Cholid Tri Tjahjono

Department of Cardiology and Vascular Medicine

Universitas Brawijaya Malang

Is hyper tension preventable

disease: Primar y and secondar y
prevention
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Definitions and classification of office BP levels (mmHg)*

Hypertension:
SBP >140 mmHg ± DBP >90 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.

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
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• Hypertension is a silent disease; the majority of cases (61%)
remain undiagnosed.
• Blood pressure should be measured at every chance
encounter.

World Health Organization (WHO). A global brief on hypertension.

Available
at: http://www.who.int/cardiovascular_diseases/publications/global_brief_hypertension/en/.
 Diseases Attributable to
Hypertension
Heart Lef`t
Gangrene of the Ventricular Myocardial
Failure
Lower Extremities Hypertrophy Infarction

Aortic Coronary Heart

Aneurysm Disease
HYPERTENSION
Hypertensive
Blindness encephalopathy

Chronic Cerebral
Stroke Preeclampsia/ Hemorrhage
Kidney
Eclampsia
Failure

Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935
What is the goal BP?
Goal BP
Group BP Goal (mm Hg)
General DM* CKD**
JNC 8: <60 yr: <140/90 < 140/90 < 140/90
>60 yr: <150/90

ESH/ESC: < 140/90 < 140/85 < 140/90

Elderly 140-150/90 (SBP < 130 if proteinuria)

(<80 yr: SBP<140)
ASH/ISH < 140/90 < 140/90 < 140/90
>80 yr: <150/90 (Consider < 130/80 if proteinuria)
AHA/ACC < 140/90 < 140/90 < 140/90

*ADA: < 140/80 or lower

**KDIGO: <140/90 w/o albuminuria
<130/80 if >30 mg/24hr
 National Health and Nutrition Examination Survey (NHANES) III

Hypertension* Prevalence (%)

72%
66%

51%
38%

18%
9%
3%

18-29 30-39 40-49 50-59 60-69 70-79 80+

Age
The prevalence of high blood pressure increases with age

*Hypertension defined as blood pressure >140/90 mmHg or treatment

Source: JNC-VI. Arch Intern Med 1997;157:2413-2446

 National Health and Nutrition Examination Survey (NHANES)

*High blood pressure defined as blood pressure 140/90 mmHg or treatment

Source: Yoon SS et al. NCHS Data Brief 2012;107:1-7
 Method Brief Description

In-office Two readings, 5 minutes apart, sitting in chair

Confirm elevated reading in contralateral arm

Ambulatory BP Indicated for evaluation of “white-coat” HTN.

monitoring Absence of 10–20% BP decrease during sleep
indicates increased CVD risk

Self-measurement Provides information on response to treatment.

May help improve adherence to treatment and
evaluate “white-coat” HTN

BP=Blood pressure, CVD=Cardiovascular

disease, HTN=Hypertension
Source: Chobanian AV et al. JAMA 2003;289:2560-2572
 Medical Conditions Drugs
Chronic kidney disease NSAIDs
Primary hyperaldosteronism Oral contraceptives
Renovascular disease Adrenal steroids
Chronic steroid therapy Sympathomimetics
Cushing’s syndrome Cyclosporine or tacrolimus
Pheochromocytoma Erythropoietin
Aortic coarctation Ephedra, mu huang, bitter orange
Thyroid or parathyroid disease Cocaine or amphetamines
Sleep apnea Alcohol

NSAIDs=Non-steroidal anti-inflammatory drugs

Source: Chobanian AV et al. JAMA 2003;289:2560-2572
 Ischemic heart disease mortality and blood pressure
Age at Risk (Y) Age at Risk (Y)
Ischemic Heart Disease Mortality 80-89 80-89
256 256

Ischemic Heart Disease Mortality

128 70-79 128 70-79
(Floating absolute risk)

(Floating absolute risk)

64 60-69 64 60-69

32 50-59 32 50-59
16 40-49 16 40-49
8 8
4 4
2 2
1 1
0 0
120 140 160 180 70 80 90 100 110
Usual Systolic BP (mm Hg) Usual Diastolic BP (mm Hg)

BP=Blood pressure
Source: Prospective Studies Collaboration. Lancet 2002;360:1903-1913
 Trial (SBP Achieved)
UKPDS (144 mm Hg)

ABCD (127 mm Hg)

MDRD (132 mm Hg)

HOT (138 mm Hg)

AASK (127 mm Hg)

1 1.5 2 2.5 3 3.5 4

Number of BP Meds

AASK=African American Study of Kidney Disease and Hypertension,

ABCD=Appropriate Blood Pressure Control in Diabetes, BP=Blood pressure,
HOT=Hypertension Optimal Treatment, MDRD=Modification of Dietary Protein in Renal
Disease, SBP=Systolic blood pressure, UKPDS=UK Prospective Diabetes Study

Source: Abbott K et al. J Clin Pharmacology 2004;44:431-438

 Antihypertensive and Lipid-Lowering Treatment to Prevent Heart
Attack Trial (ALLHAT)
33,357 patients with HTN and >1 CHD risk factor randomized to
chlorthalidone, amlodipine, or lisinopril for 5 years
.20
Chlorthalidone
.16 Amlodipine
Rate of MI or

Lisinopril
fatal CHD

.12

.08 RR (95% CI) P-value

A/C 0.98 (0.90-1.07) 0.65
.04
L/C 0.99 (0.91-1.08) 0.81
0
0 1 2 3 4 5 6 7
Years to CHD Event
All three BP lowering agents provide similar efficacy
BP=Blood pressure, CHD=Coronary heart disease,
HTN=Hypertension, MI=Myocardial infarction

Source: ALLHAT Investigators. JAMA 2002;288:2981-2997

 Losartan Intervention for Endpoint (LIFE) Reduction in
Hypertension Study
9,193 high-risk hypertensive* patients with LVH randomized to losartan
(100 mg) or atenolol (100 mg) for 5 years
death, MI, or stroke (%)
16
Proportion with CV

12
Atenolol
8 Losartan

4
13% RRR, P=0.021
0
0 6 12 18 24 30 36 42 48 54 60 66
Study Month

An ARB provides greater efficacy in patients with LVH

*Defined by SBP=160-200 mmHg or DBP=95-115 mmHg
ARB=Angiotensin receptor blocker, CV=Cardiovascular,
DBP=Diastolic blood pressure, LVH=Left ventricular hypertrophy,
MI=Myocardial infarction, SBP=Systolic blood pressure
Source: Dahlöf B et al. Lancet 2002;359:995-1003
 Anglo-Scandinavian Cardiac Outcomes Trial—Blood Pressure
Lowering Arm (ASCOT-BPLA)
19,342 high-risk hypertensive patients with 3 additional CV risk factors
randomized to amlodipine (10 mg) & perindopril (8 mg) or atenolol (100 mg)
& bendroflumethiazide (2.5 mg) for 5.5 years
Nonfatal MI and 6
fatal CHD (%) Atenolol-based regimen
4
Amlodipine-based regimen
2
RRR=10%, P=0.1052
0
0 1 2 3 4 5 6
Time since randomization (years)

Both BP lowering regimens provide similar efficacy

BP=Blood pressure, CV=Cardiovascular,

CHD=Coronary heart disease, MI=Myocardial infarction
Source: Dahlöf B et al. Lancet 2005;366:895-906
 International Verapamil-Trandolapril Study (INVEST)
22,576 patients with HTN and CAD randomized to a BP lowering
strategy with verapamil SR (240 mg) or atenolol (50 mg) for 2.7 years

Calcium antagonist strategy (CAS)*

Incidence of all cause
death, nonfatal MI, or

20 Non-calcium antagonist strategy (NCAS)*

nonfatal stroke

15

10

5
RR=0.98, P=0.57
0
0 6 12 18 24 30 36 42 48 54 60
Months
Both a CAS and NCAS provide similar efficacy
*Trandolapril (up to 4 mg) was added in those with diabetes
mellitus, chronic kidney disease, or heart failure
BP=Blood pressure, CAS=Calcium antagonist strategy, HTN=Hypertension,
MI=Myocardial infarction, NCAS=Non-calcium antagonist strategy
Source: Pepine CJ et al. JAMA 2003;290:2805-2816
Comparison of Amlodipine vs Enalapril to Limit Occurrences of
Thrombosis (CAMELOT) Trial
1,991 patients with CAD and a DBP <100 mmHg randomized to amlodipine
(10 mg), enalapril (20 mg), or placebo for 2 years

0.25 130/78
Placebo Follow-up BP
CV event rate*

0.20 Enalapril 124/77

(mmHg)
Amlodipine 125/77
0.15
0.10
0.05
0
0 6 12 18 24
Months
Treatment with amlodipine results in reduced CV events
*Includes CV death, myocardial infarction, cardiac arrest, coronary revascularization,
hospitalization for heart failure or angina pectoris, stroke, transient ischemic attack,
development of peripheral arterial disease
BP=Blood pressure, CAD=Coronary artery disease,
CV=Cardiovascular, DBP=Diastolic blood pressure
Source: Nissen S et al. JAMA 2004;292:2217-2226
 Hypertension Optimal Treatment (HOT) Study
18,790 patients with a baseline diastolic BP of 100-115 mm Hg randomized
to a target diastolic BP of <90 mm Hg, <85 mm Hg, or <80 mm Hg

Patients with Patients without

Major CV events per Diabetes Diabetes
1000 patient-years

Diastolic BP goal Diastolic BP goal

More intensive blood pressure control provides greater benefit in diabetics

Source: Hansson L et al. Lancet 1998;351:1755-1762

BP=Blood pressure, CV=Cardiovascular
 Cardio-SIS Trial
1,111 patients >55 years with SBP >150 mm Hg randomized to
treatment to achieve usual BP control (SBP <140 mm Hg) or intensive
BP control (SBP <130 mm Hg)
P=0.013

21 15 P=0.003
Incidence of LVH (%)

17.0

Composite of CV
events* (%)
14 10 9.4
11.4
4.8
7 5

0 0
Usual Control Tight Control Usual Control Tight Control
More intensive blood pressure control provides greater benefit
*Composite of death, MI, CVA, TIA, CHF, angina, new AF,
revascularization, aortic dissection, PAD, and ESRD
AF=Atrial fibrillation, ESRD=End stage renal disease, CHF=Congestive heart failure,
CVA=Cerebrovascular accident, LVH=Left ventricular hypertrophy, MI=Myocardial infarction,
PAD=Peripheral artery disease, SBP=Systolic blood pressure, TIA=Transient ischemic attack
Source: Verdecchia P et al. Lancet 2009;374:525-533
 Modification Recommendation Approximate SBP
Reduction Range

Weight reduction Maintain normal body weight (BMI=18.5- 5-20 mmHg/10 kg weight
25) lost

DASH eating plan Diet rich in fruits, vegetables, low fat dairy 8-14 mmHg
and reduced in fat

Restrict sodium <2.4 grams of sodium per day 2-8 mmHg

intake

Physical activity Regular aerobic exercise for at least 30 4-10 mmHg

minutes most days of the week

Moderate alcohol <2 drinks/day for men and <1 drink/day 2-4 mmHg
for women

BMI=Body mass index, BP=Blood pressure, SBP=Systolic blood pressure

Source: Chobanian AV et al. JAMA 2003;289:2560-2572
 Primary and Secondary Prevention
I IIa IIb III Counsel regarding the need for lifestyle modification: weight
control; increased physical activity; alcohol moderation;
sodium reduction; and emphasis on increased consumption
of fresh fruits, vegetables, and low-fat dairy products.

Source: Smith SC Jr. et al. JACC 2011;58:2432-2446

 Primary Prevention
• Multiple-drug therapy is generally required to achieve BP targets.

• In elderly hypertensive patients, BP should be lowered gradually to avoid

complications.

• Orthostatic measurement of BP should be performed when clinically

indicated.

• Patients not achieving target BP despite multiple-drug therapy should be

referred to a physician specializing in the care of patients with hypertension.

AHA=American Heart Association, BP=Blood pressure,

CV=Cardiovascular, DM=Diabetes Mellitus
Source: Buse JB et al. Circulation 2007;115:114-126
 Primary Prevention
• Patients with a SBP >140 mm Hg or DBP >90 mm Hg should
receive drug therapy in addition to lifestyle and behavioral therapy.

• All patients with hypertension should be treated with a regimen that

includes an ACE inhibitor or an ARB. If one class is not tolerated,
the other should be substituted. Other drug classes* that have been
demonstrated to reduce CVD events should be added as needed to
achieve BP targets.

• If ACE inhibitors, ARBs, or diuretics are used, renal function and

serum potassium levels should be monitored within the first 3
months. If stable, follow-up could occur every 6 months.

*Includes beta-blockers, thiazide diuretics, and calcium channel blockers

ACE=Angiotensin converting enzyme, ARB=Angiotensin receptor blocker,
BP=Blood pressure, CV=Cardiovascular, CVD=Cardiovascular disease, DBP=Diastolic blood
pressure, DM=Diabetes mellitus, SBP=Systolic blood pressure
Source: Buse JB et al. Circulation 2007;115:114-126
 Primary Prevention
• Patients with a SBP >140 mm Hg or DBP >90 mm Hg should
receive drug therapy in addition to lifestyle and behavioral therapy.

• All patients with hypertension should be treated with a regimen that

includes an ACE inhibitor or an ARB. If one class is not tolerated,
the other should be substituted. Other drug classes* that have been
demonstrated to reduce CVD events should be added as needed to
achieve BP targets.

• If ACE inhibitors, ARBs, or diuretics are used, renal function and

serum potassium levels should be monitored within the first 3
months. If stable, follow-up could occur every 6 months.

*Includes beta-blockers, thiazide diuretics, and calcium channel blockers

ACE=Angiotensin converting enzyme, ARB=Angiotensin receptor blocker,
BP=Blood pressure, CV=Cardiovascular, CVD=Cardiovascular disease, DBP=Diastolic blood
pressure, DM=Diabetes mellitus, SBP=Systolic blood pressure
Source: Buse JB et al. Circulation 2007;115:114-126
• Hypertension could be prevented through lifestyle modification and optimal
medication
• Know the current blood pressure of all your patients
• Encourage the use of approved devices and proper technique to measure blood
pressure at home
• Assess and manage CV risk in hypertensives including: high dietary sodium
intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating,
and physical inactivity.
• Sustained lifestyle modification is the cornerstone for the prevention and control
of hypertension and the management of CV disease.
• Treat blood pressure to <140/90 mmHg and more than one drug is usually
required to achieve BP targets