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Genetics
Environment
Neurohormonal
mediators
4
Pathophysiology II
Contributing factors for
Primary HTN:
Increased activity of:
sympathetic nervous system (SNS)
Renin-angiotensin-aldosterone system
(RAA)
Defects in natriuretic hormone
function
Inflammation
Obesity
Endothelial dysfunction
Insulin resistance
5
Pathophysiology III
Secondary Hypertension
Causes
Complications
Treatment
6
Pathophysiology IV
Hypertensive Crisis
7
Natural History of Hypertensive Disease
80 73
68 70
70
US population (%)*
59
60 55 54
51
50
40 34
31 29
30 27
20
10
10
0
NHANES II NHANES III NHANES III NHANES IV
(1976-1980) (1988-1991) (1991-1994) (1999-2000)
[Phase I] [Phase II]
7% reduction in risk
of ischemic heart
disease mortality
2 mm Hg decrease
in mean SBP
10% reduction in
risk of stroke
mortality
Hypertension:
SBP >140 mmHg DBP >90 mmHg
* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be
graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Recommendations for
General Population Age 60 Years
JNC 7 Evidence for JNC8
BP Goal < 140/90 mmHg HYVET Trial
(No age recommendations) SHEP Trial
JATOS Trial
JNC8 VALISH Trial
BP Goal < 150/90 mmHg
Rated Grade A
Recommendations for
General Population Age < 60 Years
JNC 7 Evidence for JNC8
BP Goal < 140/90 mmHg HDFP Trial
Hypertension-Stroke
JNC8 Cooperative Trial
SBP Goal < 140 mmHg MRC Trial
Grade E ANBP Trial
DBP Goal < 90 mmHg VA Cooperative Trial
Ages 30-59 years (Grade A)
Ages 18-29 years (Grade E)
Recommendations for
General Non-black Population (Including DM)
JNC 7 Evidence for JNC8
First-line: Thiazide diuretics
ALLHAT Trial
(no racial distinction made) BP control more important than
JNC8 medication used
Alpha blockers not recommended
First-line first-line
Thiazide diuretics LIFE Study
CCB Beta-blockers not recommended
ACE inhibitor first-line
ARB Insufficient evidence to
Grade B recommend other classes
Recommendations for
General Black Population (Including DM)
JNC 7 ALLHAT Trial
First-line: Thiazide diuretics Pre-specified subgroup analysis
(no racial distinction made) Thiazide more effective in
JNC8 improving CV outcomes
compared to ACEi in black
Initial treatment for black patient subgroup
population (Grade B) with DM 51% higher rate of stroke (RR 1.51;
(Grade C) 95% CI 1.22-1.86) with use of ACEi
Thiazide diuretics as initial therapy in black patients
(compared to CCB)
CCB
46% of patients in subgroup
analysis had DM
Recommendations for
General Population Age 18 with CKD
JNC 7 Evidence for JNC8
Goal BP: < 130/80 mmHg AASK Trial
First-line agent: ACEi or ARB MDRD Trial
Potential benefit of goal <130/80 for
JNC8 patients with proteinuria (>3g/24
Goal BP: < 140/90 mmHg hours)
Grade E REIN-2 Trial
Initial or add-on treatment: ACEi No trials showed goal
or ARB <130/80 mmHg significantly
Grade B lowered kidney or CV end points
Regardless of race or DM status compared to 140/90
Recommendations for
General Population Age 18 with DM
JNC 7 Evidence for JNC8
Goal BP: < 130/80 mmHg ACCORD-BP Trial
No difference in outcomes with SBP
< 140 vs. SBP < 120
JNC8 No good or fair quality trials to
Goal BP: < 140/90 mmHg support DBP < 80
Grade E
ADA Guidelines for 2014
Goal BP for patients with DM
Less than 140/80 mmHg
ACCORD-BP trial
HOT Trial
Showed 51% reduction in major CV events in patients with DM
Post-hoc analysis of small subgroup of the study (not pre-specified)
Evidence graded as low quality by JNC8
Preferred Agents
ACEi or ARB
HOPE Study
Included non-hypertensive patients
Decreased risk of stroke with ACEi
Despite conflicting evidence, continue to recommend ACE/ARB first-line
Cite high CVD risk and high prevalence of undiagnosed CVD in patients with DM
JNC8: Treatment Strategies (Grade E)
If goal BP not met after 1 month of treatment:
Increase dose of initial drug, or
Add a second drug (Thiazide, CCB, ACEi, or ARB)
If goal BP not met with 2 medications:
Add and titrate a third medication (Thiazide, CCB, ACEi, or ARB)
Do not use ACE and ARB together
Other classes may be used in the following scenarios:
Goal BP not met with 3 medications
Contraindication to thiazide, ACE/ARB, or CCB
Strategies to Dose Antihypertensive Drugs
Titrate to max dose, then add a second drug
Add a second drug before achieving max dose of the
initial drug
Start with 2 drugs at the same time
If SBP 160mmHg and/or DBP 100 mmHg
If SBP 20mmHg above goal and/or DBP 10mmHg above
goal
***Consider scheduling follow-up with the Enhanced
Care Clinic for titration of BP Meds
Guideline Population Goal BP, Initial Drug Treatment Options
mm Hg
JNC 8 General 60 y <150/90 Nonblack: thiazide-type diuretic, ACEI, ARB, or CCB
2014 Hypertension
guideline
SBP goal for elderly >80 years with SBP 140-150 mmHg
160 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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2013 ESH/ESC Guidelines for the management of arterial hypertension
All hypertension treatment agents are recommended RAS blockers may be preferred
and may be used in patients with diabetes Especially in presence of preoteinuria or
microalbuminuria
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, reninangiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Consider SBP <130 mmHg with overt proteinuria Monitor changes in eGFR
RAS blockers more effective to reduce albuminuria than Indicated in presence of microalbuminuria or overt
other agents proteinuria
Combination therapy usually required to reach BP goals Combine RAS blockers with other agents
Aldosterone antagonist not recommended in CKD Especially in combination with a RAS blocker
Risk of excessive reduction in renal function,
hyperkalemia
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, reninangiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Quit smoking
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
Medical Education & Information for all Media, all Disciplines, from all over the World
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Pregnant Women
Hypertension is common.
SBP is a better predictor of events than DBP.
Pseudohypertension and white-coat
hypertension may indicate a need for
readings outside the office.
Primary hypertension is the most common
cause, but common identifiable causes
(e.g., renovascular hypertension) should be
considered.
Older Persons (continued)
34
Hospitalization
Hospitalization should be considered if:
Very high BP
Severe headache
Chest pain
Neurologic symptoms
35
Summary
Hypertension is a major factor responsible for
progression of atherosclerotic disease. Therefore,
a comprehensive treatment of hypertension should
aim at CV risk reduction strategies, including
management of all associated risk factors.