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Paradigm Shifts inHypertension Management    Dr. Sachin Verma MD, FICM, FCCS, ICFC       Fellowship in Intensive Care Medi...
Paradigm Shifts in         Hypertension Management1. Hypertension is an important global problem;   Controlling it is chal...
Global Burden of Hypertension                       2025 Projection             Year 2000               Year 2025 • 26.4% ...
Long-Term Antihypertensive Therapy       Significantly Reduces CV Events                                                  ...
Consensus Target BP Levels Since JNC 7 in the     Prevention and Management of                Ischemic Heart Disease     A...
Inadequate Control of Hypertension •    New England VA Study         – 800 men; mean age, 66 years, many with comorbid    ...
Inadequate Control of Hypertension                 Clinical Inertia • In 75% of visits documenting elevated blood   pressu...
Therapeutic (Clinical) Inertia?                                                               Causes:                     ...
Value: Early Onset of BP Effect“The trial gives new insights into the clinicalimportance of the rate of achieving BPcontro...
BP Goal Attainment: JNC VII              Expert Roundtable Conclusions“In addition to prescribing the right agent from the...
The Practical Reality of Combination Therapy  Adding another drug provides greater blood  pressure reduction than can be a...
Olmesartan Medoxomil/HCTZ       Reduction in SeSBP                                                       26.8             ...
Need for Combination Therapy                          0                                                   Progress        ...
Lifestyle Modifications
Dietary modifications and exerciseLow calorie diets have modest effect on BP inoverweight individuals (avg. 5-6 mm Hg).Aer...
Limit alcohol consumption  Excessive alcohol consumption is associated with  raised blood pressure, poorer CV and hepatic ...
Initiating Treatment
Offer antihypertensive drug treatment to peopleaged under 80 years with Stage 1 hypertensionwho have one or more of the fo...
For people aged under 40 years withstage 1 hypertension and no evidence oftarget organ damage, CV disease, renaldisease or...
The ABCDE algorithm          Young subjects (<55 yr)      Older subjects (>55 yr)          A or B (if associatedStep I    ...
What is New in Indian Guidelines on       Hypertension - 2013
Due to health related toxic effectsof mercury, mercurysphygmomanometersare being replaced by aneroid anddigital sphygmoman...
Use of beta-blockers as first lineagents in hypertension has recededand these are now recommended asagents for use only in...
Diuretics are now considered at parwith of ACEI’s or ARB’s and calciumchannel blockers and not as preferredagents as in pr...
When blood pressure is high bymore than 20/10 mm of Hg systolicand diastolic it is nowrecommended to start with acombinati...
Certain combinations havebeen shown to be betterthan others in recent trials. Specially ACEI’s/ARB’s incombination with CC...
J shaped curve exist specially fornon revascularised coronary arterydisease patients and caution hasbeen advocated in tryi...
A new form of non pharmacological,interventional sympatheticdenervation therapy has becomerecently available and is beinge...
JNC-8:What Might Be Expected
Either a thiazide-type diuretic, CCB,ACEI/ARB will be recommended as initialdrug therapy for most patients.Direct renin in...
Summary
It makes less difference which antihypertensiveagent is used, unless the patient has a compellingindication for a specific...
The current recommended BP goals inthose with Diabetes and CKD from theADA, NKF, and JNC 7 is   <130/80 mm Hg.
The initial drug chosen will bebroadened to include Thiazide-diuretic,ACEI/ARB, or CCB and mayinclude non-atenolol BB’s.
Most patients will require 2 or moreantihypertensive agents to get BPeffectively controlled which may bebest approached wi...
Hypertension management
Hypertension management
Hypertension management
Hypertension management
Hypertension management
Hypertension management
Hypertension management
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Hypertension management

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Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

Hypertension management

  1. 1. Paradigm Shifts inHypertension Management Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
  2. 2. Paradigm Shifts in Hypertension Management1. Hypertension is an important global problem; Controlling it is challenging; All have room for improvement2. Focus on BP goal attainment– sooner rather than later3. Resort to combination therapy readily4. Prevent or reduce target organ damage V052004
  3. 3. Global Burden of Hypertension 2025 Projection Year 2000 Year 2025 • 26.4% of world adult • 29.2% of world adult population population had hypertension will have hypertension • Total of 972 million adults • Total of 1.56 billion adults (60% ↑ overall; 24% ↑ in developed nations, 80% ↑ in developing nations) • Highest prevalence will be in • Highest prevalence is in economically developing established market continents (eg, Asia, Africa) economies (eg, North – will account for 75% of world’s America, Europe) hypertensive patientsKearney PM et al. Lancet. 2005;365:217-223.
  4. 4. Long-Term Antihypertensive Therapy Significantly Reduces CV Events Myocardial Stroke infarction Heart failure 0 –10 –20 Average reduction –30 20%-25% in events (%) –40 35%-40% –50 >50% –60Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.
  5. 5. Consensus Target BP Levels Since JNC 7 in the Prevention and Management of Ischemic Heart Disease American Heart Association (AHA) Scientific Statement Area of Concern BP Target (mmHg) General CAD prevention <140/90 High CAD risk* <130/80 Stable Angina <130/80 Unstable Angina/NSTEMI <130/80 STEMI <130/80 LV Dysfunction <120/80 *High CAD risk = diabetes mellitus, chronic kidney disease, known CAD, CAD equivalent (carotid artery disease, peripheral artery disease, abdominal aortic aneurysm), or 10-year Framingham risk score >10%Rosendorff et al, Circulation,2007;115: 2761-2788
  6. 6. Inadequate Control of Hypertension • New England VA Study – 800 men; mean age, 66 years, many with comorbid conditions – Mean duration of HTN = 12.6 years – Index visit BP: 146/84 mmHg – Mean of 6.4 hypertension-related visits per year • Followed for two 2 years < 25% reached goal BP < 140/< 90 mm Hg – 40% had BP ≥ 160/≥ 90 mm Hg • Percentage of visits where therapy was increased: – 11.2% overall – 22%, if DBP ≤ 90 mm Hg and SBP ≥ 165 mm Hg – 35% of time when DBP > 90 mmHgBerlowitz et al. N Engl J Med. 1998;339:1957-1963. V052004
  7. 7. Inadequate Control of Hypertension Clinical Inertia • In 75% of visits documenting elevated blood pressure, physicians failed to increase the dose of antihypertensive medications or to try new treatments. • But clinicians did not ignore patients with elevated blood pressure. Follow-up visits occurred 2-3 weeks sooner for patients with poorly controlled hypertension. • Thus, although physicians closely monitored elevated blood pressure, they repeatedly delayed making changes to a patient’s regimen.Berlowitz et al. N Engl J Med. 1998;339:1957-1963. V052004
  8. 8. Therapeutic (Clinical) Inertia? Causes:  Satisfaction with current BP level The failure of  Elevated SBP more acceptable health care  Use of “soft” reasons to avoid providers to intensifying therapy initiate or  Time constraints (15 min visits) intensify  Reluctance to use combination therapies therapy when  Competing priorities indicatedPhillips LS et al. Ann Intern Med. 2001;135:825–834.
  9. 9. Value: Early Onset of BP Effect“The trial gives new insights into the clinicalimportance of the rate of achieving BPcontrol:BP goals need to be reached within arelatively short time (weeks rather thanmonths), at least in patients with hypertensionwho are at high cardiovascular risk.”-VALUE Trial, 2004 Julius S, et al. Lancet. 2004;363(9426):2022-2031.
  10. 10. BP Goal Attainment: JNC VII Expert Roundtable Conclusions“In addition to prescribing the right agent from the start, based on the individual needs of the patient, physicians need to be more aggressive in bringing their patients to goal” -Michael A. Weber, MD; Founder & Past President of The American Society of Hypertension“We want them to attain BP goals while making sure they are adhering to the therapy. The problem is that physicians stopevaluating the patient’s progress toward the targeted BP level” -Jan N. Basile, MD; Review Committee, JNC 7 Adapted from Weber et al., J Clin Hypertens 2004;6:699–705). V112004
  11. 11. The Practical Reality of Combination Therapy Adding another drug provides greater blood pressure reduction than can be achieved by titrating the current drug to a higher dose V052004
  12. 12. Olmesartan Medoxomil/HCTZ Reduction in SeSBP 26.8 27.1 20.6 30 23.0 20.1 16.0 25 15.5 17.4 20 Reduction 17.1 in SeSBP 15 10.7 (mmHg) 10 9.6 40 20 5 3.3 10 Olmesartan 0 0 medoxomil dose 25 12.5 0 (mg/day) HCTZ dose (mg/day)HCTZ = hydrochlorothiazide; SeSBP = seated systolic blood pressureChrysant SG et al. Am J Hypertens 2004; 17(3):252-9.
  13. 13. Need for Combination Therapy 0 Progress HOPE Syst-China -5 PROGRESS-Combo Change in DBP (mm Hg) STOP II-β Syst-EUR RENAAL SHEP -10 IDNT TOMHS EWPHE UKPDS -15 STOP-β INSIGHT ABCD VA II NORDIL -20 HOT <90 HOT <85 -25 HOT <80 VA I -30 0 0.5 1 1.5 2 2.5 3 3.5 4 Number of Antihypertensive AgentsElliott WJ. Curr Hypertens Rep. 2002;4:278–285.
  14. 14. Lifestyle Modifications
  15. 15. Dietary modifications and exerciseLow calorie diets have modest effect on BP inoverweight individuals (avg. 5-6 mm Hg).Aerobic exercise (brisk walking, jogging, or cycling)for 30-60 min., 3-5 times/week, had small effect onBP (2-3 mm Hg). Relaxation therapiesThese activities (stress management, meditation,cognitive therapy, muscle relaxation) reduce byaverage of 3-4 mm Hg.
  16. 16. Limit alcohol consumption Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health. Reducing alcohol can lower BP 3-4 mm Hg.Limiting excessive consumption ofcoffee/caffeineLimit dietary sodium intake < 6 g/day, modest reduction of 2-3 mm Hg.Encourage smoking cessation
  17. 17. Initiating Treatment
  18. 18. Offer antihypertensive drug treatment to peopleaged under 80 years with Stage 1 hypertensionwho have one or more of the following: Target organ damage Established cardiovascular disease Renal disease Diabetes 10-year CV risk equivalent to 20% or greater.Offer antihypertensive drug treatment to peopleof any age with stage 2 hypertension.
  19. 19. For people aged under 40 years withstage 1 hypertension and no evidence oftarget organ damage, CV disease, renaldisease or diabetesConsider specialist evaluation ofsecondary causes ofhypertension and more detailedassessment of potential targetorgan damage.
  20. 20. The ABCDE algorithm Young subjects (<55 yr) Older subjects (>55 yr) A or B (if associatedStep I A and/or C sympathetic hyperactivity)Step 2 Add C or D or both Add D A and C, and/or D, add BStep 3 A or B, C and/or D, add E or E
  21. 21. What is New in Indian Guidelines on Hypertension - 2013
  22. 22. Due to health related toxic effectsof mercury, mercurysphygmomanometersare being replaced by aneroid anddigital sphygmomanometers.
  23. 23. Use of beta-blockers as first lineagents in hypertension has recededand these are now recommended asagents for use only in younghypertensives with specific indications. For routine patients these are nolonger recommended as first lineagents
  24. 24. Diuretics are now considered at parwith of ACEI’s or ARB’s and calciumchannel blockers and not as preferredagents as in previous guidelines.Chlorthalidone is now available andshown to be better thanHydrochlorothiazide and its usage is tobe preferred.
  25. 25. When blood pressure is high bymore than 20/10 mm of Hg systolicand diastolic it is nowrecommended to start with acombination of drugs.Monotherapy is not going to beeffective in achieving target bloodpressure.
  26. 26. Certain combinations havebeen shown to be betterthan others in recent trials. Specially ACEI’s/ARB’s incombination with CCB’sforms a good combination.
  27. 27. J shaped curve exist specially fornon revascularised coronary arterydisease patients and caution hasbeen advocated in trying to lowerblood pressure to low target levelsspecially in these patients.
  28. 28. A new form of non pharmacological,interventional sympatheticdenervation therapy has becomerecently available and is beingevaluated.
  29. 29. JNC-8:What Might Be Expected
  30. 30. Either a thiazide-type diuretic, CCB,ACEI/ARB will be recommended as initialdrug therapy for most patients.Direct renin inhibitors will be recommendedas an additive• Chlorthalidone or indapamide should behighlighted as the evidence-based thiazidetype diuretic of choice
  31. 31. Summary
  32. 32. It makes less difference which antihypertensiveagent is used, unless the patient has a compellingindication for a specific antihypertensive classIt matters more that BP isappropriately reduced tothe chosen BP goal.
  33. 33. The current recommended BP goals inthose with Diabetes and CKD from theADA, NKF, and JNC 7 is <130/80 mm Hg.
  34. 34. The initial drug chosen will bebroadened to include Thiazide-diuretic,ACEI/ARB, or CCB and mayinclude non-atenolol BB’s.
  35. 35. Most patients will require 2 or moreantihypertensive agents to get BPeffectively controlled which may bebest approached with initial combinationtherapy, either as a fixed-dosecombination (FDC) or as 2 individualinitial agents

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