All over the world,

I am a gentle killer I am called HYPERTENSION

World Hypertension Day,

annually celebrated on May 17th
 Statement of Need
Please write down your answer to the following:

“My greatest challenge as a doctor in the

management of patients with hypertension
is……………”

When to begin treatment,

How low to aim for, and
Which antihypertensive medications to use.
Evidence-Based Cardiology Consult
 OE
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Levels Of Evidence Pyramid

oct 2011 oct 2013

Nov 2013

2013 2012 2010

JuN 2013

Dec 2013 Dec 2013

Definitions and classification of office BP levels (mmHg)
Category Systolic Diastolic
Optimal <120 and 80>
Normal 120-129 and/or 84–80

High normal 130-139 and/or 89–85

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 140≤ and 90>

hypertension

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
 Risk FactoRs

• Fasting plasma glucose 102–

• Male sex 125 mg/dL
• Age (men ≥55 years; women ≥65 • Abnormal glucose tolerance
years) test
• Smoking • Obesity [BMI ≥30 kg/m²
• Dyslipidaemia
(height²)]
TC > 190 mg/dL, and/or
• Abdominal obesity
LDL >115 mg/dL, and/or
HDL: men <40 mg/dL, women < 46 (waist circumference: men ≥102
mg/dL, and/or cm;women ≥88 cm)
Triglycerides >150 mg/dL • Family history of premature
CVD (men aged <55 years;
women aged <65 years)
 asymptomatic oRgan
damage
• Carotid wall thickening (IMT
>0.9 mm) or plaque
• Pulse pressure (in the • Carotid–femoral PWV >10 m/s
elderly) ≥60 mmHg • Ankle-brachial index <0.9
• ECG :LVH (Sokolow–Lyon
• CKD with eGFR 30–60
index >3.5 mV;RaVL >1.1 mV;
ml/min/1.73 m² (BSA)
Cornell voltage duration
product >244 mV x ms), or • Microalbuminuria (30–300
mg/24 h), or albumin–
• Echo: LVH [LVM index: men
creatinine ratio 30–300 mg/g;
>115 g/m²;women >95 g/m²
(preferentially on morning spot
(BSA)]
urine)
 diabetes mellitus

• Fasting plasma glucose ≥126 mg/dL on two

repeated measurements, and/or
• HbA1c >7% , and/or
• Post-load plasma glucose >198 mg/dL
 established cV
or Renal disease
• Cerebrovascular disease: stroke; TIA
• CHD:MI; angina; revascularization with PCI or CABG
• HF, including HF with preserved EF
• Symptomatic lower extremities PAD
• CKD with eGFR <30 mL/min/1.73m²(BSA);
proteinuria (>300 mg/24 h).
• Advanced retinopathy: haemorrhages or exudates,
papilledema
 (Blood Pressure (mmHg
,Other risk factors
asymptomatic organ High normal Grade 1 HT Grade 2 HT Grade 3 HT
damage or disease SBP 130–139 SBP 140–159 SBP 160–179 SBP ≥180
or DBP 85–89 or DBP 90–99 or DBP 100–109 or DBP ≥110
No other RF
RF 1-2
RF 3≤
OD, CKD stage 3 or
diabetes
,Symptomatic CVD
CKD stage ≥4 or
Total CV RISK
diabetes with OD/RFs

BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; CVD =

cardiovascular disease; DBP = diastolic blood pressure; HT = hypertension;
OD = organ damage; RF = risk factor; SBP = systolic blood pressure
 High risk

Moderate risk

Low risk
Stratification of total CV risk in categories of low, moderate, high and very high
risk according to SBP and DBP and prevalence of RFs , asymptomatic OD , diabetes ,
CKD stage or symptomatic CVD.
Initiation of lifestyle changes and antihypertensive drug treatment.
Targets of treatment are also indicated(<140/90).
(in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)
 (Blood Pressure (mmHg
,Other risk factors
asymptomatic organ High normal Grade 1 HT Grade 2 HT Grade 3 HT
damage SBP 130–139 SBP 140–159 SBP 160–179 SBP ≥180
or disease or DBP 85–89 or DBP 90–99 or DBP 100–109 or DBP ≥110
No other RF
RF 1-2
RF 3≤
OD, CKD stage 3 or s
n
diabetes
tio
,Symptomatic CVD ica n s
CKD stage ≥4 or in
d
ca tio
g i
diabetes with OD/RFs
llin
g ind
e in
m
p
p ell
Co om
o C
N
 Any Body Can Dance 2
Any Body Can Dance

2013  
2014

Any Body Can Dance

A B C D
The A,B,C,D drug classes
 Choice of drug treatment AA BB
No suggestion, all 5 classes CC DD
No ranking or classification of preferred
drugs
Diuretics (thiazides,chlorthalidone and
indapamide), beta-blockers,calcium antagonists,
ACE inhibitors, and ARBs are all suitable and
recommended for the initiation and maintenance of
antihypertensive treatment, either as monotherapy or
in some combinations with each other
 Possible combinations of classes of
antihypertensive drugs
DD

BB
AA

CC
AA
Green continuous lines: preferred combinations;
green dashed line: useful combination (with some limitations);
black dashed lines: possible but less well-tested combinations;
red continuous line: not recommended combination .
The Joint National Committee (JNC )
 This JNC 8 guideline has not redefined high BP,
and considers the 140/90 mm Hg definition from
JNC 7 reasonable.

Category SBP (mm Hg) DBP (mm Hg)

Normal < 120 < 80

Pre – hypertension 120-139 80-90

Hypertension
Stage 1 140 – 159 90 – 99

Stage 2 160 and above 100 and above

 Diabetes
Hypertension

Chronic Kidney
Disease
Coronary Heart Disease

Heart Failure
 JNC 7 Compelling Indications

† ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo

ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.
 Compelling Indicator: Heart Failure
ACE-I (or ARB) is indicated in nearly all patients
with LV systolic dysfunction.
ACE-I (or ARB) should be titrated to target HF doses,
even if BP is low, as long as the patient does not
become symptomatic or develop impaired renal
perfusion.
Beta Blockers in nearly all patients with LV
systolic dysfunction .Titrate to target HF doses.
Consider spironolactone after the patient is placed on the maximum
doses of ACE-I and beta-blocker,especially if Class III or IV

Diuretics (usually loop) are often required

for fluid management
Compelling Indicator : Chronic Kidney Disease
ACE-I and ARB’s can slow
progression of kidney disease.

AA limited
limited increase
increase in
in serum
serum creatinine
creatinine of
of as
as much
much
as
as 30%
30% above
above baseline
baseline with
with ACE-I
ACE-I or
or ARB
ARB isis
acceptable
acceptable andand not
not aa reason
reason to
to withhold
withhold
treatment,
treatment, unless
unless hyperkalemia
hyperkalemia develops.
develops.

In
In CKD
CKD stages
stages 44 and
and 55 (eGFR<30
(eGFR<30 mL/min/per
mL/min/per 1.73m²)
1.73m²)
higher
higher doses
doses of
of loop
loop diuretics
diuretics may
may be
be needed
needed in
in
combination
combination with
with other
other drug
drug classes.
classes.
Stages of Chronic Kidney Disease
Two Screening Tests
• eGFR

• ACR
–Albumin/
Creatinine ratio
 Questions guiding the JNC 8 review
This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management.
They address thresholds, goals for pharmacologic treatment, and whether particular
antihypertensive drugs or drug classes improve important health outcomes compared to others.

1.In adults with hypertension, does initiating antihypertensive pharmacologic

therapy at specific BP thresholds improve health outcomes?

2.In adults with hypertension, does treatment with antihypertensive

pharmacologic therapy to a specified BP goal lead to improvements in health
outcomes?

3.In adults with hypertension, do various antihypertensive drugs or drug classes

differ in comparative benefits and harms on specific health outcomes?

 The answers to these three questions are reflected in 9 recommendations

 Recommendations
BP thresholds Goals
Recommendation 1
(Strong recommendation)

General population SBP ≥150 mm Hg SBP <150 mm Hg

≥60 years or DBP ≥90 mm Hg and DBP <90 mm Hg

Recommendation 2
(Strong recommendation)
General population
DBP ≥90 mm Hg DBP <90 mm Hg
<60 years

Recommendation 3
(Expert opinion)
General population
SBP ≥140 mm Hg SBP <140 mm Hg
<60 years
 Recommendations
Recommendation 4 BP thresholds Goals
(Expert opinion)

Population with CKD SBP ≥140 mm Hg SBP <140 mm Hg

≥18 years or DBP ≥90 mm Hg and DBP <90 mm Hg

Recommendation 5
(Expert opinion)

Population with diabetes SBP ≥140 mm Hg SBP <140 mm Hg

≥18 years or DBP ≥90 mm Hg and DBP <90 mm Hg

Initial treatment
Recommendation 6
(Moderate recommendation)

General nonblack
population ( ± diabetes ) AA or CC or DD
 Recommendations
Recommendation 7
(Moderate recommendation)
Initial treatments
Black CD
General ( ± diabetes )
black population CC or DD
Recommendation 8 Initial or add-on treatments
(Moderate recommendation)
Population with CKD
≥18 years(irrespective of
race or diabetes)
AA
Recommendation 9
Non control strategies
(Expert opinion)

Goal BP not reached Increase the dose of the initial drug,

within a month of treatment or add a second drug (from the list provided)

Goal BP not reached Add and titrate a third drug (from the list provided)
with 2 drugs Do not use an ACEI and an ARB together in the same patient
 DM CKD

AA CC DD CC DD AA
Alone or in
combination with
Alone or in combination other drug class

BB
 Major changes from JNC 7
 Focus on evidence based recommendations
 Higher target SBP for patients over 60 y/o
Limited data to support either 150 or 140 mmHg
 Removed special lower target BP
for those with CKD or DM
 Liberalized initial drug choices
AA CC DD
 JNC 8 :Relaxing blood pressure goals

Higher real-world blood pressures

This is akin to the “speed limit rule”—
people are more likely to hover above target,no matter
what the target is.
 Recommendation in patients with grade I hypertension
(BP 140–159 mm Hg systolic or 90–99 mm Hg diastolic)

ESH/ESC BP-lowering drugs recommended when total

cardiovascular risk is high because of organ
damage, diabetes, cardiovascular
disease, or chronic kidney disease
JNC 8 BP-lowering drugs recommended to lower BP
<140 mm Hg systolic and 90 mm Hg diastolic in
patients aged <60 years ,and <150 mm Hg systolic
and 90 mm Hg diastolic in patients aged >60 years
Guidelines are meant to “guide”
and not to “mandate”
One Size Does Not Fit All.

?
New
New hypertension
hypertension
guidelines:
guidelines:
One
One size
size fits
fits most?
most?
Lo
we
r yo
ur
Lo num
we b
r y er
ou
rr
isk
 Population ,Goal BP Initial Drug Treatment Options
mm Hg
General nonelderly 140/90>
C
General elderly <80 y
ES

General ≥80 y 150/90> AA BB CC DD

H/
ES

Diabetes 140/85>
CKD 140/90> AA
CKD + proteinuria 130/90>

General <60 y 140/90> Nonblack

General ≥60 y 150/90>
AA CC DD
8
JNC

Black
CC DD
Diabetes 140/90>
AA CC DD
CKD 140/90
AA
The JNC 8 : Nine recommendations
 Initial Drug Choices
AA AA
CC BB
DD
Replaces CC
DD
As first line drug 2013 JNC 8 “ 2014
”ESH/ESC“ ”

Beta-blockers Yes (No (Step 4

 Possible combinations of ABCD classes

DD

AA CC
ß-blocker should be Angina Pectoris
included in the Post-MI
regimen if there a
BB Heart Failure
compelling indication Atrial Fib.
for a ß-blocker Aortic Aneurysm