Template Clinical Case 1 - hypertension.pptx

Hypertension

1. Dr. Achmad Rifai, SpPD KGH Clinical Case Achieved BP Target

2. Family History Father: MI at 60-years-old; still alive at 90 years of age with dementia; nursing home resident Treatment history:     Treated with amlodipine 5 mg for 5 months Then swithed to amlodipine 10 mg, 3 months Lifestyle: Sedentary Smoker for 35 years, smokes 10 cigarettes per day BMI: body mass index; BP: blood pressure; OD: once daily; MI: myocardial infarction. PATIENT PROFILE Gender: male Age: 52 years old BP : 160/100 mm Hg Weight: 85 kg Height: 178 cm BMI: 27 (slightly overweight) Treated for 8 months Sedentary 10 cigarettes per day – for 35 years PATIENT HISTORY

3. The patient is suffering from Grade 2 hypertension and is at moderate risk Category Systolic (mm Hg) Diastolic (mm Hg) 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 Isolated dystolic hypertension <140 and ≥90 ESH Guideline 2023 BP levels: 160/100 mm Hg

4. Discussion What is the first thing to do in the case above?

5. Correct Blood Pressure Measurement 1. think about

6. BP thresholds for the diagnosis of hypertension with different types of measurement Adapted from Unger T, et al. 2020 International Society of Hypertension global hypertension practice guidelines. J Hypertens .  2020;38(6):984 .

7. Patterns of in-office and out-of-office blood pressure in treated hypertension Adapted from Unger T, et al. International Society of Hypertension global hypertension practice guidelines. J Hypertens .  2020;38(6 ):984 .

8. Prevalence of white-coat hypertension Manuel Gorostidi et al ,Hypertension Research   volume 38 , pages1–7 (2015) George Stergiou ,Current Hypertension Reports 21(8) 2019 .

9. Discussion Next, The second stage is what must be done ?

10. 2. think about patient adherence/compliance

11. Factors leading to nonadherence . (Adapted from WHO’s framework for adherence) Dr. Spoorthy Kulkarni, ESC, Vol. 22, N° 6 - 23 Mar 2022

12. Proportion of clinicians’ adherence to JNC-8 hypertension treatment guidelines Bekalu Kebede , SAGE Open Medicine , March 2021

13. Prevalence of patients’ medication adherence at JUMC, 2018 Bekalu Kebede , SAGE Open Medicine , March 2021

14. Discussion Next, The third stage is what must be done ?

15. 3. Lifestyle interventions are important An S, et al. BMJ Open. 2015;5:e008730. Maseli A, et al. Am J Hypertens . 2017;30:690-699. National Institute for Health and Clinical Excellence (NICE). Hypertension. Clinical Guideline 127. Last updated: November 2016. Weber MA, et al. J Clin Hypertens . 2014;16:14-26. Mancia G, et al. Eur Heart J. 2013;34:2159-2219. Image source: 1) ©Alona_S/Shutterstock.com 2) ©AF studio/Shutterstock.com 3) ©Alex_Murphy/Shutterstock.com 4) ©VectorShop/Shutterstock.com 5) ©Best Vector Elements/Shutterstock.com 6) ©Satika/Shutterstock.com 7) ©Nobelus/Shutterstock.com 8) ©VoodooDot/Shutterstock.com A healthy lifestyle and positive cardiovascular health behaviours are associated with low BP variability 1,2 Provide guidance on diet – primarily increased vegetables, fruit and low-fat dairy products - consider the DASH diet 3–5 Relaxation therapies to reduce BP 3 Reduce alcohol consumption 3–5 Reduce caffeine intake 3 Reduce dietary sodium 3–5 Regular exercise 3–5 ‘Group-working’ to support healthy lifestyle change 3 Stop smoking 3–5

16. Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension   Nonpharmacologi-cal Intervention Dose Approximate Impact on SBP Hypertension Normotension Weight loss Weight/body fat Best goal is ideal body weight, but aim for at least a 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1-kg reduction in body weight. -5 mm Hg -2/3 mm Hg Healthy diet DASH dietary pattern Consume a diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced content of saturated and total fat. -11 mm Hg -3 mm Hg Reduced intake of dietary sodium Dietary sodium Optimal goal is <1500 mg/d, but aim for at least a 1000-mg/d reduction in most adults. -5/6 mm Hg -2/3 mm Hg Enhanced intake of dietary potassium Dietary potassium Aim for 3500–5000 mg/d, preferably by consumption of a diet rich in potassium. -4/5 mm Hg -2 mm Hg *Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure. Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH? Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to . Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

17.   Nonpharmacological Intervention Dose Approximate Impact on SBP Hypertension Normotension Physical activity     Aerobic ● 90–150 min/ wk ● 65%–75% heart rate reserve -5/8 mm Hg -2/4 mm Hg Dynamic resistance ● 90–150 min/ wk ● 50%–80% 1 rep maximum ● 6 exercises, 3 sets/exercise, 10 repetitions/set -4 mm Hg -2 mm Hg Isometric resistance ● 4 × 2 min (hand grip), 1 min rest between exercises, 30%–40% maximum voluntary contraction, 3 sessions/ wk ● 8–10 wk -5 mm Hg -4 mm Hg Moderation in alcohol intake Alcohol consumption In individuals who drink alcohol, reduce alcohol† to: ● Men: ≤2 drinks daily ● Women: ≤1 drink daily -4 mm Hg -3 mm * Type, dose, and expected impact on BP in adults with a normal BP and with hypertension. †In the United States, one“standard ” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

18. Discussion Next, The fourth stage is what must be done ?

19. Patient G roup ASH/ISH 1 JNC8 2 ESH/ESC 3 NICE 4–6 ACC/AHA 7 General population Age <60 years: ACE inhibitor or ARB Age ≥60 years: CCB or thiazide-type diuretic Thiazide-type diuretic, CCB, ACE inhibitor or ARB* Thiazide-type diuretic, CCB, ACE inhibitor, ARB, beta-blocker Age <55 years: ACE inhibitor or ARB Age ≥55 years: CCB Thiazide-type diuretic, CCB, ACE inhibitor or ARB Very high baseline blood pressure or at high cardiovascular risk Two-drug combination (CCB or thiazide and ACE inhibitor or ARB) Initiate with two drugs simultaneously or as single drug Consider initiation of antihypertensive therapy with a 2-drug combination n/a Two first-line drugs of different classes (separately or fixed-dose combination) Black population CCB or thiazide Thiazide, CCB Diuretic or CCB CCB (or thaizide ) Thiazide, CCB Non-diabetic chronic kidney disease ACE inhibitor, ARB ACE inhibitor, ARB With proteinuria: ACE inhibitor, ARB ACE inhibitor or ARB (if pretreatment serum potassium <5 mmol/L) With albuminuria: ACE inhibitor (or ARB if not tolerated) Diabetic ACE inhibitor, ARB Thiazide, CCB, ACE inhibitor, ARB With proteinuria: ACE inhibitor, ARB Without proteinuria: all classes ACE inhibitor (or CCB in women wanting to become pregnant) With albuminuria : ACE inhibitor, ARB Without albuminuria: all classes *If goal blood pressure is not reached within a month of treatment, increase the dose of the initial drug or add a second drug (thiazide-type diuretic, CCB, ACE inhibitor or ARB). The clinician should continue to assess blood pressure and adjust the treatment regimen until goal blood pressure is reached. 4. Review your drug treatment ACC, American College of Cardiology; ACE, angiotensin-converting enzyme; AHA, American Heart Association; ARB, angiotensin receptor blocker; ASH, American Society of Hypertension; CCB, calcium channel blocker; ESC, European Society of Cardiology; ESH, European Society of Hypertension; ISH, International Society of Hypertension; JNC, Joint National Committee; NICE, National Institute for Health and Clinical Excellence Weber MA, et al. J Clin Hypertens . 2014;16:14-26. James PA, et al. JAMA. 2014;311:507-520. Mancia G, et al. Eur Heart J. 2013;34:2159-2219. NICE . Hypertension. Clinical Guideline 127. Updated November 2016. NICE. Chronic kidney disease. Clinical Guideline 182. Updated January 2015. NICE. Type 2 diabetes. Clinical Guideline 87. Updated December 2014. Whelton PK, et al. Hypertension. 2017 Nov 13. [Epub ahead of print]

20. ESH guidelines recommendation PILLS Initial therapy Dual combination Consider referral to specialist center for further investigation Aim for BP control (<140/90 mm Hg) within 3 months Step 3 Triple combination + spironolactone or other drug Using long-acting drugs that require once-daily dosage is recommended ACEi or ARB + CCB or diuretic T/TL Resistant hypertension Consider to consult to hypertension specialist in patients who are still not controlled ACEi or ARB + CCB + diuretic T/TL Step 2 Triple combination *for patients <65 years old. ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; BP: blood pressure; CCB: calcium channel blocker; CV: cardiovascular; HMOD: hypertension-mediated organ damage; MI: myocardial infarction; od: once daily; SPC: single-pill combination. T/TL: Thiazide/Thiazide like Diuretic ESH Guideline 2023

21. 1. Do not combine with the same group 2. The combinations carried out are not of the same group P rinciple of antihypertensive combination

22. CCB + ARB: The Synergies of Counter-Regulation Mistry, et al. Expert Opin Pharmacother . 2006; 7: 575–581; Sica . Drugs. 2002; 62: 443–462; Quan , et al. Am J Cardiovasc Drugs. 2006; 6: 103-113. ARB Venodilation Attenuates peripheral oedema Effective in high-renin patients No effect on cardiac ischaemia ARB RAS blockade CHF and renal benefits Synergistic BP reduction Complementary clinical benefits CCB Arteriodilation Peripheral oedema Effective in low-renin patients Reduces cardiac ischaemia CCB RAS activation No renal or CHF benefits BP

23. SPC Perindopril/Amlodipine proven effective BP reduction as early as 2 weeks 1. Bahl VK et al. Am J Cardiovasc Drugs 2009;9(3):135-142. Baseline 2 weeks 1 month 2 months Office blood pressure (mm Hg) P <0.0001 DBP 101 mm Hg 167 mm Hg SBP 125 mm Hg 78 mm Hg Recommended BP targets 130/80 mm Hg -21 mm Hg 1 11 mm Hg 1 -29 mm Hg 1 -42 mm Hg 1 -16 mm Hg 1 -23 mm Hg 1 146 138 90 85 1 pill a day Example combination tx

24. SPC Perindopril/Amlodipine further reduces ankle edema vs a CCB alone ACE: angiotensin-converting enzyme; CCB: calcium channel blocker; NS: non significative. Hatala R et al. Clin Drug Invest. 2012;32(9):603-6012. CCB monotherapy Precapillary vasodilatation CCB + ACE inhibitor Pre- and postcapillary vasodilatation Reduction in amlodipine-related ankle edema -58 % Prospective, real-life, open-label, longitudinal, phase IV study conducted in 223 outpatient medical centers across Slovakia. 2132 previously treated patients whose hypertension was insufficiently controlled at baseline or who tolerated treatment poorly were included. Patients were treated for 3 months with fixed-combination perindopril/amlodipine 5 mg/5 mg, 5 mg/10 mg, 10 mg/5 mg and 10 mg/10 mg.

25. SPC Perindopril/Amlodipine significantly reduces the risk of cardiovascular events and mortality 1. Bahl VK et al. Am J Cardiovasc Drugs 2009;9(3):135-142.

26. Summary Correct Blood Pressure Measurement Check patient adherence Review life style patient Review drug treatment 4 steps to achieve hypertension therapy targets

27. Matur nuwun