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Updated Hypertension Management – ESH 2023.pdf
- 1. Updated Hypertension Management – ESH 2023 Dr. Nayan Ray MBBS Mymensingh Medical College and Hospital
- 2. NYN/DMA/BPL
- 3. Prevalence of hypertension • Hypertension is the most prevalent CV disorder in the world and according to the WHO, it affects 1.28 billion adults aged 30–79 years worldwide, two-thirds living in low-income and middle-income countries. • In 2019, the global age-standardized average prevalence of hypertension in adults aged 30–79 years was reported to be 34% in men and 32% in women. • At younger ages (<50 years), hypertension is more prevalent in men, whereas a steeper increase of SBP in women from their third decade (and more so following menopause) makes the prevalence of hypertension greater in women in older age categories (>65 years). Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 4. Rule of Halves • Half the people with high blood pressure are not known (“rule 1”), • Half of those known are not treated (“rule 2”) and • Half of those treated are not controlled (“rule 3”)' Family Practice, Volume 16, Issue 2, April 1999, Pages 123-128, https://doi.org/10.1093/fampra/16.2.123 Journal of Hypertension 37(12):p 2470-2480, December 2019. | DOI: 10.1097/HJH.0000000000002192 NYN/DMA/BPL
- 5. Definition • Hypertension is defined based on repeated office SBP values ≥ 140 mmHg and/or DBP ≥ 90 mmHg. NYN/DMA/BPL
- 6. Category SBP (mmHg) DBP (mmHg) Optimal <120 and <80 Normal 120-129 and 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/or <90 Isolated Diastolic Hypertension <140 and/or ≥90 Category SBP (mmHg) DBP (mmHg) Office BP ≥140 and/or ≥90 Ambulatory BP Daytime (or awake) mean ≥135 and/or ≥85 Night-time (or asleep) mean ≥120 and/or ≥70 24 h mean ≥130 and/or ≥80 Home BP mean ≥135 and/or ≥85 Home and ambulatory BP values with office BP Classification Classification of office BP and definitions of hypertension grades ESH 2023 ESC 2021 NYN/DMA/BPL
- 7. White Coat Hypertension • BP is elevated in the office but is normal when measured by ABPM, HBPM or both • 30% of people attending hypertension clinics • Less CV risk Masked Hypertension • BP is normal in the office but elevated when measured by HBPM or ABPM • About 10–20% of patients attending hypertension clinics have MH • High CV risk NYN/DMA/BPL
- 8. Recommendations for BP measurements in the office and at home Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 9. Diagnosis by office BP and initial management of hypertension. Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 10. Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 Cardiovascular risk according to grade and stage of hypertension NYN/DMA/BPL
- 11. When to refer a hypertensive patient to a specialist or to hospital Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 12. Management- Lifestyle Modification Modification Recommendation Approximate Systolic BP Reduction, Range Weight reduction Maintain normal body weight (BMI, 18.5-24.9) 5-20 mm Hg/10- kg weight loss Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat 8-14 mm Hg Dietary sodium reduction Reduced dietary sodium intake to no more than 100 mEq/L ( 2.4 g sodium or 6 g sodium chloride) 2-8 mm Hg Physical activity Engage in regular aerobic physical activity such as brisk walking(at least 30 minutes per day) most days of the week 4-9 mmHg Moderation of alcohol consumption Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in most woman 2-4 mmHg ESH 2023 ISH 2020 NYN/DMA/BPL
- 13. General BP Lowering Strategy Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 14. BP-lowering strategy in true resistant hypertension Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 16. BP lowering therapy in patients with Hypertension and Coronary Artery Disease e.g: Amlodipine Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 17. BP-lowering therapy in hypertension and HFpEF Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 18. Heart failure with reduced ejection fraction (HFrEF) BP-lowering drugs in hypertension and heart failure. (a) Non-DHP CCB are not recommended in HFrEF and should not be combined with BB. (b) Use of Diuretics: I. Use T/TL Diuretic if eGFR >45 ml/min/1.73 m2. II. Consider transition to Loop Diuretic if eGFR is between 30 to 45 ml/min/1.73 m2. III. Use loop Diuretic if eGFR <30 ml/min/1.73 m2 or in patients with fluid retention/oedema. NYN/DMA/BPL
- 19. BP-lowering therapy in hypertension and atrial fibrillation Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 20. BP-lowering in patients with hypertension and chronic kidney disease Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 21. First Choice (Combination) DM ACEi/ ARB, CCB Dyslipidaemia ARBs, Amlodipine, Indapamide, Labetalol, Clonidine, Obesity ACEis/ ARBs or CCBs, Vasodialating BB, Diuretics BEP Alpha blocker HTN with Other Co-morbidities ISH 2020 NYN/DMA/BPL
- 24. Hypertensive Emergency Hypertensive Urgency SBP>180 and/or DBP>120 + EOD SBP>180 and/or DBP>120 - EOD IV Drug Labetelol, Nitropruside, Nicardipin, Nitroglycerin Oral drug 1st hour 25% SBP 2-6 hours 160/100-110 6-24 hours stable 24-48 hours normal Hypertensive Crisis ESH 2023 ISH 2020 NYN/DMA/BPL
- 25. Clinical Presentations of Hypertensive Emergency ➢Malignant hypertension ➢Hypertensive encephalopathy ➢Hypertensive thrombotic micro- angiopathy ➢Severe preeclampsia and eclampsia ➢ Severe BP elevation with cerebral hemorrhage ➢Acute stroke ➢ Acute coronary syndrome, ➢Cardiogenic pulmonary edema ➢Aortic dissection ESH 2023 ISH 2020 NYN/DMA/BPL
- 26. Investigations Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 27. Management of HTN Emergencies Clinical presentation Timeline and Target BP First line treatment alternative Malignant hypertension with or without acute renal failure Several hours , MAP-20 to-25% Labetalol, Nicardipine Nitroprusside Urapidil Hypertensive encephalopathy Immediate, MAP-20 to-25% Labetalol, Nicardipine Nitroprusside Acute ischemic stroke and BP >220 mmHg or DBP >120 mmHg 1 h, -15% Labetalol, Nicardipine Nitroprusside Acute ischemic stroke with indication for thrombolytic therapy and SBP >185 mmHg or DBP >110 mmHg 1 h, -15% Labetalol, Nicardipine Nitroprusside Acute hemorrhagic stroke and SBP >180 mmHg Several Hours, 130<SBP <180 Labetalol, Nicardipine Urapidil ESH 2023 ISH 2020 NYN/DMA/BPL
- 28. BP management in acute stroke. (a) Avoid absolute reductions of SBP >60 mmHg from initial SBP. NYN/DMA/BPL
- 29. Clinical presentation Timeline and Target BP First line treatment alternative Acute coronary event Immediate, SBP <140 mmHg Labetalol, Nicardipine Urapidil Acute cardiogenic pulmonary edema Immediate, SBP <140 mmHg Nitroprusside or nitroglycerine (with loop diuretic) Urapidil (with loop diuretic) Acute aortic disease Immediate, SBP <120 mmHg and heart rate <60 bpm Esmolol and nitroprusside or nitroglycerine or nicardipine Labetalol or metoprolol Eclampsia and severe preeclampsia/ HELLP Immediate, SBP <160 mmHg and DBP <105 mmHg Labetalol or nicardipine and magnesium sulphate Management of HTN Emergencies ESH 2023 ISH 2020 NYN/DMA/BPL
- 30. Doses Drug Onset of Action Durati on of Action Dose Contraindications Adverse Effects Labetalol 5 – 10 min 3 – 6 h 10–20 mg i.v. bolus in 1 min; incremental doses ≥20 mg may be administered i.v. at 10 min intervals (max 80 mg) or 1–3 mg/min i.v. infusion until goal BP is reached Second-degree or third-degree AV block, systolic heart failure, asthma, bradycardia Bronchocostriction , Foetal bradycardia Nicardipine 5 – 15 min 4 – 6 h 5–15 mg/h i.v. infusion, starting dose 5 mg/h, increase every 15–30 min with 2.5 mg until goal BP, maximum 15 mg/h Liver failure Headache, reflex tachycardia ESH 2023 ISH 2020 NYN/DMA/BPL
- 31. Drug Onset of Action Durati on of Action Dose Contraindication s Adverse Effects Nitrogly- cerine 1 – 5 min 5 – 10 min 5–200 mg/min i.v. infusion, 5 mg/min increase every 5 min Headache, reflex tachycardia Nitro- prusside Immed iate 1 – 3 min 0.3–0.5 mg/kg/min i.v. infusion, increase by 0.5 mg/ kg/min every 5 min until goal BP (maximum dose 10 mg/kg/min) Liver/kidney failure (relative) Cyanide intoxication Esmolol 1 min 10 -30 min 0.5–1 mg/kg i.v. bolus; 50–300 mg/kg/min i.v. infusion Second-degree or third-degree AV block, systolic heart failure, asthma, bradycardia Bronchoconstri ction, foetal bradycardia Doses ESH 2023 ISH 2020 NYN/DMA/BPL
- 32. Key Points 1. In most patients, treatment should be initiated with an SPC of two drugs to improve the speed, efficiency and predictability of BP control. 2. Although several two-drug combinations can be used, the preferred two-drug combinations should be an RAS blocker with a CCB or a Thiazide/Thiazide-like diuretic. 3. A BB can be used at any step of combination with any drug from the other major drug classes as GDMT or in several other conditions but no longer a first line hypertensive drug. Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL
- 33. Key Points 4. Initial monotherapy is recommended for very-high-risk patients with a high-normal BP as well as (for cautionary reasons) for very old and frail patients. It may also be considered in low-risk patients with stage 1 hypertension whose SBP is more modestly elevated (<150 mmHg). 5. A combination of two antihypertensive agents and a statin at low doses reduced the risk of CV outcomes by 38%. 6. >80% of the patient adhere to combination therapy. Journal of Hypertension : June 21, 2023 doi: 10.1097/HJH.0000000000003480 NYN/DMA/BPL