ESC/ESH in the aspect of categorizing
those with no established hypertension.
• How can we describe them? Are they
prehypertensives or normal and high normal
individuals? Indeed to tell your patient “You
are a prehypertensive.” is not as “you are
normal/you are high normal.”
• According to ESC/ESH you don’t have to say
“Prehypertensive” because this term causes more
worry to the individual, in a manner which urges
him to look for any suitable drug to treat his
“misery”, although no drug is recommended at
that stage (unless there is compelling indication).
• Others see that telling the patient that he is
“prehypertensive” makes the individual
continuously caring about himself, being more
cautious and avoiding any factor that may cause a
potential rise in blood pressure.
What is normal & what is optimal?
• Another debate which arises is the difference
between “normal” and “optimal” blood pressures.
It is merely a matter of “relativity”. According to
JNC 7, values below 120/90 are normal but it is
optimal in ESC/ESH guidelines. It is like a coin with
two different faces, from one view the coin is
different from the other view according to the face
that you see at a time, but still it is the same coin.
At least it is approved that it is the value which is
associated with the least risks.
 Blood pressure more than 180/110 ?

• Now You can frankly confess that it is severe

hypertension, but academically-speaking it
may take different categories. According to
JNC 7 this is stage 2 hypertension but
according to ESC/ESH it is grade 3
hypertension.
 Nomenclatures are boring ?
• Indeed. The target is to control your patient
and reach the optimum functionality and least
risks. Staging and grading are just means to
choose the best therapeutic regimens for the
sake of the patients well-being. It is like “All
roads lead to Rome …”, no matter what road
to choose.
 Sphygmomanometer alone makes the
diagnosis prone ?
• This is an absolutely correct fact. Many
confounding factors may cause a bias in the
results. It was found that even repeated office
blood pressure measurements may not be
sufficient and give false results e.g. White coat
hypertension. A new approach is the 24-hour
ambulatory blood pressure monitoring which
results in identification of four distinct
findings:
Sustained hypertension: Ambulatory BP
measurements and the conventional office
measurements are elevated. Studies done
have consistently demonstrated that this
condition is closely related to target organ
damage and worse cardiac and renal events.
 Masked hypertension: Normal office BP but
elevated ambulatory BP measurement. This is
presumably because of sympathetic
overactivity in daily life due to job or home
stress, tobacco abuse, or other adrenergic
stimulation that becomes abolished when the
patient comes to the office. Sometimes it is
called “reverse white-coat hypertension”
 White-coat hypertension: Elevated office BP
measurement but normal ambulatory BP
measurement. Clinical studies evaluating
cardiovascular outcomes have consistently
demonstrated a lower morbidity with white
coat hypertension, supporting a more benign
course. It is presumably due to a transient
adrenergic response to the measurement of
blood pressure in the physician's office.
 Normal blood pressure: within-reference
measurements in office as well as ambulatory
setting.
 Sphygmomanometer & ambulatory
measurements alone make the therapy prone ?

• Patient evaluation after diagnosis of hypertension is

a must for the following reasons:
1. To assess lifestyle and identify other cardiovascular
risk factors or concomitant disorders that may
affect prognosis and guide treatment.
2. To reveal identifiable causes (secondary treatable
causes) of high BP.
3. To assess the presence or absence of target organ
damage and CVD.
• Routine laboratory tests recommended before
initiating therapy include an electrocardiogram;
urinalysis; blood glucose and hematocrit; serum
potassium, creatinine (or the corresponding
estimated glomerular filtration rate [GFR]),and
calcium; and a lipid profile, after 9- to 12-hour fast,
that includes high-density lipoprotein cholesterol
and low-density lipoprotein cholesterol, and
triglycerides. Optional tests include measurement
of urinary albumin excretion or albumin/creatinine
ratio. More extensive testing for identifiable
causes is not indicated generally unless BP control
is not achieved.
• The following step according to ESC/ESH is
stratification of your patient according to the
findings that were found in the initial
evaluation.
 What is the goal of therapy ?
• The ultimate public health goal of antihypertensive
therapy is the reduction of cardiovascular and renal
morbidity and mortality. Since most persons with
hypertension, especially those age >50 years, will
reach the DBP goal once SBP is at goal, the primary
focus should be on achieving the SBP goal. Treating
SBP and DBP to targets that are <140/90 mmHg is
associated with a decrease in CVD complications. In
patients with hypertension and diabetes or renal
disease, the BP goal is <130/80 mmHg.
Follow this algorithm ..
What are the “compelling” indications ?

• They are the conditions which are associated

with hypertension and cause modification of
the drug regimen to obtain the best results for
therapy.
Important considerations:
• Thiazide-type diuretics should be used as
initial therapy for most patients with
hypertension, either alone or in combination
with one of the other classes (ACEIs, ARBs,
BBs, CCBs). If a drug is not tolerated or is
contraindicated, then one of the other classes
proven to reduce cardiovascular events should
be used instead.
• Most patients who are hypertensive will require two or
more antihypertensive medications to achieve their BP
goals. Addition of a second drug from different class
should be initiated when use of a single drug in adequate
doses fails to achieve the BP goal. When BP is more than
20/10 mmHg above goal, consideration should be given to
initiating therapy with two drugs, either as separate
prescriptions or in fixed-dose combinations. The initiation
of drug therapy with more than one agent may increase
the likelihood of achieving the BP goal in a more timely
fashion, but particular caution is advised in those at risk
for orthostatic hypotension, such as patients with
diabetes, autonomic dysfunction, and some older
persons. Use of generic drugs or combination drugs
should be considered to reduce prescription costs.
• Once antihypertensive drug therapy is initiated, most
patients should return for follow up and adjustment of
medications at approximately monthly intervals until the BP
goal is reached. More frequent visits will be necessary for
patients with stage 2 hypertension or with complicating co-
morbid conditions. Serum potassium and creatinine should
be monitored at least 1–2 times/year. After BP is at goal and
stable, follow up visits can usually be at 3- to 6-month
intervals. Co-morbidities, such as heart failure, associated
diseases such as diabetes, and the need for laboratory tests
influence the frequency of visits. Other cardiovascular risk
factors should be treated to their respective goals, and
tobacco avoidance should be promoted vigorously. Low-
dose aspirin therapy should be considered only when BP is
controlled, because the risk of hemorrhagic stroke is
increased in patients with uncontrolled hypertension.
 What about resistant hypertension?

• Resistant hypertension is the failure to reach

goal BP in patients who are adhering to full
doses of an appropriate three-drug regimen
that includes diuretic.
 To sum up …
JNC 7 message:
• In persons older than 50 years, systolic blood
pressure greater than 140 mmHg is a much more
important cardiovascular disease (CVD) risk factor
than diastolic blood pressure.
• The risk of CVD beginning at 115/75 mmHg doubles
with each increment of 20/10 mmHg; individuals
who are normotensive at age 55 have a 90 percent
lifetime risk for developing hypertension.
• Individuals with a systolic blood pressure of 120–139
mmHg or diastolic blood pressure of 80–89 mmHg
should be considered as prehypertensive and require
health-promoting lifestyle modifications to prevent
CVD.
• Thiazide-type diuretics should be used in drug
treatment for most patients with uncomplicated
hypertension, either alone or combined with drugs
from other classes. Certain high-risk conditions are
compelling indications for the initial use of other
antihypertensive drug classes(angiotensin converting
enzyme inhibitors, angiotensin receptor blockers,
beta-blockers, calcium channel blockers).
• Most patients with hypertension will require
two or more antihypertensive medications to
achieve goal blood pressure (<140/90 mmHg,
or <130/80 mmHg for patients with diabetes
or chronic kidney disease).
• If blood pressure is >20/10 mmHg above goal
blood pressure, consideration should be given
to initiating therapy with two agents, one of
which usually should be a thiazide-type
diuretic.
OSCE