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HYPERTENSIONHYPERTENSION
AND ITSAND ITS
MANAGEMENTMANAGEMENT
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD,FACC, FESC, FRCP, FSCAI,FAPSIC,
FAPSC, FCCP
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova,
Malbagh branch.
Hypertension
A World Wide Epidemic
Nearly 1 billion hypertensive in the world
Hypertension is poorly controlled, with less than
25% controlled in developed countries and less
than 10% in developing countries.
Hypertension which is responsible for 3 million
death annually.
May 14th
is World Hypertension Day
Prevalence ofPrevalence of
HypertensionHypertension
131 144
302
584
240
0
100
200
300
400
500
600
PrevalenceRate/1000
1
India (2000) Bangladesh (2002) Malaysia (2002)
China (2002) USA (2002)
Hypertension is a hemodynamic disorder
A well accepted definition of hypertension was
suggested by Evans and Rose:
“Hypertension should be defined in the terms of blood
pressure level above which investigation and treatment
do good more than harm”
A patient is said to be hypertensive when his SBP≥
140 mm Hg & DBP ≥ 90 mm Hg provided that the
patient is not on antihypertensive drugs.
Hypertension: DefinitionHypertension: Definition
Varieties OF HTNVarieties OF HTN
Labile HTN
Isolated diastolic hypertension
Isolated systolic hypertension
Malignant or accelerated Hypertension
Refractory/ Resistant hypertension
Hypertensive emergencies/ urgencies
Classification of BP for AdultsClassification of BP for Adults
JNC-VI;1997JNC-VI;1997
BP Classification Systolic BP Diastolic BP
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT 160-179 or 100-109
Stage 3 HT ≥ 180 or ≥ 110
BP Classification Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT ≥ 160 or ≥ 100
JNC-VII;2003JNC-VII;2003
Classification of BP LevelsClassification of BP Levels
ESH-ESC Guidelines, 2003
BP Classification
Optimal
Normal
High Normal
Grade 1 HT (mild)
Grade 2 HT (moderate)
Grade 3 (severe)
Isolated systolic HT
Systolic BP
<120
120-129
130-139
140-159
160-179
>180
>140
Diastolic BP
<80
80-84
85-89
90-99
100-109
>110
<90
Regulation of BP
BP = CO X PVR
SV HR
Haemodynamic Pattern inHaemodynamic Pattern in
HypertensionHypertension
Young : ↑ BP = ↑CO X TPR
Middle Aged : ↑ BP = CO X TPR
Elderly : ↑ BP = ↓ CO X ↑ ↑ TPR
Aetiology of SystemicAetiology of Systemic
HypertensionHypertension
A) Essential or Primary HTN (95%)
A. ↑ Age
B. Genetic • Both parents (45%)
• Single (25%)
C. Environment • Diet Fat
Salt
alcohol
• Obesity
• Physical inactivity
• Stress
• Smoking
D. Hormonal
Aetiology of SystemicAetiology of Systemic
HypertensionHypertension
B) Secondary HTN (05%)
A. Renal (80%) • AGN
• CGN,
• CPN,
• Polycyst. K.D
• Renal Artery stenosis
B. Endocrine • Adrenal • Primary aldosteronism
• Cushing’s syndrome
 Pheochromocytoma
• Acromegaly
• Exogenous hormone • Oral contraceptive)
• Glucosteroids
• Hypothyroidism &
• Hyperparathyroidism
Continue…
C) Others
 Coarctation of the aorta
 Pregnancy Induced HTN (Pre-eclampsia)
 Sleep Apnea Syndrome.
Aetiology of SystemicAetiology of Systemic
HypertensionHypertension
Clinical ManifestationClinical Manifestation
• Asymptomatic in the majority of patients. Can
remain undetected for many years
• Headache may occur when SBP rises above
200mmHg or when blood pressure is rapidly
elevated.
Measuring Blood PressureMeasuring Blood Pressure
• Patient seated quietly for at least
5minutes in a chair, with feet on the
floor and arm supported at heart level
•An appropriate-sized cuff (cuff bladder encircling at
least 80% of the arm)
•At least 2 measurements
Continue…
Measuring Blood PressureMeasuring Blood Pressure
• Systolic Blood Pressure is the point at which the
first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…
Measuring Blood PressureMeasuring Blood Pressure
• Ambulatory BP Monitoring - information about BP
during daily activities and sleep.
• Correlates better than office measurements with
target-organ injury.
Continue…
Complication of HypertensionComplication of Hypertension
1. Cardiac :
LVH
LVF
•Systolic
•Diastolic
IHD
Arrhythmias
2. Vascular Peripheral arterial
disease
•Aortic dissection
3. Cerebral
Stroke
TIA
Encephalopathy
4. Renal Nephropathy
Renal failure
5. Eye Retinopathy
The scope of the problemThe scope of the problem
– Heart Attack (MI)
– Heart Failure
– Stroke
– Kidney Disease
THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO
MINIMISE CARDIOVASCULAR RISK AND DAMAGE
TO TARGET ORGANS
Hypertension even today is aHypertension even today is a
triple paradox which is :triple paradox which is :
Easy to diagnose OFTEN remains undetected
Simple to treat OFTEN remains untreated
Despite availability of potent drugs, treatment
all too OFTEN is ineffective
The "Rule of Halves" inThe "Rule of Halves" in
HypertensionHypertension
Only 1/2 have been
diagnosed
Only 1/2 of those
diagnosed have been
treated
Only 1/2 of those treated
are adequately controlled
Only 12.5% overall are adequately controlled
Not
diagnosed
Not treated
Not
controlled
Controlled
Evaluation of hypertensive patientsEvaluation of hypertensive patients
Objectives:
To know accurate and representative
measurement of BP
To identity any known cause of Hypertension
To assess presence or absence of TOD
To assess response to therapy
To identity cardiovascular risks factor
To know concomitant disorders
Continue….
Evaluation of hypertensive patientsEvaluation of hypertensive patients
Evaluation by
Medical history
Physical Examination
Laboratory investigation
 Routine tests
 Optional tests.
Effects of Antihypertensive Drug Treatment onEffects of Antihypertensive Drug Treatment on
CV Mortality and MorbidityCV Mortality and Morbidity
Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated
compared to control
Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478
-52%
-38%
-35%
-25%
-16%
-60%
-50%
-40%
-30%
-20%
-10%
0%
CHF Strokes
(fatal/nonfatal)
LVF CVD Deaths CVD events
(fatal/nonfatal
Management of HTNManagement of HTN
140
120
100
80
60
40
20
0
50
40
30
20
10
0
Historical Lessons About HypertensionHistorical Lessons About Hypertension
Hypertension
Increases Morbidity
and Mortality
Men Women
CHDIncidenceRate/1000
personsperyear
THE FRAMINGHAM STUDY
Cumulativefatal&
NonfatalEndpoints
Treatment Decreases
Morbidity and
Mortality
Men Women Placebo Active
Treatment
THE VET.ADM. STUDY II
Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152
Normotension
Hypertension
Implication of reduction in Diastolic BP forImplication of reduction in Diastolic BP for
Primary PreventionPrimary Prevention
30
20
%Reduction
Change in DBP
0
-10
-20
-30
-40
-50
7.5 mm Hg 5-6 mm Hg 2 mm Hg
-21
-46
-16
-38
-6
-15
CHD
Stroke
Cook, et al. Arch Int med. 1995; 155:711-109
Millimeters Matter……Millimeters Matter……
“ A 2-mm Hg reduction in DBP would
result in…
a 6% reduction in the risk of CHD and a 15%
reduction
in the risk of stroke and TIAs”
Cook, et al. Arch Int med. 1995; 155:711-109
Impact of High Normal BP on CVImpact of High Normal BP on CV
Disease Risk in MenDisease Risk in Men
High Normal
130-139/ 85-89 mm Hg
Normal
120-129/ 80-84 mm Hg
Optimal
<120/ 80 mm Hg
CumulativeIncidence(%)
Time (Years) N Engl J Med. 2001;345:1291-97
Benefits of Lowering BPBenefits of Lowering BP
Average percent
reduction
Stroke reduction 35-40%
Myocardial infarction 20-25%
Heart failure 50%
Goals of TherapyGoals of Therapy
• Reduction of cardiovascular and renal
morbidity and mortality. 1
• The primary focus should be on achieving the systolic
BP goal.
• Systolic BP and diastolic BP to targets < 140/90
mmHg = decrease in CVD complications.
• In patients with hypertension with diabetes or renal
disease, the BP goal is < 130/80 mmHg 1
1
JNC - VII Report, JAMA , 2003;289:2560-2572
JNC VII Algorithm for Treatment of
Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle
Modifications
Not at Goal BP
(< 140/90 mmHg or < 130/80 mmHg
for Those with Diabetes or Chronic
Kidney Disease
Initial Drug Choices
Lifestyle Modification: 1Lifestyle Modification: 1
⇒ Socioeconomic condition in the world suggest that
prevention through Lifestyle Modifications is the
universal “vaccine” against Hypertension
⇒Weight Reduction
– Maintain normal body weight
• BMI: 18.5 – 24.9
• BP reduction: 5-20 mmHg/10 kg loss
⇒DASH Eating Plan
– Dietary Approaches to Stop Hypertension
• Fruits, Vegetables, Low-fat dairy
• Reduce saturated and total fat
• 8-14 mmHg BP reduction
Lifestyle Modification: 2Lifestyle Modification: 2
⇒Dietary Sodium Reduction
•2.4 grams Sodium or 6 grams Sodium Chloride
•2-8 mmHg BP reduction
⇒Physical Activity
–Regular aerobic physical activity
•4-9 mmHg BP reduction
Lifestyle Modification: 3Lifestyle Modification: 3
⇒Smoking Cessation
•Any independent chronic effect of smoking on BP is small
•Smoking cessation does not decrease BP
•BUT total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke
should be counselled on smoking
cessation
Antihypertensive Drugs
Continue….
AT1 receptor
ARB
Antihypertensive Drugs
JNC VII Algorithm for
Treatment of Hypertension
Hypertension without
compelling indications
Hypertension with
compelling indication
(Systolic Bp 140-159
mmHg
or Diastolic BP 90-99
mmHg)
Thiazide-Type
Diuretics for Most
May Consider ACE
inhibitor, ARB, ß-
blocker, CCB or
combination
Systolic Bp >160
mmHg
or Diastolic BP > 100
mmHg)
2- Drug Combination
for Most
(Usually Thiazide -
Type Diuretic and
ACE Inhibitor or ARB
or ß-blocker, CCB)
Drug (s) for the
Compelling
Indications
Other
Anithypertensive
Drugs
(Diuretics, ACE
inhibitor, ARB, ß-
blocker, CCB) as
Initial Drug Choices
ChoiceChoice of antihypertensiveof antihypertensive
• Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors,
angiotensin receptor antagonists) are suitable for the initiation and
maintenance of therapy
• Choice:
→ Previous experience of the patient
→ Cost
→ Risk profile, target organ damage, clinical cardiovascular or renal
disease or diabetes or lung disorder
→ Patient’s preference
• Long acting preparations providing 24-h efficacy on a once daily
basis
(2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).
Special ConsiderationsSpecial Considerations
Guideline Basis for Compelling Indications for
Individual Drug Classes
High Risk Conditions
With Compelling
Indication
Heart failure
Post-myocardial
infarction
High coronary disease
risk
Diabetes
Chronic Kidney Disease
Recurrent stroke
prevention
Recommended Drugs
Diuretic β-blocker ACE inhibitor ARB CCB Aldosterone Antagonist
JNC - VII Report, JAMA , 2003;289:2560-2572
Choice Between MonotherapyChoice Between Monotherapy
and Combination therapyand Combination therapy
Possible Combination ofPossible Combination of
Antihypertensive AgentsAntihypertensive Agents
Diuretics
Beta
Blocker
∝-Blocker
ACE inhibitor
CCBs
ARBs
EHS-ESC Guidelines, 2003;
Indications and Contraindications forIndications and Contraindications for
the Major Classes of Antihypertensiuethe Major Classes of Antihypertensiue
DrugsDrugs
Class Conditions favouring
the use
Compelling
contraindications
Possible
contraindications
ACEIs CHF
LV dysfunction
Post-MI
Nondiabetic nephropathy
Type 1 diabetic nephropathy
Protienuria
Pregnancy
Hyperkalaemia
Bilateral RAS
ARBs Type 2 diabetic nephropathy
Diabetic microalbuminuria
Proteinuria
LVH
ACE inhibitor cough
Pregnancy
Hyperkalaemia
Bilateral RAS
a-Blockers Prostatic hyperplasia (BPH)
Hyperlipidaemia
Orthostatic
hypotension
CHF
EHS-ESC Guidelines, 2003;
EVOLUTION OF HYPERTENSIONEVOLUTION OF HYPERTENSION
MANAGEMENTMANAGEMENT
JNC I
1977
JNC II
1980
JNC III
1984
JNC IV
1988
JNC V
1993
JNC VI
1997
JNC VII
2003
High
Dose
diuretic
High
Dose
diuretic
Lower
Dose
diuretic
Or
β-blocker
Lower
Dose
diuretic
Or
β-blocker
Or
ACEI
Or
CCB
Lower
Dose
diuretic
Or
β-blocker
Or
ACEI
Or
CCB
α-blocker
Or
α / β blocker
•
Individulised
Therapy
•Single-agent
titration
preferred
•Loe-dose
combo
therapy as a
secondary
option
•Focus on
Systolic
BP Control
•Thiazide-
type
diuretics
preferred
as initial
drug
treatment
•Emphasis
on
combinatio
n therapy
High-dose Monotherapy Low-dose Combination
Management of HTN in SpecialManagement of HTN in Special
SituationSituation
1. Hypertension Crises
Hypertension Emergencies
Hypertension Urgencies
2. Refractory/ Resistant hypertension
3. HTN in Pregnancy
4. HTN with coexisting Cardiovascular & other disorders
4. Management of Secondary HTN
Resistant Hypertension
• Not uncommon : 15-20%
• Persistence of elevated systo-diastolic pressure in
spite of at 3 anti-hypertensive drugs ( including
diuretics)
• Pre-requisites: Exclusion of pseudo-hypertension;
white-coat hypertension,use of not-appropriate
cuffs.
Resistant hypertension: Causes
• Insufficient patient compliance
• Inability to follow prescribed life-style
modifications ( weight loss, increased
alcohol consumption)
• Use of offending drugs: steroids,NSAID
• Obstructive Sleep apnoea syndrome
• Volume overload
Therapeutic intervention
• Exclude undiagnosed secondary
hypertension
• Compliance of drugs
• Adherence to life style changes
• Consider use of 3 or more anti-hypertensive
drugs
• Consider the use of drugs such as
spironolactone
Failure of reduction of DBP<90 mm Hg
despite the use of three or more drugs
which include a diuretic
Resistant hypertension
Braunwald’s Heart Disease, 2005
Volume overload & pseudotolerance
“White coat”
Pseudohypertension in the elderly
Excess sodium intake
Inadequate diuretic therapy
Volume retention
Drug related
Dosage too low
Inappropriate combination
Drug interaction
Associated conditions
Smoking
Obesity
Excess alcohol
Sleep apnea
Secondary hypertension
Resistant hypertension
Causes:
Braunwald’s Heart Disease, 2005
Current recommendations for primary
prevention of hypertension involve:
 a population based approach, and
 an intensive targeted strategy focused on
individuals at high risk for hypertension.
Primary Prevention of Hypertension
Hypertension Primer, AHA, 2004
Conclusion
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from
the deleterious effect
• Pharmacological armament of antihypertensive drugs so
rich that we have wide range of options. And this makes
the physicians comfortable in varied situations.
Conversely one needs to be judicious regarding the
choice of the drug
• Besides pharmacology we have other choices and one
has to be acquainted with that choice
• Primary prevention of hypertension should be highlighted
and it should get more priority than it is getting now.
Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in developing
countries
Early diagnosis & management can prevent end organ damage from HTN
Target goal of BP in hypertensive patients:-
< 140/90 mm Hg
< 130/80 mm Hg for patients with DM & renal disease
Lifestyle modification is the universal “Vaccine” against Hypertension
ConclusionConclusion
Thank you !Thank you !

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Management of Hypertension

  • 1. HYPERTENSIONHYPERTENSION AND ITSAND ITS MANAGEMENTMANAGEMENT Dr. Md.Toufiqur Rahman MBBS, FCPS, MD,FACC, FESC, FRCP, FSCAI,FAPSIC, FAPSC, FCCP Associate Professor of Cardiology National Institute of Cardiovascular Diseases Sher-e-Bangla Nagar, Dhaka-1207 Consultant, Medinova, Malbagh branch.
  • 2. Hypertension A World Wide Epidemic Nearly 1 billion hypertensive in the world Hypertension is poorly controlled, with less than 25% controlled in developed countries and less than 10% in developing countries. Hypertension which is responsible for 3 million death annually. May 14th is World Hypertension Day
  • 3. Prevalence ofPrevalence of HypertensionHypertension 131 144 302 584 240 0 100 200 300 400 500 600 PrevalenceRate/1000 1 India (2000) Bangladesh (2002) Malaysia (2002) China (2002) USA (2002)
  • 4. Hypertension is a hemodynamic disorder A well accepted definition of hypertension was suggested by Evans and Rose: “Hypertension should be defined in the terms of blood pressure level above which investigation and treatment do good more than harm” A patient is said to be hypertensive when his SBP≥ 140 mm Hg & DBP ≥ 90 mm Hg provided that the patient is not on antihypertensive drugs. Hypertension: DefinitionHypertension: Definition
  • 5. Varieties OF HTNVarieties OF HTN Labile HTN Isolated diastolic hypertension Isolated systolic hypertension Malignant or accelerated Hypertension Refractory/ Resistant hypertension Hypertensive emergencies/ urgencies
  • 6. Classification of BP for AdultsClassification of BP for Adults JNC-VI;1997JNC-VI;1997 BP Classification Systolic BP Diastolic BP Optimal <120 and <80 Normal <130 and <85 High Normal 130-139 or 85-89 Stage 1 HT 140-159 or 90-99 Stage 2 HT 160-179 or 100-109 Stage 3 HT ≥ 180 or ≥ 110 BP Classification Systolic BP Diastolic BP Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 HT 140-159 or 90-99 Stage 2 HT ≥ 160 or ≥ 100 JNC-VII;2003JNC-VII;2003
  • 7. Classification of BP LevelsClassification of BP Levels ESH-ESC Guidelines, 2003 BP Classification Optimal Normal High Normal Grade 1 HT (mild) Grade 2 HT (moderate) Grade 3 (severe) Isolated systolic HT Systolic BP <120 120-129 130-139 140-159 160-179 >180 >140 Diastolic BP <80 80-84 85-89 90-99 100-109 >110 <90
  • 8. Regulation of BP BP = CO X PVR SV HR
  • 9. Haemodynamic Pattern inHaemodynamic Pattern in HypertensionHypertension Young : ↑ BP = ↑CO X TPR Middle Aged : ↑ BP = CO X TPR Elderly : ↑ BP = ↓ CO X ↑ ↑ TPR
  • 10. Aetiology of SystemicAetiology of Systemic HypertensionHypertension A) Essential or Primary HTN (95%) A. ↑ Age B. Genetic • Both parents (45%) • Single (25%) C. Environment • Diet Fat Salt alcohol • Obesity • Physical inactivity • Stress • Smoking D. Hormonal
  • 11. Aetiology of SystemicAetiology of Systemic HypertensionHypertension B) Secondary HTN (05%) A. Renal (80%) • AGN • CGN, • CPN, • Polycyst. K.D • Renal Artery stenosis B. Endocrine • Adrenal • Primary aldosteronism • Cushing’s syndrome  Pheochromocytoma • Acromegaly • Exogenous hormone • Oral contraceptive) • Glucosteroids • Hypothyroidism & • Hyperparathyroidism Continue…
  • 12. C) Others  Coarctation of the aorta  Pregnancy Induced HTN (Pre-eclampsia)  Sleep Apnea Syndrome. Aetiology of SystemicAetiology of Systemic HypertensionHypertension
  • 13. Clinical ManifestationClinical Manifestation • Asymptomatic in the majority of patients. Can remain undetected for many years • Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated.
  • 14. Measuring Blood PressureMeasuring Blood Pressure • Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level •An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) •At least 2 measurements Continue…
  • 15. Measuring Blood PressureMeasuring Blood Pressure • Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard • Diastolic Blood Pressure is the point of disappearance of the sounds (Korotkoff 5th) Continue…
  • 16. Measuring Blood PressureMeasuring Blood Pressure • Ambulatory BP Monitoring - information about BP during daily activities and sleep. • Correlates better than office measurements with target-organ injury. Continue…
  • 17. Complication of HypertensionComplication of Hypertension 1. Cardiac : LVH LVF •Systolic •Diastolic IHD Arrhythmias 2. Vascular Peripheral arterial disease •Aortic dissection 3. Cerebral Stroke TIA Encephalopathy 4. Renal Nephropathy Renal failure 5. Eye Retinopathy
  • 18. The scope of the problemThe scope of the problem – Heart Attack (MI) – Heart Failure – Stroke – Kidney Disease THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO MINIMISE CARDIOVASCULAR RISK AND DAMAGE TO TARGET ORGANS
  • 19. Hypertension even today is aHypertension even today is a triple paradox which is :triple paradox which is : Easy to diagnose OFTEN remains undetected Simple to treat OFTEN remains untreated Despite availability of potent drugs, treatment all too OFTEN is ineffective
  • 20. The "Rule of Halves" inThe "Rule of Halves" in HypertensionHypertension Only 1/2 have been diagnosed Only 1/2 of those diagnosed have been treated Only 1/2 of those treated are adequately controlled Only 12.5% overall are adequately controlled Not diagnosed Not treated Not controlled Controlled
  • 21. Evaluation of hypertensive patientsEvaluation of hypertensive patients Objectives: To know accurate and representative measurement of BP To identity any known cause of Hypertension To assess presence or absence of TOD To assess response to therapy To identity cardiovascular risks factor To know concomitant disorders Continue….
  • 22. Evaluation of hypertensive patientsEvaluation of hypertensive patients Evaluation by Medical history Physical Examination Laboratory investigation  Routine tests  Optional tests.
  • 23. Effects of Antihypertensive Drug Treatment onEffects of Antihypertensive Drug Treatment on CV Mortality and MorbidityCV Mortality and Morbidity Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated compared to control Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478 -52% -38% -35% -25% -16% -60% -50% -40% -30% -20% -10% 0% CHF Strokes (fatal/nonfatal) LVF CVD Deaths CVD events (fatal/nonfatal Management of HTNManagement of HTN
  • 24. 140 120 100 80 60 40 20 0 50 40 30 20 10 0 Historical Lessons About HypertensionHistorical Lessons About Hypertension Hypertension Increases Morbidity and Mortality Men Women CHDIncidenceRate/1000 personsperyear THE FRAMINGHAM STUDY Cumulativefatal& NonfatalEndpoints Treatment Decreases Morbidity and Mortality Men Women Placebo Active Treatment THE VET.ADM. STUDY II Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152 Normotension Hypertension
  • 25. Implication of reduction in Diastolic BP forImplication of reduction in Diastolic BP for Primary PreventionPrimary Prevention 30 20 %Reduction Change in DBP 0 -10 -20 -30 -40 -50 7.5 mm Hg 5-6 mm Hg 2 mm Hg -21 -46 -16 -38 -6 -15 CHD Stroke Cook, et al. Arch Int med. 1995; 155:711-109
  • 26. Millimeters Matter……Millimeters Matter…… “ A 2-mm Hg reduction in DBP would result in… a 6% reduction in the risk of CHD and a 15% reduction in the risk of stroke and TIAs” Cook, et al. Arch Int med. 1995; 155:711-109
  • 27. Impact of High Normal BP on CVImpact of High Normal BP on CV Disease Risk in MenDisease Risk in Men High Normal 130-139/ 85-89 mm Hg Normal 120-129/ 80-84 mm Hg Optimal <120/ 80 mm Hg CumulativeIncidence(%) Time (Years) N Engl J Med. 2001;345:1291-97
  • 28. Benefits of Lowering BPBenefits of Lowering BP Average percent reduction Stroke reduction 35-40% Myocardial infarction 20-25% Heart failure 50%
  • 29. Goals of TherapyGoals of Therapy • Reduction of cardiovascular and renal morbidity and mortality. 1 • The primary focus should be on achieving the systolic BP goal. • Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease in CVD complications. • In patients with hypertension with diabetes or renal disease, the BP goal is < 130/80 mmHg 1 1 JNC - VII Report, JAMA , 2003;289:2560-2572
  • 30. JNC VII Algorithm for Treatment of Hypertension JNC - VII Report, JAMA , 2003;289:2560-2572 Lifestyle Modifications Not at Goal BP (< 140/90 mmHg or < 130/80 mmHg for Those with Diabetes or Chronic Kidney Disease Initial Drug Choices
  • 31. Lifestyle Modification: 1Lifestyle Modification: 1 ⇒ Socioeconomic condition in the world suggest that prevention through Lifestyle Modifications is the universal “vaccine” against Hypertension ⇒Weight Reduction – Maintain normal body weight • BMI: 18.5 – 24.9 • BP reduction: 5-20 mmHg/10 kg loss ⇒DASH Eating Plan – Dietary Approaches to Stop Hypertension • Fruits, Vegetables, Low-fat dairy • Reduce saturated and total fat • 8-14 mmHg BP reduction
  • 32. Lifestyle Modification: 2Lifestyle Modification: 2 ⇒Dietary Sodium Reduction •2.4 grams Sodium or 6 grams Sodium Chloride •2-8 mmHg BP reduction ⇒Physical Activity –Regular aerobic physical activity •4-9 mmHg BP reduction
  • 33. Lifestyle Modification: 3Lifestyle Modification: 3 ⇒Smoking Cessation •Any independent chronic effect of smoking on BP is small •Smoking cessation does not decrease BP •BUT total cardiovascular risk is increased by smoking. Therefore hypertensives who smoke should be counselled on smoking cessation
  • 36. JNC VII Algorithm for Treatment of Hypertension Hypertension without compelling indications Hypertension with compelling indication (Systolic Bp 140-159 mmHg or Diastolic BP 90-99 mmHg) Thiazide-Type Diuretics for Most May Consider ACE inhibitor, ARB, ß- blocker, CCB or combination Systolic Bp >160 mmHg or Diastolic BP > 100 mmHg) 2- Drug Combination for Most (Usually Thiazide - Type Diuretic and ACE Inhibitor or ARB or ß-blocker, CCB) Drug (s) for the Compelling Indications Other Anithypertensive Drugs (Diuretics, ACE inhibitor, ARB, ß- blocker, CCB) as Initial Drug Choices
  • 37. ChoiceChoice of antihypertensiveof antihypertensive • Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors, angiotensin receptor antagonists) are suitable for the initiation and maintenance of therapy • Choice: → Previous experience of the patient → Cost → Risk profile, target organ damage, clinical cardiovascular or renal disease or diabetes or lung disorder → Patient’s preference • Long acting preparations providing 24-h efficacy on a once daily basis (2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).
  • 38. Special ConsiderationsSpecial Considerations Guideline Basis for Compelling Indications for Individual Drug Classes High Risk Conditions With Compelling Indication Heart failure Post-myocardial infarction High coronary disease risk Diabetes Chronic Kidney Disease Recurrent stroke prevention Recommended Drugs Diuretic β-blocker ACE inhibitor ARB CCB Aldosterone Antagonist JNC - VII Report, JAMA , 2003;289:2560-2572
  • 39. Choice Between MonotherapyChoice Between Monotherapy and Combination therapyand Combination therapy
  • 40. Possible Combination ofPossible Combination of Antihypertensive AgentsAntihypertensive Agents Diuretics Beta Blocker ∝-Blocker ACE inhibitor CCBs ARBs EHS-ESC Guidelines, 2003;
  • 41. Indications and Contraindications forIndications and Contraindications for the Major Classes of Antihypertensiuethe Major Classes of Antihypertensiue DrugsDrugs Class Conditions favouring the use Compelling contraindications Possible contraindications ACEIs CHF LV dysfunction Post-MI Nondiabetic nephropathy Type 1 diabetic nephropathy Protienuria Pregnancy Hyperkalaemia Bilateral RAS ARBs Type 2 diabetic nephropathy Diabetic microalbuminuria Proteinuria LVH ACE inhibitor cough Pregnancy Hyperkalaemia Bilateral RAS a-Blockers Prostatic hyperplasia (BPH) Hyperlipidaemia Orthostatic hypotension CHF EHS-ESC Guidelines, 2003;
  • 42. EVOLUTION OF HYPERTENSIONEVOLUTION OF HYPERTENSION MANAGEMENTMANAGEMENT JNC I 1977 JNC II 1980 JNC III 1984 JNC IV 1988 JNC V 1993 JNC VI 1997 JNC VII 2003 High Dose diuretic High Dose diuretic Lower Dose diuretic Or β-blocker Lower Dose diuretic Or β-blocker Or ACEI Or CCB Lower Dose diuretic Or β-blocker Or ACEI Or CCB α-blocker Or α / β blocker • Individulised Therapy •Single-agent titration preferred •Loe-dose combo therapy as a secondary option •Focus on Systolic BP Control •Thiazide- type diuretics preferred as initial drug treatment •Emphasis on combinatio n therapy High-dose Monotherapy Low-dose Combination
  • 43. Management of HTN in SpecialManagement of HTN in Special SituationSituation 1. Hypertension Crises Hypertension Emergencies Hypertension Urgencies 2. Refractory/ Resistant hypertension 3. HTN in Pregnancy 4. HTN with coexisting Cardiovascular & other disorders 4. Management of Secondary HTN
  • 44.
  • 45. Resistant Hypertension • Not uncommon : 15-20% • Persistence of elevated systo-diastolic pressure in spite of at 3 anti-hypertensive drugs ( including diuretics) • Pre-requisites: Exclusion of pseudo-hypertension; white-coat hypertension,use of not-appropriate cuffs.
  • 46. Resistant hypertension: Causes • Insufficient patient compliance • Inability to follow prescribed life-style modifications ( weight loss, increased alcohol consumption) • Use of offending drugs: steroids,NSAID • Obstructive Sleep apnoea syndrome • Volume overload
  • 47. Therapeutic intervention • Exclude undiagnosed secondary hypertension • Compliance of drugs • Adherence to life style changes • Consider use of 3 or more anti-hypertensive drugs • Consider the use of drugs such as spironolactone
  • 48. Failure of reduction of DBP<90 mm Hg despite the use of three or more drugs which include a diuretic Resistant hypertension Braunwald’s Heart Disease, 2005
  • 49. Volume overload & pseudotolerance “White coat” Pseudohypertension in the elderly Excess sodium intake Inadequate diuretic therapy Volume retention Drug related Dosage too low Inappropriate combination Drug interaction Associated conditions Smoking Obesity Excess alcohol Sleep apnea Secondary hypertension Resistant hypertension Causes: Braunwald’s Heart Disease, 2005
  • 50. Current recommendations for primary prevention of hypertension involve:  a population based approach, and  an intensive targeted strategy focused on individuals at high risk for hypertension. Primary Prevention of Hypertension Hypertension Primer, AHA, 2004
  • 51. Conclusion • Hypertension is easy to diagnose and easy to treat • Aim of the management is to save the target organ from the deleterious effect • Pharmacological armament of antihypertensive drugs so rich that we have wide range of options. And this makes the physicians comfortable in varied situations. Conversely one needs to be judicious regarding the choice of the drug • Besides pharmacology we have other choices and one has to be acquainted with that choice • Primary prevention of hypertension should be highlighted and it should get more priority than it is getting now.
  • 52. Hypertension - a worldwide epidemic It’s a disease which is responsible for 3 million death annually About 15-20% of Bangladeshi population is suffering from Hypertension HTN is very poorly controlled - < 25% in developed & < 10% in developing countries Early diagnosis & management can prevent end organ damage from HTN Target goal of BP in hypertensive patients:- < 140/90 mm Hg < 130/80 mm Hg for patients with DM & renal disease Lifestyle modification is the universal “Vaccine” against Hypertension ConclusionConclusion