Hypertension Management

Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.
this presentation have various hypertension management guidelines used in the Indian context, hypertension management algorithm, medication used and AYUSH interventions

1. Hypertension Management Dr. Aparna Sen Chaudhary 13-05-2018 1

2. Contents Introduction Management of Hypertension Classification of Antihypertensive Drugs HTN associated clinical conditions DASH Diet National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke Primary Prevention Public health approach AYUSH Intervention Joint National Committee 8 report: How it differ from JNC 7 13-05-2018 2

3. Introduction Most common controllable disease affecting around 40% of adult population worldwide.¹ It is reported to be fourth contributor of premature mortality in developed and seventh in developing countries.¹ In India, overall prevalence of 29.8% (urban: 33.8% vs. rural: 27.6%).² 13-05-2018 3

4. Introduction 13-05-2018 4 *Raj GM, Priyadarshini R, Mathaiyan J. Current Perspectives in the Management of Hypertension. SAJ Cardiol.2015;1:101

5. Hypertension Definition : Chronic elevation in BP (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg). 13-05-2018 5

6. Hypertension Types: Essential Hypertension (80-95%) Ethnicity (African, Americans and Japanese) Genetic Factors High salt intake Alcohol excess Obesity Lack of exercise Impaired intrauterine growth Secondary Hypertension (5-20%) Renal disease Endocrine disorders Pregnancy Drugs Coarctation of the aorta 13-05-2018 6

7. Treatment Guidelines Joint National Committee of America (JNC) – 8 th (2014) National Institute for Health and Clinical Excellence (NICE) – 2011 AHA/ACC/ASH Guidelines for Management of Hypertension in Patients With Coronary Artery Disease – 2015 Guidelines for the Management of Hypertension by International Society of Hypertension – 2013 Indian Guidelines for Management of Hypertension – III (2013) 13-05-2018 7

8. Classification of Blood Pressure (mmHg) Category Systolic (mmHg) Diastolic (mmHg) Optimal < 120 and < 80 Pre hypertension 120-139 and/or 80-89 Stage – 1 hypertension 140-159 and/or 90-99 Stage – 2 hypertension ≥160 and/or ≥100 JNC – 7 GUIDELINES 13-05-2018 8

9. 13-05-2018 9 Category Systolic (mmHg) Diastolic (mmHg) Optimal <120 And <80 Normal 120-129 And/or 80-84 High Normal 130-139 And/or 85-89 Grade 1 140-159 And/or 90-99 Grade 2 160-179 And/or 100-109 Grade 3 ≥180 And/or ≥110 Isolated systolic hypertension ≥ 140 and <90 Hypertensive urgency >180 and/or >110 Hypertensive emergency >180 and/or >110-120 *The Association of Physicians of India (2007)

10. Risk Stratification of Patients with Hypertension Blood Pressure (mm Hg) Stage Other risk factors and disease history Stage 1 Stage 2 Stage 3 (severe hypertension SBP - 140-159 or DBP – 90-99 SBP- 160-179 or DBP 100-109 SBP ≥ 180 or DBP ≥ 110 I No other risk factor LOW –RISK MEDIUM RISK HIGH- RISK II 1-2 risk factors MEDIUM RISK MEDIUM RISK VERY HIGH-RISK III 3 or more risk factors HIGH- RISK HIGH- RISK VERY HIGH-RISK IV Comorbid conditions : Diabetes, CKD, CAD, CVD VERY HIGH-RISK VERY HIGH-RISK VERY HIGH-RISK 13-05-2018 10 *The Association of Physicians of India (2007)

11. 13-05-2018 11 Standardized BP measurement procedure Patient preparation and position Relaxed state for 5 minute before measurement Should not have had caffeine in past 1hour or smoked in past 30 mins. Seated comfortably with back supported Choice of BP device Mercury sphygmomanometer or any other device which has been validated Cuff size and placement Length of bladder - 80% of arm circumference; width – 40% of arm circumference Large adult cuff for obese patients Constrictive clothing to be avoided Place the cuff over the pulsating brachial artery 2-3 cm above cubital fossa Procedure to measure systolic and diastolic pressure Inflate the cuff to 30 mm beyond the disappearance of the radial pulse Deflate 2-3 mm/sec and record the first and last sounds as the systolic and diastolic pressure with the stethoscope No. of measurements and recording Atleast 2 readings should be taken at an interval of 1 minute. If the readings differ by more than 5 mm Hg take a third reading. The lower of the readings should be taken as the representative.

12. Source of Error during measurement of Blood Pressure Source of measurement error Increase in Blood Pressure Back is not supported Diastolic BP may increase by 6mm Arm not at level of heart Increase BP by 10-12 mmHg Legs are crossed Systolic BP increases by 2-8mm Hg Caffeine in last 1hr Transient increase in BP Smoking in previous 30 mins Transient increase in BP Cuff size not appropriate Overestimate BP in Obese patients by 10-50 mmHg Rapid deflation (>3mm/sec) Underestimate systolic BP and over estimate diastolic BP Presence of anxiety Elevated BP readings (“WHITE COAT HYPERTENSION” or “ISOLATED OFFICE HYPERTENSION”) 13-05-2018 12

13. RISK FACTORS Age (M>55yrs; W>65 yrs ) Smoking Dyslipidaemia TC > 190mg/dl LCL-C > 115 mg/dl HDL-C: M < 40mg/dl ; W < 46mg/dl TG > 150 mg/dl Fasting plasma glucose – 102-125mg/dl Abnormal glucose tolerance Abnormal obesity (WC > 102cm (M); >88cm (W)) Family history of premature CV disease 13-05-2018 13

14. Management of Hypertension Aim : Reduction of BP to the target level Lower the risk of cardiovascular risk in the patient. Target : Gradual reduction of BP 13-05-2018 14 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

15. Suggested response to Initial BP readings Initial BP reading on Screening Advice and Recommendation for Follow up SBP mmHg DBP mmHg <130 <85 Lifestyle modification : Recheck in 2 years 130-139 85-89 Lifestyle modification : Recheck in 1 year 140-159 90-99 Recheck BP within 1-2 weeks . Advise lifestyle modification. Refer to nearest health facility within 1 month for diagnosis and assessment. 160-179 100-109 Recheck BP within 1 week . Advise lifestyle modifications. Refer to nearest health facility for confirmation of diagnosis and initiation of treatment. >180 >110 Check for any signs/symptoms of any target organ damage . In cases of acute target organ damage, treat as hypertensive emergency. Refer to PHC/CHC for evaluation and treatment 13-05-2018 15 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

16. Treatment Strategies Lifestyle measures Drug therapy Patient’s Education 13-05-2018 16 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

17. Treatment Strategies Lifestyle measures Heart – healthy diet with reduction of salt intake, fat intake, stoppage of tobacco products , regular exercise and body weight reduction . Sufficient for treatment of Grade 1 hypertension, and will also it reduces the cardiovascular risk. A trial of 1-3 months is given following the diagnosis of Grade 1 Hypertension. 13-05-2018 17 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

18. Modification Recommendation Approximate SBP Reduction Range Weight Reduction Maintain normal body weight (BMI < 23 kg/m²) 5-20 mm Hg/ 10 kg weight loss DASH* eating plan Diet rich in fruits, vegetables, low fat dairy products, low in salt 8-14 mm Hg Dietary sodium restriction <6g salt or <2.4g sodium 2-8 mm Hg Physical Activity Regular aerobic physical activity for at least 30 min most days of the week 4-9 mm Hg Alcohol moderation Men <60 ml per day , twice a week Women <30 ml per day, twice a week. 2-4 mm Hg Tobacco Total abstinence *DASH = Dietary Approach to Stop Hypertension 13-05-2018 18

19. Treatment Strategies Drug therapy In patients with Grade 1 hypertension (140-159/90-99 mmHg) with Organ failure Coronary artery disease, congestive heart failure, cerebrovascular disease, peripheral arterial disease Diabetes Chronic kidney disease 3 or more risk factors After trial of 1-3 months of lifestyle modifications. In all patients with Grade 2(160-179/100-109mmHg) and Grade 3 hypertension (≥ 180/≥110mmHg) and should be combined with lifestyle measure. 13-05-2018 19 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

20. Treatment goals for management of Hypertension TARGET < 80 years: Systolic BP < 140 mmHg Diastolic BP <90 mm Hg >80 years : Systolic BP < 150 mm Hg Diastolic BP < 90 mm Hg Diabetics : Systolic BP < 140 mm Hg Diastolic BP < 90 mm Hg 13-05-2018 20 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

21. Principles of Drug Treatment Optimal lowering of blood pressure along with overall well being of the patient. Choice of an antihypertensive is influenced by age, risk factors, target organ damage, co-existing disease, socioeconomic factors, availability of drugs and past experience of the physician. Combining low doses of two or more drugs to produce BP control with lesser side effects. 13-05-2018 21 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

22. Principles of Drug Treatment Fixed dose formulations for better compliance Long acting drugs providing 24-hour efficacy provide greater protection and improves compliance. Decrease the dosage and number of antihypertensive drugs after effective control of hypertension. (step-down therapy). 13-05-2018 22 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

23. Treatment regimen Increasing the dosage of the drug or addition of the new drug to control BP should be done at an interval of 2-4 weeks. Addition of new drug in patients with Grade 1 or Grade 2 hypertension is preferable to maximising the dose of the initial drug. If the second drug fails to reduce BP to target levels then the third class of previously unutilized should be added. 13-05-2018 23 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

24. Treatment regimen Aim for patients to reach target BP levels with an effective treatment regimen, whether 1,2or 3 drugs within 6 to 8 weeks. If the BP is not controlled despite use of 3 anti-hypertensives, the hypertension is termed RESISTANT and the patient should be referred to specialist for further evaluation and management. 13-05-2018 24 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

25. Patient’s Education 13-05-2018 25 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

26. 13-05-2018 26 GRADE 1 & 2 HYPERTENSION – Drug therapy - A or C or D Add second Drug - A+C or C+D or D+A Add third drug – A+C+D ALL PATIENTS REQUIRE LIFE-LONG LIFESTYLE MODIFICATION GRADE 3 HYPERTENSION – Drug therapy – A+C or C+D or D+A Add third drug – A+C+D *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016 MANAGEMENT OF HYPERTENSION (Standard Treatment Guideline) A – ACE inhibitors C – CCB D – Diuretics

27. Medication Pathway Initiation with Single drug STEP 1 Initiation with 2 drugs or titration of drugs in a patient not controlled on a single drug: STEP 2 Use of three drugs in a patient not controlled with 2 drugs STEP 3 CCB (AMLODIPINE) Diuretic (HYDROCHLOROTHIAZIDE) ACE inhibitor (ENALAPRIL) ACE inhibitor (ENALAPRIL 5mg) OR Enalapril 5mg + Amlodipine 2.5mg (later rise to 5mg) Enalapril 5mg+ Hydrochlorothiazide 12.5mg Enalapril 10mg (less preferred) ACE inhibitor (Enalapril 5/10mg + CCB (Amlodipine 5/10 mg) + Thiazide (hydrochlorothiazide 12.5/25mg) CCB (AMLODIPINE 5mg) OR Amlodipine 10 mg (less preferred) Amlodipine 5mg + Thiazide 12.5mg Amlodipine 5mg + Enalapril 5mg Thiazide diuretic (HYDROCHLOROTHIAZIDE 12.5mg) Diuretic + CCB Hydrochlorothiazide 25mg (less preferred) Hydrochlorothiazide 12.5mg + Enalapril 2.5 mg (later 5mg) 13-05-2018 27 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

28. 13-05-2018 28 MANAGEMENT OF HYPERTENSION (JNC 8 Algorithm)

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30. Classes of Antihypertensive drugs Class of drugs Definite Indication/s Possible indication/s Definite contraindication/s Relative contraindication/s Diuretics Heart failure Elderly patients Systolic hypertension Diabetes Gout Dyslipidaemia Β - blockers Angina Post-myocardial infarction Heart failure Pregnancy Diabetes Heart block Dyslipidaemia PVD Asthma and COPD Elderly > 50 years CCBs Metabolic Syndrome Angina Elderly Diabetes Systolic hypertension Peripheral vascular disease Heart block * Congestive Heart Failure* First line Antihypertensive drugs * Verapamil or diltiazem 13-05-2018 30

31. Classes of Antihypertensive drugs Class of drugs Definite indication/s Possible indications/s Definite contraindication/s Relative contraindication/s ACE inhibitors Metabolic syndrome Heart failure Left ventricular dysfunction Post-myocardial Infarction Diabetes CVA Pregnancy and lactation Bilateral renal artery stenosis Hyperkalaemia Moderate renal failure (Creatinine levels >3 mg/dl) Angiotensin II Receptor Blockers (ARBs) Metabolic syndrome Diabetes Proteinuria LV dysfunction ACE inhibitor induced cough Heart failure CVA Pregnancy and Lactation Bilateral; renal artery stenosis Hyperkalaemia Moderate renal failure (Creatinine levels >3 mg/dl) First line Antihypertensive drugs 13-05-2018 31

32. Classes of Antihypertensive drugs Class of Drugs Definite indication/s Possible indication/s Definite contraindication/s Relative contraindication/s α blockers Prostatic hypertrophy Chronic kidney disease Glucose intolerance Dyslipidaemia Orthostatic hypertension Congestive heart failure Centrally acting agents α methyl dopa Hypertension in pregnancy Resistant hypertension Acute or chronic liver disease Clonidine Resistant Hypertension CKD Pregnancy, Lactation Vasodilators Resistant Hypertension CAD Direct renin inhibitors liskiren Resistant Hypertension Pregnancy, lactation Moderate renal failure Other Antihypertensive drugs 13-05-2018 32

33. Hypertension with Associated Clinical Conditions CLINICAL CONDITION PREFERRED DRUG SECOND DRUG THIRD DRUG Isolated systolic hypertension CCB/Thiazide diuretic ACE Inhibitors Thiazide diuretic + ACE+ CCB Hypertension with Diabetes ACE inhibitors CCB or Thiazide diuretic Thiazide diuretic + ACE+ CCB Hypertension with chronic kidney disease ACE inhibitors (close monitoring) else CCB CCB or Thiazide diuretic ( loop diuretic – e GFR < 30mi/min) Thiazide diuretic + ACE+ CCB Hypertension and previous MI BB, ACE Inhibitors CCB or diuretic Hypertension with Heart Failure Thiazide/ loop diuretics + ACE Inhibitor+ BB+ spironolactone Hypertension with previous stroke ACE Inhibitor Diuretic or CCB Diuretic + ACE+ CCB 13-05-2018 33 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

34. Interventions to reduce Cardiovascular Risks Low dose aspirin (75mg/day) Controlled hypertension with previous history of cardiovascular event Controlled hypertension with high cardiovascular risk Statins Aged more than 40 years, with LDL >190mg/dl. Diabetic and in age group of 40-79 years Glycaemic control Cessation of Tobacco consumption . 13-05-2018 34 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

35. DASH Diet (Dietary Approach to stop hypertension) Rich in important nutrients and fibre. Include foods that contain two and a half times the amounts of electrolyte, potassium, calcium and magnesium . 13-05-2018 35

36. DASH Diet (Dietary Approach to stop hypertension) Recommendation of DASH diet include : Avoid saturated fats Include monounsaturated fatty acids (Omega 9 MUFA) Include polyunsaturated fatty acids (Omega 3 and 6 PUFA) Whole grains in place of white flour Include fresh fruits and vegetables Include nuts, seeds or legumes Moderate amount of protein - fish or poultry 13-05-2018 36

37. Food items to be avoided in hypertensives Salt preserved foods Pickles and canned foods; Ketchup; Prepared mixes Highly salted foods Potato chips; cheese; peanut butter; papads Bakery products Biscuits; cakes; breads and pastries Fried foods Alcohol 13-05-2018 37 *Management of Hypertension. JAPI.2013;61:17-23.

38. Sodium content in common foods per 100 gm < 25 mg Low 25-50 mg Moderate 50-100 gm Moderately high >100mg High Amla Ragi Raisins Cauliflower Bacon Bitter gourd Vermicelli Carrots Fenugreek Egg Brinjal Wheat Black gram dal Lettuce Lobster Cabbage Maida Red gram dal Beetroot Cucumber Milk Banana Water melon Peas Grapes Bengal gram Bengal gram dal Onion Papaya Apple Liver Potato Orange Pineapple Chicken Tomato ripe Prawns 13-05-2018 38 *Management of Hypertension. JAPI.2013;61:17-23.

39. Food with high Potassium Fruits Vegetables Amla Plums Cabbage Potato Peaches Lemons Bitter gourd Brinjal Oranges Pineapple Ladies finger Pumpkin Papaya Apple Cauliflower French beans Banana Watermelon Spinach Tapioca 13-05-2018 39 *Management of Hypertension. JAPI.2013;61:17-23.

40. National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke (NPCDCS) MANAGEMENT OF HYPERTENSION: The Risk assessment should cover: Assessment of medical history Physical Examination Laboratory Investigation 13-05-2018 40

41. Medical history: Risk factors Family history Symptoms Frequent intake of pain relieving drugs (NSAIDS) Steroid intake for asthma Breathing difficulty particularly on exertion Swelling of feet Urinary difficulties, history of passing stones in the past 13-05-2018 41

42. Physical examination : BP measurement at least in one upper and one lower limb Measurement of Body weight and height to obtain BMI Measurement of Waist circumference Palpating all peripheral pulses Auscultation for bruit (renal, carotid, abdominal and others) Eye evaluation if ophthalmology facility is available 13-05-2018 42

43. Laboratory Tests under NPCDCS: Essential: • Blood Sugar • Urine analysis for proteinuria Desirable: (at CHC/sub-district/district level hospitals) • Haemogram , • Serum creatinine • Serum sodium and potassium levels • Lipid profile • Complete Urine analysis • Electrocardiogram(ECG) • X-Ray chest 13-05-2018 43

44. Treatment Goals under NPCDCS Initial aim should be to obtain blood pressure level less than 130/85 mm Hg Ideally the aim should be to get to blood pressure levels of less than 120/80 without bothersome side-effects. Don't accept blood pressure levels of 140/90 mm Hg or more Maintain healthy blood pressure throughout the person’s lives Prevent and control risk factors which could give rise to high blood pressure. Always make sure that risk factors are controlled . Prevent and control risk factors which could increase risk of complications due to high blood pressure. 13-05-2018 44

45. Hypertension Management under NPCDCS Life style advice is advocated for the first six month after the diagnosis of high BP in the following situations: If the BP is less than 160/100 mm of Hg There is no diabetes, co-existing heart disease stroke or peripheral vascular disease No evidence of LVH on ECG Absence of urinary proteinuria and Serum creatinine <1.6mg/dl Start with calcium channel blockers in the person is older than 55 years and ACE inhibitors if less than 55 years. 13-05-2018 45

46. Prevention of Hypertension Primary Prevention Population strategy High – risk strategy Secondary Prevention Early case detection Treatment Patient compliance 13-05-2018 46

47. Primary Prevention Population strategy : Directed to whole population Involves health promotive measures : Dietary changes DASH Diet Weight reduction Behavioural changes Health education Self-care 13-05-2018 47

48. Primary Prevention High-risk strategy: Screening of all ‘high-risk’ cases by recording BP. Aim is to prevent the attainment of levels of blood pressure at which treatment has to be started 13-05-2018 48

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53. Public Health Approach 13-05-2018 53 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

54. Public Health Approach 13-05-2018 54 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

55. Public Health Approach 13-05-2018 55 *Standard treatment guidelines. Ministry of Health & welfare. Government of India. 2016

56. AYUSH interventions for Hypertension Management Ayurveda interventions: Nidana parivarjana - avoidance of causative factors is the first line of treatment. Samshodhana chikikitsa - Bio-cleansing therapies followed by Samana chikitsa (Palliative therapy) should be advocated. 13-05-2018 56

57. 13-05-2018 57 Plant name Dosage( perdose ) Vehicle Duration Sarpagandha Powder 1 -3 gm Water 15 days Ashvagandha Powder 3-6 gm Milk 15 days Jatamansi Powder 1-3 gm Water 15 days Arjuna Bark Powder 3-6 gm Water 15 days Arjuna Bark ksheerapaka 10 -30ml   15 days Rasona ksheerapaka 10-30 ml   15 days Common medicinal plants * Ksheerapaka  is a preparation in which the milk is processed with the desired plant part.

58. 13-05-2018 58 Drug Dosage Vehicle Duration Mamsyadi kvatha 10-20 ml Water 15 days Sarpagandha ghana vati 125-250 mg Water 15 days Brahmi vati 125-250 mg Water 15 days Prabhakara   vati 125-250 mg Water/Milk 15 days Arjunarishta 10-15 ml Water 15 days Abhayarisha 10-15 ml Water 15 days Pravala pishti 250-500 mg Water 15 days shveta parpati 125-250 mg Water 15 days Nagarjun!bhra rasa 125-250 mg Water/Honey 15 days Hridayarnava rasa 125-250 mg Honey/ Triphala 15 days Common Ayurvedic Drug Formulation used for Hypertension Management

59. AYUSH interventions for Hypertension Management Yoga Interventions: following yoga practices are beneficial for hypertension management. Breathing exercises   Asana-   Shavasana , Vajrasana , Bhujangasana , Vakrasana , Gomukhasana , Pranayama  13-05-2018 59

60. 13-05-2018 60 Medication Indication Aconitum high blood pressure of sudden origin Argentum nitricum essential hypertension caused by anxiety Natrum muriaticum high blood pressure caused by suppressed anger Veratum viride lowers arterial tension, and treats atrial fibrillation Baryta carbonica Treats high blood pressure in elderly 50  yrs  and older Berberis vulgaris Secondary hypertension caused by kidney disease. Aurum muriaticum   treats high blood pressure due to disturbed function of the nervous mechanism Ignatia   High blood pressure caused from emotional upset Lycopodium  Recommended if blood pressure goes up when one goes to the doctor. Nux vomica   Indicated for high blood pressure due to overeating AYUSH interventions for Hypertension Management Homeopathic Medication for Hypertension Management:

61. 13-05-2018 61 Topic JNC 7 JNC 8 Methodology Non systematic literature review by expert committee. Initial systematic review by methodologists restricted to RCT evidence. Subsequent review of RCT evidence and recommendations by the panel according to a standardized protocol. Definitions Defined hypertension and pre-hypertension. Definitions of hypertension and prehypertension not addressed, thresholds for pharmacologic treatment were defined. Treatment Goals Separate treatment goals defined for “uncomplicated” hypertension and for subsets with various comorbid conditions Similar treatment goals defined for all hypertensive populations. Lifestyle recommendations Based on literature review and expert opinion Recommended by endorsing the evidence based recommendations Joint National Committee 8 report: How it differ from JNC 7 Source: James PA, Oparil S, Carter BL. 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 . 311(5), 2014, 507-20.

62. 13-05-2018 62 Joint National Committee 8 report: How it differ from JNC 7 Topic JNC 7 JNC 8 Drug therapy Thiazide-type diuretics as initial therapy for most patients without compelling indication for another class. Specified particular antihypertensive medication classes for patients with compelling indications, ie , diabetes, CKD, heart failure. Included a comprehensive table of oral antihypertensive drugs including names and usual dose range. Recommended specific medication classes based on evidence review for racial, CKD, and diabetic subgroups. Panel created a table of drugs and doses used in the outcome trials. Scope of topics Addressed multiple issues (blood pressure measurement, secondary hypertension, adherence to regimens, resistant hypertension, and hypertension in special populations) based on literature review and expert opinion. Evidence review of RCTs addressed a limited number of questions, those judged by the panel to be of highest priority. Source: James PA, Oparil S, Carter BL. 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 . 311(5), 2014, 507-20.

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64. References Raj GM, Priyadarshini R, Mathaiyan J. Current Perspectives in the Management of Hypertension. SAJ Cardiol.2015;1:101. Standard Treatment Guidelines. Screening, diagnosis, assessment, and Management of Primary Hypertension in Adults in India. Ministry of Health & Family Welfare Government of India. 2016. Chandarana A. Hypertension Guidelines. Gujarat Medical Journal.2010;65(2):27-35. Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med. 1995;155:701-9. Your guide to lowering Blood Pressure. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health.National Heart, Lung, and Blood Institute.2003 Management of Hypertension. JAPI.2013;61:17-23. Park K. Textbook of Preventive and Social Medicine. 23rd Edition. Jabalpur: Bhanot;2015 13-05-2018 64

65. References Kumanyika SK, Cook NR, Cutler JA, Belden L, Brewer A, Cohen JD., etal . Sodium reduction for hypertension prevention in overweight adults: further results from the Trials of Hypertension Prevention Phase II. J Hum Hypertens. 2005 ;19(1):33-45. Stevens VJ, Obarzanek E, Cook NR, Lee IM, Appel LJ, Smith West D, etal . Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II. Ann Intern Med. 2001 Jan 2;134(1):1-11. Paul K. Whelton , MD; Lawrence Appel, MD; Jeanne Charleston, RN; et al. Long-term weight loss and changes in blood pressure: results of the Trials of Hypertension Prevention, phase II. JAMA. 1992;267(9):1213-20. National Programme for Prevention and Control of Diabetes, Cardiovascular Disease and Stroke. A Manual for Medical Officer. Developed under the Government of India – WHO Collaborative Programme 2008-2009 : 29-33. Suryakantha AH. Community Medicine with Recent Advances. 4th Edition. New Delhi:Jaypee Brothers;2017 Joseph AC, Karthik MS, Sivasakthi R, Venkatanarayanan R, Chander SJU. JNC 8 versus JNC 7 – Understanding the Evidences. Int. J. Pharm. Sci. Rev. Res.2016;36(1):38-43. 13-05-2018 65

66. 13-05-2018 66 Thank You