hypertension Head of prevention and control of CVD disease office Ministry of heath

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2 hypertension t. Samavat MD,Cadiologist,MPH Head of prevention and control of CVD disease office Ministry of heath

3 RECOMMENDATIONS FOR HYPERTENSION DIAGNOSIS, ASSESSMENT, AND TREATMENT

4 Definition of hypertension Hypertension is sustained elevation of resting systolic BP ( 140mmhg),diastolic BP( 90mmhg),or both. Two type of hypertension was categorized: -Primary HTN,that hemodynamics and physiologic components vary indicating that primary HTN have no a single cause but multiple factors involved in sustaining elevated BP. -secondary HTN cause include renal parenchyma disease,renovascular diseas,pheochromacytoma,cushing, Hyper and hypothyroidism, alcohol consumption,coarctaion Of aorta, adrenal disease.

5 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 the hypertensive patient requires assessment and communication 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.

6 Reversible Risk Factors for Developing Hypertension Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption

7 Prevalence of Hypertension 21.8% Number of adults + 15 suffering from hypertension 3.3% 21.8 % 52.4 % of those age 15 to 39 of those age 40 to 59 of those age 60 to 70 have hypertension.

8 Staging of hypertension for office blood pressure determination HYPERTENSION STAGE Normal Pre hypertension Stage1 hypertension SYSTOLIC PRESSURE)mmhg) < DIASTOLIC PRESSURE(mmhg( < Stage2 hypertension

9 Definition of HTN by office and out-of-office BP level category Systolic BP(mmhg) DdiastolicBP(m mhg) Office BP 140 and/or 90 Home BP 135 and/or 85 Amb BP Daytime(or awake) 135 and/or 85 Nighttime(or sleep( 120 and/or hour 130 and/or 80

10 High Risk of Developing Hypertension in Those with pre hypertension pre hypertensive Individuals are at high risk of progression to overt hypertension. Annual follow-up of patients with pre - hypertension is recommended.

11 Blood Pressure Assessment: Patient preparation and posture 1.Standardized Preparation: 2.Patient 3.No acute anxiety, stress or pain. 4.No caffeine, smoking or nicotine in the preceding 30 minutes. 5.No use of substances containing adrenergic stimulants such as phenylephrine or pseudoephedrine (may be present in nasal decongestants or ophthalmic drops). 6.Bladder and bowel comfortable. 7.No tight clothing on arm or forearm. 8.Quiet room with comfortable temperature 9.Rest for at least 5 minutes before measurement 10.Patient should stay silent prior and during the procedure.

12 Blood Pressure Assessment: Patient preparation and posture Standardized technique: Posture The patient should be calmly seated with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.

13 Blood Pressure Assessment: Patient position X

Criteria for the Diagnosis of Hypertension and Recommendations for

1 BP Measurement, History and Physical examination Elevated Random

Visit 2 Target Organ Damage or Diabetes or BP >180/110?

14 Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up Elevated Out of the Office BP measurement Hypertension Visit 1 BP Measurement, History and Physical examination Elevated Random Office BP Measurement Hypertensive Urgency / Emergency Hypertension Visit 2 Target Organ Damage or Diabetes or BP >180/110? Yes Diagnosis of HTN No BP: / Clinic BPM ABPM (If available) Home BPM (If available)

15 Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up Diagnosis of hypertension Non pharmacological treatment With or without pharmacological treatment *Consider home blood pressure measurement for follow-up readings, to assess for the presence of masked hypertension or white coat effect and to enhance adherence. Are BP readings below target during 2 consecutive visits? Follow-up at 3-6 month intervals * Yes No Symptoms, severe hypertension, intolerance to anti-hypertensive treatment or target organ damage Yes No More frequent visits * Visits every 1 to 2 months*

Home BPM Hypertension visit 3 >160 SBP or >100 DBP <160 / 100

Diagnosis of HTN ABPM or HBPM Diagnosis of HTN Continue to

follow-up Awake BP >135 SBP or >85 DBP or 24-hour >130 SBP or >80

Continue to follow-up >135 SBP or >85 DBP Diagnosis of HTN

16 Criteria for the Diagnosis of Hypertension and Recommendations for Follow-up BP: / Clinic BPM ABPM (If available) Home BPM Hypertension visit 3 >160 SBP or >100 DBP <160 / 100 >140 SBP or >90 DBP < 140 / 90 or Hypertension visit 4-5 Diagnosis of HTN ABPM or HBPM Diagnosis of HTN Continue to follow-up Awake BP <135/85 and 24-hour <130/80 Continue to follow-up Awake BP >135 SBP or >85 DBP or 24-hour >130 SBP or >80 DBP Diagnosis of HTN < 135/85 Repeat Home BPM If < 135/85 Continue to follow-up >135 SBP or >85 DBP Diagnosis of HTN Patients with high normal blood pressure (office SBP and/or DBP 85-89) should be followed annually. or

17 A assessment of the Overall Cardiovascular Risk 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

Assessment of the Overall Cardiovascular Risk Search for target organ damage Cerebrovascular disease 50% transient ischemic attack ischemic or

by Echo Coronary artery disease Ischemic heart disease more than 50% myocardial infarction congestive heart failure(the most common cause is HTN)

18 Assessment of the Overall Cardiovascular Risk Search for target organ damage Cerebrovascular disease 50% transient ischemic attack ischemic or hemorrhagic stroke vascular dementia Hypertensive retinopathy Left ventricular dysfunction Left ventricular hypertrophy 30% of hypertensive patients by Echo Coronary artery disease Ischemic heart disease more than 50% myocardial infarction congestive heart failure(the most common cause is HTN) Chronic kidney disease hypertensive nephropathy (GFR < 60 ml/min/1.73 m2) albuminuria Peripheral artery disease intermittent claudication ankle brachial index < 0.9

19 Assessment of the Overall Cardiovascular Risk Over 90% of hypertensive have other cardiovascular risks Assess and manage hypertensive patients for dyslipidemia, dysglycemia (e.g. impaired fasting glucose, diabetes) abdominal obesity, unhealthy eating and physical inactivity

20 Routine Laboratory Tests Preliminary Investigations of patients with hypertension 1. Urinalysis 2. Blood chemistry (potassium, sodium and creatinine) 3. Fasting glucose and/or glycated hemoglobin (A1c) 4. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides 5. Standard 12-leads ECG Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes

21 Routine Laboratory Tests Follow-up investigations of patients with hypertension During the maintenance phase of hypertension management, tests (including electrolytes, creatinine, glucose, and fasting lipids) should be repeated with a frequency reflecting the clinical situation. Diabetes develops in 1-3%/year of those with drug treated hypertension. The risk is higher in those treated with a diuretic or beta blocker, in the obese, sedentary, with higher fasting glucose and who have unhealthy eating patterns. Assess for diabetes more frequently in these patients.

22 The Role of Echocardiography Echocardiography is useful for: Assessment of left ventricular dysfunction and the presence of left ventricular hypertrophy Echocardiography is not useful for routine evaluation of hypertensive patients

23 The Role of Echocardiography Echocardiography is useful for: Assessment of left ventricular dysfunction and the presence of left ventricular hypertrophy Echocardiography is not useful for routine evaluation of hypertensive patients

24 Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmhg (< 150 mmhg if age > 60 years) INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB

25 Add-on Therapy for Systolic/Diastolic Hypertension without Other Compelling Indications If partial response to monotherapy 1. Add-on Therapy 2. Triple or Quadruple Therapy IF BLOOD PRESSURE IS NOT CONTROLLED CONSIDER No adherence Secondary HTN Interfering drugs or lifestyle White coat effect If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers or centrally acting agents).

26 Drug Combinations When combining drugs, use first-line therapies. Two drug combinations of beta blockers, ACE inhibitors and angiotensin receptor blockers have not been proven to have additive hypotensive effects. Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication Combinations of an ACEI with an ARB do not reduce cardiovascular events more than the ACEI alone and have more adverse effects therefore are not generally recommended

27 Drug Combinations Caution should be exercised in combining a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block. Monitor serum creatinine and potassium when combining K sparing diuretics (such as aldosterone antagonists), ACE inhibitors and/or angiotensin receptor blockers. If a diuretic is not used as first or second line therapy, triple therapy should include a diuretic, when not contraindicated.

28 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 nicardipine labetolol.nitroproside Left Ventricular Hypertrophy Non Diabetic Chronic Kidney Disease Renovascular Disease Smoking Diabetes Mellitus With Nephropathy ARB but NO amlodipine Without Nephropathy Global Vascular Protection for Hypertensive Patients Statins if 3 or more additional cardiovascular risks Aspirin once blood pressure is controlled

29 Vascular Protection for Hypertensive Patients: Statins In addition to current recommendations on management of dyslipidemia, statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria: Male Age 55 or older Smoking Total-C/HDL-C ratio of 6 mmol/l or higher Family History of Premature CV disease LVH ECG abnormalities Microalbuminuria or Proteinuria

30 Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications TARGET <140 mmhg, < 150 mmhg for age > 60years Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect Dual therapy Triple therapy *If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

31 Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmhg Lifestyle modification Initial therapy 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 Thiazide diuretic ACEI ARB Long-acting CCB Betablocker* CONSIDER Nonadherence Secondary HTN Interfering drugs or lifestyle White coat effect Dual Combination Triple or Quadruple Therapy *Not indicated as first line therapy over 60 y

VA/DoD Clinical Practice Guideline for the Diagnosis and Management of Hypertension - Pocket Guide Update 2004 Revision July 2005

VA/DoD Clinical Practice Guideline for the Diagnosis and Management of Hypertension - Pocket Guide Update 2004 Revision July 2005 1 Any adult in the health care system 2 Obtain blood pressure (BP) (Reliable,