Hypertension – The Latest Management

DR AWADHESH KUMAR SHARMAConsultant CardiologyGracian superspeciality HospitalMohali

Hypertension

Hypertension is the most common condition

in primary care.

1 in 3 patients have hypertension.

Risk factor for MI, CVA, ARF, death.

Benefits of lowering BP

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.

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.

HTN IN INDIA

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.

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

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

What should be the goal BP?

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.

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

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

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

JNC 8: Graded Recommendations

A – Strong evidence

B – Moderate evidence

C – Weak evidence

D – Against

E – Expert Opinion

N – No recommendation

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

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

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)

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)

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

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

Possible combinations of classes of antihypertensive drugs

Anti-hypertensive drugs and their usual dosage

Anti-hypertensive drugs and their usual dosage

Hypertension

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

Management of HTN in specific conditions

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)

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).

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).

Cerebrovascular disease

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).

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.

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).

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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