Post on 17-Jan-2016
PHARMACOTHERAPY OF HYPERTENSION
Based on New Guidelines
Fariborz Nikaeen; MDInterventional cardiologist
2 november 2015
Prevalence of HypertensionAdults have elevated Blood Pressure
Patients with HTN
Diagnosed HTN 78%
Treated HTN 68%
Uncontrolled HTN 38%
Resistant HTN 9%
Patients with HTN
Diagnosed HTN
Treated HTN
Uncontrolled HTN
HTN=Hypertension
Only relying on manual office pressures misses out on white coat and masked hypertension
Manual Office BP mmHg
Am
bula
tory
BP m
mH
g
Hypertension
NormotensionWhite Coat Hypertension
Masked Hypertension
200
180
160
140
120
100100 120 140 160 180 200
135
2014
The prognosis of masked hypertension
Prevalence is approximately 10% in hypertensive patients.
0
5
10
15
20
25
30
35
Normal23/685
White coat24/656
Uncontrolled41/462
Masked236/3125
CV
eve
nts
per
100
0 p
atie
nt-y
ear
CV Events
Okhubo et al. J. Am. Coll. Cardiol. 2012;46;508-515
2014
What’s The Worst That Could Happen?
Importance OF HTN
• HTN is the most important modifiable CV risk factor
• HTN is the commonest cause of premature death
• HTN is the commonest cause of CKD & commonest cause of ESRD in elderly
• Continuum of increasing CV risk from SBP 115mmHg
• CV mortality doubles for every10/5 increase in BP>120/70
• High BP causes:
• 35% of all cardiovascular deaths
• 50% of all stroke deaths
• 25% of all CAD deaths
• 50% of all congestive heart failure
Benefits of Lowering BP
New Guidelines for Hypertension• National Institute for Health and Clinical Excellence
(NICE), 2011• Kidney Disease: Improving Global Outcome (KDIGO),
2012• European Society of Hypertension/European Society of
Cardiology, (ESH/ESC), 2013• American Diabetes Association (ADA), 2014• American Society of Hypertension and the International
Society of Hypertension (ASH/ISH), 2014• Eighth Joint National Committee (JNC8), 2014
JNC 82014 Evidence-Based Guideline for
the Management of
High Blood Pressure in Adults
JNC 8 (2014 Hypertension Guideline Management Algorithm)
1
JNC 8 (2014 Hypertension Guideline Management Algorithm)
2
JNC 8 2014 Hypertensionguideline
Goal BP and Initial Drug Therapy for Adults With Hypertension
Population Goal BP,mm Hg
Initial Drug Treatment Options
General ≥60 y <150/90 Nonblack: thiazide-type diuretic, ACEI, ARB, or CCBBlack: thiazide-type diuretic or CCB
General <60 y <140/90 Nonblack: thiazide-type diuretic, ACEI, ARB, or CCBBlack: thiazide-type diuretic or CCB
Diabetes <140/90 Thiazide-type diuretic, ACEI, ARB, or CCB
CKD <140/90 ACEI or ARB
Start one drug, titrate to maximum dose, and then add a second drug
Start one drug and then add a second drug before achieving maximum dose of the initial drug
Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination
A
C
B
Strategies to Dose of Antihypertensive Drugs
Ratio of Incremental SBP lowering effect at “standard dose”– Combine or Double?
1.04 1
1.16
0.891.01
0.19 0.23 0.2
0.37
0.22
0
0.2
0.4
0.6
0.8
1
1.2
1.4
Thiazide β-blocker ACE-I CCB All
Combine Double
Incr
emen
al S
BP
red
uct
ion
rat
ioO
bse
rved
/Exp
ecte
d (
add
itiv
e)
BP lowering effects from antihypertensive drugs
Dose response curves for efficacy are relatively flat
80% of the BP lowering efficacy is achieved at half-standard dose
Combinations of standard doses have additive blood pressure lowering effects
key issues must be addressed during the initial office evaluation of a person with elevated BP readings:
1. Documenting that the BP is elevated 2. Defining the presence or absence of TOD related
to hypertension3. Screening for other CV risk factors that often accompany
hypertension4. Estimating the person’s absolute risk for CV and renal
disease
5. Assessing whether the person is likely to have an identifiable cause of HTN (secondary HTN) and should have further diagnostic testing to confirm or exclude that diagnosis
6. Obtaining data that may be helpful in the initial and subsequent choices for therapy.
GENERAL RULES1-Decrease CV mortality :ACEI ;ARBs, Diuretics, 2-Age:Elderly ,Middle age,Women at reproductive age3- Race/Ethnicity : Blacks,African-American ,whites,….4- Concomitant disease & Conditions: BPH,CRF,Asthma, …5- Compelling indications:Post MI,CKD , stroke,DM ,CHF, CAD,…6-Long acting Drugs : Patient compliance7-Start low (dosage)&go slow
Treatment of Hypertension
CONSIDER
• Nonadherence• Secondary HTN• Interfering drugs or
lifestyle• White coat effect
Dual Combination
Triple Therapy
Lifestyle modification
Thiazidediuretic ACEI Long-acting
CCB
TARGET <140/90 mmHg For age<60 & <150/90 mmHg For age ≥60
ARB
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
Treatment of Isolated Systolic Hypertension
CONSIDER
• Nonadherence• Secondary HTN• Interfering drugs or
lifestyle• White coat effect
Thiazide Amlodipin
Dual therapy
Triple therapy
Lifestyle modificationtherapy
ARB orACEI
TARGET : SBP <140 mmHg, for age<60 yr SBP< 150 mmHg for age > 60 years
*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined
Choice of Pharmacological Treatment for Hypertension
• Compelling indications:• Stable IHD• Recent ST Elevation-MI or non-ST Elevation-MI• LV Systolic Dysfunction• Cerebrovascular Disease• Non Diabetic CKD
• Diabetes Mellitus• With Nephropathy• Without Nephropathy
Treatment of HTN in Patients with Stable IHD
• Caution should be exercised when combining (Verapamil Or Diltiazem) +beta-blocker• If abnormal systolic left ventricular function: avoid (Verapamil or Diltiazem)• Dual therapy with an ACEI +ARB are not recommended in the absence of refractory CHF• The combination of an ACEi and CCB is preferred
1. Beta-blocker2. Long-acting CCBStable angina
ACEI are recommended for most patients with established CAD*
ARBs are not inferior to ACEI in IHD
Short-actingnifedipine
Treatment of HTN in Patients with Recent STEMI or NSTEMI
Amlodipine*(Avoid diltiazem, verapamil)
Beta-blocker +ACEI (or ARB)Recent
myocardialinfarction
CHF?
NO
YES
Long-acting CCB
If beta-blocker contraindicated( Asthma, COPD, Heart Block,….) or not effective
*
Treatment of HTN with LV Systolic Dysfunction
If additional therapy is needed:• Diuretic (Thiazide for hypertension; Loop for volume control Or eGFR,30cc/min) • Spironolactone : for CHF NYHA-FC II-IV or post MI (clinical HF Or LVEF<40% Or DM)
SystolicLV
dysfunction
• ACEI(or ARB)+Beta blocker (carvedilol Or metoprolol)
Up titrate doses of ACEI or ARB
If ACEI and ARB are contraindicated: Hydralazine + Isosorbide dinitrate
If additional antihypertensive therapy is needed:
• ACEI / ARB Combination• Amlodipine
Verapamil Diltiazem
Treatment of HTN in Association With StrokeAcute Stroke: Onset to 72 Hours
Treat extreme BP elevation (systolic > 220 mmHg, diastolic > 120 mmHg)
by 15-25% over the first 24 hour with gradual reduction after.
Acute ischemic
Stroke
Avoid excessive lowering of BP which can exacerbate ischemia
Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA .
Target BP < 140/90 mmHg
An ACEI / diuretic combination is preferred
StrokeTIA
Combinations of an ACEI with an ARB are not recommended
Treatment of HTN in Association With StrokeAcute Stroke: After72 Hours
Treatment of HTN in Patients with Non Diabetic CKD
Chronic kidney disease and proteinuria *
ACEI(or ARB)±Diuretic(Thiazide Or Loop)
Combination with other agents
Target BP: < 140/90 mmHg
* albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr
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 association with Diabetes
Mellitus
Treatment of HTN in DM without CKDThreshold ≥130/80 mmHg and Target below 130/80 mmHg
*Combinations of an ACEI with an ARB are specifically
not recommended
If eGFR <30 ml/min, a Furosemide should be substituted for a thiazide
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg
DIABETESwith
Nephropathy
ACE Inhibitoror ARB
IF ACEI and ARB are contraindicated or not tolerated, SUBSTITUTE: • Long-acting CCB• Thiazide
Addition of one or more ofLong-acting CCB or Thiazide
3 - 4 drugs combination may be needed
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Treatment of HTN in DM +CKD
•The use of the combination of ACE inhibitor with an ARB should only be considered in selected and closely monitored Patients with Refractory CHF or Marked proteinuria.