based on ESC 2018 and ACC/AHA 2017

1. Dr. Md. Ahasanul Kabir (Shahin)
Resident, Phase B
UCC, BSMMU

2.  Hypertension is defined as office SBP values ≥140
mmHg and/or diastolic BP (DBP) values ≥ 90 mmHg.

4.  Based on office BP, the global prevalence - 1.13
billion in 2015
 The overall prevalence in adults is around 30 - 45%
with a global age standardized prevalence of 24 and
20% in men and women, respectively, in 2015.
 Prevalence of >60% in people aged >60 years

5. CVD Risk Factors Common in Patients With
Hypertension
*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status,
obstructive sleep apnea, cannot be changed (family history, increased age, male sex), or,
if changed through the use of current intervention techniques, may not reduce CVD risk
(psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
Modifiable Risk Factors* Relatively Fixed Risk Factors†
 Current cigarette smoking,
secondhand smoking
 Diabetes mellitus
 Dyslipidemia/hypercholesterolemia
 Overweight/obesity
 Physical inactivity/low fitness
 Unhealthy diet
 CKD
 Family history
 Increased age
 Low socioeconomic/educational
status
 Male sex
 Obstructive sleep apnea
 Psychosocial stress

6. Category Systolic (mmHg) Diastolic (mmHg)
Optimal <120 and <80
Normal 120–129 and/or 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 <90

7. Categories of BP in Adults*
*Individuals with SBP and DBP in 2 categories should be
designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm
Hg
and <80 mm Hg
Hypertension
Stage 1 130–139 mm
Hg
or 80–89 mm
Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

8. Very high risk People with any of the following:
Documented CVD, either clinical or unequivocal on imaging.
• Clinical CVD includes acute myocardial infarction, acute coronary
syndrome, coronary or other arterial revascularization, stroke, TIA,
aortic aneurysm, and PAD
• Unequivocal documented CVD on imaging includes significant plaque
(i.e. ≥ 50% stenosis) on angiography or ultrasound; it does not include
increase in carotid intima media thickness
• Diabetes mellitus with target organ damage, e.g. proteinuria or a
with a major risk factor such as grade 3 hypertension or
hypercholesterolaemia
• Severe CKD (eGFR <30 mL/min/1.73 m2)
• A calculated 10 year SCORE of ≥10%

9. High risk People with any of the following:
• Marked elevation of a single risk factor, particularly
cholesterol >8 mmol/L (>310 mg/dL), e.g. familial
hypercholesterolaemia or grade 3 hypertension (BP ≥180/110
mmHg)
• Most other people with diabetes mellitus (except some
young people with type 1 diabetes mellitus and without
major risk factors, who may be at moderate-risk)
Hypertensive LVH
Moderate CKD eGFR 30-59 mL/min/1.73 m2)
A calculated 10 year SCORE of 5-10%
Moderate risk People with:
• A calculated 10 year SCORE of 1 to <5%
• Grade 2 hypertension
• Many middle-aged people belong to this category
Low risk People with:
• A calculated 10 year SCORE of <1%

10.  Leading global contributor to premature death in
2015, accounting for almost 10 million deaths and
over 200 million disability-adjusted life years.
 SBP ≥140 mmHg accounts for most of the mortality
and disability burden (70%)
 Largest number of SBP-related deaths per year are
due to IHD (4.9 million), haemorrhagic stroke (2.0
million), and ischaemic stroke (1.5million).

11.  Since 2003, the European Guidelines on CVD
prevention have recommended use of the
Systematic COronary Risk Evaluation (SCORE) system
 The SCORE system estimates the 10 year risk of a
first fatal atherosclerotic event, in relation to age,
sex, smoking habits, total cholesterol level, and SBP.

12. Recommendation Class Level
CV risk assessment with the SCORE system is recommended
for hypertensive patients who are not already at high or very
high risk due to established CVD, renal disease, or diabetes, a
markedly elevated single risk factor (e.g. cholesterol), or
hypertensive LVH
I B

14.  Auscultatory or oscillometric semiautomatic or
automatic sphygmomanometers are the preferred
method for measuring BP in the doctor’s office.
 Both upper arms, using an appropriate cuff size for the
arm circumference.
 A consistent and significant SBP difference between
arms (i.e. >15 mmHg) is associated with an increased
CV risk

15.  In older people, people with diabetes, or people with
other causes of orthostatic hypotension, BP should
also be measured 1 min and 3 min after standing.
 Orthostatic hypotension is defined as a reduction in
SBP of ≥ 20 mmHg or in DBP of ≥10 mmHg within 3
min of standing, and is associated with an increased
risk of mortality and CV events

16. Checklist for Accurate Measurement of BP
Key Steps for Proper BP Measurements
Step 1: Properly prepare the patient.
Step 2: Use proper technique for BP measurements.
Step 3: Take the proper measurements needed for diagnosis and
treatment of elevated BP/hypertension.
Step 4: Properly document accurate BP readings.
Step 5: Average the readings.
Step 6: Provide BP readings to patient.

17. Selection Criteria for BP Cuff Size for Measurement of
BP in Adults
Arm
Circumference
Usual Cuff Size
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigh

18.  Out-of-office BP measurement refers to the use of
either HBPM or ABPM, the latter usually over 24 h

19.  At least 3 days & preferably for 6–7 consecutive days
before each clinic visit, with readings in the morning
and the evening, taken in a quiet room after 5 min of
rest, with the patient seated with their back and arm
supported.
 Diagnostic threshold for hypertension is ≥135/85
mmHg (equivalent to office BP ≥140/90 mmHg)

20.  Avg BP readings over a defined period, usually 24 h.
Programmed to record BP at 15 - 30 min intervals, &
avg BP values are usually provided for daytime, night-
time, and 24 h.
 Patient’s activities diary & sleep time can be recorded.
 Diagnostic threshold for HTN is ≥130/80 mmHg over 24
h, ≥ 135/85 mmHg for the daytime average, and ≥
120/70 for the nighttime average (all equivalent to
office BP ≥ 140/90 mmHg)

22. BP Patterns Based on Office and Out-of-Office
Measurements
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Office/Clinic/Healthcare
Setting
Home/Nonhealthcare/
ABPM Setting
Normotensive No hypertension No hypertension
Sustained
hypertension
Hypertension Hypertension
Masked
hypertension
No hypertension Hypertension
White coat
hypertension
Hypertension No hypertension

23. ABPM HBPM
Advantages
o Can identify white-coat and masked
hypertension
o Stronger prognostic evidence
o Night-time readings
o Measurement in real-life settings
o Additional prognostic BP phenotypes
o Abundant information from a single
measurement session, including
o short-term BP variability
Advantages
o Can identify white-coat and masked
hypertension
o Cheap and widely available
o Measurement in a home setting, which
may be more relaxed than the doctor’s
office
o Patient engagement in BP measurement
o Easily repeated and used over longer
periods to assess day-to-day BP
o variability
Disadvantages
o Expensive and sometimes limited
availability
o Can be uncomfortable
Disadvantages
o Only static BP is available
o Potential for measurement error
o No nocturnal readings

24.  White-coat hypertension - untreated condition in
which BP is elevated in the office, but is normal
when measured by ABPM, HBPM, or both
 Masked hypertension - untreated patients in whom
the BP is normal in the office, but is elevated when
measured by HBPM or ABPM.

25.  ‘True normotension’ is used when both office and
out-of-office BP measurements are normal
 ‘Sustained hypertension’ is used when both are
abnormal.
 In white-coat hypertension, the difference between
the higher office and the lower out-of-office BP is
referred to as the‘white-coat effect’,

26.  Up to 30 - 40% of people (and >50% in the very old)
with an elevated office BP.
 More common with increasing age, in women, and in
non-smokers

27.  Can be found in approximately 15% of patients with
a normal office BP.
 Prevalence is greater in
- younger people
- Men
- Smokers
- higher levels of physical activity
- alcohol consumption
- Anxiety
- job stress.

28.  Obesity, DM, CKD, F/H of HTN & high–normal office
BP associated with an increased prevalence of
masked hypertension.
 Masked hypertension is associated with
- Dyslipidaemia and Dysglycaemia
- HMOD
- adrenergic activation
- increased risk of developing diabetes and sustained
hypertension.

29.  Meta-analyses and recent studies have shown that
the risk of CV events is substantially greater in
masked hypertension compared with normotension,
and close to or greater than that of sustained
hypertension.

31. From: 2018 ESC/ESH Guidelines for the management of arterial hypertension
Eur Heart J. 2018;39(33):3021-3104. doi:10.1093/eurheartj/ehy339
Eur Heart J | This article has been co-published in the European Heart Journal (doi: 10.1093/eurheartj/ehy339) and
Journal of Hypertension (doi:10.1097/HJH. 10.1097/HJH.0000000000001940), and in a shortened version in Blood
Pressure. All rights reserved. ©European Society of Cardiology and European Society of Hypertension 2018. The
articles in European Heart Journal and Journal of Hypertension are identical except for minor stylistic and spelling
differences in keeping with each journal's style. Any citation can be used when citing this article.This article is

32. Conditions in which white-coat hypertension is more common, e.g.:
• Grade I hypertension on office BP measurement
• Marked office BP elevation without HMOD
Conditions in which masked hypertension is more common, e.g.:
• High–normal office BP
• Normal office BP in individuals with HMOD or at high total CV risk
Postural and post-prandial hypotension in untreated and treated patients
Evaluation of resistant hypertension
Evaluation of BP control, especially in treated higher-risk patients
Exaggerated BP response to exercise
When there is considerable variability in the office BP
Evaluating symptoms consistent with hypotension during treatment
Specific indications for ABPM rather than HBPM:
• Assessment of nocturnal BP values and dipping status (e.g. suspicion of nocturnal hypertension,
such as in sleep apnoea, CKD, diabetes, endocrine hypertension, or autonomic dysfunction)

34.  Medical history
o Risk factors
o History and symptoms of HMOD, CVD, stroke, and renal
disease
o History of possible secondary hypertension
o Antihypertensive Drug Treatment

35.  Body habitus
 Signs of HMOD
 Secondary hypertension

36. o Haemoglobin and/or haematocrit
o Fasting blood glucose and glycated HbA1c
o Blood lipids: total cholesterol, LDL cholesterol, HDL cholesterol
o Blood triglycerides
o Blood potassium and sodium
o Blood uric acid
o Blood creatinine and eGFR
o Blood liver function tests
o Urine analysis: microscopic examination; urinary protein by dipstick
test or, ideally, albumin:creatinine ratio
o 12-lead ECG

37.  Basic screening tests for HMOD
12-lead ECG
Urine albumin:creatinine ratio
Blood creatinine and eGFR
Fundoscopy
 More detailed screening for HMOD
Echocardiography
Carotid ultrasound
Abdominal ultrasound and Doppler studies
Pulse wave velocity (PWV)
ABI
Cognitive function testing
Brain imaging

38.  Patients in whom secondary hypertension is
suspected
 Younger patients (<40 years) with grade 2 or more
severe hypertension in whom secondary
hypertension should be excluded
 Patients with treatment-resistant hypertension

39.  Patients in whom more detailed assessment of
HMOD would influence treatment decisions
 Patients with sudden onset of hypertension when BP
has previously been normal
 Other clinical circumstances in which the referring
doctor feels more specialist evaluation is required.

41.  Meta-analyses of RCTs shown that a 10 mmHg
reduction in SBP or a 5 mmHg reduction in DBP is
associated with significant reductions in
- all major CV events by 20%,
- all-cause mortality by 10 - 15%,
- stroke by 35%,
- coronary events by 20%, and
- heart failure by 40%.

42.  Grade 2 or 3 HTN should receive antihypertensive drug
treatment alongside lifestyle interventions.
 Patients with grade 1 HTN and high CV risk or HMOD
should be treated with BP-lowering drugs.
 Whether BP-lowering drugs should be offered to patients
with grade 1 hypertension and low–moderate CV risk or
grade 1 hypertension in older patients (>60 years), or the
need for BP-lowering drug treatment in patients with
high–normal BP levels.

43. Initiation of blood pressure-lowering treatment (lifestyle changes
and medication) at different initial office blood pressure levels.

46. Recommendations Class Level
It is recommended that the first objective of treatment should be to lower BP to <140/ 90
mmHg in all patients and, provided that the treatment is well tolerated, treated BP values
should be targeted to 130/80 mmHg
or lower in most patients.
I I A
In patients <65 years receiving BP-lowering drugs, it is recommended that SBP should be
lowered to a BP range of 120–129 mmHg in most patients.
I I A
In older patients (aged >_65 years) receiving BP-lowering drugs:
• It is recommended that SBP should be targeted to a BP range of 130–139 mmHg.
• Close monitoring of adverse effects is recommended.
• These BP targets are recommended for patients at any level of CV risk and in patients
with and without established CVD.
I
I A
I C
I A
DBP target of <80 mmHg should be considered for all hypertensive patients, independent
of the level of risk and comorbidities.
IIa B
ESC/ESH 2018

48. Non pharmacological Interventions
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Weight loss is recommended to reduce BP in adults
with elevated BP or hypertension who are overweight
or obese.
I A
A heart-healthy diet, such as the DASH (Dietary
Approaches to Stop Hypertension) diet, that facilitates
achieving a desirable weight is recommended for
adults with elevated BP or hypertension.
I A
Sodium reduction is recommended for adults with
elevated BP or hypertension.
I A
Potassium supplementation, preferably in dietary
modification, is recommended for adults with elevated
BP or hypertension, unless contraindicated by the
presence of CKD or use of drugs that reduce
potassium excretion.

49. Nonpharmacological Interventions (cont.)
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Increased physical activity with a structured
exercise program is recommended for adults with
elevated BP or hypertension.
I A
Adult men and women with elevated BP or
hypertension who currently consume alcohol should
be advised to drink no more than 2 and 1 standard
drinks* per day, respectively.
*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which
is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine
(usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

50. Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension*
Nonpharmacologi
-cal Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.
-5 mm Hg -2/3 mm Hg
Healthy diet DASH dietary
pattern
Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
-11 mm Hg -3 mm Hg
Reduced intake
of dietary
sodium
Dietary sodium Optimal goal is <1500 mg/d, but aim
for at least a 1000-mg/d reduction in
most adults.
-5/6 mm Hg -2/3 mm Hg
Enhanced
intake of
dietary
potassium
Dietary
potassium
Aim for 3500–5000 mg/d, preferably
by consumption of a diet rich in
potassium.
-4/5 mm Hg -2 mm Hg
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.
Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?
Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to.
Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

51. Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension* (cont.)
Nonpharmacologica
l Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Physical
activity
Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
-5/8 mm Hg -2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
-4 mm Hg -2 mm Hg
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
-5 mm Hg -4 mm Hg
Moderation
in alcohol
intake
Alcohol
consumption
In individuals who drink alcohol,
reduce alcohol† to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
-4 mm Hg -3 mm
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz
of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

54. Core drug treatment strategy for uncomplicated hypertension.

55. Drug treatment strategy for hypertension and coronary artery disease.

56. Drug treatment strategy for hypertension and chronic kidney disease.

57. Drug treatment strategy for hypertension and hear failure with reduced ejection
fraction.

58. Drug treatment strategy for hypertension and atrial fibrillation

61.  Hypertension is defined as resistant to treatment
when the recommended treatment strategy fails to
lower office SBP and DBP values to <140 mmHg
and/or <90 mmHg, respectively, and the inadequate
control of BP is confirmed by ABPM or HBPM in
patients whose adherence to therapy has been
confirmed.

62.  prevalence rates range from 5–30% in patients with
treated hypertension.
 After applying a strict definition and having excluded
causes of pseudo resistant hypertension, the true
prevalence of resistant hypertension is likely to be
<10% of treated patients.
 Patients with resistant hypertension are at higher
risk of HMOD, CKD, and premature CV events.

63.  Several possible causes of pseudo-resistant
hypertension should be evaluated and ruled out
before concluding that the patient has resistant
hypertension:
 Poor adherence to prescribed medicines
 White-coat phenomenon
 Poor office BP measurement technique
 Marked brachial artery calcification
 Clinician inertia

64.  Lifestyle factors, such as obesity or large gains in weight,
excessive alcohol consumption, and high sodium intake.
 Intake of vasopressor or sodium-retaining substances, drugs
prescribed for conditions other than hypertension, some
herbal remedies, or recreational drug use (cocaine, anabolic
steroids, etc.)
 Obstructive sleep apnoea (usually, but not invariably,
associated with obesity
 Undetected secondary forms of hypertension
 Advanced HMOD, particularly CKD or large-artery stiffening.

66. Recommendations Class Level
It is recommended that hypertension be defined as resistant to treatment (i.e.
resistant hypertension) when:
• Optimal doses (or best-tolerated doses) of an appropriate therapeutic strategy,
which should include a diuretic (typically an ACE inhibitor or an ARB with a CCB
and a thiazide/ thiazide-type diuretic), fails to lower clinic SBP and DBP values to
<140 mmHg and/or <90 mmHg, respectively; and
• The inadequate control of BP has been confirmed by ABPM or HBPM; and
• After exclusion of various causes of pseudo-resistant hypertension (especially
poor medication adherence) and secondary hypertension.
I C
Recommended treatment of resistant hypertension is:
• Reinforcement of lifestyle measures, especially sodium restriction.395
• Addition of low-dose spironolactonec to existing treatment;
• Or the addition of further diuretic therapy if intolerant to spironolactone, with
either eplerenone, amiloride, a higher dose thiazide/thiazide-like diuretic, or a
loop diuretic;
• Or the addition of bisoprolol or doxazosin.
I B

67. Causes of Secondary Hypertension With Clinical
Indications
Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly

69.  Hypertension emergencies are situations in which
severe hypertension (grade 3) is associated with
acute HMOD, which is often life threatening and
requires immediate but careful intervention to lower
BP, usually with intravenous (i.v.) therapy.
 Typical presentations of a hypertension emergency
are: