Well understanding HTN

1. CHALLENGE
IN MANAGEMENT OF
HTN
21/05/2018
SAKHAN SOLIDA, MD
Cardiologist
ESC, EHRA and ESH member
Preah Kossamak Hospital
Why BP targets matters ?
Which BP should be targeted ?
How far should BP be lowered ?

2. OUTLINE
1
• Review recent evidence affecting the diagnosis
of
• patients with elevated blood pressure.
1
• Compare and contrast BP targets from various
clinical
• practice hypertension guidelines.
1
• Discuss the therapeutics used in managing
patients with
• hypertension.

3. Global Leading Risks for Death, 2010
Systolic blood
pressure > 115
mmHg
Global Burden of Disease Study 2010 , Lancet 2012; 380: 2224–60

4. • 33% pf adults ➢ 60% increase by 2025(1)
• Worldwide responsible for 1 out of 8 deaths
• Average 5 years loss of life
• Presence of other CV risk factors will “ multiplicative in risk for CV events” (2)
• Most common modifiable CVD risk factor contributes to > 50% of adverse
CVD outcomes (3)
• BP control reduces HF 50%, CVA 40%, MI 25% (4)
HYPERTENSION
(1) Med Clin N Am 16;100;665-93
(2) Circulation 15;131;e435-e70
(3) JAMAD 16;17;571-3,edit
(4) Prim care Clin Office Pract 13;40;179-94

5. BP & CVD risks
Lewington et al. Prospective Studies Collaboration. Lancet. 2002;360:1903-13.

6. 0
5
10
15
20
25
30
35
Normal White coat Uncontrolled Masked
CVeventsper1000patient-year
Okhubo T, et al. J Am Coll Cardiol 2005;46;508-15
The Prognosis of
White Coat and Masked Hypertension

7. Screening for High BP in Adults
• Office BP monitoring (OBPM)
• Automate BP monitoring (AOBP)
• Ambulatory BP monitoring (ABPM) ➢ Record regular intervals
(eg, 20-30mm) over 24-48h
• Home BP measurement (HBPM) ➢ Record BP by automated
oscillometric devices

8. BP Measurement
• HBPM and ABPM correlate better with HTN outcomes than OBPM (5)
• USPSTF considers ABPM to be reference standard for conforming the
diagnosis of HTN
• Accurate BP reading and recognizing white-coat and masked
hypertension is imperative.
- WCH : Intensive therapy ➢ Over treat.
- MHT : No Treatment ➢ Complications.
(5) Mayo Clin Proc 15;90;273-9

9. A very common question :
WHAT IS YOUR BLOOD PRESSURE ?
The correct question should be :
WHAT IS YOUR BLOOD PRESSURE PROFIL ?

11. Target BP and Guidelines
AHA/ACC
2017
SYSTOLICBP
160 mmHg
150 mmHg
140 mmHg
130 mmHg
?

12. • The definition of hypertension was changed from 160/90 mm Hg to
140/90 mm Hg in the 5th report of JNC published in 1993.
• In 2007 the target is reduce to 130/85 mmHg in populations with
stroke, MI or CKD. The revision in 2009 incorporates previous
objective.
• ACC/ AHA (2017) shift in the definition of hypertension from 140/90
mm Hg to 130/80 mm Hg for systolic/diastolic.
Impact of 2017 ACC/AHA Guidelines

13. J Am Coll Cardiol.2017 Nov pii: S0735-1097(17)45519-1
Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†
SBP/DBP ≥130/80 mm Hg or
Self-Reported
Antihypertensive Medication†
SBP/DBP ≥140/90 mm Hg or Self-
Reported Antihypertensive
Medication‡
Overall, crude 46% 32%
Men
(n=4717)
Women
(n=4906)
Men
(n=4717)
Women
(n=4906)
Overall, age-sex
adjusted
48% 43% 31% 32%
Age group, y
20–44 30% 19% 11% 10%
45–54 50% 44% 33% 27%
55–64 70% 63% 53% 52%
65–74 77% 75% 64% 63%
75+ 79% 85% 71% 78%
Race-ethnicity
Non-Hispanic White 47% 41% 31% 30%
Non-Hispanic Black 59% 56% 42% 46%
Non-Hispanic Asian 45% 36% 29% 27%
Hispanic 44% 42% 27% 32%
The prevalence estimates have been rounded to the nearest full percentage.
*130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.
†BP cutpoints for definition of hypertension in the present guideline.
‡BP cutpoints for definition of hypertension in JNC 7.
Adjusted to the 2010 age-sex distribution of the U.S. adult population.
BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health
and Nutrition Examination Survey; and SBP, systolic blood pressure.

17. < 120mmHg interpretation

22. The Lower the better
Vs
J-Curve Phenomenon

23. Bangalore et al, Circulation 2010

24. Bohm et al, Lancet 2017

25. 1. Out of office assessment is
the preferred means of
hypertension Dx
1. Measurement using
electronic
(oscillometric) upper arm
devices is preferred over
auscultation
Hypertension Diagnostic Algorithm
ABPM = ambulatory blood pressure measurement
AOBP = automated office blood pressure
Leung AA, et al. Hypertension Canada’s 2017 Guidelines. Can J Cardiol. 2017.

26. JNC 8 guideline for managing high BP in adults
James PA, et al, JAMA 2014;311(5):507-520
Managing patients with hypertension

27. British NICE Hypertension Treatment Guideline
NICE Pathway last updated: 27 March 2018

28. LIFESTYLE MODIFICATION
Modification Approximate SBP reduction
(range)
Weight reduction 5–20 mmHg/10 kg weight loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
J Am Coll Cardiol.2017 Nov pii: S0735-1097(17)45519-1
Avoid harmful habits ,smoking ,alcohal
Reduce salt and high fat diets
Loose weight , if obese
Regular exercise
DASH
diet

30. TAKE HOME MESSAGES
• We should spend important debated on discussing the ideal BP targets.
• But should not forget to firstly correctly diagnose of the patient.
• Target lower BP value must be balanced by careful monitoring of
adverse effects.
• Lifestyle is important-weight, exercise, DASH
• LET’S TREAT THE PATIENT AND NOT ONLY BP NUMBERS!

31. …Waiting ESC/ESH HTN guideline

32. QUESTIONS...