Hypertension

Syakib Bakri, Hasyim Kasim, Haerani Rasyid

Epidemiology

Blood Pressure Distribution in the Population

According to Age
Men

Women

PP

PP

PP=Pulse Pressure
Adapted from: Wilkins et al. Health Rep 2010;21:37-46

Life time Risk of Hypertension in

Normotensive Women and men aged 65 years

Risk of Hypertension %

Risk of Hypertension %
100

100

Women

Men

80

80

60

60

40

40

20

20

0
0

10

12

14

16

Years to Follow-up

18

20

10

12

14

16

18

20

Years to Follow-up
JAMA 2002:297:1003-10. Framingham data.

Frequency of Hypertension
According to Age
Age

Percentage

18-29 years old

4%

30-39 years old

11%

40-49 years old

21%

50-59 years old

44%

60-69 years old

54%

70-79 years old

62%

More than 80 years

65%

old

Burden of disease attributable to 20 leading risk factors in 2010,

expressed as a percentage of global disability-adjusted life-years

Lancet 2012;380:2224-60

DIAGNOSIS OF HYPERTENSION

Blood Pressure Assessment

Blood Pressure Assessment

Blood pressure of all adults should be measured by a
trained healthcare professional at all appropriate visits.
For example:
new patient visits,
periodic health exams,
urgent office visits for neurological or cardiovascular
related issues,
medication renewal visits
Blood pressure of adults with high normal blood pressure
(130-139/80-89 mmHg) should be assessed annually

Health care professionals should know the blood pressure of all

of their patients and clients.
To screen for hypertension
To assess cardiovascular risk
To monitor antihypertensive treatment

Blood pressure measurement devices

Mercury Blood Pressure Monitor

Aneroid Blood Pressure Monitor
Automated Blood Pressure Monitor

Blood Pressure Assessment:

Patient preparation and posture
Standardized Preparation:
Patient
1. No acute anxiety, stress or pain.
2. No caffeine, smoking or nicotine in the preceding
30 minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. No tight clothing on arm or forearm.
6. Quiet room with comfortable temperature
7. Rest for at least 5 minutes before measurement
8. Patient should stay silent prior and during the
procedure.

Blood Pressure Assessment:

Patient preparation and posture
Standardized technique:
Posture

The patient should be calmly

seated with his or her back
well supported and arm
supported at the level of the
heart.
No talk during the procedure.
His or her feet should touch
the floor and legs should not
be crossed.

Blood Pressure Assessment:

Patient position

Recommended Technique
for Measuring Blood Pressure (cont.)
The seated BP
measurement is the
standard position to
determine diagnostic and
therapeutic treatment
decisions.
The standing blood
pressure is used to test for
postural hypotension,
which may modify the
treatment.

Recommended Technique for Measuring BP:

Standing BP
Perform in patients
over age 65
with diabetes
if there are symptoms of postural hypotension

Check after 1 to 5 minutes in the standing position and if

the patient complains of symptoms suggestive of
hypotension

Recommended Technique
for Measuring Blood Pressure* (cont.)
Drop pressure by 2 mmHg / beat
Appearance of sound (phase I
Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat

Disappearance of sound (phase
V Korotkoff) = diastolic pressure

Record measurement & Record

heart rate
Take at least 2 blood pressure
measurements, 1 minute apart
*with manual or semi automated devices

Korotkoff sounds and auscultatory gaps

Korotkoff sounds
200
180

No sound
Clear sound

Phase 1

Muffling

Phase 2

140

No sound

Auscultato
ry gap

120

Clear sound

Phase 3

160

100

Muffled sound

Phase 4

No sound

Phase 5

80
60
40
20
0
mmHg

Systolic BP

Phase 3
Phase 4
Diastolic BP

Recommended Technique
for Measuring Blood Pressure
Standardized technique:
For initial readings, take
the blood pressure in
both arms and
subsequently measure it
in the arm with the
highest reading.
Thereafter, take two
measurements on the
side where BP is higher.

Recommended Technique
for Measuring Blood Pressure* (cont.)
Record the blood
pressure to the closest 2
mmHg on the manometer
Record patient position
(supine, sitting or
standing).
Aneroid devices should not be used unless they are known to be accurately calibrated
and are checked regularly (minimally every 12 months).
* For manual blood pressure measurement

Recommended Technique
for Measuring Blood Pressure (cont.)
Select a device with an appropriate size cuff

Use an appropriate size cuff

Arm circumference (cm)

Size of Cuff (cm)

From 18 to 26

9 x 18 (child)

From 26 to 33

12 x 23 (standard adult model)

From 33 to 41

15 x 33 (large)

More than 41

18 x 36 (extra large, obese)

For automated devices, follow the manufacturers directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.

Recommended Technique
for Measuring Blood Pressure (cont.)
Locate the brachial pulse
and centre the cuff
bladder over it
Position cuff at the heart
level
Arm should be supported

Recommended Technique
for Measuring Blood Pressure* (cont.)
To exclude possibility of
auscultatory gap,
increase cuff pressure
rapidly to 30 mmHg
above level of
disappearance of radial
pulse
Place stethoscope over
the brachial artery

*with manual or semi automated devices

Recommended Equipment for

Measuring Blood Pressure
Use a mercury
manometer or a recently
calibrated aneroid or a
validated automated
device.
Aneroid devices should
only be used if there is an
established calibration
check every 12 months.

Recommended Equipment for

Measuring Blood Pressure
Automated oscillometric devices:
Use a validated automated device
according to BHS, AAMI or IP clinical
protocols.
For home blood pressure measurement
devices, a logo on the packaging ensures
that this type of device and model meets
the international standards for accurate
blood pressure measurement.
AAMI=Association for the Advancement of Medical Instrumentation;
BHS=British Hypertension Society;
IP: International Protocol.

Blood Pressure Measurement with Aneroid Blood

Pressure Monitor

Place the stethoscope diaphragm over the

brachial artery and deflate at a rate of
2mmHg/beat until you hear regular tapping
sounds. Measure systolic (first regular sound)
to nearest 2mmHg.

Deflate at a rate of 2mmHg/beat until

disappearance. Measure diastolic blood
pressure to nearest 2mmHg.

Aneroid devices should not be used unless they are known to be in calibration and are
checked regularly (minimally every 12 months).

Blood Pressure Measurement with Aneroid Blood

Pressure Monitor

Aneroid devices should not be used unless

they are known to be in calibration and are
checked regularly (minimally every 12
months).

If the needle on an aneroid device does not

zero it is inaccurate; however the converse is
not true.

Attaching an aneroid device to a Mercury device

for calibration testing

Note: check the mercury column is at zero before testing.

ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE

Encourage hypertensive patients to use an approved blood pressure

measuring device and use proper technique to assess blood
pressure at home.
Measuring blood pressure at home has a stronger association with
cardiovascular prognosis than office based readings.
Home measurement can confirm the diagnosis of hypertension,
improve blood pressure control, reduce the need for medications
in some, detect those with white coat and masked hypertension
and improve medication adherence in non adherent patients.
Average BP 135/85 mmHg should be considered elevated

Home Measurement of BP:

Confirm contradictory home measurement readings

If office BP measurement
is elevated and home BP
is normal or vice versa

Consider further assess

using 24-h ambulatory
blood pressure monitoring

Not all patients are suited to home measurement

Undue anxiety in response to high blood pressure
readings
Physical or mental disability prevents accurate
technique or recording
Arm not suited to blood pressure cuff (e.g. conical
shaped arm)
Irregular pulse or arrhythmias prevent accurate
readings
Lack of interest
Most patients can be trained to measure blood pressure
Periodic reassessment of technique and retraining is desirable

Suggested Protocol for Home Measurement of

Blood Pressure for the Diagnosis of Hypertension
Home blood pressure values should be based on:
duplicate measures,
morning and evening,
for an initial 7-day period.

Singular and first day home BP values should not be

considered.
Daytime average BP equal to or over 135/85 mmHg
should be considered elevated.

HYPERTENSION CRITERIA

ESH ,
2013

JNC
2003

7,

Development of aortic pressure abnormalities due to

age-related aortic stiffening

Smulyan H, Safar ME. Ann Intern Med. 2000;132:230.

Hypertension

Common, Responsible for the

majority of office visits
Number one reason for drug
prescription
Simple and cheap detection
Established treatment
Significant preventable
outcomes
Observational studies suggest

Approximately 73% of European patients with

hypertension remain untreated
Patients (%)

England

Sweden

Germany

Spain

Italy

Wolf-Maier et al. Hypertension 2004;43:1017

Approximately 70% of treated patients* in Europe do not

reach blood pressure goal
Patients (%)

England

*Treated for hypertension

BP goal is <140/90 mmHg

Sweden

Germany

Spain

Italy

Wolf-Maier et al. Hypertension 2004;43:1017

Global health burden of uncontrolled blood pressure

Events attributable to non-optimal BP control
(mean SBP >115 mmHg) (%)

Worldwide this equates to approximately 7.1 million deaths (12.8% of total deaths)
and 64.3 million disability-adjusted life years (4.4% of the total)
*Hypertensive disease includes essential HTN, hypertensive heart
disease and hypertensive renal disease

Lawes et al. J Hypertens 2006;24:42330

Suboptimal treatment of hypertension imposes an

enormous economic burden on society
Estimated costs ($ billion)

Hospital

Nursing Physicians Medical

home
durables

Home
h/care

Morbidity Mortality

Estimated total costs of hypertension in the US in 2006: $63.5 billion

American Heart Association. Heart Disease and Stroke
Statistics 2006 Update. Dallas, TX

Modifiable risks for developing hypertension

Obesity
Poor dietary habits
High sodium intake
Sedentary lifestyle
High alcohol consumption

New onset hypertension in people with high

normal blood pressure
772 subjects, overweight, mean age 48.5
Not receiving treatment for hypertension
Average of 3 blood pressures at baseline:

SBP 130-139 and DBP < 89 OR

SBP < 139 and DBP 85-89

Primary endpoint new onset hypertension

NEJM 2006;354:1685-97

New onset hypertension in people with high

normal blood pressure

NEJM 2006;354:1685-97

Development of hypertension in those with high normal blood

pressure

Framingham cohort Vasan. Lancet 2001

New onset hypertension in people with high

normal blood pressure
40% of overweight patients with systolic 130-139 or
diastolic 85-89 mmHg developed hypertension in 2 years
and 63% in 4 years
Annual follow-up of patients with high normal blood
pressure is recommended by CHEP

Hypertension as a Risk Factor

Hypertension is a significant risk factor for:

cerebrovascular disease
coronary artery disease
congestive heart failure
renal failure
peripheral vascular disease
dementia
atrial fibrillation
erectile dysfunction

Public Perceptions on Hypertension

44% of people could not identify a normal or a high blood pressure

reading
80% of people were unaware of the association between
hypertension and heart disease
63% believed that hypertension was not a serious condition
38% of people thought they could control high blood pressure
without the help of a health professional

Can J Cardiol 2005;21:589-93

Blood Pressure and

Risk of Stroke Mortality

Lancet 2002;360:1903-13

Blood Pressure and Risk of Ischemic

Heart Disease (IHD) Mortality

Lancet 2002;360:1903-13

Effect of SBP and DBP on

Age-Adjusted CAD Mortality: MRFIT
CAD Death Rate per 10,000 Person-years
80.6

48.3

43.8

37.4
31.0

25.8

34.7

25.3

24.6

38.1

25.2

24.9

23.8
16.9

20.6

10.3

100+

90-99

13.9
11.8

80-89

12.6

12.8
8.8

75-79

8.5

70-74

11.8
9.2

<70

160+
140-159
120-139
Systolic BP
<120
(mmHg)

Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64

Impact of High-Normal Blood Pressure on the Risk

of Cardiovascular Disease
Cumulative incidence of cv events in men without hypertension
according to baseline blood pressure

(130-139) mmHg
(121-129) mmHg

(< 120) mmHg

N Engl J Med 2001;345:1291-7

Benefits of Treating Hypertension

Younger than 60 (reducing BP 10/5-6 mmHg)
reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%

Older than 60 (reducing BP 15/6 mmHg)

reduces overall mortality by 15%

reduces cardiovascular mortality by 36%
reduces incidence of stroke by 35%
reduces coronary artery disease by 18%

Lancet 1990;335:827-38
Arch Fam Med 1995;4:943-50

Benefits of Treating to Target

Older than 60 with isolated systolic hypertension (SBP

160 mm Hg and DBP <90 mm Hg)
42% reduction in the risk of stroke
26% reduction in the risk of coronary events

Lancet 1997;350:757-64

Correlation Between Reduction in SBP and

Stroke or MI
Stroke

Myocardial Infarction

Staessen et al. Lancet 2001;358:1305-15

Correlation Between Reduction in SBP and

Cardiovascular Mortality or Events
Cardiovascular mortality

Cardiovascular events

Staessen et al. Lancet 2001;358:1305-15

Prevalence %

Epidemiologic impact on mortality of blood

pressure reduction in the population
After
Intervention

Before
Intervention

Reduction in BP
% Reduction in Mortality

Reduction in SBP
(mmHg)

Stroke

CHD

Total

-6

-4

-3

-8

-5

-4

-14

-9

-7

Adapted from Whelton, PK et al. JAMA 2002;288:1882-1888

Pathophysiology

Pathophysiology Of Hypertension

Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors
Presence of Risk Factors

Presence of Target Organ Damage

Increasing age
Male gender
Smoking
Family history of premature cardiovascular disease (age< 55 in men and < 65 in women)
Dyslipidemia
Sedentary lifestyle
Unhealthy eating
Abdominal obesity
Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting glucose)
Microalbuminuria or proteinuria
Left ventricular hypertrophy
Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)

Presence of atherosclerotic vascular disease

Previous stroke or TIA

Coronary Heart Disease
Peripheral arterial disease

CV Risk Factors that may alter thresholds and targets in the treatment of HTN

Assessment of the overall cardiovascular risk

Search for exogenous potentially modifiable factors that can

induce/aggravate hypertension
Prescription Drugs:

NSAIDs, including coxibs

Corticosteroids and anabolic steroids
Oral contraceptive and sex hormones
Vasoconstricting/sympathomimetic decongestants
Calcineurin inhibitors (cyclosporin, tacrolimus)
Erythropoietin and analogues
Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs
Midodrine

Other:

Licorice root
Stimulants including cocaine
Salt
Excessive alcohol use

Laboratory Examinations

Shin et al. Clinical Hypertension

Laboratory Examinations

Shin et al. Clinical Hypertension

Laboratory Examinations

Shin et al. Clinical Hypertension

Treatment

Paradigm Shift in HT Therapy

It is not just B.P
TODAY
.
we must
striverisk
to factors
1. Alter the modifiable

73

2. Keep the SBP < 140 and DBP < 90

3. Prevent or halt or reduce TOD
LVH, CHD, CHF, CVA, CRF, PVD &
Retino.
4. Prevent or control DM (as HT + DM is
hazardous)
5. Prevent or control Dyslipidemia
6. Prevent or control Endothelial
Dysfunction
7. Reduce morbidity and mortality
8. Improve QUALY Quality Adjusted Life
Years

Goals of Treatment

To optimally reduce cardiovascular risk, reduce the blood

pressure to specified targets.
This usually requires two or more drugs and lifestyle
changes
The systolic target is more difficult to achieve however
controlling systolic blood pressure is as important if
not more important than controlling diastolic blood
pressure

Treatment Approaches
Lifestyle Modification
Pharmacological

Lifestyle management
(Non-Pharmacological Treatment)

LIFESTYLE MODIFICATION IN HYPERTENSION

Lifestyle measures should be instituted, whenever
appropriate in all hypertensive patients, including those
who require drugs
Lifestyle measures are also advisable in subjects with
high normal BP and additional risk factors to reduce the
risk of developing hypertension
Lifestyle recommendations should not be given as lip
service and reinforced periodically

Non-pharmacological Treatment
Objective of lifestyle changes in
hypertension
Lower blood pressure
Minimize drug use
Reduce overall cardiovascular risk
Improve outcome
Maintain or improve quality of life

Lifestyle Recommendations for Hypertension:

Dietary
Dietary Sodium

High in:
Fresh fruits
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre
Plant protein

Low in:
Saturated fat and cholesterol
Sodium

Less than 2300mg / day

(Most of the salt in food is hidden and comes
from processed food)

Dietary Potassium
Daily dietary intake >80 mmol

Calcium supplementation
No conclusive studies for hypertension

Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

Potential Benefits of a Wide Spread Reduction in

Dietary Sodium in Canada
Reduction in average dietary sodium from about
3500 mg to 1700 mg1,2

1 million fewer hypertensives

5 million fewer physicians visits a year for hypertension
Health care cost savings of $430 to 540 million per year related
to fewer office visits, drugs and laboratory costs for
hypertension
Improvement of the hypertension treatment and control rate
13% reduction in CVD
Total health care cost savings of over $1.3 billion/year
1. Penz ED. Cdn J Cardiol 2008
2. Joffres MR. Cdn J Cardiol 2007:23(6)

Recommendations for adequate daily sodium intake

Age

Adequate
Intake
(mg)

Upper
Limit
(mg)

19-50

1500

2300

51-70

1300

2300

71 and
over

1200

2300

2,300 mg sodium (Na)

= 100 mmol sodium (Na)
= 5.8 g of salt (NaCl)
= 1 level teaspoon of
table salt

80% of average sodium intake is in processed foods

Only 10% is added at the table or in cooking
Institute of Medicine, 2003

Sodium: Meta-analyses
Average Reduction of sodium
in mg/day
1800 mg/day
2300 mg/day

Hypertensives
Reduction of BP
5.1 / 2.7 mmHg
7.2/3.8 mmHg

Average Reduction of sodium

in mg/day
1700 mg/day
2300 mg/day

Normotensives
Reduction of BP
2.0 / 1.0 mmHg
3.6/1.7 mmHg

The Cochrane Library 2006;3:1-41

Meta analysis on different reductions in dietary

sodium intake on blood pressure

Graham A. MacGregor Hypertension 2003;42:1093-1099

Where in our diet does sodium come from?

1. 12% natural content of foods

2. Hidden sodium: 77% from processing of food -manufacturing and
restaurants
3. Conscious sodium: 11% added at the table (5%) and in cooking (6%)

J Am College of Nutrition 1991;10:383-

Salt mechanisms leading to

hypertension:
By expanding the extracellular volume
High salt intake increases the action of aldosterone
High salt intake is a permissive factor for the
hypertensinogenic effect of aldosterone
Increase in the sodium concentration progressively
increases endothelial cell stiffness, causes inhibition of
endothelial NO synthase and decreases release of nitric
oxide
Changes in plasma sodium concentration are transmitted
into the cerebrospinal fluid triggering the release of
cardiotonic steroids, namely, analogues of digitalis such as
ouabain and marinobufagenin which cause vasoconstriction

NON-BLOOD PRESSURE-RELATED EFFECTS OF DIETARY SALT

Atherosclerosis
Stroke
Left ventricle hypertrophy
Proteinuric kidney disease
Heart failure

Putative mechanisms of the deleterious cardiovascular

effects of excessive dietary sodium through blood pressure
increase independent of blood pressure

All cases of hypertension should restrict sodium intake to

approximately 6 g sodium chloride salt or 2.4 g sodium per
day by adopted the following measures:

Reduce salt for cooking by 50%

Substitute natural foods for processed
foods.
No sprinkling of salt on dining table
Avoid salty snacks such as pickles,
chutneys, papad, salted nuts
Use salt substitutes containing potassium
Avoid medications such as antacids as
these are rich in salt

Lifestyle Recommendations for Hypertension:

Physical Activity
Should be prescribed to reduce blood pressure

Frequency

Intensity

Time

Type

- Four to seven days per week

- Moderate
- 30-60 minutes

Cardiorespiratory Activity
- Walking, jogging
- Cycling
- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension:

Weight Loss
Height, weight, and waist circumference (WC) should be measured
and body mass index (BMI) calculated for all adults.

Hypertensive and all patients

BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference
Men <102 cm

Women <88 cm

For patients prescribed pharmacological therapy: weight loss has

additional antihypertensive effects. Weight loss strategies should employ a
multidisciplinary approach and include dietary education, increased physical
activity and behaviour modification
CMAJ 2007;176:1103-6

Waist Circumference Measurement

Measure here
Iliac crest

Courtesy J.P. Desprs 2006

Lifestyle Recommendations for Hypertension:

Alcohol
Low risk alcohol consumption
0-2 standard drinks/day
Men: maximum of 14 standard drinks/week
Women: maximum of 9 standard drinks/week
A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or
12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

Lifestyle Recommendations for Hypertension:

Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behaviour Modification
Individualized cognitive behavioural interventions are
more likely to be effective when relaxation techniques
are employed.

Non-pharmacological Treatment
Intervention

Weight Reduction

Recommendation

Expected systolic blood

Pressure reduction (range)

Maintain ideal body mass index

(20-23 kg/m2)

5-10 mmHg per 10 kg

weight loss

All put together reduce SBP 8-14

by mmHg

DASH eating plan Consume diet rich in fruit, vegetables,

low-fat dairy products with reduced
content of saturated and total fat

20 to 55 mmHg

Dietary sodium
restriction

Physical Activity

Alcohol
moderation

Reduce dietary sodium intake to

<100 mmol/day (<2.4 g sodium or
<6 g sodium chloride)

2-8 mmHg

Engage in regular aerobic

physical activity, for example,
brisk walking for at least 30 min
most days
Men < 21 units per week
Women < 14 units per week

4-9 mmHg

2-4 mmHg

Pharmacotherapy

BP lowering effects from antihypertensive drugs

Dose response curves for efficacy are relatively flat

80% of the BP lowering efficacy is achieved at halfstandard dose
Combinations of standard doses have additive blood
pressure lowering effects

Law. BMJ 2003

Two patients with identical blood pressures (150/96 mm Hg)

but pronounced differences in othermajor risk factors, illustrating
a 20-fold difference in absolute cardiovascular risk and in chance
of benefitfrom treatment between patients with
mild hypertension

Blood pressure (mm Hg)

Sex
Age (years)
Total cholesterol (mmol/l)
HDL cholesterol (mmol/l)
Smoking
Diabetes
Left ventricular hypertrophy
Absolute CVD risk (% over 10 years)
Absolute benefit (% over 10 years)
NNT (5 years)

Patient A

Patient B

150/96
Female
35
5.0
1.4
No
No
No
2.5
0.6
321

150/96
Male
65
7.0
1.0
Yes
No
No
51.0
12.8
16

Treatment of Hypertension According to the Level of Blood Pressure and

Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

130-139/85-89 mmHg
(High normal - Prehypertension stage
2)
No Diabetes
No Chronic Kidney Disease
No proteinuria

Life style
modification

Diabetes
Chronic Kidney Disease
Proteinuria

Life style modification

plus
drug treatment

Treatment of Hypertension According to the Level of Blood Pressure and

Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

140-159/90-99 mmHg
(Stage 1)
No risk factors
no cardiovascular
or other target
organ disease

1 risk factors, no
cardiovascular or other
target organ disease or
diabetes

Cardiovascular or other
target organ disease or
diabetes

Life style
modification

Life style modification

Life style modification

plus
drug treatment

> 140/90 mmHg

> 140/90 mmHg

Drug treatment
in addition to life
style modification

Drug treatment
in addition to life
style modification

Treatment of Hypertension According to the Level of Blood Pressure and

Cardiovascular Risk
Blood pressure measurement, history, physical
examination, laboratory test, ECG

160/100 mmHg
(Stage 2/3)
Life style modification
plus
drug treatment

Choice of
Pharmacological Therapy

Choice of Pharmacological Treatment

Uncomplicated
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO

Treatment in the
absence of compelling
indications for specific
therapies

YES

Individualized
Treatment
(and compelling
indications)

NICE clinical guideline 127, 2011

Considerations Regarding the Choice of

First-Line Therapy

Use caution in initiating therapy with 2 drugs in whom adverse

events are more likely (e.g. frail elderly, those with postural
hypotension or who are dehydrated).
ACE inhibitors, renin inhibitors and ARBs are contraindicated in
pregnancy and caution is required in prescribing to women of child
bearing potential.
Beta blockers are not recommended as first line therapy for patients
age 60 and over without another compelling indication.
Diuretic-induced hypokalemia should be avoided through the use of
potassium sparing agents if required.
The use of dual therapy with an ACE inhibitor and an ARB should
only be considered in selected and closely monitored people with
advanced heart failure or proteinuric nephropathy.
ACE-inhibitors are not recommended (as monotherapy)
for black patients without another compelling indication.

Considerations in the individualization of antihypertensive

treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive

treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive

treatment

CHEP Guidelines 2007

VIII. Treatment of Hypertension in Association With Stroke

Acute Stroke: Onset to 72 Hours

Acute
ischemic
Stroke

Treat extreme BP elevation (systolic

> 220 mmHg, diastolic > 120 mmHg)
by 15-25% over the first 24 hour
with gradual reduction after.
If eligible for thrombolytic therapy
treat very high BP (>185/110
mmHg)

Avoid excessive lowering of BP which can exacerbate ischemia

Treatment of Hypertension in Association With Stroke

Acute Stroke: Onset to 72 Hours

Strongly consider blood pressure reduction in all patients after

the acute phase of stroke or TIA .

Stroke
TIA

Target BP < 140/90 mmHg

An ACEI / diuretic
combination is preferred

Combinations of an ACEI with an ARB are not recommended

RD

AL

AT

N
T
LH

ID

AA
SK

H
O
T

M
D

AB
CD

U
KP
D
S

Number of drugs

Most HTN Pts need more than 1 drug

5

Incremenal SBP reduction ratio

Observed/Expected (additive)

Ratio of Incremental SBP lowering effect at

standard dose Combine or Double?

Wald et al. Combination Versus Monotherapy for Blood Pressure Reduction,

The American Journal of Medicine, Vol 122, No 3, March 2009

Recommendations for Initial

Combination Antihypertensive Therapy

Norris K& Neutel JM. J Clin Hypertens. 2007;9(12 suppl 5):514

Drug combination in hypertension :

Preferred
ACE inhibitor/diuretic
ARB/diuretic
ACE inhibitor/CCB
ARB/CCB

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Acceptable
-blocker/diuretic
CCB (dihydropyridine)/-blocker
CCB/diuretic
Renin inhibitor/diuretic
Renin inhibitor / ARB
Thiazide diuretics/K+-sparing
diuretics

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Less effective
ACE inhibitor/ARB
ACE inhibitor/-blocker
ARB/-blocker
CCB (nondihydropyridine)/blocker
Centrally acting agent/blocker

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Choice of Pharmacological Treatment

for Hypertension
Individualized treatment
Compelling indications:

Ischemic Heart Disease

Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Left Ventricular Systolic Dysfunction
Cerebrovascular Disease
Left Ventricular Hypertrophy
Non Diabetic Chronic Kidney Disease
Renovascular Disease
Smoking

Diabetes Mellitus
With Nephropathy
Without Nephropathy

Global Vascular Protection for Hypertensive Patients

Statins if 3 or more additional cardiovascular risks
Aspirin once blood pressure is controlled

Global Vascular Protection for

Patients with Hypertension

Vascular Protection for Hypertensive

Patients: Statins
In addition to current Canadian recommendations on management
of dyslipidemia, statins are recommended in high-risk
hypertensive patients with established atherosclerotic disease
or with at least 3 of the following criteria:
Male
Age 55 or older
Smoking
Total-C/HDL-C ratio of 6
mmol/L or higher

Family History of Premature

CV disease
LVH
ECG abnormalities
Microalbuminuria or Proteinuria

ASCOT-LLA Lancet 2003;361:1149-58

Vascular Protection for Hypertensive

Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

Treating Hypertension and

Other Risk Factors

Predicted Reduction in
Major CVD (%)

Treatment
Based on lipids
(statin)

Treatment
Based on BP

Treatment Based on
Overall Absolute Risk
(ASA, lipids, BP)

-5
-10
-15

-6

-9

-6
-12

-30
-35
-40

-10
-17

-20
-25

-8

Treatment thresholds
Top 10%
Top 20%
Top 30%

-28
-37
Adapted from Emberson et al. Eur Heart J. 2004;25:484-491

Secondary Hypertension

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension

Clinical Clues And Diagnostic Tests Of Secondary Hypertension

Shin et al. Clinical Hypertension

Resistant Hypertension
Blood pressure that remains above goal (<140/90
mmHg in non-complicated patients & <130/80 mmHg in
high risk patients) in spite of the concurrent use of of
three antihypertensive agent of different classes
Ideally, one of the three agents should be diuretic and
all agents should be prescribed at optimal dose
amounts
Includes patient whose blood pressure is controlled
with use of more than three medications
In a compliant patient

Difficult-to-Control
Hypertension
Inadequately treated hypertension (pseudo-resistance)
True resistant hypertension

Difficult-to-Control
Hypertension

Inadequately treated hypertension

(pseudo-resistance)
Under treatment
Treatment with inappropriate agents
Incorrect blood pressure measurement
White coat effects
Medications nonadherence
Pseudo-hypertension

Under Treatment (Suboptimal Medical

Treatment)
Clinical inertia : the providers failure
to increse therapy when the
treatment goal is not reached.
Lack of knowledge of treatment
guidelines
Underestimation of cardiovascular
risk
The use of spurious reason to avoid
intensification of therapy.

Medication Poor Adherence

High cost of treatment

Complex medical regimen
Adverse effect of medical therapy
Poor relation between doctors
and patients

Clinical clues suggestive of

pseudohypertension

Marked hypertension in the absence of

target organ damage
Antihypertensive therapy produces
symptoms consistent with hypotension in
the absence of successful reduction of BP
Radiological evidence of pipe stem
calcification in the brachial arteries
Brachial artery pressure higher than lower
extremity pressure
Severe and isolated systolic hypertension

Clinical clues suggestive of white

coat effects

Clinic blood pressure measurements are

consistently higher than out-of-office
measurements.
Patients show signs of overtreatment,
particularly orthostatic symptoms.
Patients with chronically high office blood
pressures values but an absence of target
organ damage.

Difficult-to-Control
Hypertension

True resistant hypertension

Associated
Identifiable causes
factors:

(NSAID, oral contraceptive,

Medications
Primary aldosteronism
sympathomimetic, corticosteroid, erythropoetin,
Renovascular disease
cyclophospamid.
Pheocromocytoma
Excessive alcohol consumption
Chronic
kidney
disease
Coarctation
of the
aorta

Obesity
Intracranial tumor
Obstructive sleep apnea

Suggested algorithm for the treatment of resistant hypertension

Insure therapy meets JNC-7 criteria for compelling indications
Uncontrolled blood pressure
on 3 or more antihypertensives
Consider ambulatory blood
pressure monitoring if
available to rule out whitecoat phenomenon

* if not already part of

regimen, consider B for
addition if pulse >84
A= ACEI or ARB
B = Beta Blocker
C= CCB (long-acting)
D= Diuretic

Thiazide-type
diuretic present?

NO

Correct identifiable causes if

present; consider work-up of
secondary conditions
Add low-dose diuretic
(chlorthalidone 12.5 mg
preferred; titrate to 25mg/d)

YES

Optimize combination as follows:

A or B* + C + D
If blood pressure
remains uncontrolled

Re-evaluate
If blood pressure
remains uncontrolled

+ spironolactone (12.5 mg/d to

25 mg/d)

If blood pressure remains uncontrolled, adjust regimen to include:

Trewet CLB, et al. South Med. 2008;101(2):166-174

Suggested algorithm for the treatment of resistant hypertension

If blood pressure remains uncontrolled, adjust regimen to include:

ACEI
+ ARB

or

2 CCBs
(different types)

or

alpha-blocker or
combined
alpha/beta blocker

or

Centrally-acting
(e.g. Clonidine)

+ vasodilator (e.g.
hydralazine)

Trewet CLB, et al. South Med. 2008;101(2):166-174

Questions guiding the JNC 8 review

This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management.
They address thresholds, goals for pharmacologic treatment, and whether particular
antihypertensive drugs or drug classes improve important health outcomes compared to others.

When to begin
treatment,
how low to aim for,
and
which

1. In adults with hypertension, does initiating antihypertensive pharmacologic

therapy at specific BP thresholds improve health outcomes?
2. In adults with hypertension, does treatment with antihypertensive pharmacologic
therapy to a specified BP goal lead to improvements in health outcomes?

3. In adults with hypertension, do various antihypertensive drugs or drug

classes differ in comparative benefits and harms on specific health
outcomes?

The answers to these three questions are reflected in

9 recommendations

Recommendations
Recommendation 1
(Strong recommendation)

General
population 60
years

BP
thresholds

Goals

SBP 150 mm
Hg
or DBP 90
mm Hg

SBP <150 mm
Hg
and DBP <90
mm Hg

DBP 90 mm
Hg

DBP <90 mm
Hg

SBP 140 mm
Hg

SBP <140 mm
Hg

Recommendation 2
(Strong recommendation)

General
population <60
years

Recommendation 3
(Expert opinion)

General
population <60
years

Recommendations
Recommendation 4
(Expert opinion)

Population with
CKD 18 years

BP
thresholds

Goals

SBP 140 mm
Hg
or DBP 90
mm Hg

SBP <140 mm
Hg
and DBP <90
mm Hg

SBP 140 mm
Hg
or DBP 90
mm Hg

SBP <140 mm
Hg
and DBP <90
mm Hg

Recommendation 5
(Expert opinion)

Population with
diabetes 18 years

Initial
treatment

Recommendation 6
(Moderate recommendation)

General nonblack
population (
diabetes )

or

or

Recommendations
Recommendation 7
(Moderate recommendation)

General (
diabetes )
black population

Recommendation 8
(Moderate recommendation)

Population with
CKD 18
years(irrespective
of race or diabetes)

Recommendation 9
(Expert opinion)

Goal BP not
reached

within a month of
treatment
Goal BP not reached
with 2 drugs

Initial
treatments

Black CD

or

Initial or add-on
treatments

Non control
strategies
Increase the dose of the initial drug,
or add a second drug (from the list
provided)

Add and titrate a third drug (from the list

provided)
Do not use an ACEI and an ARB together in
the same patient

CRISIS HYPERTENSION

Emergency Hypertension
Urgency Hypertension

Hypertensive Emergencies :
Definition
A rapid decompensation of vital organ
function secondary to an inapropriately
elevated BP
Require lowering of BP within 1 hour to
decrease morbidity
Not determined by a BP level, but rather
the imminent compromise of vital organ
function

Hypertensive Emergencies
CNS - Hypertensive encephalopathy
CVS
Acute myocardial ischemia
Acute cardiogenic pulmonary edema
Acute aortic dissection
Post-op vascular surgery

Renal - Acute renal failure

Eclampsia
Catechol excess- Pheochrom, Drugs

Therapeutic considerations in
hypertensive emergencies
Need for rapid reduction of BP
Potential complications of therapy
Prevalence of cerebrovascular disease and
coronary artery disease (Stenotic lesions)
Altered cerebral autoregulation
Impaired baroreflexes
Blood viscosity
Ability to increase oxygen extraction

How far can BP be safely

lowered?

Lower limit usually 25% below MAP

50% of chronic hypertensives reached lower
autoregulation limit with 11 to 20% reduction
in MAP
50% had lower limit above usual mean
Most ischemic complications develop with
reductions greater than 20 - 30 % (over 24 to 48
hours)
Blindness, paralysis, coma, death, MI

Initial Lowering of BP :
Therapeutic Guidelines
Do not lower BP more than 20% over the
first 1 to 2 hours unless necessary to
protect other organs
Decreasing to DBP of 110 or patients
normal levels may not be safe
Further reductions should be very
gradual ( days)
Follow neuro status closely

Concept of Hypertensive
Urgencies
Potentially dangerous BP elevation without
acute, life-threatening end-organ damage
Examples (controversial!)
Retinal changes without encephalopathy or
acute visual symptoms
High BP with nonspecific Sx (headache,
dizziness, weakness)
Very high BP without symptoms

Hypertensive Urgencies
Severe elevation of BP ( DBP > 115)
No progressive end-organ disease
Joint National Committee on Detection,
Evaluation, and Treatment of HBP
1984 - lower BP within 24 hours
1988 - urgent therapy rarely required
1993 - Gradual lowering of BP
Risks of rapid reduction (cerebral and myocardial
ischemia)

Adherence

Factors contributing to low

adherence/persistence with
antihypertensive drugs

Category

Examples

Poor communication
Patient-physician
relationship

Insufficient patient
information/education
Physical/cognitive impairments
(vision problems, dementia)
Asymptomatic

Condition

Therapy

Lifelong treatment
No immediate consequences of
stopping therapy
Adverse effects
Complexity of regimen
Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol 2011;2:63-70

Factors contributing to low

adherence/persistence with
antihypertensive drugs
Category

Examples
Cost of medication
Unemployment/poverty

Socioeconomic

Lack of insurance
Lack of transportation
Social deprivation
Inadequate health care coverage

Health system

Difficult access to health care

Lack of continuity of care
Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol

Guidelines for the physician to

improve antihypertensive drug
compliance
Educate the patient about hypertension and its
treatment with clear and accepted goals. Need
to continue treatment, control does not mean
cure, one cannot tell if BP is elevated by
feeling or symptoms-> BP must be measured
Keep the treatment as simple and cheap as
possible (using long-acting once-daily dosing)
with written information.
Combine efficient and well tolerated drugs in the
same pill (fixed-dose combination)

Contd
Stimulate the patient to be active in

medical management
Create a multidisciplinary team to
improve family and community
support
Use all possible modern reminder aids to
ensure daily drug intake.

Key Messages for the

Management of Hypertension
1. All patients should have their blood pressure assessed at all
appropriate clinical visits.
2. Optimum management of BP requires assessment of overall
cardiovascular risk.
3. Home BP monitoring is an important tool in self-monitoring and
self-management.
4. Treat to target.
5. Lifestyle modifications are effective in preventing hypertension,
treating hypertension and reducing cardiovascular risk.
6. Combinations of both lifestyle changes and drugs are generally
necessary to achieve target blood pressures.
7. Focus on adherence.

Thank You