PRIMARY

HYPERTENSION
Akhmad Jalaludinsyah

Overview
Essential hypertension refers to high blood
pressure with no identifiable cause.

Blood Pressure
BP = CO x PVR
Peripheral Vascular Resistance

Inherent stiffness of arterial wall

Vasodilation

- Beta-2 adrenergic innervation

- Nitric oxide c-AMP
Vasoconstriction
- Alpha-1 adrenergic innervation
- Circulating catecholamines
- Angiotensin II

Aetiology of
Hypertension
Primary hypertension (90-95% of cases)
Secondary hypertension
* Renal
* Drugs
Hormonal / oral contraceptive
NSAIDs

* Endocrine

Phaeochromocytoma
Cusings syndrome
Conns syndrome
Acromegaly and hypothyroidism

* Coarctation of the aorta and aortitis

* Pregnancy-induced hypertension

Pathogenesis of Hypertension

Kaplan. Clinical Hypertension. 2006

Hypertension Pathophysiology
Three teories:
1. Inability of the kidneys to excrete sodium,
resulting in natriuretic factors such as
Atrial Natriuretic Factor being secreted to
promote salt excretion with the side-effect
of raising total peripheral resistance.
2. An overactive renin / angiotensin system
leads to vasoconstriction and retention of
sodium and water. The increase in blood
volume leads to hypertension.
3. An overactive
Sympathetic nervous system, leading to
increased stress responses.

2013 ESH/ESC Guidelines for the

management of arterial
hypertension
European Heart Journal
Advance Access published June 14,
2013

ESH ESC HT guidelines

Whats new for 2013

(1) Epidemiological data on hypertension
and BP control in Europe.
(2) Strengthening of the prognostic value
of home blood pressure monitoring
(HBPM) and of its role for diagnosis and
management of hypertension, next to
ambulatory blood pressure monitoring
(ABPM).
(3) Update of the prognostic significance of
night-time BP, white-coat hypertension
and masked hypertension.

(4) Re-emphasis on integration of BP,

cardiovascular (CV) risk factors,
asymptomatic organ damage (OD) and
clinical complications for total CV risk
assessment.
(5) Update of the prognostic significance of
asymptomatic OD, including heart, blood
vessels, kidney, eye and brain.
(6) Reconsideration of the risk of
overweight and target body mass index
(BMI) in hypertension.

(7) Hypertension in young people.

(8) Initiation of antihypertensive
treatment. More evidence-based
criteria and no drug treatment of
high normal BP.
(9) Target BP for treatment. More
evidence-based criteria and unified
target systolic blood pressure (SBP)
(<140 mmHg) in both higher and
lower CV risk patients.

(10) Liberal approach to initial

monotherapy, without any allranking purpose.
(11) Revised schema for priorital twodrug combinations.
(12) New therapeutic algorithms for
achieving target BP.
(13) Extended section on therapeutic
strategies in special conditions.

(14) Revised recommendations on

treatment of hypertension in the elderly.
(15) Drug treatment of octogenarians.
(16) Special attention to resistant
hypertension and new treatment
approaches.

(17) Increased attention to OD-guided

therapy.
(18) New approaches to chronic
management of hypertensive
disease.

New for
2013

Same with 2003, 2007

HT : BP 140/90

Office BP measurement
Sit 3-5 min before.
At least 2 times, 12 min apart.
Consider average BP if appropriate.
First visit: both arms use higher
value.
Elderly, DM: check orthostatic
hypotension.

White-coat HT

BP in
office
High

BP out-ofoffice
Normal

Normal

High

- Gr 1 HT in office
- Female, non-smoking
- No TOD, low CV risk
- Dx should be confirmed within
3-6 mo

Masked HT
- High normal office BP
- Male, smoking, alcohol, anxiety,
obesity, DM, CKD, FHx of HT
- Asymptomatic TOD, high CV
risk

Indications for out-of-office

BP
HBPM
or ABPM
Specific I/C for ABPM
Suspicious
of whitecoat or masked HT
Marked difference
BP vary in same /
between office BP and
different visits
home BP
Hypotension:
Suspicious nocturnal
autonomic, orthostatic,
HT
post-prandial, drug Assess BP variability
induced
Assess dipping* status
High BP in pregnant
women
*Dipping: BP normally decrease at
Resistant HT
night
No dipping ->inc. CV events: OSA,
DM, CKD

Search for asymptomatic organ

damage
EKG in all HT patients (I, B)
Stress EKG if chest pain (I, C)
Serum Cr & eGFR,
urine protein (dipstick),
microalbuminuria (spot) in all HT
patients (I,B)
Difficult-to-control HT: fundoscopy
(IIa, C)
ABI (IIa, C)

When to start Anti-HT Rx

BP 140/90 after lifestyle change (I,
B)
BP 160/100: start drug promptly (I,
A)
Elderly: SPB 160 mmHg (I,A)
Not recommend anti-HT drug for
High normal BP (130-139 / 85-89
2007
mmHg) (III, A)
Elderly: start drug if BP 140/90
ISH in
young
patient,
butifshould
DM,
CKD, CVD:
start drug
BP > 130close
/
85
F/U with lifestyle change
(III, A)

Risk Fx: Initiation

male, ofage
55
(M)and
antihypertensive
65 (F), smoking,
dyslipidemia,
lifestyle
changes
drug treatment.
IFG, abnormal OGTT, obesity, abdominal obesity, FHx
premature CVD < 55 yr (M), < 65 yr (F)

Unified target SBP < 140

mmHg
in both lower, higher CV
risk
DM: high to very high risk
Risk: Low Moderate High Very
high

BP target
SBP < 140 mmHg
DM (I,B) Low-moderate CV risk (I,A)
Previous stroke/TIA, CHD, CKD (IIa)

Elderly < 80 yr: SPB keep 140-150

mmHg (I, A)
Elderly > 80 yr: 140-150 mmHg if
good physical and mental condition
(I, B)
DBP < 90 mmHg for all
Except DM: DBP < 85 mmHg

Lifestyle change (I,A for all)

Salt restriction 5-6 gm/day
Moderate alcohol intake: not more
than 20-30 gm/d (M), 10-20 gm/d (F)
Increased fruits, vegetables
Reduce weight to BMI of 25 kg/m2,
waist circumference < 102 cm (M), <
88 cm (F)
Regular exercise 30 min/day, 5
days/wk
Stop smoking

1 drink

Moderate drinking: no more than two drinks a

day for men and no more than one drink a day
for women.
* One drink = 0.6 fluid oz. = 13.7 gm of
alcohol

New

Drug choice / treatment

strategy
Main benefit of drug: to reduce BP.
Most patients need 2 drugs to achieve
target BP.

Start / maintain, monotherapy /

combination Diuretics, BB, CCB, ACEI,
ARB all suitable & recommended (I, A).
Some drugs should be preferred in
specific conditions (IIa, C).
Markedly high baseline BP or high CV
risk: start two-drug combination may
be considered (IIb, C).

Monotherapy vs. drug combination strategies to achieve target BP. Moving from a less
intensive to a more intensive therapeutic strategy should be done whenever BP target is
not achieved.

 Combination of 2 antagonists of RAS:

not recommended and should be
discouraged (III, A).
Combinations of 2 drugs at fixed
doses in single tablet may be
recommended and favored (IIb, B).

Possible combinations of classes of antihypertensive drugs.

Thiazide + BB:
increased newonset DM

Only DHP-CCB should

normally be combined
with beta-blockers

Green continuous lines: preferred combinations;

Green dashed line: useful combination (with some limitations);
Black dashed lines: possible but less well-tested combinations;
Red continuous line: not recommended combination.

White-coat & masked HT

White-coat HT, no risk Fx:
lifestyle change & close F/U (IIa, C)

White-coat HT + high CV risk or TOD:

consider drug Rx (IIb, C)

Masked HT:
lifestyle change + drug Rx (IIa, C)

Elderly

All drugs are recommended and can be

used (I, A)
Diuretics & CCB: preferred in isolated
systolic HT (I, A).
Start drug when SBP 160 mmHg: -> aim
SBP 140-150 mmHg (I, A)

Age < 80 yr: may consider start drug when SBP

140 mmHg & target < 140 if tolerated (IIb, C)
Age > 80 yr: 140-150 mmHg if good physical and
mental condition (I, B).
When reach > 80 yr: consider to continue drug if
well-tolerated (IIa, C)
Frail elderly: depend on clinicians judgement (I, C)

Pregnant women
If BP > 160/110 mmHg, treatment is
recommended (I, C).
Consider drug Rx (IIb, C)
BP 150/95mmHg, or
BP 140/90 mmHg + TOD

Methyldopa, labetolol, nifedipine

preferred (IIa, B)
Pre-eclampsia: IV labetolol or
nitroprusside (IIa, B)

DM
Start drug Rx when SPB 140 mmHg
(I, A).
Target SBP < 140/85 mmHg (I, A).
All classes of drugs are
recommended and can be used (I, A).
RAS blockers preferred, especially if
having proteinuria / microalbuminuria
(I, A).

Metabolic syndrome
Start drug Rx if 140/90 mmHg (I, B).
Target BP < 140/90 mmHg (I, B).
Lifestyle changes, particularly weight
loss and exercise (I, B).
RAS blockers and CCB should be
preferred (IIa, C).
Newer
vasodilating
BB (carvedilol,
nebivolol):
affect
*BB*
and
thiazides:
only as
add-on
Rx
insulin sensitivity LESS than metoprolol.
(IIa, C).
Nebivolol
not worsen glucose tolerance when added to
HCTZ.

HT with nephropathy
Target SBP < 140 mmHg (IIa, B).
Overt proteinuria: target SBP < 130 mmHg may
be considered (IIb, B).
RAS blockers indicated for HT with over
proteinuria or microalbuminuria (I, A).
Recommend combining RAS blockers with other
anti-HT drugs to achieve target BP (I, A).
Combining two RAS blockers is not recommended
(III, A).
Aldosterone antagonists not recommened in CKD
(III, C).

Atherosclerosis, arteriosclerosis,
peripheral artery disease
Target BP < 140/90 mmHg.
Carotid atherosclerosis: CCB, ACEI
(IIa, B).
PAD: BB may be considered. Their
use does not appear to be associated
with worsening of PAD symptoms
(IIIb, A).

Resistant HT
MR antagonist, amiloride, doxazosin
should be considered.
If drugs are ineffective: renal
denervation and baroreceptor
stimulation may be considered (IIb,
C) (only by experienced operators at
restricted HT centers).

Summary: ESH ESC 2013

Diagnosis of HT

Office BP 140/90
ABPM (daytime) or HBPM 130/85

When to start Rx

BP 140/90 after lifestyle change

160/100 start promptly
Elderly SBP 160

Initial medication

ACEI, ARB, CCB, BB, Thiazides all

suitable and recommended

When to start 2 drug

combination

Marked BP elevation
High/very high CV risk

Target BP

SBP < 140 for all *

140-150 for elderly < 80 yr
< 130 for overt proteinuria **
DBP < 90 mmHg for all
< 85 mmHg for DM

SBP < 140 recommended in DM

should be considered in CHD, previous
stroke/TIA, CKD/DKD

Summary: ESH ESC 2013

Compelling indications

LVH: ACEI/ARB, CCB

Microalbuminuria: ACEI/ARB
DM: ACEI/ARB
MetS: ACEI/ARB, CCB
Prev stroke: any drug effectively
lower BP
Prev MI: BB, ACEI/ARB
ESRD/proteinuria: ACEI/ARB
PAD: ACEI, CCB
ISH (elderly): Diuretic, CCB

Preferred combination

Thiazide + ACEI or ARB or CCB

CCB + ACEI or ARB

Not recommended

ACEI + ARB combination