This document discusses hypertension guidelines and management. It covers the epidemiology of hypertension, guidelines for classification and treatment targets, detection of white coat and masked hypertension, and management of hypertension in patients with comorbidities like chronic kidney disease. Proper control of hypertension is important for reducing cardiovascular and renal risks. Treatment involves lifestyle changes and antihypertensive medications, with certain drugs offering additional organ protective effects. Management is more complex in patients on dialysis or after kidney transplantation.

1. BP targets-
Where are we now?
Presenter’s details

2. Content
 Epidemiology of hypertension and CV risks
 Recent guidelines
 Classification of office BP
 Detection of white-coat and masked hypertension
 Initiation of antihypertensive treatment
 Hypertension and comorbidities
 Hypertension in CKD
 Pathogenesis
 Management
 Office BP target range
 Treatment adherence

3. Epidemiology
1.39 billion
people worldwide are affected
(25% of the total adult population)
7,500,000 premature deaths/year
(12.8% of global casualties)
Diabetes (3,400,000 deaths, 3.4%)
Obesity (2,800,000 deaths, 4.8%)
Hypertension causes
Gentile G, et al. J Cardiovasc Dev Dis. 2022 Apr 30;9(5):139.

4. 48%
28%
10%
4%
7%
2%
1%
None HBMI HLD DM HBMI + HLD HBMI + DM HLD + DM HBMI + HLD + DM
Prevalence of other risk factors for cardiovascular disease a
mong hypertensive patients
Schmieder RE, et al. J Clin Hypertens (Greenwich). 2008 Aug;10(8):624-31.

5. Prevalence of other risk factors for cardiovascular disease
among hypertensive patients
Patients with concomitant HTN and hyperlipidemia have a greater
additive risk of CVD compared with patients who have either
condition in isolation
The intensive BP lowering to lower targets is beneficial in reducing
the rate of CV events; small decreases in BP are accompanied by
substantial reductions in CV risk.
Schmieder RE, et al. J Clin Hypertens (Greenwich). 2008 Aug;10(8):624-31.

6. Clinical practice guidelines for hypertension

7. Classification of office BP and definitions of hypertension grade
Williams B, et al. Eur Heart J. 2018 Sep 1;39(33):3021-3104.

8.  Out-of-office BP measurements (by patients at home or with 24-hour ambulatory blood pressure monitoring
[ABPM]) are
• More reproducible than office measurements
• More closely associated with hypertension-induced organ damage and the risk of cardiovascular events
• Identify the white coat and masked hypertension phenomena
 Out-of-office BP measurement is often necessary for the accurate diagnosis of hypertension and for
treatment decisions.
Out-of-office BP measurements
Unger T, eta l. J Hypertens. 2020 Jun;38(6):982-1004.

9. Out-of-office BP measurements
Unger T, eta l. J Hypertens. 2020 Jun;38(6):982-1004.

10. Detection of white coat hypertension or masked hypertension in
patients not on drug therapy
Whelton PK, et al. Hypertension. 2018 Jun;71(6):1269-1324.

11. Detection of white coat effect or
masked uncontrolled hypertension
in patients on drug therapy
Whelton PK, et al. Hypertension. 2018 Jun;71(6):1269-1324.

12. Initiation of antihypertensive treatment
Williams B, et al. Eur Heart J. 2018 Sep 1;39(33):3021-3104.

13. Hypertension and comorbidities
 Hypertensive patients have several common and other comorbidities that can affect cardiovascular risk
and treatment strategies.
 The number of comorbidities increases with age, with the prevalence of hypertension and other
diseases.
 Common comorbidities include coronary artery disease (CAD), stroke, CKD, HF, and COPD.
 Uncommon comorbidities include rheumatic diseases and psychiatric diseases.
 Uncommon comorbidities are largely underestimated by guidelines and frequently treated with drugs
often self-prescribed and possibly interfering with BP control.
Unger T, eta l. J Hypertens. 2020 Jun;38(6):982-1004.

14. Underlying comorbidity ACC/AHA ESC/ESH NICE ACP/AAFP ADA KDIGO
Established atherosclerotic
cardiovascular disease
<130/80 <130/80 <140/90
Heart failure <130/80 <130/80 <140/90
Diabetes mellitus <130/80 <130/80 <140/90 <140/90
Chronic kidney disease <130/80 <130/80 <140/90 <120/80
High cardiovascular risk <130/80 <130/80 <140/90
Older adults <130/80 <130/80 <140/90 <150/90
No comorbidity <130/80 <130/80 <140/90
Goal blood pressure thresholds from different society guidelines
according to underlying comorbidity
https://www.uptodate.com/contents/image?imageKey=NEPH%2F131587

15. Classification of hypertension according to presence of CV risk
factors, hypertension-mediated organ damage, or comorbidities.
Williams
B,
et
al.
Eur
Heart
J.
2018
Sep
1;39(33):3021-3104.

16. Management of comorbidities
In addition to BP control, the therapeutic strategy should include lifestyle changes, body weight control and the
effective treatment of the other risk factors to reduce the residual cardiovascular risk.
 LDL-cholesterol should be reduced according to risk profile:
(1) >50% and <70 mg/dL (1.8 mmol/L) in hypertension and CVD, CKD, DM or no CVD
and high risk;
(2) >50% and <100 mg/dL (2.6 mmol/L) in high-risk patients;
(3) <115 mg/dL (3 mmol/L) in moderate-risk patients.
 Fasting serum glucose levels should be reduced below 126 mg/dL (7 mmol/L) or HbA1c
below 7% (53 mmol/mol).
 s-UA should be maintained below 6.5 mg/dL (0.387 mmol/L), and <6 mg/dL (0.357
mmol/L) in patients with gout.
 Antiplatelet therapy should be considered in patients with CVD (secondary prevention
only)
Unger
T,
eta
l.
J
Hypertens.
2020
Jun;38(6):982-1004.

17. Hypertension and CKD
 Hypertension is a major risk factor for the development and progression of albuminuria and any form of CKD.
 A lower eGFR is associated with resistant hypertension, masked hypertension, and elevated nighttime BP
values.
 The effects of BP lowering on renal function (and albuminuria) are dissociated from cardiovascular benefit.
 BP should be lowered if ≥140/90 mmHg and treated to a target <130/80 mmHg (<140/80 in elderly
patients).
 RAS-inhibitors are first-line drugs because they reduce albuminuria in addition to BP control. CCBs and
diuretics (loop-diuretics if eGFR <30 ml/min/1.73m2) can be added.
 eGFR, microalbuminuria and blood electrolytes should be monitored.
Unger T, eta l. J Hypertens. 2020 Jun;38(6):982-1004.

18. Different therapeutic targets in CKD patients as suggested by
older and newer guidelines
Carriazo S, et al. Clin Kidney J. 2022 Feb 11;15(5):845-851.

19. Landmark randomized trials comparing standard with intensive
blood pressure control
Pugh D, et al. Drugs. 2019 Mar;79(4):365-379..

20. Pathogenesis and
management of
hypertension in CKD
Pugh D, et al. Drugs. 2019 Mar;79(4):365-379..

21. Drug treatment strategy for hypertension and CKD
Williams
B,
et
al.
Eur
Heart
J.
2018
Sep
1;39(33):3021-3104.

22. Office blood pressure treatment target range
Williams
B,
et
al.
Eur
Heart
J.
2018
Sep
1;39(33):3021-3104.

23.  Individualize BP targets and agents according to age, coexistent cardiovascular disease, and other
comorbidities, risk of progression of CKD, presence or absence of retinopathy (in CKD patients with
diabetes), and tolerance of treatment.
 Inquire about postural dizziness and check for postural hypotension regularly when treating CKD patients
with BP-lowering drugs.
 Lowering salt intake to less than 90 mmol/day (<2 g) of sodium (corresponding to 5 g of sodium chloride),
unless contraindicated. Achieving or maintaining a healthy weight (BMI 20–25 and at least less than 30
kg/m2).
 An exercise program compatible with cardiovascular health and tolerance, aiming for at least 30 min five
times per week.
 Limit alcohol intake to no more than two standard drinks per day for men and no more than one standard
drink per day for women.
Lifestyle modification for patients with CKD to lower BP
Nicholas SB, et al. Curr Opin Cardiol. 2013 Jul;28(4):439-45.

24. Managing Hypertension in the Context of Hemodialysis
Lower blood pressure does not always imply better survival in this group, as
it does in the general population and those with pre-dialysis CKD.
Changes in blood pressure during hemodialysis may potentially indicate a
poor prognosis.
• Pre- and post-dialytic BPs may differ dramatically due to large changes
in fluid and electrolytes.
• Sodium and water overload may be a major cause of hypertension in
hemodialysis patients. Despite intensive ultrafiltration, hypertension
frequently persists.
The use of -blockers is particularly convincing because they
• Diminish arterial stiffness and left ventricular hypertrophy, both of
which are accelerated in ESRD
• Attenuate some of the arrhythmogenic effects of dialysis.
Pugh D, et al. Drugs. 2019 Mar;79(4):365-379..

25. Blood pressure management in patients with CKD, with or
without diabetes, not receiving dialysis
Initiation of renin-angiotensin-system inhibitors (RASi) (angiotensin-converting enzyme inhibitor [ACEi] or
angiotensin II receptor blocker [ARB]) are suggested for people with moderately-to-severely increased
albuminuria (G1–G4, A2 and A3) with/ without diabetes
Combination of ACEi, ARB, and direct renin inhibitor (DRI) therapy should be avoided in patients with CKD,
with or without diabetes
KDIGO guidelines. Kidney Int 2021; 99:S1

26. Blood pressure management in kidney transplant recipients
A dihydropyridine calcium channel blocker (CCB) or an ARB can be used as the first-line antihypertensive agent
in adult kidney transplant recipients
Factors contributing to the
development of hypertension
following kidney transplantation
KDIGO guidelines. Kidney Int 2021; 99:S1

27. Treatment adherence
 Despite the risks of CKD progressing to ESRD and patients requiring dialysis and/or transplantation,
adherence to therapy is no better in those with CKD than in those without.
 Adherence improves as CKD advances but deteriorates again as patients start dialysis.
 Studies examining the reasons for non-compliance in those with CKD highlight the importance of
communication and perceived benefit of the therapies in question.
 Pill burden, drug interactions and adverse effects are also important.
 Antihypertensive regimens should therefore be simplified wherever possible, with consideration given to
the quantity, timing and formulation of interventions.
 Continuity of care may also have an impact and, where possible, attempts should be made to allow
patients to see the same clinician at each visit, something that has been demonstrated to improve
outcomes
Pugh D, et al. Drugs. 2019 Mar;79(4):365-379..

28. Summary
 Hypertension increases the risk of atherosclerotic cardiovascular disease, congestive
heart failure, and ESKD, and is a leading contributor to morbidity and mortality
worldwide.
 The identification and management of these risk factors is an important part of the
overall management of hypertensive patients.
 Controlling hypertension in those with chronic kidney CKD not only slows progression of
renal damage but reduces the risk of cardiovascular disease.
 Patients with CKD and hypertension will often require a combination of
antihypertensive medications to achieve target BP.
 Certain pharmacological therapies provide additional BP-independent renoprotective
and/or cardioprotective action and this must be considered when instituting therapy.
 Managing hypertension in the context of hemodialysis and following kidney
transplantation presents further challenges.