Hypertension guidelines

1. PRESENTER:DR.NAVAS SHAREEF
MODERATOR:DR.MAHALAKSHMI

2. • Hypertension is defined as systolic blood pressure (SBP) of 140
mmHg or greater, diastolic blood pressure (DBP) of 90 mmHg or
greater, or taking antihypertensive medication.

3. BLOOD PRESSURE MEASUREMENT
• Options
- Office BP measurement
- Out of office BP measurement
1. • mbulatory Blood Pressure Monitoring ( BPM)
2. • Home Blood Pressure Monitoring (HBPM)

4. Office Blood Pressure monitoring
• Most widely performed
• Easy, cost effective
• Most of the studies use office BP

5. Office Blood Pressure monitoring
• Between-arm SBP difference of >15 mmHg is suggestive of
atheromatous disease and is associated with an increased CV risk.
• If a between-arm difference in BP is recorded, then it is
recommended that all subsequent BP readings use the arm with the
higher BP reading.
2018 ESC/ESH Guidelines

6. ABPM: Ambulatory BP monitoring
Advantages
• Can identify white-coat and masked hypertension
• Stronger prognostic evidence
• Night-time readings
• Measurement in real-life settings
• Abundant information from a single measurement session, including
short-term BP Variability
• Detect postural and postprandial hypotension
• Evaluation of resistant hypertension
• ssessment of symptoms of hypotension
during course of treatment
• Evaluate considerable variability of office BP

7. ABPM: Ambulatory BP monitoring
Disadvantages
• Expensive and sometimes limited availability
• Can be uncomfortable

8. HBPM: Home BP monitoring
Advantages
• Can identify white-coat and masked
hypertension
• Cheap and widely available
• Measurement in a home setting, which may
be more relaxed than the doctor’s office
• Patient engagement in BP measurement
• Easily repeated and used over longer periods
to assess day-to-day BP variability

9. HBPM: Home BP monitoring
Disadvantages
• Only static BP is available
• Potential for measurement error
• No nocturnal readings

10. Scope of Out-of-office BP
Out-of-office BP (i.e. ABPM or HBPM) is specifically recommended for a
number of clinical indications, such as
• identifying white coat and masked hypertension,
• Quantifying the effects of treatment, and
• identifying possible causes of side effects (e.g. symptomatic
hypotension).

11. Gangrene of the
Heart Left Ventricular
Hypertrophy
Lower Extremities
Aortic
Aneurysm
Failure Myocardial
Infarction
Coronary Heart
Disease
HYPERTENSION
Hypertensive
Blindness
Chronic
Kidney
Failure
Stroke Preeclampsia/
Eclampsia
encephalopathy
Cerebral
Hemorrhage

12. HYPERTENSION GUIDELINES͙..
• Indian Guidelines on Hypertension IV- 2019
LATEST
• American College of Cardiology (ACC)/American Heart Association
(AHA)-2017
• European Society of Cardiology (ESC)/European Society of
Hypertension (ESH)-2018
• American Society of Hypertension(ASH)-2014
• WHO classification/International Society of Hypertension(ISH)-2014
• Joint National Committee (JNC 8)- merica’s -2014
• Canadian Hypertension Education Program (CHEP) guidelines-2015

13. HYPERTENSION GUIDELINES
• The lengthy delay in producing revision reflects vulnerability of the
guideline process?
• What to follow?

14. change in definition of HTN
• ACC/ AHA guidelines were released in November, 2017. They have
changed the definition of hypertension from 140/90 to 130/80 mm
Hg.
• This change was primarily on the basis of interpretation of the SPRINT
(Systolic Blood Pressure Intervention Trial) study which was published
in November, 2015.
• The ACC/ AHA have categorised the BP levels as normal, elevated,
stage 1 and stage 2 HTN.
• ESC/FSH guidelines have refined the previous categories of HTN as
optimal, normal, high normal, grade l, 2, and 3 HTN and isolated
systolic hypertension (ISH)

15. change in definition of HTN͙But͙.?
• The latest Canadian guidelines 2017 and the Australian
guidelines 2016 were both released after the SPRINT study but
they have retained the original definition of 140/90 mm Hg.
• The European Society of Hypertension and European Society of
Cardiology (ESH/ESC) have recently come out with their 2018
guidelines and are the most recent ones. They also did not change
the original definition of 140/90 mm Hg.
• Thus, most experts are not ready to change the definition of
hypertension as has been done in the ACC/ AHA guidelines

16. American College of Cardiology (ACC)/American Heart
Association (AHA)-2017

17. ACC/AHA guidelines: perfect?
• It is well known that with increasing levels of BP the
target organ damage is higher. Two patients—one with a
BP of 144/90 mmHg and other with a BP of 190/110mmHg—will
be stamped and diagnosed as stage 2 H TN according to
the ACC/ AHA guidelines which pretty much down sizes
the magnitude of the problem in the second patient.
• The ACC/ AHA also does not give much importance to the well-
known entity of ISH which is very common in the elderly
and which mandates special attention
• ACC/AHA have clubbed all such patients also the same entity of stage 2
HTN.

18. Guidelines in India
• The latest Indian guidelines on hypertension (Indian Guidelines on
Hypertension (IGH) IV) from the Association of Physicians of India
(API), were released in October 2019.
• Definition : Remains same

19. HYPERTENSIVE CRISIS
• Hypertensive emergencies/ Malignant hypertension
• Hypertensive urgencies/ Accelerated hypertension

20. HYPERTENSIVE EMERGENCIES (MALIGNANT HYPERTENSION)
• BP >180/120 mmHg, complicated by evidence of impending or progressive target
organ dysfunction.
• Examples :Hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left
ventricular failure with pulmonary edema, unstable angina pectoris, aortic dissection,
or eclampsia.
• IV nitroglycerine is generally used, recommended dose is initially 5mcg/min, then
titrate by 5 mcg/min at 3 to 5 minute intervals, upto 10 mcg/min.
• IV Labetalol is also being used in hypertensive emergencies in a bolus dosage of 2-10
mg and infusion of 2.5-30 mcg/kg/min.
• IV enalaprilat is useful in presence of heart failure.
• IV esmolol has been shown to be specially useful for peri-operative HE
• IV nitroprusside is required rarely, in situations like dissection of aorta and
subarachnoid haemorrhage with very high blood pressure.
• Sublingual captopril can also be used when less rapid reduction is required.

21. HYPERTENSIVE URGENCIES (ACCELERATED HYPERTENSION)
• BP >180/120 mmHg without progressive target organ dysfunction.
Examples :upper levels of stage II hypertension associated with severe
headache, shortness of breath, epistaxis, or severe anxiety.
• Aim should be safe, prompt and gradual lowering of blood pressure
with oral medication over a period of 1-3 days. In most urgencies,
blood pressure can be controlled with rapidly acting oral medications
like calcium channel blockers and ACEI/ARB.
• Sublingual nifedipine should not be used in hypertensive crises as it
can cause precipitous fall in blood pressure, reflex tachycardia and
may precipitate renal, cerebral or coronary hypoperfusion.

22. RESISTANT HYPERTENSION : DEFINITION
Uncontrolled BP in spite of concurrent use of 3 anti hypertensive
agents of different classes in which are at maximum tolerated dose.

23. Resistant hypertension :Causes
• Volume overload
• - Excess sodium intake
• - Volume retention from kidney
disease
• Associated conditions
• - Obesity
• - Excess alcohol intake
• Drug
• - Inadequate doses
• - Inappropriate combinations
• - NSAIDs and cyclooxygenase 2
inhibitors
• - Cocaine, Amphetamines, other
illicit drugs
• -Cyclosporine and tacrolimus
•-Tobacco

24. Resistant hypertension :Causes
• Secondary causes of
hypertension
• - Chronic kidney disease
• - Coarctation of the aorta
• - Non-specific aortoarteritis
• - Cushing syndrome and other
glucocorticoid excess states
including chronic steroid therapy
• - Obstructive uropathy
• - Pheochromocytoma
• - Primary aldosteronism and
other mineralocorticoid excess
states
• - Renovascular hypertension
• - Obstructive sleep apnea
syndrome
•-Thyroid or parathyroid disease

25. Initiation of therapy IGH-IV
• Stage I hypertension
lifestyle modification
repeat readings within 2-3 weeks
Pharmacotherapy after 1 month.
• stage II hypertension & Stage III hypertension
shorter waiting period . ie,repeat readings after few hours will be
desirable.

26. Initiation of therapy IGH-IV
• BP needs to be recorded in both arms and in lying and standing
before initiation of pharmacotherapy
• In patients who have evidence of ASCVD and HMOD,
pharmacotherapy should be started early.
• DBP is a more potent cardiovascular risk factor than SBP until age 50;
thereafter, SBP is more important
• SBP is a major risk factor for CVDs. The rise in SBP continues
throughout life while Diastolic hypertension predominates before 50
years of age, .

27. ASCVD Risk Calculator
• http://static.heart.org/riskcalc/
app/index.html#!/baseline-risk
• The purpose of the ASCVD Risk
Calculator is to estimate a
patient’s 10-year ASCVD risk at
an initial visit to establish a
reference point.
• More than 10% is significant.

28. ACC / AHA Initiation of therapy
Hypertension: stage 1
Assess the 10-year risk for heart disease and stroke using
the atherosclerotic cardiovascular disease (ASCVD) risk calculator
• If risk is less than 10%, start with healthy lifestyle recommendations and
reassess in 3-6 months
• If risk is greater than 10% or the patient has known clinical cardiovascular
disease (CVD), diabetes mellitus, or chronic kidney disease, recommend
lifestyle changes and BP-lowering medication (1 medication); reassess in
1 month for effectiveness of medication therapy
-- If goal is met after 1 month, reassess in 3-6 months
-- If goal is not met after 1 month, consider different medication
or titration
-- Continue monthly follow-up until control is achieved

29. ACC / AHA Initiation of therapy
Hypertension: stage 2
Recommend healthy lifestyle changes and BP-lowering medication (2
medications of different classes) reassess in 1 month for effectiveness
• If goal is met after 1 month, reassess in 3-6 months
• If goal is not met after 1 month, consider different medications or
titration
• Continue monthly follow-up until control is achieved

30. IGH IV GOAL

31. GOAL
The first objective of treatment should be to lower BP to <140/90 mmHg in all patients
And if well tolerated
<65 years <130/80
>65 years <140/80

32. GOAL
Clinical Condition(s)
BP Goal,
mm Hg
General
Clinical CVD or 10-year SCVD risk ≥10%
No clinical CVD and 10-year ASCVD risk <10%
Older persons (≥65 years of age͖ noninstitutionalized, <130/80
ambulatory, community-living adults)
Specific comorbidities
Diabetes mellitus
Chronic kidney disease
Chronic kidney disease after renal transplantation
Heart failure <130/80
Stable ischemic heart disease
Secondary stroke prevention
Secondary stroke prevention (lacunar)
Peripheral arterial disease
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.

33. • Lose weight, if overweight
• Increase physical activity :30-45 minutes of brisk walking or swimming at
least 3-4 times a week could lower SBP by 7-8 mm Hg.
Isometric exercises such as weight lifting should be avoided
• Daily intake of salt should be restricted to 6gms (amounting to 3-4 gms of
sodium)
1 tsp of salt (flattened) = 5g of salt. A hypertensive patient should eat not more that 5 g of salt in a day.
• Stop smoking. E cigarettes are also harmful
• Limit intake of foods rich in fats and cholesterol
• Increase consumption of fruits and vegetables
• Alcohol consumption should be limited to no more than 2 drinks per day
(24oz beer, 10oz wine, 3oz 80-proof whiskey)

35. Beneficial
in HTN

37. ACC/AHA-2017 comments on antihypertensive
When initiating antihypertensive drug
therapy, use first-line agents that include
• Thiazide diuretics
• Calcium channel blockers
• ACE inhibitors or ARBs

38. ACE inhibitors
Do not use in combination with ARBs or direct
renin inhibitor
•
Increased risk of hyperkalemia, especially in
patients with chronic kidney disease or in those
on K+ supplements, or K+ sparing drugs
•
May cause acute renal failure in patients with
severe bilateral renal artery stenosis
•
Do not use if history of angioedema with ACE
inhibitors

39. ACE inhibitors
ACE inhibitors are first line agents in patients with diabetes, individuals
with other metabolic risk factors, post-MI and patients with heart
failure. In diabetes mellitus, they retard the onset and progression of
renal disease (patients with microalbuminuria and early CKD).

40. ARBs
Do not use in combination with ACE/direct renin
inhibitors
•
Increased risk of hyperkalemia in chronic kidney disease
or in those on K+ supplements or K+ sparing drugs
•
May cause acute renal failure in patients with severe
bilateral renal artery stenosis
•
Do not use if history of angioedema with ARBs.
patients with a history of angioedema with an ACE
inhibitor can receive an ARB beginning 6 weeks after ACE
inhibitor discontinued

41. ARBs
• In the recent randomized double blind ROADMAP89 trial involving
4,447 diabetic patients with olmesartan (40 mg OD), the onset of
microalbuminuria has been shown to be delayed in patients with type
2 diabetes.
• Monitoring eGFR change and serum potassium should be added.
This monitoring should be after 1 week of initiating this therapy and
after each dose increase.

42. CCB—dihydropyridines
•
Avoid use in patients with heart failure with reduced ejection
fraction
•
But amlodipine or felodipine may be used in the presence of
congestive heart failure if required as no effect on heart rate
and cardiac contractility, hence safe even
•
Associated with dose-related pedal edema.

43. Thiazide or
thiazide-like diuretics
Chlorthalidone preference based on prolonged half-life and proven trial
reduction of CVD
•
Monitor for hyponatremia and hypokalemia, uric acid and calcium
levels (CI in Gout). Steroids can worsen hypokalemia due to diuretics.
•
Use with caution in patients with history of acute gout unless patient is
on uric acid-lowering therapy

44. Diuretics—loop
•
Preferred diuretics in patients with symptomatic heart
failure
•
Preferred over thiazides in patients with moderate-to-
severe chronic kidney disease (eg:GFR <30 mL/min)

45. Diuretics—potassium sparing
•
Monotherapy agents minimally effective
antihypertensives
•
Combination therapy of potassium-sparing diuretic
with a thiazide can be considered in patients with
hypokalemia on thiazide monotherapy
•
Avoid in patients with significant chronic kidney disease
(eg, GFR <45 mL/min)

46. Diuretics—aldosterone antagonists
•
Preferred agents in primary aldosteronism and resistant
hypertension
•
Spironolactone associated with greater risk of gynecomastia
and impotence compared to eplerenone
•
Common add-on therapy in resistant hypertension
•
Avoid use with K+ supplements, other K+-sparing diuretics
or significant renal dysfunction
•
Eplerenone often requires twice daily dosing for adequate
BP lowering

47. β-Blockers—cardioselective
β-Blockers are not recommended as first-line agents
unless the patient has ischemic heart disease or
heart failure
• Preferred in patients with bronchospastic airway
disease requiring a β-blocker
• Bisoprolol and metoprolol succinate preferred in
patients with heart failure with reduced ejection
fraction and in IHD
• Avoid abrupt cessation

48. Direct renin inhibitor
•
Do not use in combination with ACE inhibitors or ARBs
•
Aliskiren is very long acting
•
Increased risk of hyperkalemia in chronic kidney disease or in those on K+
supplements or K+-sparing drugs
•
May cause acute renal failure in patients with severe bilateral renal artery stenosis
•
Avoid in pregnancy

49. α1-blockers
•
Associated with orthostatic hypotension, especially in older adults
•
May consider as second-line agent in patients with concomitant benign
prostatic hyperplasia

50. Central α1-agonist and other centrally acting
drugs
•
Generally reserved as last-line due to significant central nervous system
adverse effects, especially in older adults
•
Avoid abrupt discontinuation of clonidine, which may induce
hypertensive crisis; clonidine must be tapered to avoid rebound
hypertension

51. TYPE 2 DM + HTN: SGLT2 inhibitors ͙͙?
• Empagliflozin, Canagliflozin and Dapagliflozin have been
evaluated recently amongst diabetic patients in three large
trials (EMPA-REG, CANVAS Program and DECLARE-TIMI 58).
These agents have significant CV benefits and reduce blood
pressure. They reduce BP significantly in patients of diabetes
or hypertension irrespective of the level of BP.
• There is significantly reduced progression of kidney disease
and renal events with these agents.

52. IGH-IV

53. 2017 American Heart Association

55. *GDMT beta blockers for BP control or relief of angina include carvedilol,
metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and
timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta
blocker
†If needed for BP control.

56. Treatment of hypertension in patients with CKD
BP goal <130/80 mm Hg
(Class I)
Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)
Yes No
ACE inhibitor Usual “first-line”
(Class IIa) medication choices
ACE inhibitor
intolera nt
Yes No
ARB* ACE inhibitor*
(Class IIb) (Class IIa)

57. Maintenance and Follow-up of
Therapy : IGH-IV
• At least once in a fortnight, blood pressure should be
measured at the clinic or at home

58. Thank You