update in RX of HTN.pptx

Update In Treatment Of
Hypertension
Mohammed J. AL-Hayali
CABMS Internal Medicine
Mosul collage of Medicine/ Internal Medicine Dep.
Dr. Mohammed Al-Hayali/ Hypertension Treatment

Scope of the problem
• Based on office BP, the global prevalence of hypertension was
estimated to be 1.13 billion in 2015 .The overall prevalence of
hypertension in adults is around 30 - 45%. This high prevalence of
hypertension is consistent across the world, irrespective of income
status, i.e. in lower, middle, and higher income countries.
Epidemiological studies indicate that the prevalence of
hypertension in adults in Iraq is known to be approximately 57%
Dr. Mohammed Al-Hayali/ Hypertension Treatment Department of Community Medicine, Hawler Medical University, Erbil, Kurdistan, Iraq.
PMID: 32281635; DOI: 10.26719/emhj.19.029

Definition and values
• ‘hypertension’ is defined as the level of BP at which the benefits of
treatment (either with lifestyle interventions or drugs)
unequivocally outweigh the risks of treatment, as documented by
clinical trials.

Dr. Mohammed Al-Hayali/ Hypertension Treatment https://www.jacc.org/doi/10.1016/j.jacc.2017.11.006?_ga=2.127227341.1592428894.164755700
1-1830171281.1647458074

Dr. Mohammed Al-Hayali/ Hypertension Treatment https://doi.org/10.1093/eurheartj/ehy339.

https://www.jacc.org/doi/10.1016/j.jacc.2017.11.006?_ga=2.127227341.1592428894.164
7557001-1830171281.1647458074

Recommendation COR LOE
1. Adults with an elevated BP or stage 1 hypertension who have an estimated
10-year ASCVD risk less than 10% should be managed with
nonpharmacological therapy and have a repeat BP evaluation within 3 to 6
months
I B
2. Adults with stage 1 hypertension who have an estimated 10-year ASCVD
risk of 10% or higher should be managed initially with a combination of
nonpharmacological and antihypertensive drug therapy and have a repeat BP
evaluation in 1 month
I B
3. Adults with stage 2 hypertension should be evaluated by or referred to a
primary care provider within 1 month of the initial diagnosis, have a
combination of nonpharmacological and antihypertensive drug therapy (with
2 agents of different classes) initiated, and have a repeat BP evaluation in 1
month
I B
4. For adults with a very high average BP (e.g., SBP ‡180 mm Hg or DBP ‡110
mm Hg), evaluation followed by prompt antihypertensive drug treatment is
recommended
I B
5. For adults with a normal BP, repeat evaluation every year is reasonable. IIa C-EO
Dr. Mohammed Al-Hayali/ Hypertension Treatment https://www.jacc.org/doi/10.1016/j.jacc.2017.11.006?_ga=2.127227341.1592428894.164
7557001-1830171281.1647458074

1- Non-pharmacological treatment
Nonpharmacological
Intervention
dose Impact on BP
Weight loss Weight/body fat Expect about 1 mm Hg
for every 1-kg
reduction in body
weight.
5 mm Hg
Healthy diet DASH diet 11mm Hg
Reduced intake of
dietary sodium
Optimal goal is <1500
mg/d, aim for at least a
1000-mg/d reduction
6 mm Hg
Enhanced intake of
dietary potassium
Aim for 3500–5000
mg/d
5 mm HG
Physical activity Aerobic 90–150 min/wk 5-8 mm Hg
Reduce alcohol intake < 2 drinks/day 4 mm Hg
https://www.jacc.org/doi/10.1016/j.jacc.2017.11.006?_ga=2.127227341.1592428894.164
7557001-1830171281.1647458074

Pharmacological Therapy
• Primary agents : thiazide diuretics, ACE inhibitors, ARBs, and CCBs.
• Factors to consider before starting antihypertensive medication:
Age
concurrent medications
drug adherence
drug interactions
out of pocket costs
 comorbidities

ACEI and ARBS
• Both ACEI and ARBs reduce albuminuria in diabetic and non-diabetic CKD
• Reduce HMOD such as LVH and both classes reduce incidence of AF ,also
indicated post myocardial infarction and in patients with chronic HFrEF,
which are frequent complications of hypertension.
• ACE inhibitors are associated with cough and a small increased risk of
angioneurotic oedema, especially in people of black African origin and, in
such patients, when RAS blockers are used, an ARB may be preferred.
• Patients with a history of angioedema with an ACE inhibitor can receive an
ARB beginning 6 weeks after ACE inhibitor is discontinued.
• Contraindicated in pregnancy.

CCBs
• CCBs have similar effectiveness as other major drug classes on BP,
major CV events, and mortality outcomes.
• CCBs have a greater effect on stroke reduction than expected for
the BP reduction achieved, but may also be less effective at
preventing HFrEF.
• CCBs are a heterogeneous class of agents. Most RCTs
demonstrating the benefits of CCBs on outcomes have used
dihydropyridines (especially amlodipine).
• They are associated with dose-related pedal edema, which is more
common in women than men.

Thiazide/thiazide-like diuretics
• Introduced in 1960, they have important role in HTN management
since then.
• In modern therapy chlortalidone and indapamide are often used.
• can reduce serum potassium, They also exhibit dysmetabolic
effects that increase insulin resistance and the risk of new-onset
diabetes.
• Less effective in patients with GFR<45, and ineffective if GFR<30,
in this case loop diuretic can be used.

Secondary agents:
• Potassium sparing diuretics: (Amiloride, Triamterene,
Eplerenone, Spironolactone) often used in resistant hypertension.
• Beta-blockers: have been shown to be particularly useful for the
treatment of hypertension in specific situations such as
symptomatic angina, for heart rate control, post-myocardial
infarction, HFrEF.

Morning Hypertension

Two Types of Morning Hypertension
Nocturnal-hypertensive
morning hypertension.
• It include non dipper
(diminished nocturnal fall in
BP) and riser (nocturnal level
higher than daytime level)
Morning-surge hypertension:
BP elevation 2hrs before
getting out from the bed

Treatment of morning hypertension
• The first step in treatment of morning hypertension in clinical practice
is to self monitor BP at home to determine hypertension of nocturnal-
hypertension type or morning-surge type.
• In principal long acting antihypertensive that last for 24hrs should be
used as non-specific treatment.
• Specific treatment include inhibitor of sympathetic nervous system like
alpha blocker administered at bed time while B-blocker monotherapy
provide less specific treatment for morning hypertension.
• Since renin angiotensin system is augmented at early morning
treatment with ACEi and ARBs can be considered as specific therapy

The True Sartan
Telmisartan
• Antihypertensive.
• Reduce proteinuria.
• Reduce CV morbidity and
mortality.
• Promote weight loss.

Conclusion
• Telmisartan was significantly more effective than Ramipril in
reducing BP throughout the 24-h dosing interval and particularly
during the last 6 h, a time when patients appear to be at greatest
risk of cerebral- and cardiovascular events. Both drugs were well
tolerated, although Ramipril was associated with a higher
incidence of cough.

• the 12-week EVERESTE (EValuation de
l’EfficaciteRESiduelle du Telmisartan)
study in 441 patients, trough diastolic
BP (DBP) was found to be significantly
lower in the Telmisartan 40 mg group
than in the perindopril4 mg group, both
by BP self-measurement (87.6
versus89.6 mmHg, P<0.05) and clinic
BP measurement (88.7 versus 91.3
mmHg, P<0.005) after 12 weeks.
Similar findings were observed for
trough systolic BP (SBP; BP self-
measurement 139.3 versus 143.3
mmHg, respectively, P<0.005; clinic BP
measurement 144.0 versus 148.0
mmHg, respectively, P<0.05).

• 250 patient with mild to
moderate diabetic
nephropathy.
• Assigned to receive enalipril
20mg vs Telmisartan 80mg
• Telmisartan conferred
comparable renoprotection to
enalipril and was associated
with a low incidence of
mortality.

AMADEO
• 860 patients with diabetes, hypertension and overt proteinuria.
• Assigned to receive Telmisartan 80mg vs losartan 100mg.
• Telmisartan is superior to losartan in reducing proteinuria in
hypertensive patients with diabetic nephropathy, despite a similar
reduction in blood pressure.

Dr. Mohammed Al-Hayali/ Hypertension Treatment https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672468/

ONTARGET and TRANSCEND

The True Sartan
Telmisartan
• Antihypertensive.
• Reduce proteinuria.
• Reduce CV morbidity and
mortality.
• Promote weight loss.
Dr. Mohammed Al-Hayali/ Hypertension Treatment 36

Dr. Mohammed Al-Hayali/ Hypertension Treatment Note: this activation increase of adiponectin, and promotion of caloric expenditure

DISCUSSION
• The major findings of this study are that Telmisartan significantly
upregulated PPAR-δ expression and activity in 3T3-L1
preadipocytes, activated PPAR-δ–dependent lipolytic pathway, and
finally reduced adipogenesis in vitro. The effect of Telmisartan on
lipolysis was abolished after PPAR-δ gene knockout of
preadipocytes. In vivo, long-term administration of Telmisartan
significantly reduced the rise of body weight and prevented high-
fat diet-induced obesity in wild-type mice and hypertensive rats
but not in PPAR-δ knockout mice.

update in RX of HTN.pptx

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