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Individualized TherapyIndividualized Therapyfor for

HypertensionHypertension

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

To describe the "stepwise approach" to therapy.

To discuss: 1. The evidence for the role of lifestyle

changes 2. The indications, contraindications

and side effects of various antihypertensive classes

Prompt diagnosis Assess the risk Achieve target levels of BP

Lifestyle Combination therapy

Promote adherence

1. Global cardiovascular risk should be assessed.

2. In the absence of data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds.

3. Shared decision-making may improve the effectiveness of preventive health interventions.

Counting risk factors underestimates the risk

Condition Initiation

SBP / DBP mmHg

Diastolic ± systolic hypertension 140/90

Isolated systolic hypertension SBP = or >160

Diabetes 130/80

Renal disease ( 130/80)

Proteinuria >1 g/day ( 125/75)

Target

SBP / DBP mmHg

<140/90

<140

<130/80

<130/80

<125/75

1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet

2. Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week or more

3. Reduction in alcohol consumption in those who drink excessively ( ( ≤ 2 drinks/ day)

4. Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25)

5. Waist Circumference< 102 cm for men< 88 cm for women

5. In individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day

6. Smoke free environment

Strongly consider prescription if: Average DBP equal or over 90 mmHg Hypertensive Target-organ damage (or

CVD) Independent cardiovascular risk

factors: Elevated systolic BP Cigarette smoking Abnormal lipid profile Strong family history of premature CV disease Truncal obesity Sedentary Lifestyle Average DBP equal or over 80 mmHg in a patient with diabetes

Associated risk factors?or

Target organ damage/complications?or

Concomitant diseases/conditions?

IndividualizedTreatment

(with compelling indications)

YES

Treatment in theabsence of compelling

indication

NO

INITIAL TREATMENT AND MONOTHERAPY

* No longer preferred as routine initial therapy

Beta-blocker*

Long-actingCCB

Thiazide ACE-I ARB

Lifestyle modificationtherapy

TARGET <140 mm Hg systolic and < 90 mmHg diastolic

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or lifestyle?• White coat effect?• Resistant Hypertension?

If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

2. Triple or Quadruple Therapy

1. Dual Combination Therapy

If partial response to monotherapy

* Not indicated as first line therapy over 60

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or

lifestyle?• White coat effect?

Dual Combination

Triple or Quadruple Therapy

Lifestyle modificationtherapy

Thiazidediuretic ACE-I Long-acting

CCBBeta-

blocker* ARB

TARGET <140 mm Hg systolic and < 90 mmHg diastolic

Column 1 Column 2

• Thiazide diuretic

• Long-acting calcium channel blocker*

• Beta adrenergic blocker

• ACE Inhibitor

• ARB

For additive hypotensive effect in dual therapy Combine an agent from Column 1 with any in Column 2

* Caution should be exercised when using a non DHP-CCB and a beta-blocker

(ACE=Angiotensin Converting Enzyme, ARB=Angiotension Receptor Blocker)

Column 1 Column 2

• Thiazide diuretic

• Long-acting calcium channel blocker*

• Beta adrenergic blocker

• ACE Inhibitor

• ARB

For additive hypotensive effect in triple therapy Combine 2 agents from one Column with any in the other Column

* Caution should be exercised when using a non DHP-CCB and a beta-blocker

Target BP (mm Hg)Number of antihypertensive agents

1Trial 2 3 4

AASK MAP <92

UKPDS DBP <85

ABCD DBP <75

MDRD MAP <92

HOT DBP <80

IDNT SBP <135/DBP <85

ALLHAT SBP <140/DBP <90

DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure. Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.Lewis EJ et al. N Engl J Med. 2001;345:851-860.Cushman WC et al. J Clin Hypertens. 2002;4:393-405.

Individualized treatment Compelling indications:

• Smoking• Ischemic Heart Disease• Recent ST Segment Elevation-MI or non-ST Segment

Elevation-MI• Left Ventricular Systolic Dysfunction• Cerebrovascular Disease• Left Ventricular Hypertrophy• Non Diabetic Chronic Kidney Disease• Renovascular Disease

Diabetes Mellitus• With Diabetic Nephropathy• Without Diabetic Nephropathy

Global Vascular Protection for Hypertensive Patients• Statins• Aspirin

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diuretic

Long-actingDHP CCB

Lifestyle modificationtherapy

ARB

TARGET <140 mmHg Systolic BP

CONSIDER

• Nonadherence?• Secondary HTN?• Interfering drugs or

lifestyle?• White coat effect?

Thiazide diuretic

Long-actingDHP CCB

Dual combination

Triple or Quadruple* combination

Lifestyle modificationtherapy

ARB

TARGET <140 mmHg Systolic BP

*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

Thiazide - type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.

Certain high-risk conditions are compelling indications for other drug classes.

Most patients will require two or more antihypertensive drugs to achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.

Motivation improves when patients have positive experiences with, and trust in, the clinician.

Empathy builds trust and is a potent motivator.

The responsible physician’s judgment remains paramount.

CVD risk has now replaced CHD risk (to include strokes)

The current CVD risk threshold is >20% over 10 years (equivalent to CHD risk of 15%)

Current advice from the BHS is to prescribe a statin in all patients with hypertension and a CVD risk of 20% or greater.

Unless contra-indicated low dose aspirin should be considered in patients over 50 with a CVD risk of >20% when the blood pressure is controlled.

CVD risk has implications regarding levels to treat.

Saudi Hypertension Management Guidelines 2007

Specialist referral is indicated if there is a possible underlying cause or

presenting as: •sudden onset •worsening of hypertension •resistance to multi-drug regimen

three or more drugs •Hypertension diagnosed in young age

( < 35 years) •persistent noncompliance