Which one is more important, Target BP or Medicine

1. While Controlling Hypertension
What is More Important?
Target BP
OR
Medicine Chosen to Correct BP

2. Setting Target for Blood pressure and drug selection
• To set target for blood pressure reduction and selection of
antihypertensive medication are crucial steps in hypertension
management
• Neither BP target nor hypertensive medication will fit for all
individual
• Co-morbid conditions, age, gender, socioeconomic status and many
other factors contribute to set a BP target and choose appropriated
antihypertensive medication

3. TARGET BP

4. Hypertension BP Level and Classification
Aram V. Chobanian. Med Clin N Am 101 (2017) 219–227.

5. Circulation. 2018;137:549–550. DOI: 10.1161/CIRCULATIONAHA.117.032877

7. ESC 2018

8. ACC/AHA 2018: BP Thresholds and
Goals in Hypertension According to
Clinical Conditions
Hypertension. 2017 Nov 13. pii: HYP.0000000000000066.

9. ESC 2018: BP Thresholds and Goals in Hypertension
According to Clinical Conditions

10. 1. BP Target for Hypertension in Elder
population
JAMA. 2014;311(5):507-520, ; Canadian Journal of Cardiology 33 (2017) 557e576; JAPI 2013; vol. 61:17-23; The Journal of Clinical Hypertension Vol 16 | No 1 | January 2014
Guidelines Population Goal BP (mm Hg)
CHEP-2017 < 80 yrs <140/90
JNC 8 2014 > 60 years or older <150/90
ESH/ESC-2013 <80 years of Age <140/90;
Elderly > 80 years of
age
SBP 140-150
ASH/ISH- 2013
60-80 yrs <140/90
>80 yrs <150/90
NICE-2011
< 80 yrs <140/90
> 80 yrs <150/90
IGH-III 2013 > 55 yrs <140-145/90

11. 2. BP Target in Hypertension with CKD
Guideline Population Goal BP (mm Hg)
CHEP 2017 CKD
<140/90
JNC 8 CKD <140/90
ESH/ESC-2013
CKD, no Proteinuria <140/90
CKD + Proteinuria
<130/90
ASH/ISH- 2013 CKD <140/90
NICE-2011 CKD <140/90
IGH-III 2013 CKD <130/80
JAMA. 2014;311(5):507-520, ; Canadian Journal of Cardiology 33 (2017) 557e576; JAPI 2013; vol. 61:17-23; The Journal of Clinical Hypertension Vol 16 | No 1 | January 2014

12. Guidelines Population Blood pressure
Target (mm Hg)
ADA Guidelines (2017) DM <140/90 1A <130/80
2B
Hypertension Canada’s 2017 DM < 130/80
JNC8, 2014 DM <140/90
ASH, 2014 DM <140/90
JSH, 2014 DM <130/80
ESH, 2013 DM <140/85
KDIGO/KDOQI, 2013 DM <140/90
NICE Guidelines,2011 DM <140/90
3. BP Target in Hypertension with DM
The Journal of Clinical Hypertension Vol 18 | No 2 | February 2016, 95-100, ADA 2017, Canadian Journal of Cardiology 33 (2017) 557e576

13. Comparison between ESH 2018 and AHA 2107
guidelines
Points AHA 2017 ESH 2018
Category of BP Elevated BP
120-129 mm Hg SBP &
< 80 mm Hg DBP
Normal BP
120-129 mm Hg SBP &
< 80-84 mm Hg mm Hg DBP
BP Goal < 130/80 mm of Hg < 130/80 mm of Hg
Systolic not less than 120 &
Diastolic < 80-70
Initial therapy of
recommendation
ACE i/ ARB/CCBs/Thiazide
diuretics
Initial dual combination therapy.
ACEi or ARB+CCB or Diuretics

14. ANTIHYPERTENSIVE DRUGS

15. What Do Past Guidelines Suggest: Goal and
Treatment
JNC 8, 2014.

16. Evolution of BP thresholds for initiation and titration
of antihypertensive medication
• Pfeffer M. N Engl J Med. 2016
UKPDS 38
2017
2017 ACC/AHA
2017 ACC/AHA
Age < 65 yrs at low CVD risk
Age >65 yrs or at high CVD risk
Age < 65 yrs at low CVD risk
Age >65 yrs or at high CVD risk
N=143N=380 N=10,940
N=3,427
N=17,345
N=4,736
N=1,627
N=4,695 N=33,357 N=3,845 N=9,361
N=12,705
N=12,705
ACCOMPLISH
N=11,506
N=18,790
SPS3
N=1,148
Drug vs. Placebo
Comparing different drugs
Comparing different BP targets

17. Hypertension. 2017 Nov 13. pii: HYP.0000000000000066.
ACC/AHA 2017: Recommendation for pharmacological
and non-pharmacological therapy

18. ESC 2018: Recommendation for treatment

19. Some criteria for selecting drugs for antihypertensive
treatment
DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013

20. Algorithm for recommended drug combination

21. How to choose BP drug in CV risk
ESC Guidelines, 2013

22. Guidelines for selecting the most appropriate
antihypertensive drugs

23. Major contraindications to antihypertensive drugs
ESC 2018

24. Adverse drug reactions

25. Summary
• We can not conclude that BP target is more important or Antihypertensive
drug selection
• Both plays significant role in management of Hypertension
• In BP target and antihypertensive drug selection; co-morbid conditions,
patient’s age, gender, other ongoing medications, contraindication, patient
clinical condition are the major criteria that help to decide setting a BP
target and drug selection for treatment

26. THANK YOU