Management in HypertensionMunchukorn Leelatanon, MD

ContentsLifestyle interventionsCriteria for starting antihypertensive drug

treatmentBlood pressure targetsPatients education and adherence to drug

treatment

Reference

Lifestyle interventions Weight reduction Diet and exercise Relaxation Reduce alcohol

consumption and stop smoking

Discourage excessive consumption of caffeine

Low sodium diet

Weight reductionWeight circumference

Men < 90 cm Women < 80 cm

BMI 22.5 – 25 kg/m2

OrlistatBariatic surgery

Diet control Mediterranean dietDASH diet

Low salt diet< 2,300 mg/day

NaCl <6g/day

Moderate alcohol consumptionMen 2 drink (20-30g/day)Women 1 drink (10-20g/day)

Stop smokingNicotine replacement therapyBupropionVarenicline Motivational interview

ExercisePreventing cardiovascular

disease

50-70% max HR

70-85% max HR

Maximum HR = 220 - age

Effectiveness of lifestyle modification

Criteria for starting antihypertensive drug treatmentJNC 8

Age ≥ 60 years BP ≥ 150/90 mmHg

Age < 60 years BP ≥ 140/90 mmHg

Diabetes BP ≥ 140/90 mmHg

CKD BP ≥ 140/90 mmHg

SBP ≥ 160 mmHg or DBP ≥100 mmHg

Criteria for starting antihypertensive drug treatmentNICE guideline

Age < 80 years old with stage 1 HT with target organ damage established cardiovascular disease renal disease Diabetes 10-year cardiovascular risk equivalent to 20% or

greater. Any age with stage 2 HT

BP ≥ 140/90 at clinicOr

BP ≥ 135/85 at home

BP ≥ 160/100 at clinic

OrBP ≥ 150/95 at

home

Choosing antihypertensive drug treatmentOffer drugs taken only once a dayPrescribe non-proprietary drugs where these

are appropriate and minimise cost.Do not combine ACEI and ARB

Treatment steps for hypertension

1

SBP >160 mmHg and/orDBP >100 mmHg

2

3

4

Treatment steps for hypertension

Beta-blockers may be considered in younger people :

•intolerance or contraindication to ACEI and ARB or

•women of child-bearing potential or

•increased sympathetic drive

If a CCB is not suitable•Edema •intolerance•evidence of heart failure•high risk of heart failure

offer a thiazide-like diuretic. (Chlortalidone or indapamide)

If a CCB is not suitable•offer a thiazide-like diuretic. (Chlortalidone or indapamide)

For black people of African or Caribbean family origin, •ARB in preference to an ACE inhibitor in combination with CCB

If initiated with a beta-blocker and a second drug is required•CCB is better than a thiazide-like diuretic to reduce risk of developing diabetes

If clinic BP > 140/90 mmHg after optimal or best tolerated doses of an •ACE inhibitor or an ARB plus a •CCB plus a •diuretic

Resistant HT •consider adding a fourth antihypertensive drug and/or seeking expert advice.

If serum K ≤ 4.5 mmol/l •low-dose spironolactone (25 mg once daily)

If serum K > 4.5 mmol/l •higher-dose thiazide-like diuretic

If further diuretic therapy is not tolerated, or is contraindicated or ineffective, •consider an alpha- or beta-blocker.

Monitor •serum Na •Serum K •renal function within 1 month & repeat as required thereafter.

Blood pressure targets< 80 years

Clinic BP < 140/90 mmHg Home BP < 135/85 mmHg

≥ 80 years Clinic BP < 150/90 mmHg Home BP < 145/85 mmHg

JNC 8 (2014)< 60 years

BP < 140/90 mmHg ≥ 60 years

BP < 150/90 mmHg

Antihypertensive drugs Beta-blockers Diuretics Calcium antagonists Angiotensin-converting enzyme inhibitors Angiotensin receptor blockers Renin inhibitors Alpha blockers Vasodilators

RE Jackson, MC Bellamy, antihypertensive drugs, BJA education, 14 January 2015 http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku061

Calcium channel blocker

Renin inhibitors

ACE inhibitors

ARB

Aldosterone

antagonists

SE: hyperkalemia, hypotension

http://my-lifespan.com/coverex.html

Renin inhibitors

Aliskiren Great use if combine with

HCTZ or ARB

Cough, Angioedema

Diuretics

FurosemideBumetanid

e

Thiazide-- HCTZThiazide like -- Indapamide-- Chlortalidone

Epithelial sodium channel blockers-- Amiloride-- Triamterene

Aldosterone antagonist-- Spinorolactone-- Eplerenone

Thiazide VS thiazide like diuretics

Rik H.G. Olde E, Wijnanda JF, Bas VB, Lizzy MB, Liffert V, Bert-JH. Effects of Thiazide-Type and Thiazide-Like Diuretics on Cardiovascular Events and Mortality, American Heart Association,2015.

TL diuretics resulted in a 12% additional risk reduction for cardiovascular events (P=0.049) and a 21% additional risk reduction for heart failure (P=0.023) when compared with TT diuretics.

Beta-blockers

Alpha blockers Doxazosin Prazosin Terazosin

Vasodilators

Hydralazine Minoxidil

Sodium nitroprusside

Contraindications

White coat hypertensionWithout additional risk factors

Lifestyle changes only + close F/U

With a higher CV risk because of metabolic derangements or asymptomatic OD drug treatment + addition to lifestyle changes

Masked hypertensionLifestyle modification + antihypertensive drug

treatment

Isolated systolic hypertensionStart with diuretics or DHP or CCB

ElderlyPatients with SBP ≥160 mmHg

Reduce SBP to 140 – 150 mmHg In fit elderly patients <80 years old

Start drug at SBP values ≥140 mmHg Target SBP <140 mmHg if treatment is well tolerated.

All hypertensive agents are recommended and can be used in the elderly,

Diuretics and CCB may be preferred in isolated systolic hypertension.

DiabetesStart drug treatment when SBP is ≥140 mmHg. SBP goal <140 mmHgDBP goal <85 mmHg. All classes of antihypertensive agents are

recommended RAS blockers may be preferred, especially in

the presence of proteinuria or microalbuminuria.

CKDLowering SBP to <140 mmHg If overt proteinuria is present, SBP values <130

mmHg RAS blockers are more effective in reducing

albuminuria than other antihypertensive agentsCombination of two RAS blockers is not

recommendedAldosterone antagonists is not recommended

Stroke or TIADon’t start drug in first week after acute stroke

Clinical judgement should be used in very high SBP

Start drug treatment even SBP is in the 140–159 mmHg

SBP goal of <140 mmHg ]Drug of choice : ACE inhibitors, diuretics

Coronary heart diseaseSBP goal <140 mmHg Recent myocardial infarction beta-blockers

are recommendedDiuretics, beta-blockers, ACE inhibitors,

angiotensin receptor blockers, and/or mineralocorticoid receptor antagonists are recommended in patients with heart failure or severe LV dysfunction to reduce mortality and hospitalization.

Resistant hypertension Resistance to treatment when lifestyle modification + 3

antihypertensive drugs (include diuretics) fail to reach goal of SBP < 140 mmHg, DBP < 90 mmHg

Consider stopping all current drugs and restart with a simpler treatment regimen under close medical supervision

Mineralocorticoid receptor antagonists (amiloride) and alpha-1-blocker (doxazosin) should be considered

Invasive procedures renal denervation and baroreceptor stimulation

Renovascular hypertension RAS blockers cannot be used in bilateral

renal artery stenosis or in unilateral artery stenosis with evidence of functional importance by ultrasound examinations or scintigraphy.

Primary aldosteronism the treatment of choice is unilateral

laparoscopic adrenalectomy mineralocorticoid receptor antagonists is

indicated in patients with bilateral adrenal disease (idiopathic adrenal hyperplasia and bilateral adenoma

Pregnancy Start when BP ≥140/90 mmHg with

Gestational hypertension (with or without proteinuria) Pre-existing hypertension with the superimposition of

gestational hypertension Hypertension with asymptomatic OD or symptoms at any

time during pregnancy

Methyldopa, labetalol and nifedipine Beta-blockers and diuretics should be used with caution ACE inhibitors, ARBs, renin inhibitors are contraindated

JNC8

NICE

ESC