Management of Hypertension

1. HYPERTENSIONHYPERTENSION
AND ITSAND ITS
MANAGEMENTMANAGEMENT
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD,FACC, FESC, FRCP, FSCAI,FAPSIC,
FAPSC, FCCP
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova,
Malbagh branch.

2. Hypertension
A World Wide Epidemic
Nearly 1 billion hypertensive in the world
Hypertension is poorly controlled, with less than
25% controlled in developed countries and less
than 10% in developing countries.
Hypertension which is responsible for 3 million
death annually.
May 14
th
is World Hypertension Day

3. Prevalence of Prevalence of
HypertensionHypertension
131
144
302
584
240
0
100
200
300
400
500
600
P
r
e
v
a
l
e
n
c
e

R
a
t
e
/
1
0
0
0
1
India (2000) Bangladesh (2002)Malaysia (2002)
China (2002) USA (2002)

4. Hypertension is a hemodynamic disorder
A well accepted definition of hypertension was
suggested by Evans and Rose:
“Hypertension should be defined in the terms of blood
pressure level above which investigation and treatment
do good more than harm”
A patient is said to be hypertensive when his SBP≥
140 mm Hg & DBP ≥ 90 mm Hg provided that the
patient is not on antihypertensive drugs.
Hypertension: DefinitionHypertension: Definition

5. Varieties OF HTNVarieties OF HTN
Labile HTN
Isolated diastolic hypertension
Isolated systolic hypertension
Malignant or accelerated Hypertension
Refractory/ Resistant hypertension
Hypertensive emergencies/ urgencies

6. Classification of BP for AdultsClassification of BP for Adults
JNC-VI;1997JNC-VI;1997
BP Classification Systolic BP Diastolic BP
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT 160-179 or 100-109
Stage 3 HT ≥ 180 or ≥ 110
BP Classification Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT ≥ 160 or ≥ 100
JNC-VII;2003JNC-VII;2003

7. Classification of BP LevelsClassification of BP Levels
ESH-ESC Guidelines, 2003
BP Classification
Optimal
Normal
High Normal
Grade 1 HT (mild)
Grade 2 HT (moderate)
Grade 3 (severe)
Isolated systolic HT
Systolic BP
<120
120-129
130-139
140-159
160-179
>180
>140
Diastolic BP
<80
80-84
85-89
90-99
100-109
>110
<90

8. Regulation of BP
BP = CO X PVR
SV
HR

9. Haemodynamic Pattern in Haemodynamic Pattern in
HypertensionHypertension
Young : ­ BP = ­CO X TPR
Middle Aged : ­ BP = CO X TPR
Elderly : ­ BP = ¯ CO X ­ ­ TPR

10. Aetiology of Systemic Aetiology of Systemic
HypertensionHypertension
A)Essential or Primary HTN (95%)
A. ­ Age
B. Genetic
•Both parents (45%)
•Single (25%)
C. Environment
•Diet Fat
Salt
alcohol
•Obesity
•Physical inactivity
•Stress
•Smoking
D. Hormonal

11. Aetiology of Systemic Aetiology of Systemic
HypertensionHypertension
B) Secondary HTN (05%)
A. Renal (80%) • AGN
• CGN,
• CPN,
• Polycyst. K.D
• Renal Artery stenosis
B. Endocrine • Adrenal • Primary aldosteronism
• Cushing’s syndrome
 Pheochromocytoma
• Acromegaly
• Exogenous hormone• Oral contraceptive)
• Glucosteroids
• Hypothyroidism &
• Hyperparathyroidism
Continue…

12. C) Others
Coarctation of the aorta
Pregnancy Induced HTN (Pre-eclampsia)
Sleep Apnea Syndrome.
Aetiology of Systemic Aetiology of Systemic
HypertensionHypertension

13. Clinical ManifestationClinical Manifestation
• Asymptomatic in the majority of patients. Can
remain undetected for many years
• Headache may occur when SBP rises above
200mmHg or when blood pressure is rapidly
elevated.

14. Measuring Blood PressureMeasuring Blood Pressure
•Patient seated quietly for at least
5minutes in a chair, with feet on the
floor and arm supported at heart level
•An appropriate-sized cuff (cuff bladder encircling at
least 80% of the arm)
•At least 2 measurements
Continue…

15. Measuring Blood PressureMeasuring Blood Pressure
•Systolic Blood Pressure is the point at which the
first of 2 or more sounds is heard
•Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…

16. Measuring Blood PressureMeasuring Blood Pressure
•Ambulatory BP Monitoring - information about BP
during daily activities and sleep.
•Correlates better than office measurements with
target-organ injury.
Continue…

17. Complication of HypertensionComplication of Hypertension
1. Cardiac :
LVH
LVF
•Systolic
•Diastolic
IHD
Arrhythmias
2. Vascular Peripheral arterial
disease
•Aortic dissection
3. Cerebral
Stroke
TIA
Encephalopathy
4. Renal Nephropathy
Renal failure
5. Eye Retinopathy

18. The scope of the problemThe scope of the problem
–Heart Attack (MI)
–Heart Failure
–Stroke
–Kidney Disease
THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO
MINIMISE CARDIOVASCULAR RISK AND DAMAGE
TO TARGET ORGANS

19. Hypertension even today is aHypertension even today is a
triple paradox which is :triple paradox which is :
Easy to diagnose OFTEN remains undetected
Simple to treat OFTEN remains untreated
Despite availability of potent drugs, treatment
all too OFTEN is ineffective

20. The "Rule of Halves" inThe "Rule of Halves" in
Hypertension Hypertension
Only 1/2 have been
diagnosed
Only 1/2 of those
diagnosed have been
treated
Only 1/2 of those treated
are adequately controlled
Only 12.5% overall are adequately controlled
Not
diagnosed
Not treated
Not
controlled
Controlled

21. Evaluation of hypertensive patients Evaluation of hypertensive patients
Objectives:
To know accurate and representative
measurement of BP
To identity any known cause of Hypertension
To assess presence or absence of TOD
To assess response to therapy
To identity cardiovascular risks factor
To know concomitant disorders
Continue….

22. Evaluation of hypertensive patients Evaluation of hypertensive patients
Evaluation by
Medical history
Physical Examination
Laboratory investigation
Routine tests
Optional tests.

23. Effects of Antihypertensive Drug Treatment on Effects of Antihypertensive Drug Treatment on
CV Mortality and MorbidityCV Mortality and Morbidity
Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated
compared to control
Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478
-52%
-38%
-35%
-25%
-16%
-60%
-50%
-40%
-30%
-20%
-10%
0%
CHF Strokes
(fatal/nonfatal)
LVF CVD Deaths CVD events
(fatal/nonfatal
Management of HTN Management of HTN

24. 140
120
100
80
60
40
20
0
50
40
30
20
10
0
Historical Lessons About HypertensionHistorical Lessons About Hypertension
Hypertension
Increases Morbidity
and Mortality
Men Women
C
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D

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p
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a
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THE FRAMINGHAM STUDY
C
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u
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t
iv
e

f
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a
l
&

N
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n
f
a
t
a
l
E
n
d
p
o
in
t
s
Treatment Decreases
Morbidity and
Mortality
Men Women Placebo Active
Treatment
THE VET.ADM. STUDY II
Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152
Normotension
Hypertension

25. Implication of reduction in Diastolic BP for Implication of reduction in Diastolic BP for
Primary PreventionPrimary Prevention
30
20
%

R
e
d
u
c
t
i
o
n
Change in DBP
0
-10
-20
-30
-40
-50
7.5 mm Hg 5-6 mm Hg 2 mm Hg
-21
-46
-16
-38
-6
-15
CHD
Stroke
Cook, et al. Arch Int med. 1995; 155:711-109

26. Millimeters Matter…… Millimeters Matter……
“ A 2-mm Hg reduction in DBP would
result in…
a 6% reduction in the risk of CHD and a 15%
reduction
in the risk of stroke and TIAs”
Cook, et al. Arch Int med. 1995; 155:711-109

27. Impact of High Normal BP on CV Impact of High Normal BP on CV
Disease Risk in MenDisease Risk in Men
High Normal
130-139/ 85-89 mm Hg
Normal
120-129/ 80-84 mm Hg
Optimal
<120/ 80 mm Hg
C
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m
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l
a
t
i
v
e

I
n
c
i
d
e
n
c
e

(
%
)
Time (Years) N Engl J Med. 2001;345:1291-97

28. Benefits of Lowering BPBenefits of Lowering BP
Average percent
reduction
Stroke reduction 35-40%
Myocardial infarction 20-25%
Heart failure 50%

29. Goals of TherapyGoals of Therapy
•Reduction of cardiovascular and renal
morbidity and mortality.
1
•The primary focus should be on achieving the systolic
BP goal.
•Systolic BP and diastolic BP to targets < 140/90
mmHg = decrease in CVD complications.
•In patients with hypertension with diabetes or renal
disease, the BP goal is < 130/80 mmHg
1
1
JNC - VII Report, JAMA , 2003;289:2560-2572

30. JNC VII Algorithm for Treatment of
Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle
Modifications
Not at Goal BP
(< 140/90 mmHg or < 130/80 mmHg
for Those with Diabetes or Chronic
Kidney Disease
Initial Drug Choices

31. Lifestyle Modification: 1Lifestyle Modification: 1
ÞSocioeconomic condition in the world suggest that
prevention through Lifestyle Modifications is the
universal “vaccine” against Hypertension
ÞWeight Reduction
–Maintain normal body weight
•BMI: 18.5 – 24.9
•BP reduction: 5-20 mmHg/10 kg loss
ÞDASH Eating Plan
–Dietary Approaches to Stop Hypertension
•Fruits, Vegetables, Low-fat dairy
•Reduce saturated and total fat
•8-14 mmHg BP reduction

32. Lifestyle Modification: 2Lifestyle Modification: 2
ÞDietary Sodium Reduction
•2.4 grams Sodium or 6 grams Sodium Chloride
•2-8 mmHg BP reduction
ÞPhysical Activity
–Regular aerobic physical activity
•4-9 mmHg BP reduction

33. Lifestyle Modification: 3Lifestyle Modification: 3
ÞSmoking Cessation
•Any independent chronic effect of smoking on BP is small
•Smoking cessation does not decrease BP
•BUT total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke
should be counselled on smoking
cessation

34. Antihypertensive Drugs
Continue….
AT
1
receptor
ARB

35. Antihypertensive Drugs

36. JNC VII Algorithm for
Treatment of Hypertension
Hypertension without
compelling indications
Hypertension with
compelling indication
(Systolic Bp 140-159
mmHg
or Diastolic BP 90-99
mmHg)
Thiazide-Type
Diuretics for Most
May Consider ACE
inhibitor, ARB, ß-
blocker, CCB or
combination
Systolic Bp >160
mmHg
or Diastolic BP > 100
mmHg)
2- Drug Combination
for Most
(Usually Thiazide -
Type Diuretic and
ACE Inhibitor or ARB
or ß-blocker, CCB)
Drug (s) for the
Compelling
Indications
Other
Anithypertensive
Drugs
(Diuretics, ACE
inhibitor, ARB, ß-
blocker, CCB) as
needed
Initial Drug Choices

37. ChoiceChoice of antihypertensiveof antihypertensive
•Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors,
angiotensin receptor antagonists) are suitable for the initiation and
maintenance of therapy
•Choice:
®Previous experience of the patient
®Cost
®Risk profile, target organ damage, clinical cardiovascular or renal
disease or diabetes or lung disorder
®Patient’s preference
•Long acting preparations providing 24-h efficacy on a once daily
basis
(2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).

38. Special ConsiderationsSpecial Considerations
Guideline Basis for Compelling Indications for
Individual Drug Classes
High Risk Conditions
With Compelling
Indication
Heart failure
Post-myocardial
infarction
High coronary disease
risk
Diabetes
Chronic Kidney Disease
Recurrent stroke
prevention
Recommended Drugs
Diuretic b-blocker ACE inhibitor ARB CCB Aldosterone Antagonist
JNC - VII Report, JAMA , 2003;289:2560-2572

39. Choice Between Monotherapy Choice Between Monotherapy
and Combination therapyand Combination therapy

40. Possible Combination of Possible Combination of
Antihypertensive AgentsAntihypertensive Agents
Diuretics
Beta
Blocker
µ-Blocker
ACE inhibitor
CCBs
ARBs
EHS-ESC Guidelines, 2003;

41. Indications and Contraindications for Indications and Contraindications for
the Major Classes of Antihypertensiue the Major Classes of Antihypertensiue
DrugsDrugs
Class Conditions favouring
the use
Compelling
contraindications
Possible
contraindications
ACEIs CHF
LV dysfunction
Post-MI
Nondiabetic nephropathy
Type 1 diabetic nephropathy
Protienuria
Pregnancy
Hyperkalaemia
Bilateral RAS

ARBs Type 2 diabetic nephropathy
Diabetic microalbuminuria
Proteinuria
LVH
ACE inhibitor cough
Pregnancy
Hyperkalaemia
Bilateral RAS

a-BlockersProstatic hyperplasia (BPH)
Hyperlipidaemia
Orthostatic
hypotension
CHF
EHS-ESC Guidelines, 2003;

42. EVOLUTION OF HYPERTENSION EVOLUTION OF HYPERTENSION
MANAGEMENTMANAGEMENT
JNC I
1977
JNC II
1980
JNC III
1984
JNC IV
1988
JNC V
1993
JNC VI
1997
JNC VII
2003
High
Dose
diuretic
High
Dose
diuretic
Lower
Dose
diuretic
Or
b-blocker
Lower
Dose
diuretic
Or
b-blocker
Or
ACEI
Or
CCB
Lower
Dose
diuretic
Or
b-blocker
Or
ACEI
Or
CCB
a-blocker
Or
a / b blocker
•
Individulised
Therapy
•Single-agent
titration
preferred
•Loe-dose
combo
therapy as a
secondary
option
•Focus on
Systolic
BP Control
•Thiazide-
type
diuretics
preferred
as initial
drug
treatment
•Emphasis
on
combinatio
n therapy
High-dose Monotherapy Low-dose Combination

43. Management of HTN in Special Management of HTN in Special
SituationSituation
1.Hypertension Crises
Hypertension Emergencies
Hypertension Urgencies
2.Refractory/ Resistant hypertension
3.HTN in Pregnancy
4.HTN with coexisting Cardiovascular & other disorders
4.Management of Secondary HTN

45. Resistant Hypertension
•Not uncommon : 15-20%
•Persistence of elevated systo-diastolic pressure in
spite of at 3 anti-hypertensive drugs ( including
diuretics)
•Pre-requisites: Exclusion of pseudo-hypertension;
white-coat hypertension,use of not-appropriate
cuffs.

46. Resistant hypertension: Causes
•Insufficient patient compliance
•Inability to follow prescribed life-style
modifications ( weight loss, increased
alcohol consumption)
•Use of offending drugs: steroids,NSAID
•Obstructive Sleep apnoea syndrome
•Volume overload

47. Therapeutic intervention
•Exclude undiagnosed secondary
hypertension
•Compliance of drugs
•Adherence to life style changes
•Consider use of 3 or more anti-hypertensive
drugs
•Consider the use of drugs such as
spironolactone

48. Failure of reduction of DBP<90 mm Hg
despite the use of three or more drugs
which include a diuretic
Resistant hypertension
Braunwald’s Heart Disease, 2005

49. Volume overload & pseudotolerance
“White coat”
Pseudohypertension in the elderly
Excess sodium intake
Inadequate diuretic therapy
Volume retention
Drug related
Dosage too low
Inappropriate combination
Drug interaction
Associated conditions
Smoking
Obesity
Excess alcohol
Sleep apnea
Secondary hypertension
Resistant hypertension
Causes:
Braunwald’s Heart Disease, 2005

50. Current recommendations for primary
prevention of hypertension involve:
a population based approach, and
an intensive targeted strategy focused on
individuals at high risk for hypertension.
Primary Prevention of Hypertension
Hypertension Primer, AHA, 2004

51. Conclusion
•Hypertension is easy to diagnose and easy to treat
•Aim of the management is to save the target organ from
the deleterious effect
•Pharmacological armament of antihypertensive drugs so
rich that we have wide range of options. And this makes
the physicians comfortable in varied situations.
Conversely one needs to be judicious regarding the
choice of the drug
•Besides pharmacology we have other choices and one
has to be acquainted with that choice
•Primary prevention of hypertension should be highlighted
and it should get more priority than it is getting now.

52. Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in developing
countries
Early diagnosis & management can prevent end organ damage from HTN
Target goal of BP in hypertensive patients:-
< 140/90 mm Hg
< 130/80 mm Hg for patients with DM & renal disease

Lifestyle modification is the universal “Vaccine” against Hypertension
ConclusionConclusion

53. Thank you !Thank you !