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  1. 1. HYPERTENSION :Presented by Reda A GowedaFamily medicine department
  2. 2. :Objectives• Definition • BP measurement• Classification techniques• Epidemiology • Evaluation• Benefits of lowering • Prevention BP • Treatment
  3. 3. Definition• Persistent elevation of arterial BP at or more than 140/90.• An initial elevated reading should be confirmed on at least 2 subsequent visits over 1 to several weeks.
  4. 4. the real threshold for defining”“hypertensionmust be considered as flexible, beinghigh or low based on the total CV.risk of each individual
  5. 5. Classification• 1ry & 2ry.• Controlled & Uncontrolled.• Complicated &Uncomplicated.• Systolic & Diastolic.• JNC-7 classification.• European society of hypertension
  6. 6. European society of hypertension
  7. 7. Epidemiology:• HTN prevalence ~ 50 million people in the United States.• 1 billion individuals worldwide.• Egypt has one of the highest prevalence rates in the world (26.3%).• There is age related increase in the prevalence of HTN in Egypt, reaching its peak in the age group 55-64 yrs(59.4%)• The rates of HTN awareness, ttt & control in USA are 70%, 59% &34%.but these rates in Egypt are 37.5% , 23.9% & 8% respectively.
  8. 8. RECOMMENDED BLOOD PRESSURE MEASUREMENT TECHNIQUE 2. 2. ••The cuff must be level with heart. The cuff must be level with heart. ••If arm circumference exceeds 33 cm, If arm circumference exceeds 33 cm, aalarge cuff must be used. large cuff must be used. ••Place stethoscope diaphragm over Place stethoscope diaphragm over brachial artery. brachial artery. 1. 1. 3. 3.••The patient should The patient should Stethoscope ••The column of The column of be relaxed and the be relaxed and the mercury must be mercury must be arm must be arm must be vertical . vertical. supported. supported. Mercury ••Inflate to occlude the••Ensure no tight Inflate to occlude the Ensure no tight machine pulse. Deflate at 2 to clothing constricts pulse. Deflate at 2 to clothing constricts 3 mm/s. Measure the arm. 3 mm/s. Measure the arm. systolic (first sound) systolic (first sound) and diastolic and diastolic (disappearance) to (disappearance) to nearest 2 mm Hg. nearest 2 mm Hg. Continuing Medical© 3 Implementation
  9. 9. :When measuring BP, care should be taken to;Allow the patients to sit quietly for several minutes ■;Take at least two measurements spaced by 1–2 minutes ■(Use a standard bladder (12–13 cm long and 35 cm wide ■but have a larger bladder available for fat arms and a;smaller one for thin arms and childrenHave the cuff at the level of the heart, whatever the■;position of the patient;Deflate the cuff at a speed of 2 mmHg/s■Use phase I and V (disappearance( Korotkoff sounds to ■;identify SBP and DBP, respectivelyMeasure BP in both arms at first visit to detect possible■differences due to peripheral vascular disease. In this;instance, take the higher value as the reference oneMeasure BP 1 and 5 min after assumption of the standing ■position in elderly subjects, diabetic patients, and when;postural hypotension may be frequent or suspected(.Measure heart rate by pulse palpation (at least 30 sec ■
  10. 10. Optimum conditions for measurementRelaxed patientComfortable temperatureQuiet room—no telephones or noises
  11. 11. Posture and position:Measure blood pressure routinely with sitting position Back should be supported. Legs should be uncrossed. Patient should be relaxed. Measure after ten minutes of rest.
  12. 12. Arm supportIf the arm in which blood pressure is being measured isunsupported—as tends to happen when the patient is sitting orstanding—the patient is performing isometric exercise, whichincreases blood pressure by as much as 10%. The armtherefore must be supported during measurement of bloodpressure, especially when the patient is in the standingposition. This is achieved best in practice by the observerholding the patient’s arm at the elbow
  13. 13. Arm positionThe forearm should be at the level of the heart—that is, themid-sternum. Measurement in an arm lower than the level ofthe heart leads to an overestimation of systolic and diastolicpressures, while measurement in an arm above the level of theheart leads to underestimation. Such inaccuracy can be asmuch as 10 mm Hg, especially when the patient is in the sittingor standing position, when the arm is likely to be below heart.level by the side
  14. 14. Cuff hypertensionHowever sophisticated a blood pressure measuring device, if itis dependent on cuff occlusion of the arm (as most devicesare(, it will be prone to the inaccuracy of miscuffing. Thisoccurs when a cuff contains a bladder that is too long or too.short relative to the circumference of the patient’s armMiscuffing is a serious source of error that leads inevitably toincorrect diagnosis in clinical practice and erroneousconclusions in research into hypertension. A further problem isthat inflation of the cuff itself may result in a transient butsubstantial increase (up to 40 mm Hg( in the patient’s blood.pressure
  15. 15. ?Which arm
  16. 16. ?Which armArterial disease can cause differences in blood pressurebetween arms, but because blood pressure varies from beat tobeat, any differences may simply reflect blood pressurevariability or measurement errors, or both. Bilateralmeasurement should be made at the first consultation; ifdifferences 20 mm Hg for systolic or 10 mm Hg for diastolicblood pressure are present on consecutive readings, thepatient should be referred to a cardiovascular centre forfurther evaluation with simultaneous bilateralmeasurement and for the exclusion of arterial disease
  17. 17. AMBULATORY BP,Although office BP should be used as the reference■ambulatory BP may improve prediction of CV risk in.untreated and treated patients,h ambulatory BP monitoring should be considered-24■in particular, whenconsiderable variability of office BP is found■high office BP is measured in subjects otherwise at low■total CV riskthere is a marked discrepancy between BP values■measured in the office and at homeresistance to drug treatment is suspected■hypotensive episodes are suspected, particularly in■elderly and diabetic patie
  18. 18. sleep apnoea is suspected■office BP is elevated in pregnant women and■pre-eclampsia is suspectedNormal values for 24 hour average BP are lowerthan foroffice BP, i.e. 125–130mmHg systolic and 80mmHgdiastolic. Normal values of daytime BP are 130–135mmHg.systolic and 85 mmHg diastolic
  19. 19. HOME BPSelf-measurement of BP at home is of clinical value. Home ■:BP measurements should be encouraged in order toprovide more information on the BP lowering effect of ■treatment at trough, and thus on therapeutic coveragethroughout the dose-to-dose time intervalimprove patient’s adherence to treatment regimens ■understand technical reliability/environmental■conditions of ambulatory BP dataSelf-measurement of BP at home should be discouraged ■:wheneverit causes anxiety to the patient■it induces self-modification of the treatment regimen■,Normal values for home BP are lower than for office BP ■i.e. 130–135mmHg systolic and 85 mmHg diastolic
  20. 20. 0320 Home (Self) Measurement of BP: Specific Role in Selected Patients Which patients? Non adherence Hypertension and diabetes Further assess Normal using Office-induced blood ambulatory pressure elevation Home BP? blood pressure monitoring BP over 135/85 mm Hg should be considered elevated Continuing Medical© Implementation Canadian Hypertension Education Program Recommendations 47
  21. 21. 0320 Home (Self) Measurement of BP: Patient Education How to? Use devices: - appropriate for the individual (cuff size) - have met the standards of the AAMI Adequate patient training in: and or the BHS and or IP - measuring their BP - interpreting these readings Values over 135 / 85 mm Hg should be Regular verifications considered elevated - accuracy of the device - measuring techniques Self measurement can help to improve patient adherence AAMI=Association for the Advancement of Medical Instrumentation; BHS=British Hypertension Society; IP: International Protocol. Continuing Medical© Implementation Canadian Hypertension Education Program Recommendations 48
  22. 22. )HYPERTENSIONOffice BP persistently 140/90mmHgNormal daytime ambulatory (130–135/85mmHg( or home135/85mmHg( BP–130(In these subjects CV risk is less than in individuals withraised office and ambulatory or home BP but may beslightly greater than that of individuals with in and out-ofoffice normotension
  23. 23. )MASKED HYPERTENSION(ISOLATED AMBULATORY HYPERTENSION(Office BP persistently normal (140/90mHgElevated ambulatory (125–130/80 mmHg( or home135/85mmHg( BP–130(In these subjects CV risk is close to that of individualswith in and out-of-office hypertension
  24. 24. DIAGNOSTIC EVALUATIONAIMSEstablishing BP values■Identifying secondary causes of■hypertensionSearching for■;other risk factors■;subclinical organ damage■;concomitant diseases■accompanying CV and renal complications■
  25. 25. DIAGNOSTIC EVALUATION: MEDICAL HISTORY AND PHYSICAL EXAMINATIONFAMILY AND CLINICAL HISTORYDuration and previous level of high BP . 1Indications of secondary hypertension . 2Risk factors. 3Symptoms of organ damage. 4Previous antihypertensive therapy . 5((efficacy, adverse eventsPersonal, family, environmental factors. 6
  26. 26. PHYSICAL EXAMINATIONSSigns suggesting secondary hypertension . 1Signs of organ damage. 2.Evidence of visceral obesity . 3
  27. 27. :Framingham Heart Study.Calculation of the 10-Year CHD Risk in Men and Women
  29. 29. A 72-year-old white female, previously wellcontrolled on a once-dailycombination pill containing atenolol 50 mg andhydrochlorothiazide 25 mg, presentswith a rise in her blood pressure to 170/110. You add5 mg of lisinopril, and hercreatinine rises from 1.1 to 1.9. What do you?suspectA. NonadherenceB. Hypertensive nephrosclerosisC. HyperaldosteronismD. Atherosclerotic renal artery stenosisE. Pheochromocytoma
  30. 30. Answer: D. The recurrence of hypertensionin a previously well-controlled patientshould prompt the clinician to considernonadherence to the medication, as well asasecondary cause of hypertension. The declinein renal function after addition of anangiotensin-converting enzyme inhibitor,however, is most suggestive of bilateralrenal artery stenosis
  31. 31. A 42-year-old obese male returns for follow-up. His last visit with youwas threevyears ago, and since that time his weight has increased by15 kg, such that his BMIis now 32. He reports feeling tired during the day, and has increased hiscoffeevconsumption to four cups per day and his tobacco use to onepack of cigarettes pervday. His blood pressure has increased from136/86 at last visit to 152/90 today. Hevstates that he has not drunkcoffee or smoked in the last six hours. Which of thevfollowing is most?likely to be contributing to his elevated blood pressure at this visitA. Type 2 diabetesB. Excessive licorice consumptionC. Obstructive sleep apneaD. Increased coffee intakeE. Tobacco use
  32. 32. Answer: C. Type 2 diabetes is an important comorbidityin patients withhypertension, but not a cause of hypertension. Excessivelicorice intake is a very rarecause of hypertension. Obstructive sleep apnea is a commonidentifiable cause ofhypertension. Coffee and tobacco use can raise bloodpressure acutely, but do not.increase the risk of development of hypertension
  33. 33. You are treating a 61-year-old man for hypertension. He isnot respondingwell to combination therapy with a thiazide diuretic and a.beta-blockerOn physical examination, you note an abdominal bruit.Which of the following?tests is most likely to help you evaluate him furthera. Chest x-rayb. Captopril renal scanc. Urinary metanephrines and vanillymandelic acid levelsd. Aortic CT scane. Echocardiogram
  34. 34. The answer is b. (Mengel, pp 499–507.) The patientdescribed in thequestion has physical examination findings consistent withrenal arterystenosis. A captopril renal scan or renal magnetic resonanceangiographywould evaluate this. Urinary metanephrines andvanillymandelic acid levelswould help rule out pheochromocytoma. A chest x-ray wouldbe helpfulif coarctation of the aorta were suspected. An aortic CTwould help toor quantify an aortic aneurysm, and an echocardiogram wouldhelp to.identify left ventricular hypertrophy or systolic dysfunction
  35. 35. You are treating a 40-year-old man for hypertension. He isnot respondingwell to a thiazide diuretic, and on further evaluation reportsintermittenttachycardia, diaphoresis, and dizziness upon standing. Whichof the following?tests is most likely to help you evaluate these symptomsa. Chest x-rayb. Captopril renal scanc. Urinary metanephrines and vanillymandelic acid levelsd. Plasma renin activity levelse. Echocardiogram
  36. 36. The answer is c. (Mengel, pp 499–507.) The patient described inthe question has symptoms consistent with pheochromocytoma. The besttest to rule this out is urinary metanephrines and vanillymandelic acid.levels.A chest x-ray would be helpful if coarctation of the aorta were suspectedA captopril renal scan or renal magnetic resonance angiographywould evaluate renal artery stenosis. Plasma renin activity levels wouldidentify primary aldosteronism, and an echocardiogram would help toidentify left ventricular hypertrophy or systolic dysfunction
  37. 37. You are examining a 40-year-old patient forthe first time, and find herblood pressure to be 155/92 mm Hg. Whichof the following physical examinationfindings, if present, would indicate a?secondary cause of hypertensiona. A left-sided carotid bruitb. Distended jugular veinsc. A precordial heaved. Absence of a femoral pulsee. Papilledema
  38. 38. When examining a hypertensivepatient, the physician should be alert for signs of end-organ damage andpossible causes of secondary hypertension. Signs of end-organ damageinclude arteriolar narrowing, hemorrhages, exudates or papilledema,carotidbruits or jugular venous distension, a loud second heart sound orprecordialheave, arrhythmias, absent peripheral pulses, and peripheral edema, justtoname a few. Signs suggestive of secondary hypertension includeabdominal orflank masses (polycystic kidneys(, absence of femoral pulses (coarctationofthe aorta(, tachycardia/flushing/diaphoresis (pheochromocytoma(,abdominalbruits (renal artery stenosis(, pigmented striae (Cushing’s syndrome(, oran(.enlarged thyroid gland (hyperthyroidism
  39. 39. Patient evaluation::History• Risk factors• Symptoms of 2ry HTN• Symptoms of TOD.• Drug history
  40. 40. Examination:• BP• BMI• Fundus Ex• LL• Cardiac ex.• Chest ex.• Abd. Ex.• Thyroid gland ex.
  41. 41. You have just diagnosed a 35-year-old man withhypertension. He isotherwise healthy and has no complaints. Which ofthe following laboratory?tests is not indicated in the initial workupa. Hemoglobin and hematocritb. Potassiumc. A thyroid stimulating hormone leveld. Fasting glucosee. A resting electrocardiogram
  42. 42. The answer is c. (Mengel, pp 499–507.) Baseline laboratoryscreeningis important to assess for end-organ damage and identifypatients athigh risk for cardiovascular complications. The routine testsfor a newlydiagnosed hypertensive patient include: hemoglobin and,hematocritpotassium, creatinine, fasting glucose, calcium, a fasting lipid,profile, urinalysisand a resting electrocardiogram. Other tests are not indicatedunless physical examination or history makes them likely tobe positive
  43. 43. RECOMMENDED TESTSEchocardiogram■Carotid ultrasound■Quantitative proteinuria (if dipstick test ■(positiveAnkle-brachial BP Index■Fundoscopy■Glucose tolerance test (if fasting plasma ■glucose(mmol/L (100 mg/dL 5.6Home and 24 h ambulatory BP monitoring ■
  44. 44. GOALS OF TREATMENTIn hypertensive patients, the primary goal of treatment■is to achieve maximum reduction in the long-term total.risk of CV diseaseThis requires treatment of the raised BP per se as well as■.of all associated reversible risk factorsBP should be reduced to at least below 140/90mmHg■systolic/diastolic(, and to lower values, if tolerated, in(.all hypertensive patientsTarget BP should be at least 130/80 mmHg in patients■with diabetes and in high or very high risk patients, such,as those with associated clinical conditions (stroke(.myocardial infarction, renal dysfunction, proteinuria.
  45. 45. Despite use of combination treatment, reducing systolic■BP to 140mmHg may be difficult and more so if thetarget is a reduction to 130mmHg. Additionaldifficulties should be expected in the elderly, in patientswith diabetes, and in general, in patients with CV.damage,In order to more easily achieve goal BP■antihypertensive treatment should be initiated beforesignificant CV damage develops
  46. 46. You are counseling a 33-year-old obese woman withhypertension. Whichof the following interventions would lower her systolic blood?pressure the mosta. Weight loss amounting to 10% of her total body weightb. Adopting a diet high in fruits, vegetables, and low fat dairyproductsc. Restricting dietary sodiumd. Increasing physical activity at least 30 minutes a day, mostdays of the weeke. Limit alcohol consumption to no more than 1 drink per day
  47. 47. The answer is b. (Mengel, pp 499–507.) While all of the interventions,listed in this question have the potential to lower systolic blood pressurethe DASH diet (described in the landmark study, Dietary Stop Hypertension( has been shown to lower blood pressure the mostThe diet is high in potassium, calcium, and magnesium. The study foundthat diets high in fruits and vegetables, with a reduced content ofsaturatedand total fat can lower systolic blood pressure by 8–14 mm Hg. A 10%weight loss will lower blood pressure by 5–10 mm Hg. Sodiumrestrictionwill lower blood pressure 2–8 mm Hg. Regular aerobic activity is also,beneficiallowering blood pressure by 4–9 mm Hg, and limiting alcohol can.lower systolic blood pressure by 2–4 mm Hg
  48. 48. Pharmacologic treatment
  49. 49. You have seen a 36-year-old man with elevated blood pressure. Onone occasion, his blood pressure was 163/90 mm Hg, and on a secondoccasion, his blood pressure was 158/102 mm Hg. You have encouragedlifestyle modifications including weight loss using exercise and dietarychanges. Despite some modest weight loss, at his current visit, his bloodpressure is 166/92 mm Hg. Which of the following is the best treatment?strategy at this pointa. Use a thiazide diureticb. Use an ACE inhibitorc. Use an angiotensin receptor blockerd. Use a beta-blockere. Use a two drug combination of medications
  50. 50. The answer is e. (Mengel, pp 499–507.) The patient described above hasstage 2 hypertension (systolic blood pressure greater or equal to 160 mm,Hgor diastolic blood pressure greater or equal to 90 mm Hg(. Since lifestylemodificationshave not helped, the next step is to institute drug therapy. JNCguidelines state that in patients with stage 2 hypertension, two-drug 7combinationtherapy is indicated. The most common regimen would be a thiazidediuretic along with either an ACE inhibitor, ARB, beta-blocker, orcalciumchannelblocker
  51. 51. INITIATION OF BP LOWERINGTHERAPYInitiation of BP lowering therapy should be decided on■:two criteriaThe level of SBP and DBP■The level of total CV risk■This is detailed in the Figure 47.2 which considers■treatment based on lifestyle changes and,anti-hypertensive drugs with, in additionrecommendations on the time delay to be used for.assessing the BP lowering effects
  52. 52. :The following points should be emphasizedDrug treatment should be initiated promptly in grade 3■hypertension as well as in grade 1 and 2 when total CV.risk is high or very highIn grade 1 or 2 hypertensives with moderate total CV■risk drug treatment may be delayed for several weeksand in grade 1 hypertensives without any other riskfactor for several months. However, even in thesepatients lack of BP control after a suitable period.should lead to initiation of drug treatment.
  53. 53. When initial BP is in the high normal range the decision■.on drug intervention heavily depends on the level of riskIn the case of diabetes, history of cerebrovascular, coronaryor peripheral artery disease, the recommendation to startBP lowering drugs is justified by the results of controlledtrials. Subjects with BP in the high normal range in whomtotal CV risk is high because of a subclinical organ damageshould be advised to implement intense lifestylemeasures. In these subjects BP should be closelymonitored and drug treatment considered in the presenceof a worsening of the clinical condition
  55. 55. The main benefits of antihypertensive therapy are due■to lowering of BP per seFive major classes of antihypertensive agents–thiazide■,diuretics, calcium antagonists, ACE-inhibitorsblockers–are‫ -ك‬angiotensin receptor blockers andsuitable for the initiation and maintenance of.antihypertensive treatment, alone or in combinationblockers, especially in combination with a thiazide-‫ك‬diuretic, should not be used in patients with themetabolic syndrome or at high risk of incidentdiabetes
  56. 56. In many patients more than one drug is■needed, soemphasis on identification of the first class ofdrugs tobe used is often futile. Nevertheless, there areconditionsfor which there is evidence in favour of somedrugsversus others either as initial treatment or aspart of a.combination
  57. 57. ,The choice of a specific drug or a drug combination■and the avoidance of others should take into account:the followingThe previous favourable or unfavourable experience of■the individual patient with a given class of.compoundsThe effect of drugs on CV risk factors in relation to the■.CV risk profile of the individual patient,The presence of subclinical organ damage■clinical CV disease, renal disease or diabetes, whichmay be more favourably treated by some drugs than.others
  58. 58. The presence of other disorders that may limit theuse.of particular classes of antihypertensive drugsThe possibilities of interactions with drugs used■for.other conditionsThe cost of drugs, either to the individual■patient or to the health provider. However, costconsiderations should never predominate overefficacy, tolerability, and protection of the individualpatient
  59. 59. Continuing attention should be given to side-effects■of drugs, because they are the most importantcause of non-compliance. Drugs are not equal interms of adverse effects, particularly in individual.patientsThe BP lowering effect should last 24 hours. This can be■checked by office or home BP measurements at trough.or by ambulatory BP monitoringDrugs which exert their antihypertensive effect over■hours with a once-a-day administration should be 24preferred because a simple treatment schedule favours.compliance
  61. 61. MONOTHERAPY VERSUS COMBINATION THERAPYRegardless of the drug employed, monotherapy allows■to achieve BP target in only a limited number of.hypertensive patientsUse of more than one agent is necessary to achieve■target BP in the majority of patients. A vast arrayof effective and well tolerated combinations is.availableInitial treatment can make use of monotherapy or■combination of two drugs at low doses with asubsequent increase in drug doses or number, if.needed
  62. 62. Monotherapy could be the initial treatment■for mild BP elevation with low or moderate total CVrisk. A combination of two drugs at low dosesshould be preferred as the first step intreatment when the initial BP is in the grade 2 or 3or total CV risk is high or very high with mild BP.elevationFixed combinations of two drugs can simplify the ■.treatment schedule and favour complianceIn several patients BP control is not achieved by two ■drugs, and a combination of three of more drugs is.required,In uncomplicated hypertensives and in the elderly■antihypertensive therapy should normally be initiatedgradually. In higher risk hypertensives, goal BPshould be achieved more promptly, which favoursinitial combination therapy and quicker adjustment of.doses
  63. 63. Classes&generic Trade Dail Time/ Side effects Compellin Possible Possible Compelling names names y day g indication contraindication contraindication dose indication s s s sI-Diuretics •Isolated systolic ---------- •Dyslipid •Gout HTN e-mia1-Thiazides Hypokalemia (elderly) Hyponatremia •Systolic Hypovolemia HFhydrochlorothiazid Hydrex 12.5 1 Hypochloremic e t. -50 alkalosis Hyperglycemia2-Loop Hyperureicemia Hyperlipidemia hypercalcemiafurosemide Lasix 20- 1-2 tab,amp 3203-K-sparingspironolactone aldacton 25- 2-3 Gynacomastia e 100 hyperkalemia
  64. 64. Classes&gener Trade Dail Time/d Side effects Compelling Possible Possible Compelling ic names names y ay indications indicatio contraindicatio contraindicatio dose ns ns nsII_Adrenergicblockers1-Beta Bronchospas MI HF HF BAblockers m angina Dyslipidemia COPD Sexual P.V.D. Heart blockAtenolol Ateno 25- 1 dysfunction Tenormi 100 Mask s. of n hypoglycemia blokium Enhance s. of P.V.D.propranolol inderal 30- 3-4 Enhance HF 240 Depression dyslipidemiabisoprolol Concor 2.5- 1 (no sexual 10 dysfunction(2-Alpha-betablockerslabetalol 200- 2-3 As beta pheochromocytom As beta blockers 120 blockers a 03-Alphablockers
  65. 65. Classes&generic Trade Daily Time/da Side effects Compellin Possible Possible Compelling names names dose y g indication contraindicatio contraindication indication s ns s sIII_ACE_Icaptopril Capoten 12.5- 2-3 Dry cough HF CRF Renal Pregnancy 150 Hyperkalemi LV DM impairment Renovascular a dysfunctio PVD disease Increase n S.creat.IV-ARBsvalsartan tareg 80- 1 Same as Cough HF PVD Pregnancy 320 ACE-I(no induced by Renovascular dry cough( ACE-I diseaseV-CCBDiltiazem Altiazem 90- 3 Bradycardia Isolated MI migraine HB 360 Dizziness systolic Systolic HF HF HTNNifedipine Epilat 30- 1 Headache 120 Gum huperplasia Ankle edema flushing
  66. 66. You have diagnosed a 39-year-old woman withhypertension. Lifestylemodifications helped reduce her blood pressure, but shewas still above goalYou chose to starthydrochlorothiazide, 25 mg daily. This helped her bloodpressure, but her blood pressure is still 142/94. Which ofthe following is thebest approach to take in this situation?a. Increase her hydrochlorothiazide to 50 mg per dayb. Change to a loop diureticc. Change to an ACE inhibitord. Change to a beta-blockere. Add an ACE inhibitor
  67. 67. The answer is e. (Mengel, pp 499–507.) According to JNC 7guidelines,if the initial agent does not control blood pressure sufficiently, asecondagent of a different class should be added. Keeping both agents atlower doses will decrease side effects. ACE inhibitors anddiuretics workwell together with a relatively low incidence of side effects.
  68. 68. Combination therapy Spironolactone BBDiuretics CCBACE-I verapamil
  69. 69. PATIENTS’ FOLLOW-UPEffective and timely titration to BP control requires■frequent visits in order to timely modify the treatmentregimen in relation to BP changes and the appearance.of side-effectsOnce the target BP has been reached, the frequency of ■visits can be considerably reduced. However, excessivelywide intervals between visits are not advisable because,they interfere with a good doctor-patient relationship.which is crucial for patient’s compliancePatients at low risk or with grade 1 hypertension may be ■seen every 6 months and regular home BP measurementsmay further extend this interval. Visits should be morefrequent in high or very high risk patients. This is the casealso in patients under non-pharmacological treatmentalone due to the variable antihypertensive response and.the low compliance to this intervention
  70. 70. Follow-up visits should aim at maintaining control ofall reversible risk factors as well as at checking the statusof organ damage. Because treatment-induced changes inleft ventricular mass and carotid artery wall thicknessare slow, there is no reason to perform these.examinations at less than 1 year intervalsTreatment of hypertension should be continued for life■because in correctly diagnosed patients cessation oftreatment is usually followed by return to the hypertensivestate. Cautious downward titration of the existingtreatment may be attempted in low risk patients afterlong-term BP control, particularly if non-pharmacologicaltreatment can be successfully implemented
  71. 71. 3 0Recommendations for Follow-up2 0 Diagnosis of hypertension Non Pharmacological treatment With or without Pharmacological treatment Are BP readings below target during 2 consecutive visits? Yes No Follow-up at 3-6 Symptoms, Severe month intervals hypertension, Intolerance to anti-hypertensive treatment or Target Organ Damage Yes No More frequent Monthly visits visits Continuing Medical© Implementation Canadian Hypertension Education Program Recommendations 52
  72. 72. :Referral points• BP .=180/120• S&S of TOD• HTN refractory to outpatient ttt.• 2ry HTN• HTN in pregnancy.
  73. 73. A 42-year-old male patient of yours presented to theemergency departmentwith a stroke. After full recovery, he presents to your office.for follow upAssuming he has no other medical concerns, which of thefollowing medicationsis best to lower his blood pressure and prevent recurrent?strokea. An aldosterone antagonistb. An ACE inhibitorc. An angiotensin receptor blockerd. A calcium-channel blockere. A beta-blocker
  74. 74. The answer is b. (Mengel, pp 499–507.) ThePROGRESS studyPerindopril Protection against Recurrent (Stroke Study( found that an ACEinhibitor and diuretic in combination areeffective in preventing recurrent.stroke
  75. 75. ELDERLY PATIENTS,Drug treatment can be initiated with thiazide diuretics ■,calcium antagonists, angiotensin receptor antagonistsblockers, in line with general‫ -ك‬ACE-inhibitors, andguidelines. Trials specifically addressing treatment ofisolated systolic hypertension have shown the benefit ofthiazides and calcium antagonists but subanalysis ofother trials also show efficacy of angiotensin receptor.blockersInitial doses and subsequent dose titration should be ■more gradual because of a greater chance of undesirable.effects, especially in very old and frail subjects/BP goal is the same as in younger patients, i.e. 140 ■mmHg or below, if tolerated. Many elderly patients 90need two or more drugs to control blood pressure andreductions to 140mmHg systolic may be difficult to.obtain.
  76. 76. ,Drug treatment should be tailored to the risk factors■target organ damage and associated cardiovascular andnon-cardiovascular conditions that are frequent in theelderly. Because of the increased risk of posturalhypotension, BP should always be measured also in the.erect postureIn subjects aged 80 years and over, evidence for benefits■.of antihypertensive treatment is as yet inconclusiveHowever, there is no reason for interrupting a successfuland well tolerated therapy when a patient reachesyears of age 80
  77. 77. DIABETIC PATIENTSWhere applicable, intense non-pharmacological■measures should be encouraged in all patients withdiabetes, with particular attention to weight loss and.reduction of salt intake in type 2 diabetesGoal BP should be 130/80mmHg and■antihypertensive drug treatment may be started already.when BP is in the high normal rangeTo lower BP, all effective and well tolerated drugs can be■used. A combination of two or more drugs is frequently.■needed
  78. 78. Available evidence indicates that lowering BP alsoexertsa protective effect on appearance and progression ofrenal damage. Some additional protection can beobtained by the use of a blocker of thereninangiotensinsystem (either an angiotensin receptor(.antagonist or an ACE-inhibitorA blocker of the renin-angiotensin system should■be aregular component of combination treatment and theone preferred when monotherapy is sufficient
  79. 79. Microalbuminuria should prompt the use of■antihypertensive drug treatment also when initial BP isin the high normal range. Blockers of the reninangiotensinsystem have a pronounced antiproteinuric.effect and their use should be preferredTreatment strategies should consider an intervention■.against all CV risk factors, including a statin,Because of the greater chance of postural hypotension■.BP should also be measured in the erect posture
  80. 80. PATIENTS WITH RENAL DYSFUNCTIONRenal dysfunction and failure are associated with a very ■.high risk of CV eventsProtection against progression of renal dysfunction has■two main requirements: a( strict blood pressure control/mmHg and even lower if proteinuria islg 130/80(day(; b( lowering proteinuria to values as near to.normal as possibleTo achieve the BP goal, combination therapy of several■antihypertensive agents (including loop diuretics( is.usually requiredTo reduce proteinuria, an angiotensin receptor■antagonist, an ACE-inhibitor or a combination of both.are required.
  81. 81. There is controversial evidence as to whether blockade■of the renin-angiotensin system has a specific beneficialrole in preventing or retarding nephro-sclerosis innon-diabetic non-proteinuric hypertensives, except,perhaps in Afro-American individuals. Howeverinclusion of one of these agents in the combinationtherapy required by these patients appears well.founded,An integrated therapeutic intervention (antihypertensive■statin and antiplatelet therapy( has to be frequentlyconsidered in patients with renal damage because, underthese circumstances, CV risk is extremely high
  82. 82. PATIENTS WITH CEREBROVASCULARDISEASEIn patients with a history of stroke or transient■ischaemic attacks, antihypertensive treatmentmarkedly reduces the incidence of stroke recurrenceand also lowers the associated high risk of cardiac.eventsAntihypertensive treatment is beneficial in hypertensive■patients as well as in subjects with BP in the high.normal range. BP goal should be 130/80mmHgBecause evidence from trials suggests that the benefit■largely depends on BP lowering per se, all availabledrugs and rational combinations can be used. Trialdata have been mostly obtained with ACE-inhibitorsand angiotensin receptor antagonists, in associationwith or on the top of diuretic and conventionaltreatment, but more evidence is needed before theirspecific cerebrovascular protective properties are.establishedThere is at present no evidence that BP lowering has a■beneficial effect in acute stroke but more research isunder way. Until more evidence is obtainedantihypertensive treatment should start when
  83. 83. post-stroke clinical conditions are stable, usuallyseveral days after the event. Additional research inthis is necessary because cognitive dysfunction ispresent in about 15% and dementia in 5% of subjects.aged 65 yearsIn observational studies, cognitive decline and■incidence of dementia have a positive relationship withBP values. There is some evidence that both can be.somewhat delayed by antihypertensive treatment
  84. 84. PATIENTS WITH CORONARY HEART DISEASEAND HEART FAILUREIn patients surviving a myocardial infarction, early■blockers, ACE-inhibitors or‫ -ك‬administration ofangiotensin receptor blockers reduces the incidence ofrecurrent myocardial infarction and death. Thesebeneficial effects can be ascribed to the specificprotective properties of these drugs but possibly also to.the associated small BP reductionAntihypertensive treatment is also beneficial in ■hypertensive patients with chronic coronary heartdisease. The benefit can be obtained with differentdrugs and drug combinations (including calciumantagonists( and appears to be related to thedegree of BP reduction. A beneficial effect has beendemonstrated also when initial BP is 140/90mmHgand for achieved BP around 130/80mmHg.or less.
  85. 85. A history of hypertension is common while a raised BP■.is relatively rare in patients with congestive heart failureIn these patients, treatment can make use of thiazide,and loop diuretics, as well as of -blockersACE-inhibitors, angiotensin receptor antagonist andantialdosterone drugs on top of diuretics. Calciumantagonists should be avoided unless needed to control.BP or anginal symptomsDiastolic heart failure is common in patients with a■.history of hypertension and has an adverse prognosisThere is at present no evidence on the superiority ofspecific antihypertensive drugs
  86. 86. ORAL CONTRACEPTIVESEven oral contraceptives with low oestrogencontent areassociated with an increased risk ofhypertension, stroke andmyocardial infarction. The progestogen-onlypill is acontraceptive option for women with high BP,but theirinfluence on cardiovascular outcomes hasbeen insufficiently.investigated
  87. 87. HYPERTENSION IN PREGNANCY,Hypertensive disorders in pregnancy, particularly preeclampsia ■may adversely affect neonatal and maternal.outcomesNon-pharmacological management (including close■supervision and restriction of activities( should beconsidered for pregnant women with SBP 140–149mmHgor DBP 90–95 mmHg. In the presence of gestationalhypertension (with or without proteinuria( drug.treatment is indicated at BP levels 140/ 90mmHgSBP levels 170 or DBP 110 mmHg should be.considered an emergency requiring hospitalization,In non-severe hypertension, oral methyldopa, labetalol■blockers are‫ (-ك‬calcium antagonists and (less frequently.drugs of choice■
  88. 88. ,In pre-eclampsia with pulmonary oedemanitroglycerine is the drug of choice. Diuretic therapy is.inappropriate because plasma volume is reducedAs emergency, intravenous labetalol, oral methyldopa■and oral nifedipine are indicated. Intravenoushydralazine is no longer the drug of choice because ofan excess of perinatal adverse effects. Intravenousinfusion of sodium nitroprusside is useful inhypertensive crises, but prolonged administration.should be avoidedCalcium supplementation, fish oil and low dose aspirin■are not recommended. However, low dose aspirin maybe used prophylactically in women with a history ofearly onset pre-eclampsia
  89. 89. Hypertensive urgenciesSevere uncomplicated essential hypertensionSevere uncomplicated secondary hypertensionPostoperative hypertensionaHypertension associated with severe epistaxisDrug-induced hypertension(Rebound hypertension (i.e., sudden withdrawal of clonidineCessation of prior antihypertensive therapySevere hypertensive crises related to anxiety, panic attacks orpain
  90. 90. HOW TO IMPROVE COMPLIANCEWITH BLOOD PRESSURE LOWERINGTHERAPYInform the patient of the risk of hypertension and the■.benefit of effective treatmentProvide clear written and oral instructions about■.treatmentTailor the treatment regimen to patient’s lifestyle and ■.needsSimplify treatment by reducing, if possible, the number ■.of daily medicamentsInvolve the patient’s partner or family in information■.on disease and treatment plansMake use of self measurement of BP at home and of■.behavioural strategies such as reminder systemsPay great attention to side-effects (even if subtle( and be ■.prepared to timely change drug doses or types, if neededDialogue with patient regarding adherence and be■informed of his/her problems
  91. 91. Provide reliable support system and ■.affordable prices.Arrange a schedule of follow-up visits■
  92. 92. RESISTANT HYPERTENSIONDEFINITIONBP140/90 mmHg despite treatment with at least threedrugs (including a diuretic( in adequate doses andafterexclusion of spurious hypertension such as isolatedofficehypertension and failure to use large cuffs on large.arms
  93. 93. TREATMENT OF ASSOCIATED RISKFACTORSLIPID LOWERING AGENTSAll hypertensive patients with established CV disease or■with type 2 diabetes should be considered for statintherapy aiming at serum total and LDL cholesterol levelsof, respectively, 4.5 mmol/L (175 mg/dL( and.mmol/L (100 mg/dL(, and lower, if possible 2.5Hypertensive patients without overt CV disease but with■high CV risk (20% risk of events in 10 years( shouldalso be considered for statin treatment even if theirbaseline total and LDL serum cholesterol levels are notelevated
  94. 94. ANTIPLATELET THERAPY,Antiplatelet therapy, in particular low-dose aspirin■should be prescribed to hypertensive patients withprevious CV events, provided that there is no excessive.risk of bleedingLow-dose aspirin should also be considered in■hypertensive patients without a history of CV disease ifolder than 50 years and with a moderate increase inserum creatinine or with a high CV risk. In all theseconditions, the benefit-to-risk ratio of this interventionreduction in myocardial infarction greater than the risk(.of bleeding( has been proven favourable,To minimize the risk of haemorrhagic stroke■antiplatelet treatment should