Updated Hypertension Management – ESH 2023.pdf

Hypertension is the most prevalent CV disorder in the world and according to the WHO, it affects 1.28 billion adults aged 30–79 years worldwide, two-thirds living in low-income and middle-income countries.
In 2019, the global age-standardized average prevalence of hypertension in adults aged 30–79 years was reported to be 34% in men and 32% in women.
At younger ages (65 years).

Rule of Halves
Half the people with high blood pressure are not known (“rule 1”),

Half of those known are not treated (“rule 2”) and

Half of those treated are not controlled (“rule 3”)'

Definition:
Hypertension is defined based on repeated office SBP values ≥ 140 mmHg and/or DBP ≥ 90 mmHg.

1. Updated Hypertension
Management –ESH 2023
Dr. Nayan Ray
MBBS
Mymensingh Medical College and Hospital

2. NYN/DMA/BPL

3. Prevalence of hypertension
•Hypertension is the most prevalent CV disorder in the world and
according to the WHO, it affects 1.28 billion adults aged 30–79 years
worldwide, two-thirds living in low-income and middle-income
countries.
•In 2019, the global age-standardized average prevalence of
hypertension in adults aged 30–79 years was reported to be 34% in
men and 32% in women.
•At younger ages (<50 years), hypertension is more prevalent in men,
whereas a steeper increase of SBP in women from their third decade
(and more so following menopause) makes the prevalence of
hypertension greater in women in older age categories (>65 years).
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480
NYN/DMA/BPL

4. Rule of Halves
•Half the people with high blood pressure are not
known (“rule 1”),
•Half of those known are not treated (“rule 2”) and
•Half of those treated are not controlled (“rule 3”)'
Family Practice, Volume 16, Issue 2, April 1999, Pages 123-128,https://doi.org/10.1093/fampra/16.2.123
Journal ofHypertension37(12):p 2470-2480, December 2019.|DOI:10.1097/HJH.0000000000002192
NYN/DMA/BPL

5. Definition
•Hypertension is defined based on
repeated office SBP values ≥ 140
mmHg and/or DBP ≥ 90 mmHg.
NYN/DMA/BPL

6. Category SBP
(mmHg)
DBP
(mmHg)
Optimal <120 and <80
Normal 120-129and 80-84
High Normal 130-139and/or85-89
Grade 1 Hypertension 140-159and/or90-99
Grade 2 Hypertension 160-179and/or100-109
Grade 3 Hypertension ≥180 and/or≥110
Isolated Systolic Hypertension≥140 and/or<90
Isolated Diastolic Hypertension<140and/or≥90
Category SBP
(mmHg)
DBP
(mmHg)
Office BP ≥140and/or≥90
Ambulatory BP
Daytime (or
awake) mean
≥135and/or≥85
Night-time (or asleep)
mean
≥120and/or≥70
24 h mean ≥130and/or≥80
Home BP mean ≥135and/or≥85
Home and ambulatory BP values with office BP
Classification
Classification of office BP and definitions of hypertension grades
ESH 2023
ESC 2021
NYN/DMA/BPL

7. White Coat Hypertension
•BP is elevated in the office but is
normal when measured by
ABPM, HBPM or both
•30% of people attending
hypertension clinics
•Less CV risk
Masked Hypertension
•BP is normal in the office but
elevated when measured by
HBPM or ABPM
•About 10–20% of patients
attending hypertension clinics
have MH
•High CV risk
NYN/DMA/BPL

8. Recommendations for BP measurements in the office and at home
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480
NYN/DMA/BPL

9. Diagnosis by office BP and initial management of hypertension.
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

10. Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480
Cardiovascular risk according to grade and stage of hypertension
NYN/DMA/BPL

11. When to refer a hypertensive patient to a
specialist or to hospital
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

12. Management-Lifestyle Modification
Modification Recommendation Approximate Systolic
BPReduction, Range
Weight reductionMaintain normal body weight (BMI, 18.5-24.9) 5-20 mm Hg/10-kg
weight loss
Adopt DASH eating
plan
Consume a diet rich in fruits, vegetables,and low-fat dairy products with
a reduced content of saturated and total fat
8-14 mm Hg
Dietary sodium
reduction
Reduced dietary sodium intaketo no more than 100 mEq/L ( 2.4 g sodium
or 6 g sodium chloride)
2-8 mm Hg
Physical activityEngagein regular aerobic physical activity such as brisk walking(at least
30 minutes per day) most days of the week
4-9 mmHg
Moderationof
alcohol consumption
Limit consumption to no more than 2 drinks per day in most men and no
more than1 drink per day in most woman
2-4 mmHg
ESH 2023
ISH 2020
NYN/DMA/BPL

13. General BP Lowering Strategy
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

14. BP-lowering strategy in true resistant hypertension
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

15. Hypertension with
Established CVD
NYN/DMA/BPL

16. BP lowering therapy in patients with Hypertension and Coronary Artery Disease
e.g: Amlodipine
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

17. BP-lowering therapy in hypertension and HFpEF
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

18. Heart failure with reduced ejection fraction (HFrEF)
BP-lowering drugs in hypertension and heart failure.
(a)Non-DHP CCB are not recommended in HFrEF and should
not be combined with BB.
(b)Use of Diuretics:
I.Use T/TL Diuretic if eGFR >45 ml/min/1.73 m2.
II.Consider transition to Loop Diuretic if eGFR is
between 30 to 45 ml/min/1.73 m2.
III.Use loop Diuretic if eGFR <30 ml/min/1.73 m2 or in
patients with fluid retention/oedema.
NYN/DMA/BPL

19. BP-lowering therapy in hypertension and atrial fibrillation
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

20. BP-lowering in patients with hypertension and chronic kidney
disease
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

21. First Choice (Combination)
DM ACEi/ ARB, CCB
Dyslipidaemia ARBs, Amlodipine, Indapamide, Labetalol,
Clonidine,
Obesity ACEis/ ARBs or CCBs, VasodialatingBB, Diuretics
BEP Alpha blocker
HTN with Other Co-morbidities
ISH 2020
NYN/DMA/BPL

22. NYN/DMA/BPL
Contraindications

23. NYN/DMA/BPL
Contraindications

24. Hypertensive Emergency Hypertensive Urgency
SBP>180and/or DBP>120
+
EOD
SBP>180and/or DBP>120
-
EOD
IV Drug
Labetelol,Nitropruside, Nicardipin,
Nitroglycerin
Oral drug
1
st
hour 25% SBP
2-6 hours 160/100-110
6-24hours stable
24-48 hours normal
Hypertensive Crisis
ESH 2023
ISH 2020
NYN/DMA/BPL

25. Clinical Presentations of Hypertensive Emergency
➢Malignant hypertension
➢Hypertensive encephalopathy
➢Hypertensive thrombotic micro-
angiopathy
➢Severe preeclampsia and
eclampsia
➢Severe BP elevation with
cerebral hemorrhage
➢Acute stroke
➢Acute coronary syndrome,
➢Cardiogenic pulmonary edema
➢Aortic dissection
ESH 2023
ISH 2020
NYN/DMA/BPL

26. Investigations
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

27. Management of HTN Emergencies
Clinical presentation Timelineand Target BP First line treatmentalternative
Malignant hypertension with or
without acute renal failure
Severalhours , MAP-20 to-25%Labetalol, NicardipineNitroprusside
Urapidil
Hypertensive encephalopathyImmediate, MAP-20 to-25% Labetalol,NicardipineNitroprusside
Acute ischemic stroke and BP
>220 mmHg or DBP >120
mmHg
1h, -15% Labetalol,NicardipineNitroprusside
Acute ischemic stroke with
indication for thrombolytic
therapy and SBP >185 mmHg or
DBP >110 mmHg
1 h, -15% Labetalol,NicardipineNitroprusside
Acute hemorrhagic stroke and
SBP >180 mmHg
Several Hours, 130<SBP <180Labetalol,NicardipineUrapidil
ESH 2023
ISH 2020
NYN/DMA/BPL

28. BP management in acute stroke.
(a) Avoid absolute reductions of SBP >60 mmHg from initial SBP.
NYN/DMA/BPL

29. Clinical presentation Timelineand Target BP First line treatment alternative
Acute coronary event Immediate, SBP <140 mmHgLabetalol,Nicardipine Urapidil
Acute cardiogenic pulmonary
edema
Immediate, SBP <140 mmHgNitroprussideor nitroglycerine
(with loop diuretic)
Urapidil(with
loop diuretic)
Acute aortic disease Immediate, SBP <120 mmHg
and heart rate <60 bpm
Esmololand nitroprussideor
nitroglycerine
or nicardipine
Labetalol or
metoprolol
Eclampsia and severe
preeclampsia/
HELLP
Immediate, SBP <160 mmHg
and
DBP <105 mmHg
Labetalol or nicardipineand
magnesium sulphate
Management of HTN Emergencies
ESH 2023
ISH 2020
NYN/DMA/BPL

30. Doses
Drug Onset
of
Action
Durati
on of
Action
Dose ContraindicationsAdverse Effects
Labetalol5 –10
min
3 –6 h10–20 mg i.v. bolus in 1 min;
incremental doses ≥20 mg may
be administered i.v. at 10 min
intervals (max 80 mg) or 1–3
mg/min i.v. infusion until goal
BP is reached
Second-degree or
third-degree AV
block, systolic heart
failure, asthma,
bradycardia
Bronchocostriction
, Foetal
bradycardia
Nicardipine5 –15
min
4 –6 h5–15 mg/h i.v. infusion,
starting dose 5 mg/h, increase
every 15–30 min with 2.5 mg
until goal BP, maximum 15
mg/h
Liver failure Headache, reflex
tachycardia
ESH 2023
ISH 2020
NYN/DMA/BPL

31. Drug Onset
of
Action
Durati
on of
Action
Dose Contraindication
s
Adverse
Effects
Nitrogly-
cerine
1 –5
min
5 –10
min
5–200 mg/min i.v. infusion, 5
mg/min increase every 5 min
Headache,
reflex
tachycardia
Nitro-
prusside
Immed
iate
1 –3
min
0.3–0.5 mg/kg/min i.v. infusion,
increase by 0.5 mg/ kg/min every 5
min until goal BP (maximum dose
10 mg/kg/min)
Liver/kidney
failure
(relative)
Cyanide
intoxication
Esmolol 1 min10 -30
min
0.5–1 mg/kg i.v. bolus; 50–300
mg/kg/min i.v. infusion
Second-degree or
third-degree AV
block, systolic
heart failure,
asthma,
bradycardia
Bronchoconstri
ction,
foetal
bradycardia
Doses
ESH 2023
ISH 2020
NYN/DMA/BPL

32. Key Points
1. In most patients, treatment should be initiated with an SPC of two
drugs to improve the speed, efficiency and predictability of BP control.
2. Although several two-drug combinations can be used, the preferred
two-drug combinations should be an RAS blocker with a CCB or a
Thiazide/Thiazide-like diuretic.
3. A BB can be used at any step of combination with any drug from the
other major drug classes as GDMT or in several other conditions but no
longer a first line hypertensive drug.
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

33. Key Points
4. Initial monotherapy is recommended for very-high-risk patients with
a high-normal BP as well as (for cautionary reasons) for very old and
frail patients. It may also be considered in low-risk patients with stage 1
hypertension whose SBP is more modestly elevated (<150 mmHg).
5. A combination of two antihypertensive agents and a statin at low
doses reduced the risk of CV outcomes by 38%.
6. >80% of the patient adhere to combination therapy.
Journal of Hypertension : June 21, 2023
doi: 10.1097/HJH.0000000000003480NYN/DMA/BPL

34. NYN/DMA/BPL
Thank You