The document summarizes the 2020 ISH Global Hypertension Practice Guidelines. It discusses the process of writing the guidelines, which involved an international committee reviewing evidence and receiving input from experts globally. The guidelines were developed to be practical, realistic, and feasible for clinicians, nurses and community health workers globally in both high and low resource settings. The guidelines cover definitions of hypertension, methods for blood pressure measurement and diagnosis, diagnostic tests, risk factors, hypertension-mediated organ damage, exacerbators of hypertension, and treatment recommendations.
- Bisoprolol is a highly selective beta-1 blocker used to treat heart failure, hypertension, and myocardial infarction.
- Studies show bisoprolol lowers blood pressure and heart rate more effectively than atenolol, with greater reductions throughout the day.
- The CIBIS II trial found adding bisoprolol to standard heart failure treatment reduced all-cause mortality by 34% and reduced hospitalizations compared to placebo.
http://www.theheart.org/web_slides/1135309.do
A study on Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients (ADVANCE)
The document discusses the rationale and history of using combination therapy to treat hypertension. It notes that combination therapy has been used since the 1950s and studies in the 1960s showed improved blood pressure control and reduced morbidity. Guidelines now recommend initial combination therapy using single pill combinations over stepwise monotherapy due to greater effectiveness in reducing blood pressure and heart disease risk. For patients still uncontrolled on dual therapy, guidelines recommend adding a third drug, often in a single pill combination, to help achieve target blood pressure goals.
The document discusses the role of incretins in the management of diabetes. It describes how incretins like GLP-1 and GIP are released after eating to stimulate insulin production and suppress glucagon levels. However, in type 2 diabetes patients, incretin levels and effects are reduced. DPP-4 inhibitors are discussed as a treatment approach that blocks the breakdown of incretins, thereby increasing their levels and effects. Studies show that DPP-4 inhibitors like sitagliptin prolong the levels and actions of incretins, lowering glucose levels and being weight neutral. They represent a new class of diabetes drugs that mimic the normal incretin response.
SGLT-2 inhibitors lower blood glucose levels by reducing renal glucose reabsorption and increasing glucose excretion in the urine. Empagliflozin is a selective SGLT-2 inhibitor that lowers both fasting and post-prandial plasma glucose levels. In clinical trials, empagliflozin led to an HbA1c reduction of over 1% compared to placebo when used as both monotherapy and add-on therapy to other glucose-lowering medications. Empagliflozin was also associated with weight loss, reduced blood pressure, and a lower risk of hypoglycemia compared to sulfonylurea therapy.
This document provides guidelines for the treatment of dyslipidemia to reduce cardiovascular risk. It defines dyslipidemia as abnormal lipid levels measured in a blood sample. The guidelines classify risk based on LDL cholesterol, total cholesterol, and HDL cholesterol levels. They recommend screening adults over certain ages for lipid levels and cardiovascular risk. Risk is assessed using tools like the Framingham Risk Score. Treatment involves starting statin therapy, with the intensity based on a patient's risk category. Lifestyle changes and other medications may also be used. The guidelines aim to identify those who will benefit most from treatment to lower lipid levels and cardiovascular risk.
Fasting during Ramadan poses risks for people with diabetes, especially those with type 1 diabetes who should be advised not to fast. For those who insist, risks include hypoglycemia, hyperglycemia, dehydration, and diabetic ketoacidosis. Management requires individualizing plans based on risk factors, educating patients, adjusting medications like insulin and timing/doses, frequent glucose monitoring, proper nutrition and hydration, and medical supervision. The goal is reducing risks while allowing observance of religious practices.
- Bisoprolol is a highly selective beta-1 blocker used to treat heart failure, hypertension, and myocardial infarction.
- Studies show bisoprolol lowers blood pressure and heart rate more effectively than atenolol, with greater reductions throughout the day.
- The CIBIS II trial found adding bisoprolol to standard heart failure treatment reduced all-cause mortality by 34% and reduced hospitalizations compared to placebo.
http://www.theheart.org/web_slides/1135309.do
A study on Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients (ADVANCE)
The document discusses the rationale and history of using combination therapy to treat hypertension. It notes that combination therapy has been used since the 1950s and studies in the 1960s showed improved blood pressure control and reduced morbidity. Guidelines now recommend initial combination therapy using single pill combinations over stepwise monotherapy due to greater effectiveness in reducing blood pressure and heart disease risk. For patients still uncontrolled on dual therapy, guidelines recommend adding a third drug, often in a single pill combination, to help achieve target blood pressure goals.
The document discusses the role of incretins in the management of diabetes. It describes how incretins like GLP-1 and GIP are released after eating to stimulate insulin production and suppress glucagon levels. However, in type 2 diabetes patients, incretin levels and effects are reduced. DPP-4 inhibitors are discussed as a treatment approach that blocks the breakdown of incretins, thereby increasing their levels and effects. Studies show that DPP-4 inhibitors like sitagliptin prolong the levels and actions of incretins, lowering glucose levels and being weight neutral. They represent a new class of diabetes drugs that mimic the normal incretin response.
SGLT-2 inhibitors lower blood glucose levels by reducing renal glucose reabsorption and increasing glucose excretion in the urine. Empagliflozin is a selective SGLT-2 inhibitor that lowers both fasting and post-prandial plasma glucose levels. In clinical trials, empagliflozin led to an HbA1c reduction of over 1% compared to placebo when used as both monotherapy and add-on therapy to other glucose-lowering medications. Empagliflozin was also associated with weight loss, reduced blood pressure, and a lower risk of hypoglycemia compared to sulfonylurea therapy.
This document provides guidelines for the treatment of dyslipidemia to reduce cardiovascular risk. It defines dyslipidemia as abnormal lipid levels measured in a blood sample. The guidelines classify risk based on LDL cholesterol, total cholesterol, and HDL cholesterol levels. They recommend screening adults over certain ages for lipid levels and cardiovascular risk. Risk is assessed using tools like the Framingham Risk Score. Treatment involves starting statin therapy, with the intensity based on a patient's risk category. Lifestyle changes and other medications may also be used. The guidelines aim to identify those who will benefit most from treatment to lower lipid levels and cardiovascular risk.
Fasting during Ramadan poses risks for people with diabetes, especially those with type 1 diabetes who should be advised not to fast. For those who insist, risks include hypoglycemia, hyperglycemia, dehydration, and diabetic ketoacidosis. Management requires individualizing plans based on risk factors, educating patients, adjusting medications like insulin and timing/doses, frequent glucose monitoring, proper nutrition and hydration, and medical supervision. The goal is reducing risks while allowing observance of religious practices.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
1) Statins are highly effective in reducing LDL-C and cardiovascular risk, playing a cornerstone role in lipid management. They work by inhibiting HMG-CoA reductase.
2) Atorvastatin has been extensively studied in large trials and shown to significantly reduce major cardiovascular events when doses are increased from 10 mg to 80 mg.
3) Studies in India found that high dose atorvastatin (80 mg) was well tolerated and more effective at reducing LDL-C and hs-CRP than lower doses in ACS patients. However, many ACS patients in India were not receiving statins as recommended.
The EMPEROR-Preserved trial evaluated whether empagliflozin reduces cardiovascular death or hospitalization for heart failure in adults with either heart failure with mid-range or preserved ejection fraction. The trial randomized over 5,000 patients to empagliflozin 10 mg daily or placebo, with a median follow up of 26 months. Empagliflozin reduced the primary composite outcome of cardiovascular death or hospitalization for heart failure by 21% compared to placebo, driven mainly by a 29% lower risk of hospitalization for heart failure.
Empagliflozin is an SGLT2 inhibitor that has shown cardiovascular benefits in clinical trials. SGLT2 inhibitors work by inhibiting glucose reabsorption in the kidneys, leading to increased glucose excretion and reduced blood glucose levels. Empagliflozin in particular has demonstrated reductions in cardiovascular death and hospitalization for heart failure. However, SGLT2 inhibitors also carry risks like genitourinary infections and volume depletion that require monitoring. Overall, SGLT2 inhibitors provide an additional treatment option for type 2 diabetes that can help lower glucose levels while also reducing cardiovascular outcomes.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. It has a prevalence of 0.5-24.7% depending on the population. Causes include nonadherence, lifestyle factors like obesity and sleep apnea, secondary causes like primary aldosteronism and renal artery stenosis, and drug interactions. Evaluation involves assessing medication adherence, lifestyle behaviors, screening for secondary causes with tests like the aldosterone-renin ratio, and imaging of the kidneys and arteries. Management consists of optimizing lifestyle modifications, adjusting medications like adding mineralocorticoid receptor antagonists, and treating any identified
The document summarizes clinical trials evaluating SGLT2 inhibitors:
1) The EMPA-REG trial found that empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure, and all-cause mortality compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
2) The CANVAS trial found that canagliflozin reduced the risk of major adverse cardiovascular events and hospitalization for heart failure compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
3) The DECLARE-TIMI 58 trial found that dapagliflozin did not increase the risk of major adverse cardiovascular events compared to placebo in patients with type 2 diabetes
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
This document provides guidelines for healthcare professionals on managing diabetes during Ramadan fasting. It aims to give practical recommendations to minimize health risks for Muslims with diabetes who choose to fast. The guidelines cover topics like epidemiology, physiology, risk assessment, nutrition, medication adjustment, and implementing recommendations. They emphasize individualization and education as part of a diabetes management plan. The number of Muslims with diabetes is rising globally and most fast during Ramadan, so ensuring optimal care is important. More research is still needed, but these guidelines aim to provide immediate guidance for patients fasting in coming years.
This document discusses guidelines for treating diabetes and hypertension. It recommends that all diabetic patients have their blood pressure checked and receive non-pharmacological treatment. For those with BP above 140/90, single drug treatment should begin, while BP above 160/100 warrants two drugs. The preferred initial drugs are ACE inhibitors or ARB. Target blood pressure depends on cardiovascular risk factors. While cost is a consideration, affordable options exist like ACE/ARB plus thiazide diuretics or calcium channel blockers.
This lecture presents the 1-Updated recommendations regarding definition and proper diagnosis of HTN. 2-Updated guidelines for threshold of BP to start treatment and targets of treatment. 3- Updated recommendations on CV risk assessment and management. 4-Hypertension and comorbidities: updated guidelines
Simultaneous or Rapid Sequence Initiation of Quadruple Therapy for HFrEFDuke Heart
1) Initiating all four guideline directed medical therapies (GDMT) simultaneously or in rapid sequence for heart failure with reduced ejection fraction (HFrEF) provides early clinical benefits by reducing mortality and hospitalization within weeks.
2) Starting medications together enables better tolerance as therapies help patients tolerate side effects of each other. Delaying any medication needlessly increases risks.
3) There is no evidence that simultaneous initiation increases intolerance, and initiating at low doses with up-titration mitigates risks. Not starting medications exposes patients to worsening health outcomes.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
The document provides guidelines for cholesterol management and cardiovascular disease (CVD) risk assessment. It discusses guidelines for measuring cholesterol and lipid levels, calculating LDL and VLDL values, and assessing CVD risk. It recommends starting moderate- or high-intensity statin therapy for most adults aged 40-75 years with diabetes or LDL ≥70 mg/dL. For those without diabetes but with a CVD risk of 7.5% or higher, it recommends discussing statin therapy. The guidelines also provide recommendations for managing statin side effects, evaluating risk factors, and refining risk assessment using coronary artery calcium scoring. The main messages are to emphasize lifestyle changes, use high-intensity statins for high-risk patients, and consider patient risk
Diabetes is fast gaining the status of a potential epidemic in India with more than 65 million diabetic individuals currently diagnosed with the disease. Ranked second in the world, the burden of the disease is expected to compound in the years to come. Worryingly, diabetes is now being shown to be associated with a spectrum of complications and to be occurring at a relatively younger age within the country.
It is a known fact that most of the diabetes cases in our country is managed by primary care Physicians(PCP) who have a pivotal role to play in ensuring that diabetes patients receive effective care by practicing evidence based management. This said, the sad fact is that health care providers-primary care and specialists alike are not managing our patients with diabetes as well as we should be.
The complexities of the disease and its association with lot of other medical conditions make the management of diabetes more challenging to the PCPs. Patients feeling of frustration and denial about having the chronic condition often are a challenge to the practitioners in convincing the patients for initiation of treatment. With no clear cut national policy guidelines for management of diabetes, we rely on western guidelines which have certain pitfalls and fallacies in our setting.
Hypertension is defined as high blood pressure with a systolic reading of 140 mmHg or higher or a diastolic reading of 90 mmHg or higher. It can be caused by primary or secondary factors. Primary hypertension makes up 90-95% of cases and has contributing lifestyle factors like increased sodium intake, obesity, lack of exercise, and excessive alcohol consumption. Secondary hypertension is caused by an underlying medical condition. Treatment involves lifestyle modifications like diet, exercise, weight loss and lowering sodium intake as well as medication to control blood pressure. The goal of treatment is to reduce cardiovascular risk by maintaining a blood pressure reading under 140/90 mmHg or under 130/80 mmHg for those with diabetes or kidney disease.
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
Updates on Hypertension (Short)- ISH 2020.pdfDr. Nayan Ray
This document summarizes updates on hypertension from the 2020 guidelines of the International Society of Hypertension. It discusses the definition and classification of hypertension based on office blood pressure measurements. It also covers diagnostic tests, hypertension-mediated organ damage, treatment including lifestyle changes and drug treatment, resistant hypertension, secondary hypertension, and hypertensive emergencies. The guidelines provide guidance on screening, assessing, and managing these hypertension-related conditions and circumstances.
SGLT2I The paradigm change in diabetes managementPraveen Nagula
Just like ARNI, SGLT2I have changed the face of diabetes management and they have a good profile in multimodality management because of pleiotropic effects
Dapagliflozin is an SGLT2 inhibitor that has shown benefits in managing type 2 diabetes and reducing cardiovascular outcomes. The document summarizes results from several key studies on dapagliflozin. The DECLARE-TIMI trial showed that dapagliflozin reduced the risk of cardiovascular death or hospitalization for heart failure compared to placebo in patients with type 2 diabetes with high cardiovascular risk. The DAPA-HF trial found that dapagliflozin reduced the risks of worsening heart failure or cardiovascular death compared to placebo in patients with heart failure regardless of diabetes status. Dapagliflozin also improved outcomes related to heart failure in the DEFINE-HF trial.
Dpp4i vs sglt2 inhibitors against the motionSujoy Majumdar
A debate showing why SGLT2 inhibitors have not have a major advantage over DPP4 inhibitors as the next add on drug after Metformin in the management of Type 2 Diabetes
1) Statins are highly effective in reducing LDL-C and cardiovascular risk, playing a cornerstone role in lipid management. They work by inhibiting HMG-CoA reductase.
2) Atorvastatin has been extensively studied in large trials and shown to significantly reduce major cardiovascular events when doses are increased from 10 mg to 80 mg.
3) Studies in India found that high dose atorvastatin (80 mg) was well tolerated and more effective at reducing LDL-C and hs-CRP than lower doses in ACS patients. However, many ACS patients in India were not receiving statins as recommended.
The EMPEROR-Preserved trial evaluated whether empagliflozin reduces cardiovascular death or hospitalization for heart failure in adults with either heart failure with mid-range or preserved ejection fraction. The trial randomized over 5,000 patients to empagliflozin 10 mg daily or placebo, with a median follow up of 26 months. Empagliflozin reduced the primary composite outcome of cardiovascular death or hospitalization for heart failure by 21% compared to placebo, driven mainly by a 29% lower risk of hospitalization for heart failure.
Empagliflozin is an SGLT2 inhibitor that has shown cardiovascular benefits in clinical trials. SGLT2 inhibitors work by inhibiting glucose reabsorption in the kidneys, leading to increased glucose excretion and reduced blood glucose levels. Empagliflozin in particular has demonstrated reductions in cardiovascular death and hospitalization for heart failure. However, SGLT2 inhibitors also carry risks like genitourinary infections and volume depletion that require monitoring. Overall, SGLT2 inhibitors provide an additional treatment option for type 2 diabetes that can help lower glucose levels while also reducing cardiovascular outcomes.
What’s new in Lipidology, Lessons from “recent guidelines“Arindam Pande
1. The 2018 ACC/AHA cholesterol guidelines provide 10 key take-home messages focusing on lifestyle management, statin therapy for various risk groups, and risk assessment approaches.
2. The guidelines emphasize lifestyle therapy and statins for secondary prevention, with an LDL-C goal of 70 mg/dL for very high risk patients to consider adding nonstatins.
3. They provide guidance on statin use for various primary prevention groups based on risk levels and discussion, including an expanded definition of intermediate risk factors.
Combination Therapy In Hypertension - Dr Vivek Baliga PresentationDr Vivek Baliga
Dr Vivek Baliga of Baliga Diagnostics, Bangalore, discusses the common combination therapies used in the management of hypertension in clinical practice.
Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. It has a prevalence of 0.5-24.7% depending on the population. Causes include nonadherence, lifestyle factors like obesity and sleep apnea, secondary causes like primary aldosteronism and renal artery stenosis, and drug interactions. Evaluation involves assessing medication adherence, lifestyle behaviors, screening for secondary causes with tests like the aldosterone-renin ratio, and imaging of the kidneys and arteries. Management consists of optimizing lifestyle modifications, adjusting medications like adding mineralocorticoid receptor antagonists, and treating any identified
The document summarizes clinical trials evaluating SGLT2 inhibitors:
1) The EMPA-REG trial found that empagliflozin reduced the risk of cardiovascular death, hospitalization for heart failure, and all-cause mortality compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
2) The CANVAS trial found that canagliflozin reduced the risk of major adverse cardiovascular events and hospitalization for heart failure compared to placebo in patients with type 2 diabetes at high cardiovascular risk.
3) The DECLARE-TIMI 58 trial found that dapagliflozin did not increase the risk of major adverse cardiovascular events compared to placebo in patients with type 2 diabetes
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
This document provides guidelines for healthcare professionals on managing diabetes during Ramadan fasting. It aims to give practical recommendations to minimize health risks for Muslims with diabetes who choose to fast. The guidelines cover topics like epidemiology, physiology, risk assessment, nutrition, medication adjustment, and implementing recommendations. They emphasize individualization and education as part of a diabetes management plan. The number of Muslims with diabetes is rising globally and most fast during Ramadan, so ensuring optimal care is important. More research is still needed, but these guidelines aim to provide immediate guidance for patients fasting in coming years.
This document discusses guidelines for treating diabetes and hypertension. It recommends that all diabetic patients have their blood pressure checked and receive non-pharmacological treatment. For those with BP above 140/90, single drug treatment should begin, while BP above 160/100 warrants two drugs. The preferred initial drugs are ACE inhibitors or ARB. Target blood pressure depends on cardiovascular risk factors. While cost is a consideration, affordable options exist like ACE/ARB plus thiazide diuretics or calcium channel blockers.
This lecture presents the 1-Updated recommendations regarding definition and proper diagnosis of HTN. 2-Updated guidelines for threshold of BP to start treatment and targets of treatment. 3- Updated recommendations on CV risk assessment and management. 4-Hypertension and comorbidities: updated guidelines
Simultaneous or Rapid Sequence Initiation of Quadruple Therapy for HFrEFDuke Heart
1) Initiating all four guideline directed medical therapies (GDMT) simultaneously or in rapid sequence for heart failure with reduced ejection fraction (HFrEF) provides early clinical benefits by reducing mortality and hospitalization within weeks.
2) Starting medications together enables better tolerance as therapies help patients tolerate side effects of each other. Delaying any medication needlessly increases risks.
3) There is no evidence that simultaneous initiation increases intolerance, and initiating at low doses with up-titration mitigates risks. Not starting medications exposes patients to worsening health outcomes.
Management strategy in HF with ARNI - Recent updates Praveen Nagula
- The document discusses management strategies for heart failure with reduced ejection fraction (HFrEF), including recent updates.
- It summarizes key differences between Indian and Western HF patients, noting that Indians develop HF at a younger age and with lower ejection fractions. Prognosis is also worse for Indian patients compared to those in the West.
- Core therapies for HFrEF are discussed, including a paradigm shift with the approval of sacubitril-valsartan which has been shown to reduce cardiovascular death compared to ACE inhibitors or ARBs alone in clinical trials.
The document provides guidelines for cholesterol management and cardiovascular disease (CVD) risk assessment. It discusses guidelines for measuring cholesterol and lipid levels, calculating LDL and VLDL values, and assessing CVD risk. It recommends starting moderate- or high-intensity statin therapy for most adults aged 40-75 years with diabetes or LDL ≥70 mg/dL. For those without diabetes but with a CVD risk of 7.5% or higher, it recommends discussing statin therapy. The guidelines also provide recommendations for managing statin side effects, evaluating risk factors, and refining risk assessment using coronary artery calcium scoring. The main messages are to emphasize lifestyle changes, use high-intensity statins for high-risk patients, and consider patient risk
Diabetes is fast gaining the status of a potential epidemic in India with more than 65 million diabetic individuals currently diagnosed with the disease. Ranked second in the world, the burden of the disease is expected to compound in the years to come. Worryingly, diabetes is now being shown to be associated with a spectrum of complications and to be occurring at a relatively younger age within the country.
It is a known fact that most of the diabetes cases in our country is managed by primary care Physicians(PCP) who have a pivotal role to play in ensuring that diabetes patients receive effective care by practicing evidence based management. This said, the sad fact is that health care providers-primary care and specialists alike are not managing our patients with diabetes as well as we should be.
The complexities of the disease and its association with lot of other medical conditions make the management of diabetes more challenging to the PCPs. Patients feeling of frustration and denial about having the chronic condition often are a challenge to the practitioners in convincing the patients for initiation of treatment. With no clear cut national policy guidelines for management of diabetes, we rely on western guidelines which have certain pitfalls and fallacies in our setting.
Hypertension is defined as high blood pressure with a systolic reading of 140 mmHg or higher or a diastolic reading of 90 mmHg or higher. It can be caused by primary or secondary factors. Primary hypertension makes up 90-95% of cases and has contributing lifestyle factors like increased sodium intake, obesity, lack of exercise, and excessive alcohol consumption. Secondary hypertension is caused by an underlying medical condition. Treatment involves lifestyle modifications like diet, exercise, weight loss and lowering sodium intake as well as medication to control blood pressure. The goal of treatment is to reduce cardiovascular risk by maintaining a blood pressure reading under 140/90 mmHg or under 130/80 mmHg for those with diabetes or kidney disease.
The document summarizes guidelines from the International Society of Hypertension (ISH), World Health Organization (WHO), American College of Cardiology/American Heart Association (ACC/AHA), and European Society of Cardiology/European Society of Hypertension (ESC/ESH) on the diagnosis and treatment of hypertension. It compares the guidelines on prevalence of hypertension, treatment thresholds and targets, drug choice and sequencing, and targets for specific patient groups. While the guidelines have some differences, they also have many similarities, including treatment targets of under 140/90 mmHg for most patients and under 130/80 mmHg for high-risk groups.
Updates on Hypertension (Short)- ISH 2020.pdfDr. Nayan Ray
This document summarizes updates on hypertension from the 2020 guidelines of the International Society of Hypertension. It discusses the definition and classification of hypertension based on office blood pressure measurements. It also covers diagnostic tests, hypertension-mediated organ damage, treatment including lifestyle changes and drug treatment, resistant hypertension, secondary hypertension, and hypertensive emergencies. The guidelines provide guidance on screening, assessing, and managing these hypertension-related conditions and circumstances.
This document discusses guidelines and considerations for clinical trials in hypertension. It provides information on:
1. The increasing global prevalence and costs of hypertension, with an estimated 1.6 billion hypertensive patients by 2025.
2. Guidelines for classifying and treating hypertension from organizations like JNC, WHO, and ESC/ESH. The JNC 8 guideline is evidence-based and recommends treatment thresholds, goals, and medications based on randomized controlled trials.
3. Methodological considerations for designing and conducting clinical trials to evaluate antihypertensive drugs and combinations, including study populations, measures of efficacy like blood pressure and target organ damage, safety aspects, and trial durations. Long-term safety data is important
This session will help pharmacists enhance their expertise in managing patients with hypertension through updates on the latest hypertension guidelines, discussion on the role that pharmacists can and should play in the detection and ongoing management of hypertension and hands-on experience with blood pressure measurement devices.
2020 International Society of Hypertension Global Hypertension Practice Guide...Angela Fonseca Latino
This document provides an overview and summary of the 2020 International Society of Hypertension (ISH) Global Hypertension Practice Guidelines. It begins with an introduction stating the purpose and motivation for developing worldwide guidelines. It describes the guideline development process, including the composition of the guidelines committee. The document then provides definitions of hypertension based on blood pressure readings and classifications of blood pressure levels. It outlines recommendations for diagnosing hypertension through office blood pressure measurements and details proper measurement techniques. The summary highlights the key goals and approaches of the 2020 ISH Global Hypertension Practice Guidelines.
This document provides guidelines for the management of hypertension from the International Society of Hypertension (ISH). It aims to provide evidence-based recommendations that are practical for both low and high resource settings.
The guidelines were developed by extracting evidence from recently published guidelines and tailoring them to be concise and easy to use globally. They define hypertension as a blood pressure over 140/90 mmHg based on office measurements. The guidelines recommend lifestyle modifications and pharmacological treatment for confirmed hypertension. They also provide guidance on diagnostic tests, risk factors, target organ damage, comorbidities and special circumstances like pregnancy. The goal is to reduce the global burden of raised blood pressure through practical standards of care.
Newest 2020 ISH global hypertension practice guidelinesChanRyan4
This document provides an introduction and table of contents for guidelines on the management of hypertension. It aims to provide evidence-based recommendations tailored for both high and low resource settings. The guidelines were developed by extracting content from recently published extensively reviewed guidelines. It recognizes that optimal care may not always be possible, so essential standards of care are provided that recognize limitations in clinical evidence and resources. The motivation for developing these guidelines is the large global burden of raised blood pressure, with awareness, treatment and control rates especially low in low- and middle-income countries.
This document provides guidelines for the management of hypertension from the International Society of Hypertension (ISH). It aims to extract evidence-based recommendations from major guidelines and tailor them for both high and low resource settings. Section 1 introduces the context and purpose of the guidelines, which is to reduce the global burden of raised blood pressure. It notes that while over 1 billion people have hypertension, rates of awareness, treatment and control remain low, especially in low- and middle-income countries. The guidelines thus seek to provide practical, globally-applicable recommendations to improve hypertension management worldwide.
This document discusses guidelines for the management of hypertension. Key points include:
- Longer-acting thiazide-like diuretics are preferred over shorter-acting thiazides.
- Single pill combinations should be used as first-line treatment for hypertension regardless of blood pressure level.
- Blood pressure targets are lower for those at high risk, such as a target under 120 mmHg systolic for those over age 50 with cardiovascular disease.
This document summarizes guidelines for the diagnosis and management of hypertension. It defines hypertension and outlines methods for blood pressure measurement, including office, ambulatory, and home monitoring. It discusses various hypertension guidelines and the changes in definitions. It also covers hypertensive crises, resistant hypertension, treatment goals, lifestyle modifications, and classes of antihypertensive medications.
This document provides guidance on the management of hypertension. It begins with educational objectives and a case study example. It then reviews the magnitude of hypertension, definitions of true hypertension versus white coat hypertension, and the role of ambulatory blood pressure monitoring. Guidelines for diagnosing and staging hypertension from ACC/AHA and JNC-8 are presented. Non-pharmacologic and pharmacologic treatment options are discussed, including diuretics, ACE inhibitors, ARBs, beta blockers, calcium channel blockers, and vasodilators. Resistant hypertension, hypertensive crises, and hypertension management in specific clinical contexts like stroke are also addressed. Recommendations are provided for evaluating and managing different patient cases.
- Hypertension is defined as systolic blood pressure over 140 mmHg or diastolic over 90 mmHg. Options for blood pressure measurement include office, ambulatory, and home monitoring.
- Ambulatory blood pressure monitoring provides advantages like identifying white-coat hypertension but is more expensive. Home blood pressure monitoring is cheaper but lacks nocturnal readings.
- Uncontrolled hypertension despite three or more antihypertensive classes at maximum dose is defined as resistant hypertension. Causes include non-adherence, secondary causes, and volume overload.
The 2015 CHEP Recommendations document provides an annual update on evidence-based guidelines for the treatment of hypertension in Canada. Key points include:
1) Clinic blood pressures should be measured using electronic monitors rather than auscultation. The diagnosis of hypertension should be based on out-of-office measurements such as ambulatory blood pressure monitoring.
2) The management of hypertension involves assessing global cardiovascular risk and providing vascular protection, including advising patients to quit smoking and considering medication to support smoking cessation.
3) Treatment of atherosclerotic renal artery stenosis is primarily medical, as stenting offers no additional benefits over optimal medical therapy alone.
The document provides guidelines for the management of hypertension from the 2020 International Society of Hypertension. It begins by defining its scope and purpose in providing worldwide guidelines tailored for both low and high resource settings. It then discusses definitions of hypertension, recommendations for blood pressure measurement, diagnostic evaluations, treatment approaches, and specific circumstances. The guidelines are intended to standardize hypertension care globally and address the needs of all clinical settings.
This study aimed to determine if early antihypertensive therapy in patients with acute ischemic stroke leads to different outcomes in those with and without a history of hypertension. Over 4 years, 4,071 patients were randomly assigned to either strict blood pressure control or usual care. Strict control led to greater reductions in blood pressure over 24 hours, 7 days and 14 days, with no differences in short-term death or disability regardless of hypertension history. However, early blood pressure reduction was associated with a lower rate of recurrent stroke in patients with a history of hypertension.
The document outlines guidelines for the management of arterial hypertension from the 2018 ESC/ESH conference. It discusses definitions of hypertension, recommendations for blood pressure measurement, classifications of hypertension, screening and diagnosis, assessment of hypertension-mediated organ damage, and initiation of blood pressure-lowering treatment. Key points include defining hypertension as a blood pressure over 140/90 mmHg, outlining options for office and out-of-office blood pressure measurement, stratifying cardiovascular risk, and recommending prompt initiation of treatment for grade 2 or 3 hypertension or grade 1 hypertension with high risk or organ damage.
HYPERTENSION introduction, recommendations for accurate measurements of BP, evaluation of patient with hypertension, management of patient with hypertension, resistant hypertension, hypertensive crisis, hypertensive emergencies
Hypertension- Update on current guideline 02.18.16Thu Nguyen
The presentation provided an overview of current hypertension guidelines, discussing the JNC7, JNC8, and American/International Society of Hypertension guidelines. It summarized the SPRINT clinical trial which evaluated maintaining a systolic blood pressure of 120 mmHg among adults aged 50+. The presentation also briefly touched on reimbursement issues around guideline compliance and ended with an opportunity for questions.
Protocols and Pathways Ischemic and Hemorrhagic Strokes.pptFitz Jaminit
This document discusses protocols and clinical pathways for ischemic and hemorrhagic stroke. It defines clinical pathways as multidisciplinary and evidence-based approaches to standardized patient care, while protocols provide guideline-based outlines for managing specific conditions. The document reviews evidence that clinical pathways can streamline stroke care, avoid delays, and improve outcomes. It identifies key components for inclusion in ischemic and hemorrhagic stroke pathways, such as diagnostic testing, treatment guidelines, and monitoring plans. Examples of pathways are provided to illustrate components like blood pressure and nutrition management in the first 72 hours after different stroke types.
Hypertension is a major public health concern affecting over 1 billion people worldwide. It is a leading cause of death and its prevalence is increasing. The document discusses guidelines for defining and classifying hypertension from organizations like JNC and WHO. It also summarizes lifestyle modifications and pharmacological treatments recommended for managing hypertension, including initial drug classes like ACE inhibitors, ARBs, calcium channel blockers, and thiazides. The guidelines emphasize starting with one drug and titrating dosage before adding additional medications to control blood pressure.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central19various
Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central Clinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa CentralClinic ^%[+27633867063*Abortion Pills For Sale In Tembisa Central
4. Introduction
• 1.39 billion estimated with hypertension in 2010
• 349 million from HIC
• 1.04 billion from LMIC
5. Introduction
• To align with the mission of the ISH:
to reduce the global burden of raised BP –
we developed the ISH 2020 Global Hypertension
Practice Guidelines for adults.
• We extracted evidence-based content from recently
published guidelines and tailored
standards of care; and
standards of care
6. Introduction
The ISH 2020 Global Hypertension Practice Guidelines
were thus developed based on evidence criteria,
a) to be used globally
b) to be fit for application in low-resource and high-
resource settings by advising on and
ooooooo standards of care; and
c) to be concise, simplified and easy to use by
clinicians, nurses and community health workers,
as appropriate.
8. Process of Writing
Scepticism
● Is it necessary at all?
● Is this a hypersimplistic view?
● Is it strictly evidence-based?
● Is it helpful for low-income settings?
9. Process of Writing
1st Meeting of ISH Hypertension Guidelines Committee
Feb. 3, 2019 London, UK
Further Meetings: Paris, France (28.08.2019),
Frankfurt, Germany (01.12.2019), Glasgow, UK (26.02.2020)
Thomas Unger (Chair) The Netherlands
Claudio Borghi Italy
Fadi Charchar Australia
Nadia Khan Canada
Neil Poulter United Kingdom
Dorairaj Prabhakaran India
Agustin Ramirez Argentina
Markus Schlaich Australia
George Stergiou Greece
Maciej Tomaszewski United Kingdom
Richard Wainford USA
Bryan Williams United Kingdom
Alta Schutte S Africa/Australia
COMMITTEE:
13 ISH Scientific
Council members
10. Process of Writing
Define our goal (1):
● Not to review the current evidence again - done by
ACC/AHA-, ESC/ESH- and other colleagues.
● Develop a balanced practical, realistic, feasible hands-
on proposal for global use in line with the ISH mission.
11. Process of Writing
Define our Goal (2):
● Stick to recent guidelines (ESC/ESH, ACC/AHA,
NICE) as background.
● Define ESSENTIAL vs OPTIMAL criteria of
diagnosis and treatment according to resources
availability in LMI vs HI settings.
12. Process of Writing
● Definition of office hypertension
● Diagnosis of hypertension (office and out-of-of office)
● Investigation (essential vs optimal tests)
● Non-pharmacological measures
● Treatment initiation (duration of observation, BP level,
high-risk groups)
● Stepwise drug choices – Combination therapies
● Goal of treatment
● When to refer to hypertension specialist
● Long-term follow-up plan (how often do you see Dr.)
Practical questions to be addressed:
13. Process of Writing: Contents
Section 1. Introduction
Section 2. Definition of Hypertension
Section 3. Blood Pressure Measurement and Diagnosis of Hypertension
Section 4. Diagnostic and Clinical Tests
Section 5. Cardiovascular Risk Factors
Section 6. Hypertension-mediated Organ Damage
Section 7. Exacerbators and Inducers of Hypertension
Section 8. Treatment of Hypertension
8.1. Lifestyle Modification
8.2. Pharmacological Treatment
8.3. Adherence to Antihypertensive Treatment
Section 9. Common and other Comorbidities of Hypertension
Section 10. Specific Circumstances
10.1. Resistant Hypertension
10.2. Secondary Hypertension
10.3. Hypertension in Pregnancy
10.4. Hypertensive Emergencies
10.5. Ethnicity, Race and Hypertension
Section 11. Resources
Section 12. Hypertension Management at a Glance
14. Process of Writing
● Internal Review: Each section reviewed by another
member of the Guidelines committee
● External Review. Two rounds with 24 Experts around the
world with special consideration of colleagues from LMICs
Review Process
15. Document Reviewers (24)
Hind Beheiry Sudan
Irina Chazova Russia
Albertino Damasceno Mozambique
Anna Dominiczak UK
Anastase Dzudie Cameroon
Stephen Harrap Australia
Hiroshi Itoh Japan
Tazeen Jafar Singapore
Marc Jaffe USA
Patricio Jaramillo-Lopez Colombia
Kazuomi Kario Japan
Giuseppe Mancia Italy
Ana Mocumbi Mozambique
Sanjeevi N. Narasingan India
Elijah Ogola Kenya
Srinath Reddy India
Ernesto Schiffrin Canada
Ann Soenarta Indonesia
Rhian Touyz UK
Yudah Turana Indonesia
Michael Weber USA
Paul Whelton USA
Xin Hua Zhang Australia
Yuqing Zhang China
16. May 6: Online in Journal of Hypertension, Hypertension
May 6: First Webinar: Global and Chinese
May 20: Second Webinar with Q & A.
Internet, Social Media:
Homepage ISH:
Translations:
Publication Schedule
21. ● 2-3 office visits at 1-4-week
intervals.
● Whenever possible, the
diagnosis should not be made
on a single visit (unless BP
≥180/110 mmHg and CVD).
● If possible and available the
diagnosis of hypertension
should be confirmed by out-
of-office measurement.
Office Blood Pressure
Measurement
Blood Pressure Measurement and
Diagnosis of Hypertension
22. Protocol
Interpretation
• Average 2nd-3rd
measurement
• 2-3 office visits
required
OFFICE BP MEASUREMENT
Conditions
Position
• Setting
• Body position
• Talking
Device
Cuff
• Validated electronic
upper-arm cuff
(www.stridebp.org)
• Alternatively manual
auscultatory device
• Cuff size
Blood Pressure Measurement and
Diagnosis of Hypertension
23. ABLE 4. Blood pressure measurement plan according to office blood pressure levels
Office blood pressure levels (mmHg)
<130/85 130-159/85-99 >160/100
Remeasure within 3 years
(1 year in those with other
risk factors)
If possible confirm with
out-of-office blood
pressure measurement
(high possibility of white
coat or masked
Confirm within a few days
or weeks
• Confirm within a
few days/weeks.
• Remeasure within
3 years (1 year if
other risk factors).
• If possible confirm with
out-of-office measurement.
• Alternatively confirm with
repeated office visits.
BP Measurement Plan according to Office BP levels
Blood Pressure Measurement and
Diagnosis of Hypertension
24. Office Blood Pressure
Initial evaluation
● Measure BP in both arms. Difference >10
mmHg: use arm with higher BP; >20 mmHg:
consider further investigation.
Standing BP
● In treated patients when symptoms of
postural hypotension.
● At first visit in elderly and diabetics.
Unattended BP
● More standardized. Lower BP levels with
uncertain threshold.
● Out-of-office BP again needed in most cases.
Blood Pressure Measurement and
Diagnosis of Hypertension
26. Home BP Monitoring Ambulatory BP Monitoring
Blood Pressure Measurement and
Diagnosis of Hypertension
27. ● Intermediate CV risk.
● If low total CV risk and no
organ damage, drug treatment
may not be prescribed.
● Follow with lifestyle changes.
● Similar CV risk as
sustained hypertensives.
● Drug treatment may be
required aiming to
normalise out-of-office BP.
White-coat Hypertension Masked Hypertension
Blood Pressure Measurement and
Diagnosis of Hypertension
31. Cardiovascular Risk Factors
● More than 50% of hypertensive patients have additional
CV risk factors
● Most commonly: Met Syn, T2DM, lipid disorders, uric acid
● CV risk assessment is important and should be assessed
in all hypertensive patients
● Consider increased risk with: chronic inflammatory disease,
COPD, psychiatric disorders, psycho-social stressors
34. Hypertension-mediated Organ Damage
● Hypertension-mediated organ damage (HMOD) defined as
structural or functional alterations of arterial vasculature
and/or organs it supplies caused by elevated BP.
● HMOD assessment can provide important therapeutic
guidance on:
1. management for hypertensive patients with low or
moderate overall risk through re-classification due to
presence of HMOD.
2. preferential selection of drug treatment based on the
specific impact on HMOD.
35. Hypertension-mediated Organ Damage
HMOD Assessment
● Brain
● Eyes
● Heart
● Kidneys
● Arteries
Serial assessment of HMOD
may help to determine efficacy of treatment
● Serum creatinine
● eGFR
● Dipstick urine test
● 12-lead ECG
38. ● Specific medications and substances may increase
BP or antagonize antihypertensive therapy.
● The effect on BP can vary widely between individuals.
● All patients with or at risk for hypertension be
screened for such medications and substances.
● Where appropriate, consider reducing or eliminating
these substances or medications.
Exacerbators & Inducers of Hypertension
39. Most common medications that can increase BP
● Non-selective or traditional NSAIDs
● Combined oral contraceptive pill
● Select anti depressant medications including tricyclic
antidepressants and SNRIs
● Acetaminophen when used almost daily and for
prolonged periods
Exacerbators & Inducers of Hypertension
40. ● The effect of Anti-retroviral therapy is unclear as studies
demonstrate either no effect on BP or some increase.
● Alcohol raises BP regardless of the type of alcoholic
drink.
● Limited evidence on herbal and other substances.
● Ma Huang, Ginseng at high doses and St. John’s Wort
reported to increased BP.
Exacerbators & Inducers of Hypertension
42. ● Healthy lifestyle choices can prevent or delay
the onset of high BP and can reduce CV risk
● Lifestyle modification is often the first line of
antihypertensive treatment.
● Modifications in lifestyle can also enhance the
effects of antihypertensive treatment.
Non-pharmacological Treatment
43. Non-pharmacological Treatment - Diet
● Reducing salt added when preparing foods and at the
table. Avoid or limit consumption of high salt foods.
● Eating a diet rich in whole grains, fruits, vegetables, poly-
unsaturated fats and dairy products, such as DASH diet.
● Reducing food high in sugar, saturated fat and trans fats.
● Increasing intake of vegetables high in nitrates (leafy
vegetables and beetroot). Other beneficial foods and
nutrients include those high in magnesium, calcium and
potassium (avocados, nuts, seeds, legumes and tofu).
44. ● Moderate consumption of healthy drinks (coffee,
green and black tea, Karkadé (Hibiscus) tea,
pomegranate juice, beetroot juice and cocoa.
● Moderation of alcohol consumption and
avoidance of binge drinking.
● Reduce weight and avoid obesity.
● Be careful with complementary, alternative or
traditional medicines – little/no evidence.
Non-pharmacological Treatment - Diet
45. ● Smoking cessation.
● Engage in regular moderate intensity aerobic and
resistance exercise, 30 minutes on 5 – 7 days per
week or HIIT (High Intensity Interval Training).
● Reduce stress and introduce mindfulness.
● Reduce exposure to air pollution and cold temperature.
Non-pharmacological Treatment - Lifestyle
46. Drug Treatment of Hypertension
Neil Poulter
2020 ISH Global
Hypertension Practice Guidelines
49. TABLE 9. Ideal Characteristics of Drug Treatment
1.
Treatments should be evidence-based in relation to morbidity/mortality
prevention.
2. Use a once-daily regimen which provides 24-hour blood pressure control.
3. Treatment should be affordable and/or cost-effective relative to other agents.
4. Treatments should be well-tolerated.
5.
Evidence of benefits of use of the medication in populations to which it is to be
applied.
Ideal Drug Characteristics
Drug Treatment of Hypertension
50. Drug Treatment of Hypertension
Drug Treatment Threshold
≥140/90 mmHg (raising to ≥160/100 mmHg
for those at lowest risk)
Summary 1
In established hypertension, uncontrolled by lifestyle measures:
Drug Treatment Target
Optimal: <65 years: <130/80 mmHg
≥65 years: <140/90 mmHg
: reduce BP by ≥20/10 mmHg
51. Drug Treatment of Hypertension
(i) Uptitration to target, of the following:
Low dose A+C Full dose A+C A+C+D
A+C+D + spironolactone
(ii) Consider other initial combinations for
specific patient subgroups
(iii) Use SPC’s where possible
(iv) Use thiazide-like diuretics preferentially
• Where less ideal agents are available, focus
on effective BP lowering (≥20/10 mmHg)
Summary 2
53. Comorbidities of Hypertension
● Most Hypertensive patients have several comorbidities
affecting CV risk profile and treatment strategies.
● The number of comorbidities increases with age, duration
of hypertension and emerging clinical complexity.
● The management of comorbidities is insufficent.
● Common and uncommon comorbidities should be identified
and managed according to the best available evidence.
54. Comorbidities of Hypertension
● Well established common comorbidities include CAD,
stroke, CKD, Heart failure, COPD and HIV/AIDS.
● Emerging uncommon comorbidities include
rheumatic/inflammatory diseases and psychiatric diseases.
● Uncommon comorbidities are largely underestimated by
guidelines and often treated with self-prescribed drugs
frequently interfering with BP control.
55. Comorbidities of Hypertension
In patients with common comorbidities the therapeutic
strategy depends on CV risk profile and includes:
● Lifestyle changes (diet, exercise, body weight,
smoking).
● BP control to target.
● Effective treatment of CV risk factors (LDL-C,
Fasting Glucose, SUA).
● Antiplatelet therapy in patients with CVD.
56. Comorbidities of Hypertension
TABLE 10. Outline of evidence-based management of other comorbidities and hypertension
Additional
co-morbidity
Recommended Drugs Warning
Rheumatic
disorders
• RAS-inhibitors and CCBs ± Diuretics
• Biologic drugs not affecting blood pressure
should be preferred
(where available)
High doses of
NSAID’s
Psychiatric
disorders
• RAS-inhibitors and diuretics
• Beta-blockers (not metoprolol) if drug-induced
tachycardia (antidepressant, antipsychotic
drugs).
• Lipid-lowering drugs/Antidiabetic drugs
according to risk profile
Avoid CCBs if
orthostatic
hypotension (SRI’s)
RAS: Renin-Angiotensin System; CCBs: Calcium Channel Blockers; NSAID's: Non-
Steroidal Anti-Inflammatory Drugs; SRI’s: Serotonin Reuptake Inhibitors
Additional
co-morbidity
Recommended Drugs Warning
58. ● Suspect resistant hypertension if office BP >140/90 mmHg
on treatment with at least 3 antihypertensives (in maximal
or maximally tolerated doses) including a diuretic.
● Exclude pseudo-resistant hypertension (white-coat effect,
non-adherence to treatment, incorrect BP measurements,
errors in antihypertensive therapy) and substance-induced
hypertension as contributors.
● Optimise health behaviours and lifestyle.
Resistant Hypertension
59. ● Consider changes in the diuretic-based treatment prior to
adding the fourth antihypertensive medication.
● Add a low dose of spironolactone (if serum potassium is <4.5
mmol/L and eGFR is >45 ml/min/1.73 m2).
● Consider amiloride, doxazosin, eplerenone, clonidine and
beta-blockers as alternatives to spironolactone. If unavailable,
consider any antihypertensive class not already in use.
● Optimally, consider referring to a specialist centre with
sufficient expertise/resources.
Resistant Hypertension
61. • Consider screening for secondary hypertension in:
early onset hypertension, resistant hypertension, sudden BP
control deterioration, hypertensive urgencies and emergencies,
high clinical probability of secondary hypertension.
• Exclude:
pseudo-resistant hypertension and drug/substance-induced
hypertension prior to investigations for secondary hypertension.
Secondary Hypertension
62. Basic screening for secondary hypertension
thorough history + physical examination (clinical clues) +
basic blood biochemistry (including serum sodium,
potassium, eGFR, TSH) + dipstick urine analysis.
Arrange other investigations for secondary hypertension
(additional biochemistry/imaging/others) based on information
from history, physical examination and basic clinical
investigations and/or if feasible refer to a specialist centre
Secondary Hypertension
65. Hypertension in Pregnancy
● Affects 5-10% of pregnancies worldwide.
● Maternal risks include placental abruption, stroke
and long term risk of cardiovascular disease.
● Fetal and newborn risks include fetal growth
restriction, pre-term delivery, increased fetal and
neonatal morbidity and mortality.
66. BP Measurement in Pregnancy
Essential
• Use either: office manual auscultation or an office
automated upper arm BP device validated specifically
in pregnancy (www.stridebp.com).
Optimal
• Use either 24hr ABPM or home BP monitoring
validated in pregnancy to evaluate white coat
hypertension.
Hypertension in Pregnancy
67. Investigation of Hypertension in Pregnancy
Essential
• Urinalysis, complete blood count, liver enzymes,
serum uric acid and serum creatinine.
• Test for proteinuria in early and the second half
of pregnancy. A positive urine dipstick should be
followed with a spot UACR.
Optimal
• Ultrasound of kidneys, doppler ultrasound of
uterine arteries
Hypertension in Pregnancy
68. Prevention of Pre-eclampsia
In women at increased risk of pre-eclampsia:
• Aspirin (75-162 mg/day) and
• Oral calcium (1.5-2 g/day if low dietary intake)
• Increased Risk: 1st pregnancy >40 y age,
pregnancy interval >10 y, BMI >35 kg/m2, multiple
pregnancy, chronic hypertension, diabetes, CKD,
autoimmune disease, hypertension in previous
pregnancy or family history of pre-eclampsia
Hypertension in Pregnancy
69. Management (1)
Initiate Drug treatment if BP persistently:
• >150/95 mmHg in all women
• >140/90 mmHg if gestational hypertension or
subclinical HMOD
First Line Drug Therapy Options
Methyldopa, beta-blockers (labetalol), and
Dihydropyridine-Calcium Channel Blockers (DHP-CCBs)
Hypertension in Pregnancy
70. Management (2)
If SBP ≥170mmHg or DBP ≥110mmHg (Emergency):
• Immediately hospitalize
• Initiate IV labetalol (alternative i.v. nicardipine,
esmolol, hydralazine, urapidil), or oral methyldopa or
DHP-CCBs)
• Magnesium
• If pulmonary edema, IV nitroglycerin
Hypertension in Pregnancy
71. Hypertension in Pregnancy
Delivery in Gestational Hypertension or Pre-Eclampsia
• At 37 weeks if asymptomatic
• Expedite delivery in women with pre-eclampsia with
visual disturbances or haemostatic disorders or HELLP
syndrome.
Post Partum
• ESSENTIAL Lifestyle adjustment
• OPTIMAL: Lifestyle adjustment with annual BP checks
73. Emergency:
• Severely elevated BP associated with acute
hypertension mediated organ damage (HMOD).
• Requires immediate BP lowering, usually with IV
therapy.
Urgency:
• Severely elevated BP without acute HMOD.
• Can be managed with oral antihypertensive agents.
Hypertensive Emergencies
74. Hypertensive Emergencies
Assessment
Essential:
• Clinical exam: Evaluate for HMOD including fundoscopy
• Investigations: Hemoglobin, platelets, creatinine, sodium,
potassium, lactate dehydrogenase, haptoglobin,
urinalysis for protein, urine sediment, ECG.
75. Assessment
Optimal:
In addition, context specific testing:
• Troponins (chest pain or anginal equivalent)
• Chest x-ray (congestion/fluid overload)
• Transthoracic echocardiogram (cardiac structure and
function)
• CT/MRI brain (cerebral hemorrhage/stroke)
• CT-angiography thorax/abdomen (acute aortic disease)
Hypertensive Emergencies
76. Management
● Requires immediate BP lowering to prevent or
limit further HMOD
● Sparse evidence to guiding management –
recommendations largely consensus based.
● Time to lower BP and magnitude of BP
reduction depends on clinical context.
● IV Labetalol and nicardipine generally safe to
use in all hypertensive emergencies
Hypertensive Emergencies
78. Ethnicity, Race and Hypertension
Doraidaj Prabhakaran
2020 ISH Global
Hypertension Practice Guidelines
79. Prevalence, treatment and control rates vary
significantly according to ethnicity
Mainly attributed to:
- Genetic differences
- Contextual and cultural practices
• Lifestyle and socio-economic status differences
• Health behaviors such as diet, alcohol and PA
- Access to health system
- Availability and Distribution of essential drugs
Ethnicity, Race and Hypertension
80. Populations from African descent
• Hypertension & associated organ damage at younger ages.
• Resistant & nighttime hypertension.
• Risk of kidney disease, stroke, HF & mortality.
• ? Physiological differences ( RAAS, altered renal sodium
handling, CV reactivity & early vascular aging).
Ethnicity, Race and Hypertension
81. Populations from AFRICAN descent
Management of hypertension:
● Annual screening (for adults >18 years)
● Lifestyle modification
● First line pharmacological therapy – single pill
combination (thiazide-like diuretic + CCB or CCB + ARB)
ARBs preferred over ACEIs among black patients
(3x chances of angioedema with ACEIs)
Ethnicity, Race and Hypertension
82. Populations from ASIA
● Morning & nighttime hypertension vs Europeans
EAST ASIAN populations
● Likelihood of salt-sensitivity + mild obesity in
hypertensive patients
● Stroke prevalence (esp. hemorrhagic) & non-
ischemic HF vs Western populations
SOUTH ASIAN populations (Indian subcontinent)
● Risk for CV & metabolic diseases (CAD & T2DM)
Management of hypertension
SOUTH EAST ASIA: Standard treatment until more
evidence becomes available
Ethnicity, Race and Hypertension
86. ISH- vs European Guidelines
Bryan Williams
2020 ISH Global
Hypertension Practice Guidelines
87. ISH vs European Guidelines
ESC-ESH 2018 ISH 2020
Target Population Focus on Optimal Care
Optimal Care when possible
Essential Care as a minimum
BP Classification
and Definition
of Hypertension
Based of office BP
Hypertension ≥140/90mmHg
Based on Office BP
Hypertension ≥140/90mmHg
Diagnosis
of Hypertension
Screening: Office BP
Confirmation: ABPM, Home, or
repeated office BP
Optimal: Same as ESC-ESH
Essential: Office BP, confirm
with ABPM or Home BP if
possible
Cardiovascular
Risk Assessment
High Risk: CV disease, CKD3,
Diabetes, HMOD
CV risk assessment in all others
Same as ESC-ESH
CV risk assessment tool not
specified
Drug Treatment
BP Threshold
Drug Treatment & Lifestyle for:
Grade 2 hypertension
Grade 1 & High risk
Grade 1 & low risk after 3-6
months lifestyle intervention
Same as ESC-ESH
Essential: Focus on Grade 2
and high-risk Grade 1 if
resources limited
88. ESC-ESH 2018 ISH 2020
Lifestyle
Interventions
Smoking cessation, healthy
diet/drinks, reduce salt, alcohol
moderation, weight control and
regular exercise
Same as ESC-ESH
Optimal: In addition, stress
reduction and avoid air pollution
Initial Drug
Treatment
Dual therapy single pill
combination (SPC) for most patients
- Usually A+C or A+D
Beta-blockers when indicated Other
Drugs for Specific indications
Optimal: Ideally A+C SPC for
most, or C+D in Black patients.
Other drugs same as ESC-ESH
Essential: As above if possible,
or any available drugs proven to
lower BP
Further Drug
Treatment
Triple therapy:
A+C+D, ideally as SPC
Four drugs (Resistant Hypertension)
e.g. spironolactone, or other drugs if
needed
Optimal: Same as ESC-ESH
Essential: As above if possible,
or any available drugs proven to
lower BP
ISH vs European Guidelines
89. ESC-ESH 2018 ISH 2020
Treatment
Targets
Target Ranges
18-65yrs <140/90mmHg down
to to 130/80mmHg or lower if
tolerated
65+yrs <140/90mmHg down to
130/80mmHg, if possible and if
tolerated
Optimal: <130/80 but
individualize in the elderly
based on frailty
Essential: Reduce BP by at
20/10mmHg and ideally to
<140/90 and individualize in
the elderly based on frailty
Monitoring
Treatment
Aim for BP control within 3
months
Monitor for side effects
Check adherence if BP not
controlled
Optimal and Essential:
Aim for BP control within 3
months
Monitor for side effects
Monitor adherence
Cardiovascular
Risk
Management
Statins for all high-risk patients
Consider statins for
moderate/low risk patients
Antiplatelets for secondary prev.
No specific recommendation
ISH vs European Guidelines
90. ISH- vs ACC/AHA Guidelines
Richard Wainford
2020 ISH Global
Hypertension Practice Guidelines
91. ISH vs ACC/AHA Guidelines
● Blood pressure definitions of normal blood pressure
stages of hypertension are different.
● Inclusion of high-normal blood pressure category.
● Blood pressure value thresholds for treatment are
therefore different (i.e., treatment initiated at lower
blood pressure in ACC/AHA guidelines).
● Adoption of essential vs. optimal throughout ISH
guidelines.
92. TABLE 1. Classification of hypertension based on office blood pressure (BP) measurement*
Category Systolic (mmHg) Diastolic (mmHg)
Normal BP <130 and <85
High-normal BP 130-139 and/or 85-89
Grade 1
Hypertension
140-159 and/or 90-99
Grade 2
Hypertension
≥160 and/or ≥100
*Isolated Systolic Hypertension (see text above)
ISH vs ACC/AHA Guidelines
93. ISH- vs Latin American Guidelines
Agustin Ramirez
2020 ISH Global
Hypertension Practice Guidelines
94. ISH vs Latin American Guidelines
LA and Challenges Referring Arterial Hypertension
● Among the challenges common to all parts of the world, in
LA there are growing global burden of morbidity and
premature mortality associated with NCDs and the
financial constraints and inefficiencies that traditional
healthcare models have for coping with chronic diseases.
● Specific challenges result from the fact that LA is one of
the world regions with the greatest disparities in socio-
economic conditions and availability of healthcare.
95. ISH vs Latin American Guidelines
● In general, more congruence than discrepancy
between the new ISH 2020 Guidelines and the last
Latin America Guidelines of 2017.
● Diagnosis and use of Office and Out of Office blood
pressure measurements, Ambulatory or Home
Blood Pressure Monitoring are points of agreement.
96. ISH vs Latin American Guidelines
Classification
LASH
SBP/DBP
(mmHg)
Optimal <120/<80
Normal 120-129/80-84
High Normal 130-139/85-89
Arterial Hypertension
Grade 1 140-159/90-99
Grade 2 160-179/100-109
Grade 3 >180/>110
Isolated Systolic ≥140/<90
Categories
ISH
SBP/DBP
(mmHg)
Not Considered
Normal <130/<85
High Normal 130-139/85-89
Arterial Hypertension
Grade 1 140-159/90-99
Grade 2 ≥160/≥100
Isolated Systolic Included in Text
97. Non-Pharmacological Treatment
● Despite the differences in the usual daily diet in LA, there is
agreement on the benefit of lifestyle changes to the general
population.
Common and Other Comorbidities
● Due to the prevalence of specific pathologies, the LA
Guidelines emphasize the accuracy in diagnosis and treatment
of malnutrition, especially in children and adolescents.
Relating to Ethnic Populations
● In addition to Afro-descendants, the LA Guidelines give
directives for people living on high altitude in the Andes
Mountain Range (Andinean populations).
ISH vs Latin American Guidelines
98. ISH- vs Japanese Guidelines
Hiroshi Itoh
2020 ISH Global
Hypertension Practice Guidelines
99. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● Office BP ≥140/90 mmHg is the criterion of hypertension in JSH
2019, which the same in ISH 2020.
● Normal BP <120/80 mmHg, in contrast to ISH 2020 <130/85 mmHg.
● JSH 2019 has a category of “Elevated BP,” which implies a disease
-state required for intervention.
● JSH 2019 shows the criteria of both office and home BP with equal
values for BP classification.
100. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● “Elevated BP” in JSH 2019 is regarded as having high risk
when it is complicated with CVD, diabetes, CKD with
proteinuria, nonvalvular atrial fibrillation or >3 risk factors.
● That is the case with “high-normal BP” in ISH 2020. It can
be high risk if it is complicated with hypertension-mediated
organ damage, CKD grade 3, diabetes mellitus, or CVD.
101. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● In patients with” elevated BP”, pharmacological therapy can
be initiated when CV risk is high and BP control is insufficient
with non-pharmacological therapy.
● That is the case with “high-normal BP” in ISH 2020 and 2018
ESC/ESH guidelines, which indicate that drug treatment
should be considered if CV risk is very high.
102. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● In ISH 2020, the diagnosis of hypertension is made by
repeated office BP but not home BP.
● In JSH 2019, the diagnosis of hypertension is made by
office BP and home BP.
● When an office BP-based diagnosis differs from a home
BP-based diagnosis, the latter is prioritized.
103. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● In ISH 2020 the BP target differs at age 65 years, but in JSH
2019 at 75 years.
● In JSH 2019, BP of patients with CVD, CAD, diabetes, CKD
with proteinuria or on antithrombotic drugs should be lowered
to <130/80, even if in age ≥75 years.
● In ISH 2020, the lower limit (120/70) is shown.
● JSH 2019 calls attention against excessive BP lowering.
104. ● JSH 2019 gives concrete values to the goals.
● ISH 2020 gives additional goals.
Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
105. Japanese Society of Hypertension
Hypertens Res 2019;42:1235-1481.
● As 1st line, JSH recommends monotherapy, whereas ISH 2020
recommends combination therapy using combination tablet.
● In JSH 2019, thiazide diuretics are included in 1st line drugs.
● JSH 2019 does not mention triple combination using single pill.
● In JSH 2019, β- and α-blockers are equally recommended as
MR antagonist at step 4.