Hypertension

Syakib Bakri, Hasyim Kasim, Haerani Rasyid

Nephrology & Hypertension Div., Dept. of Internal Medicine,

Medical Faculty, Hasanuddin University
 What is blood pressure?
 Blood pressure refers to the force exerted by
circulating blood on the walls of blood vessels.
 The pressure of the circulating blood decreases
as blood moves through arteries, arterioles,
capillaries, and veins.
 Blood pressure values are reported in
millimetres of mercury (mmHg).
 Blood pressure is recorded as systolic over
diastolic e.g. 120/60.
 The systolic arterial pressure is defined as the
peak pressure in the arteries, which occurs near
the beginning of the cardiac cycle.
 The diastolic arterial pressure is the lowest
pressure (at the resting phase of the cardiac
cycle)
 Measures of arterial pressure are not static, but
undergo natural variations from one heartbeat to
another and throughout the day.
 Blood pressure also changes in response to
stress, nutritional factors, drugs, or disease.
Systole is the
contraction of heart
chambers, driving blood
out of the chambers.
The chamber valves are
closed.
Diastole is the period of
time when the heart fills
with blood after systole
(contraction).
The chamber valves are
open. The heart is at rest.
 The classification of blood pressure and hypertension
WHO-ISH, WSH-ESC, BSH, JNC-7
WHO-ISH, ESH-ESC, BP BP JNC VII
BSH BP Classification (mmHg) (mmHg) Bp Classification

Optimal <120 / <80 <120/<80 Normal

Normal 120-129 / 80-84 120-129 /80-84 Prehypertension

grade 1

High normal 130-139 / 85-89 130-139 / 85-89 Prehypertension

grade 2
Grade 1 Hypertension 140-159 / 90-99 140-159 / 90-99 Stage 1
(mild) Hypertension

Grade 2 Hypertension 160-179 /100- >160 / >100 Stage 2

(moderate) 109 Hypertension

Grade 3 Hypertension > 180 / >110

(severe)

Isolated Systolic > 140 / < 90 Isolated Systolic

Hypertension Hypertension
 Blood Pressure Distribution in the Population
According to Age

Men Women
150 150

140 140

130 130

120 120

mmHg
mmHg

110 110

100 PP 100 PP
90 90

80 80

70 70

60 60
20-29 30-39 40-49 50-59 60-69 70-79 20-29 30-39 40-49 50-59 60-69 70-79

Age Age
PP=Pulse Pressure

Adapted from: Wilkins et al. Health Rep 2010;21:37-46

 Life time Risk of Hypertension in
Normotensive Women and men aged 65 years

Risk of Hypertension % Risk of Hypertension %

100 100

Women Men
80 80

60 60

40 40

20 20

0 0
0 2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18 20

Years to Follow-up Years to Follow-up

JAMA 2002:297:1003-10. Framingham data.
Frequency of Hypertension
According to Age

Age Percentage
18-29 years old 4%

30-39 years old 11%

40-49 years old 21%

50-59 years old 44%

60-69 years old 54%

70-79 years old 62%

More than 80 years old 65%

 Hypertension
• Common, Responsible for the majority of
office visits
• Number one reason for drug prescription
• Simple and cheap detection
• Established treatment
• Significant preventable outcomes

• Observational studies suggest detection &

treatment suboptimal
Pathophysiology of Hypertension
Blood Pressure Assessment
 Blood Pressure Assessment

• Blood pressure of all adults should be measured by a

trained healthcare professional at all appropriate visits.
For example:
– new patient visits,
– periodic health exams,
– urgent office visits for neurological or cardiovascular
related issues,
– medication renewal visits
• Blood pressure of adults with high normal blood pressure
(130-139/80-89 mmHg) should be assessed annually
Health care professionals should know the blood pressure of all
of their patients and clients.

•To screen for hypertension

•To assess cardiovascular risk
•To monitor antihypertensive treatment
 Office Blood Pressure Measurement
Correct methods for office blood pressure measurement
• Before measurement
Timing
1 hour Avoiding coffee food, smoking, decongestants
30 minutes Avoiding exercise
5 minutes Sitting calmly
• During measurement
Body position Seated, back supported, legs uncrossed, feet flat on floor, and
relaxed
Arm Supported, using the arm higher value
Cuff At heart level, using appropriate sized one
Measurement Taking two measurement, spaced 1-2 minutes apart, and additional
maesurement if needed,
For initial readings, take the blood pressure in both arms and
subsequently measure it in the arm with the highest reading
• Other
No talk during the procedure, No acute anxiety, stress or pain, Bladder and bowel
comfortable, No tight clothing on arm or forearm, Quiet room with comfortable
temperature, Patient should stay silent prior and during the procedure
 Recommended Technique for Measuring BP:
Standing BP

• Perform in patients
– over age 65
– with diabetes
– if there are symptoms of postural hypotension

• Check after 1 to 5 minutes in the standing position and if

the patient complains of symptoms suggestive of
hypotension
Blood Pressure Assessment:
Patient position

X
 Blood pressure measurement devices

• Mercury Blood Pressure Monitor

• Aneroid Blood Pressure Monitor

• Automated Blood Pressure Monitor

Approaches can be used to assess BP

1. Office BP Measurement
1. Auscultation (Conventional Sphygmomanometer)
2. Automated BP recording
2. Home BP Recording 24-H / Ambulatory BP
Monitoring
3. Home BP Measurement
1. Auscultation (Conventional Sphygmomanometer)
2. Automated BP recording
 Criteria for diagnosis of hypertension
using different methods of measurement

Gabb GM et al. Med J Aust. 2016;18;205(2):85-9.

 Initial Evaluation (1)

Objectives of Initial Evaluation

1. Establish the diagnosis and stage of HTN (including
office and non-office BP readings),
2. The likelihood of secondary HTN,
3. The presence of TOD,
4. The level of global CVD risk.
 Initial Evaluation (2)

History
1. Family History : A comprehensive family history should be
obtained with particular attention to HTN, DM, stroke,
dyslipidemia, premature coronary artery disease, peripheral
artery disease or renal disease.
2. Clinical History :
(a) Duration and previous levels of high BP.
(b) General symptomatology
(c) Symptoms and indicators of organ damage
(d) Symptoms suggestive of secondary causes
(e) Intake of drugs or substances that can raise BP
(f) Lifestyle factors
 Initial Evaluation (3)

History
2. Clinical History :
(h) Past history or current symptoms of coronary artery
disease, heart failure, cerebrovascular or peripheral
vascular disease, renal disease, DM, gout,
dyslipidemia, asthma or any other significant
illnesses, and drugs used to treat those
conditions.
(i) Previous antihypertensive therapy, its results and
adverse effects
 Initial Evaluation (4)

Symptoms and indicators of organ damage

1. brain and eyes: headache, vertigo, impaired vision,
transient ischemic attacks, sensory or motor
deficit, stroke, carotid revascularization.
2. heart: palpitation, chest pain, shortness of breath,
swollen ankles.
3. kidney: thirst, polyuria, nocturia, hematuria.
4. peripheral arteries: cold extremities, intermittent
claudication, peripheral revascularization.
 Initial Evaluation (5)

Lifestyle factors:
dietary intake of fat (animal fat in particular), salt and
alcohol, quantification of smoking and physical activity,
weight gain since early adult life..
• Search for exogenous potentially modifiable factors that can
induce/aggravate hypertension
– Prescription Drugs:
• NSAIDs, including coxibs
• Corticosteroids and anabolic steroids
• Oral contraceptive and sex hormones
• Vasoconstricting/sympathomimetic decongestants
• Calcineurin inhibitors (cyclosporin, tacrolimus)
• Erythropoietin and analogues
• Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs
• Midodrine
– Other:
• Licorice root
• Stimulants including cocaine
• Salt
• Excessive alcohol use
 Physical Examination (1)
1. Blood pressure/pulse rate

2. General condition and obesity

a) Height/body weight : BMI
b) Waist circumference (standing position measurement at the
umbilical level)
c) Dermal findings Striated abdominal wall skin, hypertrichosis
(Cushing’s syndrome)
 Physical Examination (2)
3. Facial/cervical regions
a) Anemia
b) Fundic findings
c) Goiter
d) Carotid artery murmurs
e) Dilatation of the jugular vein

4. Thoracic region
a) Heart  Apical beat and thrill on palpation (strongest
point and extent of palpation), cardiac murmurs, gallop
rhythms, arrhythmia on auscultation
b) Lung field  Rales
 Physical Examination (3)

5. Abdomen
• Vascular murmurs and the direction of their projection, kidney
enlargement (polycystic kidney)
6. Limbs
• Arterial pulse (radial artery, dorsal artery of the foot, posterior
tibial artery, femoral artery) on palpation (disappearance,
attenuation, laterality), coldness, ischemic ulcers, edema
7. Nerves
• Dyskinesia of the limbs, sensory disturbance, increased tendon
reflex
Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

Laboratory Examinations

Shin et al. Clinical Hypertension (2015) 21:1

 Hypertension as a Risk Factor

Hypertension is a significant risk factor for:

– cerebrovascular disease
– coronary artery disease
– congestive heart failure
– renal failure
– peripheral vascular disease
– impaired vision
– dementia
– atrial fibrillation
– erectile dysfunction
 Blood Pressure and
Risk of Stroke Mortality

Lancet 2002;360:1903-13
Blood Pressure and Risk of Ischemic
Heart Disease (IHD) Mortality

Lancet 2002;360:1903-13
 Effect of SBP and DBP on
Age-Adjusted CAD Mortality: MRFIT

CAD Death Rate per 10,000 Person-years

80.6

48.3 43.8
37.4 34.7 38.1

31.0
25.8 24.6 25.3 25.2 24.9

23.8
160+
16.9 13.9 12.8 12.6 11.8
20.6 140-159
10.3 11.8 8.8 8.5 9.2 120-139
<120 Systolic BP
100+ 90-99 80-89 75-79 70-74 <70 (mmHg)
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992; 152:56-64
Impact of High-Normal Blood Pressure on the Risk
of Cardiovascular Disease
Cumulative incidence of cv events in men without hypertension according to baseline blood
pressure

(130-139) mmHg

(121-129) mmHg

(< 120) mmHg

N Engl J Med 2001;345:1291-7

 Benefits of Treating Hypertension
• Younger than 60 (reducing BP 10/5-6 mmHg)
– reduces the risk of stroke by 42%
– reduces the risk of coronary event by 14%

• Older than 60 (reducing BP 15/6 mmHg)

– reduces overall mortality by 15%
– reduces cardiovascular mortality by 36%
– reduces incidence of stroke by 35%
– reduces coronary artery disease by 18%
• Older than 60 with isolated systolic hypertension
(SBP 160 mm Hg and DBP <90 mm Hg)
– reduces the risk of stroke by 42%
– reduces the risk of coronary events by 26%
Lancet 1990;335:827-38
Arch Fam Med 1995;4:943-50
 Paradigm Shift in HT Therapy
It is not just ↓BP. TODAY we must strive to
1. Alter the modifiable risk factors
2. Keep the SBP < 140 and DBP < 90
3. Prevent or halt or reduce TOD –
• Left Ventricular Hypertrophy, Coronary Heart
Disease, Congestif Heart Failure, Stroke, Chronic
Kidney Disease, Peripheral Vascular Disease &
Retinopathy.
4. Prevent or control DM (as HT + DM is hazardous)
5. Prevent or control Dyslipidemia
6. Prevent or control Endothelial Dysfunction
7. Improve QUALY – Quality Adjusted Life Years
43
8. Reduce morbidity and mortality
 Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors

• Presence of Risk Factors
– Increasing age
– Male gender
– Smoking
– Family history of premature cardiovascular disease (age< 55 in men and < 65 in women)
– Dyslipidemia
– Sedentary lifestyle
– Unhealthy eating
– Abdominal obesity
– Dysglycemia (diabetes, impaired glucose tolerance, impaired fasting glucose)
• Presence of Target Organ Damage
– Microalbuminuria or proteinuria
– Left ventricular hypertrophy/Left ventricular dysfunction
– Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2)
• Presence of atherosclerotic vascular disease
– Previous stroke or Transient Ischaemic Attack
– Coronary Heart Disease
– Peripheral arterial disease

CV Risk Factors that may alter thresholds and targets in the treatment of HTN
Treatment Approaches

Lifestyle Modification
Pharmacological
 Lifestyle management
(Non-Pharmacological Approach)
LIFESTYLE MODIFICATION IN HYPERTENSION

• Lifestyle modification should be instituted, whenever

appropriate in all hypertensive patients, including those
who require drugs
• Lifestyle measures are also advisable in subjects with
high normal BP and additional risk factors to reduce the
risk of developing hypertension
• Lifestyle recommendations should not be given as lip
service and reinforced periodically
 Non-pharmacological Treatment

Objective of lifestyle changes in

hypertension

Lower blood pressure

Minimize drug use
Reduce overall cardiovascular risk
Maintain or improve quality of life
Improve outcome
 Lifestyle Recommendations for Hypertension:
Dietary
Dietary Sodium

High in: Less than 2300mg / day

(Most of the salt in food is ‘hidden’ and comes
• Fresh fruits from processed food)
• Fresh vegetables
• Low fat dairy products
• Dietary and soluble fibre Dietary Potassium
• Plant protein Daily dietary intake >80 mmol

Low in: Calcium supplementation

• Saturated fat and cholesterol No conclusive studies for hypertension

• Sodium
Magnesium supplementation
No conclusive studies for hypertension

www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.
 Where in our diet does sodium come from?

11%

12%

77%

1. 12% natural content of foods

2. “Hidden“ sodium: 77% from processing of food -manufacturing and
restaurants
Occurs Naturally in Foods
3. “Conscious“ sodium: 11%
Added added at the
at the table
Table or(5%) and in cooking (6%)
in Cooking
Restaurant/Processed Food

J Am College of Nutrition 1991;10:383-93

All cases of hypertension should restrict sodium
intake to approximately 6 g sodium chloride salt or
2.4 g sodium per day by adopted the following
measures:
• Reduce salt for cooking by 50%
• Substitute natural foods for processed foods.
• No sprinkling of salt on dining table
• Avoid salty snacks such as pickles, chutneys,
papad, salted nuts
• Use salt substitutes containing potassium
• Avoid medications such as antacids as these
are rich in salt
Lifestyle Recommendations for Hypertension:
Physical Activity
Should be prescribed to reduce blood pressure

F Frequency - Four to seven days per week

I Intensity - Moderate

T Time - 30-60 minutes

Type Cardiorespiratory Activity

T - Walking, jogging
- Cycling
- Non-competitive swimming

Exercise should be prescribed as an adjunctive to pharmacological therapy

Lifestyle Recommendations for Hypertension:
Weight Loss
Height, weight, and waist circumference (WC) should be measured
and body mass index (BMI) calculated for all adults.
Hypertensive and all patients
BMI over 25
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2

Waist Circumference
Men <102 cm Women <88 cm

For patients prescribed pharmacological therapy: weight loss has

additional antihypertensive effects. Weight loss strategies should employ a
multidisciplinary approach and include dietary education, increased physical
activity and behaviour modification

CMAJ 2007;176:1103-6
 Lifestyle Recommendations for Hypertension:
Alcohol

Low risk alcohol consumption

• 0-2 standard drinks/day

• Men: maximum of 14 standard drinks/week

• Women: maximum of 9 standard drinks/week

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or

12 oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).
Lifestyle Recommendations for Hypertension:
Stress Management

Stress management
Hypertensive patients
in whom stress appears to be an important issue

Behaviour Modification

Individualized cognitive behavioural interventions are

more likely to be effective when relaxation techniques
are employed.
 Non-pharmacological Treatment
Intervention Recommendation Expected systolic blood
Pressure reduction (range)

Weight Reduction Maintain ideal body mass index 5-10 mmHg per 10 kg
(20-23 kg/m2) weight loss

DASH eating plan Consume diet rich in fruit, vegetables, 8-14 mmHg
low-fat dairy products with reduced
All put together reduce SBP by
content of saturated and total fat

Dietary sodium Reduce dietary sodium intake to 2-8 mmHg

restriction 20 to 55 mmHg
<100 mmol/day (<2.4 g sodium or
<6 g sodium chloride)

Physical Activity Engage in regular aerobic 4-9 mmHg

physical activity

Alcohol Men < 21 units per week

Women < 14 units per week 2-4 mmHg
moderation
Treatment Approaches

Pharmacological
 Initiating Pharmacologic Therapy (1)
First visit.
1. Patients with SBP ≥180 mmHg and/or DBP ≥110 mmHg, with or without
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) require immediate management (non-
pharmagological & pharmacological treatment)
2. If SBP is between 160–179 mmHg and/or DBP 100–109 mmHg with
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) require immediate management (non-
pharmagological & pharmacological treatment)
3. If SBP is between 160–179 mmHg and/or DBP 100–109 mmHg, without
macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus (DM), or CKD
(GFR<60 mL/min/1.73 m2) a second visit within 1-2 week should be scheduled
for confirmation of HTN. Non-pharmacological treatment should be initiated.
4. If average BP levels is within stage 1 range, a second visit within 3-4 weeks
should be scheduled for the assessment of HTN. Non-pharmacological
treatment should be initiated.
 Criteria for Diagnosis of Hypertension (2)

Second Visit.
1. Patients with macrovascular (CAD, stroke, or PAD), TOD, diabetes mellitus
(DM), or CKD (GFR<60 mL/min/1.73 m2) if SBP is ≥140 mmHg and/or DBP is
≥90 mmHg, pharmacological treatment should be initiated
2. Patients without macrovascular TOD, DM, or CKD and SBP is between ≥140–
159 mmHg and/or DBP ≥90–99 mmHg, third visit within 2-4 week should be
scheduled for confirmation of HTN

Third Visit
1. If SBP is ≥140 mmHg and/or DBP is ≥90 mmHg, pharmacological treatment
should be initiated.
 Choice of Pharmacological Treatment
for Hypertension
Individualized treatment
• Compelling indications:
– Ischemic Heart Disease
– Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
– Left Ventricular Systolic Dysfunction
– Cerebrovascular Disease
– Left Ventricular Hypertrophy
– Non Diabetic Chronic Kidney Disease
– Renovascular Disease
– Smoking
• Diabetes Mellitus
– With Nephropathy
– Without Nephropathy
• Global Vascular Protection for Hypertensive Patients
– Statins if 3 or more additional cardiovascular risks
– Aspirin once blood pressure is controlled
 Anti-hypertensive Drugs
Diuretic
Beta adrenergic blocker
Calcium channel blocker
Drugs inhibiting Renin Angiotensin System
Angiotensin Converting Enzyme inhibitors
Angiotensin Receptor Blockers
Renin Inhibitor
Alpha-adrenergic blockers
Central acting drugs
Direct vasodilators
 Treatment of Adults with Systolic/Diastolic
Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Long-
Thiazide ACEI ARB acting
CCB

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

*BBs are not indicated as first line therapy for age 60 and above

ACEI, ARB and direct renin inhibitors are contraindicated in pregnancy and caution is required in
prescribing to women of child bearing potential
NICE clinical guideline 127, 2011
Indications and contraindications of antihypertensive drugs

Shin et al. Clinical Hypertension (2015) 21:2

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

Considerations in the individualization of antihypertensive
treatment

CHEP Guidelines 2007

 Strategies are offered to dose/titrate
antihypertensive drugs
1. Start one drug, titrate to maximum dose, and
then add a second drug
2. Start one drug and then add a second drug
before achieving the maximum dose of the initial
drug
3. Begin with two drugs at the same time, either as
two separate pills or as a single pill combination

JNC 8 (2014)
Recommendations for Initial Combination
Antihypertensive Therapy

Norris K& Neutel JM. J Clin Hypertens. 2007;9(12 suppl 5):5–14

 “Rule of 10” and a “Rule of 5”
to predict the reduction in SBP and DBP

Combination of drugs from different Combination of drugs from different

classes is more effective in reducing SBP classes is more
than increasing doses of the same drug. effective in reducing DBP than increasing
doses of the same drug.
Chiang et al.. J Chin Med Assoc.2015;78(1):1-47.
 Ratio of Incremental SBP lowering effect at
“standard dose”– Combine or Double?

1,4
1,16
1,2
Incremenal SBP reduction ratio

1,04
Observed/Expected (additive)

1 1,01
1 0,89
0,8
0,6
0,37
0,4
0,19 0,23 0,2 0,22
0,2
0
Thiazide β-blocker ACE-I CCB All

Combine Double
Wald et al. Combination Versus Monotherapy for Blood Pressure Reduction,
The American Journal of Medicine, Vol 122, No 3, March 2009
What is the optimal combination ?
Drug combination in hypertension

Preferred Acceptable Less effective

• ACE inhibitor/diuretic • β-blocker / diuretic • ACE inhibitor / ARB
• ARB/diuretic • CCB • ACE inhibitor / β-blocker
• ACE inhibitor/CCB (dihydropyridine) / • ARB / β-blocker
• ARB/CCB β-blocker • CCB (nondihydropyridine) / β-
• CCB/diuretic blocker *
• Renin inhibitor / • Centrally acting agent / β-
diuretic blocker*
• Renin inhibitor /
ARB
• Thiazide diuretics / *Potentially Dangerous
K+-sparing diuretics
Resistant Hypertension
• Blood pressure that remains above goal (<140/90
mmHg in non-complicated patients & <130/80 mmHg in
high risk patients) in spite of the concurrent use of of
three antihypertensive agent of different classes
• Ideally, one of the three agents should be diuretic and
all agents should be prescribed at optimal dose
amounts
• Includes patient whose blood pressure is controlled
with use of more than three medications
• In a compliant patient
DIFFERENTIAL DIAGNOSIS OF UNCONTROLLED HYPERTENSION

Shin et al. Clinical Hypertension (2015) 21:2

DIFFERENTIAL DIAGNOSIS OF UNCONTROLLED HYPERTENSION
 Suggested algorithm for the treatment of resistant hypertension
Insure therapy meets JNC-7 criteria for compelling indications

Uncontrolled blood pressure Correct identifiable causes if

on 3 or more antihypertensives present; consider work-up of
Consider ambulatory blood secondary conditions
pressure monitoring if
available to rule out “white-
coat” phenomenon NO Add low-dose diuretic
Thiazide-type
(chlorthalidone 12.5 mg
diuretic present?
preferred; titrate to 25mg/d)
YES
* if not already part of
regimen, consider B for Re-evaluate
addition if pulse >84
Optimize combination as follows:
A or B* + C + D If blood pressure
If blood pressure remains uncontrolled
A= ACEI or ARB
B = Beta Blocker remains uncontrolled
C= CCB (long-acting)
D= Diuretic
+ spironolactone (12.5 mg/d to 25 mg/d)

If blood pressure remains uncontrolled, adjust regimen to include:

Trewet CLB, et al. South Med. 2008;101(2):166-174

Suggested algorithm for the treatment of resistant hypertension

If blood pressure remains uncontrolled, adjust regimen to include:

ACEI 2 CCBs alpha-blocker or Centrally-acting

or or or
+ ARB (different types) combined (e.g. Clonidine)
alpha/beta blocker

+ vasodilator (e.g.
hydralazine)

Trewet CLB, et al. South Med. J 2008;101(2):166-174

Overall BP targets for various clinical
conditions

Chiang et al. 2015 Guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension
Society for the Management of Hypertension. J Chin Med Assoc.;78(1):1-47, 2015.
 Overall BP targets (JNC-8)
Target SBP Target DBP
Patient subgroup
(mmHg) (mmHg)
≥ 60 years <150 <90
< 60 years <140 <90
> 18 years with CKD <140 <90
> 18 years with diabetes <140 <90
Adherence
Factors contributing to low adherence/persistence
with antihypertensive drugs
Category Examples
Poor communication
Patient-physician Insufficient patient information/education
relationship Physical/cognitive impairments (vision
problems, dementia)
Asymptomatic

Condition Lifelong treatment

No immediate consequences of stopping
therapy

Adverse effects
Therapy
Complexity of regimen
Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol 2011;2:63-70
Factors contributing to low adherence/persistence
with antihypertensive drugs
Category Examples
Cost of medication

Unemployment/poverty

Socioeconomic Lack of insurance

Lack of transportation

Social deprivation

Inadequate health care coverage

Health system Difficult access to health care

Lack of continuity of care

Gert WC. Curr Hypertens Rep. 2002,4(6):424-33
Krzensinski J-M. Res Rep Clin Cardiol 2011;2:63-70
 Guidelines for the physician to improve
antihypertensive drug compliance

Educate the patient about hypertension and its

treatment with clear and accepted goals. Need to
continue treatment, control does not mean
cure, one cannot tell if BP is elevated by feeling
or symptoms-> BP must be measured
Keep the treatment as simple and cheap as possible
(using long-acting once-daily dosing) with written
information.
Combine efficient and well tolerated drugs in the
same pill (fixed-dose combination)
Adherence to anti-hypertensive management can
be improved by a multi-pronged approach (1)
• Assess adherence to pharmacological and non-
pharmacological therapy at every visit
• Teach patients to take their pills on a regular schedule
associated with a routine daily activity e.g. brushing
teeth.
• Simplify medication regimens using long-acting once-
daily dosing
• Utilize fixed-dose combination pills
• Utilize unit-of-use packaging e.g. blister packaging
• Replacing multiple pill antihypertensive combinations
with single pill combinations!
Adherence to anti-hypertensive management can
be improved by a multi-pronged approach (2)
• Encourage greater patient responsibility/autonomy in
regular monitoring of their blood pressure
• Educate patients and patients' families about their
disease/treatment regimens verbally and in writing
• Use an interdisciplinary care approach coordinating with
work-site health care givers and pharmacists if available
 Key Messages for the
Management of Hypertension

1. All adults should have their blood pressure assessed at all

appropriate clinical visits.
2. Optimum management of BP requires assessment of overall
cardiovascular risk.
3. Home BP monitoring is an important tool in self-monitoring and
self-management.
4. Treat to target.
5. Lifestyle modifications are effective in preventing hypertension,
treating hypertension and reducing cardiovascular risk.
6. Combinations of both lifestyle changes and drugs are generally
necessary to achieve target blood pressures.
7. Focus on adherence.
THANK YOU ALL

For Your Kind Attention