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Current major guidelines to future guidelines
WHY DO WE NEED GUIDELINES ? 
Physicians are continuously flooded with studies. 
Guidelines should help to find the right way through this jungle of information. 
Experts should review existing data to provide clear recommendations based on evidence. 
Guidelines are increasingly used by healthcare providers and politicians to assess the “appropriate use” and develop disease management programs.
Proportion of deaths attributable to leading risk factors worldwide 
High mortality, developing region 
Lower mortality, developing region 
Developed region 
0 
8000 
7000 
6000 
5000 
4000 
3000 
2000 
1000 
Attributable Mortality (In thousands; total 55,861,000) 
Ezzati et al. WHO 2000 Report. Lancet.2002;360:1347-1360
BP(mmHg) 
WHO(1970) 
JNC V(1991) 
JNC VI (1997) 
WHO/ISH 1999 
ESH.ESC 2003 -2013 
JNC VII (2003) 
JNC VIII (2014) 
< 120 & < 80 
Normal 
Optimal 
Optimal 
Normal 
< 130 & < 85 
Normal 
Normal 
Pre-hypertension 
130-139 or 
85-89 
High-Normal 
High-Normal 
140-159 or 
90-99 
Borderline 
Stage 1 
Stage 1 
160-179 or 100-109 
Hypertension 
SBP >160 
or DBP >95 
Stage 2 
Stage 2 
180-199 or 110-119 
Stage 3 
Stage 3 
≥ 200 or 
≥ 120 
Stage 4 
Classifications of Blood Pressure
2013 ESH/ESC
Definitions 
Stage 1 hypertension: 
•Clinic blood pressure (BP) is 140/90mmHg orhigher and 
•ABPM or HBPM average is 135/85mmHg or higher. Stage 2 hypertension: 
•Clinic BP 160/100mmHg is or higher and 
•ABPM or HBPM daytime average is 150/95mmHgor higher. Severe hypertension: 
•Clinic BP is 180mmHg or higher or 
•Clinic diastolic BP is 110mmHg or higher. 
2013
NATIONAL HEALTH & NUTRITION EXAMINATION, PERCENT 
NHANES II 
(1976-80) 
NHANES III (Phase1 88-91) 
NHANES III (Phase 2 91-94) 
1999-2000 
Awareness 
51 
73 
68 
70 
Treatment 
31 
55 
54 
59 
Control 
10 
29 
27 
34Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 
M Wolt, National Heart, Lung, and Blood Institute; JNC 6
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
Cardiovascular Risk Factors 
Hypertension 
Cigarette smoking 
Obesity ( BMI ≥ 30 ) 
Physical inactivity 
Dyslipidemia 
Diabetes mellitus 
Microalbuminuria or estimate GFR <60 mL/min 
Age (older than 55 for men , 65 for women) 
Family history of premature cardiovascular disease (men under age 55 or women under age 65) 
JNC VII EXPRESS
DMsmoking 
agegenetics/sex 
obesity 
HTN 
DYS 
Global Risk: Overlapping CV Risk Factors
Target Organ Damage 
Heart 
Left ventricular hypertrophy 
Angina or prior myocardial infarction 
Prior coronary revascularization 
Heart failure 
Brain 
Stroke or transient ischemic attack 
Chronic kidney disease 
Peripheral arterial disease 
Retinopathy 
JNC VII EXPRESS
Identifiable causes of hypertension 
Sleep apnea 
Drug –induced or related causes 
Chronic kidney disease 
Primary aldosteronism 
Renovascular disease 
Chronic steroid therapy & Cushing’s syndrome 
Pheochromocytoma 
Coarctation of the aorta 
Thyroid or parathyroid disease 
JNC VII EXPRESS
Laboratory Tests & Other Diagnostic Procedures 
JNC VII EXPRESS 
Electrocardiogram 
Urinalysis 
Blood glucose & hematocrit 
Serum potassium & calcium 
Creatinine 
Lipid profile
* Individuals, 40-69 years, beginning at 115/75 mm Hg. 
Lewington S, et al. Lancet. 2002; 60:1903-1913. 
The JNC 7 Report. JAMA.2003 
Risk of mortality 
SBP (mm Hg) / DBP (mm Hg) 
0 
1 
2 
3 
4 
5 
6 
7 
8 
115/75 
135/85 
155/95 
175/105
WHITE COAT HYPERTENSION 
BP recording in office or clinic is high while at home is normotensive 
"white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology )
HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" 
UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION 
SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSMASKED HYPERTENSION
Hypertension 2014
Hypertension 2014
135/85 Ambulatory Pressure 
140/90 
Clinic PressureSustained Hypertension 
White Coat Hypertension 
True Normotension 
Masked Hypertension
Hypertension 2014
Hypertension 2014
Hypertension 2014
2013 ESH/ESC
2013 ESH/ESC
2013 ESH/ESC
2013 ESH/ESC
2013 ESH/ESC
Care pathway 
CBPM ≥160/100 mmHg & ABPM/HBPM ≥150/95mmHg 
Stage 2 hypertension 
Consider specialist referral 
Offer antihypertensive drug treatment 
Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication 
Offer patient education and interventions to support adherence to treatment 
CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg 
Stage 1 hypertension 
2013
Step 4 
Summary of antihypertensive drug treatment 
Aged over 55 years or black person of African or Caribbean family origin of any age 
Aged under55 years 
C2 
A 
A + C2 
A + C + D 
Resistant hypertension 
A + C + D + consider further diuretic3, 4 or alpha-or beta-blocker5 
Consider seeking expert advice 
Step 1Step 2Step 3KeyA –ACE inhibitor or low-cost angiotensinII receptor blocker (ARB)1C –Calcium-channel blocker (CCB) D –Thiazide-like diuretic 
See slide notes for details of footnotes 1-5 
2013
2013 ESH/ESC
BP thresholds for drug treatment* 
General population (including CKD) (CHEP 2011**) 
140/90 
Very elderly (>80) (CHEP 2013**) 
150 
Diabetes (CHEP2000**) 
130/80 
Very lowCV risk (CHEP 2000**) 
160/100 
* lifestyle modification is recommended for all regardless of BP 
** Year of incorporation into CHEP recommendations 
2013
III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents 
New Recommendation for 2013 
B) Recommendations for Individuals with Isolated Systolic Hypertension 
ADD: 
In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmHg (Grade C). 
CHEP Recommendation: the very elderly 
2013
Summary of evidence in patients with diabetes and hypertension 
•SBP lowering below 140 mmHg appears beneficial with respect to all cause mortality and stroke 
•SBP lowering below 135mmHg or 130 mmHg appears to confer significant benefit with respect to stroke 
•As SBP decreases below 140 mmHg, the risk of SAEs increasesbut the absolute number of these events is low 
2013
III. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling IndicationsTARGET <140/90 mmHg 
INITIAL TREATMENT AND MONOTHERAPY 
*BBs are not indicated as first line therapy for age 60 and above 
Beta- blocker* 
Long- acting 
CCB 
Thiazide 
ACEI 
ARB 
Lifestyle modification 
therapyACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potentialA 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 
2013
III. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling IndicationsCONSIDER 
•Nonadherence 
•Secondary HTN 
•Interfering drugs or lifestyle 
•White coat effect 
Dual Combination 
Triple or Quadruple Therapy 
Lifestyle modification 
Thiazide 
diuretic 
ACEILong-actingCCBTARGET <140/90 mmHg 
ARB 
*Not indicated as first line therapy over 60 yInitial 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*
III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications 
INITIAL TREATMENT AND MONOTHERAPY 
Thiazide diuretic 
Long-acting 
DHP CCBLifestyle modificationtherapyARBTARGET <140 mmHg (< 150 mmHg if age >80 years) 
2013
III. Add-on therapy for Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER 
•Nonadherence 
•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 ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). 
If partial response to monotherapy 
Long-acting 
DHP CCB 
Triple therapy 
Thiazide diuretic 
ARB 
Dual combination 
Combine first line agents2013
III. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER 
•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 >80 years 
*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). 
2013
39Blood pressure target values for treatment of hypertension 
Condition 
Target 
SBP and DBP mmHg 
Isolated systolic hypertension 
Age >80 years 
<140 
< 150 
Systolic/Diastolic Hypertension 
• Systolic BP 
• Diastolic BP 
<140 
<90 
Diabetes 
• Systolic 
• Diastolic 
<130 
<80 
V. Goals of Therapy
2013 ESH/ESC
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. 2013;():. doi:10.1001/jama.2013.284427 
JNC VIII
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. 2013;():. doi:10.1001/jama.2013.284427 
JNC VIII
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. 2013;():. doi:10.1001/jama.2013.284427 
Strategies to Dose Antihypertensive DrugsJNC VIII
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. 2013;():. doi:10.1001/jama.2013.284427 
Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With HypertensionJNC VIII
Hypertension 2014
Recurrent stroke 
Diuretic 
Recurrent stroke 
ACE inhibitor + diuretic 
CEREBROVASCULAR DISEASE 
Cardiovascular morbidity and mortality 
ARB 
Left ventricular hypertrophy 
Mortality 
Spironolactone 
Mortality 
Beta-blocker 
CHF (diuretics almost always included) 
Mortality 
ACE inhibitor 
Heart failure 
ACE inhibitor 
Mortality 
Beta-blocker 
Left ventricular dysfunction 
Mortality 
ACE inhibitor 
Post MI 
CARDIAC DISEASE 
Progression of renal failure 
ACE inhibitor 
Nondiabetic nephropathy 
Progression of renal failure 
ARB 
Diabetic nephropathy type 2 
Progression of renal failure 
ACE inhibitor 
Diabetic nephropathy type 1 
RENAL DISEASE 
Stroke 
DHCCB 
Stroke 
Diuretic 
ELDERLY WITH ISOLATED SYSTOLIC HYPERTENSION 
PRIMARY ENDPOINT 
PREFERRED DRUG 
COMPELLING INDICATION 
Compelling Indications for Specific Antihypertensive Drugs ISH/WHO
Indications for the Major Classes of Antihypertensive Drugs 
BPH; hyperlipidemia 
Alpha-blockers 
type 2 nephropathy; diabetic microalbuminuria; proteinuria; LV hypertrophy; ACE inhibitor cough 
ARBs 
CHF; LV dysfunction; post MI; nondiabetic nephropathy; type 1 diabetic nephropathy; proteinuria 
ACE inhibitors 
Angina pectoris, carotid atherosclerosis; supraventricular tachycardia 
CCBs (verapamil, diltiazem) 
Elderly; ISH; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy 
CCBs (DHP) 
Angina pectoris; post MI; CHF (up-titration); pregnancy; tachyarrhythmias 
Beta-blockers 
CHF; post MI 
Diuretics (antialdosterone) 
Renal insufficiency; CHF 
Diuretics (loop) 
CHF; elderly; ISH; hypertensives of African origin 
Diuretics (Thiazide) 
Conditions Favoring Use 
Drug
-Chobanian AV et al. JNC 7. JAMA 2003 ; 289 : 2560-2572 
-ESH Guidelines Committee. J Hypertens 2003 ; 21 : 1011-1053 
Compelling indications for beta-blockade 
Hypertension /Heart Failure 
Hypertension /post MI 
Hypertension /high CAD risk 
Hypertension /Diabetes Mellitus 
Hypertension /arrhythmias 
Hypertension /angina pectoris
Choice of anti-hypertensive drugs in patient with concomitant disease 
Concomitant disease 
Diuretics 
B-Blockers 
ACEI 
Ca channel blocker 
Alpha blocker 
ARB 
Diabetes 
Careful 
Careful 
Yes 
Yes 
Yes 
Yes 
Gout 
No 
Yes 
Yes 
Yes 
Yes 
Yes/No 
Hyperlipidemia 
Careful 
Careful 
Yes 
Yes 
Yes 
Yes 
IHD 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes 
Heart Failure 
Yes 
Careful 
Yes 
Careful 
Yes 
Yes 
Asthma 
Yes 
No 
Yes 
Yes 
Yes 
Yes 
PVD 
Yes 
Careful 
Yes 
Yes 
Yes 
Yes 
Renal impairment 
Yes 
Yes 
Careful 
Yes 
Yes 
Careful 
Renal A Stenosis 
Yes 
Yes 
Careful 
Yes 
Yes 
Careful 
Elderly with no co morbid cond. 
Yes 
Yes 
Yes 
Yes 
Yes 
Yes
Group 
Effective Agents 
Ineffective Agents 
Young white 
ACE inhibitors, beta blocker 
Diuretic 
Older white 
CCB, beta-blocker 
Young black 
CCB 
ACE inhibitors, beta-blocker 
Other black 
Diuretic 
ACE inhibitors, beta-blocker 
Isolated systolic hypertension 
Diuretic 
ACE inhibitors 
CurrentDiagnosis&TreatmentinCardiology 
Response by demographic group
Stratification and Management 
Blood pressure 
(mmHg) 
Other risk factors & disease history 
No other risk factors 
1-2 risk factors 
≥ 3 risk factors or TOD or ACC 
Pre-hypertension 
120-139 or 80-89 
Lifestyle modification 
Lifestyle modification 
Drug for the compelling indications 
Grade I: SBP 140-159 or DBP 90-99 
Lifestyle modification 
6 months 
One drug therapy 
Drug combination 
Grade II & III: 
SBP ≥160 or 
DBP ≥ 100 
Drug combination 
Drug combination 
Drug combination
Renin-angiotensin system 
Sympathetic nervous system 
Vasoconstriction/ 
Renal Retention of Excess Sodium 
Vascular Hypertrophy 
Hypertension: a multifactorial entity 
Patient 1Patient 2Patient 3
Renin-angiotensin system 
Sympathetic nervous system 
Vasoconstriction/ 
Diuretic 
Vascular Hypertrophy 
Renal Retention of Excess Sodium 
Hypertension: a multifactorial entity
MDs have not been aggressive enough in controlling hypertension in their patients 
Patients w/ 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 
Summary
Hypertension 2014

More Related Content

Hypertension 2014

  • 1. Current major guidelines to future guidelines
  • 2. WHY DO WE NEED GUIDELINES ? Physicians are continuously flooded with studies. Guidelines should help to find the right way through this jungle of information. Experts should review existing data to provide clear recommendations based on evidence. Guidelines are increasingly used by healthcare providers and politicians to assess the “appropriate use” and develop disease management programs.
  • 3. Proportion of deaths attributable to leading risk factors worldwide High mortality, developing region Lower mortality, developing region Developed region 0 8000 7000 6000 5000 4000 3000 2000 1000 Attributable Mortality (In thousands; total 55,861,000) Ezzati et al. WHO 2000 Report. Lancet.2002;360:1347-1360
  • 4. BP(mmHg) WHO(1970) JNC V(1991) JNC VI (1997) WHO/ISH 1999 ESH.ESC 2003 -2013 JNC VII (2003) JNC VIII (2014) < 120 & < 80 Normal Optimal Optimal Normal < 130 & < 85 Normal Normal Pre-hypertension 130-139 or 85-89 High-Normal High-Normal 140-159 or 90-99 Borderline Stage 1 Stage 1 160-179 or 100-109 Hypertension SBP >160 or DBP >95 Stage 2 Stage 2 180-199 or 110-119 Stage 3 Stage 3 ≥ 200 or ≥ 120 Stage 4 Classifications of Blood Pressure
  • 6. Definitions Stage 1 hypertension: •Clinic blood pressure (BP) is 140/90mmHg orhigher and •ABPM or HBPM average is 135/85mmHg or higher. Stage 2 hypertension: •Clinic BP 160/100mmHg is or higher and •ABPM or HBPM daytime average is 150/95mmHgor higher. Severe hypertension: •Clinic BP is 180mmHg or higher or •Clinic diastolic BP is 110mmHg or higher. 2013
  • 7. NATIONAL HEALTH & NUTRITION EXAMINATION, PERCENT NHANES II (1976-80) NHANES III (Phase1 88-91) NHANES III (Phase 2 91-94) 1999-2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 M Wolt, National Heart, Lung, and Blood Institute; JNC 6
  • 8. 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
  • 9. Cardiovascular Risk Factors Hypertension Cigarette smoking Obesity ( BMI ≥ 30 ) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimate GFR <60 mL/min Age (older than 55 for men , 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65) JNC VII EXPRESS
  • 10. DMsmoking agegenetics/sex obesity HTN DYS Global Risk: Overlapping CV Risk Factors
  • 11. Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy JNC VII EXPRESS
  • 12. Identifiable causes of hypertension Sleep apnea Drug –induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy & Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease JNC VII EXPRESS
  • 13. Laboratory Tests & Other Diagnostic Procedures JNC VII EXPRESS Electrocardiogram Urinalysis Blood glucose & hematocrit Serum potassium & calcium Creatinine Lipid profile
  • 14. * Individuals, 40-69 years, beginning at 115/75 mm Hg. Lewington S, et al. Lancet. 2002; 60:1903-1913. The JNC 7 Report. JAMA.2003 Risk of mortality SBP (mm Hg) / DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75 135/85 155/95 175/105
  • 15. WHITE COAT HYPERTENSION BP recording in office or clinic is high while at home is normotensive "white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology )
  • 16. HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSMASKED HYPERTENSION
  • 19. 135/85 Ambulatory Pressure 140/90 Clinic PressureSustained Hypertension White Coat Hypertension True Normotension Masked Hypertension
  • 28. Care pathway CBPM ≥160/100 mmHg & ABPM/HBPM ≥150/95mmHg Stage 2 hypertension Consider specialist referral Offer antihypertensive drug treatment Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication Offer patient education and interventions to support adherence to treatment CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg Stage 1 hypertension 2013
  • 29. Step 4 Summary of antihypertensive drug treatment Aged over 55 years or black person of African or Caribbean family origin of any age Aged under55 years C2 A A + C2 A + C + D Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha-or beta-blocker5 Consider seeking expert advice Step 1Step 2Step 3KeyA –ACE inhibitor or low-cost angiotensinII receptor blocker (ARB)1C –Calcium-channel blocker (CCB) D –Thiazide-like diuretic See slide notes for details of footnotes 1-5 2013
  • 31. BP thresholds for drug treatment* General population (including CKD) (CHEP 2011**) 140/90 Very elderly (>80) (CHEP 2013**) 150 Diabetes (CHEP2000**) 130/80 Very lowCV risk (CHEP 2000**) 160/100 * lifestyle modification is recommended for all regardless of BP ** Year of incorporation into CHEP recommendations 2013
  • 32. III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents New Recommendation for 2013 B) Recommendations for Individuals with Isolated Systolic Hypertension ADD: In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmHg (Grade C). CHEP Recommendation: the very elderly 2013
  • 33. Summary of evidence in patients with diabetes and hypertension •SBP lowering below 140 mmHg appears beneficial with respect to all cause mortality and stroke •SBP lowering below 135mmHg or 130 mmHg appears to confer significant benefit with respect to stroke •As SBP decreases below 140 mmHg, the risk of SAEs increasesbut the absolute number of these events is low 2013
  • 34. III. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling IndicationsTARGET <140/90 mmHg INITIAL TREATMENT AND MONOTHERAPY *BBs are not indicated as first line therapy for age 60 and above Beta- blocker* Long- acting CCB Thiazide ACEI ARB Lifestyle modification therapyACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potentialA 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 2013
  • 35. III. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling IndicationsCONSIDER •Nonadherence •Secondary HTN •Interfering drugs or lifestyle •White coat effect Dual Combination Triple or Quadruple Therapy Lifestyle modification Thiazide diuretic ACEILong-actingCCBTARGET <140/90 mmHg ARB *Not indicated as first line therapy over 60 yInitial 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*
  • 36. III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications INITIAL TREATMENT AND MONOTHERAPY Thiazide diuretic Long-acting DHP CCBLifestyle modificationtherapyARBTARGET <140 mmHg (< 150 mmHg if age >80 years) 2013
  • 37. III. Add-on therapy for Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER •Nonadherence •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 ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). If partial response to monotherapy Long-acting DHP CCB Triple therapy Thiazide diuretic ARB Dual combination Combine first line agents2013
  • 38. III. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER •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 >80 years *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). 2013
  • 39. 39Blood pressure target values for treatment of hypertension Condition Target SBP and DBP mmHg Isolated systolic hypertension Age >80 years <140 < 150 Systolic/Diastolic Hypertension • Systolic BP • Diastolic BP <140 <90 Diabetes • Systolic • Diastolic <130 <80 V. Goals of Therapy
  • 41. 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. 2013;():. doi:10.1001/jama.2013.284427 JNC VIII
  • 42. 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. 2013;():. doi:10.1001/jama.2013.284427 JNC VIII
  • 43. 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. 2013;():. doi:10.1001/jama.2013.284427 Strategies to Dose Antihypertensive DrugsJNC VIII
  • 44. 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. 2013;():. doi:10.1001/jama.2013.284427 Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With HypertensionJNC VIII
  • 46. Recurrent stroke Diuretic Recurrent stroke ACE inhibitor + diuretic CEREBROVASCULAR DISEASE Cardiovascular morbidity and mortality ARB Left ventricular hypertrophy Mortality Spironolactone Mortality Beta-blocker CHF (diuretics almost always included) Mortality ACE inhibitor Heart failure ACE inhibitor Mortality Beta-blocker Left ventricular dysfunction Mortality ACE inhibitor Post MI CARDIAC DISEASE Progression of renal failure ACE inhibitor Nondiabetic nephropathy Progression of renal failure ARB Diabetic nephropathy type 2 Progression of renal failure ACE inhibitor Diabetic nephropathy type 1 RENAL DISEASE Stroke DHCCB Stroke Diuretic ELDERLY WITH ISOLATED SYSTOLIC HYPERTENSION PRIMARY ENDPOINT PREFERRED DRUG COMPELLING INDICATION Compelling Indications for Specific Antihypertensive Drugs ISH/WHO
  • 47. Indications for the Major Classes of Antihypertensive Drugs BPH; hyperlipidemia Alpha-blockers type 2 nephropathy; diabetic microalbuminuria; proteinuria; LV hypertrophy; ACE inhibitor cough ARBs CHF; LV dysfunction; post MI; nondiabetic nephropathy; type 1 diabetic nephropathy; proteinuria ACE inhibitors Angina pectoris, carotid atherosclerosis; supraventricular tachycardia CCBs (verapamil, diltiazem) Elderly; ISH; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy CCBs (DHP) Angina pectoris; post MI; CHF (up-titration); pregnancy; tachyarrhythmias Beta-blockers CHF; post MI Diuretics (antialdosterone) Renal insufficiency; CHF Diuretics (loop) CHF; elderly; ISH; hypertensives of African origin Diuretics (Thiazide) Conditions Favoring Use Drug
  • 48. -Chobanian AV et al. JNC 7. JAMA 2003 ; 289 : 2560-2572 -ESH Guidelines Committee. J Hypertens 2003 ; 21 : 1011-1053 Compelling indications for beta-blockade Hypertension /Heart Failure Hypertension /post MI Hypertension /high CAD risk Hypertension /Diabetes Mellitus Hypertension /arrhythmias Hypertension /angina pectoris
  • 49. Choice of anti-hypertensive drugs in patient with concomitant disease Concomitant disease Diuretics B-Blockers ACEI Ca channel blocker Alpha blocker ARB Diabetes Careful Careful Yes Yes Yes Yes Gout No Yes Yes Yes Yes Yes/No Hyperlipidemia Careful Careful Yes Yes Yes Yes IHD Yes Yes Yes Yes Yes Yes Heart Failure Yes Careful Yes Careful Yes Yes Asthma Yes No Yes Yes Yes Yes PVD Yes Careful Yes Yes Yes Yes Renal impairment Yes Yes Careful Yes Yes Careful Renal A Stenosis Yes Yes Careful Yes Yes Careful Elderly with no co morbid cond. Yes Yes Yes Yes Yes Yes
  • 50. Group Effective Agents Ineffective Agents Young white ACE inhibitors, beta blocker Diuretic Older white CCB, beta-blocker Young black CCB ACE inhibitors, beta-blocker Other black Diuretic ACE inhibitors, beta-blocker Isolated systolic hypertension Diuretic ACE inhibitors CurrentDiagnosis&TreatmentinCardiology Response by demographic group
  • 51. Stratification and Management Blood pressure (mmHg) Other risk factors & disease history No other risk factors 1-2 risk factors ≥ 3 risk factors or TOD or ACC Pre-hypertension 120-139 or 80-89 Lifestyle modification Lifestyle modification Drug for the compelling indications Grade I: SBP 140-159 or DBP 90-99 Lifestyle modification 6 months One drug therapy Drug combination Grade II & III: SBP ≥160 or DBP ≥ 100 Drug combination Drug combination Drug combination
  • 52. Renin-angiotensin system Sympathetic nervous system Vasoconstriction/ Renal Retention of Excess Sodium Vascular Hypertrophy Hypertension: a multifactorial entity Patient 1Patient 2Patient 3
  • 53. Renin-angiotensin system Sympathetic nervous system Vasoconstriction/ Diuretic Vascular Hypertrophy Renal Retention of Excess Sodium Hypertension: a multifactorial entity
  • 54. MDs have not been aggressive enough in controlling hypertension in their patients Patients w/ 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 Summary

Editor's Notes

  1. NOTES FOR PRESENTERS:DefinitionsIn this guideline the following definitions are used:Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.Additional information:ABPM – ambulatory blood pressure monitoringHBPM – home blood pressure monitoring