HYPERTENSION

FACING AN OLD FOE AND OPTIMISING MEDICAL MANAGEMENT

OBJECTIVES

• To discuss more recent definitions and the pathophysiology of

hypertension
• To associate hypertension with cardiovascular risk factors
• To develop strategies for the optimal treatment of
hypertension based on recent trials and international
guidelines
NEW DEFINITION OF HYPERTENSION

• A complex cardiovascular disorder rather than just a

blood pressure value.
• A progressive cardiovascular syndrome with many causes
that result in both functional and structural changes to
the heart and vascular system and lead to premature
morbidity and death.
• Early markers of the syndrome are often present before BP
elevation is sustained; therefore, hypertension cannot be
classified solely by discrete BP thresholds.
TARGET ORGAN DAMAGE IN
HYPERTENSION
• Primarily the
consequence of changes
in structure and function
of large and small arteries
as well as the
microcirculation in these
organs.
HEMODYNAMICS OF HYPERTENSION

3 segments of the arterial

tree:
1. Elastic Arteries
2. Muscular Arteries
3. Microcirculation with
arterioles
 RAREFACTION AND TARGET ORGAN
DAMAGE
Elevated blood pressure
Vasoconstriction

Rarefacti
Increased peripheral
on
resistance

Increased diffusion Decreased blood flow

distance

Reduction in oxygen
delivery
Impaired organ function
 Early Markers of Cardiovascular Disease
BP
• Loss of nocturnal dipping
• Exaggerated response to
exercise
• Salt sensitivity
• Widened pulse pressure
Vascular
• Increased arterial stiffness
• Increased wave reflection &
systolic augmentation
• Increased CIMT
• Endothelial dysfunction
• Coronary calcification
Cardiac
• Increased atrial filling pressure
• Decreased diastolic relaxation
Renal
• Microalbuminuria
• Elevated creatinine
• Decreased eGFR
Retinal
• Hypertensive retinal changes
ESTABLISHED BENEFITS OF TREATMENT OF
HYPERTENSION IN 2015

• Reduces development of Cardiovascular Disease

• Reduces Premature Death
• Reduces Stroke
• Preserves Cognitive function
• Reduces Myocardial Infarction
• Reduces Heart Failure
• Preserves Renal Function
• Prevents accelerated hypertension
 THE HYPERTENSIVE PHENOTYPE

BLOOD • Elevation

PRESSURE
• Circadian Rhythm Disturbances

STRUCTUR • Small Artery

AL Large Artery
•
• Left ventricular Hypertrophy

DAMAGE
• Target Organ Damage

METABOLI • Dysplipidaemia

C EFFECTS
• Impaired Glucose Tolerance
 Requirements for Modern
Blood Pressure lowering therapy

• Effective 24hr BP control

• Cardiovascular disease prevention
• Metabolically "friendly"
• Well tolerated
GUIDELINES
Made to Help Us Treat
HYPERTENSION
 SOME KEY QUESTIONS REMAIN REGARDING
THE OPTIMAL TREATMENT OF
HYPERTENSION IN 2015

• What are the appropriate BP treatment thresholds?

• How low should BP be lowered?
• What is the most effective treatment strategy — what
drugs should we be using?
BLOOD PRESSURE THRESHOLDS FOR DIAGNOSIS
AND TREATMENT OF HYPERTENSION – NICE
GUIDELINES

STAGE OF OFFICE BP 24hr. Daytime Home ABPM

HYPERTENSION (mmHg) ABPM Average Average

≥140/90 but ≥135/85 ≥135/85

Stage 1 <160/100
hypertension

Stage 2 ≥160/100 ≥150/95 ≥150/95

hypertension
 NICE Blood Pressure Treatment Targets
• Use Clinic BP to monitor BP control;
• Best evidence suggests that optimal clinic BP control is
<140/90mmHg;
• In people with "white coat effect", i.e. clinic BP is
>20/10mmHg more than ABPM or Home average, use Home
BP average to monitor treatment — target home BP average
of <135/85mmHg;
• Review BP control at least annually once BP treatment
is stable.
ESC/ESH Single SBP target for almost
all patient

• SBP «140 mmHg is recommended/should be

considered,
regardless of the level of risk, in patients with:

• Low/moderate CV risk
• Diabetes
• Diabetic/non-diabetic CKD
• CHD/previous stroke or TIA

• A DBP «90 mmHg is always recommended

SUMMARY
• Hypertension is a complex vascular disorder that
carries a large burden of disease
• We should treat the patient and not the BP, thus
determine total cardiovascular risk
• Appropriate BP targets to be achieved with drugs
with best evidence in appropriate situations
• The patient and the doctor must work together to
find the best solutions to control hypertension
SUMMARY
• Blood pressure lowering remains a key objective of
treatment for hypertension;
• Most people need drug combinations to achieve
their BP goal;
• Combination therapy also reduces adverse affects
associated with single agents;
• Combination therapy restores dose response and
reduces the heterogeneity and unpredictability of
response — good response in all patients;
• Combination of ARB + CCB or ARB + CCB + HCTZ are
likely to be the best tolerated, most effective, most
protective and the preferred combination for most
patients.