Hypertension

Syakib Bakri

The classification of blood pressure and hypertension

Shin et al. Clinical Hypertension (2015)

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
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
31.0

25.8

34.7

25.3

24.6

38.1

25.2

24.9

23.8
16.9

20.6

10.3

100+

90-99

13.9
11.8

80-89

12.6

12.8
8.8

75-79

8.5

70-74

11.8
9.2

<70

160+
140-159
120-139
Systolic BP
<120
(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%
Lancet 1990;335:827-38
Arch Fam Med 1995;4:943-50

Benefits of Treating Hypertension

Older than 60 with isolated systolic hypertension (SBP
160 mm Hg and DBP <90 mm Hg)
42% reduction in the risk of stroke
26% reduction in the risk of coronary events

Lancet 1997;350:757-64

Blood pressure measurement using auscultation method

(1)
After resting for 5 or more minutes in a quiet, appropriate
environment
Avoiding smoking, alcohol, or caffeine before
measurement
Measuring 2 or more times at 1- to 2-min intervals in one
visit
A cuff with a bladder at least 40% of arm circumference
wide; 80% to 10% of arm circumference long (a standard
bladder for adults: 13 cm wide; 22 to 24 cm long)

Blood pressure measurement using auscultation method

(2)
Maintaining the upper arm cuff at the heart level
Inflating the cuff rapidly and deflating slowly at a speed
of 2 mm Hg per heart beat
Identifying the blood pressure as the systolic blood
pressure at the first Korotkoff sound; the blood pressure
as the diastolic blood pressure at the fifth Korotkoff
sound
Regarding the blood pressure as the diastolic blood
pressure at the fourth Korotkoff sound in pregnancy,
arteriovenous shunt, and chronic aortic insufficiency

Blood pressure measurement using auscultation method

(3)
Taking blood pressure in both arms on the initial visit;
subsequently using the arm of higher pressure for
measuring blood pressure
Taking blood pressure in legs to exclude peripheral
arterial disease, when pulses in the lower extremities are
weak
Repeating the measurement three or more times to
estimate the average systolic and diastolic pressure in
case of arrhythmia
Measuring BP after 1- and 3-min standing in elderly
persons and persons with diabetes and suspected
orthostatic hypotension

Blood Pressure Assessment:

Patient position

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

Criteria for Diagnosis

First Visit
SBP 140 and/or DBP 90 mmHg (at least two more
readings, the first reading should be discarded and
the latter two averaged).
SBP 180 and/or DBP 110 mmHg should be
diagnosed as hypertensive
require immediate management.
SBP 160179 and/or DBP 100109 mmHg second
visit within one week for confirmation of HTN.
If average BP levels is within stage 1 range second
visit within 2 weeks for the assessment of HTN.

Criteria for Diagnosis

Second Visit
Patients with macrovascular (CAD, stroke, or PAD),
TOD, DM, or CKD : diagnosed as hypertensive if
SBP 140 and/or DBP 90 mmHg
Patients without macrovascular TOD, DM, or CKD
can be diagnosed as hypertensive if SBP 160 and/or
the DBP 100 mmHg
Patients without macrovascular TOD, DM, or CKD but
with ower BP levels further follow-up. Patient can
be diagnosed as hypertensive if SBP 140 or the DBP
90 mmHg in the first 5 visits.

Out-of-office BP monitoring
ABPM = Ambulatory BP Monitoring ; HBPM = Home BP
Monitoring
ABPM : Holter BP
HBPM : Self measurement BP
Which patients?

For the diagnosis of hypertension

Suspected non adherence
White coat hypertension or effect
Masked hypertension
Average BP equal to or over 135/85 mmHg should be
considered elevated

Criteria for Diagnosis of Hypertension

Out-of-Office BP Measurement
important adjunct to conventional office BP
measurement (the gold standard for screening,
diagnosis and management of HTN).
differences between Ambulatory BP Monitoring
(ABPM) and Home BP Monitoring (HBPM),
the choice depend on indication, availability,
ease, cost of use and, if appropriate, patient
preference.
For initial assessment
HBPM in primary care
ABPM in specialist care.

Benefits of Out-of-office Blood Pressure Monitoring

Rapid confirmation of the diagnosis of hypertension

Better prediction of cardiovascular prognosis
Diagnosis of white coat and masked hypertension
Reduced medication use in white coat effect
Improved adherence to drug therapy
Better blood pressure control

Not all patients are suited to home measurement

Undue anxiety in response to high blood pressure
readings
Physical or mental disability prevents accurate
technique or recording
Arm not suited to blood pressure cuff (e.g. conical
shaped arm)
Irregular pulse or arrhythmias prevent accurate
readings
Lack of interest
The vast majority of patients can be trained to measure
blood pressure

Initial Evaluation
Objectives of Initial Evaluation
History
Clinical History

Initial Evaluation
Objectives of Initial Evaluation
Establish the diagnosis and stage of HTN (including
office and non-office BP readings)
The likelihood of secondary HTN
The presence of TOD
The level of global CVD risk

Initial Evaluation
History
A comprehensive family history should be obtained
with particular attention to HTN, DM, dyslipidemia,
premature CAD, stroke, PAD or renal disease.

Initial Evaluation (Clinical History)

Duration and previous levels of high BP

General symptomatology (usualy asymptomatic)
Symptoms and indicators of organ damage
Symptoms suggestive of secondary causes
Intake of drugs or substances that can raise BP
Lifestyle factors dietary intake of fat, salt and alcohol, smoking
and physical activity, weight gain since early adult life
Sleep history Sleep apnea
Past history or current symptoms of coronary artey 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
Previous antihypertensive therapy

Physical Examination

weight
height
body mass index.
waist circumference:
metabolic syndrome
risk for type 2 diabetes. High risk >102 cm in men
or >88 cm in women.

Physical Examination (Cardiac)

Heart rate rhythm
Ectopic beats
atrial fibrillation
Signs of cardiomegaly
forceful, laterally displaced apical impulse LVH.
An accentuated aortic second sound
especially with DBP values >100 mm Hg.
A fourth heart sound
atrial enlargement
increased ventricular stiffness
a third heart sound
dilated cardiomyopathy
reduced LV function.

Physical Examination (Abdomen)

Periumbilical or flank bruits
renal artery stenosis, especially if there is a diastolic
component.
Active, forceful pulsations along the aorta
normal finding in young,
abdominal aortic aneurysm in older.
Palpation of the abdomen (laterally)
trigger a BP surge in individuals with
pheochromocytomas
Polycystic kidneys palpable in the flanks
related renal insufficiency
may be the etiology of the patients hypertension.

Physical Examination (Neurologic)

examination for
motor nerve function
cranial nerve function,
gait,
stance,
coordination
important to establish a baseline for therapeutic followup.

Physical Examination (Peripheral Pulses)

The carotid arteries presence of bruits.
Peripheral arteries:
absence,
reduction,
asymmetry of pulses,
cold extremities,
ischemic skin lesions

Cardiovascular Risk Factors and Subclinical Organ Damages

Shin et al. Clinical Hypertension

Cardiovascular Risk Factors and Subclinical Organ Damages

Shin et al. Clinical Hypertension

Laboratory Examinations

Shin et al. Clinical Hypertension

Laboratory Examinations

Shin et al. Clinical Hypertension

Laboratory Examinations

Shin et al. Clinical Hypertension

Secondary HTN
General Clinical Clues

Severe or resistant HTN.

An acute rise in BP over a previously stable value.
Proven age of onset before puberty.
Age less than 30 years with no family history of HTN
and no obesity.

Secondary HTN

Drugs and substances that can induce/aggravate HTN

a) Cough and cold medicines, eye and nasal preparations (most of
them are over-the-counter) may contain sympathomimetic
agents (decongestants) that can induce or aggravate HTN such
as
Phenylephrine hydrochloride, dipivalyl adrenaline hydrochloride,
tetrahydrozoline hydrochloride, naphazoline hydrochloride.
Ephedrine, pseudoephedrine hydrochloride.
b) Corticosteroids and Anabolic Steroids
c) NSAIDs, including coxibs
d) Sex Hormones : Estrogen ? progesterone (Contraception,
replacement therapy), androgens, danazol (semisynthetic
androgen)
e) Antidepressive Agents: Tricyclic antidepressants, buspirone,
fluoxetine, thioridazine hydrochloride
f) Immunosuppressants: cyclosporine, tacrolimus, rapamycin,
paclitaxel
g) Dietary Supplements: ginseng, natural licorice, yohimbine
h) Herbal Products: mainly relate to dietary supplements that

Paradigm Shift in HT Therapy

It is not just B.P
TODAY
.
we must
striverisk
to factors
1. Alter the modifiable
2. Keep the SBP < 140 and DBP < 90
3. Prevent or halt or reduce TOD
LVH, CHD, CHF, CVA, CRF, PVD &
Retino.
4. Prevent or control DM (as HT + DM is
hazardous)
5. Prevent or control Dyslipidemia
6. Prevent or control Endothelial
Dysf.unction
7. Reduce morbidity and mortality
38

8. Improve QUALY Quality Adjusted Life

Treatment Approaches:
Lifestyle
Pharmacological

Lifestyle management

LIFESTYLE MODIFICATION IN HYPERTENSION

Lifestyle measures 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

Objective of lifestyle changes in

hypertension
Lower blood pressure
Minimize drug use
Reduce overall cardiovascular risk
Improve outcome
Maintain or improve quality of life

Life style modification for managing hypertension

Chiang et al. Journal of the Chinese Medical Association 78 (2015)

1e47

Potential Benefits of a Wide Spread Reduction in

Dietary Sodium
Reduction in average dietary sodium from about
3500 mg to 1700 mg1,2

1 million fewer hypertensives

5 million fewer physicians visits a year for hypertension

Health care cost savings of $430 to 540 million per year related
to fewer office visits, drugs and laboratory costs for
hypertension

Improvement of the hypertension treatment and control rate

13% reduction in CVD

Total health care cost savings of over $1.3 billion/year

1. Penz ED. Cdn J Cardiol 2008
2. Joffres MR. Cdn J Cardiol 2007:23(6)

Recommendations for adequate daily sodium intake

Age

Adequate
Intake
(mg)

Upper
Limit
(mg)

19-50

1500

2300

51-70

1300

2300

71 and
over

1200

2300

2,300 mg sodium (Na)

= 100 mmol sodium (Na)
= 5.8 g of salt (NaCl)
= 1 level teaspoon of
table salt

80% of average sodium intake is in processed foods

Only 10% is added at the table or in cooking
Institute of Medicine, 2003

Sodium: Meta-analyses
Average Reduction of sodium
in mg/day
1800 mg/day
2300 mg/day

Hypertensives
Reduction of BP
5.1 / 2.7 mmHg
7.2/3.8 mmHg

Average Reduction of sodium

in mg/day
1700 mg/day
2300 mg/day

Normotensives
Reduction of BP
2.0 / 1.0 mmHg
3.6/1.7 mmHg

The Cochrane Library 2006;3:1-41

Salt mechanisms leading to hypertension:

By expanding the extracellular volume
High salt intake increases the action of aldosterone
High salt intake is a permissive factor for the hypertensinogenic
effect of aldosterone
Increase in the sodium concentration progressively increases
endothelial cell stiffness, causes inhibition of endothelial NO
synthase and decreases release of nitric oxide
Changes in plasma sodium concentration are transmitted into the
cerebrospinal fluid triggering the release of cardiotonic steroids,
namely, analogues of digitalis such as ouabain and
marinobufagenin which cause vasoconstriction

NON-BLOOD PRESSURE-RELATED EFFECTS OF DIETARY SALT

Atherosclerosis
Stroke
Left ventricle hypertrophy
Proteinuric kidney disease
Heart failure

Putative mechanisms of the deleterious cardiovascular

effects of excessive dietary sodium through blood pressure
increase independent of blood pressure

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:

Dietary
Dietary Sodium

High in:
Fresh fruits
Fresh vegetables
Low fat dairy products
Dietary and soluble fibre
Plant protein

Low in:
Saturated fat and cholesterol
Sodium

Less than 2300mg / day

(Most of the salt in food is hidden and comes
from processed food)

Dietary Potassium
Daily dietary intake >80 mmol

Calcium supplementation
No conclusive studies for hypertension

Magnesium supplementation
No conclusive studies for hypertension
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php.

Lifestyle Recommendations for Hypertension:

Physical Activity
Should be prescribed to reduce blood pressure

Frequency

Intensity

Time

Type

- Four to seven days per week

- Moderate
- 30-60 minutes

Cardiorespiratory Activity
- 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

Weight Reduction

Recommendation

Expected systolic blood

Pressure reduction (range)

Maintain ideal body mass index

(20-23 kg/m2)

DASH eating plan Consume diet rich in fruit, vegetables, lowfat dairy products with reduced content of
saturated and total fat

5-10 mmHg per 10 kg

weight loss
8-14 mmHg

All put together reduce SBP by

Dietary sodium
restriction

Physical Activity

Alcohol
moderation

Reduce dietary sodium intake to <100

mmol/day (<2.4 g sodium or <6 g
sodium chloride)

20 to 55 mmHg

2-8 mmHg

Engage in regular aerobic physical

activity, for example, brisk walking
for at least 30 min most days

4-9 mmHg

Men < 21 units per week

Women < 14 units per week

2-4 mmHg

Treatment for hypertension according to the risk

Shin et al. Clinical Hypertension (2015)

21:2

Treatment algorithm

Chiang et al. J Chinese Med Ass 78 (2015) 1-47

Treatment of Adults with Systolic/Diastolic

Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy

Thiazide

ACEI

ARB

Long-acting
CCB

Betablocker*

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

Considerations Regarding the Choice of

First-Line Therapy

Use caution in initiating therapy with 2 drugs in whom adverse events

are more likely (e.g. frail elderly, those with postural hypotension or
who are dehydrated).
ACE inhibitors, renin inhibitors and ARBs are contraindicated in
pregnancy and caution is required in prescribing to women of child
bearing potential.
Beta blockers are not recommended as first line therapy for patients
age 60 and over without another compelling indication.
Diuretic-induced hypokalemia should be avoided through the use of
potassium sparing agents if required.
The use of dual therapy with an ACE inhibitor and an ARB should only
be considered in selected and closely monitored people with
advanced heart failure or proteinuric nephropathy.
ACE-inhibitors/ARBs/Renin inhibitors are not recommended (as
monotherapy) for black patients without another compelling indication.

BP lowering effects from antihypertensive drugs

Dose response curves for efficacy are relatively flat
80% of the BP lowering efficacy is achieved at halfstandard dose
Combinations of standard doses have additive blood
pressure lowering effects

Law. BMJ 2003

Treatment of Systolic-Diastolic Hypertension

without Other Compelling Indications
TARGET <140/90 mmHg
Lifestyle modification

Initial therapy

Thiazide
diuretic

CONSIDER
Nonadherence
Secondary HTN
Interfering drugs or
lifestyle
White coat effect

ACEI

ARB

Long-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

Betablocker*

Dual Combination

Triple or Quadruple
Therapy

*Not indicated as first

line therapy over 60 y

Incremenal SBP reduction ratio

Observed/Expected (additive)

Ratio of Incremental SBP lowering effect at

standard dose Combine or Double?

Wald et al. Combination Versus Monotherapy for Blood Pressure Reduction,

The American Journal of Medicine, Vol 122, No 3, March 2009

Drug Combinations contd

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.

Drug combination in hypertension :

Preferred
ACE inhibitor/diuretic
ARB/diuretic
ACE inhibitor/CCB
ARB/CCB

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Acceptable
-blocker/diuretic
CCB (dihydropyridine)/-blocker
CCB/diuretic
Renin inhibitor/diuretic
Renin inhibitor / ARB
Thiazide diuretics/K+-sparing
diuretics

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Drug combination in hypertension :

Less effective
ACE inhibitor/ARB
ACE inhibitor/-blocker
ARB/-blocker
CCB (nondihydropyridine)/blocker
Centrally acting agent/blocker

Hopkins KA & Bakris GL. Curr Opin Nephrol Hypertens.2010;19:450-455

Treatment of Isolated Systolic Hypertension

without Other Compelling Indications
TARGET <140 mmHg, < 150 mmHg for age > 80 years
Lifestyle modification
therapy

Thiazide
diuretic

CONSIDER
Nonadherence
Secondary HTN
Interfering drugs or
lifestyle
White coat effect

ARB

Dual therapy

Triple therapy

Long-acting
DHP CCB

*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).

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

Indications and contraindications of antihypertensive drugs

Shin et al. Clinical Hypertension (2015)

Choice of single drug or combination drugs according to the level of blood

pressure and the global cardiovascular risk

Shin et al. Clinical Hypertension (2015)

Vascular Protection for Hypertensive

Patients: Statins
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

ASCOT-LLA Lancet 2003;361:1149-58

Vascular Protection for Hypertensive

Patients: ASA

Consider low dose ASA

Caution should be exercised if BP is not controlled.

Monitoring and Adverse Effects with

Antihypertensive Drug Therapy

Adherence to anti-hypertensive management can

be improved by a multi-pronged approach
Assess adherence to pharmacological and nonpharmacological 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 oncedaily 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
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

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)

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
on 3 or more antihypertensives
Consider ambulatory blood
pressure monitoring if
available to rule out whitecoat phenomenon

Thiazide-type
diuretic present?

NO

Correct identifiable causes if

present; consider work-up of
secondary conditions
Add low-dose diuretic
(chlorthalidone 12.5 mg
preferred; titrate to 25mg/d)

YES
* if not already part of
regimen, consider B for
addition if pulse >84
A= ACEI or ARB
B = Beta Blocker
C= CCB (long-acting)
D= Diuretic

Optimize combination as follows:

A or B* + C + D
If blood pressure
remains uncontrolled

Re-evaluate
If blood pressure
remains uncontrolled

+ 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
+ ARB

or

2 CCBs
(different types)

or

alpha-blocker or
combined
alpha/beta blocker

or

Centrally-acting
(e.g. Clonidine)

+ vasodilator (e.g.
hydralazine)

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

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.

Whats still important?

Out-of-office blood pressure measurements are
important in both the diagnosis and management of
hypertension
The management of hypertension is all about global
cardiovascular risk management and vascular
protection
Single pill combinations help achieve blood pressure
control
The most important step in prescription of
antihypertensive therapy is achieving patient buy-in

THANK
YOU ALL
For Your Kind Attention

Assessment for Renovascular Hypertension

Patients presenting with two or more of the following clinical clues
listed below suggesting renovascular hypertension should be
investigated.
I.
II.
III.
IV.

Sudden onset or worsening of hypertension and age >55 or <30 years

The presence of an abdominal bruit
Hypertension resistant to 3 or more drugs
A rise in creatinine of 30% or more associated with use of an
angiotensin converting enzyme inhibitor or angiotensin II receptor
blocker
V. Other atherosclerotic vascular disease, particularly in patients who
smoke or have dyslipidemia
VI. Recurrent pulmonary edema associated with hypertensive surges

Assessment for Renovascular Hypertension

The following tests are recommended, when available, to
screen for renal vascular disease:
captopril-enhanced radioisotope renal scan*
doppler sonography
magnetic resonance angiography
CT-angiography (for those with normal renal function)
* captopril-enhanced radioisotope renal scan is not recommended for
those with glomerular filtration rates <60 mL/min)

Screening for Hyperaldosteronism

Should be considered for patients with the following
characteristics:

Spontaneous hypokalemia (<3.5 mmol/L).

Profound diuretic-induced hypokalemia (<3.0 mmol/L).
Hypertension refractory to treatment with 3 or more drugs.
Incidental adrenal adenomas.

Screening for Hyperaldosteronism

Screening for hyperaldosteronism should include
plasma aldosterone and renin activity (or renin
concentration)
measured in morning samples.
taken from patients in a sitting position after resting at least 15
minutes.

Aldosterone antagonists, ARBs, beta-blockers and

clonidine should be discontinued prior to testing.
A positive screening test should lead to referral or
further testing.

Screening for Pheochromocytoma

Should be considered for patients with the following
characteristics:
Paroxysmal and/or severe sustained hypertension refractory to
usual antihypertensive therapy;
Hypertension and symptoms suggestive of catecholamine
excess (two or more of headaches, palpitations, sweating, etc);
Hypertension triggered by beta-blockers, monoamine oxidase
inhibitors, micturition, or changes in abdominal pressure;
Incidentally discovered adrenal mass;
Multiple endocrine neoplasia (MEN) 2A or 2B; von
Recklinghausens neurofibromatosis, or von Hippel-Lindau
disease.

Screening for Pheochromocytoma

Screening for pheochromocytoma should include a 24
hour urine for metanephrines and creatinine.
Assessment of urinary VMA is inadequate.
A normal plasma metanephrine level can be used to
exclude pheochromocytoma in low risk patients but the
test is performed by few laboratories.

Laboratory Tests
Preliminary Investigations of patients with hypertension
1.
2.
3.
4.

Urinalysis
Blood chemistry (potassium, sodium and creatinine)
Fasting glucose
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

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.

Optional Laboratory Tests

Investigation in specific patient subgroups
For those with diabetes or chronic kidney disease:
assess urinary albumin excretion, since therapeutic
recommendations differ if proteinuria is present.
For those suspected of having an endocrine cause for
the high blood pressure, or renovascular hypertension,
see following slides.
Other secondary forms of hypertension require specific
testing.

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

JNC-7 (American) Classification

of Blood Pressure
Category

Systolic

Diastolic

Optimal

<120

and / or

<80

Normal (PreHT stage 1)

<130

and / or

<85

High-Normal (PreHT stage 2)

130-139

and / or

85-89

Stage 1 (mild hypertension )

140-159

and / or

90-99

Stage 2 (moderate to severe

hypertension)

160

and / or

100-109

Isolated Systolic Hypertension

(ISH)

140

and

<90

The category pertains to the highest risk blood pressure

*ISH=Isolated Systolic Hypertension.

JAMA 2003;289:2560-72

Assessment of the overall cardiovascular risk

Over 90% of hypertensive patients 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

Assessment of the overall cardiovascular risk

Cardiovascular Risk Factors
Presence of Risk Factors

Presence of Target Organ Damage

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)
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 TIAo

Coronary Heart Disease
Peripheral arterial disease

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

Blood Pressure Assessment:

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

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.

Difficult-to-Control
Hypertension

Inadequately treated hypertension

(pseudo-resistance)
Under treatment
Treatment with inappropriate agents
Incorrect blood pressure measurement
White coat effects
Medications nonadherence
Pseudo-hypertension

Under Treatment (Suboptimal Medical

Treatment)
Clinical inertia : the providers failure
to increse therapy when the treatment
goal is not reached.
Lack of knowledge of treatment
guidelines
Underestimation of cardiovascular risk
The use of spurious reason to avoid
intensification of therapy.

Medication Poor Adherence

High cost of treatment

Complex medical regimen
Adverse effect of medical therapy
Poor relation between doctors
and patients

Clinical clues suggestive of

pseudohypertension

Marked hypertension in the absence of

target organ damage
Antihypertensive therapy produces
symptoms consistent with hypotension in
the absence of successful reduction of BP
Radiological evidence of pipe stem
calcification in the brachial arteries
Brachial artery pressure higher than lower
extremity pressure
Severe and isolated systolic hypertension

Clinical clues suggestive of white

coat effects

Clinic blood pressure measurements are

consistently higher than out-of-office
measurements.
Patients show signs of overtreatment,
particularly orthostatic symptoms.
Patients with chronically high office blood
pressures values but an absence of target
organ damage.

Difficult-to-Control
Hypertension

Inadequately treated hypertension (pseudo-resistance)

True resistant hypertension

Associated
Identifiable causes
factors:

(NSAID, oral contraceptive,

Medications
Primary aldosteronism
sympathomimetic, corticosteroid, erythropoetin,
Renovascular disease
cyclophospamid.

Pheocromocytoma
Excessive alcohol consumption
Chronic
kidney
disease
Coarctation
of the
aorta

Obesity
Intracranial tumor
Obstructive sleep apnea

Treatment of Hypertension in Patients with

Ischemic Heart Disease
Stable angina

1. Beta-blocker
2. Long-acting CCB

ACEI are recommended for most

patients with established CAD*
ARBs are not inferior to ACEI in IHD
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)
Dual therapy with an ACEI and an ARB are not recommended in the absence of
refractory heart failure
The combination of an ACEi and CCB is preferred
*Those at low risk with well controlled risk factors may not benefit from ACEI therapy

Short-acting
nifedipine

Treatment of Hypertension in Patients with Recent ST Segment

Elevation-MI or non-ST Segment Elevation-MI
Recent
myocardial
infarction

Beta-blocker
and ACEI or
ARB

If beta-blocker
contraindicated
or not effective

Heart
Failure
?

NO
Long-acting CCB

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

YES

Long-acting
Dihydropyridine
CCB*

Treatment of Hypertension with Left Ventricular

Systolic Dysfunction
Systolic
cardiac
dysfunction

ACEI and Beta blocker

if ACEI intolerant: ARB
Titrate doses of ACEI or ARB to those used in clinical trials

If additional therapy is needed:

Diuretic (Thiazide for hypertension; Loop for volume control)
for CHF class II-IV or post MI and selected patients with LV dysfunction (see notes): Aldosterone
Antagonist

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide

dinitrate in combination

Non
dihydropyridine
CCB

If additional antihypertensive therapy is needed:

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

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

Treatment of Hypertension in Association With Stroke

Acute Stroke: Onset to 72 Hours

Acute
ischemic
Stroke

Treat extreme BP elevation (systolic

> 220 mmHg, diastolic > 120 mmHg)
by 15-25% over the first 24 hour
with gradual reduction after.
If eligible for thrombolytic therapy
treat very high BP (>185/110 mmHg)

Avoid excessive lowering of BP which can exacerbate ischemia

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

Left ventricular
hypertrophy

- ACEI
- ARB,
- CCB
- Thiazide Diuretic
- BB (if age below 60)

Vasodilators:
Hydralazine, Minoxidil can increase LVH

Treatment of Hypertension in Patients with Non

Diabetic Chronic Kidney Disease
Target BP: < 140/90 mmHg
Chronic kidney disease
and proteinuria *

ACEI or ARB (if ACEI intolerant)

Additive therapy: Thiazide diuretic.
Alternate: If volume overload: loop diuretic
Combination with other agents

* albumin:creatinine ratio [ACR] > 30 mg/mmol

or urinary protein > 500 mg/24hr

ACEI/ARB:
Bilateral renal
artery stenosis

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

Treatment of Hypertension in Patients with

Renovascular Disease

Renovascular
disease

Does not imply specific

treatment choice

Caution in the use of ACEI or ARB in

bilateral renal artery stenosis or
unilateral disease with solitary kidney

Close follow-up and intervention (angioplasty and stenting or surgery) should

be considered for patients with: uncontrolled hypertension despite therapy
with three or more drugs, or deteriorating renal function, or bilateral
atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a
single kidney), or recurrent episodes of flash pulmonary edema.

Treatment of Hypertension in association with

Diabetes Mellitus
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
with
Nephropathy*

*Urinary albumin to creatinine

ratio > 2.0 mg/mmol in men or
> 2.8mg/mmol in women*

Diabetes

without
Nephropathy**
Systolicdiastolic
Hypertension
Isolated
Systolic
Hypertension
* based on at least 2 of 3 measurements

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

Combinations of an ACEI with an ARB are specifically

not recommended in the absence of proteinuria

Treatment of Hypertension in association with

Diabetes Mellitus
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
ACE Inhibitor
or ARB
Diabetes
without
Nephropathy

1. ACE
Inhibitor or
ARB
or
2. DHP-CCB or
Thiazide
diuretic

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. Combining an ACEi and a
DHP-CCB is recommended.

> 2-drug
combinations

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria
More than 3 drugs may be needed to reach target values for diabetic patients
If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a
thiazide diuretic if control of volume is desired