SlideShare a Scribd company logo
CASO CLÍNICO HAS
■ Hombre de 48 años.
■ Acude a evaluación de rutina
■ Niega antecedentes relevantes. Asintomático
■ TA 145/95, peso 95 kg (IMC)
■ Dice estar “nervioso y agitado” por la visita
■ Acude una semana después, con bitácora de
automonitoreo
■ TA 160/100
PREGUNTA 1. ¿Cuál es el primer paso
en el tratamiento ?
■ A. Tiazidas
■ B. Inhibidores de la enzima convertidora de
angiotensina (IECAs)
■ C. Betabloqueo selectivo.
■ D. Modificación de estilo de vida
■ E. Envío a urgencias
PREGUNTA 2. ¿Qué otra opción de
tratamiento agregaría al paciente?
■ A. Tiazidas
■ B. Minoxidil
■ C. Betabloqueador selectivo
■ D. Modificacion de estilo de Vida
■ E. Bloqueador ARA-2
PREGUNTA 3. Un 30% de la población no se
controlará con lo seleccionado. ¿Qué se debe
realizar?
■ A. Agregar un segundo medicamento
■ B. Cambiar por otro medicamento
■ C. Mantener el mismo medicamento
■ D. Incrementar la dosis
■ E. Enviar a 3er Nivel para rastreo de Hipertensión
secundaria
PREGUNTA 4. Otro paciente con antecedente
de IAM,HAS, EPOC. ¿Mejor opción de
tratamiento inicial?
■ A. Tiazidas
■ B. Alfa-Metildopa
■ C. Betabloqueador selectivo
■ D. Antagonista de canal de calcio
■ E. Diurético de asa.
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
Detection of White Coat Hypertension or Masked
Hypertension in Patients Not on Drug Therapy
Colors correspond to Class of Recommendation in Table 1.
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM,
home blood pressure monitoring.
Detection of White Coat Effect or Masked Uncontrolled Hypertension
in Patients on Drug Therapy
Colors correspond to Class of Recommendation in Table 1.
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and
HBPM, home blood pressure monitoring.
Office BP
≥5–10 mm Hg
above goal on
≥3 agents
Continue titrating
therapy
Yes
Screening
not necessary
(No Benefit)
Screen for
white coat effect with
HBPM
(Class IIb)
White coat effect:
Confirm with ABPM
(Class IIa)
No
Yes
HBPM BP
at goal
No
Increased
CVD risk or
target organ
damage
Continue current
therapy
(Class IIa)
Yes
Screening
not necessary
(No Benefit)
Screen for
masked uncontrolled
hypertension with HBPM
(Class IIb)
Masked uncontrolled
hypertension:
Intensify therapy
(Class IIb)
No
Yes
HBPM BP
above goal
No
Yes No
Detection of white coat effect or masked uncontrolled
hypertension in patients on drug therapy
Office BP
at goal
ABPM BP
above goal
Screening for Secondary Hypertension
Colors correspond to Class of Recommendation in Table 1 .
TOD indicates target organ damage (e.g., cerebrovascular disease,
hypertensive retinopathy, left ventricular hypertrophy, left ventricular
dysfunction, heart failure, coronary artery disease, chronic kidney disease,
albuminuria, peripheral artery disease).
New-onset or uncontrolled hypertension in adults
Referral not
necessary
(No Benefit)
Refer to cli nician with
speci fic experti se
(Class IIb)
No
Yes
Screening not
indicated
(No Benefit)
Screen for
seco ndary hypertension
(Class I)
(see Table 13)
Yes No
Positive
screening test
Cond itions
• Drug-resi stant/induced hypertension
• Abrupt onset of hypertension
• Onset of hypertension at <30 y
• Exacerbation of previously controlled hypertension
• Disproportionate TOD for degree of hypertensi on
• Accelerated/malignant hypertension
• Onset of diastolic hypertension in older adul ts (age ≥65 y)
• Unprovoked or excessive hypokalemia
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
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
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).
Basic and Optional Laboratory Tests for Primary
Hypertension
Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
*May be included in a comprehensive metabolic panel.
eGFR indicates estimated glomerular filtration rate.
Blood Pressure (BP) Thresholds and Recommendations for
Treatment and Follow-Up (continued on next slide)
Normal BP
(BP <120/80
mm Hg)
Promote optimal
lifestyle habits
Elevated BP
(BP 120–129/<80
mm Hg)
Stage 1 hypertension
(BP 130–139/80-89
mm Hg)
Nonpharmacologic
therapy
(Class I)
Reassess in
3–6 mo
(Class I)
Reassess in
1 mo
(Class I)
Nonpharmacologic
therapy and
BP-lowering medication
(Class I)
Reassess in
1 y
(Class IIa)
Clinical ASCVD
or estimated 10-y CVD risk
≥10%*
Yes
No
Nonpharmacologic
therapy
(Class I)
BP thresholds and recommendations for treatment and follow-up
Nonpharmacologic therapy
and
BP-lowering medication†
(Class I)
Reassess in
3–6 mo
(Class I)
Stage 2 hypertension
(BP ≥ 140/90 mm Hg)
Colors correspond to Class of Recommendation in Table 1.
*Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM or CKD are automatically placed in the high-
risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4
weeks after initiating therapy.
†Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different
classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and
subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement,
detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms), identification of white coat
hypertension or a white coat effect, documentation of adherence, monitoring of the response to therapy, reinforcement of
the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP
target.
3–6 mo
(Class I)
BP goal met
No Yes
Reassess in
3–6 mo
(Class I)
Assess and
optimize
adherence to
therapy
Consider
intensification of
therapy
Reassess in
1 mo
(Class I)
BP-lowering medication
(Class I)
1 y
(Class IIa)
therapy
(Class I)
BP-lowering medication†
(Class I)
Reassess in
3–6 mo
(Class I)
Follow-Up After Initial BP Evaluation
COR LOE
Recommendations for Follow-Up After Initial BP
Elevation
I B-R
Adults with an elevated BP or stage 1 hypertension who
have an estimated 10-year ASCVD risk less than 10%
should be managed with nonpharmacological therapy and
have a repeat BP evaluation within 3 to 6 months.
I B-R
Adults with stage 1 hypertension who have an estimated
10-year ASCVD risk of 10% or higher should be managed
initially with a combination of nonpharmacological and
antihypertensive drug therapy and have a repeat BP
evaluation in 1 month.
I B-R
Adults with stage 2 hypertension should be evaluated by
or referred to a primary care provider within 1 month of
the initial diagnosis, have a combination of
nonpharmacological and antihypertensive drug therapy
(with 2 agents of different classes) initiated, and have a
repeat BP evaluation in 1 month.
Follow-Up After Initial BP Evaluation (cont.)
COR LOE
Recommendations for Follow-Up After Initial BP
Elevation
I B-R
For adults with a very high average BP (e.g., SBP ≥180
mm Hg or DBP ≥110 mm Hg), evaluation followed by
prompt antihypertensive drug treatment is recommended.
IIa C-EO
For adults with a normal BP, repeat evaluation every year
is reasonable.
BP Goal for Patients With Hypertension
COR LOE
Recommendations for BP Goal for Patients
With Hypertension
I
SBP:
B-RSR
For adults with confirmed hypertension and known
CVD or 10-year ASCVD event risk of 10% or higher
a BP target of less than 130/80 mm Hg is
recommended.
DBP:
C-EO
IIb
SBP:
B-NR
For adults with confirmed hypertension, without
additional markers of increased CVD risk, a BP
target of less than 130/80 mm Hg may be
reasonable.
DBP:
C-EO
SR indicates systematic review.
Choice of Initial Medication
COR LOE Recommendation for Choice of Initial Medication
I ASR
For initiation of antihypertensive drug therapy, first-
line agents include thiazide diuretics, CCBs, and
ACE inhibitors or ARBs.
SR indicates systematic review.
Choice of Initial Monotherapy Versus Initial Combination
Drug Therapy
COR LOE
Recommendations for Choice of Initial Monotherapy
Versus Initial Combination Drug Therapy*
I C-EO
Initiation of antihypertensive drug therapy with 2 first-line
agents of different classes, either as separate agents or in
a fixed-dose combination, is recommended in adults with
stage 2 hypertension and an average BP more than 20/10
mm Hg above their BP target.
IIa C-EO
Initiation of antihypertensive drug therapy with a single
antihypertensive drug is reasonable in adults with stage 1
hypertension and BP goal <130/80 mm Hg with dosage
titration and sequential addition of other agents to achieve
the BP target.
Follow-Up After Initiating Antihypertensive Drug
Therapy
COR LOE
Recommendation for Follow-Up After Initiating
Antihypertensive Drug Therapy
I B-R
Adults initiating a new or adjusted drug regimen for
hypertension should have a follow-up evaluation of
adherence and response to treatment at monthly intervals
until control is achieved.
Management of Hypertension in Patients With SIHD
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker;
BP, blood pressure; CCB, calcium channel blocker; GDMT, guideline-directed
management and therapy; and SIHD, stable ischemic heart disease.
Hypertension With SIHD
Reduce BP to <130/80 mm Hg with
GDMT beta blockers*, ACE inhibitor, or ARBs†
(Class I)
Add
dihydropyridine CCBs
if needed
(Class I)
Add
dihydropyridine CCBs,
thiazide-type diuretics,
and/or MRAs as needed
(Class I)
Angina
pectoris
No
BP goal not met
Yes
Colors correspond to Class of Recommendation in Table 1.
*GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate,
nadolol, bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta
blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events.
†If needed for BP control.
Heart Failure With Reduced Ejection Fraction
COR LOE
Recommendations for Treatment of Hypertension
in Patients With HFrEF
I C-EO
Adults with HFrEF and hypertension should be prescribed
GDMT titrated to attain a BP of less than 130/80 mm Hg.
III: No
Benefit
B-R
Nondihydropyridine CCBs are not recommended in the
treatment of hypertension in adults with HFrEF.
Chronic Kidney Disease
COR LOE
Recommendations for Treatment of Hypertension
in Patients With CKD
I
SBP:
B-RSR
Adults with hypertension and CKD should be treated to a BP
goal of less than 130/80 mm Hg.
DBP:
C-EO
IIa B-R
In adults with hypertension and CKD (stage 3 or higher or
stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g
albumin-to-creatinine ratio or the equivalent in the first
morning void]), treatment with an ACE inhibitor is
reasonable to slow kidney disease progression.
IIb C-EO
In adults with hypertension and CKD (stage 3 or higher or
stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g
albumin-to-creatinine ratio in the first morning void]),
treatment with an ARB may be reasonable if an ACE
inhibitor is not tolerated.
SR indicates systematic review.
Management of Hypertension in Patients With CKD
•Colors correspond to Class of Recommendation in Table 1.
•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g
creatinine.
•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP
blood pressure; and CKD, chronic kidney disease.
Treatment of hypertension in patients with CKD
Albuminuria
(≥300 mg/d or ≥300 mg/g
creatinine)
ACE inhibitor*
(Class IIa)
Yes
Usual “first-line”
medication choices
ACE inhibitor
(Class IIa)
ARB*
(Class IIb)
No
Yes
ACE inhibitor
intolerant
No
BP goal <130/80 mm Hg
(Class I)
Hypertension After Renal Transplantation
COR LOE
Recommendations for Treatment of Hypertension
After Renal Transplantation
IIa
SBP:
B-NR
After kidney transplantation, it is reasonable to treat patients
with hypertension to a BP goal of less than 130/80 mm Hg.
DBP:
C-EO
IIa B-R
After kidney transplantation, it is reasonable to treat patients
with hypertension with a calcium antagonist on the basis of
improved GFR and kidney survival.
Acute Intracerebral Hemorrhage
COR LOE
Recommendations for Management of Hypertension
in Patients With Acute Intracerebral Hemorrhage (ICH)
IIa C-EO
In adults with ICH who present with SBP greater than 220 mm
Hg, it is reasonable to use continuous intravenous drug infusion
and close BP monitoring to lower SBP.
III:
Harm
A
Immediate lowering of SBP to less than 140 mm Hg in adults
with spontaneous ICH who present within 6 hours of the acute
event and have an SBP between 150 mm Hg and 220 mm Hg is
not of benefit to reduce death or severe disability and can be
potentially harmful.
Management of Hypertension in Patients With Acute ICH
Colors correspond to Class of Recommendation in Table 1.
BP indicates blood pressure; ICH, intracerebral hemorrhage; IV,
intravenous; and SBP, systolic blood pressure.
Acute (<6 h from symptom onset)
spontaneous ICH
SBP lowering to
<140 mm Hg
(Class III:Harm)
SBP lowering with
continuous IV infusion and
close BP monitoring
(Class IIa)
SBP 150–220 mm Hg SBP >220 mm Hg
Acute Ischemic Stroke
COR LOE
Recommendations for Management of Hypertension
in Patients With Acute Ischemic Stroke
I B-NR
Adults with acute ischemic stroke and elevated BP who are
eligible for treatment with intravenous tissue plasminogen
activator should have their BP slowly lowered to less than
185/110 mm Hg before thrombolytic therapy is initiated.
I B-NR
In adults with an acute ischemic stroke, BP should be less than
185/110 mm Hg before administration of intravenous tissue
plasminogen activator and should be maintained below
180/105 mm Hg for at least the first 24 hours after initiating
drug therapy.
IIa B-NR
Starting or restarting antihypertensive therapy during
hospitalization in patients with BP greater than 140/90 mm Hg
who are neurologically stable is safe and reasonable to
improve long-term BP control, unless contraindicated.
Acute Ischemic Stroke (cont.)
COR LOE
Recommendations for Management of Hypertension
in Patients With Acute Ischemic Stroke
IIb C-EO
In patients with BP of 220/120 mm Hg or higher who did not
receive intravenous alteplase or endovascular treatment and
have no comorbid conditions requiring acute antihypertensive
treatment, the benefit of initiating or reinitiating treatment of
hypertension within the first 48 to 72 hours is uncertain. It
might be reasonable to lower BP by 15% during the first 24
hours after onset of stroke.
III:
No
Benefit
A
In patients with BP less than 220/120 mm Hg who did not
receive intravenous thrombolysis or endovascular treatment
and do not have a comorbid condition requiring acute
antihypertensive treatment, initiating or reinitiating treatment of
hypertension within the first 48 to 72 hours after an acute
ischemic stroke is not effective to prevent death or
dependency.
Management of Hypertension in Patients With Acute Ischemic Stroke
Colors correspond to Class of Recommendation in Table 1.
BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP,
systolic blood pressure.
Acute (<72 h from symptom onset) ischemic
stroke and elevated BP
Yes
Initiating or reinitiating treatment of
hypertension within the first 48-72
hours after an acute ischemic stroke is
ineffective to prevent death or
dependency
(Class III: No Benefit)
Lower SBP to <185 mm Hg and
DBP <110 mm Hg before
initiation of IV thrombolysis
(Class I)
Lower BP 15%
during first 24 h
(Class IIb)
Patient
qualifies for IV
thrombolysis
therapy
BP ≤220/110 mm Hg BP >220/110 mm Hg
For preexisting hypertension,
reinitiate antihypertensive drugs
after neurological stability
(Class IIa)
Maintain BP <180/105 mm Hg for
first 24 h after IV thrombosis
(Class I)
No
And
Diabetes Mellitus
COR LOE
Recommendations for Treatment of Hypertension in
Patients With DM
I
SBP:
B-RSR
In adults with DM and hypertension, antihypertensive drug
treatment should be initiated at a BP of 130/80 mm Hg or
higher with a treatment goal of less than 130/80 mm Hg.
DBP:
C-EO
I ASR
In adults with DM and hypertension, all first-line classes of
antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs,
and CCBs) are useful and effective.
IIb B-NR
In adults with DM and hypertension, ACE inhibitors or ARBs
may be considered in the presence of albuminuria.
SR indicates systematic review.
Valvular Heart Disease
COR LOE
Recommendations for Treatment of Hypertension in
Patients With Valvular Heart Disease
I B-NR
In adults with asymptomatic aortic stenosis, hypertension
should be treated with pharmacotherapy, starting at a low dose
and gradually titrating upward as needed.
IIa C-LD
In patients with chronic aortic insufficiency, treatment of systolic
hypertension with agents that do not slow the heart rate (i.e.,
avoid beta blockers) is reasonable.
Aortic Disease
COR LOE
Recommendation for Management of Hypertension
in Patients With Aortic Disease
I C-EO
Beta blockers are recommended as the preferred
antihypertensive agents in patients with hypertension and
thoracic aortic disease.
Pregnancy
COR LOE
Recommendations for Treatment of Hypertension in
Pregnancy
I C-LD
Women with hypertension who become pregnant, or are
planning to become pregnant, should be transitioned to
methyldopa, nifedipine, and/or labetalol during pregnancy.
III:
Harm
C-LD
Women with hypertension who become pregnant should not be
treated with ACE inhibitors, ARBs, or direct renin inhibitors.
Resistant Hypertension: Diagnosis, Evaluation, and Treatment
.
BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood
pressure; eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal anti-
inflammatory drugs; and SBP, systolic blood pressure.
Adapted with permission from Calhoun et al.
Hypertensive Crises: Emergencies and Urgencies
COR LOE
Recommendations for Hypertensive Crises and
Emergencies
I B-NR
In adults with a hypertensive emergency, admission to an
intensive care unit is recommended for continuous monitoring
of BP and target organ damage and for parenteral
administration of an appropriate agent.
I C-EO
For adults with a compelling condition (i.e., aortic dissection,
severe preeclampsia or eclampsia, or pheochromocytoma
crisis), SBP should be reduced to less than 140 mm Hg during
the first hour and to less than 120 mm Hg in aortic dissection.
I C-EO
For adults without a compelling condition, SBP should be
reduced by no more than 25% within the first hour; then, if
stable, to 160/100 mm Hg within the next 2 to 6 hours; and
then cautiously to normal during the following 24 to 48 hours.
Colors correspond to Class of Recommendation in Table 1.
*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care
unit; and SBP, systolic blood pressure.
Diagnosis and Management of a Hypertensive Crisis
SBP >180 mm Hg and/or
DBP >120 mm Hg
Target organ damage new/
progressive/worsening
Reduce SBP to <140 mm Hg
during first h* and to <120 mm Hg
in aortic dissection†
(Class I)
Yes
Yes
Reduce BP by max 25% over first h†, then
to 160/100–110 mm Hg over next 2–6 h,
then to normal over next 24–48 h
(Class I)
No
Markedly elevated BP
Reinstitute/intensify oral
antihypertensive drug therapy
and arrange fo llow-up
Hypertensive
emergency
Admit to ICU
(Class I)
No
Conditions:
• Aortic dissection
• Severe preeclampsia or eclampsia
• Pheochromocytoma crisis
Clinician’s Sequential Flow Chart for the Management of Hypertension
Clinician’s Sequential Flow Chart for the Management of Hypertension
Measure office BP accurately
Detect white coat hypertension or masked hypertension by using ABPM and HBPM
Evaluate for secondary hypertension
Identify target organ damage
Introduce lifestyle interventions
Identify and discuss treatment goals
Use ASCVD risk estimation to guide BP threshold for drug therapy
Align treatment options with comorbidities
Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment
Initiate antihypertensive pharmacological therapy
Insure appropriate follow-up
Use team-based care
Connect patient to clinician via telehealth
Detect and reverse nonadherence
Detect white coat effect or masked uncontrolled hypertension
Use health information technology for remote monitoring and self-monitoring of BP
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.

More Related Content

Similar to Caso clínico hasaaaaaaaaaaaaaaaaaaaaaaaaa

Hypertension the silent killer
Hypertension the silent killer Hypertension the silent killer
Hypertension the silent killer
hospital
 
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdfPHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
samthamby79
 
Management of hypertension problems in gp
Management of hypertension problems in gpManagement of hypertension problems in gp
Management of hypertension problems in gp
Amir Mahmoud
 
Hypertension jnc 8 guideline(1)
Hypertension jnc 8 guideline(1)Hypertension jnc 8 guideline(1)
Hypertension jnc 8 guideline(1)
Dr.Chandan Kumar
 
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
thito6
 
HYPERTENSION -THE LATEST MANAGEMENT
HYPERTENSION -THE LATEST MANAGEMENTHYPERTENSION -THE LATEST MANAGEMENT
HYPERTENSION -THE LATEST MANAGEMENT
LPS Institute of Cardiology Kanpur UP India
 
diagnosis-treatment-of-resistant-hypertension.pdf
diagnosis-treatment-of-resistant-hypertension.pdfdiagnosis-treatment-of-resistant-hypertension.pdf
diagnosis-treatment-of-resistant-hypertension.pdf
VinayReddy241577
 
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
Vinh Pham Nguyen
 
HYPERTENSION.pptx
HYPERTENSION.pptxHYPERTENSION.pptx
HYPERTENSION.pptx
MishiSoza
 
Hypertension - Role of Azilsartan ( Case based & Evidence based)
Hypertension  - Role of Azilsartan ( Case based & Evidence based)Hypertension  - Role of Azilsartan ( Case based & Evidence based)
Hypertension - Role of Azilsartan ( Case based & Evidence based)
PROFESSOR DR. MD. TOUFIQUR RAHMAN
 
JNC-8.ppt
JNC-8.pptJNC-8.ppt
JNC-8.ppt
dtettam1
 
Treatment of Hypertension Treatment of Hypertension
Treatment of Hypertension 	 Treatment of HypertensionTreatment of Hypertension 	 Treatment of Hypertension
Treatment of Hypertension Treatment of Hypertension
MedicineAndHealthCancer
 
Essential Hypertension
Essential Hypertension Essential Hypertension
Essential Hypertension
raheef
 
Overview of Guidelines in the Management of Hypertension
Overview of Guidelines in the Management of HypertensionOverview of Guidelines in the Management of Hypertension
Overview of Guidelines in the Management of Hypertension
Jayaprakash Appajigol
 
Hypertension Guidelines JNC 8
Hypertension Guidelines JNC 8Hypertension Guidelines JNC 8
Hypertension Guidelines JNC 8
nik_sat
 
Hypertension (HTN)
Hypertension (HTN)Hypertension (HTN)
Hypertension (HTN)
mahadev deuja
 
Hypertension
HypertensionHypertension
5 hypertension final.ppt¹1111111111111111
5 hypertension final.ppt¹11111111111111115 hypertension final.ppt¹1111111111111111
5 hypertension final.ppt¹1111111111111111
marrahmohamed33
 
update in RX of HTN.pptx
update in RX of HTN.pptxupdate in RX of HTN.pptx
update in RX of HTN.pptx
mohammedalhayali4
 
Pharmacist Management of Hypertension
Pharmacist Management of HypertensionPharmacist Management of Hypertension
Pharmacist Management of Hypertension
PASaskatchewan
 

Similar to Caso clínico hasaaaaaaaaaaaaaaaaaaaaaaaaa (20)

Hypertension the silent killer
Hypertension the silent killer Hypertension the silent killer
Hypertension the silent killer
 
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdfPHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
PHARMACOTHERAPY POINTERS FOR HTN (MALAYSIAN CPGs).pdf
 
Management of hypertension problems in gp
Management of hypertension problems in gpManagement of hypertension problems in gp
Management of hypertension problems in gp
 
Hypertension jnc 8 guideline(1)
Hypertension jnc 8 guideline(1)Hypertension jnc 8 guideline(1)
Hypertension jnc 8 guideline(1)
 
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
Dt benh THA và chien luoc phoi hop thuoc nham dat muc tieu dt - Cn cac khuye...
 
HYPERTENSION -THE LATEST MANAGEMENT
HYPERTENSION -THE LATEST MANAGEMENTHYPERTENSION -THE LATEST MANAGEMENT
HYPERTENSION -THE LATEST MANAGEMENT
 
diagnosis-treatment-of-resistant-hypertension.pdf
diagnosis-treatment-of-resistant-hypertension.pdfdiagnosis-treatment-of-resistant-hypertension.pdf
diagnosis-treatment-of-resistant-hypertension.pdf
 
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
Dieu tri-benh-tang-huyet-ap-va-chien-luoc-phoi-hop-thuoc-nham-dat-muc-tieu-di...
 
HYPERTENSION.pptx
HYPERTENSION.pptxHYPERTENSION.pptx
HYPERTENSION.pptx
 
Hypertension - Role of Azilsartan ( Case based & Evidence based)
Hypertension  - Role of Azilsartan ( Case based & Evidence based)Hypertension  - Role of Azilsartan ( Case based & Evidence based)
Hypertension - Role of Azilsartan ( Case based & Evidence based)
 
JNC-8.ppt
JNC-8.pptJNC-8.ppt
JNC-8.ppt
 
Treatment of Hypertension Treatment of Hypertension
Treatment of Hypertension 	 Treatment of HypertensionTreatment of Hypertension 	 Treatment of Hypertension
Treatment of Hypertension Treatment of Hypertension
 
Essential Hypertension
Essential Hypertension Essential Hypertension
Essential Hypertension
 
Overview of Guidelines in the Management of Hypertension
Overview of Guidelines in the Management of HypertensionOverview of Guidelines in the Management of Hypertension
Overview of Guidelines in the Management of Hypertension
 
Hypertension Guidelines JNC 8
Hypertension Guidelines JNC 8Hypertension Guidelines JNC 8
Hypertension Guidelines JNC 8
 
Hypertension (HTN)
Hypertension (HTN)Hypertension (HTN)
Hypertension (HTN)
 
Hypertension
HypertensionHypertension
Hypertension
 
5 hypertension final.ppt¹1111111111111111
5 hypertension final.ppt¹11111111111111115 hypertension final.ppt¹1111111111111111
5 hypertension final.ppt¹1111111111111111
 
update in RX of HTN.pptx
update in RX of HTN.pptxupdate in RX of HTN.pptx
update in RX of HTN.pptx
 
Pharmacist Management of Hypertension
Pharmacist Management of HypertensionPharmacist Management of Hypertension
Pharmacist Management of Hypertension
 

More from BrunoHernndez16

Trauma musculo esquelético final para poder exponer
Trauma musculo esquelético  final para poder exponerTrauma musculo esquelético  final para poder exponer
Trauma musculo esquelético final para poder exponer
BrunoHernndez16
 
HERIDA POR ARMA BLANCA presentacion para exponer
HERIDA POR ARMA BLANCA  presentacion  para exponerHERIDA POR ARMA BLANCA  presentacion  para exponer
HERIDA POR ARMA BLANCA presentacion para exponer
BrunoHernndez16
 
enfermedadrenalcronica EN MEDICINA para el estudio
enfermedadrenalcronica EN MEDICINA para el estudioenfermedadrenalcronica EN MEDICINA para el estudio
enfermedadrenalcronica EN MEDICINA para el estudio
BrunoHernndez16
 
IVUs y pielonefritis PARA ESTUDIOS Y REPASO
IVUs y pielonefritis PARA ESTUDIOS Y REPASOIVUs y pielonefritis PARA ESTUDIOS Y REPASO
IVUs y pielonefritis PARA ESTUDIOS Y REPASO
BrunoHernndez16
 
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptxppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
BrunoHernndez16
 
extremidadessuperiores-131109172646-phpapp02.pptx
extremidadessuperiores-131109172646-phpapp02.pptxextremidadessuperiores-131109172646-phpapp02.pptx
extremidadessuperiores-131109172646-phpapp02.pptx
BrunoHernndez16
 
ESOFAGITIS.pptx
ESOFAGITIS.pptxESOFAGITIS.pptx
ESOFAGITIS.pptx
BrunoHernndez16
 

More from BrunoHernndez16 (7)

Trauma musculo esquelético final para poder exponer
Trauma musculo esquelético  final para poder exponerTrauma musculo esquelético  final para poder exponer
Trauma musculo esquelético final para poder exponer
 
HERIDA POR ARMA BLANCA presentacion para exponer
HERIDA POR ARMA BLANCA  presentacion  para exponerHERIDA POR ARMA BLANCA  presentacion  para exponer
HERIDA POR ARMA BLANCA presentacion para exponer
 
enfermedadrenalcronica EN MEDICINA para el estudio
enfermedadrenalcronica EN MEDICINA para el estudioenfermedadrenalcronica EN MEDICINA para el estudio
enfermedadrenalcronica EN MEDICINA para el estudio
 
IVUs y pielonefritis PARA ESTUDIOS Y REPASO
IVUs y pielonefritis PARA ESTUDIOS Y REPASOIVUs y pielonefritis PARA ESTUDIOS Y REPASO
IVUs y pielonefritis PARA ESTUDIOS Y REPASO
 
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptxppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
ppurasyprpuratrombocitopnicainmune-141217082839-conversion-gate02.pptx
 
extremidadessuperiores-131109172646-phpapp02.pptx
extremidadessuperiores-131109172646-phpapp02.pptxextremidadessuperiores-131109172646-phpapp02.pptx
extremidadessuperiores-131109172646-phpapp02.pptx
 
ESOFAGITIS.pptx
ESOFAGITIS.pptxESOFAGITIS.pptx
ESOFAGITIS.pptx
 

Recently uploaded

JULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
JULY 2024 Oncology Cartoons by Dr Kanhu Charan PatroJULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
JULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
Kanhu Charan
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
AmandaChou9
 
Text book of comprehensive Medical Surgical Nursing
Text book of comprehensive Medical Surgical NursingText book of comprehensive Medical Surgical Nursing
Text book of comprehensive Medical Surgical Nursing
BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL
 
lessonplan JTR.pptx For medical education
lessonplan JTR.pptx For medical educationlessonplan JTR.pptx For medical education
lessonplan JTR.pptx For medical education
DrJALAGAMTHIRUPATHIR
 
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptxApproach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
Bipul Thakur
 
Text Book of Nursing Concepts - Fundamental of Nursing
Text Book of Nursing Concepts - Fundamental of NursingText Book of Nursing Concepts - Fundamental of Nursing
Text Book of Nursing Concepts - Fundamental of Nursing
BP KOIRALA INSTITUTE OF HELATH SCIENCS,, NEPAL
 
Nosodes in Homeopathy, Understanding the Basis and Applications.pptx
Nosodes in Homeopathy, Understanding the Basis and Applications.pptxNosodes in Homeopathy, Understanding the Basis and Applications.pptx
Nosodes in Homeopathy, Understanding the Basis and Applications.pptx
jeearu
 
selllllllllllllllllllllllllllllllllllllllllllllll.pptx
selllllllllllllllllllllllllllllllllllllllllllllll.pptxselllllllllllllllllllllllllllllllllllllllllllllll.pptx
selllllllllllllllllllllllllllllllllllllllllllllll.pptx
Joebest8
 
Therapeutic modalities ( Psychopharmacology).pptx
Therapeutic modalities ( Psychopharmacology).pptxTherapeutic modalities ( Psychopharmacology).pptx
Therapeutic modalities ( Psychopharmacology).pptx
vidyariner7
 
medical law and ethics presentation .ppt
medical law and ethics presentation .pptmedical law and ethics presentation .ppt
medical law and ethics presentation .ppt
PseudoPocket
 
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptx
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptxProstatitis Severity- How to Determine if You Have Mild Symptoms.pptx
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptx
AmandaChou9
 
Respiratory system at glance- Neonatology
Respiratory system at glance- NeonatologyRespiratory system at glance- Neonatology
Respiratory system at glance- Neonatology
Dr. Habibur Rahim
 
Building a Strong Partnership with Your Medical Team
Building a Strong Partnership with Your Medical TeamBuilding a Strong Partnership with Your Medical Team
Building a Strong Partnership with Your Medical Team
bkling
 
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
NephroTube - Dr.Gawad
 
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptxPOTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
souravpaul769171
 
MALARIA- PowerPoint presentation pptx part 1
MALARIA- PowerPoint presentation pptx part 1MALARIA- PowerPoint presentation pptx part 1
MALARIA- PowerPoint presentation pptx part 1
kavyanshiverma75
 
Care and Maintenance of Laboratory Equipment in Histotechnology.pptx
Care and Maintenance of Laboratory Equipment in Histotechnology.pptxCare and Maintenance of Laboratory Equipment in Histotechnology.pptx
Care and Maintenance of Laboratory Equipment in Histotechnology.pptx
Dr. Jagroop Singh
 
Top 10 Habits for Longevity [Biohacker Summit 2024]
Top 10 Habits for Longevity [Biohacker Summit 2024]Top 10 Habits for Longevity [Biohacker Summit 2024]
Top 10 Habits for Longevity [Biohacker Summit 2024]
Olli Sovijärvi
 
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptxExploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
FFragrant
 
Perforation.pptx
Perforation.pptxPerforation.pptx
Perforation.pptx
Nandish Sannaiah
 

Recently uploaded (20)

JULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
JULY 2024 Oncology Cartoons by Dr Kanhu Charan PatroJULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
JULY 2024 Oncology Cartoons by Dr Kanhu Charan Patro
 
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptxHow to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
How to Relieve Prostate Congestion- Here are some Effective Strategies.pptx
 
Text book of comprehensive Medical Surgical Nursing
Text book of comprehensive Medical Surgical NursingText book of comprehensive Medical Surgical Nursing
Text book of comprehensive Medical Surgical Nursing
 
lessonplan JTR.pptx For medical education
lessonplan JTR.pptx For medical educationlessonplan JTR.pptx For medical education
lessonplan JTR.pptx For medical education
 
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptxApproach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
Approach to Head Injuiry, Intracranial Pressure Measurement and Management.pptx
 
Text Book of Nursing Concepts - Fundamental of Nursing
Text Book of Nursing Concepts - Fundamental of NursingText Book of Nursing Concepts - Fundamental of Nursing
Text Book of Nursing Concepts - Fundamental of Nursing
 
Nosodes in Homeopathy, Understanding the Basis and Applications.pptx
Nosodes in Homeopathy, Understanding the Basis and Applications.pptxNosodes in Homeopathy, Understanding the Basis and Applications.pptx
Nosodes in Homeopathy, Understanding the Basis and Applications.pptx
 
selllllllllllllllllllllllllllllllllllllllllllllll.pptx
selllllllllllllllllllllllllllllllllllllllllllllll.pptxselllllllllllllllllllllllllllllllllllllllllllllll.pptx
selllllllllllllllllllllllllllllllllllllllllllllll.pptx
 
Therapeutic modalities ( Psychopharmacology).pptx
Therapeutic modalities ( Psychopharmacology).pptxTherapeutic modalities ( Psychopharmacology).pptx
Therapeutic modalities ( Psychopharmacology).pptx
 
medical law and ethics presentation .ppt
medical law and ethics presentation .pptmedical law and ethics presentation .ppt
medical law and ethics presentation .ppt
 
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptx
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptxProstatitis Severity- How to Determine if You Have Mild Symptoms.pptx
Prostatitis Severity- How to Determine if You Have Mild Symptoms.pptx
 
Respiratory system at glance- Neonatology
Respiratory system at glance- NeonatologyRespiratory system at glance- Neonatology
Respiratory system at glance- Neonatology
 
Building a Strong Partnership with Your Medical Team
Building a Strong Partnership with Your Medical TeamBuilding a Strong Partnership with Your Medical Team
Building a Strong Partnership with Your Medical Team
 
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
Hemodialysis: Chapter 9, Arteriovenous Fistula and Graft: Basics, Creation, U...
 
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptxPOTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
POTENTIAL TARGET DISEASES FOR GENE THERAPY SOURAV.pptx
 
MALARIA- PowerPoint presentation pptx part 1
MALARIA- PowerPoint presentation pptx part 1MALARIA- PowerPoint presentation pptx part 1
MALARIA- PowerPoint presentation pptx part 1
 
Care and Maintenance of Laboratory Equipment in Histotechnology.pptx
Care and Maintenance of Laboratory Equipment in Histotechnology.pptxCare and Maintenance of Laboratory Equipment in Histotechnology.pptx
Care and Maintenance of Laboratory Equipment in Histotechnology.pptx
 
Top 10 Habits for Longevity [Biohacker Summit 2024]
Top 10 Habits for Longevity [Biohacker Summit 2024]Top 10 Habits for Longevity [Biohacker Summit 2024]
Top 10 Habits for Longevity [Biohacker Summit 2024]
 
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptxExploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
Exploring Alternatives- Why Laparoscopy Isn't Always Best for Hydrosalpinx.pptx
 
Perforation.pptx
Perforation.pptxPerforation.pptx
Perforation.pptx
 

Caso clínico hasaaaaaaaaaaaaaaaaaaaaaaaaa

  • 2. ■ Hombre de 48 años. ■ Acude a evaluación de rutina ■ Niega antecedentes relevantes. Asintomático ■ TA 145/95, peso 95 kg (IMC) ■ Dice estar “nervioso y agitado” por la visita ■ Acude una semana después, con bitácora de automonitoreo ■ TA 160/100
  • 3. PREGUNTA 1. ¿Cuál es el primer paso en el tratamiento ? ■ A. Tiazidas ■ B. Inhibidores de la enzima convertidora de angiotensina (IECAs) ■ C. Betabloqueo selectivo. ■ D. Modificación de estilo de vida ■ E. Envío a urgencias
  • 4. PREGUNTA 2. ¿Qué otra opción de tratamiento agregaría al paciente? ■ A. Tiazidas ■ B. Minoxidil ■ C. Betabloqueador selectivo ■ D. Modificacion de estilo de Vida ■ E. Bloqueador ARA-2
  • 5. PREGUNTA 3. Un 30% de la población no se controlará con lo seleccionado. ¿Qué se debe realizar? ■ A. Agregar un segundo medicamento ■ B. Cambiar por otro medicamento ■ C. Mantener el mismo medicamento ■ D. Incrementar la dosis ■ E. Enviar a 3er Nivel para rastreo de Hipertensión secundaria
  • 6. PREGUNTA 4. Otro paciente con antecedente de IAM,HAS, EPOC. ¿Mejor opción de tratamiento inicial? ■ A. Tiazidas ■ B. Alfa-Metildopa ■ C. Betabloqueador selectivo ■ D. Antagonista de canal de calcio ■ E. Diurético de asa.
  • 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. Detection of White Coat Hypertension or Masked Hypertension in Patients Not on Drug Therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring.
  • 9. Detection of White Coat Effect or Masked Uncontrolled Hypertension in Patients on Drug Therapy Colors correspond to Class of Recommendation in Table 1. ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure; and HBPM, home blood pressure monitoring. Office BP ≥5–10 mm Hg above goal on ≥3 agents Continue titrating therapy Yes Screening not necessary (No Benefit) Screen for white coat effect with HBPM (Class IIb) White coat effect: Confirm with ABPM (Class IIa) No Yes HBPM BP at goal No Increased CVD risk or target organ damage Continue current therapy (Class IIa) Yes Screening not necessary (No Benefit) Screen for masked uncontrolled hypertension with HBPM (Class IIb) Masked uncontrolled hypertension: Intensify therapy (Class IIb) No Yes HBPM BP above goal No Yes No Detection of white coat effect or masked uncontrolled hypertension in patients on drug therapy Office BP at goal ABPM BP above goal
  • 10. Screening for Secondary Hypertension Colors correspond to Class of Recommendation in Table 1 . TOD indicates target organ damage (e.g., cerebrovascular disease, hypertensive retinopathy, left ventricular hypertrophy, left ventricular dysfunction, heart failure, coronary artery disease, chronic kidney disease, albuminuria, peripheral artery disease). New-onset or uncontrolled hypertension in adults Referral not necessary (No Benefit) Refer to cli nician with speci fic experti se (Class IIb) No Yes Screening not indicated (No Benefit) Screen for seco ndary hypertension (Class I) (see Table 13) Yes No Positive screening test Cond itions • Drug-resi stant/induced hypertension • Abrupt onset of hypertension • Onset of hypertension at <30 y • Exacerbation of previously controlled hypertension • Disproportionate TOD for degree of hypertensi on • Accelerated/malignant hypertension • Onset of diastolic hypertension in older adul ts (age ≥65 y) • Unprovoked or excessive hypokalemia
  • 11. 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
  • 12. 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
  • 13. 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).
  • 14. Basic and Optional Laboratory Tests for Primary Hypertension Basic testing Fasting blood glucose* Complete blood count Lipid profile Serum creatinine with eGFR* Serum sodium, potassium, calcium* Thyroid-stimulating hormone Urinalysis Electrocardiogram Optional testing Echocardiogram Uric acid Urinary albumin to creatinine ratio *May be included in a comprehensive metabolic panel. eGFR indicates estimated glomerular filtration rate.
  • 15. Blood Pressure (BP) Thresholds and Recommendations for Treatment and Follow-Up (continued on next slide) Normal BP (BP <120/80 mm Hg) Promote optimal lifestyle habits Elevated BP (BP 120–129/<80 mm Hg) Stage 1 hypertension (BP 130–139/80-89 mm Hg) Nonpharmacologic therapy (Class I) Reassess in 3–6 mo (Class I) Reassess in 1 mo (Class I) Nonpharmacologic therapy and BP-lowering medication (Class I) Reassess in 1 y (Class IIa) Clinical ASCVD or estimated 10-y CVD risk ≥10%* Yes No Nonpharmacologic therapy (Class I) BP thresholds and recommendations for treatment and follow-up Nonpharmacologic therapy and BP-lowering medication† (Class I) Reassess in 3–6 mo (Class I) Stage 2 hypertension (BP ≥ 140/90 mm Hg)
  • 16. Colors correspond to Class of Recommendation in Table 1. *Using the ACC/AHA Pooled Cohort Equations. Note that patients with DM or CKD are automatically placed in the high- risk category. For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy. †Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP target. 3–6 mo (Class I) BP goal met No Yes Reassess in 3–6 mo (Class I) Assess and optimize adherence to therapy Consider intensification of therapy Reassess in 1 mo (Class I) BP-lowering medication (Class I) 1 y (Class IIa) therapy (Class I) BP-lowering medication† (Class I) Reassess in 3–6 mo (Class I)
  • 17. Follow-Up After Initial BP Evaluation COR LOE Recommendations for Follow-Up After Initial BP Elevation I B-R Adults with an elevated BP or stage 1 hypertension who have an estimated 10-year ASCVD risk less than 10% should be managed with nonpharmacological therapy and have a repeat BP evaluation within 3 to 6 months. I B-R Adults with stage 1 hypertension who have an estimated 10-year ASCVD risk of 10% or higher should be managed initially with a combination of nonpharmacological and antihypertensive drug therapy and have a repeat BP evaluation in 1 month. I B-R Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacological and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have a repeat BP evaluation in 1 month.
  • 18. Follow-Up After Initial BP Evaluation (cont.) COR LOE Recommendations for Follow-Up After Initial BP Elevation I B-R For adults with a very high average BP (e.g., SBP ≥180 mm Hg or DBP ≥110 mm Hg), evaluation followed by prompt antihypertensive drug treatment is recommended. IIa C-EO For adults with a normal BP, repeat evaluation every year is reasonable.
  • 19. BP Goal for Patients With Hypertension COR LOE Recommendations for BP Goal for Patients With Hypertension I SBP: B-RSR For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher a BP target of less than 130/80 mm Hg is recommended. DBP: C-EO IIb SBP: B-NR For adults with confirmed hypertension, without additional markers of increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable. DBP: C-EO SR indicates systematic review.
  • 20. Choice of Initial Medication COR LOE Recommendation for Choice of Initial Medication I ASR For initiation of antihypertensive drug therapy, first- line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs. SR indicates systematic review.
  • 21. Choice of Initial Monotherapy Versus Initial Combination Drug Therapy COR LOE Recommendations for Choice of Initial Monotherapy Versus Initial Combination Drug Therapy* I C-EO Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as separate agents or in a fixed-dose combination, is recommended in adults with stage 2 hypertension and an average BP more than 20/10 mm Hg above their BP target. IIa C-EO Initiation of antihypertensive drug therapy with a single antihypertensive drug is reasonable in adults with stage 1 hypertension and BP goal <130/80 mm Hg with dosage titration and sequential addition of other agents to achieve the BP target.
  • 22. Follow-Up After Initiating Antihypertensive Drug Therapy COR LOE Recommendation for Follow-Up After Initiating Antihypertensive Drug Therapy I B-R Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved.
  • 23. Management of Hypertension in Patients With SIHD •ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; GDMT, guideline-directed management and therapy; and SIHD, stable ischemic heart disease. Hypertension With SIHD Reduce BP to <130/80 mm Hg with GDMT beta blockers*, ACE inhibitor, or ARBs† (Class I) Add dihydropyridine CCBs if needed (Class I) Add dihydropyridine CCBs, thiazide-type diuretics, and/or MRAs as needed (Class I) Angina pectoris No BP goal not met Yes Colors correspond to Class of Recommendation in Table 1. *GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol. Avoid beta blockers with intrinsic sympathomimetic activity. The beta blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events. †If needed for BP control.
  • 24. Heart Failure With Reduced Ejection Fraction COR LOE Recommendations for Treatment of Hypertension in Patients With HFrEF I C-EO Adults with HFrEF and hypertension should be prescribed GDMT titrated to attain a BP of less than 130/80 mm Hg. III: No Benefit B-R Nondihydropyridine CCBs are not recommended in the treatment of hypertension in adults with HFrEF.
  • 25. Chronic Kidney Disease COR LOE Recommendations for Treatment of Hypertension in Patients With CKD I SBP: B-RSR Adults with hypertension and CKD should be treated to a BP goal of less than 130/80 mm Hg. DBP: C-EO IIa B-R In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio or the equivalent in the first morning void]), treatment with an ACE inhibitor is reasonable to slow kidney disease progression. IIb C-EO In adults with hypertension and CKD (stage 3 or higher or stage 1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-creatinine ratio in the first morning void]), treatment with an ARB may be reasonable if an ACE inhibitor is not tolerated. SR indicates systematic review.
  • 26. Management of Hypertension in Patients With CKD •Colors correspond to Class of Recommendation in Table 1. •*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g creatinine. •ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP blood pressure; and CKD, chronic kidney disease. Treatment of hypertension in patients with CKD Albuminuria (≥300 mg/d or ≥300 mg/g creatinine) ACE inhibitor* (Class IIa) Yes Usual “first-line” medication choices ACE inhibitor (Class IIa) ARB* (Class IIb) No Yes ACE inhibitor intolerant No BP goal <130/80 mm Hg (Class I)
  • 27. Hypertension After Renal Transplantation COR LOE Recommendations for Treatment of Hypertension After Renal Transplantation IIa SBP: B-NR After kidney transplantation, it is reasonable to treat patients with hypertension to a BP goal of less than 130/80 mm Hg. DBP: C-EO IIa B-R After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium antagonist on the basis of improved GFR and kidney survival.
  • 28. Acute Intracerebral Hemorrhage COR LOE Recommendations for Management of Hypertension in Patients With Acute Intracerebral Hemorrhage (ICH) IIa C-EO In adults with ICH who present with SBP greater than 220 mm Hg, it is reasonable to use continuous intravenous drug infusion and close BP monitoring to lower SBP. III: Harm A Immediate lowering of SBP to less than 140 mm Hg in adults with spontaneous ICH who present within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is not of benefit to reduce death or severe disability and can be potentially harmful.
  • 29. Management of Hypertension in Patients With Acute ICH Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; ICH, intracerebral hemorrhage; IV, intravenous; and SBP, systolic blood pressure. Acute (<6 h from symptom onset) spontaneous ICH SBP lowering to <140 mm Hg (Class III:Harm) SBP lowering with continuous IV infusion and close BP monitoring (Class IIa) SBP 150–220 mm Hg SBP >220 mm Hg
  • 30. Acute Ischemic Stroke COR LOE Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke I B-NR Adults with acute ischemic stroke and elevated BP who are eligible for treatment with intravenous tissue plasminogen activator should have their BP slowly lowered to less than 185/110 mm Hg before thrombolytic therapy is initiated. I B-NR In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before administration of intravenous tissue plasminogen activator and should be maintained below 180/105 mm Hg for at least the first 24 hours after initiating drug therapy. IIa B-NR Starting or restarting antihypertensive therapy during hospitalization in patients with BP greater than 140/90 mm Hg who are neurologically stable is safe and reasonable to improve long-term BP control, unless contraindicated.
  • 31. Acute Ischemic Stroke (cont.) COR LOE Recommendations for Management of Hypertension in Patients With Acute Ischemic Stroke IIb C-EO In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or endovascular treatment and have no comorbid conditions requiring acute antihypertensive treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after onset of stroke. III: No Benefit A In patients with BP less than 220/120 mm Hg who did not receive intravenous thrombolysis or endovascular treatment and do not have a comorbid condition requiring acute antihypertensive treatment, initiating or reinitiating treatment of hypertension within the first 48 to 72 hours after an acute ischemic stroke is not effective to prevent death or dependency.
  • 32. Management of Hypertension in Patients With Acute Ischemic Stroke Colors correspond to Class of Recommendation in Table 1. BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP, systolic blood pressure. Acute (<72 h from symptom onset) ischemic stroke and elevated BP Yes Initiating or reinitiating treatment of hypertension within the first 48-72 hours after an acute ischemic stroke is ineffective to prevent death or dependency (Class III: No Benefit) Lower SBP to <185 mm Hg and DBP <110 mm Hg before initiation of IV thrombolysis (Class I) Lower BP 15% during first 24 h (Class IIb) Patient qualifies for IV thrombolysis therapy BP ≤220/110 mm Hg BP >220/110 mm Hg For preexisting hypertension, reinitiate antihypertensive drugs after neurological stability (Class IIa) Maintain BP <180/105 mm Hg for first 24 h after IV thrombosis (Class I) No And
  • 33. Diabetes Mellitus COR LOE Recommendations for Treatment of Hypertension in Patients With DM I SBP: B-RSR In adults with DM and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mm Hg or higher with a treatment goal of less than 130/80 mm Hg. DBP: C-EO I ASR In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. IIb B-NR In adults with DM and hypertension, ACE inhibitors or ARBs may be considered in the presence of albuminuria. SR indicates systematic review.
  • 34. Valvular Heart Disease COR LOE Recommendations for Treatment of Hypertension in Patients With Valvular Heart Disease I B-NR In adults with asymptomatic aortic stenosis, hypertension should be treated with pharmacotherapy, starting at a low dose and gradually titrating upward as needed. IIa C-LD In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that do not slow the heart rate (i.e., avoid beta blockers) is reasonable.
  • 35. Aortic Disease COR LOE Recommendation for Management of Hypertension in Patients With Aortic Disease I C-EO Beta blockers are recommended as the preferred antihypertensive agents in patients with hypertension and thoracic aortic disease.
  • 36. Pregnancy COR LOE Recommendations for Treatment of Hypertension in Pregnancy I C-LD Women with hypertension who become pregnant, or are planning to become pregnant, should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy. III: Harm C-LD Women with hypertension who become pregnant should not be treated with ACE inhibitors, ARBs, or direct renin inhibitors.
  • 37. Resistant Hypertension: Diagnosis, Evaluation, and Treatment . BP indicates blood pressure; CKD, chronic kidney disease; DBP, diastolic blood pressure; eGFR, estimated glomerular filtration rate; NSAIDs, nonsteroidal anti- inflammatory drugs; and SBP, systolic blood pressure. Adapted with permission from Calhoun et al.
  • 38. Hypertensive Crises: Emergencies and Urgencies COR LOE Recommendations for Hypertensive Crises and Emergencies I B-NR In adults with a hypertensive emergency, admission to an intensive care unit is recommended for continuous monitoring of BP and target organ damage and for parenteral administration of an appropriate agent. I C-EO For adults with a compelling condition (i.e., aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), SBP should be reduced to less than 140 mm Hg during the first hour and to less than 120 mm Hg in aortic dissection. I C-EO For adults without a compelling condition, SBP should be reduced by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours.
  • 39. Colors correspond to Class of Recommendation in Table 1. *Use drug(s) specified in Table 19. †If other comorbidities are present, select a drug specified in Table 20. BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit; and SBP, systolic blood pressure. Diagnosis and Management of a Hypertensive Crisis SBP >180 mm Hg and/or DBP >120 mm Hg Target organ damage new/ progressive/worsening Reduce SBP to <140 mm Hg during first h* and to <120 mm Hg in aortic dissection† (Class I) Yes Yes Reduce BP by max 25% over first h†, then to 160/100–110 mm Hg over next 2–6 h, then to normal over next 24–48 h (Class I) No Markedly elevated BP Reinstitute/intensify oral antihypertensive drug therapy and arrange fo llow-up Hypertensive emergency Admit to ICU (Class I) No Conditions: • Aortic dissection • Severe preeclampsia or eclampsia • Pheochromocytoma crisis
  • 40. Clinician’s Sequential Flow Chart for the Management of Hypertension Clinician’s Sequential Flow Chart for the Management of Hypertension Measure office BP accurately Detect white coat hypertension or masked hypertension by using ABPM and HBPM Evaluate for secondary hypertension Identify target organ damage Introduce lifestyle interventions Identify and discuss treatment goals Use ASCVD risk estimation to guide BP threshold for drug therapy Align treatment options with comorbidities Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment Initiate antihypertensive pharmacological therapy Insure appropriate follow-up Use team-based care Connect patient to clinician via telehealth Detect and reverse nonadherence Detect white coat effect or masked uncontrolled hypertension Use health information technology for remote monitoring and self-monitoring of BP ASCVD indicates atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.