This lecture presents the 1-Updated recommendations regarding definition and proper diagnosis of HTN. 2-Updated guidelines for threshold of BP to start treatment and targets of treatment. 3- Updated recommendations on CV risk assessment and management. 4-Hypertension and comorbidities: updated guidelines

1. Hypertension Management -2018
(Major Novelties in Definition, Measurement and Therapy)
Dr Monkez M Yousif
Professor of Internal Medicine
Member of AGA, EASL and ISC-Hepatitis WG
Zagazig University
August 27, 2018

2. Objectives
• Updated recommendations regarding
definition and proper diagnosis of HTN.
• Updated guidelines for threshold of BP to start
treatment and targets of treatment
• Updated recommendations on CV risk
assessment and management
• Hypertension and comorbidities: updated
guidelines

3. References

7. Applying Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions,
Treatments, or Diagnostic Testing in Patient Care*
(Updated August 2015)

9. Epidemiology of Hypertension

10. • One of the key risk factors for cardiovascular
disease is hypertension or raised blood
pressure.
• Hypertension already affects 1.1 billion
people worldwide (WHO 2015), leading to
heart attacks and strokes. By 2025, it is
estimated over 1.5 billion people will have
hypertension.
• Researchers have estimated that raised blood
pressure currently kills nine million people
every year.

11. Epidemiology of Hypertension in
Egypt

12. 1.002.00
2008
2015
55-59 Y 15-59 Y
2008
2015
Prevalence of HTN among adults 15-59
years: EDHS 2008 vs 2015
53.5 % 45.6%
17% 12.8%

13. Awareness of condition and treatment status among
hypertensive women and men age 15-59
EHIS 2015

15. Figure 2
The Lancet 2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8)
Stroke mortality rate in each decade of age versus
usual blood pressure at the start of that decade

16. Figure 4
The Lancet 2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8)
IHD mortality rate in each decade of age versus usual
blood pressure at the start of that decade

17. CV benefits of treating HTN
Hebert et al, Archives Int Med 1993

19. BP and CVD Risk

20. CVD Risk Factors Common in Patients With Hypertension
*Factors that can be changed and, if changed, may reduce CVD risk.
†Factors that are difficult to change (CKD, low socioeconomic/educational status, obstructive
sleep apnea, cannot be changed (family history, increased age, male sex), or, if changed through
the use of current intervention techniques, may not reduce CVD risk (psychosocial stress).
CKD indicates chronic kidney disease; and CVD, cardiovascular disease.
Modifiable Risk Factors* Relatively Fixed Risk Factors†
 Current cigarette smoking,
secondhand smoking
 Diabetes mellitus
 Dyslipidemia/hypercholesterolemia
 Overweight/obesity
 Physical inactivity/low fitness
 Unhealthy diet
 CKD
 Family history
 Increased age
 Low socioeconomic/educational status
 Male sex
 Obstructive sleep apnea
 Psychosocial stress

22. Classification of BP

23. 1) The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. Arch Intern Med 1997;157:2413–46.
2) The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. JAMA 2003;289:2560–71.

24. ESC/ESH 2013/2018
Definitions and classification of office blood pressure levels
Category SBP DBP
Optimal < 120 and < 80
Normal 120-129 and / or 80-84
High normal 130-139 and/or 85-89
Hypertension stage I 140-159 and/or 90-99
Hypertension stage II 160-179 and/or 100-109
Hypertension stage III ≥ 180 and/or ≥ 110
Isolated SBP ≥ 140 and < 80

25. Categories of BP in Adults* ACC/AHA 2017
*Individuals with SBP and DBP in 2 categories should be
designated to the higher BP category.
BP indicates blood pressure (based on an average of ≥2
careful readings obtained on ≥2 occasions, as detailed in
DBP, diastolic blood pressure; and SBP systolic blood
pressure.
BP Category SBP DBP
Normal <120 mm Hg and <80 mm Hg
Elevated 120–129 mm
Hg
and <80 mm Hg
Hypertension
Stage 1 130–139 mm
Hg
or 80–89 mm
Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg

26. Prevalence of Hypertension Based on 2 SBP/DBP Thresholds*†
SBP/DBP ≥130/80 mm Hg or
Self-Reported
Antihypertensive Medication†
SBP/DBP ≥140/90 mm Hg or Self-
Reported Antihypertensive
Medication‡
Overall, crude 46% 32%
Men
(n=4717)
Women
(n=4906)
Men
(n=4717)
Women
(n=4906)
Overall, age-sex
adjusted
48% 43% 31% 32%
Age group, y
20–44 30% 19% 11% 10%
45–54 50% 44% 33% 27%
55–64 70% 63% 53% 52%
65–74 77% 75% 64% 63%
75+ 79% 85% 71% 78%
Race-ethnicity§
Non-Hispanic White 47% 41% 31% 30%
Non-Hispanic Black 59% 56% 42% 46%
Non-Hispanic Asian 45% 36% 29% 27%
Hispanic 44% 42% 27% 32%
The prevalence estimates have been rounded to the nearest full percentage.
*130/80 and 140/90 mm Hg in 9623 participants (≥20 years of age) in NHANES 2011–2014.
†BP cutpoints for definition of hypertension in the present guideline.
‡BP cutpoints for definition of hypertension in JNC 7.
§Adjusted to the 2010 age-sex distribution of the U.S. adult population.
BP indicates blood pressure; DBP, diastolic blood pressure; NHANES, National Health
and Nutrition Examination Survey; and SBP, systolic blood pressure.

27. Measurement of BP

28. Accurate Measurement of BP in the Office
COR LOE
Recommendation for Accurate Measurement of
BP in the Office
I C-EO
For diagnosis and management of high BP, proper
methods are recommended for accurate
measurement and documentation of BP.

29. Selection Criteria for BP Cuff Size for Measurement of
BP in Adults
Arm
Circumference
Usual Cuff Size
22–26 cm Small adult
27–34 cm Adult
35–44 cm Large adult
45–52 cm Adult thigh

30. Out-of-Office and Self-Monitoring of BP
COR LOE
Recommendation for Out-of-Office and Self-
Monitoring of BP
I ASR
Out-of-office BP measurements are recommended
to confirm the diagnosis of hypertension and for
titration of BP-lowering medication, in conjunction
with telehealth counseling or clinical interventions.
SR indicates systematic review.

31. Clinical indications for HBPM & ABPM
• Conditions in which white-coat hypertension is more
common, e.g.:
– Grade I hypertension on office BP measurement
– Marked office BP elevation without HMOD
• Conditions in which masked hypertension is more
common, e.g.:
– High–normal office BP
– Normal office BP in individuals with HMOD or at high total
CV risk
• When there is considerable variability in the office BP
• Evaluation of resistant hypertension

32. Corresponding Values of SBP/DBP for Clinic, HBPM,
Daytime, Nighttime, and 24-Hour ABPM Measurements
ABPM indicates ambulatory blood pressure monitoring; BP, blood pressure;
DBP diastolic blood pressure; HBPM, home blood pressure monitoring; and
SBP, systolic blood pressure.
Clinic HBPM Daytime
ABPM
Nighttime
ABPM
24-Hour
ABPM
120/80 120/80 120/80 100/65 115/75
130/80 130/80 130/80 110/65 125/75
140/90 135/85 135/85 120/70 130/80
160/100 145/90 145/90 140/85 145/90

33. BP Patterns Based on Office and Out-of-Office
Measurements
ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
Office/Clinic/Healthcare
Setting
Home/Nonhealthcare/
ABPM Setting
Normotensive No hypertension No hypertension
Sustained
hypertension
Hypertension Hypertension
Masked
hypertension
No hypertension Hypertension
White coat
hypertension
Hypertension No hypertension

34. Screening and Diagnosis of Hypertension
Optimal BP
<120/80
Normal BP
<120-129/80-84
High normal BP
130-139/85-89
Hypertension
≥140/90
Repeat BP at
least every 5 y
Repeat BP at
least every 3 y
Repeat BP at
least annually
Repeated visits
for office BP
measurement
Out of office BP
measurement
(ABPM-HBPM)
Out of office BP
measurement
(ABPM-HBPM)
Consider
Masked HTN
Use either to
confirm diagnosis

35. Patient Evaluation

36. Basic and Optional Laboratory Tests for Primary
Hypertension
Basic testing Fasting blood glucose*
Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram
Optional testing Echocardiogram
Uric acid
Urinary albumin to creatinine ratio
*May be included in a comprehensive metabolic panel.
eGFR indicates estimated glomerular filtration rate.

37. Hypertension and CV Risk
Assessment

39. 10-y CV Risk Categories
Subjects with any of the following:
CVD
Type 2 diabetes, or type 1 diabetes & target organ damage
 Patients with moderate to severe CKD (GFR <60mL/min/1.73m2)
 SCORE ≥10%
Very high risk
Subjects with:
Markedly elevated single risk factors such as:
−Familial dyslipidaemias
−Severe hypertension.
SCORE ≥ 5% and <10%
High risk
SCORE is ≥1 and <5% at 10 years, further modulated by:
family history of premature CAD
abdominal obesity
physical activity pattern
HDL-C
TG
hsCRP
social class
Moderate risk
SCORE less than 1% and free of qualifiersLow risk

40. Hypertension and Total CV Risk Assessment
• There is also emerging evidence that
increased serum uric acid to levels lower than
those typically associated with gout (6.5-7
mg/dl) is independently associated with
increased CV risk in both the general
population and hypertensive patients.

41. Classification of hypertensive stages according to BP levels,
presence of cv risk factors, HMOD, or comorbidities
BP grading
Other risk
factors, HMOD,
or disease
Hypertension
disease staging Grade III
≥180/110
Grade II
160-179/ 100-
109
Grade I
140-159/ 90-99
High normal
130-139/ 85-89
High riskModerate riskLow riskLow risk
No other risk
factors
Stage I
(Uncomplicated)
High risk
Moderate high
risk
Moderate riskLow risk1 or 2 risk factors
High riskHigh risk
Moderate high
risk
Low moderate≥ 3 risk factors
High-very high
risk
High riskHigh risk
Moderate high
risk
HMOD, CKD
grade 3, or DM
without organ
damage
Stage II
(Asymptomatic
disease)
Very High riskVery High riskVery High riskVery High risk
Symptomatic
CVD, CKD ≥ grade
4 or DM with
organ damage
Stage III
( Established
disease)

42. Initiation of BP Lowering Treatment

43. Initiation of BP Lowering Treatment
(Life style changes and medications) at different initial office BP levels
High-normal BP
130-139/85-89
Grade I
140-159/90-99
Grade II
160-179/100-109
Grade III
≥180/110
Consider drug
treatment in
very high risk
patients with
CVD especially
CAD
Immediate drug
treatment in
high or very high
risk patients with
CVD, HMOD or
renal disease
Immediate
drug treatment
in all patients
Immediate
drug treatment
in all patients
Life style advice Life style advice Life style advice Life style advice
Drug treatment in low moderate risk
patients without CVD, renal disease, or
HMOD after 3-6 months of life style
intervention if BP not controlled
Aim for BP control in 3 months

44. Summary of office BP thresholds for treatment
Office SBP treatment threshold (mmHg)
Age
Group DBP
treatment
threshold
+ Stroke/
TIA
+CVD+CKD+ DMHTN
≥ 90≥ 140≥ 140≥ 140≥ 140≥ 140
18-65
years
≥ 90≥ 140≥ 140≥ 140≥ 140≥ 14065-79
years
≥ 90
≥ 160≥ 160≥ 160≥ 160≥ 160
≥ 80 years
≥ 90≥ 90≥ 90≥ 90≥ 90
DBP
treatment
threshold

45. Office BP treatment targets in hypertensive patients-
General recommendations
Class/LevelRecommendation
I A
The first objective of treatment should be to
lower BP to < 140/90 mmHg in all patients
I A
Provided that treatment is well tolerated
treatment BP should be targeted to 130/80
mmHg or lower in most patients
II aB
A DBP target of < 80 mmHg should be considered
for all hypertensive patients, independent of the
level and risk of comorbidities.

46. Office BP treatment target ranges
Office SBP treatment target ranges (mmHg)
Age
Group
DBP
treatment
target
range
+ Stroke/
TIA
+CVD+CKD+ DMHTN
< 80 - 70
Target to 130
or lower if
tolerated
Not < 120
Target to 130
or lower if
tolerated
Not < 120
Target to
<130 – 140
if tolerated
Target to 130
or lower if
tolerated
Not < 120
Target to 130
or lower if
tolerated
Not < 120
18-65
years
< 80 - 70Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
65-79
years
< 80 - 70Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated
Target to
<130 – 140
if tolerated≥ 80 years
< 80 - 70< 80 - 70< 80 - 70< 80 - 70< 80 - 70DBP
treatment
target
range

47. Nonpharmacological Interventions
2017 Hypertension Guideline

48. Nonpharmacological Interventions
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Weight loss is recommended to reduce BP in adults
with elevated BP or hypertension who are overweight
or obese.
I A
A heart-healthy diet, such as the DASH (Dietary
Approaches to Stop Hypertension) diet, that facilitates
achieving a desirable weight is recommended for
adults with elevated BP or hypertension.
I A
Sodium reduction is recommended for adults with
elevated BP or hypertension.
I A
Potassium supplementation, preferably in dietary
modification, is recommended for adults with elevated
BP or hypertension, unless contraindicated by the
presence of CKD or use of drugs that reduce
potassium excretion.

49. Nonpharmacological Interventions (cont.)
COR LOE
Recommendations for Nonpharmacological
Interventions
I A
Increased physical activity with a structured
exercise program is recommended for adults with
elevated BP or hypertension.
I A
Adult men and women with elevated BP or
hypertension who currently consume alcohol should
be advised to drink no more than 2 and 1 standard
drinks* per day, respectively.
*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which
is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine
(usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

50. Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension*
Nonpharmacologi
-cal Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Weight loss Weight/body fat Best goal is ideal body weight, but aim
for at least a 1-kg reduction in body
weight for most adults who are
overweight. Expect about 1 mm Hg for
every 1-kg reduction in body weight.
-5 mm Hg -2/3 mm Hg
Healthy diet DASH dietary
pattern
Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat.
-11 mm Hg -3 mm Hg
Reduced intake
of dietary
sodium
Dietary sodium Optimal goal is <1500 mg/d, but aim
for at least a 1000-mg/d reduction in
most adults.
-5/6 mm Hg -2/3 mm Hg
Enhanced
intake of
dietary
potassium
Dietary
potassium
Aim for 3500–5000 mg/d, preferably
by consumption of a diet rich in
potassium.
-4/5 mm Hg -2 mm Hg
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.
Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?
Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to.
Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

51. Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension* (cont.)
Nonpharmacologica
l Intervention
Dose Approximate Impact on SBP
Hypertension Normotension
Physical
activity
Aerobic ● 90–150 min/wk
● 65%–75% heart rate reserve
-5/8 mm Hg -2/4 mm Hg
Dynamic resistance ● 90–150 min/wk
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
-4 mm Hg -2 mm Hg
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
-5 mm Hg -4 mm Hg
Moderation
in alcohol
intake
Alcohol
consumption
In individuals who drink alcohol,
reduce alcohol† to:
● Men: ≤2 drinks daily
● Women: ≤1 drink daily
-4 mm Hg -3 mm
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz
of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

52. Drug Therapy for Hypertension

53. Drugs for the treatment of Hypertension
• In previous guidelines 5 major drug classes (ACEIs,
ARBs, BBs, CCBs, Ds) were recommended based on
– Proven ability to reduce BP
– CV event reduction in placebo-controlled studies
– Broad equivalence in overall CV morbidity/mortality
– Conclusion that benefit predominantly derives from BP
lowering
• These conclusions have since been confirmed by recent
meta-analyses
• These guidelines thus recommend that the same 5
major classes of drugs should form the basis of
antihypertensive therapy

54. Major Novelties on antihypertensive treatment
• Increasing dose of initial monotherapy.
• Monotherapy substitution.
• “Stepped - care” approach (monotherapy with
subsequent addition of other drugs).
• Initial two drug combination treatment.
• Use of single pill combinations.

55. Rationale for initial two drug-combination therapy
in most patients
• Greater BP reduction even vs maximum dose monotherapy.
• Reduced heterogeneity of the BP response to initial
therapy.
• Steeper dose-response relationship with treatment up-
titration.
• No/small increase in risk of hypotensive episodes (even in
grade I hypertension).
• More frequent BP control after 1 year
– Better adherence to treatment
– Reduced therapeutic inertia
• Reduce CV events (grade I hypertension, HOPE-3)

56. Single-pill combination
• Already favored by 2013 ESC/ESH Guidelines
(improved adherence to treatment)
• Further supported by recent studies using
various methods to assess adherence
(direct/indirect)
• Facilitated by availability of several SPCs with a
range of doses

57. What is the best effective evidence-based
treatment strategy to improve BP control
• Use combination treatment in most patients,
especially in the context of lower BP targets
• Use single-pill-combination therapy in most
patients to improve adherence to treatment
• Above treatment algorithm, that is simple,
applies extensively and is pragmatic.
• Exceptions: BP in the high normal range and in
frail older patients

58. Core drug treatment strategy for
uncomplicated hypertension
The core algorithm is also appropriate for most patients with HMOD, CVA, DM, or PAD

61. Drug treatment strategy for hypertension
+ DM

62. Drug treatment strategy for hypertension CAD

64. Drug treatment strategy for hypertension and
hear failure with reduced ejection fraction

66. Drug treatment strategy for hypertension and CKD

68. Drug treatment strategy for hypertension and AF

71. Clinician’s Sequential Flow Chart for the Management of Hypertension
Clinician’s Sequential Flow Chart for the Management of Hypertension
Measure office BP accurately
Detect white coat hypertension or masked hypertension by using ABPM and HBPM
Evaluate for secondary hypertension
Identify target organ damage
Introduce lifestyle interventions
Identify and discuss treatment goals
Use ASCVD risk estimation to guide BP threshold for drug therapy
Align treatment options with comorbidities
Account for age, race, ethnicity, sex, and special circumstances in antihypertensive treatment
Initiate antihypertensive pharmacological therapy
Insure appropriate follow-up
Use team-based care
Connect patient to clinician via telehealth
Detect and reverse nonadherence
Detect white coat effect or masked uncontrolled hypertension
Use health information technology for remote monitoring and self-monitoring of BP
ASCVD indicates atherosclerotic cardiovascular
disease; BP, blood pressure; CVD, cardiovascular
disease; and SBP, systolic blood pressure.

72. Conclusions
• BP measurement:
– Wider use of out of office BP measurement with ABPM
and/or HBPM especially HBOM, is an option to confirm
the diagnosis of hypertension, detect white coat and
masked hypertension and monitor BP control.
• Less conservative treatment of BP in older and
very old patients:
– Lower BP thresholds and treatment targets for older
patients- with emphasis on consideration of biological
rather than chronological age( i.e the importance of
frailty, independence and the tolerability of treatment).
Recommendations that treatment should never be
denied or withdrawn on basis of age, provided that
treatment is tolerated.

73. • A SPC strategy to improve BP control:
– Preferred use of two-drug combination for the initial
treatment of most patients with hypertension.
– A single pill treatment strategy for hypertension with
the preferred use of SPC therapy for most patients.
– Simplified drug treatment algorithms with the
preferred use of ACEI or ARB combined with a CCB or/
and a thiazide/thiazide-like diuretic as the core
treatment strategy for most patients, with BB used for
specific indications.
• New target ranges for BP in treated patients
– Target BP ranges for treated patients to better
identify the recommended BP target and lower safety
boundaries for treated patients according to a
patient’s age and comorbidities.

74. • Detection of poor adherence to drug therapy
– A strong emphasis on the importance of
evaluating treatment adherence as a major cause
of poor BP control.
• A key role for nurses, pharmacists in the
longer-term management of hypertension
– The important role of nurses and pharmacists in
the education, support, and follow up of treated
hypertensive patients is emphasized as part of the
overall strategy to improve BP control.