Diagnosis & Management

of Hypertension
2 3 %
1 6 %
4 2 % 1 9 %
Hypertensive patients
who are treated
but uncontrolled
Hypertensive patients
who are treated
and controlled
Hypertensive patients
who are unaware
Patients who are aware
but remain untreated
and uncontrolled
22 % of American adults 18 to 70 years of age have hypertension
20 % of Indonesian adults have hypertension
New Criteria (WHO-ISH 1999) 140 / 90 mmHg
Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102
DIAGNOSIS
OF HYPERTENSION
Jan 18, 2001

To confirm hypertension ( if noTOD )
To determine Total Cardiovascular Risk
To evaluate Target Organ Damage and
Associated Condition
To evaluate the possibility of secondary
etiology of hypertension
To monitor antihypertensive treatment
Clinical Assessment of Hypertension
Recommended Technique
for Measuring Blood Pressure
Standardized technique:

Have the patient rest for 5 minutes
Use an appropriate cuff size
Use a mercury manometer or a recently
calibrated electronic device
Position cuff appropriately
Increase pressure rapidly
Support arm with antecubital fossa or heart
level
To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
Place stethoscope over the brachial artery
Recommended Technique
for Measuring Blood Pressure (cont.)
Recommended Technique
for Measuring Blood Pressure (cont.)
Drop pressure by 2 mmHg / beat :
- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
Take 2 blood pressure measurements, 1
minute apart
Diagnosis of Hypertension
Hypertension is defined as:
- BP 140/90 mm Hg
- during 1-5 visits
- with an average of 2 readings per visit
- over a 6-month period if the blood pressure is
mildly elevated and there is no hypertensive
target organ damage
Diagnosis of hypertension: Summary
Visit 1
Visit 2
Visit 3
Visit 5
Blood pressure
measurement
every year
- Hypertensive
urgency?

- Target Organ
Damage or BP >
180/105? (Visit 3)

- High CVD Risk?
Hypertension
diagnosis
confirmed
Blood Pressure
> 140 / 90
Yes
No
Validated technique and
BP measurement Device
Visit 4
History-taking,
physical examination
B
P

1
4
0
/
9
0

1
8
0
/
1
0
5

JNC VI Classification of
Blood Pressure for Adults
Optimal <120 and <80
Normal <130 and <85
HighNormal 130139 or 8589

Hypertension
Stage 1 140159 or 9099
Stage 2 160179 or 100109
Stage 3 180 or 110
JNC 6 - Arch Int Med / Jan 1998
Category SBP DBP
1. Urinalysis
2. Complete blood count
3. Blood chemistry (Potassium, Sodium and creatinine)
4. Fasting Glucose
5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low
density lipoprotein cholesterol (LDL), triglycerides
6. Standard 12 leads ECG
Investigation of all patients with hypertension
For specific patient subgroups
1. For those with diabetes or renal disease: 24hour or over night urine protein, as lower goal
blood pressure targets are appropriate.
2. For those with an increased creatinine or renal disease: renal ultrasound to exclude
obstruction.
3. For those with a symptom triad of headache, sweating, palpitations; measure 24 hour urine
catecholamine metabolites to assess for pheochromocytoma.
Routine and optional laboratory tests
Berkin K and Ball SG. Essential Hypertension : the heart and
hypertension. Heart 2001; 86 : 467-475
Investigation for renovascular hypertension
Red Flags for renovascular hypertension
Sudden onset or
Worsening of hypertension at age below 30 or over 55,
Abdominal bruit,
Hypertension resistant to three or more drugs,
Rise in creatinine with a ACE inhibitor or angiotensin receptor
blocker,
Presence of overt atherosclerotic lesions, or
Recurrent pulmonary edema of unknown cause.
Captopril enhanced radioisotope renal scan
Ambulatory Monitoring of BP:
To Be Considered for Specific Indications *
Untreated
- Mild (Stage 1) to moderate (Stage 2) clinic blood pressure elevation and
without target organ damage, normal blood pressure at home

Treated patients
- Apparent resistance to drug therapy
- Symptoms suggestive of hypotension
- Fluctuating office blood pressure readings
Which patients?
Those with suspicion of office-induced BP elevation
* When available
Introduction
Hypertension as a Risk Factor

Hypertension is a significant risk factor
for:

cerebrovascular disease
coronary artery disease
congestive heart failure
renal failure
peripheral vascular disease
Target Organ
Damage
Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = less than 15%; medium risk
= about 15-20% risk; high risk = about 20-30%; very high risk = 30% or more

1. TOD Target Organ Damage
2. ACC Associated Clinical Conditions, including clinical cardiovascular disease or renal disease
Stratification of Risk to Quantify Prognosis
Reference: Chalmers J et al. WHO-ISH Hypertension Guidelines Committee. 1999 World Health Organization - International Society of Hypertension
Guidelines for the Management of Hypertension. J Hypertens, 1999, 17:151-185.
Other Risk Factors &
Disease History
Grade 1 Grade 2 Grade 3
BLOOD PRESSURE (mm Hg)
(mild hypertension)
SBP 140-159 or
DBP 90-99
(moderate hypertension)
SBP 160-179 or
DBP 100-109
(severe hypertension)
SBP 180 or
DBP 110
MED RISK LOW RISK HIGH RISK
V HIGH RISK
V HIGH RISK
V HIGH RISK MED RISK MED RISK
HIGH RISK HIGH RISK
V HIGH RISK V HIGH RISK
I. no other risk factors

II. 1-2 risk factor

III. 3 or more risk factors or TOD
or diabetes
IV. ACC
Risk Assessment
TREATMENT
OF HYPERTENSION
Jan 18, 2001
Benefits of Treating Hypertension

Younger than 60
reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%

Older than 60
reduces overall mortality by 20%
reduces cardiovascular mortality by 33%
reduces incidence of stroke by 40%
reduces coronary artery disease by 15%


Benefits of Treating to Target

Older than 60 with isolated systolic
hypertension (SBP 160 mm Hg and DBP <
90 mm Hg)

36% reduction in the risk of stroke
25% reduction in the risk of coronary
events
Risk Stratification and Treatment
Lifestyle
modifications
(up to 12 months)
Lifestyle
modifications
(up to 6 mos)
Adapted from JNC VI; TOD = Target organ damage CCD = Clinical cardiovascular disease
Blood Pressure
Stages (mm Hg)
No Risk Factors
No TOD/CCD
One Risk Factor
other than DM
No TOD/CCD
TOD/CCD
and/or DM
High-Normal
(130-139/ 85-89)
Lifestyle
modifications
Lifestyle
modifications
Drug therapy
Drug therapy
Drug therapy Drug therapy Drug therapy
Stages 2 and 3
( 160/ 100)
Stage 1
(140-159/ 90-99)
Risk Group A Risk Group B Risk Group C
Hypertensive
patient
Dietary Potassium
Dietary Sodium
Non Pharmacologic Recommendations for Hypertension
Lifestyle: Dietary
Magnesium supplementation
Calcium supplementation
For age over 44,
Restricted to a target range of 90-130 mmol/day.
(Limitation of salt additives and foods with
excessive added salt)
Daily dietary intake 60 mmol

Fresh fruits,
Vegetables,
Low fat dairy products,
Low fat diet,
in accordance with
Canada's Guide
to Healthy Eating

No conclusive studies for hypertension
No conclusive studies for hypertension
Jan 18, 2001
Non Pharmacologic Recommendations for Hypertension
Lifestyle: Weight excess
Overweight
Hypertensive
and all patients
- Encourage weight reduction
- Lose a minimum of 4.5 kg
BMI over 25
For patients prescribed pharmacological
therapy: weight loss has additional
antihypertensive effects.
Non Pharmacologic Recommendations for Hypertension
Lifestyle: Physical activity
Hypertensive
patient
- Walking
- Cycling
- Non-competitive swimming
Should be prescribed to reduce blood pressure.
- Dynamic exercise
- Moderate intensity
- 50-60 minutes
- Three or four times per week
For patients who are prescribed
pharmacological therapy:
Exercise should be prescribed as adjunctive
therapy .
Non Pharmacologic Recommendations for Hypertension
Lifestyle: Smoking
Smoking cessation for risk reduction
Hypertensive
and all
patients
Minimal Intervention
Short clear personalized advice

Medical intervention
Nicotine replacement Therapy
Bupropion

Other methods
Psychological support
Group support

Ask, Assess, Advise, Assist, Arrange Follow up

Simplify medication regimens to once daily dosing

Tailor pill-taking to fit patients daily habits

Encourage greater patient responsibility/autonomy in monitoring their
blood pressure and adjusting their prescriptions

Coordinate with worksite health care givers to improve monitoring of
adherence with pharmacological and lifestyle modification
prescriptions

Educate patients and patients families about their disease/treatment
regimens


Non Pharmacologic Recommendations for Hypertension
Adherence to antihypertensive prescription
Adherence to an antihypertensive prescription can be
improved by a multi-pronged approach
Pharmacological
Treatment
AVERAGE NUMBER OF ANTIHYERTENSIVES
REQUIRED TO ACHIEVE TARGET BP
0 1 2 3 4
Trial Target BP (mmHg)
AASK MAP<92
HOT DBP<80
MDRD MAP<92
ABCD DBP<75
UKPDS DBP<85
no. of antihypertensives
Consider prescription if:
Sustained diastolic blood pressure of > 90 mm Hg or
Isolated systolic hypertension of > 160 mm Hg and
No other risk factors

Prescribe if:
Target-organ damage or CVD, or
Concomitant diseases such as diabetes mellitus or
Other cardiovascular risk factors

Prescribe if:
Diastolic blood pressure readings average > 100 mm Hg,
regardless of other factors
Indications for Pharmacotherapy
Adults under 60 years (summary)
Indications for Pharmacotherapy
Adults over 60 years
160
105
120
110
100
90
80
70
200
180
160
140
120
100
Systolic blood pressures
of > 160 mm Hg

Diastolic blood
pressures of > 105 mm
Hg
Indications for Pharmacotherapy
Diabetics
140
90
Diabetes
without
target-organ damage:

BP 140/90 mmHg
120
110
100
90
80
70
200
180
160
140
120
100
Indications for Pharmacotherapy
Diabetics
130
80
Diabetes with
target-organ
damage:

BP 130/80 mmHg
120
110
100
90
80
70
200
180
160
140
120
100
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
Individualized
treatment

Standardized
treatment
YES NO
Choice of Treatment
Associated risk factors

Dyslipidemia, Smoking, Diabetes
Target organ damage /
complications
Ischemic heart disease,
Systolic cardiac dysfunction
Peripheral vascular disease
Arrhythmia and AV-node conduction problems
Cerebral vascular disease
Left ventricular hypertrophy
Concomitant
diseases/conditions

Renal and renovascular diseases, Airway
disease, Gout
Individualization
of treatment

Standardized
therapy
algorithm
Associated risk factors? or
Target organ damage / complications? or
Concomitant diseases / conditions?
YES NO
and/or
and/or
Standardized Therapy Algorithm
Adults under 60 years
ACE-I
Beta-
blockers *
Low-dose
thiazides
Combination
Lifestyle Modification
Therapy
Other classes
Non DHP-CCB, ARB, CNS Agent
Long-Acting
DHP-CCB
Alpha-blocker
as initial
monotherapy
<- Substitution -> <- Substitution ->
* Not recommended for patients over 60
DHP-CCB: Long acting dihydropyridine. ARB: Angiotensin Receptor Blocker. CNS Agent:: Central Nervous System Agent.
Non adherence?
Secondary HTN?
Interfering drugs or lifestyle?
White coat effect?
CONSIDER
Standardized Therapy Algorithm
Adults over 60 years
C.C.B
Long-acting
dihydropyridine
ACE-I
Low-dose
Thiazide
Combination
Thiazide
and
-blocker
Alternate
ARB
Other
combinations and or
other classes
Alpha-blockers and
Beta-blockers
as initial
monotherapy
Lifestyle Modification
Therapy
Non
adherence
?
Secondary
HTN?
Interfering
drugs or
lifestyle?
White coat
effect?
CONSIDER
<- Substitution -> <- Substitution ->
Blood Pressure Treatment Targets *
Condition
- 18-80 years, Systolic-diastolic hypertension
- 60-80 years, Isolated systolic hypertension
- Diabetes
- Non diabetic nephropathy
- Proteinuria >1 g / 24 h
Target (mmHg)
< 140 / < 90
< 130 / < 80
< 125 / < 75
* According to Risk assessment
- Chronic hypertension following a stroke
Treatment of Hypertension
with Diabetes
< 130/80 mm Hg Target BP
Diabetes
with
Nephropathy
without
Nephropathy
ACE-I
Alternate:
ARB
High dose diuretics, Alpha-blockers and
Centrally acting agents if autonomic
neuropathy
ACE-I
Beta-blocker
Ischemic
cardiopathy
Stable
angina
Post-
myocardial
infarction
Normal systolic
left ventricular
function
Beta-blocker* or
Long acting CCB
(*Preferred therapy)
Combination
Beta-blocker
and long-acting
dihydropyridine
ACE-I,
Beta-blocker
or both
Verapamil
or
Diltiazem
Alternate ACE-I should be strongly
considered in all
hypertensive patients with
coronary disease
Short-acting
nifedipine
Treatment of Hypertension
with Ischemic Heart Disease
Treatment of Hypertension
with Peripheral Vascular Diseases
Peripheral
vascular
disease
Atherosclerotic
PVD
Renal artery
stenosis
Raynauds
syndrome
Treatment of uncomplicated hypertension,
hypertension associated with other
conditions or concomitant risk factors.
Beta-blocker
Vasodilators:
Alpha-blockers, CCB,
ACE-I, ARB
May aggravate
symptoms
May induce renal
insufficiency
May have
beneficial effects
severe
mild
Beta-blocker
ACE-I
(use with caution)
ACE-I ?
Treatment of Hypertension
with Systolic Dysfunction
Physicians who are not yet experienced in the use of beta-blockers should consider initiation of treatment in
conjunction with a physician experienced in heart failure management- particularly for NYHA Class III-IV
patients.
* Diuretics:
- Thiazides
- Loop diuretics
- Spironolactone
for Class III- IV
CHF
Systolic
cardiac
dysfunction
ACE-I
+
Additional therapy, if
abnormal water
retention: Diuretic*
If ACE-I are contraindicated
or not tolerated:
Hydralazine and Isosorbide
dinitrate in combination
Or ARB
Additional
therapy with
Carvedilol or Metoprolol
Additional
therapy
Amlodipine or
Felodipine
NYHA class II - IV
Non
dihydropyridine
CCB or nifedipine
Treatment of Hypertension
with Arrhythmia*
Arrhythmia
and
conduction
problems
Atrial fibrillation and
supraventricular
tachycardia
Sinoatrial node
dysfunction and
atrioventricular
conduction problems
Beta-blocker
Verapamil
Diltiazem
Beta-blocker
Verapamil
Diltiazem
Clonidine
Methyldopa
May inhibit
ventricular
response
Avoid
* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs
Caution if systolic
dysfunction is
present
Treatment of Hypertension
with Airways Diseases*
Airway disease*
Standard HTN treatment.
If thiazide, add
potassium-sparing diuretic
Beta-blocker
This add-on is
recommended in patients
taking a beta-2
agonist. e.g.: salbutamol,
which lowers potassium
All Beta-blockers are
contraindicated if asthma
or bronchial
hyperreactivity
* Asthma, Bronchial hyperreactivity
Treatment of Hypertension
with Cerebrovascular Disease
Acute
cerebrovascular
accidents
Patients with moderate to severe hypertension:
the agent of choice should be chosen to avoid
precipitous falls in BP and should not increase
intracranial pressure.
Following a
cerebrovascular
accident
Treatment of uncomplicated hypertension,
hypertension associated with other
conditions or concomitant risk factors.
< 140/80 mm Hg
Target BP
Treatment of Hypertension
with Left Ventricular Hypertrophy
Left ventricular
hypertrophy
Vasodilators:
Hydralazine, Minoxidil
Most
antihypertensives
Can Increase
LVH
Most antihypertensives regress LVH over 6 months treatment period except arterial vasodilators
(eg. Hydralazine)
Can reduce LVH
over a 6 months
treatment period
Treatment of Hypertension
with Non Diabetic Renal Disease
Renal
disease
Additive therapy:
Diuretic
ACE-I
Alternative therapy:
Dihydropyridine CCB
Non diabetic: < 130/80
Proteinuria > 1 g/day: < 125/ 85
Target BP
Bilateral renal artery
stenosis
Treatment of Hypertension
with Gout
Gout Thiazides
Add on allopurinol
if a diuretic is
essential
Avoid diuretics.
Note: asymptomatic
hyperuricemia is not a
contraindication of
treatment
with diuretics
Summary I

Regarding the treatment of Hypertension,
the recommendations endorse:

Individualized therapy, primarily based on consideration
of : 1. concomitant risk factors or concurrent diseases,
2. target organ damage
both cardiovascular and noncardiovascular disease

Summary II
Regarding the treatment of Hypertension, the
recommendations endorse:
The addition of long-acting dihydropyridine calcium-
channel blockers to thiazide diuretics, beta-blockers
and ACE inhibitors as first-line therapy for adults under
60 years of age with uncomplicated hypertension

The addition of ACE inhibitors to thiazide diuretics and
long-acting dihydropyridine calcium-channel blockers as
first-line therapy for adults older than 60 years of age
with uncomplicated hypertension
Key messages

Lifestyle recommendations
Treat to target
Work on adherence/compliance