Hypertension

Syakib Bakri, Hasyim Kasim, Haerani Rasyid

Epidemiology
 Blood Pressure Distribution in the Population
According to Age

Men Women
150 150
140 140
130 130
120 120
mmHg

mmHg
110 110
100 PP 100 PP
90 90
80 80
70 70
60 60
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79
Age Age
PP=Pulse Pressure

Adapted from: Wilkins et al. Health Rep 2010;21:37-46

 Life time Risk of Hypertension in
Normotensive Women and men aged 65 years

Risk of Hypertension % Risk of Hypertension %

100 100

Women Men
80 80

60 60

40 40

20 20

0 0
0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20

Years to Follow-up Years to Follow-up

JAMA 2002:297:1003-10. Framingham data.
Frequency of Hypertension
According to Age

Age Percentage
18-29 years old 4%

30-39 years old 11%

40-49 years old 21%

50-59 years old 44%

60-69 years old 54%

70-79 years old 62%

More than 80 years old 65%

Burden of disease attributable to 20 leading risk factors in 2010,
expressed as a percentage of global disability-adjusted life-years

Lancet 2012;380:2224-60
DIAGNOSIS OF HYPERTENSION
Blood Pressure Assessment
 Blood Pressure Assessment

Blood pressure of all adults should be measured by a

trained healthcare professional at all appropriate visits.
For example:
new patient visits,
periodic health exams,
urgent office visits for neurological or cardiovascular
related issues,
medication renewal visits
Blood pressure of adults with high normal blood pressure
(130-139/80-89 mmHg) should be assessed annually
Health care professionals should know the blood pressure of all
of their patients and clients.

To screen for hypertension

To assess cardiovascular risk
To monitor antihypertensive treatment
 Blood pressure measurement devices

Mercury Blood Pressure Monitor

Aneroid Blood Pressure Monitor

Automated Blood Pressure Monitor

 Blood Pressure Assessment:
Patient preparation and posture

Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the preceding
30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the
procedure.
 Blood Pressure Assessment:
Patient preparation and posture

Standardized technique:
Posture
The patient should be calmly
seated with his or her back
well supported and arm
supported at the level of the
heart.
No talk during the procedure.
His or her feet should touch
the floor and legs should not
be crossed.
Blood Pressure Assessment:
Patient position

X
 Recommended Technique
for Measuring Blood Pressure (cont.)

The seated BP
measurement is the
standard position to
determine diagnostic and
therapeutic treatment
decisions.
The standing blood
pressure is used to test for
postural hypotension,
which may modify the
treatment.
 Recommended Technique for Measuring BP:
Standing BP

Perform in patients
over age 65
with diabetes
if there are symptoms of postural hypotension

Check after 1 to 5 minutes in the standing position and if

the patient complains of symptoms suggestive of
hypotension
 Recommended Technique
for Measuring Blood Pressure* (cont.)

Drop pressure by 2 mmHg / beat

Appearance of sound (phase I
Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase
V Korotkoff) = diastolic pressure

Record measurement & Record

heart rate

Take at least 2 blood pressure

measurements, 1 minute apart
*with manual or semi automated devices
Korotkoff sounds and auscultatory gaps

Korotkoff sounds

200 No sound

180 Systolic BP
Clear sound Phase 1
160
Muffling Phase 2
No sound Auscultatory
140 gap
Phase 3
120 Clear sound Phase 3

100 Phase 4
Muffled sound Phase 4
Diastolic BP
80

60

40 No sound Phase 5

20
0
mmHg
 Recommended Technique
for Measuring Blood Pressure

Standardized technique:
For initial readings, take
the blood pressure in
both arms and
subsequently measure it
in the arm with the
highest reading.
Thereafter, take two
measurements on the
side where BP is higher.
 Recommended Technique
for Measuring Blood Pressure* (cont.)

Record the blood

pressure to the closest 2
mmHg on the manometer

Record patient position

(supine, sitting or
standing).

Aneroid devices should not be used unless they are known to be accurately calibrated
and are checked regularly (minimally every 12 months).

* For manual blood pressure measurement

 Recommended Technique
for Measuring Blood Pressure (cont.)

Select a device with an appropriate size cuff

 Use an appropriate size cuff

Arm circumference (cm) Size of Cuff (cm)

From 18 to 26 9 x 18 (child)

From 26 to 33 12 x 23 (standard adult model)

From 33 to 41 15 x 33 (large)

More than 41 18 x 36 (extra large, obese)

For automated devices, follow the manufacturers directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.
 Recommended Technique
for Measuring Blood Pressure (cont.)

Locate the brachial pulse

and centre the cuff
bladder over it

Position cuff at the heart

level

Arm should be supported

 Recommended Technique
for Measuring Blood Pressure* (cont.)

To exclude possibility of
auscultatory gap,
increase cuff pressure
rapidly to 30 mmHg
above level of
disappearance of radial
pulse
Place stethoscope over
the brachial artery

*with manual or semi automated devices

 Recommended Equipment for
Measuring Blood Pressure

Use a mercury
manometer or a recently
calibrated aneroid or a
validated automated
device.
Aneroid devices should
only be used if there is an
established calibration
check every 12 months.
 Recommended Equipment for
Measuring Blood Pressure

Automated oscillometric devices:

Use a validated automated device
according to BHS, AAMI or IP clinical
protocols.
For home blood pressure measurement
devices, a logo on the packaging ensures
that this type of device and model meets
the international standards for accurate
blood pressure measurement.

AAMI=Association for the Advancement of Medical Instrumentation;

BHS=British Hypertension Society;
IP: International Protocol.
 Blood Pressure Measurement with Aneroid Blood
Pressure Monitor

Place the stethoscope diaphragm over the

brachial artery and deflate at a rate of
2mmHg/beat until you hear regular tapping
sounds. Measure systolic (first regular sound)
to nearest 2mmHg.

Deflate at a rate of 2mmHg/beat until

disappearance. Measure diastolic blood
pressure to nearest 2mmHg.

Aneroid devices should not be used unless they are known to be in calibration and are
checked regularly (minimally every 12 months).
Blood Pressure Measurement with Aneroid Blood
Pressure Monitor

Aneroid devices should not be used unless

they are known to be in calibration and are
checked regularly (minimally every 12
months).

If the needle on an aneroid device does not

zero it is inaccurate; however the converse is
not true.
 Attaching an aneroid device to a Mercury device
for calibration testing

Note: check the mercury column is at zero before testing.

 ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE

Encourage hypertensive patients to use an approved blood pressure

measuring device and use proper technique to assess blood
pressure at home.
Measuring blood pressure at home has a stronger association with
cardiovascular prognosis than office based readings.
Home measurement can confirm the diagnosis of hypertension,
improve blood pressure control, reduce the need for medications
in some, detect those with white coat and masked hypertension
and improve medication adherence in non adherent patients.
Average BP 135/85 mmHg should be considered elevated
 Home Measurement of BP:
Confirm contradictory home measurement readings

If office BP measurement Consider further assess

is elevated and home BP using 24-h ambulatory
is normal or vice versa blood pressure monitoring
Not all patients are suited to home measurement

Undue anxiety in response to high blood pressure

readings
Physical or mental disability prevents accurate
technique or recording
Arm not suited to blood pressure cuff (e.g. conical
shaped arm)
Irregular pulse or arrhythmias prevent accurate
readings
Lack of interest
Most patients can be trained to measure blood pressure
Periodic reassessment of technique and retraining is desirable
 Suggested Protocol for Home Measurement of
Blood Pressure for the Diagnosis of Hypertension
Home blood pressure values should be based on:
duplicate measures,
morning and evening,
for an initial 7-day period.

Singular and first day home BP values should not be

considered.

Daytime average BP equal to or over 135/85 mmHg

should be considered elevated.
HYPERTENSION CRITERIA
ESH ,2013 JNC 7, 2003
Development of aortic pressure abnormalities due to
age-related aortic stiffening

Smulyan H, Safar ME. Ann Intern Med. 2000;132:230.

 Hypertension
Common, Responsible for the majority of
office visits
Number one reason for drug prescription
Simple and cheap detection
Established treatment
Significant preventable outcomes

Observational studies suggest detection &

treatment suboptimal
Approximately 73% of European patients with
hypertension remain untreated

Patients (%) Treated Untreated

100
75 74 74 73 68
80

60

40

20

England Sweden Germany Spain Italy

Wolf-Maier et al. Hypertension 2004;43:1017

Approximately 70% of treated patients* in Europe do not
reach blood pressure goal

Patients (%) BP goal achieved BP goal not achieved

100
60 79 71 81 71
80

60

40

20

0
England Sweden Germany Spain Italy

*Treated for hypertension

BP goal is <140/90 mmHg Wolf-Maier et al. Hypertension 2004;43:1017
 Global health burden of uncontrolled blood pressure
Events attributable to non-optimal BP control
(mean SBP >115 mmHg) (%)
80 76

62
60
49

40

20 14

0
Stroke Ischaemic heart Hypertensive Other CVD
disease disease*

Worldwide this equates to approximately 7.1 million deaths (12.8% of total deaths)
and 64.3 million disability-adjusted life years (4.4% of the total)
*Hypertensive disease includes essential HTN, hypertensive heart
disease and hypertensive renal disease Lawes et al. J Hypertens 2006;24:42330
Suboptimal treatment of hypertension imposes an
enormous economic burden on society

Estimated costs ($ billion)

30
24,4
25
20
15
11
10 7,7 8,3
6,2
4,2
5 1,7
0
Hospital Nursing Physicians Medical Home Morbidity Mortality
home durables h/care

Estimated total costs of hypertension in the US in 2006: $63.5 billion

American Heart Association. Heart Disease and Stroke

Statistics 2006 Update. Dallas, TX
 Modifiable risks for developing hypertension

Obesity

Poor dietary habits

High sodium intake

Sedentary lifestyle

High alcohol consumption

 New onset hypertension in people with high
normal blood pressure
772 subjects, overweight, mean age 48.5

Not receiving treatment for hypertension

Average of 3 blood pressures at baseline:

SBP 130-139 and DBP < 89 OR
SBP < 139 and DBP 85-89

Primary endpoint new onset hypertension

NEJM 2006;354:1685-97
New onset hypertension in people with high
normal blood pressure

80
New hypertension (%)
60

40

20

0
YEAR 1 YEAR 2 YEAR 3 YEAR 4
NEJM 2006;354:1685-97
 Development of hypertension in those with high normal blood
pressure

Age 35-64 Age 65-94

45
40
35
30
Percent

25
20
15
10
5
0
Year 1 Year 2 Year 3

Framingham cohort Vasan. Lancet 2001

 New onset hypertension in people with high
normal blood pressure

40% of overweight patients with systolic 130-139 or

diastolic 85-89 mmHg developed hypertension in 2 years
and 63% in 4 years

Annual follow-up of patients with high normal blood

pressure is recommended by CHEP
 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
dementia
atrial fibrillation
erectile dysfunction
 Public Perceptions on Hypertension

44% of people could not identify a normal or a high blood pressure

reading
80% of people were unaware of the association between
hypertension and heart disease
63% believed that hypertension was not a serious condition
38% of people thought they could control high blood pressure
without the help of a health professional

Can J Cardiol 2005;21:589-93

 Blood Pressure and
Risk of Stroke Mortality

Lancet 2002;360:1903-13
Blood Pressure and Risk of Ischemic
Heart Disease (IHD) Mortality

Lancet 2002;360:1903-13
 Effect of SBP and DBP on
Age-Adjusted CAD Mortality: MRFIT

CAD Death Rate per 10,000 Person-years

80.6

48.3 43.8
37.4 34.7 38.1

31.0
25.8 24.6 25.3 25.2 24.9

23.8
160+
16.9 13.9 12.8 12.6 11.8
20.6 140-159
10.3 11.8 8.8 8.5 9.2 120-139
<120 Systolic BP
100+ 90-99 80-89 75-79 70-74 <70 (mmHg)
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64
Impact of High-Normal Blood Pressure on the Risk
of Cardiovascular Disease
Cumulative incidence of cv events in men without hypertension according to baseline blood
pressure

(130-139) mmHg

(121-129) mmHg

(< 120) mmHg

N Engl J Med 2001;345:1291-7

 Benefits of Treating Hypertension

Younger than 60 (reducing BP 10/5-6 mmHg)

reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%

Older than 60 (reducing BP 15/6 mmHg)

reduces overall mortality by 15%
reduces cardiovascular mortality by 36%
reduces incidence of stroke by 35%
reduces coronary artery disease by 18%

Lancet 1990;335:827-38
Arch Fam Med 1995;4:943-50
 Benefits of Treating to Target

Older than 60 with isolated systolic hypertension (SBP

160 mm Hg and DBP <90 mm Hg)
42% reduction in the risk of stroke
26% reduction in the risk of coronary events

Lancet 1997;350:757-64
Correlation Between Reduction in SBP and
Stroke or MI
Stroke Myocardial Infarction

Staessen et al. Lancet 2001;358:1305-15

Correlation Between Reduction in SBP and
Cardiovascular Mortality or Events
Cardiovascular mortality Cardiovascular events

Staessen et al. Lancet 2001;358:1305-15

 Epidemiologic impact on mortality of blood
pressure reduction in the population

After Before
Prevalence %

Intervention Intervention

Reduction in BP

Reduction in SBP % Reduction in Mortality

(mmHg) Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7
Adapted from Whelton, PK et al. JAMA 2002;288:1882-1888
Pathophysiology
Pathophysiology Of Hypertension
 Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors

Presence of Risk Factors
Increasing age
Male gender
Smoking
Family history of premature cardiovascular disease (age< 55 in men and < 65 in women)
Dyslipidemia
Sedentary lifestyle
Unhealthy eating
Abdominal obesity
Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting glucose)
Presence of Target Organ Damage
Microalbuminuria or proteinuria
Left ventricular hypertrophy
Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)
Presence of atherosclerotic vascular disease
Previous stroke or TIA
Coronary Heart Disease
Peripheral arterial disease
CV Risk Factors that may alter thresholds and targets in the treatment of HTN
 Assessment of the overall cardiovascular risk

Search for exogenous potentially modifiable factors that can

induce/aggravate hypertension
Prescription Drugs:
NSAIDs, including coxibs
Corticosteroids and anabolic steroids
Oral contraceptive and sex hormones
Vasoconstricting/sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs
Midodrine
Other:
Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use
Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

Treatment
 Paradigm Shift in HT Therapy
It is not just B.P. TODAY we must strive to
1. Alter the modifiable risk factors
2. Keep the SBP < 140 and DBP < 90
3. Prevent or halt or reduce TOD
LVH, CHD, CHF, CVA, CRF, PVD & Retino.
4. Prevent or control DM (as HT + DM is hazardous)
5. Prevent or control Dyslipidemia
6. Prevent or control Endothelial Dysfunction
7. Reduce morbidity and mortality
8. Improve QUALY Quality Adjusted Life Years

73
 Goals of Treatment

To optimally reduce cardiovascular risk, reduce the blood

pressure to specified targets.
This usually requires two or more drugs and lifestyle
changes
The systolic target is more difficult to achieve however
controlling systolic blood pressure is as important if
not more important than controlling diastolic blood
pressure
Treatment Approaches

Lifestyle Modification
Pharmacological
 Lifestyle management
(Non-Pharmacological Treatment)
LIFESTYLE MODIFICATION IN HYPERTENSION

Lifestyle measures should be instituted, whenever

appropriate in all hypertensive patients, including those
who require drugs
Lifestyle measures are also advisable in subjects with
high normal BP and additional risk factors to reduce the
risk of developing hypertension
Lifestyle recommendations should not be given as lip
service and reinforced periodically
 Non-pharmacological Treatment

Objective of lifestyle changes in

hypertension

Lower blood pressure

Minimize drug use
Reduce overall cardiovascular risk
Improve outcome
Maintain or improve quality of life
 Lifestyle Recommendations for Hypertension:
Dietary
Dietary Sodium
High in: Less than 2300mg / day
(Most of the salt in food is hidden and comes
Fresh fruits from processed food)
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre Dietary Potassium
Plant protein Daily dietary intake >80 mmol

Low in: Calcium supplementation

Saturated fat and cholesterol No conclusive studies for hypertension

Sodium
Magnesium supplementation
No conclusive studies for hypertension

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
Potential Benefits of a Wide Spread Reduction in
Dietary Sodium in Canada

Reduction in average dietary sodium from about

3500 mg to 1700 mg1,2
1 million fewer hypertensives
5 million fewer physicians visits a year for hypertension
Health care cost savings of $430 to 540 million per year related
to fewer office visits, drugs and laboratory costs for hypertension
Improvement of the hypertension treatment and control rate
13% reduction in CVD
Total health care cost savings of over $1.3 billion/year

1. Penz ED. Cdn J Cardiol 2008

2. Joffres MR. Cdn J Cardiol 2007:23(6)
Recommendations for adequate daily sodium intake

2,300 mg sodium (Na)

Age Adequate Upper
= 100 mmol sodium (Na)
Intake Limit
= 5.8 g of salt (NaCl)
(mg) (mg)
= 1 level teaspoon of
19-50 1500 2300 table salt
51-70 1300 2300
71 and 1200 2300
over

80% of average sodium intake is in processed foods

Only 10% is added at the table or in cooking
Institute of Medicine, 2003
 Sodium: Meta-analyses

Average Reduction of sodium Hypertensives

in mg/day Reduction of BP
1800 mg/day 5.1 / 2.7 mmHg
2300 mg/day 7.2/3.8 mmHg
Average Reduction of sodium Normotensives
in mg/day Reduction of BP
1700 mg/day 2.0 / 1.0 mmHg
2300 mg/day 3.6/1.7 mmHg

The Cochrane Library 2006;3:1-41

Meta analysis on different reductions in dietary
sodium intake on blood pressure
12

SBP hyper
10 DBP hyper
SBP normal
BP reduction mmHg

8 DBP normal

0
1200 2400 3600
mg/day reduction in sodium mg/day

Graham A. MacGregor Hypertension 2003;42:1093-1099

 Where in our diet does sodium come from?

11%

12%

77%

1. 12% natural content of foods

2. Hidden sodium: 77% from processing of food -manufacturing and
restaurants
Occurs Naturally in Foods
3. Conscious sodium: 11%
Added added at the
at the table
Table or(5%) and in cooking (6%)
in Cooking
Restaurant/Processed Food

J Am College of Nutrition 1991;10:383-93

Salt mechanisms leading to hypertension:
By expanding the extracellular volume
High salt intake increases the action of aldosterone
High salt intake is a permissive factor for the
hypertensinogenic effect of aldosterone
Increase in the sodium concentration progressively increases
endothelial cell stiffness, causes inhibition of endothelial NO
synthase and decreases release of nitric oxide
Changes in plasma sodium concentration are transmitted into
the cerebrospinal fluid triggering the release of cardiotonic
steroids, namely, analogues of digitalis such as ouabain and
marinobufagenin which cause vasoconstriction
NON-BLOOD PRESSURE-RELATED EFFECTS OF DIETARY SALT

Atherosclerosis
Stroke
Left ventricle hypertrophy
Proteinuric kidney disease
Heart failure
 Putative mechanisms of the deleterious cardiovascular
effects of excessive dietary sodium through blood pressure
increase independent of blood pressure
All cases of hypertension should restrict sodium intake to
approximately 6 g sodium chloride salt or 2.4 g sodium per
day by adopted the following measures:
Reduce salt for cooking by 50%
Substitute natural foods for processed
foods.
No sprinkling of salt on dining table
Avoid salty snacks such as pickles,
chutneys, papad, salted nuts
Use salt substitutes containing potassium
Avoid medications such as antacids as
these are rich in salt
Lifestyle Recommendations for Hypertension:
Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four to seven days per week

I Intensity - Moderate

T Time - 30-60 minutes

Type Cardiorespiratory Activity

T - Walking, jogging
- Cycling
- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension:
Weight Loss
Height, weight, and waist circumference (WC) should be measured
and body mass index (BMI) calculated for all adults.

Hypertensive and all patients

BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2
Waist Circumference
Men <102 cm Women <88 cm

For patients prescribed pharmacological therapy: weight loss has

additional antihypertensive effects. Weight loss strategies should employ a
multidisciplinary approach and include dietary education, increased physical
activity and behaviour modification
CMAJ 2007;176:1103-6
Waist Circumference Measurement

Measure here

Iliac crest

Courtesy J.P. Desprs 2006

 Lifestyle Recommendations for Hypertension:
Alcohol

Low risk alcohol consumption

0-2 standard drinks/day

Men: maximum of 14 standard drinks/week

Women: maximum of 9 standard drinks/week

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or

12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
Lifestyle Recommendations for Hypertension:
Stress Management

Stress management
Hypertensive patients
in whom stress appears to be an important issue

Behaviour Modification

Individualized cognitive behavioural interventions are

more likely to be effective when relaxation techniques
are employed.
 Non-pharmacological Treatment
Intervention Recommendation Expected systolic blood
Pressure reduction (range)

Weight Reduction Maintain ideal body mass index 5-10 mmHg per 10 kg
(20-23 kg/m2) weight loss

All put together reduce SBP 8-14

bymmHg
DASH eating plan Consume diet rich in fruit, vegetables,
low-fat dairy products with reduced
content of saturated and total fat
20 to 55 mmHg
Dietary sodium Reduce dietary sodium intake to 2-8 mmHg
restriction <100 mmol/day (<2.4 g sodium or
<6 g sodium chloride)

Physical Activity Engage in regular aerobic 4-9 mmHg

physical activity, for example,
brisk walking for at least 30 min
most days
Alcohol Men < 21 units per week
Women < 14 units per week 2-4 mmHg
moderation
Pharmacotherapy
 BP lowering effects from antihypertensive drugs

Dose response curves for efficacy are relatively flat

80% of the BP lowering efficacy is achieved at half-
standard dose
Combinations of standard doses have additive blood
pressure lowering effects

Law. BMJ 2003

 Two patients with identical blood pressures (150/96 mm Hg)
but pronounced differences in othermajor risk factors, illustrating
a 20-fold difference in absolute cardiovascular risk and in chance
of benefitfrom treatment between patients with
mild hypertension

Patient A Patient B

Blood pressure (mm Hg) 150/96 150/96

Sex Female Male
Age (years) 35 65
Total cholesterol (mmol/l) 5.0 7.0
HDL cholesterol (mmol/l) 1.4 1.0
Smoking No Yes
Diabetes No No
Left ventricular hypertrophy No No
Absolute CVD risk (% over 10 years) 2.5 51.0
Absolute benefit (% over 10 years) 0.6 12.8
NNT (5 years) 321 16
Treatment of Hypertension According to the Level of Blood Pressure and
Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

130-139/85-89 mmHg
(High normal - Prehypertension stage 2)

No Diabetes Diabetes
No Chronic Kidney Disease Chronic Kidney Disease
No proteinuria Proteinuria

Life style Life style modification

modification plus
drug treatment
Treatment of Hypertension According to the Level of Blood Pressure and
Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

140-159/90-99 mmHg
(Stage 1)

No risk factors 1 risk factors, no Cardiovascular or other

no cardiovascular cardiovascular or other target organ disease or
or other target target organ disease or diabetes
organ disease diabetes

Life style Life style modification Life style modification

modification plus
drug treatment
> 140/90 mmHg > 140/90 mmHg

Drug treatment Drug treatment

in addition to life in addition to life
style modification style modification
Treatment of Hypertension According to the Level of Blood Pressure and
Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

160/100 mmHg
(Stage 2/3)

Life style modification

plus
drug treatment
 Choice of
Pharmacological Therapy
Choice of Pharmacological Treatment
Uncomplicated

Associated risk factors?

or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO YES

Treatment in the Individualized

absence of compelling Treatment
indications for specific (and compelling
therapies indications)
NICE clinical guideline 127, 2011
 Considerations Regarding the Choice of
First-Line Therapy
Use caution in initiating therapy with 2 drugs in whom adverse
events are more likely (e.g. frail elderly, those with postural
hypotension or who are dehydrated).
ACE inhibitors, renin inhibitors and ARBs are contraindicated in
pregnancy and caution is required in prescribing to women of child
bearing potential.
Beta blockers are not recommended as first line therapy for patients
age 60 and over without another compelling indication.
Diuretic-induced hypokalemia should be avoided through the use of
potassium sparing agents if required.
The use of dual therapy with an ACE inhibitor and an ARB should
only be considered in selected and closely monitored people with
advanced heart failure or proteinuric nephropathy.
ACE-inhibitors are not recommended (as monotherapy)
for black patients without another compelling indication.
Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

VIII. Treatment of Hypertension in Association With Stroke
Acute Stroke: Onset to 72 Hours

Treat extreme BP elevation (systolic

> 220 mmHg, diastolic > 120 mmHg)
Acute by 15-25% over the first 24 hour
ischemic with gradual reduction after.
Stroke
If eligible for thrombolytic therapy
treat very high BP (>185/110 mmHg)

Avoid excessive lowering of BP which can exacerbate ischemia

 Treatment of Hypertension in Association With Stroke
Acute Stroke: Onset to 72 Hours

Strongly consider blood pressure reduction in all patients after

the acute phase of stroke or TIA .

Target BP < 140/90 mmHg

Stroke
TIA An ACEI / diuretic
combination is preferred

Combinations of an ACEI with an ARB are not recommended

Most HTN Pts need more than 1 drug
5

4
Number of drugs

0
 Ratio of Incremental SBP lowering effect at
standard dose Combine or Double?

1.4
1.16
1.2
Incremenal SBP reduction ratio

1.04
Observed/Expected (additive)

1 1.01
1 0.89
0.8
0.6
0.37
0.4
0.19 0.23 0.2 0.22
0.2
0
Thiazide -blocker ACE-I CCB All

Combine Double
Wald et al. Combination Versus Monotherapy for Blood Pressure Reduction,
The American Journal of Medicine, Vol 122, No 3, March 2009
Recommendations for Initial Combination
Antihypertensive Therapy

Norris K& Neutel JM. J Clin Hypertens. 2007;9(12 suppl 5):514

Drug combination in hypertension :

Preferred
ACE inhibitor/diuretic
ARB/diuretic
ACE inhibitor/CCB
ARB/CCB

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Acceptable
-blocker/diuretic
CCB (dihydropyridine)/-blocker
CCB/diuretic
Renin inhibitor/diuretic
Renin inhibitor / ARB
Thiazide diuretics/K+-sparing diuretics

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Less effective
ACE inhibitor/ARB
ACE inhibitor/-blocker
ARB/-blocker
CCB (nondihydropyridine)/-blocker
Centrally acting agent/-blocker

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

 Choice of Pharmacological Treatment
for Hypertension
Individualized treatment
Compelling indications:
Ischemic Heart Disease
Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Left Ventricular Systolic Dysfunction
Cerebrovascular Disease
Left Ventricular Hypertrophy
Non Diabetic Chronic Kidney Disease
Renovascular Disease
Smoking
Diabetes Mellitus
With Nephropathy
Without Nephropathy
Global Vascular Protection for Hypertensive Patients
Statins if 3 or more additional cardiovascular risks
Aspirin once blood pressure is controlled
Global Vascular Protection for
Patients with Hypertension
 Vascular Protection for Hypertensive
Patients: Statins

In addition to current Canadian recommendations on management

of dyslipidemia, statins are recommended in high-risk
hypertensive patients with established atherosclerotic disease
or with at least 3 of the following criteria:

Male Family History of Premature

Age 55 or older CV disease
Smoking LVH
Total-C/HDL-C ratio of 6 ECG abnormalities
mmol/L or higher Microalbuminuria or Proteinuria

ASCOT-LLA Lancet 2003;361:1149-58

 Vascular Protection for Hypertensive
Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

 Treating Hypertension and
Other Risk Factors
Treatment Treatment Treatment Based on
Based on lipids Based on BP Overall Absolute Risk
(statin) (ASA, lipids, BP)
0
Predicted Reduction in

-5

-10
-6 -6
Major CVD (%)

-9 -8
-10
-15 -12
-20 -17
-25 Treatment thresholds

-30 Top 10%

-28
Top 20%
-35
Top 30%
-40 -37
Adapted from Emberson et al. Eur Heart J. 2004;25:484-491
Secondary Hypertension
Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension (2015) 21:1

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension (2015) 21:1

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension (2015) 21:1

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension (2015) 21:1

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension (2015) 21:1

Resistant Hypertension
Blood pressure that remains above goal (<140/90
mmHg in non-complicated patients & <130/80 mmHg in
high risk patients) in spite of the concurrent use of of
three antihypertensive agent of different classes
Ideally, one of the three agents should be diuretic and
all agents should be prescribed at optimal dose
amounts
Includes patient whose blood pressure is controlled
with use of more than three medications
In a compliant patient
Difficult-to-Control Hypertension

Inadequately treated hypertension (pseudo-resistance)

True resistant hypertension
Difficult-to-Control Hypertension

Inadequately treated hypertension

(pseudo-resistance)
Under treatment
Treatment with inappropriate agents
Incorrect blood pressure measurement
White coat effects
Medications nonadherence
Pseudo-hypertension
 Under Treatment (Suboptimal Medical
Treatment)

Clinical inertia : the providers failure to increse

therapy when the treatment goal is not reached.

Lack of knowledge of treatment guidelines

Underestimation of cardiovascular risk
The use of spurious reason to avoid intensification
of therapy.
 Medication Poor Adherence

High cost of treatment

Complex medical regimen
Adverse effect of medical therapy
Poor relation between doctors
and patients
 Clinical clues suggestive of
pseudohypertension

Marked hypertension in the absence of

target organ damage
Antihypertensive therapy produces
symptoms consistent with hypotension in
the absence of successful reduction of BP
Radiological evidence of pipe stem
calcification in the brachial arteries
Brachial artery pressure higher than lower
extremity pressure
Severe and isolated systolic hypertension
Clinical clues suggestive of white coat
effects

Clinic blood pressure measurements are

consistently higher than out-of-office
measurements.
Patients show signs of overtreatment,
particularly orthostatic symptoms.
Patients with chronically high office blood
pressures values but an absence of target
organ damage.
Difficult-to-Control Hypertension

True resistant hypertension

Associated
Identifiable causes
factors:

Medications (NSAID, oral contraceptive,
Primary aldosteronism
sympathomimetic, corticosteroid, erythropoetin,
Renovascular
cyclophospamid. disease
Pheocromocytoma
Excessive alcohol consumption
Chronic kidney
Coarctation disease
of the aorta

Obesity
Intracranial tumor
Obstructive sleep apnea
 Suggested algorithm for the treatment of resistant hypertension
Insure therapy meets JNC-7 criteria for compelling indications

Uncontrolled blood pressure Correct identifiable causes if

on 3 or more antihypertensives present; consider work-up of
Consider ambulatory blood secondary conditions
pressure monitoring if
available to rule out white-
coat phenomenon NO Add low-dose diuretic
Thiazide-type
(chlorthalidone 12.5 mg
diuretic present?
preferred; titrate to 25mg/d)
YES
* if not already part of
regimen, consider B for Re-evaluate
addition if pulse >84
Optimize combination as follows:
A or B* + C + D If blood pressure
If blood pressure remains uncontrolled
A= ACEI or ARB
B = Beta Blocker remains uncontrolled
C= CCB (long-acting)
D= Diuretic
+ spironolactone (12.5 mg/d to 25 mg/d)

If blood pressure remains uncontrolled, adjust regimen to include:

Trewet CLB, et al. South Med. 2008;101(2):166-174

Suggested algorithm for the treatment of resistant hypertension

If blood pressure remains uncontrolled, adjust regimen to include:

ACEI 2 CCBs alpha-blocker or Centrally-acting

or or or
+ ARB (different types) combined (e.g. Clonidine)
alpha/beta blocker

+ vasodilator (e.g.
hydralazine)

Trewet CLB, et al. South Med. 2008;101(2):166-174

 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 ) A or C or D
 Recommendations

Recommendation 7
(Moderate recommendation)
Initial treatments
Black CD
General ( diabetes )
black population C or D
Recommendation 8
(Moderate recommendation)
Initial or add-on treatments

Population with CKD

18 years(irrespective A
of race or diabetes)

Recommendation 9
(Expert opinion)
Goal BP not reached
within a month of treatment
Non control strategies
Increase the dose of the initial drug,
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
 CRISIS HYPERTENSION

Emergency Hypertension
Urgency Hypertension
 Hypertensive Emergencies :
Definition
A rapid decompensation of vital organ
function secondary to an inapropriately
elevated BP
Require lowering of BP within 1 hour to
decrease morbidity
Not determined by a BP level, but rather
the imminent compromise of vital organ
function
Hypertensive Emergencies
CNS - Hypertensive encephalopathy
CVS
Acute myocardial ischemia
Acute cardiogenic pulmonary edema
Acute aortic dissection
Post-op vascular surgery
Renal - Acute renal failure
Eclampsia
Catechol excess- Pheochrom, Drugs
 Therapeutic considerations
in hypertensive
emergencies

Need for rapid reduction of BP

Potential complications of therapy
Prevalence of cerebrovascular disease
and coronary artery disease (Stenotic
lesions)
Altered cerebral autoregulation
Impaired baroreflexes
Blood viscosity
Ability to increase oxygen extraction
 How far can BP be safely
lowered?
Lower limit usually 25% below MAP
50% of chronic hypertensives reached
lower autoregulation limit with 11 to 20%
reduction in MAP
50% had lower limit above usual mean
Most ischemic complications develop with
reductions greater than 20 - 30 % (over 24
to 48 hours)
Blindness, paralysis, coma, death, MI
 Initial Lowering of BP :
Therapeutic Guidelines

Do not lower BP more than 20% over

the first 1 to 2 hours unless
necessary to protect other organs
Decreasing to DBP of 110 or patients
normal levels may not be safe
Further reductions should be very
gradual ( days)
Follow neuro status closely
 Concept of Hypertensive
Urgencies
Potentially dangerous BP elevation
without acute, life-threatening end-organ
damage
Examples (controversial!)
Retinal changes without
encephalopathy or acute visual
symptoms
High BP with nonspecific Sx (headache,
dizziness, weakness)
Very high BP without symptoms
 Hypertensive Urgencies
Severe elevation of BP ( DBP > 115)
No progressive end-organ disease
Joint National Committee on Detection,
Evaluation, and Treatment of HBP
1984 - lower BP within 24 hours
1988 - urgent therapy rarely required
1993 - Gradual lowering of BP
Risks of rapid reduction (cerebral and myocardial
ischemia)
Adherence
Factors contributing to low adherence/persistence
with antihypertensive drugs
Category Examples
Poor communication
Patient-physician Insufficient patient information/education
relationship Physical/cognitive impairments (vision
problems, dementia)
Asymptomatic

Condition Lifelong treatment

No immediate consequences of stopping
therapy

Adverse effects
Therapy
Complexity of regimen
Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol 2011;2:63-70
Factors contributing to low adherence/persistence
with antihypertensive drugs
Category Examples
Cost of medication

Unemployment/poverty

Socioeconomic Lack of insurance

Lack of transportation

Social deprivation

Inadequate health care coverage

Health system Difficult access to health care

Lack of continuity of care

Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol 2011;2:63-70
 Guidelines for the physician to improve
antihypertensive drug compliance

Educate the patient about hypertension and its

treatment with clear and accepted goals. Need to
continue treatment, control does not mean cure,
one cannot tell if BP is elevated by feeling or
symptoms-> BP must be measured
Keep the treatment as simple and cheap as possible
(using long-acting once-daily dosing) with written
information.
Combine efficient and well tolerated drugs in the
same pill (fixed-dose combination)
 Contd
Stimulate the patient to be active in medical
management
Create a multidisciplinary team to improve family
and community support
Use all possible modern reminder aids to ensure
daily drug intake.
 Key Messages for the
Management of Hypertension

1. All patients should have their blood pressure assessed at all

appropriate clinical visits.
2. Optimum management of BP requires assessment of overall
cardiovascular risk.
3. Home BP monitoring is an important tool in self-monitoring and
self-management.
4. Treat to target.
5. Lifestyle modifications are effective in preventing hypertension,
treating hypertension and reducing cardiovascular risk.
6. Combinations of both lifestyle changes and drugs are generally
necessary to achieve target blood pressures.
7. Focus on adherence.
Thank You