DEPARTMENT OF GENERAL MEDICINE

WELCOMES

Dr.Mohamed Omar Shariff,

2nd Year Post Graduate,

Department of General Medicine.

DR.B.R.Ambedkar Medical College

& Hospital.

1

INTRODUCTION

Leading cause of global burden of disease.

Major risk factor for stroke and MI.

Likely to end up being an epidemic in the near

future.

1/3rd of the world population vulnerable by 2020.

2

INDIAN SCENARIO

PREVALENCE RURAL (%) URBAN (%)

AWARENESS 25.3 42.0

TREATMENT 25.1 37.6

CONTROLLED BP 10.7 20.2

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(J Hypertens. Jun 2014; 32(6): 1170– 1177.)

100 million hypertensive patients.

High Prevalence rates for hypertension

In percentage are projected to 22.9 Indian men and 23.6 for

Indian women by 2025.

Rising Numbers Year after Years

Prevalence of hypertension in the last six decade has

increased from 2 to 25% among urban residents from 2% to

15 % among the rural residents in India.

Urban-Rural Phenomenon

Incidence of hypertension is increasing not only in the urban

areas but also in rural population as well.

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CSI TEXTBOOK OF CARDIOLOGY

Prehypertension

38.7-42.6% of screen subjects,highlighting the need for screening

of individuals begining at age of 30yrs or earlier.

Young Hypertensives (18-39 years)

11 to 19.6% in Indian setting

Risk Factors

Obesity,Inactivity,>Processed food rich in

salt,Stress,Smoking,Alcohol consumption

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Hypertension Co-morbidities

Diabetes, CKD, CAD,Stroke.

Other co-morbidities like obesity, obstructive sleep apnea, chronic obstructive pulmonary disease and chronic infections also need special attention.

Disability

In India hypertension is the third most common cause of years of life lost due to premature mortality (YLL) and years lived with disbility.

Cost of Disease

Large expenditure.

6

WHY SO MANY GUIDELINES?

They are changed when sufficient new evidence suggests

the old ones weren’t accurate or relevant anymore.

7

NEWER CONCEPTSBP Measurement

Out-of-office BP measurements:

1. Ambulatory BP

2. Home BP

Target BP in elderly patients

Emphasizes biological age (fragility, independence & tolerability of treatment.)

1. 65-79 y:140/90 mmHg

2. >80 y:160/90 mmHg

8

SINGLE PILL STRATEGY

Advocates single pill two-drug combination therapy for

initial treatment of most patients.

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TARGET BP

Based on:

1. Age

2. Specific comorbidities

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ESH / ESC (2018)

BP Category Systolic BP (mmHg) Diastolic BP (mmHg)

Optimal <120 & <80

Normal 120-129 &/or 80-84

High Normal 130-139 &/or 85-89

Grade 1 HTN 140-159 &/or 90-99

Grade 2 HTN 160-179 &/or 100-109

Grade 3 HTN ≥180 &/or ≥110

Isolated Systolic HTN ≥140 & <90

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Munich, Germany 24 to 29th August 2018

ESH/ESC (2018) V/s ACC/AHA (2017)

BP Category ESH/ ESC (2018) BP Category ACC/ AHA (2017)

Systolic (mmHg) Diastolic (mmHg) Systolic (mmHg) Diastolic (mmHg)

Optimal <120 & <80 Normal <120 & <80

Normal 120-129 &/or 80-84 Elevated 120-129 & <80

High Normal 130-139 &/or 85-89 Stage 1 130-139 & 80-89

Grade 1 HTN 140-159 &/or 90-99 Stage 2 >140 or >90

Grade 2 HTN 160-179 &/or 100-109

Grade 3 HTN ≥180 &/or ≥110

ISH ≥140 & <90

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JNC-7 Blood Pressure Classification

BLOOD PRESSURE CLASSIFICATION SYSTOLIC (mmhg) DIASTOLIC (mmhg)

Normal < 120 & < 80

Pre-hypertension 120-139 or 80-89

Stage 1 hypertension 140-159 or 90-99

Stage 2 hypertension > 160 or > 100

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JNC 8 Recommendations

PATIENT SUBGROUP TARGET SBP (mmHg) TARGET DBP(mmHg)

>/= 60 y <150 <90

< 60 y <140 <90

>18 y w/CKD <140 <90

>18 y w/Diabetes <140 <90

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2014 JNC 8

DEFINITIONS

Category Systolic (mmHg) Diastolic (mmHg)

OFFICE BP a ≥ 140 &/or ≥ 90

AMBULATORY BP b

Daytime (awake) mean ≥ 135 &/or ≥ 85

Night-time (asleep) mean ≥ 120 &/or ≥ 70

24 h mean ≥ 130 &/or ≥ 80

HOME BP mean c ≥ 135 &/or ≥ 85

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a: Blood Pressure measurement in primary care setting.

b: Blood Pressure measurement at regular intervals. It is able to reduce white coat hypertension.

c: Self Measurement of Blood Pressure at home.

OFFICE BP TREATMENT TARGET

AGE

SBP(mmHg)

DBP(mmHg)

+ Diabetes + CKD +Stroke/TIA

18-65 y 130 or lower

if tolerated

Not < 120

<140 to 130

if tolerated

130 or lower

if tolerated

Not < 120

< 80 - 7065-79 y

< 140 to 120

if tolerated ≥ 80 y

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TREATMENT RECOMMENDATIONS

HIGH NORMAL

LIFESTYLE ADVICE

Drug Treatment (CAD)

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GRADE 1 HTN

LIFESTYLE ADVICE

IMMEDIATE DRUG TREATMENT IN HIGH OR VERY HIGH RISK

PATIENTS WITH CV DISEASES, RENAL DISEASES OR HMOD

DRUG TREATMENT IN LOW-MODERATE RISK AFTER 3-6

MONTHS OF LIFESTYLE CHANGES IF BP NOT

CONTROLLED

LIFESTYLE ADVICE

IMMEDIATE DRUG TREATMENT IN ALL

PATIENTS

AIM FOR BP CONTROL WITHIN 3 MONTHS

GRADE 2,3 HTN

CAD: Coronary Artery Disease,

CVD: Cardio-vascular disease,

HMOD: Hypertension mediated organ damage.

LIFESTYLE CHANGES

Prevent or delay the onset of HTN.

Reduce cardio-vascular risk.

Delay or prevent the need for drug therapy in patients with

Grade 1 HTN.

Augment the effects of BP-lowering therapy.

Should not delay the initiation of drug therapy in patients

with HMOD or at a high level of CV risk.

Drawback: Poor persistence over time.

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HEALTHY LIFESTYLE CHOICES

NO

SMOKING

AVOID BINGE DRINKING

SALT RESTRICTION <5g/DAY

REGULAR AEROBIC EXERCISES

( 30 mins of moderate dynamic exercise for 5-7 days/week)

> VEGETABLES, FRUITS, FISH, NUTS, UNSATURATED FATTY ACIDS,

< RED MEAT, AND CONSUMPTION OF LOW FAT DAIRY PRODUCTS.

BODY WEIGHT CONTROL IS INDICATED TO AVOID OBESITY.

AIM AT A HEALTHY BMI (20-25 KG/M2) AND WC VALUES (<94 CM IN MEN AND <80 CM IN WOMEN) TO REDUCE BP AND CV RISK.

19

DRUG TREATMENT STRATEGY FOR

HYPERTENSION WITH CO-

MORBIDITIES.

20

UNCOMPLICATED HYPERTENSION 21

1 pill

1 pill

1 pill

1 pill

INITIAL THERAPY

DUAL

COMBINATION

STEP 2

TRIPLE

COMBINATION

STEP 3

TRIPLE

COMBINATION +

SPIRONOLACTONE

OR OTHER DRUG.

ACEi or ARB + CCB or

Diuretic

ACEi or ARB + CCB or

Diuretic

Resistant Hypertension Add spironolactone (25-

50 mg O.D.) or other

Diuretic, Alpha blocker or

Beta blocker.

Consider monotherapy in

low risk Grade 1

Hypertension or in very old

(≥ 80 yrs) or frailer patients.

Consider referral to a

specialist centre for

further investigation.

Beta-blocker

Consider Beta-blocker at any treatment step,

when there is a specific indication for their use

e.g., Heart failure, angina, post-MI, atrial fibrillation

or younger women with or planning pregnancy.

The core algorithm is also appropriate for most patients with HMOD, CV diseases, diabetes or PAD.

ACEi: Angiotensin-converting enzyme inhibitor, ARB: Angiotensin receptor blocker, CCB: Calcium-channel blocker,HMOD: Hypertension-mediated organ damage, O.D.: Omni die (every day), PAD: Peripheral artery disease.

HTN WITH CAD 22

1 pill

1 pill

1 pill

1 pill

Initial Therapy

Dual Combination

Step 2

Triple Combination

Step 3

Triple combination

+ Spironolactone

or other drug.

Triple Combination of

above

(ACEi or ARB + Beta-

blocker) or (CCB +

Diuretic or Beta-

blocker) or (Beta-

blocker + Diuretic.)

Resistant Hypertension Add spironolactone (25-

50 mg O.D.) or other

Diuretic, Alpha blocker or

Beta blocker.

Consider monotherapy in

low risk Grade 1

Hypertension or in very old

(≥ 80 yrs) or frailer patients.

Consider referral to a

specialist centre for

further investigation.

Consider initiating therapy

when systolic BP is ≥ 130 mm

Hg in case of very high-risk

patients with established

CVD.

ACEi: Angiotensin-converting enzyme inhibitor,

ARB: Angiotensin receptor blocker,

CCB: Calcium-channel blocker,

CVD: Cardiovascular diseases.

HTN AND CKD a

23

1 pill

1 pill

1 pill

1 pill

Initial Therapy

Dual Combination

Step 2

Triple Combination

Step 3

Triple combination

+ Spironolactone

or other drug.

ACEi or ARB + CCB +

Diuretics (or loop

diuretics) (b)

ACEi or ARB + CCB or

ACEi or ARB + Diuretics

(or loop diuretics) (b)

Resistant

Hypertension Add

spironolactone ( c )

(25-50 mg O.D.) or

other diuretic, Alpha

blocker or Beta-

blocker.

Beta-blocker

Consider beta-blocker at any

treatment step, when there is

a specific indication for their

use e.g., Heart failure, angina,

post- MI, atrial fibrillation or

younger women with or

planning pregnancy.

A reduction in eGFR and rise in

serum creatinine is expected

in patients with CKD who

receive BP-lowering therapy,

especially in those treated

with ACEi or ARB but rise in

serum creatinine of > 30%

should prompt evaluation of

the patients for possible

renovascular disease.

a: CKD is defined as an eGFR <60 mL/min/1.72m2

with or without proteinuria.

b: Use of loop diuretics when eGFR is <30 mL/min/ 1.72m2 because

thiazide/thiazide-like diuretics are much less effective/ineffective when eGFR is reduced to this level.

c: Caution: risk of hyperkalemia with spironolactone, especially when eGFR is <45 mL/min/1.72

m2 or baseline K + ≥ 4.5 mmol /L.

THANK

YOU