Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion

1
 Hypertension and
Cardiovaskular disease

Muhammad Aminuddin MD
Departement Of Cardiology and Vascular
Faculty of Medicine,Airlangga University
Soetomo General Hospital
Surabaya
 Natural history of hypertensive disease

From endothelial dysfunction to target-organ damage

Endothelial Vascular Elevated Target-organ

dysfunction dysfunction BP damage
LVH
Nephropathy
Stroke
MI/CAD
Weber M. J Hypertens 2003;21 (Suppl 6):S37–S46
 New Criteria (WHO-ISH 1999) ≥ 140 / 90
mmHg
22 % of American adults 18 to 70 years of age have hypertension
20 % of Indonesian adults have hypertension

Hypertensive patients Hypertensive patients

who are treated who are treated
but uncontrolled and controlled

16%
23%

19% 42%

Patients who are aware

but remain untreated Hypertensive patients
and uncontrolled who are unaware

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

 Neurohormonal control of blood pressure
Blood pressure = Cardiac output (CO) x Peripheral resistance (PR)
Hypertension = Increased CO and/or Increased PR

Vasoconstriction
 Preload  Contractility
 Fluid volume
 Fluid volume
Sympathetic Renin-
nervous angiotensin-
Renal sodium system aldosterone
retention system

Excess Genetic
sodium factors
intake
(Adapted from Kaplan, 1994)
 Possible mechanisms leading from hypertension to
atherosclerosis

Hypertension

Shear forces Endothelial injury

 vessels wail thickness

Change in gene expression, Change in lipid Change in redox

cytokines, growth factors, metabolism status/
adhesion molecules  free radicals

ATHEROSCLEROSIS
 Caused of Hipertension :

I. Primer / essential / idiopathic

II. Sekunder :
A. Renal
B. Endocrine
C. Coartation of the aorta
D. Pregnancy induced hypertension
E. Neurological disorder
F. Drug and other abused substancen
 Recommended Technique
for Measuring Blood Pressure

Standardized technique:

• Have the patient rest for 5 minutes

• Use an appropriate cuff size
• Use a mercury manometer or a recently
calibrated electronic device
 Recommended Technique
for Measuring Blood Pressure (cont.)

• Position cuff appropriately

• Increase pressure rapidly
• Support arm with antecubital fossa or heart
level
• To exclude possibility of auscultatory gap,
increase cuff pressure rapidly to 30 mmHg
above level of diseappearance of radial
pulse
• Place stethoscope over the brachial artery
 Recommended Technique
for Measuring Blood Pressure (cont.)

• Drop pressure by 2 mmHg / beat :

- appearance of sound (phase I Korotkoff)
= systolic pressure
- disappearance of sound (phase V
Korotkoff) = diastolic pressure
• Take 2 blood pressure measurements, 1
minute apart
 Technique of blood pressure measurement
recommended by the British Hypertension Society

1.
The patient should be
relaxed and the arm must be
supported. Ensure no tight
clothing constricts the arm
2.
The cuff must be level with the
heart. If the circumference exceeds
33cm, a large cuff must be used.
Place stethoscope diaphram over
brachial artery
3.
The column of mercury must
be vertical. Inflate to occlude
the pulse. Deflate at 2-3
mm/s. measure systolic (first
sound) and diastolic
(disappearence) to nearest 2
mmHg

(From British Hypertension Society 1985)

 BP Measurement Techniques

Method Brief Description

In-office Two readings, 5 minutes apart, sitting in

chair. Confirm elevated reading in
contralateral arm.
Ambulatory BP monitoring Indicated for evaluation of “white-coat” HTN.
Absence of 10–20% BP decrease during
sleep may indicate increased CVD risk.
Self-measurement Provides information on response to
therapy. May help improve adherence to
therapy and evaluate “white-coat” HTN.
 Patient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant

disorders that affects prognosis and guides treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

 Routine and optional laboratory tests

Investigation of all patients with hypertension

1. Urinalysis
2. Complete blood count
3. Blood chemistry (Potassium, Sodium and creatinine)
4. Fasting Glucose
5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low
density lipoprotein cholesterol (LDL), triglycerides
6. Standard 12 leads ECG

For specific patient subgroups

1. For those with diabetes or renal disease: 24hour or over night urine protein, as lower goal
blood pressure targets are appropriate.
2. For those with an increased creatinine or renal disease: renal ultrasound to exclude
obstruction.
3. For those with a symptom triad of headache, sweating, palpitations; measure 24 hour urine
catecholamine metabolites to assess for pheochromocytoma.
Berkin K and Ball SG. Essential Hypertension : the heart and
hypertension. Heart 2001; 86 : 467-475
 THE CARDIOVASCULAR CONTINUUM

Myocardial Sudden Death

infarction
Coronary Arrhythmia &
thrombosis loss of muscle

Myocardial Remodelling
ischaemia
Ventricular
CAD dilatation
STROKE
Atherosclerosis Congestive
LVH heart failure

Risk factors Death

smoking, HYPERTENSION,
cholesterol, diabetes
 Risk Factors for Cardiovascular Disease

► Modifiable ► Non-modifiable
● Smoking ● Personal history
● Dyslipidaemia of CHD
• raised LDL cholesterol ● Family history
• low HDL cholesterol
of CHD
• raised triglycerides
● Age
● Raised blood pressure
● Gender
● Diabetes mellitus
● Obesity
● Dietary factors
● Thrombogenic factors
● Lack of exercise
● Excess alcohol consumption
 HTN Commonly Clusters
with Other Risk Factors
Kaiser Permanente Northwest database;
N=57,573 aged > 35 years with HTN and no CVD

HTN + 2 other
HTN + 3 other risk factors
14
risk factors 3
44 HTN only

39
HTN + 1 other risk factor

Other risk factors: obesity,* hyperlipidemia, and diabetes

Weycker D et al. Am J Hypertens. 2007;20:599-607 *Body mass index >30 kg/m2

 Consequences of Hypertension:
Organ Damage

Hypertension

Transient ischemic
attack, stroke LVH, CHD, CHF

Peripheral
Retinopathy arterial Chronic kidney disease
disease

CHF=congestive heart failure; CHD=coronary heart disease; LVH=left ventricular hypertrophy.

Chobanian AV et al. JAMA. 2003;289:2560-2572.
 Hypertension Co-Morbidities

► % of patients with BP >140/90 mm Hg:

● 69% of patients with 1st MI
● 77% of patients with 1st stroke
● 74% of patients with HF

► Hypertension precedes HF in 91% of cases

► Hypertension is associated with a 2- to 3-times higher

risk for HF

BP, blood pressure; HF, heart failure; MI, myocardial infarction.

Thom T et al. Circulation. 2006;113:e85-e151.
 BP Reductions as Small as 2 mmHg Reduce
the Risk of CV Events by Up to 10%

▶ Meta-analysis of 61 prospective, observational

studies
▶ 1 million adults
▶ 12.7 million person-years 7% reduction in
risk of ischemic
heart disease
2 mmHg
mortality
decrease in
mean SBP
10% reduction in
risk of stroke
mortality

Prospective Studies Collaboration. Lancet. 2002;360:1903-1913

 Mortality According to Blood Pressure
in Men Age 50 to 69

250
Ratio (%) of actual to
expected mortality

200

150

100 68-82
83-87
88-92
50
93-97
98-102
0
158-167 148-157 138-147 128-137 98-127
Systolic blood pressure (mmHg)

Society of Actuaries. Blood Pressure Study, 1939.

 Cardiovascular Mortality Risk Doubles with
Each 20/10 mmHg BP Increment*

7
CV Mortality Risk

0
115/75 135/85 155/95 175/105

Systolic/Diastolic Blood Pressure (mmHg)

* Individuals aged 40-69 years, starting at BP 115/75 mm Hg

Lewington S, et al. Lancet. 2002;360:1903-1913

 Consequences of
Structural Changes in Hypertension

Increased blood pressure

Structural changes in
Loss of buffering Function compliance arteries  Shear stress on Artery
wall
Transmits  Compliance
 Systolic pressure Wave to Endothelial damage
small arteries
 Load on heart

Perpetuation of Left Ventricular Predisposes of

Hypertension Hypertrophy Atherosclerosis
 Possible mechanisms leading from hypertension to
atherosclerosis

Hypertension

Shear forces Endothelial injury

 vessels wail thickness

Change in gene expression, Change in lipid Change in redox

cytokines, growth factors, metabolism status/
adhesion molecules  free radicals

ATHEROSCLEROSIS
 Atherosclerosis – Time line

Dr.Sarma@works 27
 Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT in Cardiovascular
disease
►Conclusion

28
 WHO-ISH* 1999: definition and classification
of BP levels

Category Systolic BP (mm Hg) DBP (mm Hg)

Optimal BP <120 < 80

Normal BP <130 < 85

High-normal BP 130-139 85-89

Grade 1 hypertension (mild) 140-159 90-99

Subgroup: borderline 140-149 90-94

Grade 2 hypertension (moderate) 160-179 100-109

Grade 3 hypertension (severe) ≥180 ≥110

Isolated systolic hypertension (ISH) ≥140 <90

Subgroup: borderline 140-149 <90

*World Health Organization–International Society of Hypertension.

When systolic BP and DBP fall into different categories, the higher should apply.

Adapted from the World Health Organization–International Society of Hypertension, J Hypertens, 1999.
 Hypertension
JNC BP Classifications: DBP

130
125 Stage 4
120
Severe Severe Severe
115 Hyper-
Stage 3 Stage 3

110 tensive Moderate Moderate Moderate

DBP
(mm Hg) 105 Stage 2 Stage 2 Stage 2

100 Consider
Mild Mild Mild
therapy
95 Stage 1 Stage 1 Stage 1

90 High- High- High- High-

normal normal normal normal Prehyper-
85 tension
Normal Normal Normal Normal
80
Optimal Optimal Normal

JNC I JNC II JNC III JNC IV JNC V JNC VI JNC 7

JNC IV. Arch Intern Med. 1988;148:1023-1038.

JNC I. JAMA. 1977;237:255-261. JNC V. Arch Intern Med. 1993;153:154-183.
JNC II. Arch Intern Med. 1980;140:1280-1285. JNC VI. Arch Intern Med. 1997;157:2413-2446.
JNC III. Arch Intern Med. 1984;144:1045-1057. Chobanian AV et al. JAMA. 2003;289:2560-2572.
 Hypertension
JNC BP Classifications: SBP

220 Stage 4

210
200 Stage 3
Stage 3
190
180 ISH ISH
SBP 170 Stage 2 Stage 2 Stage 2
(mm Hg) 160
Border- Border-
150 line line Stage 1 Stage 1 Stage 1
140 No recommendations
for SBP in JNC I High- High-
normal normal Prehyper-
130 or JNC II Normal tension
Normal Normal
120
110
Optimal Optimal Normal

JNC I JNC II JNC III JNC IV JNC V JNC VI JNC 7

JNC IV. Arch Intern Med. 1988;148:1023-1038.

JNC I. JAMA. 1977;237:255-261. JNC V. Arch Intern Med. 1993;153:154-183.
JNC II. Arch Intern Med. 1980;140:1280-1285. JNC VI. Arch Intern Med. 1997;157:2413-2446.
JNC III. Arch Intern Med. 1984;144:1045-1057. Chobanian AV et al. JAMA. 2003;289:2560-2572.
 Hypertension JNC 7

Blood Pressure (mm Hg) Category

Systolic Diastolic

<120 and <80 Normal

120-139 or 80-89 Prehypertension

140-159 or 90-99 Stage 1 hypertension

≥160 or ≥100 Stage 2 hypertension

JNC 7: Seventh Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure.

Chobanian AV, et al. Hypertension. 2003;42:1206-52.

ESC 2013 Classification of Blood Pressure
Category SBP DBP

Optimal < 120 and < 80

Normal 120-129 and/or 80-84
High–Normal 130–139 and/or 85–89

Hypertension
Grade 1 140–159 and/or 90–99
Grade 2 160–179 and/or 100–109
Grade 3  180 and/or  110
Isolated Systolic HT  140 and < 90
 Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion

34
 Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

 Algorithm for Treatment of Hypertension

Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
indications
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and Other antihypertensive drugs
ACEI, or ARB, or BB, or CCB) (diuretics, ACEI, ARB, BB, CCB)
or combination.
as needed.

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
 Goals of Therapy

Reduce CVD and renal morbidity and mortality.

 Treat to BP <140/90 mmHg or BP <130/80 mmHg in

patients
with diabetes or chronic kidney disease.

 Achieve SBP goal especially in persons >50 years of

age.
 ESHESC and JNC 7 Guidelines Recommend Target BP Goals of
<140/90 mmHg for Uncomplicated Hypertension and <130/80 mmHg
for Complicated Hypertension

Type of hypertension BP goal (mmHg)

Uncomplicated <140/90
Complicated
Diabetes mellitus <130/80
Kidney disease <130/80*
Other high risk (stroke, myocardial <130/80
infarction)

*Lower if proteinuria is >1 g/day

Task Force of ESH–ESC. J Hypertens 2007;25:110587

Chobanian et al. Hypertension 2003;42:1206–52
 AHA Scientific Statement—Treatment of Hypertension in the
Prevention and Management of Ischemic Heart Disease

Diagnosis Target BP (mm Hg)

<140/90

<130/80
Primary Prevention
Diabetes, Chronic Kidney Disease, CAD,
CAD Equivalents, or Framingham Risk Score
≥10%
CAD and Stable Angina
ACS – UA and NSTEMI <130/80
ACS - STEMI
HF of Ischemic Etiology <130/80, but consider <120/70

ASC: acute coronary syndrome, UA: Unstable angina, NSTEMI:

Non-ST segment elevation myocardial infarction, STEMI: ST
Rosendorff et al. Circulation. 2007;115:2761-2788. segment elevation myocardial infarction, HF: Heart failure
 Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion

40
 Lifestyle Modifications to
Prevent and Manage Hypertension

• Reduce weight • Moderate consumption of:

• alcohol
• sodium
• saturated fat
• cholesterol

• Maintain adequate intake of dietary:

• potassium
• Increase • calcium
physical • magnesium
activity

► Avoid tobacco

(JNC VI. Arch Intern Med. 1997)

 Lifestyle Modifications
Approximate Systolic Blood
Modification Recommendation Pressure Reduction
(mm Hg)a
Weight loss Maintain normal body weight (body mass 5–20 per 10-kg weight loss
2
index 18.5–24.9 kg/m )

DASH-type Consume a diet rich in fruits, vegetables, 8–14

dietary patterns and low-fat dairy products with a reduced
content of saturated and total fat
Reduced salt Reduce daily dietary sodium intake as 2–8
intake much as possible, ideally to 65 mmol/day
(1.5 g/day sodium, or 3.8 g/day sodium
chloride)
Physical activity Regular aerobic physical activity (at least 4–9
30 min/day, most days of the week)
Moderation of Limit consumption to 2 drinks/day in men 2–4
alcohol intake and 1 drink/day in women and lighter-
weight persons

DASH, Dietary Approaches to Stop Hypertension.

a Effects of implementing these modifications are time and dose dependent and could be greater for

some patients.

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition:
42
http://www.accesspharmacy.com/
 Dietary
Approaches to
Stop
Hypertension

► Lowers systolic BP
● in normotensive
patients by an
average of 3.5 mm Hg
● In hypertensive
patients by 11.4 mm
Hg
► Copies available from
NHLBI website

http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
 Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion

45
 Ideal Hypertension Agent :
S Once Daily
S Smooth anti HT effect
S Well tolerated, minimal SE
S Beneficial CV effect independent of BP lowering

Int'I Forum on Angiotensin Receptor Antagonism, Monte Carlo 1999

 1999 WHO-ISH Guidelines for Initiation of
Anti-Hypertensive Treatment

Angiotensin II type 1 (AT1) - receptor blockers have now been

included in the six classes of antihypertensive agents listed in the
new WHO/ISH guidelines :
S Diuretics
S Beta-blockers
S ACE inhibitors
S Calcium antagonists
S Alpha-blockers
S Angiotensin II Receptor Blockers

Guidelines Subcommitte 1999 WHO-Int'I Society of Hypertension. Guidelines for

Management of Hypertension. J Hypertens 1999;17:151-83
 Thiazide Diuretics
• Mechanism: inhibit Na/K pumps in
Veins
the distal tubule
• Examples:
•Hydrocholorthiazide 12.5-25 mg daily
Thiazides •Chlorthalidone 12.5-50 mg daily

• Effective first line agent and

provides synergistic benefit
• As single agent more effective if
CrCl >30 ml/min
• Compelling indications: HF, High
CAD risk, Diabetes, Stroke, ISH
 Loop Diuretics
• Mechanism: Inhibit Na/K/Cl ATPase
Veins
in ascending loop of henle
• Examples:
•Furosemide 20 mg BID
Thiazides • Typically only beneficial in patients
Loops with resistant HTN and evidence of
fluid; effective if CrCl <30 ml/min
• MUST be dosed at least twice daily
(Lasix = Lasts six hours)
• Administer AM and lunch time to
avoid nocturia
 Aldosterone Receptor Antagonists
• Mechanism: inhibit aldosterone’s
Veins
effect at the receptor, reducing Na
and water retention
• Examples:
Thiazides •Spironolactone 25 mg daily

Loops • Can provide as much as 25 mmHg

BP reduction on top of 4 drug
Aldosterone
regimen in resistant hypertension
Ant.
• Monitor SCr and K
• Compelling indications: HF

Am J Hypertension. 2003; 16:925-930.

 Beta Blockers

Heart • Mechanism: Competitively inhibit

the binding of catecholamines to
beta-adrenergic receptors
• Examples:
Beta Blockers •Atenolol 25-100 mg QD, Metoprolol 25 -
100 mg BID, Bisoprolol 2.5 – 10 mg QD
•Carvedilol 6.25-50 mg (alfa+Beta)BID

• Monitor: HR, Blood Glucose in DM

• Not contraindicated in asthma or
COPD but use caution
• Compelling indications: HF, post-MI,
High CAD risk, Diabetes
 Calcium Channel Blockers Non-Dihydropyridine:
Diltiazem and Verapamil
• Mechanism: Decrease calcium
Heart influx into cells of vascular smooth
Arteries muscle and myocardium
• Examples:
•Diltiazem Long acting; CD 100 -400 mg
Diltiazem
•Verapamil 60-480 mg, long acting SR
Verapamil
• Monitor: HR
• Verapamil causes constipation
• Relatively contraindicated in heart
failure
• Compelling indications: Diabetes,
High CAD risk
 Calcium Channel Blockers:
Dihydropyridine
• Mechanism: Decrease calcium
influx into cells of vascular smooth
Arteries
muscle
• Examples:
•Amlodipine 2.5-10 mg PO daily
Dihydropyridin
•Felodipine 2.5-10 mg PO daily
e CCBs
• OROS/GITS. Do not use immediate
release nifedipine

• Monitor: Peripheral edema, HR (can

cause reflex tachycardia)
• Good add on agent if cost is not an
issue
 ACEI

Veins • Mechanism: Inhibit vasoconstriction by

Arteries inhibiting synthesis of angiotensin II;
provides balanced vasodilation
• Examples:
•ACEI: Captopril 12.5 -50 BID, Enalapril 2.5-
ACEI 40 mg daily –BID, Lisinopril 5 – 40 mg daily,
Imidapril 5-10 QD, Perindopril 4-8 mg QD,
Ramipril 2.5-20 mg

• Monitor: S Cr, K
• Compelling indications: HF, post-MI,
High CAD risk, Diabetes, CKD, Stroke
 ARB’s

Veins • Mechanism: Inhibit vasoconstriction by

Arteries blocking action of angiotensin II;
provides balanced vasodilation
• Examples:
•ARB: Irbesartan 150-300 mg QD, Losartan
ARB 25-100 mg BID, Olmesartan 20-40 mg,
Telmisartan 20-80 mg, Valsartan 90-160
mgQD

• Monitor: S Cr, K
• Compelling indications: HF, post-MI,
High CAD risk, Diabetes, CKD, Stroke
 Choice of Treatment

Associated risk factors?

or
Target organ damage/complications?
or
Concomitant diseases/conditions?

NO YES

Standardized Individualized
treatment treatment
 Associated risk factors? or
Target organ damage / complications? or
Concomitant diseases / conditions?

NO YES

Associated risk factors

Standardized
therapy Dyslipidemia, Smoking, Diabetes

algorithm
and/or

Target organ damage /

complications

Ischemic heart disease,

Systolic cardiac dysfunction
Individualization
Peripheral vascular disease of treatment
Arrhythmia and AV-node conduction problems
Cerebral vascular disease
Left ventricular hypertrophy

and/or

Concomitant
diseases/conditions

Renal and renovascular diseases, Airway

disease, Gout
 JNC VII: Management of Hypertension by
Blood Pressure Classification

Initial Drug Therapy

Lifestyle Without Compelling With Compelling
BP Classification Modification Indication Indication

Normal Encourage
<120/80 mm Hg

Prehypertension Yes No drug indicated Drug(s) for the compelling

120-139/80-89 mm Hg indications

Stage 1 hypertension Yes Thiazide-type diuretics Drug(s) for the compelling

140-159/90-99 mm Hg for most; may consider
ACE-I, ARB, BB, CCB, or
combination
Stage 2 hypertension Yes 2-drug combination for most
≥160/100 mm Hg (usually thiazide-type diuretic
and ACE-I, ARB, BB, or
CCB)
ACE-I = angiotensin-converting enzyme inhibitor; ARB = angiotensin-receptor blocker; BB = beta blocker;
CCB = calcium channel blocker.
Chobanian AV et al. JAMA. 2003;289:2560-2572.
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB, BB,
CCB) as needed
Drug(s) for the compelling
indications; other
antihypertensive drugs
(diuretics, ACE-I, ARB,
BB, CCB) as needed
 ESH/ESC 2003: Initiation of
Antihypertensive Treatment

A B C
SBP 130-139 or SBP 140-179 or SBP 180 or
DBP 85-89 mm Hg DBP 90-109 mm Hg DBP 110 mm Hg
High normal BP Grades 1 and 2 hypertension Grade 3 hypertension

Assess risk factors, TOD, ACC Assess risk factors, TOD, ACC Begin drug Tx
Initiate lifestyle measures Initiate lifestyle measures Assess risk factors, TOD, ACC
and risk factor correction and risk factor correction
Initiate lifestyle measures
Stratify absolute risk Stratify absolute risk and risk factor correction
Very high Very high
SBP 140 or
Begin drug Tx Begin drug Tx
DBP 90 mm Hg
High High Begin drug Tx
Begin drug Tx Begin drug Tx
SBP 140-159
Moderate Moderate or DBP 90-99 mm Hg
Monitor BP Monitor & reassess after 3 mo Consider drug Tx

Low Low
No BP intervention Monitor & reassess 3-12 mo
TOD = target organ damage; ACC = associated clinical conditions.
Adapted from Guidelines Committee. J Hypertens. 2003;21:1011-1053.
 Pharmacological Treatment

1. Treatment of Systolic/Diastolic
hypertension without other compelling
indications

2. Treatment of Isolated Systolic

hypertension without other compelling
indications

2009 Canadian Hypertension Education Program Recommendations

 Treatment of Systolic-Diastolic Hypertension
without Other Compelling Indications

TARGET <140/90 mmHg

Lifestyle modification
A combination of 2 first line drugs may
be considered as initial therapy if the
Initial therapy blood pressure is >20 mmHg systolic
or >10 mmHg diastolic above target

Thiazide Long-acting Beta-

ACEI ARB
diuretic CCB blocker*

CONSIDER
• Nonadherence Dual Combination
• Secondary HTN
• Interfering drugs or
*Not indicated as first
lifestyle Triple or Quadruple line therapy over 60 y
• White coat effect Therapy

2009 Canadian Hypertension Education Program Recommendations

 Treatment of Isolated Systolic Hypertension
without Other Compelling Indications
TARGET <140 mmHg

Lifestyle modification
therapy

Thiazide Long-acting
ARB
diuretic DHP CCB

CONSIDER *If blood pressure is still not

• Nonadherence
Dual therapy controlled, or there are
• Secondary HTN adverse effects, other
• Interfering drugs or classes of antihypertensive
lifestyle drugs may be combined
• White coat effect (such as ACE inhibitors,
Triple therapy alpha blockers, centrally
acting agents, or
nondihydropyridine calcium
channel blocker).
2009 Canadian Hypertension Education Program Recommendations
 ESH 2003: Possible Combinations of Different
Classes of Antihypertensive Agents
The most effective and well tolerated combinations are shown as
solid lines

Diuretics

AT1-receptor
-blockers
blockers

Calcium
-blockers antagonists

ACE inhibitors

ESH Guidelines. J Hypertens. 2007;25:1105-1087. ESH= European Society of Hypertension

 The Seventh Report of
the Joint National Committee

Compelling
Indications Diuretic ßB ACEI ARB CCB AA

Heart failure     
Post-MI   
High CAD risk    
Diabetes     
Chronic kidney
disease
 
Recurrent
stroke  
prevention

AA, aldosterone antagonist; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II-receptor blocker; βB, ß-blocker; CCB,
calcium channel blocker; MI, myocardial infarction;
CAD, coronary artery disease.
Chobanian AV, et al. JAMA. 2003;289(19):2560-2572.
 Overview

►Introduction

►Classification of HT
►Goal of therapy
►Lifestyle modifications
►Pharmacological Therapy
►Management HT
►Conclusion

65
 Treatment of Hypertension
with Diabetes

with Alternate:
Nephropathy
ACE-I ARB

High dose diuretics, Alpha-blockers and

Diabetes Centrally acting agents if autonomic
neuropathy

without
Nephropathy ACE-I

Beta-blocker
Target BP < 130/80 mm Hg
 Treatment of Hypertension
with Non Diabetic Renal Disease

Renal Alternative therapy:

ACE-I Dihydropyridine CCB
disease

Additive therapy:
Bilateral renal artery
Diuretic stenosis

Non diabetic: < 130/80

Target BP
Proteinuria > 1 g/day: < 125/ 85
 Treatment of Hypertension
with Airways Diseases*

This add-on is
Standard HTN treatment. recommended in patients
If thiazide, add taking a beta-2
potassium-sparing diuretic agonist. e.g.: salbutamol,
which lowers potassium
Airway disease*

All Beta-blockers are

contraindicated if asthma
Beta-blocker or bronchial
hyperreactivity

* Asthma, Bronchial hyperreactivity

 Treatment of Hypertension
with Cerebrovascular Disease

Following a Treatment of uncomplicated hypertension,

cerebrovascular hypertension associated with other
accident conditions or concomitant risk factors.

Target BP < 140/80 mm Hg

Patients with moderate to severe hypertension:

Acute
cerebrovascular the agent of choice should be chosen to avoid
accidents precipitous falls in BP and should not increase
intracranial pressure.
 Treatment of Hypertension
with Gout

Avoid diuretics.
Note: asymptomatic
hyperuricemia is not a
Gout Thiazides contraindication of
treatment
with diuretics

Add on allopurinol
if a diuretic is
essential
 Treatment of Hypertension
with Peripheral Vascular Diseases

mild Treatment of uncomplicated hypertension,

Atherosclerotic hypertension associated with other
PVD conditions or concomitant risk factors.

severe May aggravate

± ACE-I ? Beta-blocker
symptoms

Peripheral May induce renal

Renal artery ACE-I
vascular
disease stenosis (use with caution) insufficiency

Vasodilators:
Raynaud’s Alpha-blockers, CCB,
May have
syndrome beneficial effects
ACE-I, ARB

Beta-blocker
 Post Myocardial Infarction

ACE Calcium Aldosterone

Diuretic -blocker Inhibitor ARB Antagonist Antagonist
Post-Myocardial
Infarction    
 Treatment of Hypertension in Patients with
Ischemic Heart Disease

1. Beta-blocker
Stable angina
2. Long-acting CCB

ACEI are recommended for most

patients with established CAD*

• Caution should be exercised when combining a non DHP-CCB and a beta-blocker

• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or
Diltiazem)
• Combinations of an ACEI with an ARB are not recommended in the absence of
heart failure
*Those at low risk with well controlled risk factors may not benefit from ACEI therapy

Short-acting
nifedipine

2009 Canadian Hypertension Education Program Recommendations

 Treatment of Hypertension in Patients with Recent ST
Segment Elevation-MI or non-ST Segment Elevation-MI

Beta-blocker and
Recent ACEI or ARB (if
myocardial
infarction ACEI not
tolerated)

If beta-blocker
contraindicated or
not effective

Heart YES Long-acting

Failure Dihydropyridine
? CCB*
(e.g. Amlodipine)
NO

Long-acting CCB

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

2009 Canadian Hypertension Education Program Recommendations
 Treatment of Hypertension with Left Ventricular
Systolic Dysfunction

• ACEI and Beta blocker

Systolic • if ACEI intolerant: ARB
cardiac Titrate doses of ACEI or ARB to those used in clinical trials
dysfunction

If additional therapy is needed:

• Diuretic (Thiazide for hypertension; Loop for volume control)
• for CHF class III-IV or post MI: Aldosterone Antagonist

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide

dinitrate in combination

If additional antihypertensive therapy is needed:

Non • ACEI / ARB Combination
dihydropyridine • Long-acting DHP-CCB (Amlodipine)
CCB

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol.

2009 Canadian Hypertension Education Program Recommendations

 Treatment of Hypertension in Patients
with Left Ventricular Hypertrophy

Hypertensive patients with left ventricular hypertrophy should be

treated with antihypertensive therapy to lower the rate of subsequent
cardiovascular events.

- ACEI
- ARB,
Left ventricular
- CCB
hypertrophy - Thiazide Diuretic
- BB (if age below 60)*

Vasodilators:
Hydralazine, Minoxidil can increase LVH

2009 Canadian Hypertension Education Program Recommendations

 Heart Failure

QuickTime™ and a
Sorenson Video 3 decompressor
are needed to see this picture.

ACE Calcium Aldosterone

Diuretic -blocker Inhibitor ARB Antagonist Antagonist

Heart Failure     
 Treatment of Hypertension
with Arrhythmia*

Atrial fibrillation and Beta-blocker May inhibit

supraventricular Verapamil ventricular
Diltiazem response
tachycardia

Arrhythmia Caution if systolic

dysfunction is
and present
conduction
problems
Sinoatrial node Beta-blocker
dysfunction and Verapamil
Diltiazem Avoid
atrioventricular Clonidine
conduction problems Methyldopa

* Caution is recommended when diuretics are used with class 1A, 1C or III antiarrythmic drugs
ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker;
DBP: diastolic blood pressure; SBP: systolic blood pressure 79
 80
80
 Key messages

• Lifestyle recommendations
• Treat to target
• Work on adherence/compliance
 ?
Hypertension

THANK YOU FOR YOUR

ATTENTION