This document summarizes the 2018 ESC guidelines for management of arterial hypertension. It discusses definitions of hypertension, epidemiology including rising prevalence in Africa and Nigeria, recommendations and evidence for treatment, changes from prior guidelines, types of blood pressure measurement, hypertension and common comorbidities, treatment strategies including lifestyle modifications and drug therapy, and management of hypertension in special populations and clinical scenarios.

1. HYPERTENSION
ESC 2018 Guidelines for Management
of Arterial Hypertension
INTERNAL MEDICINE DEPARTMENT, LAUTECH TEACHING HOSPITAL
DR ORUGUN SOPE TOPE

2. Outline
 Introduction
 Epidemiology
 Recommendation & Evidences
 Changes
 Types of BP measurement
 Hypertension and comorbidities
 Conclusion
 References

3. Introduction
 Hypertension is defined as the BP level at which
benefits undoubtedly outweigh the risk of treatment
as documented by control trials.
 SBP >/=140mmHg
and/or
 DBP >/=90mmHg

4. Epidemiology
 Based on office BP, prevalence of hypertension world
wide is about 1.13 billion personsin in 2015
 24% & 20% of male and females respectively
 150 million are in eastern and central europe
 In africa
 In subsaharan Africa incidence is rising, up to 39.8%
prevalence in adults >25years.

5. Epidemiology
 Nigeria, 22.5% prevalence in 2001, Highest in in the
urban north central and lowest in the rural south west.
20.8 million in 2010
 Increase incident case with urbanization, HIV
 Varies from 9.1 to 51.9% in rural and urban areas
respectively in Nigeria

6. Epidemiology

7. Classifications of
Hypertension
Category Systolicmm
mmHg
Diastolic90
mmHg
Optimal <120 and <80
Normal 120-129 and/or 80-84
High normal 130-139 and/or 85-89
Grade 1 140-159 and/or 90-99
Grade 2 160-179 and/or 100-109
Grade 3 >/=180 and/or >/=110
Isolated Systolic
HTN
>140 and <90

9. Changes in recommendation

11. BP Measurements
 Office BP. (OBP)
 Home BP monitoring (HBPM)
 Ambulatory BP Monitoring (ABPM)

12. Office BP measurements
 OBP should be taken 5mins after resting
 Patient should rest arm and back to allow isometric exercise influence
 Standard cuff size should be used(35cm length, 12-13cm12-13 breadth)
 BP in both arms should be measured and the highest reading hand
used.
 BP in seated adn standing position in 1&3 mins in first clinic visit and
subsequently in elderly & Diabetics
 Manual Sphygmomanometer obligatory in Atrial fibrillation.

13. Home BP
 BP should be taken 5mins after rest
 Take BP in a quiet room
 Average of BP readings done not less than 3dys,
preferrably as from 6-7dys before clinic visit.
 Semiautomated machine permissible
 Average of all readings taken morning and night.

14. Ambulatory BP Monitoring
 Average of BP readings over defined period, usually
24hrs
 Device is usually timed to record every 15-20 mins
 A minimum of 70% usable BP readings are required for
valid ABPM measurement session.

15. BP measurement table

16. Definition of Hypertension based
on office, ambulatory and home
BP levels
Category SBP (mm Hg) DBP (mmHg)
Office BP >/= 140 and/or >/=90
Ambulatory BP
Daytime (or
awake) mean
>/= 135 and/or >/=85
Night time(or
asleep) mean
>/= 120 and/or >/=70
24hr >/=130 and/or >/=80
Home BP mean >/=135 and/or >/=85

17. Screening
 Most cases of asymptomatic hypertension are picked
on opportunistic BP check.
 All adults should have their BP checked.
 Optimal BP - BP check every 5 years is advocated
 Normal BP - Remember every 3 years.
 High normal - Atleast Yearly

18. Cardiovascular disease risk
factor
 Hypertension often is accompanied by other
Cardiovascular risk factors and the coincidence of
these causes multiplied CV risk
 Assessment of these risk factors is done by SCORE
(Systemic COronary Risk Evaluation) System
 This system is used to determine also possible benefits
of statins & antiplatelets

20. Modifiers increasing cardiovascular
risk estimated by the Systemic
COronary Risk Evaluation (SCORE)
system
 Social deprivation, the origin of many causes of CVD
 Obesity (measured by BMI) and central obesity (measured by waist circumference)
 Physical inactivity Psychosocial stress, including vital exhaustion Family history of
premature
 CVD (occurring at age <55 years in men and <60 years in women)
 Autoimmune and other inflammatory disorders
 Major psychiatric disorders
 Treatment for infection with human immunodeciency virus Atrial fibrillation
 LV hypertrophy
 CKD
 Obstructive sleep apnoea syndrome

21. Hypertension can also present with
features of Hypertension mediated
organ dysfunction (HMOD) as well
as Diabetes mellitus or CKD
These comorbidities may shift the
risk as estimated by SCORE to a
higher category

22. Hypertension classification with CV
risk factors

23. Screening and diagnosis of
Hypertension

24. Diagnosis
 Diagnosis of hypertension should not be made on one
OBP measurement.
 However if there are evidence of HMOD and or Grade 3
Hypertension.
 HMOD - Hypertensive Retinopathy with exudates &
hemorrhages, LVH, Renal or vascular damage
 Aside from the aforementioned, repeated measurements
are needed for diagnosis.
 ABPM indicated if Masked or White Coat Hypertension
are suspected

25. Clinical history in personal and
family history of Hypertension

26. Work up in Hypertension

27. ECG findings in LVH

28. Echo findings in LVH

31. BP targets in Hypertensive
patients
 Basically target BP varies with
1. Age and
 120-129 <65yrs
 130- 139 >65yrs
 DBP <80 across board
2. Comorbidities

33. Resistant Hypertension
 Defined as hypertension resistant to treatment ,when
recommended treatment plan fails to lower office BP
to <140/90mmHg and inadequate BP control is
detected by ABPM or HBPM, in patients whose
adherence to therapy has been confirmed

34. Pseudo resistant
hypertension
Causes
 Poor adherence
 White coat phenomenon
 Poor Office BP measurement technique
 Marked Brachial artery calcification
 Clinician inertia

38. Common causes of secondary
hypertension contd

42. Other forms of Hypertension
 Masked Hypertension: Normal office BP with range >/=
140/90mmHg on HBPM or 24hrs ABPM
 Should be suspected when office BP is normal and there
ear features of HMOD.
 White coat hypertensiin:
 Normal BP range of 24hrs ABPM, or HBPM, however >/=
140/90mmHg
 Has moderate CV risk

43. Drug treatment strategy for
hypertension
 Five major classes recommended for routine use
 Angiotensin Receptor Blockers
 Angiotensin Converting Enzyme inhibitors
 Calcium channel blockers
 Beta Blockers
 Diuretics
 These have reduced both BP & CV risks in Randomized Control
Trials

44. Treatment Principles
 Single pill combination preferred for speed and efficacy
of control
 Combination: RAS blocker with CCB or diuretics
 Beta blockers are usually for specific indication eg Angina,
heart failure
 3 drug SPC can replace 2 drug SPC to achieve control
 Spironolactone is preferred add on in resistant
hypertension except contraindicated

45. Treatment
 When to treat
 Generally BP >/=140/90mmHg with or without
Comorbidities between age 16-79
 If >80yrs, SBP of >/=160 is recommended

46. Treatment of Hypertension

47. Treatment of Hypertension

48. Adoption of lifestyle changes in
patients with hypertension
 Smoking cessation
 Alcohol reduction(males -14units/wk, females- 8units/wk)
 Regular exercise
 Dietary modifications( saturated fats )
 Low sodium intake (<5g)
 Weight reduction

49. Management
 Device based therapies ar3 not recommended for
routine treatment of hypertension.
 It's use is class III recommendation with level B
evidence

50. Management

52. CAD
 Target SBP =/<130 but not less than 120mmHg
 130-140mmHg in older patients
 DBP - 70-80mmHg
 Medications: Beta blockers & Anti RAS agent are
recommended to be part of therapy
 In symptomatic angina: CCB and or Beta blockers are
recommended

54. Management

55. Heart failure with reduced ejection
fraction

56. Hypertension with Atrial fibrillation

57. DM
 Hypertension with DM
 BP target is 120-130mmHg
 Not less than 120
 in >/= 65yrs, 130-139mmHg
 Anti RAS agents, with Calcium channel blockers or
thiazides or thiazide like diuretics

58. LVH or HF
 HFpEF - consider for antihypertensives if BP >/=
140/90mmHg
 HFrEF - therapy should contain - ARB or ACE I, Beta
blockers, diuretics and/ or mineralocorticoid antagonist
 BP target same for HFpEF & HFrEF
 Dihydropyridine CCBs recommended only if BP control is
not thus achachieved.
 LVH- target range 120-130mmHg
 CCB or diuretics/ RAS blockers/

59. Acute ischemic stroke

60. Hypertension in Pregnancy
 Office BP - SBP >140 and or DBP 90mmHg
 Mild. - 140-159/90-109mmHg
 Severe - >/= 160/110mmHg
 Subtypes
 Preexisting HTN
 Gestational HTN
 Preexisting HTN + Superimposed Gestational HTN +
proteinuria
 Preclampsia

61. In pregnancy

62. Acute ischemic stroke

63. Drug therapy for treatment
of Hypertension
 7

66. Hypertensive emergency/urgency
Management
 Emergencies
 Malignant phase hypertension
 Hypertension with other conditions eg MI, aortic dissection
etc
 Preeclampsia
 Sudden severe hypertension dur to pheochromocytoma
 URGENCIES:
 Severe hypertension usually presenting to the ER in patients
with no acute HMOD features
 Do well on outpatient management and oral medications

67. Follow up
 BP reduction is noticed as early as 1-2weeks of therapy
and continues to fall till 1month on therapy
 Initial review within the first 2months
 Frequency of clinic visits thereafter is mostly
determined by comorbidities & renal status
 Evaluation of risk factors & asymptomatic organ
damage every 2yrs

68.  THANKS FOR YOU ATTENTION

69. Reference
 European Society of cardiology guideline on arterial
hypertension management 2018
 Current prevalence of hypertension in Nigeria, pub
med, Akinlua et al 2015