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

1. Paradigm Shifts in
Hypertension Management
Dr. Sachin Verma MD, FICM, FCCS, ICFC
Fellowship in Intensive Care Medicine
Infection Control Fellows Course
Consultant Internal Medicine and Critical Care
Web:- http://www.medicinedoctorinchandigarh.com
Mob:- +91-7508677495

2. Paradigm Shifts in
Hypertension Management
1. Hypertension is an important global problem;
Controlling it is challenging; All have room for
improvement
2. Focus on BP goal attainment– sooner rather than
later
3. Resort to combination therapy readily
4. Prevent or reduce target organ damage
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4. Global Burden of Hypertension
2025 Projection
Year 2000 Year 2025
• 26.4% of world adult • 29.2% of world adult population
population had hypertension will have hypertension
• Total of 972 million adults • Total of 1.56 billion adults
(60% ↑ overall; 24% ↑ in
developed nations, 80% ↑ in
developing nations)
• Highest prevalence will be in
• Highest prevalence is in
economically developing
established market
continents (eg, Asia, Africa)
economies (eg, North – will account for 75% of world’s
America, Europe) hypertensive patients
Kearney PM et al. Lancet. 2005;365:217-223.

6. Long-Term Antihypertensive Therapy
Significantly Reduces CV Events
Myocardial
Stroke infarction Heart failure
0
–10
–20
Average
reduction –30 20%-25%
in events
(%) –40
35%-40%
–50
>50%
–60
Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

7. Consensus Target BP Levels Since JNC 7 in the
Prevention and Management of
Ischemic Heart Disease
American Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention <140/90
High CAD risk* <130/80
Stable Angina <130/80
Unstable Angina/NSTEMI <130/80
STEMI <130/80
LV Dysfunction <120/80
*High CAD risk = diabetes mellitus, chronic kidney disease, known CAD,
CAD equivalent (carotid artery disease, peripheral artery disease, abdominal
aortic aneurysm), or 10-year Framingham risk score >10%
Rosendorff et al, Circulation,2007;115: 2761-2788

8. Inadequate Control of Hypertension
• New England VA Study
– 800 men; mean age, 66 years, many with comorbid
conditions
– Mean duration of HTN = 12.6 years
– Index visit BP: 146/84 mmHg
– Mean of 6.4 hypertension-related visits per year
• Followed for two 2 years
< 25% reached goal BP < 140/< 90 mm Hg
– 40% had BP ≥ 160/≥ 90 mm Hg
• Percentage of visits where therapy was increased:
– 11.2% overall
– 22%, if DBP ≤ 90 mm Hg and SBP ≥ 165 mm Hg
– 35% of time when DBP > 90 mmHg
Berlowitz et al. N Engl J Med. 1998;339:1957-1963.
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9. Inadequate Control of Hypertension
Clinical Inertia
• In 75% of visits documenting elevated blood
pressure, physicians failed to increase the dose
of antihypertensive medications or to try new
treatments.
• But clinicians did not ignore patients with
elevated blood pressure. Follow-up visits
occurred 2-3 weeks sooner for patients with
poorly controlled hypertension.
• Thus, although physicians closely monitored
elevated blood pressure, they repeatedly
delayed making changes to a patient’s regimen.
Berlowitz et al. N Engl J Med. 1998;339:1957-1963.
V052004

10. Therapeutic (Clinical) Inertia?
Causes:
 Satisfaction with current BP level
The failure of  Elevated SBP more acceptable
health care
 Use of “soft” reasons to avoid
providers to intensifying therapy
initiate or  Time constraints (15 min visits)
intensify
 Reluctance to use combination therapies
therapy when
 Competing priorities
indicated
Phillips LS et al. Ann Intern Med. 2001;135:825–834.

11. Value: Early Onset of BP Effect
“The trial gives new insights into the clinical
importance of the rate of achieving BP
control:
BP goals need to be reached within a
relatively short time (weeks rather than
months), at least in patients with hypertension
who are at high cardiovascular risk.”
-VALUE Trial, 2004
Julius S, et al. Lancet. 2004;363(9426):2022-2031.

13. BP Goal Attainment: JNC VII
Expert Roundtable Conclusions
“In addition to prescribing the right agent from the start, based
on the individual needs of the patient, physicians need to be
more aggressive in bringing their patients to goal”
-Michael A. Weber, MD; Founder & Past President of The
American Society of Hypertension
“We want them to attain BP goals while making sure they are
adhering to the therapy. The problem is that physicians stop
evaluating the patient’s progress toward the targeted BP level”
-Jan N. Basile, MD; Review Committee, JNC 7
Adapted from Weber et al., J Clin Hypertens 2004;6:699–705).
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14. The Practical Reality of Combination Therapy
Adding another drug provides greater blood
pressure reduction than can be achieved by
titrating the current drug to a higher dose
V052004

15. Olmesartan Medoxomil/HCTZ
Reduction in SeSBP
26.8
27.1
20.6
30
23.0 20.1 16.0
25
15.5
17.4
20
Reduction 17.1
in SeSBP 15 10.7
(mmHg) 10 9.6 40
20
5 3.3
10 Olmesartan
0 0 medoxomil dose
25 12.5 0 (mg/day)
HCTZ dose (mg/day)
HCTZ = hydrochlorothiazide; SeSBP = seated systolic blood pressure
Chrysant SG et al. Am J Hypertens 2004; 17(3):252-9.

16. Need for Combination Therapy
0
Progress
HOPE Syst-China
-5 PROGRESS-Combo
Change in DBP (mm Hg)
STOP II-β Syst-EUR
RENAAL
SHEP
-10
IDNT
TOMHS EWPHE UKPDS
-15 STOP-β
INSIGHT
ABCD
VA II
NORDIL
-20 HOT <90
HOT <85
-25 HOT <80
VA I
-30
0 0.5 1 1.5 2 2.5 3 3.5 4
Number of Antihypertensive Agents
Elliott WJ. Curr Hypertens Rep. 2002;4:278–285.

18. Lifestyle Modifications

19. Dietary modifications and exercise
Low calorie diets have modest effect on BP in
overweight individuals (avg. 5-6 mm Hg).
Aerobic exercise (brisk walking, jogging, or cycling)
for 30-60 min., 3-5 times/week, had small effect on
BP (2-3 mm Hg).
Relaxation therapies
These activities (stress management, meditation,
cognitive therapy, muscle relaxation) reduce by
average of 3-4 mm Hg.

20. Limit alcohol consumption
Excessive alcohol consumption is associated with
raised blood pressure, poorer CV and hepatic health.
Reducing alcohol can lower BP 3-4 mm Hg.
Limiting excessive consumption of
coffee/caffeine
Limit dietary sodium intake
< 6 g/day, modest reduction of 2-3 mm Hg.
Encourage smoking cessation

22. Initiating Treatment

23. Offer antihypertensive drug treatment to people
aged under 80 years with Stage 1 hypertension
who have one or more of the following:
Target organ damage
Established cardiovascular disease
Renal disease
Diabetes
10-year CV risk equivalent to 20% or greater.
Offer antihypertensive drug treatment to people
of any age with stage 2 hypertension.

24. For people aged under 40 years with
stage 1 hypertension and no evidence of
target organ damage, CV disease, renal
disease or diabetes
Consider specialist evaluation of
secondary causes of
hypertension and more detailed
assessment of potential target
organ damage.

26. The ABCDE algorithm
Young subjects (<55 yr) Older subjects (>55 yr)
A or B (if associated
Step I A and/or C
sympathetic hyperactivity)
Step 2 Add C or D or both Add D
A and C, and/or D, add B
Step 3 A or B, C and/or D, add E
or E

27. What is New in Indian Guidelines on
Hypertension - 2013

28. Due to health related toxic effects
of mercury, mercury
sphygmomanometers
are being replaced by aneroid and
digital sphygmomanometers.

29. Use of beta-blockers as first line
agents in hypertension has receded
and these are now recommended as
agents for use only in young
hypertensives with specific indications.
For routine patients these are no
longer recommended as first line
agents

30. Diuretics are now considered at par
with of ACEI’s or ARB’s and calcium
channel blockers and not as preferred
agents as in previous guidelines.
Chlorthalidone is now available and
shown to be better than
Hydrochlorothiazide and its usage is to
be preferred.

31. When blood pressure is high by
more than 20/10 mm of Hg systolic
and diastolic it is now
recommended to start with a
combination of drugs.
Monotherapy is not going to be
effective in achieving target blood
pressure.

32. Certain combinations have
been shown to be better
than others in recent trials.
Specially ACEI’s/ARB’s in
combination with CCB’s
forms a good combination.

33. J shaped curve exist specially for
non revascularised coronary artery
disease patients and caution has
been advocated in trying to lower
blood pressure to low target levels
specially in these patients.

34. A new form of non pharmacological,
interventional sympathetic
denervation therapy has become
recently available and is being
evaluated.

35. JNC-8:
What Might Be Expected

36. Either a thiazide-type diuretic, CCB,
ACEI/ARB will be recommended as initial
drug therapy for most patients.
Direct renin inhibitors will be recommended
as an additive
• Chlorthalidone or indapamide should be
highlighted as the evidence-based thiazide
type diuretic of choice

37. Summary

38. It makes less difference which antihypertensive
agent is used, unless the patient has a compelling
indication for a specific antihypertensive class
It matters more that BP is
appropriately reduced to
the chosen BP goal.

39. The current recommended BP goals in
those with Diabetes and CKD from the
ADA, NKF, and JNC 7 is
<130/80 mm Hg.

40. The initial drug chosen will be
broadened to include
Thiazide-diuretic,
ACEI/ARB, or CCB and may
include non-atenolol BB’s.

41. Most patients will require 2 or more
antihypertensive agents to get BP
effectively controlled which may be
best approached with initial combination
therapy, either as a fixed-dose
combination (FDC) or as 2 individual
initial agents