HYPERTENSION- THE LATEST MANAGEMENT Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.

1. Hypertension – The
Latest Management
DR AWADHESH KUMAR SHARMA
Consultant Cardiology
Gracian superspeciality Hospital
Mohali

2. Hypertension
 Hypertension is the most common condition
in primary care.
 1 in 3 patients have hypertension.
 Risk factor for MI, CVA, ARF, death.

4. Benefits of lowering BP

5. Triple paradox
1. Easy to diagnose often remains
undetected.
2. Simple to treat often remains
untreated.
3. Despite availability of potent drugs,
treatment all too often is ineffective.

6. Paradigm Shifts in
Hypertension Management
1. Controlling it is challenging; All have room
for improvement.
2. Focus on BP goal attainment– sooner
rather than later.
3. Resort to combination therapy readily.
4. Prevent or reduce target organ damage.

8. HTN IN INDIA

9. Case
• A 58 year old urban woman with
diabetes and dyslipidemia has a BP of
158/94 confirmed on several office
visits. Other than obesity, the exam is
normal. Labs show normal renal
function, well-controlled lipids on
atorvastatin and well-controlled
diabetes on metformin. Urine micro-
albumin is mildly elevated.

10. Case Question 1
• What goal BP is most appropriate for
this patient?
1. <150/90 mmHg
2. <130/80 mmHg
3. <140/90 mmHg
4. <140/80 mmHg
5. <140/85 mmHg

11. Case Question 2
• What is the drug of choice to start?
1. HCTZ
2. Amlodipine
3. Ramipril
4. Losartan
5. Beta blocker
6. Combination therapy

12. What should be the goal BP?

13. BP measurements
• Diagnosis of hypertension should be based
on at least 3 different BP measurements,
taken on 2 separate office visits.
• At least 2 measurements should be obtained
once the patient is seated comfortably for at
least 5 minutes with the back supported, feet
on the floor, arm supported in the horizontal
position, and the BP cuff at heart level.

14. Classification of BP – JNC 7
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Normal < 120 and < 80
Pre-HTN 120-139 or 80-89
Hypertension
Stage I 140-159 or 90-99
Stage II > 160 or > 100

15. Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
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
Definitions and classification of office BP levels (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.
Hypertension:
SBP >140 mmHg ± DBP >90 mmHg

16. JNC 8
• 2014 Evidence-Based Guidelines for
the Management of High Blood
Pressure in Adults
– JAMA. 2014;311(5):507-520
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure
in Adults: Report From the Panel Members Appointed to the Eighth Joint National
Committee (JNC 8)
JAMA. 2014

17. JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation

18. JNC 8: Drug Treatment
Thresholds and Goals
• Age > 60 yrs
– Systolic:
• Threshold > 150 mmHg
• Goal < 150 mmHg
– LOE: Grade A
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A
Based on trials HYVET,Syst-Eur,SHEP, JATOS,VALISH,andCARDIO-SIS
Recommendation 1

19. JNC 8: Drug Treatment
Thresholds and Goals
• Age < 60 yrs
- Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade A for ages 40-59; Grade E for ages 18-
39
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
(Trials HDFP,Hypertension-StrokeCooperative,MRC,ANBP,and
VA Cooperative)
Recommendation 2
Recommendation 3

20. JNC 8: Drug Treatment
Thresholds and Goals
• Age > 18 yrs with CKD or DM
– Systolic:
• Threshold > 140 mmHg
• Goal < 140 mmHg
– LOE: Grade E
– Diastolic:
• Threshold > 90 mmHg
• Goal < 90 mmHg
– LOE: Grade E
Recommendation 4 & 5
Quality evidencefrom3trials(SHEP,Syst-Eur, and UKPDS)

21. JNC 8: Initial Drug Choice
• Nonblack, including DM
– Thiazide diuretic, CCB, ACEI, ARB
• LOE: Grade B
• Black, including DM
– Thiazide diuretic, CCB
• LOE: Grade B (Grade C for diabetics)
Recommendation 6
Recommendation 7
3 federally funded trials (VA Cooperative Trial, HDFP, and SHEP)

22. JNC 8: Initial Drug Choice
• Age > 18 yrs with CKD and HTN
(regardless of race or diabetes)
– Initial (or add-on) therapy should include
an ACEI or ARB to improve kidney
outcomes
• LOE: Grade B
– Blacks w/ or w/o proteinuria
• ACEI or ARB as initial therapy (LOE: Grade E)
– No evidence for RAS-blockers > 75 yo
• Diuretic is an option for initial therapy
Recommendation 8
From trial The AASK study

23. JNC 8: Subsequent Management
• Reassess treatment monthly
• Avoid ACEI/ARB combination
• Consider 2-drug initial therapy for
Stage 2 HTN (> 160/100)
• Goal BP not reached with 3 drugs, use
drugs from other classes
– LOE: Grade E
Recommendation 9

24. Possible combinations of classes of antihypertensive drugs

25. Anti-hypertensive drugs and their usual dosage

26. Anti-hypertensive drugs and their usual dosage

27. Hypertension

28. Medical Education & Information – for all Media, all Disciplines, from all over the World
Powered by
2013 ESH/ESC Guidelines for the management of arterial hypertension
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
Lifestyle changes for hypertensive patients
* Unless contraindicated. BMI, body mass index.
Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day
Moderate alcohol intake Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
BMI goal 25 kg/m2
Waist circumference goal Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
Exercise goals ≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Quit smoking

29. Management of HTN in specific conditions

30. Pregnant women
• If BP > 160/110 mmHg, treatment is
recommended (I, C).
• Consider drug Rx (IIb, C)
– BP ≥150/95mmHg, or
– BP ≥140/90 mmHg + TOD
• Methyldopa, labetolol, nifedipine preferred
(IIa, B)
• Pre-eclampsia: IV labetolol or nitroprusside
(IIa, B)

31. DM
• Start drug Rx when SBP ≥140 mmHg (I, A).
• Target SBP < 140/90 mmHg (I, A).
• All classes of drugs are recommended and
can be used (I, A).
• RAS blockers preferred, especially if having
proteinuria / microalbuminuria (I, A).

32. HT with nephropathy
• Target SBP < 140 mmHg (IIa, B).
• RAS blockers indicated for HT with overt proteinuria
or microalbuminuria (I, A).
• Recommend combining RAS blockers with other
anti-HT drugs to achieve target BP (I, A).
• Combining two RAS blockers is not recommended
(III, A).
• Aldosterone antagonists not recommened in CKD
(III, C).

33. Cerebrovascular disease

34. Atherosclerosis, arteriosclerosis, peripheral
artery disease
• Target BP < 140/90 mmHg.
• Carotid atherosclerosis: CCB, ACEI (IIa, B).
• PAD: BB may be considered. Their use does
not appear to be associated with worsening
of PAD symptoms (IIIb, A).

35. Resistant Hypertension
• Blood pressure remaining above goal (150/90 mm
Hg for the overall population and 140/90 mm Hg for
those with DM or CKD) in spite of concurrent use of
3 antihypertensive agents of different classes.
• Ideally, 1 of the 3 agents should be a diuretic & all
agents should be prescribed at optimal dose
amounts.
The JNC 7 report. JAMA 2003; 289: 2560-72.

36. Resistant HT
• MR antagonist, amiloride, doxazosin should
be considered.
• If drugs are ineffective: renal denervation and
baroreceptor stimulation may be considered
(IIb, C) (only by experienced operators at
restricted HT centers).

37. Conclusion
• Patients with DM & CKD require more aggressive BP
control.
• Most patients with hypertension will require two or
more antihypertensive medications to control blood
pressure.
• The use of combination therapy is appropriate as
initial treatment.
• Sustained antihypertensive efficacy may protect
against the early morning rise in blood pressure that
leads to heightened risk of cardiovascular events.

38. THANKS