1. Current major guidelines to future guidelines

2. WHY DO WE NEED GUIDELINES ?
Physicians are continuously flooded with studies.
Guidelines should help to find the right way through this jungle of information.
Experts should review existing data to provide clear recommendations based on evidence.
Guidelines are increasingly used by healthcare providers and politicians to assess the “appropriate use” and develop disease management programs.

3. Proportion of deaths attributable to leading risk factors worldwide
High mortality, developing region
Lower mortality, developing region
Developed region
0
8000
7000
6000
5000
4000
3000
2000
1000
Attributable Mortality (In thousands; total 55,861,000)
Ezzati et al. WHO 2000 Report. Lancet.2002;360:1347-1360

4. BP(mmHg)
WHO(1970)
JNC V(1991)
JNC VI (1997)
WHO/ISH 1999
ESH.ESC 2003 -2013
JNC VII (2003)
JNC VIII (2014)
< 120 & < 80
Normal
Optimal
Optimal
Normal
< 130 & < 85
Normal
Normal
Pre-hypertension
130-139 or
85-89
High-Normal
High-Normal
140-159 or
90-99
Borderline
Stage 1
Stage 1
160-179 or 100-109
Hypertension
SBP >160
or DBP >95
Stage 2
Stage 2
180-199 or 110-119
Stage 3
Stage 3
≥ 200 or
≥ 120
Stage 4
Classifications of Blood Pressure

5. 2013 ESH/ESC

6. Definitions
Stage 1 hypertension:
•Clinic blood pressure (BP) is 140/90mmHg orhigher and
•ABPM or HBPM average is 135/85mmHg or higher. Stage 2 hypertension:
•Clinic BP 160/100mmHg is or higher and
•ABPM or HBPM daytime average is 150/95mmHgor higher. Severe hypertension:
•Clinic BP is 180mmHg or higher or
•Clinic diastolic BP is 110mmHg or higher.
2013

7. NATIONAL HEALTH & NUTRITION EXAMINATION, PERCENT
NHANES II
(1976-80)
NHANES III (Phase1 88-91)
NHANES III (Phase 2 91-94)
1999-2000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74
M Wolt, National Heart, Lung, and Blood Institute; JNC 6

8. Triple paradox
1.Easy to diagnose often remains undetected
2.Simple to treat often remains untreated
3.Despite availability of potent drugs, treatment all too often is ineffective

9. Cardiovascular Risk Factors
Hypertension
Cigarette smoking
Obesity ( BMI ≥ 30 )
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimate GFR <60 mL/min
Age (older than 55 for men , 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women under age 65)
JNC VII EXPRESS

10. DMsmoking
agegenetics/sex
obesity
HTN
DYS
Global Risk: Overlapping CV Risk Factors

11. Target Organ Damage
Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
JNC VII EXPRESS

12. Identifiable causes of hypertension
Sleep apnea
Drug –induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy & Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
JNC VII EXPRESS

13. Laboratory Tests & Other Diagnostic Procedures
JNC VII EXPRESS
Electrocardiogram
Urinalysis
Blood glucose & hematocrit
Serum potassium & calcium
Creatinine
Lipid profile

14. * Individuals, 40-69 years, beginning at 115/75 mm Hg.
Lewington S, et al. Lancet. 2002; 60:1903-1913.
The JNC 7 Report. JAMA.2003
Risk of mortality
SBP (mm Hg) / DBP (mm Hg)
0
1
2
3
4
5
6
7
8
115/75
135/85
155/95
175/105

15. WHITE COAT HYPERTENSION
BP recording in office or clinic is high while at home is normotensive
"white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology )

16. HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION"
UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION
SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTSMASKED HYPERTENSION

19. 135/85 Ambulatory Pressure
140/90
Clinic PressureSustained Hypertension
White Coat Hypertension
True Normotension
Masked Hypertension

23. 2013 ESH/ESC

24. 2013 ESH/ESC

25. 2013 ESH/ESC

26. 2013 ESH/ESC

27. 2013 ESH/ESC

28. Care pathway
CBPM ≥160/100 mmHg & ABPM/HBPM ≥150/95mmHg
Stage 2 hypertension
Consider specialist referral
Offer antihypertensive drug treatment
Offer lifestyle interventions If younger than 40 years If target organ damage present or 10-year cardiovascular risk > 20% Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication
Offer patient education and interventions to support adherence to treatment
CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg
Stage 1 hypertension
2013

29. Step 4
Summary of antihypertensive drug treatment
Aged over 55 years or black person of African or Caribbean family origin of any age
Aged under55 years
C2
A
A + C2
A + C + D
Resistant hypertension
A + C + D + consider further diuretic3, 4 or alpha-or beta-blocker5
Consider seeking expert advice
Step 1Step 2Step 3KeyA –ACE inhibitor or low-cost angiotensinII receptor blocker (ARB)1C –Calcium-channel blocker (CCB) D –Thiazide-like diuretic
See slide notes for details of footnotes 1-5
2013

30. 2013 ESH/ESC

31. BP thresholds for drug treatment*
General population (including CKD) (CHEP 2011**)
140/90
Very elderly (>80) (CHEP 2013**)
150
Diabetes (CHEP2000**)
130/80
Very lowCV risk (CHEP 2000**)
160/100
* lifestyle modification is recommended for all regardless of BP
** Year of incorporation into CHEP recommendations
2013

32. III. Choice of Therapy for Adults With Hypertension without Compelling Indications for Specific Agents
New Recommendation for 2013
B) Recommendations for Individuals with Isolated Systolic Hypertension
ADD:
In the very elderly (age 80 years and older), the target for systolic BP should be < 150 mmHg (Grade C).
CHEP Recommendation: the very elderly
2013

33. Summary of evidence in patients with diabetes and hypertension
•SBP lowering below 140 mmHg appears beneficial with respect to all cause mortality and stroke
•SBP lowering below 135mmHg or 130 mmHg appears to confer significant benefit with respect to stroke
•As SBP decreases below 140 mmHg, the risk of SAEs increasesbut the absolute number of these events is low
2013

34. III. Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling IndicationsTARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
*BBs are not indicated as first line therapy for age 60 and above
Beta- blocker*
Long- acting
CCB
Thiazide
ACEI
ARB
Lifestyle modification
therapyACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potentialA combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target
2013

35. III. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling IndicationsCONSIDER
•Nonadherence
•Secondary HTN
•Interfering drugs or lifestyle
•White coat effect
Dual Combination
Triple or Quadruple Therapy
Lifestyle modification
Thiazide
diuretic
ACEILong-actingCCBTARGET <140/90 mmHg
ARB
*Not indicated as first line therapy over 60 yInitial therapy
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target
Beta-
blocker*

36. III. Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications
INITIAL TREATMENT AND MONOTHERAPY
Thiazide diuretic
Long-acting
DHP CCBLifestyle modificationtherapyARBTARGET <140 mmHg (< 150 mmHg if age >80 years)
2013

37. III. Add-on therapy for Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER
•Nonadherence
•Secondary HTN
•Interfering drugs or lifestyle
•White coat effect
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha adrenergic blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
If partial response to monotherapy
Long-acting
DHP CCB
Triple therapy
Thiazide diuretic
ARB
Dual combination
Combine first line agents2013

38. III. Summary: Treatment of Isolated Systolic Hypertension without Other Compelling IndicationsCONSIDER
•Nonadherence
•Secondary HTN
•Interfering drugs or lifestyle
•White coat effect
Thiazide diuretic
Long-acting
DHP CCB
Dual therapy
Triple therapy
Lifestyle modification
therapy
ARB
TARGET <140 mmHg, < 150 mmHg for age >80 years
*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
2013

39. 39Blood pressure target values for treatment of hypertension
Condition
Target
SBP and DBP mmHg
Isolated systolic hypertension
Age >80 years
<140
< 150
Systolic/Diastolic Hypertension
• Systolic BP
• Diastolic BP
<140
<90
Diabetes
• Systolic
• Diastolic
<130
<80
V. Goals of Therapy

40. 2013 ESH/ESC

41. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
JNC VIII

42. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
JNC VIII

43. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
Strategies to Dose Antihypertensive DrugsJNC VIII

44. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2013;():. doi:10.1001/jama.2013.284427
Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With HypertensionJNC VIII

46. Recurrent stroke
Diuretic
Recurrent stroke
ACE inhibitor + diuretic
CEREBROVASCULAR DISEASE
Cardiovascular morbidity and mortality
ARB
Left ventricular hypertrophy
Mortality
Spironolactone
Mortality
Beta-blocker
CHF (diuretics almost always included)
Mortality
ACE inhibitor
Heart failure
ACE inhibitor
Mortality
Beta-blocker
Left ventricular dysfunction
Mortality
ACE inhibitor
Post MI
CARDIAC DISEASE
Progression of renal failure
ACE inhibitor
Nondiabetic nephropathy
Progression of renal failure
ARB
Diabetic nephropathy type 2
Progression of renal failure
ACE inhibitor
Diabetic nephropathy type 1
RENAL DISEASE
Stroke
DHCCB
Stroke
Diuretic
ELDERLY WITH ISOLATED SYSTOLIC HYPERTENSION
PRIMARY ENDPOINT
PREFERRED DRUG
COMPELLING INDICATION
Compelling Indications for Specific Antihypertensive Drugs ISH/WHO

47. Indications for the Major Classes of Antihypertensive Drugs
BPH; hyperlipidemia
Alpha-blockers
type 2 nephropathy; diabetic microalbuminuria; proteinuria; LV hypertrophy; ACE inhibitor cough
ARBs
CHF; LV dysfunction; post MI; nondiabetic nephropathy; type 1 diabetic nephropathy; proteinuria
ACE inhibitors
Angina pectoris, carotid atherosclerosis; supraventricular tachycardia
CCBs (verapamil, diltiazem)
Elderly; ISH; angina pectoris; peripheral vascular disease; carotid atherosclerosis; pregnancy
CCBs (DHP)
Angina pectoris; post MI; CHF (up-titration); pregnancy; tachyarrhythmias
Beta-blockers
CHF; post MI
Diuretics (antialdosterone)
Renal insufficiency; CHF
Diuretics (loop)
CHF; elderly; ISH; hypertensives of African origin
Diuretics (Thiazide)
Conditions Favoring Use
Drug

48. -Chobanian AV et al. JNC 7. JAMA 2003 ; 289 : 2560-2572
-ESH Guidelines Committee. J Hypertens 2003 ; 21 : 1011-1053
Compelling indications for beta-blockade
Hypertension /Heart Failure
Hypertension /post MI
Hypertension /high CAD risk
Hypertension /Diabetes Mellitus
Hypertension /arrhythmias
Hypertension /angina pectoris

49. Choice of anti-hypertensive drugs in patient with concomitant disease
Concomitant disease
Diuretics
B-Blockers
ACEI
Ca channel blocker
Alpha blocker
ARB
Diabetes
Careful
Careful
Yes
Yes
Yes
Yes
Gout
No
Yes
Yes
Yes
Yes
Yes/No
Hyperlipidemia
Careful
Careful
Yes
Yes
Yes
Yes
IHD
Yes
Yes
Yes
Yes
Yes
Yes
Heart Failure
Yes
Careful
Yes
Careful
Yes
Yes
Asthma
Yes
No
Yes
Yes
Yes
Yes
PVD
Yes
Careful
Yes
Yes
Yes
Yes
Renal impairment
Yes
Yes
Careful
Yes
Yes
Careful
Renal A Stenosis
Yes
Yes
Careful
Yes
Yes
Careful
Elderly with no co morbid cond.
Yes
Yes
Yes
Yes
Yes
Yes

50. Group
Effective Agents
Ineffective Agents
Young white
ACE inhibitors, beta blocker
Diuretic
Older white
CCB, beta-blocker
Young black
CCB
ACE inhibitors, beta-blocker
Other black
Diuretic
ACE inhibitors, beta-blocker
Isolated systolic hypertension
Diuretic
ACE inhibitors
CurrentDiagnosis&TreatmentinCardiology
Response by demographic group

51. Stratification and Management
Blood pressure
(mmHg)
Other risk factors & disease history
No other risk factors
1-2 risk factors
≥ 3 risk factors or TOD or ACC
Pre-hypertension
120-139 or 80-89
Lifestyle modification
Lifestyle modification
Drug for the compelling indications
Grade I: SBP 140-159 or DBP 90-99
Lifestyle modification
6 months
One drug therapy
Drug combination
Grade II & III:
SBP ≥160 or
DBP ≥ 100
Drug combination
Drug combination
Drug combination

52. Renin-angiotensin system
Sympathetic nervous system
Vasoconstriction/
Renal Retention of Excess Sodium
Vascular Hypertrophy
Hypertension: a multifactorial entity
Patient 1Patient 2Patient 3

53. Renin-angiotensin system
Sympathetic nervous system
Vasoconstriction/
Diuretic
Vascular Hypertrophy
Renal Retention of Excess Sodium
Hypertension: a multifactorial entity

54. MDs have not been aggressive enough in controlling hypertension in their patients
Patients w/ DM & CKD require more aggressive BP control
Most patients with hypertension will require two or more antihypertensive medications to control blood pressure
The use of combination therapy is appropriate as initial treatment
Sustained antihypertensive efficacy may protect against the early morning rise in blood pressure that leads to heightened risk of cardiovascular events
Summary