HYPERTENSION TREATMENT AND

MANAGEMENT

Wahyu Widjanarko MD

Algorithm for Hypertension Treatment

Recommend lifestyle modification

If not a goal, is BP < 20 / 10 mmHg above goal?

YES

NO

Mono Tx

consider combination Tx

target BP achieved ?

YES

NO

Continued Tx
increase dose medication

add additional agent

The seven report of JNC on prevention detection, evaluation, and treatment of high BP

JNC VII
Key massage :
Goal anti HTN Tx is reduced CV and renal morbidity and mortality, focus

the SBP.
Pre HTN (SBP 120-139, DBP 80-89), lifestyle modification to prevent the

progessive

BP and CV disease.

Uncomplicated HTN

thiazide alone or combination.

In high risk condition

ACE inhibitor, ARB, beta blocker, and CCB.

Drug class recommendation for

compeling indication based on various
clinical trials

HF : diuretic, Beta blocker, ACE inhibitor, ARB, Aldosteron

antagonist

Post MI : beta blocker, ACE inhibitor, aldosteron

antagonist.

CAD : diuretic, beta blocker, ACE inhibitor, CCB.

Diabetes : diuretic, beta blocker, ACE inhibitor, ARB, CCB.

CKD : ACE inhibitor, ARB.

Recurrent stroke prevention : diuretic, ACE inhibitor.

Single agent or multi agent

treatment approach ?
diuretic

- blocker

ARB

-blocker

CCB

ACE INHIBITORS

Treatment of HTN in adults with

diabetes

Guide line : - JNC VII

- American Diabetes Association
(ADA) 2011
Evidence review
- HTN as a risk factor for complication of diabetes
- UKPDS epidemiological study,each 10 mmHg
reduction in mean SBP
reduction
12 % any complication
15 % of death
11 % MI
12 % microvascular complication

Evidence for target levels of BP in pts

diabetes

Type 1 diabetes
nephropathy HTN
Type 2 diabetes, one of a group related
cardio metabolic factors
In general pts diabetes type 1 or 2 + HTN
have shown clinical improvement with 5
anti HTN agents
JNC VII and 2011 ADA recommended BP
control be controled < 130/80 mmHg,
primarily to prevent or lower the risk of
progression nephropathy
ESRD

Evidence for non drug management of

HTN

DASH dietery management

Weight reduction

Limitation intake sodium

Smoking cessation

Moderate intensity physical activity

Evidence for drug therapy of HTN

Multiple clinical trials suggest 5 class

anti HTN drugs provide the same
degree of CV protection for the same
level of BP control
NORDIL, STOP-2, INSIGHT and
ALLHAT conclude there were no
differences in primary outcome for the 5
class anti HTN agents

Evidence for drug therapy of HTN

Most study have shown superiority of
ACE inhibitor or ARB over CCB
If cannot tolerate one class of drug,
the other should be tried
Thiazide indicated for pts with
estimated GFR 30 ml/mmol/1,73m2,
if less than 30 loop diuretic is
indicated

Some trials of ACE inhibitor for HTN

in Diabetes

GUARD ( ACE inhibitor combined with

CCB have result reduce BP have favorable
metabolic effect
proteinuria
GFR
ACOMPLISH
HOPE study
CAPP trial
FACET
ABCD
SHEP

Some trials of ARB for HTN in

diabetes

NAGOYA HEART STUDY ( similar clinical

outcome valsartan vs amlodipin for HTN drug
tx in diabetes )
ONTARGET (telmisartan alone or with ramipril)
NKF KDOQI Guidelines( ACE inhibitor more
effective than other anti HTN in slowing
progression of kidney disease in HTN pts type
1 diabetes, ARB more effective in HTN pts type
2 diabetes )
LIFE, VALUE, MEDICA

Recommendation on initial tx
and goals for adult HTN
diabetes pts

A level evidence
- pts diabetes should be treated to DBP
< 80 mmHg
- Pts with SBP 130 139 mmHg or DBP
80-89 mmHg
lifestyle tx alone for max
of 3 month, if not achieved
pharmaco
tx
- pts with SBP >/=140 or DBP>/= 90
drug tx add life style tx

- Initial drug tx : ACE inhibitor, ARB, Beta

blocker or diuretic
- HTN with micro or clinical albuminuria
ACE inhibitor or ARB
- Pts over 55 yr with or w/o HTN, but CV
risk factors
ACE inhibitor
CV
event

Expert consensus

If ACE inhibitor or ARB are used check

RF and serum K
Elderly BP should be lowered gradually
Pts not achieving target BP on three
drugs or complicated referred to
specialist