hypertension, simplified, jnc 8, treatment and newer modalities to treat. surgical procedures involved for hypertension and jnc 8 versus jnc 7 is compared in this ppt, and also, prevelance and epidemeiology of hypertension is explained. antihypertensives for preffered class and age are explained

2. Problem Magnitude
• Hypertension( HTN) is the most common primary diagnosis
• Worldwide prevalence estimates for HTN may be as much as 1
billion.
• 7.1 million deaths per year may be attributable to hypertension.
N Engl J Med. 2008;358:1887–98.

3. 3
Normotensives (78%)
Hypertensives
(22%)
Under control (40%)
(7.5% of the total
hypertensives)
Uncontrolled
hypertension (60%)
Diagnosed
HT Under
treatment
(50%)
Undiagnosed
HT
How many are really Diagnosed and
Treated ??
37%
63%
Un Rx.
HT

4. Diseases Attributable to Hypertension
Hypertension
Heart failure
StrokeCoronary heart disease
Myocardial infarction
Left ventricular
hypertrophy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
Hypertensive
encephalopathy
Chronic kidney failure
Cerebral hemorrhage
Adapted from: Arch Intern Med 1996; 156:1926-1935.
All
Vascular

5. Benefits of Treatment
• Reductions in stroke incidence, averaging 35–40 percent.
• Reductions in MI, averaging 20–25 percent.
• Reductions in HF, averaging >50 percent.

6. Ambulatory Blood Pressure Monitoring - ABPM
1. 24 hour B.P monitoring (every 15 minutes)
2. Today - 24 hour B.P. control is essential
3. Identifies dippers and non-dippers
4. Excludes white coat hypertension

7. Antihypertensive Drugs
▪ Diuretics:
▪ Thiazides: Hydrochlorothiazide, chlorthalidone
▪ High ceiling: Furosemide
▪ K+ sparing: Spironolactone, triamterene and amiloride
MOA: Acts on Kidneys to increase excretion of Na and H2O –
decrease in blood volume – decreased BP
▪ Angiotensin-converting Enzyme (ACE) inhibitors:
▪ Captopril, lisinopril., enalapril, ramipril and fosinopril
MOA: Inhibit synthesis of Angiotensin II – decrease in peripheral
resistance and blood volume
▪ Angiotensin (AT1) blockers:
▪ Losartan, candesartan, valsartan and telmisartan
MOA: Blocks binding of Angiotensin II to its receptors

8. Antihypertensive Drugs – contd.
▪ Centrally acting:
▪ Clonidine, methyldopa
MOA: Act on central α2A receptors to decrease sympathetic outflow –
fall in BP
▪ ß-adrenergic blockers:
▪ Non selective: Propranolol (others: nadolol, timolol, pindolol,
labetolol)
▪ Cardioselective: Metoprolol (others: atenolol, esmolol, betaxolol)
MOA: Bind to beta adrenergic receptors and blocks the activity
▪ ß and α – adrenergic blockers:
▪ Labetolol and carvedilol
▪ α – adrenergic blockers:
▪ Prazosin, terazosin, doxazosin, phenoxybenzamine and phentolamine
MOA: Blocking of alpha adrenergic receptors in smooth muscles -

9. Antihypertensive Drugs – contd.
▪ Calcium Channel Blockers (CCB):
▪ Verapamil, diltiazem, nifedipine, felodipine, amlodipine,
nimodipine etc.
MOA: Blocks influx of Ca++ in smooth muscle cells – relaxation
of SMCs – decrease BP
▪ K+ Channel activators:
▪ Diazoxide, minoxidil, pinacidil and nicorandil
MOA: Leaking of K+ due to opening – hyper polarization of SMCs
– relaxation of SMCs
▪ Vasodilators:
▪ Arteriolar – Hydralazine (also CCBs and K+ channel
activators)
▪ Arterio-venular: Sodium Nitroprusside

10. Present
Days
Everything
tobe
EVIDENCE
BASED…!!
!!!

11. 2014
Evidence-Based Guidelines for
the Management
of
High Blood Pressure in Adults
JNC 8
2014
Evidence-Based Guidelines for
the Management
of
High Blood Pressure in Adults
JNC 8

12. Recommendation 1
▪ In the general population aged (>)60years,initiate
pharmacologic treatment to lower blood pressure(BP) at
▪ systolic blood pressure(SBP) 150 mmHg or
▪ diastolic blood pressure(DBP) 90mmHg and
▪ treat to a goal, SBP<150mmHg and goal DBP<90mmHg.
(Recommendation– Grade
A)

13. CorollaryRecommendation
▪ In the general population aged 60years, if pharmacologic
treatment for high BP results in lower achieved
SBP(eg,<140mmHg) and treatment is well tolerated and
without adverse effects on health or quality of life,
treatment does not need to be adjusted.
(ExpertOpinion–GradeE)

14. Recommendation 2
▪ In the general population <60years, initiate pharmacologic
treatment to lower BP at DBP 90mmHg and treat to a goal
DBP <90mmHg.
(For ages 30-59 years, Recommendation–GradeA;
For ages18-29years, Expert Opinion–GradeE)

15. Recommendation 3
▪ In the general population <60years, initiate
pharmacologic treatment to lower BP at SBP
140mmHg and treat to a goal SBP <140mmHg.
(Expert Opinion–GradeE)

16. Recommendation 4
▪ In the population aged (>)18 years with chronic
kidney disease (CKD), initiate pharmacologic
treatment to lower BP at SBP 140mmHg or DBP
90mmHg and treat to goal SBP <140mmHg and
goal DBP<90mmHg.
(Expert Opinion–GradeE)

17. Recommendation 5
▪ In the population aged (>) 18 years with diabetes,
initiate pharmacologic treatment to lower BP at
SBP 140 mmHg or DBP 90 mmHg and treat to a
goal SBP<140mmHg and goal DBP<90mmHg.
(ExpertOpinion–GradeE)

18. Recommendation 6
▪ In the general nonblack population, including
those with diabetes,initial antihypertensive
treatment should include a thiazide-type diuretic,
calcium channel blocker(CCB), angiotensin-
converting enzyme inhibitor (ACEI), or
angiotensin receptor blocker(ARB).
(ModerateRecommendation–GradeB)

19. Recommendation 7
▪ In the general black population, including those
with diabetes, initial antihypertensive treatment
should include a thiazide-type diuretic or CCB.
(For general black population:Moderate
Recommendation–GradeB;for black patients with
diabetes:WeakRecommendation–GradeC)

20. Recommendation 8
▪ In the population aged 18 years with CKD, initial
(or add-on) antihypertensive treatment should
include an ACEI or ARB to improve kidney
outcomes.This applies to all CKD patients with
hypertension regardless of race or diabetes status.
(ModerateRecommendation–GradeB)

21. Recommendation 9
▪ The main objective to attain and maintain goal BP.
▪ If goal BP is not reached within a month of treatment, increase
the dose of the initial drug or add a second drug from one of
the classes in recommendation 6 (thiazide-type
diuretic,CCB,ACEI,orARB).

24. Lifestyle modifications

25. Treatment of hypertension in 2016 –
Role of Beta Blockers
• Use of beta blockers started in 1960’s
• They are preferred in hypertensive patients who have suffered from
myocardial infarction, IHD, heart failure due to systolic dysfunction.
• Third generation beta blockers have advantages over first and second.
• Recent trials and meta-analyses – ASCOT-BPLA , MAPHY study.
• Vasodilatory beta blockers : safer!

26. Role of Beta Blockers – indications for
use in hypertension
• Coronary artery disease – mainly decreases myocardial oxygen demand
along with lowering BP.
• According to AHA guidelines – these are recommended in
hemodynamically stable patients after MI. Studies like BHAT ,
CAPRICORN trial.
• In heart failure mainly acts by inhibiting the negative effects associated with
sympathetic nervous system activation.

27. Treatment of hypertension in 2016 –
Role of Diuretics
• Diuretics were always first line drug in hypertension.
• It can be divided into – thiazides, thiazides like, aldosterone inhibitors, loop ,
potassium sparing.
• Mechanism of action – reduces plasma volume initially, also acts as a
vasodilator and reduces peripheral vascular resistance.
• Major trials – SHEP, MRFIT, ALLHAT study.
• Newer guidelines – JNC8, ESC, CHEP uses it as first line agent.

28. Treatment of hypertension in 2016 –
Role of Calcium Channel Blockers
• CCB includes dihydropyridine and nondihydropyridines
• Place in antihypertensive guidelines.
• 4th
generation CCB – Cilnidipine
• Newer inherently long acting dihydropyridines – Lacidipine, Lercanidipine.

30. Treatment of hypertension in 2016 –
Role of ACE-Inhibitors
• ACEI’S are time tested drugs for management of hypertension and
associated comorbidites like diabetes, CKD, CAD.
• They have strong evidence of cardio vascular protection and reducing
cardiovascular events.

31. Treatment of hypertension in 2016 –
Role of ARB
• Mechanism of action
• New ARB’s – Embusartan, Fonsartan, KRH594.

33. HYPERTENSION
IN SPECIAL
SITUATIONS

34. Hypertension in Pregnancy
Classification of hypertension in pregnancy :
•Chronic Hypertension
• Gestational Hypertension
•Pre eclampsia
•Preeclampsia superimposed on Chronic Hypertension

35. Treatment for Chronic Hypertension
• Avoid treatment in women with uncomplicated mild essential HTN as blood
pressure may decrease as pregnancy progresses.
• May taper or discontinue meds for women with blood pressures less than
120/80 in 1st
trimester.
• Reinstitute or initiate therapy for persistent diastolic pressures >95 mmHg,
systolic pressures >150 mmHg, or signs of hypertensive end-organ damage.
• Medication choices = Oral methyldopa and labetalol.

36. Treatment of Preeclampsia
• Definitive Treatment = Delivery
• Major indication for antihypertensive therapy is prevention of stroke.
Diastolic pressure ≥105-110 mmHg or systolic pressure ≥160 mmHg
• Choice of drug therapy:
Acute – IV labetalol, IV hydralazine, SR Nifedipine
Long-term – Oral methyldopa or labetalol
Eclampsia prevention = MgSO4
Contraindicated antihypertensive drugs
ACE inhibitors
Angiotensin receptor antagonists

37. Hypertensive Crises
Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated
Hypertension). Usually due to under-controlled HTN
Hypertensive Emergencies: Progressive end-organ dysfunction. (Malignant
Hypertension). Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

39. Resistant Hypertension
Uncontrolled Hypertension
Includes patients who lack blood pressure
(BP) control for any reason:1
•Inadequate treatment regimens
•Poor adherence
•Undetected secondary hypertension
•True treatment resistance
1. Calhoun DA, et al. Circulation. 2008;117:e510-e526.
2. Mancia G, et al. Eur Heart J. 2007;28:1462-1536.
Treatment-Resistant
Hypertension• BP that remains above goal with maximum
tolerated doses of ≥3 antihypertensive
medications* of different classes; ideally, 1 of
the 3 agents should be a diuretic1,2
*Patients who require ≥4 antihypertensive agents to achieve BP control are also considered treatment resistant, according to some sources.1

40. Black raceBlack race
Excessive dietary
salt ingestion
Excessive dietary
salt ingestion
Who is at risk?
ObesityObesity
High baseline
blood pressure
High baseline
blood pressure
Older ageOlder age
Chronic kidney
disease
Chronic kidney
disease
DiabetesDiabetes
Left ventricular
hypertrophy
Left ventricular
hypertrophy
Female sexFemale sex
Patient Characteristics
Associated With Treatment-
Resistant Hypertension*

41. Treatment-resistant hypertension:
a systematic approach to evaluation and
management
Confirm Accuracy of
BP Measurement
•Utilize correct BP measurement
technique
•Rule out white-coat effect
Optimize Pharmacotherapy
and Adherence
• Regimen of 3 drugs of different classes,
including a diuretic
•Assess and improve adherence
to the treatment regimen
•Intensify pharmacologic therapy
Address Lifestyle Barriers to
BP Control
•Interfering substances
•Dietary salt intake
•Alcohol consumption
•Obesity
Consider Referral to
a Specialist
•Treatment for secondary causes of
hypertension
•Hypertension specialist for
intensive management of true treatment-
resistant hypertension

42. Eliminating “white-coat” effect
▪ What Is It?
▪ Elevated BP in physician’s office, but
significantly lower when measured at home
▪ How Prevalent?
▪ A recent Spanish study of 8,295 patients with
treatment-resistant hypertension found that
37.5% actually had office-resistant hypertension
• When to Suspect?
– White-coat resistance may be present in patients with consistently
elevated BP but no evidence of target organ damage
• How to Screen?
– Consider repeated at-home BP measurements to rule out white-coat
resistance
– Where available, 24-hour ambulatory BP monitoring (ABPM) may be
used for further diagnostic evaluation

43. Future of Hypertension

44. Future of Hypertension
• Telemonitoring of BP
• Interventional therapies – baroreceptor activation therapy, renal denervation
• Endothelin A receptor antagonists
• Vaccines

45. Take Home Message
• JNC 8 – Recommendations
• ABPM
• Trials regarding HTN
• Future

46. THANK YOU