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Transcript of ASH ISH-Guidelines 2013
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8/18/2019 ASH ISH-Guidelines 2013
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A S H P A P E R
ClinicalPracticeGuidelines for
theManagement ofHypertension intheCommunity
AStatement by the American Societyof
Hypertension andtheInternationalSocietyofHyperten
sion
Michael A. eber!
M"#$ Ernesto %.
Schiffrin! M"#&
illiam '. hite!
M"#( Samuel
Mann! M"#) %ars
H. %indholm! M"#*
+ohn G.
,enerson! M"#-
+ohn M. lac/!
M"#0 'arry %.
Carter! Pharm "#1
'arry +. Materson!
-
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M"#2 C. 3en/ata
S. Ram! M"#$4
"ebbie %. Cohen!
M"#$$
+ean5
Claude Cadet!
M"#$&
Roger R.
+ean5Charles!
M"#$(
Sandra
6aler! M"#$)
"a7id
,ount8! M"#$*
Raymond R.6o9nsend! M"#
$-
+ohn Chalmers!
M"#$0
Agustin +.
Ramire8! M"#$1
George %. 'a/ris!
M"#$2
+iguang
ang! M"#&4
Aletta E. Schutte!
M"#&$
+ohn ".
'isognano! M"#&&
Rhian M. 6ouy8!
M"#
&(
"ominicSica! M"#
&)
Stephen '.
Harrap! M"&*
State :ni7ersity of;e9
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"epartment ofMedicine! :ni7ersityof Pennsyl7aniaSchool of Medicine!
Philadelphia! PA#$$
State :ni7ersitySchool of Medicine!Port Au Prince!
Haiti#$&
Hypertension
Center of Haiti! Port
Au Prince! Haiti#$(
"epartment ofMedicine! MayoClinic! Rochester!
M;#$)
+ersey Shore
:ni7ersity MedicalCenter! ;eptune!
;+#$*
Hypertension
Center! :ni7ersity ofPennsyl7ania!
Philadelphia! PA#$-
George Institute forGlobal Health!:ni7ersity of Sydney!Sydney! ;S!
Australia#$0
Arterial
Hypertension andMetabolic :nit!
:ni7ersity Hospital!a7alorooundation! 'uenos
Aires! Argentina#$1
ASH Comprehensi7eHypertensionCenter! :ni7ersity ofChicago Medicine!
Chicago! I%#$2
6he
Shanghai Institute of Hypertension!Shanghai +iaotong:ni7ersity School ofMedicine! Shanghai!
China#&4
Hypertension in Africa Research6eam! ;orth est:ni7ersity!Potchefstroom!
South Africa#&$
"epartment ofMedicine! :ni7ersityof RochesterMedical Center!
Rochester! ;
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have
been
writte
n to
provi
de a
straig
ht-
forwa
rd
approach
to
mana
ging
hyper
tensi
on in
the
com
munit
y. We
have
inten
ded
that
this
brief
curric
ulum
and
set of
reco
mme
ndati
ons be
usefu
l not
only
for
prima
ry
care
physi
cians
and
medi
cal
stude
nts,
but
for
all
profe
ssion
als
who
work
as
hands-on
practi
tioner
s.
We
are
awar
e that
there
is
great
varia bility
in
acces
s to
medi
cal
care
amon
g
com
munit
ies.Even
in so-
calle
d
wealt
hy
count
ries
there
are
sizabl
e
communit
ies in
whic
h
econ
omic,
logist
ic,
and
geogr
aphic
issues put
const
raints
on
medi
cal
care.
And,
at the
same
time,
we
areremin
ded
-
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that
even
in
count
ries
with
highl
y
limite
d
resources,
medi
cal
leade
rs
have
assig
ned
the
highe
st
priori
ty to
supp
ortin
g
their
colle
agues
in
confr
ontin
g the
growi
ngtoll
of
devas
tating
strok
es,
cardi
ovasc
ular
event
s, and
kidne
y
failur
e
cause
d by
hyper
tensi
on.
ur
goal
has
beento
give
suffic
ient
infor
matio
n to
enabl
e
healt
h
care
practitioner
s,
wher
ever
they
are
locat
ed, to
provi
de
profe
ssion
al
care
for
peopl
e
with
hyper
tensi
on.
All
the
same,
werecog
nize
that it
will
often
not
be
possi
ble to
carry
out
all of
our
sugge
stions
for
clinic
al
evalu
ation,
tests,
and
thera
pies.
!ndeed,
there
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are
situat
ions
wher
e the
most
simpl
e and
empir
-ical
carefor
hyper
tensi
on>simpl
y
distri
butin
g
Address forcorrespondence?Michael A.eber!M"!"i7ision ofCardio7ascularMedicine!State:ni7er
sity of;e9
is
better
than
doing
nothi
ng at
all.
We
hope
that
we
have
allow
ed
suffic
ient
fle"ib
ility
in
this
state
mentto
enabl
e
respo
nsibl
e
clini-
cians
to
devis
e
work
able
plans
for
provi
ding
the
best
possi
ble
care
for
patie
ntswith
hyper
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tensi
on in
their
com
munit
ies.
We
have
divid
edthis
brief
docu
ment
into
the
follo
w-ing
sectio
ns#
!ntroducti
on
Epide
miolo
gy$peci
al
!ssues
With
%lack
&atie
nts
'African
Ance
stry(
)ow
is
)ype
rtensi
on
*efin
ed+
)ow
is
)ype
rtensi
on
lass
ified+
aus
es of
)ype
rtensi
on
aki
ng
the*iag
nosis
of
)ype
rtensi
on
Evalu
ating
the
&atie
nt
&hysi
calE"am
inatio
n
Tests
oals
of
Treati
ng
)ype
rtensi
on
/onp
harm
acolo
gic
Treat
ment
of
)ype
rtensi
on
*rug
treat
ment
for)ype
rtensi
on
%rief
om
ment
s on
*rug
lass
es
Treat
ment-
0esis
tant
)ype
rtensi
on
I;6R=":C6I=;
Abou
t one
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third
of
adult
s in
most
com
munit
ies in
the
devel
opedand
devel
oping
world
have
hyper
tensi
on.
)ype
rtensi
on is
the
most
com
mon
chron
ic
condi
tion
dealt
with
by prima
ry
care
physi
cians
and
other
healt
h
practi
tioner
s.
=fficial +ournal of the American Society ofHypertension! Inc.
6he +ournal
of Clinical Hypertension
$
ASHBISHHypertensionGuidelines Deberet al.
ost
patie
nts
with
hyper
tensi
on
have
other
riskfactor
s as
well,
inclu
ding
lipid
abnor
maliti
es,
gluco
se
intole
rance
, or
diabe
tes1 a
famil
y
histor
y of
early
car-
diova
scula
r
event
s1
obesi
ty1
and
cigar
ette
smok ing.
The
succe
ss of
treati
ng
hyper
tensi
on
has
been
lim-
ited,
and
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despi
te
well-
establ
ished
appro
aches
to
diagn
osis
andtreat
ment,
in
many
com
munit
ies
fewer
than
half
of all
hyper
tensi
ve
patie
nts
have
ade2
uatel
y
contr
olled
blood
press
ure.
EPI"EMI=%=G<
There
is a
close
relati
onshi
p
betw
een
blood
press
ure
levels
and
the
risk
of
cardiovasc
ular
event
s,
strok
es,
and
kidne
y
disea
se.
The
risk
of
these
outco
mes
is
lowes
t at a
blood
press
ure of aroun
d
33456
4 mm
)g
Abov
e
33456
4 mm
)g,
foreach
incre
ase of
78
mm
)g in
systol
ic
blood
press
ure or
38
mm)g in
diast
olic
blood
press
ure,
the
risk
of
ma9or
cardi
o-
vascu
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lar
and
strok
e
event
s
doubl
es.
The
high preva
lence
of
hyper
tensi
on in
the
com
mu-
nity
is
currently
being
drive
n by
two
phen
omen
a# the
incre
ased
age
of
our popul
ation
and
the
growi
ng
preva
lence
of
obesi
ty,
which is
seen
in
devel
oping
as
well
as
devel
oped
count
ries.
!nmany
com
munit
ies,
high
dietar
y salt
intak
e is
also a
ma9or
factor .
The
main
risk
of
event
s is
tied
to an
incre
asedsystol
ic
blood
press
ure1
after
age
48 or
:8
years,
diast
olic
blood
press
ure
may
actua
lly
start
to
decre
ase,
but
systol
ic press
ure
conti
nues
to
rise
throu
ghout
life.
This
incre
ase in
systol
ic
blood
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press
ure
and
decre
ase in
diast
olic
blood
press
ure
withaging
reflec
ts the
pro-
gressi
ve
stiffe
ning
of the
arteri
al
circul
ation.
The
reaso
n for
this
effect
of
aging
is not
well
under
stood
, buthigh
systol
ic
blood
press
ures
in
older
peopl
e
repre
sent a
ma9or
risk
factor
for
cardi
ovasc
ular
and
strok
e
event
s and
kidney
disea
se
progr
essio
n.
SPECIA%ISS
:ESI6H'%AC,PA6IE;6SARIC A; A;C
ES6R
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nts
than
in
white
s.
A
highe
r
propo
rtionof
black
peopl
e are
sensit
ive to
the
blood
press
ure raisin
geffect
s of
salt
in the
diet
than
white
patie
nts,
and
this
>
together
with
obesi
ty,
espec
ially
amon
g
wom
en>may
be part
of the
e"pla
natio
n for
why
youn
g
black
peopl
e
tend
tohave
earlie
r and
more
sever
e
hyper
tensi
on
than
other
groups.
%lack
patie
nts
with
hyper
tensi
on
are
partic
ularlyvulne
rable
to
strok
es
and
hyper
tensi
ve
kidne
y dis-
ease.
They
are ;
to 4
times
as
likely
as
white
s to
have
renal
complicati
ons
and
end-
stage
kidne
y
disea
se.
There
is a
tendency
for
black
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patie
nts to
have
differ
ing
blood
press
ure
respo
nsesto the
avail
able
antih
ypert
ensiv
e
drug
class
es#
they
usually
respo
nd
well
to
treat
ment
withcalci
um
chan
nel
block
ers
and
diuret
ics
but
have
small
er
blood
press
ure
reduc
tions
with
angio
tensi
n-
conv
erting
enzyme
inhibi
tors,
angio
tensi
n
recep
tor
block
ers,
and
b-
block ers.
)ow-
ever,
appro
priate
comb
inatio
n
thera
pies
provi
de
powe
rful
antih
ypert
ensiv
e
respo
nses
that
are
simil
ar in
black and
white
patie
nts.
ost
patie
nts
will
re2ui
re
more
than
one
antih
ypert
ensiv
e
drug
to
maint
ain
blood
press
ure
contr ol.
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H=ISH
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press
ure to
levels
belo
w the
numb
ers
used
for
making
the
diagn
osis.
Thes
e
defini
tions
are
based
onthe
result
s of
ma9or
clinic
al
trials
that
have
show
n the
benef
its of
treati
ng
peopl
e to
these
levels
of
blood
press
ure.
Even
though a
blood
press
ure of
33456
4 mm
)g is
ideal,
as
discu
ssed
earlie
r,
there
is no
evide
nce
to
9ustif
y
treati
ng
hyper
-
tension
down
to
such
a low
level.
We
do
not
have
sufficient
infor
matio
n
about
youn
ger
adult
s
'betw
een
3?
and
44
years
( to
know
whet
her
they
might
benef
it
from
defining
hyper
tensi
on at
a
level
@3=85
>8
mm)
g 'eg,
3;85?
8 mm
)g(
and
treati
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ng
them
more
aggre
ssivel
y
than
older
adult
s.
Thus,guide
lines
tend
to use
3=85>
8 mm
)g
for
all
adult
s 'up
to ?8
years
(.
Even
so, at
a
practi
tioner
8
mm
)g.
H=ISH
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or
patie
nts
with
systol
ic
blood
press
ure
between
378
mm
)g
and
3;>
mm
)g,
or
diast
olic
pressures
betw
een
?8
and
?>
mm
)g,
the
term
prehy
perte
n-sion
can
be
used.
&atie
nts
with
this
condi
tion
shoul
d not be
treate
d
with
blood
press
ure
medi
catio
ns1
howe
ver,
they
shoul
d be
enco
urage
d to
make
lifestyle
chan
ges in
the
hope
of
delay
ing or
even
preve
nting progr
essio
n to
hyper
tensi
on.
$tage
3
hyper
tensi
on#
patie
nts
with
systol
ic
blood
press
ure
3=8
to
34>
mm
)g or diast
olic
blood
press
ure
>8 to
>>
mm
)g.
& 6he +ournalof Clinical Hypertension
=fficial
+ournal of the AmericanSociety of Hypertension!Inc.
-
8/18/2019 ASH ISH-Guidelines 2013
18/69
$tage
7
hyper
tensi
on#
systol
ic blood
press
ure
3:8mm
)g or
diast
olic
blood
press
ure 388
mm )g.
CA:SES=H
4B
of
adult
s
with
high
blood
press
ure
have
prima
ry
hyper
tensi
on
'som
etime
s
called
essen
tial
hyper
tensi
on(.
The
cause
of
prima
ry
hyper
tensi
on is
not
know
n,
altho
ugh
genet
ic
and
envir onme
ntal
factor
s that
affect
blood
press
ure
regul
ation
arenow
being
studi
ed.
Envir
onme
ntal
factor
s
inclu
de
e"cess
intak
e of
salt,
obesi
ty,
and
perha
ps
seden
tary
lifestyle.
-
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$ome
genet
ically
relate
d
factor
s
could
inclu
de
inap- propr
iately
high
activi
ty of
the
renin
-
angio
tensi
n-
aldos
teron
e
syste
m
and
the
symp
atheti
c
nervo
us
syste
mand
susce
ptibil
ity to
the
effect
s of
dietar
y salt
on
blood press
ure.
Anot
her
com
mon
cause
of
hyper
tensi
on is
stiffe
ning
of the
aorta
with
incre
asing
age.
This
cause
s
hyper
-
tension
referr
ed to
as
isolat
ed or
predo
mina
nt
systol
ic
hyper
tensi
on
chara
cteriz
ed by
high
systol
ic
press
ures
'ofte
n
withnorm
al
diast
olic
press
ures(,
whic
h are
found
prima
rily
in
elderl
y
peopl
e.
Secondar yHypertension
This
pertai
ns to
-
8/18/2019 ASH ISH-Guidelines 2013
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the
relati
vely
small
numb
er of
cases,
about
4B
of all
hyper tensi
on,
wher
e the
cause
of the
high
blood
press
ure
can
be
identi
fied
and
some
times
treate
d.
The
main
types
of
secon
dary
hyper
tensi
on
are
chron
ic
kidne
y
disea
se,renal
artery
steno
sis,
e"ces
-sive
aldos
teron
e
secret
ion,
pheo
chro
mocy
toma,
and
sleep
apnea
.
A
simpl
e
scree
ning
appro
ach
for
identi
fying
secon
d-ary
hyper
tensi
on is
given
later.
MA,I;G6HE"IAG;=SIS=H
-
8/18/2019 ASH ISH-Guidelines 2013
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mate
d
electr
onic
devic
e.
The
electr
onic
devic
e, ifavail
able,
is
prefe
rred
becau
se it
provi
des
more
repro
ducib
le
result
s than
the
older
meth
od
and is
not
influe
nced
by
variations
in
techn
i2ue
or by
the
bias
of the
obser
vers.
!f the
auscu
ltator
y
meth
od is
used,
the
first
and
fifth
Corot
koff
soun
ds'the
appea
rance
and
disap
peara
nce
of
soun
ds(
will
cor-
respo
nd to
the
systol
ic
and
diast
olic
blood
press
ures.
Armcuffs
are
prefe
rred.
uffs
that
fit on
the
finge
r or
wrist
are
ofteninacc
urate
and
shoul
d, in
gener
al,
not
be
used.
!t is
impo
rtant
to
ensur
e that
the
corre
ct
size
of the
armcuff
is
used
-
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'in
partic
ular,
a
wider
cuff
in
patie
nts
withlarge
arms
D;7
cm
circu
mfere
nceF(.
At
the
initial
evalu
ation, blood
press
ure
shoul
d be
meas
ured
in
both
arms1
if the
readi
ngs
are
differ
ent,
ASHBISHHypertensionGuidelines Deberet al.
the
armwith
the
highe
r
readi
ng
shoul
d be
used
for
meas
urements
there
after.
The
blood
press
ure
shoul
d be
taken
after
patie
nts
have
empti
ed
their
bladd
ers.
&atie
nts
shoul
d be
seated
with
their
backs
supp
orted
and
with
their
legs
restin
g on
the
groun
d and
-
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in the
uncro
ssed
positi
on
for 4
minut
es.
The
patie
nt
-
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after
the
first
meas
urem
ent.
n
both
occa-
sions,
thesystol
ic
blood
press
ure
shoul
d be3=8mm
)g or
the
diast
olic
press
ure
>8mm)
g, or
both,
in
order
to
make
a
diagnosis
of
hyper
tensi
on.
!f the
blood
press
ure is
very
high'for
insta
nce, a
systol
ic
blood
press
ure
3?8mm
)g(,
or if
available
resou
rces
are
not
ade2
uate
to
permi
t a
conv
enien
tsecon
d
visit,
the
diagn
osis
and,
if
appro
priate
,
treat
ment
can
be
starte
d
after
the
first
set of
readi
ngs
thatdemo
nstrat
e
hyper
tensi
on.
or
practi
tioner
s and
theirstaff
not
e"per
ience
d in
meas
uring
blood
press
ures,
it is
neces
sary
to
recei
-
8/18/2019 ASH ISH-Guidelines 2013
25/69
ve
appro
priate
traini
ng in
perfo
rmin
g this
impo
rtant
techn
i2ue.
$ome
patie
nts
may
have
blood
press
ures
thatare
high
in the
clinic
or
office
but
are
norm
al
elsew
here.
This
is
often
calle
d
white
-coat
hyper
tensi
on. !f
it is
suspe
cted,consi
der
gettin
g
home
blood
press
ure
readi
ngs
'see
belo
w( to
check
this
possi
bility.
Anot
her
appro
ach is
to use
ambu
latory
blood
pressure
monit
oring,
if it is
avail
able.
!n
this
proce
dure,
the
patie
nt
wears
an
arm
cuff
conn
ected
to a
devic
e that
auto
matic
allymea-
sures
and
recor
ds
blood
press
ures
at
regul
ar
interv
als
usual
ly
over
a 7=-
hour
perio
d.
!t can
be
helpf
ul to
meas
-
8/18/2019 ASH ISH-Guidelines 2013
26/69
ure
blood
press
ures
at
home
. !f
avail
able,
the
electr onic
devic
e is
simpl
er to
use
and is
proba
bly
more
reliab
le
than
the
sphy
gmo
ma-
nome
ter.
The
avera
ge of
blood
press
uresmeas
ured
over
4 to 6
days,
if
possi
ble in
dupli
cate
at
each
meas
urem
ent,
can
be a
usefu
l
guide
for
diagn
ostic
and
treatment
decisi
ons.
E3A%:A6I;G6HEPA6I
E;6
ften
, high
blood
press
ure is
only
one
of
sever
al
cardiovasc
ular
risk
factor
s that
re2ui
re
attent
ion.
%efor
e
starti
ng
treat
ment
for
hyper
tensi
on, it
is
usefu
l to
evalu
atethe
patie
nt
more
thoro
ughly
. The
three
meth
ods
are
perso
nal
histor
y,
-
8/18/2019 ASH ISH-Guidelines 2013
27/69
physi
cal
e"am
-
inatio
n.
and
select
ive
testin
g.
=fficial +ournal of the American Society ofHypertension! Inc.
6he +ournal
of Clinical Hypertension
(
ASHBISHHypertensionGuidelines Deberet al.
History
Ask
about
previ
ous
cardi
ovasc
ular
event
s
because
they
often
sugge
st an
incre
ased
proba
bility
of
futur
e
events that
can
influe
nce
the
choic
e of
drugs
for
treati
ng
hyper tensi
on
and
will
also
re2ui
re
more
aggre
ssive
treat
ment
of allcardi
ovasc
ular
risk
factor
s.
Also
ask
patie
nts if
they
have
previously
been
told
that
they
have
hyper
tensi
on
and,
if
relevant,
their
respo
nses
to
any
drugs
they
might
have
been
given
.
!mpo
-
8/18/2019 ASH ISH-Guidelines 2013
28/69
rtant
previ
ous
event
s
inclu
de.
$trok
e or
transi
entische
mic
attac
ks or
deme
ntia.
hyisthisinfor
mationimportant or
patie
nts with
these
previ
ous
event
s, it
may be
neces
sary
to
inclu
de
partic
ular
drug
types
in
theirtreat
ment,
for
insta
nce
angio
tensi
n
recep
tor
block
ers or
angioten-
sin-
conv
erting
enzy
me
inhibi
tors,
calci
um
chan
nel
block ers,
and
diuret
ics,
as
well
as
drugs
for
low-
densi
ty
lipop
rotein
'G*G
(
chole
sterol
'stati
ns(
and
antipl
atelet
drugs
.
oro
nary
artery
disea
se,
inclu
ding
myoc
ardial
infarc
tions,angin
a
pecto
ris,
and
coron
ary
revas
cu-
lariza
tions.
hyisthis
-
8/18/2019 ASH ISH-Guidelines 2013
29/69
important erta
in
medi-
catio
ns
woul
d be
preferred,
for
insta
nce
b- block
ers,
angio
tensi
n-
conv
erting
enzy
me
inhibi
tors
or
angio
-
tensi
n
recep
tor
block ers,
statin
s, and
antipl
atelet
agent
s
'aspir
in(.
)eart
failur e or
symp
toms
sugge
sting
left
ventri
c-ular
dysfu
nctio
n
'short
ness
of
breat
h,
edem
a(.hy isthisimportanterta
inmedi
catio
ns
woul
d be prefe
rred
in
such
patie
nts,
inclu
ding
angio
tensi
n
recep
tor
block
ers or
angio
tensi
n-
conv
ertingenzy
me
inhibi
tors,
b- block
ers,
diuret
ics,
and
spironolac
-tone.
Also,
certai
n
medi
catio
ns
shoul
d be
avoid
ed,
suchas
nondi
-
8/18/2019 ASH ISH-Guidelines 2013
30/69
hydro
pyrid
ine
calci
um
chan
nel
block
-
ers'vera
pamil
,
diltia
zem(,
in
patie
nts
with
systol
ic
heartfailur
e.
!H.
hro
nic
kidne
y
disea
se.
hyisthisimportant erta
in
medi
catio
ns
woul
d be
prefe
rred,inclu
ding
angio
tensi
n-
conv
erting
enzy
me
inhibi
tors
or
angio
-
tensi
n
recep
tor
block
ers
'altho
ugh
these
two
drug
classes
shoul
d not
be
presc
ribed
in
comb
inatio
n
with
each
other
(,
statin
s, and
diuret
ics
'loop
diuret
-ics
may
be
re2ui
red if the
estim
ated
glom
erular
filtrat
ion
rate
is
belo
w ;8(
and
blood
press
ure
treat
ment
target
s
might
be
lower
'3;85
?8
mm)g(
if
-
8/18/2019 ASH ISH-Guidelines 2013
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albu
minu
ria is
prese
nt.
/ote#
!n
patie
nts
with
moreadva
nced
kidne
y
disea
se,
the
use
of
some
of
these
drugs
often
re2ui
res
the
e"per
tise
of a
nephr
ologi
st.
&eripheral
artery
disea
se.
hyisthisimportant This
finding
sugge
sts
adva
nced
arteri
al
disea
se
that
may
also
e"istin the
coron
ary or
brain
circul
ation
s,
even
in the
absen
ce of
clinic
alhistor
y. !t
is
vital
that
smok
ing
be
disco
ntinu
ed. !n
most
cases,
antipl
atelet
drugs
shoul
d be
used.
H!.
*iab
etes.
hy
isthisimportant+
This
condi
tion
is
com
monl
y
associated
with
hyper
tensi
on
and
an
incre
ased
risk
of
cardi
ovascular
event
-
8/18/2019 ASH ISH-Guidelines 2013
32/69
s.
erta
in
medi
catio
ns
such
as
angio
tensi
nrecep
tor
block
ers
and
angio
tensi
n-conv
erting
enzy
me
inhibi
tors
shoul
d be
used,
partic
ularly
ifthere
is
evide
nce
of
albu
minu
ria or
chron
ic
kidne
y
disease.
ood
blood
press
ure
contr
ol,
often
re2ui
ring
the
addition of
calci
um
chan
nel
block
ers
and
diuret
ics, is
also
impo
rtantin
these
patie
nts.
H!!.
$leep
apnea
.
hyis
thisimportant+
$peci
al
treat-
ment
s are
often
re2ui
red
for
these patie
nts
and
their
use
may
make
it
possi
ble to
impr
ove blood
press
ure
contr
ol as
well
as
other
findi
ngs
of
this
condition.
-
8/18/2019 ASH ISH-Guidelines 2013
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Ask
about
other
risk
factor
s.hyisthisimpo
rtant 0isk
factor
s can
affect
blood
press
ure
target
s and
treat
ment
select
ion
for
the
hyper
tensi
on.
Thus,
know
ing
about
age,
dysli pide
mia,
micro
albu
minu
-ria,
gout,
or
famil
y
histor
y of
hyper
tensi
on
and
diabe
tes
can
be
valua
ble.
igar
ette
smok ing is
a risk
factor
that
must
be
identi
fied
so
that
couns
eling
can
be
given
about
stopp
ing
this
dang
erous
habit.
Askabout
conc
urren
t
drugs
.
om
monl
y
used
drugs
'for
indic
ation
s
unrel
ated
to
treati
ng
hyper
tensi
on(
can
increase
blood
press
ure
and
theref
ore
shoul
d be
stopp
ed if
possi
ble.
Thes
e
-
8/18/2019 ASH ISH-Guidelines 2013
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inclu
de
nonst
eroid
al
anti-
infla
mmat
ory
drugs
usedfor
arthri
tis
and
pain
relief,
some
tricyc
lic
and
other
types
of
antid
epres
-
sants,
older
high-
dose
oral
contr
acept
ives,
migraine
medi
catio
ns,
and
cold
reme
dies
'eg,
pseud
oeph
e-
drine
(. !n
additi
on,
some
patie
nts
may
be
takin
g
herba
lmedi
catio
ns,
folk
reme
dies,
or
recre
ation
al
drugs
'eg,
cocaine(,
whic
h can
incre
ase
blood
press
ure.
PH<
SIC A%EJAMI; A6I=;
At
the
first
visit
it is
important
to
perfo
rm a
comp
lete
physi
cal
e"am
inatio
n
because
often
gettin
g
care
for
hyper
tensi
on is
the
only
conta
ctthat
patie
-
8/18/2019 ASH ISH-Guidelines 2013
35/69
nts
have
with
a
medi
cal
practi
tioner
.
easuring
blood
press
ure
'disc
ussed
earlie
r(.
*ocu
ment
the patie
nt
-
8/18/2019 ASH ISH-Guidelines 2013
36/69
d-ing
strok
e,
parad
o"ica
lly
may
be
highe
r in
lean
hyper
tensi
ve
patie
nts
than
in
obese
patie
nts.
Waist
circu
mfere
nce.hyisthisimportant !nde-
pend
ent of
weig
ht,
this
helps
deter
mine
whet
her a
patie
nt has
the
meta bolic
syndr
ome
or is
at
risk
for
type
7
diabe
tes.
0isk
is
high
when
the
meas
urem
ent
is
387
cm in
menor
??
cm in
wom
en.
$igns
of
heart
failur
e.
hyisthisimportant This
diagn
osis
stron
gly
influe
nces
the
choic
e of
hyper
ten-
sion
thera
py.
Geft
ventri
cular
hyper
trophy can
be
suspe
cted
by
chest
palpa
tion,
and
heart
failur
e can
-
8/18/2019 ASH ISH-Guidelines 2013
37/69
) 6he +ournalof Clinical Hypertension
=fficial
+ournal of the AmericanSociety of Hypertension!Inc.
beindic
ated
by
diste
nded
9ugul
ar
veins,
rales
on
chest
e"am
ination, an
enlar
ged
liver,
and
perip
heral
edem
a.
/eur
ologic
e"am
inatio
n.
Why
is this
impo
rtant+
This
may
revea
l
signs
of
previ
ous
strok
e and
affect
treat
ment
select
ion.
Eyes#
!f
possi
ble,
the
optic
fundi
should be
check
ed for
hyper
tensi
ve or
diabe
tic
chan
ges
and
the
areas
aroun
d the
eyes
for
findi
ngs
such
as
"anth
omas.
&ulse
# !t is
impo
rtant
to
check
perip
heral
pulse
rates1
if
theyare
dimin
ished
or
absen
t, this
can
indic
ate
perip
heral
artery
disease.
-
8/18/2019 ASH ISH-Guidelines 2013
38/69
6ES6S
%loo
d
samp
le
/ote#
This prefe
rably
shoul
d be
a
fastin
g
samp
le so
that a
fastin
g
bloodgluco
se
level
and
more
accur
ate
lipid
profil
es
can
beobtai
ned.
Elect
rolyte
s.
hyisthisimportant There
is a
speci
al
emph
asis
on
potas
sium#
high
levels
can
suggest
renal
disea
se,
partic
ularly
if
creati
nine
is
eleva
ted.
Gowvalue
s can
sugge
st
aldos
teron
e
e"ces
s. !n
additi
on,
illnes
ses
assoc
iated
with
sever
e
diarr
hea
are
com
mon
in
somecom
munit
ies
and
can
cause
hypo
kale
mia
and
other
electr
olyte
chan
ges.
asti
ng
gluco
se
conce
ntrati
on.
hy
isthisimpo
-
8/18/2019 ASH ISH-Guidelines 2013
39/69
r5tant!f
eleva
ted,
this
could
be
indic
ative
of impai
red
gluco
se
tolera
nce,
or, if
suffic
iently
high,
of
diabe
tes. !f
avail
able,
glyca
ted
hemo
globi
n
shoul
d be
meas
ured
tofurth
er
asses
s an
eleva
ted
gluco
se
level
and
help
in
maki
ng a
diagn
osis.
$eru
m
creati
nine
and
blood
urea
nitrogen.
hy
aretheseimportant!ncre
ased
creati
nine
levelsare
usual
ly
indic
ative
of
kidne
y
disea
se1
creati
nine
is
also
used
in
form
ulae
for
e
0.
Whe
n
appro-
priate
, use
form
ulae
desig
ned
for
e
0
calcu
la-tions
in
patie
nts of
Afric
an
ances
try.
!H.
Gipid
s.
hyarethes
-
8/18/2019 ASH ISH-Guidelines 2013
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eimportant Eleva
ted
G*G
chole
sterol
or
lowvalue
s of
high-
densi
ty
lipop
rotein
chole
sterol
are
assoc
iated
with
incre
ased
cardi
ovas-
cular
risk.
)igh
G*G
chole
sterol
can
typically
be
treate
d
with
avail
able
drugs
,
usual
ly
statin
s.
)em
oglob
in5he
mato
crit.
hyaretheseimpo
r5tantThes
e
meas
urem
ents
can
identi
fy
issue
s beyo
ndhyper
tensi
on
and
cardi
ovasc
ular
disea
se,
inclu
ding
sickle
cell
anem
ia in
vulne
rable
popu-
lation
s and
anem
ia
assoc
iated
withchron
ic
kid-
ney
disea
se.
H!.
Giver
functi
on
tests.hyaretheseimportant erta
in
blood
press
ure
drugscan
affect
-
8/18/2019 ASH ISH-Guidelines 2013
41/69
liver
functi
on,
so it
is
usefu
l to
have
baseli
ne
values.
Also,
obese
peopl
e can
have
fatty
liver
disor
ders
that
shoul
d be
identi
fied
and
consi
dered
in
overa
ll
mana
geme
nt.
Irine
samp
le
Albu
minu
ria.hyisthis
important !f
prese
nt,
this
can
be
indic
ative
of
kidne
ydisea
se
and is
ASHBISHHypertensionGuidelines Deberet al.
also
associated
with
an
incre
ased
risk
of
cardi
o-
vascu
lar
events.
!deall
y, an
albu
min5c
reatin
ine
ratio
shoul
d be
obtai
ned,
buteven
dipsti
ck
evide
nce
of
albu
minu
ria
'J3
or
greater( is
helpf
ul.
0ed
and
white
cells.hyaretheseimportant
-
8/18/2019 ASH ISH-Guidelines 2013
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&ositi
ve
findi
ngs
can
be
indic
ative
of
urinary
tract
infect
ions,
kidne
y
stone
s, or
other
poten
tially
serious
urina
ry
tract
condi
tions,
inclu
ding
bladd
er
tumo
rs.
Elect
rocar
diogr
aphy.
hyisthisimportant Elec-
trocar diogr
aphy
'E
( can
help
identi
fy
previ
ous
myoc
ardial
infarc
tions
or
left
atrial
and
ventri
cular
hyper
troph
y
'whic
h is
evide
nceof
target
organ
dama
ge
and
indic
ative
of the
need
for
good
contr
ol of
blood
press
ure(.
E
might
also
identi
fy
cardi
ac
arrhythmia
s
such
as
atrial
fibrill
ation
'whic
h
woul
d
dictat
e the
use
of
certai
n
drugs
( or
condi
tions
such
as
heart
block 'whic
h
-
8/18/2019 ASH ISH-Guidelines 2013
43/69
woul
d
contr
aindi
cate
certai
n
drugs
, eg,
b- block
ers,
rate-
slowi
ng
calci
um
chan
nel
block
ers(.
Echocardi
ograp
hy, if
avail
able,
can
also
be
helpf
ul in
diagn
osing
leftventri
cular
hyper
troph
y and
2uant
ifyin
g the
e9ecti
on
fracti
on in patie
nts
with
suspe
cted
heart
failur
e,
altho
ugh
this
test is
notrouti
ne in
hyper
tensi
ve
patie
nts.
=3ERA%%
G= A%S=6RE A6ME;6
!.
The
goal
of
treat
mentis to
mana
ge
hyper
tensi
on
and
to
deal
with
all
the
other
identi
fied
risk
factor
s for
cardi
ovasc
ular
disea
se,
inclu
dinglipid
disor
ders,
glu-
cose
intole
rance
or
diabe
tes,
obesi
ty,and
smok
ing.
-
8/18/2019 ASH ISH-Guidelines 2013
44/69
or
hyper
tensi
on,
the
treat
ment
goal
for
systolic
blood
press
ure is
usual
ly
@3=8
mm
)g
and
for
diastolic
blood
press
ure
@>8
mm
)g.
!n the
past,
guide
lines
have
recomme
nded
treat
ment
value
s of
@3;85
?8
mm
)g
for
patients
with
diabe
tes,
chron
ic
kidne
y
disea
se,
and
coron
aryartery
disea
se.
)ow-
ever,
evide
nce
to
supp
ort
this
lower
targetin
patie
nts
with
these
condi
tions
is
lacki
ng,
so the
goal
of
@3=85
>8
mm
)g
shoul
d
gener
ally
be
used,
altho
ughsome
e"per
ts
still
reco
mme
nd
@3;85
?8
mm
)g if
albu-
minu
ria is
prese
nt in
patie
nts
with
chron
ic
kidne
y
disease.
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Are
there
other
e"cep
tions
to
@3=85
>8
mm
)g+
ostevide
nce
linkin
g the
effect
s on
cardi
ovasc
ular
or
renal
outco
mes
to
treate
d
blood
press
ures
have
been
based
on
clinic
altrials
in
middl
e-
aged
to
elderl
y
patie
nts
'typic
ally
betw
een
44
and
?8
years
(.
$ome
recen
t
trials
sugge
stthat
in
peopl
e ?8
or
older,
achie
ving
a
systol
ic
blood
pressure of
@348
mm
)g is
assoc
iated
with
stron
g
cardi
ovasc
ular
and
strok
e
prote
ction
and
so a
target
of
@3485
>8
mm
)g isnow
reco
mme
nded
for
patie
nts in
this
age
group
. We
have
almo
st no
clinic
al
trial
evide
nce
regar
ding
blood
press
ure
targets in
patie
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nts
youn
ger
than
48
years.
*iast
olic
blood
press
uremay
be
impo
rtant
in
this
age
group
, so
achie
ving
a
value
@>8
mm
)g
shoul
d be
a
priori
ty. !n
additi
on, itis
also a
reaso
nable
e"pec
tation
that
target
s
@3=85
>8
mm
=fficial +ournal of the American Society ofHypertension! Inc.
6he +ournal
of Clinical Hypertension
*
ASHBISHHypertensionGuidelines Deberet al.
)g
'eg, @
3;85?
8 mm
)g(
could
be
appro
priate
inyoun
g
adult
s and
can
be
consi
dered
.
!H.!t
is
impo
rtant
to
infor
m
patie
nts
that
the
treatment
of
hyper
tensio
n is
usuall
y
e"pec
ted to
be a
life-
longcom
mitm
ent
and
that it
can
be
dange
rous
for
them
to
terminate
their
-
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treat
ment
with
drugs
or
lifest
yle
chan
ges
witho
utfirst
consu
lting
their
practi
tioner
.
;=;PH AR
MAC=%=GIC6RE A6ME;6
$ever
al
lifest
yle
interv
entio
ns
have
been
show
n to
reduc
e
blood
press
ure.
Apartfrom
contri
butin
g to
the
treat
ment
of
hyper
tensi
on,
these
strate
gies
are
benef
icial
in
mana
ging
most
of the
other
cardi
ovasc
ularrisk
factor
s. !n
patie
nts
with
hyper
tensio
n that
is no
more
sever
e
than
stage
3 and
is not
assoc
iated
with
evide
nce
of
abnor
malcardi
ovasc
ular
findin
gs or
other
cardi
ovas-
cular
risks,
: to
37
mont
hs of
lifest
yle
chang
es
can
be
attem
pted
in the
hope
thatthey
may
-
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be
suffic
iently
effect
ive to
make
it
unne
cessa
ry to
usemedi
cines.
)ow
ever,
it
may
be
prude
nt to
start
treat
ment
with
drugs
soone
r if it
is
clear
that
the
blood
press
ure is
not
responding
to the
lifest
yle
meth
ods
or if
other
risk
factor
s
appea
r.
Also,
in
practi
ce
settin
gs
wher
e
patie
nts
have
logistical
diffic
ulties
in
maki
ng
regul
ar
clinic
visits,
it
might
bemost
practi
cal to
start
drug
thera
py
early.
!n
gener
al,
lifest
yle
chang
es
shoul
d be
regar
ded
as a
comp
leme
nt to
drug
thera py
rather
than
an
altern
ative.
Weig
ht
loss#
!n
patients
who
are
over
weig
ht or
obese
,
weig
ht
loss
is
helpf ul in
treati
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ng
hyper
tensi
on,
diabe
tes,
and
lipid
disor
ders.
$ubstitutin
g
fresh
fruits
and
veget
ables
for
more
tradit
ional
diets
may
have
benef
its
beyo
nd
weig
ht
loss.
Info
rtunat
ely,
thesediets
can
be
relati
vely
e"pe
nsive
and
incon
venie
nt for
patie
nts,
and
can
work
only
if
patie
nts
are
provi
ded
with
astron
g
suppo
rt
syste
m.
Even
mode
st
weig
ht
loss
can be
helpf
ul.
$alt
reduc
tion#
)igh-
salt
diets
are
common
in
many
com
munit
ies.
0edu
ction
of
salt
intak
e is
recom-
mend
ed
becau
se it
can
reduc
e
blood
press
ure
anddecre
ase
the
need
for
medi
catio
ns in
patie
nts
who
are
Ksaltsensit
ive,L
-
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whic
h
may
be a
fairly
com
mon
findi
ng in
black
communit
ies.
ften
,
patie
nts
are
unaw
are
that
there
is a
large
amou
nt of
salt
in
foods
such
as
bread
,
canne
d
goods, fast
foods
,
pickl
es,
soups
, and
proce
ssed
meats
. This
intak
e can
be
diffic
ult to
chan
ge
becau
se
salty
foods
are
often
partof the
tradit
ional
diets
found
in
many
cultur
es. A
relate
d
probl
em isthat
many
peopl
e eat
diets
that
are
low
in
potas
sium,and
they
shoul
d be
taugh
t
about
availa
ble
sourc
es of
dietar
y potas
sium.
E"erc
ise#
0egul
ar
aerob
ic
e"erc
ise
canhelp
reduc
e
blood
press
ure,
but
oppor
tuniti
es to
follo
w a
struc-
tured
e"erc
-
8/18/2019 ASH ISH-Guidelines 2013
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ise
regim
en
are
often
limite
d.
$till,
patie
nts
should be
enco
urage
d to
walk,
use
bicyc
les,
climb
stairs,
and
pursu
e
mean
s of
integr
ating
phys-
ical
activi
ty
into
their
daily
routines.
!H.Al
cohol
consu
mptio
n# Ip
to 7
drink
s a
day
can be
helpf
ul in
prote
cting
again
st
cardi
ovasc
ular
event
s,
but
great
er
amou
nts of
alcoh
ol
can
raise
blood
press
ure
and
shoul
d
theref
ore
be
disco
urage
d. !nwom
en,
alcoh
ol
shoul
d be
limite
d to 3
drink
a day.
igar ette
smok
ing#
$topp
ing
smok
ing
will
not
reduc
e
blood
pressure,
but
since
smok
ing
by
itself
is
such
a
ma9or
cardiovasc
ular
risk
-
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factor
,
patie
nts
must
be
stron
gly
urged
to
discontinu
e this
habit.
&atie
nts
shoul
d be
warn
ed
that
stopp
ing
smok
ing
may
be
assoc
iated
with
a
mode
st
incre
ase in
bodyweig
ht.
"R:G6RE A6ME;6=H
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not
have
evide
nce
of
abnor
mal
cardi
ovasc
ular
findings
or
other
risk
factor
s. !n
settin
gs
wher
e
healt
hcare
resou
rces
are
highl
y
limite
d,
clinic
ians
can
consi
der
e"tending
the
nondr
ug
obser
vatio
n
perio
d in
unco
mplic
ated
stage
3
hyper
tensi
ve
patie
nts
provi
ded
there
is no
evi-
dencefor an
incre
ase in
blood
press
ure or
the
appea
rance
of
cardi
ovasc
ularor
renal
findin
gs(.
!n
patie
nts
with
stage
7
hyper tensio
n
'bloo
d
press
ure
3:85388
mm
)g(,
drug
treat
mentshoul
d be
starte
d
imme
diatel
y
after
diagn
osis,
usuall
ywith
a 7-
drug
comb
inatio
n,
witho
ut
waiti
ng to
see
the
effects of
lifest
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yle
chan
ges.
*rug
treat
ment
can
also
be
starte
dimme
diatel
y in
all
hyper
tensi
ve
patie
nts in
who
m,
for
logist
ical
or
other
practi
cal
reaso
ns,
the
practi
tioner
belie
ves itis
neces
sary
to
achie
ve
more
rapid
contr
ol of
blood
press
ure.
The
prese
nce
of
other
cardi
ovasc
ular
risk
factor
sshoul
d also
accel
erate
the
start
of
hyper
tensio
n
treat
ment.
or patie
nts
older
than
?8
years,
the
sugge
sted
thres
hold
for
starti
ng
treat
ment
is at
levels
3485>8
mm
)g.
Thus,
the
targetof
treat
ment
shoul
d be
@3=85
>8
mm
)g
for
most
patie
nts
but
@3485
>8
mm
)g
for
older
patie
nts
'unle
ss
these patie
nts
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have
chron
ic
kidne
y
disea
se or
diabe
tes,
when
@3=85>8
mm
)g
can
be
consi
dered
(.
The
treat
ment
regim
en#
ost
patie
nts
will
re2ui
re
more
than
one
drug
toachie
ve
contr
ol of
their
blood
press
ure.
!n
gener
al,incre
ase
the
dose
of
drugs
or
add
new
drugs
at
appro
"imat
ely 7-
to ;-
week
interv
als.
This
fre2u
ency
can
be
faster
or
slower
depen
d-ing
on
the
9udg
ment
of the
practi
tioner
. !n
gener
al,
the
initial
doses
of
drugs
chose
n
shoul
d be
at
least
halfof the
ma"i
mum
dose
so
that
only
one
dose
ad9ust
ment
is
re2uir
ed
there
after.
!t is
gener
ally
antici
pated
that
most
patie
ntsshoul
d
-
8/18/2019 ASH ISH-Guidelines 2013
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reach
an
effect
ive
treat
ment
regim
en,
whet
her 3,
7, or;
drugs
,
withi
n : to
?
week
s.
!f the
untre
ated
blood
press
ure is
at
least
785
38mm
)g
above
the
target
blood
press
ure,
- 6he +ournalof Clinical Hypertension
=fficial+ournal of the AmericanSociety of Hypertension!Inc.
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ASHBISH Hypertension Guidelines D eber et al.
IG:RE. 6his algorithm summari8es the main recommendations of these guidelines. At any stage it is entirely appropriate to see/ help from ahypertension e@pert if treatment is pro7ing difficult. In patients 9ith stage $ hypertension in 9hom there is no history of cardio7ascular! stro/e!or renal e7ents or e7idence of abnormal findings and 9ho do not ha7e diabetes or other maor ris/ factors! drug therapy can be delayed forsome months. In all other patients including those 9ith stage & hypertensionF! it is recommended that drug therapy be started 9hen thediagnosis of hypertension is made. CC' indicates calcium channel bloc/er# ACE5i! angiotensin5con7erting en8yme inhibitors# AR'!angiotensin receptor bloc/er# thia8ide! thia8ide or thia8ide5li/e diuretics. 'lood pressure 7alues are in mm Hg.
consider starting treatment immediately with 7 drugs.
!H. hoice of drugs#
This should be influenced by the age, ethnicity5 race, and
other clinical characteristics of the patient 'Table !(.
The choice of drugs will also be influenced by other
conditions 'eg, diabetes and coronary disease(
associated with the hypertension 'Table !!(.
®nancy also influences drug choice.
Gong-acting drugs that need to be taken only once
daily are preferred to shorter-acting drugs that
re2uire multiple doses because patients are more
likely to follow a simple treatment regi-men. orthe same reason, when more than one drug is
prescribed, the use of a combination product with
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two appropriate medications in a single tablet can simplify
treatment for patients, although these products can
sometimes be more
e"pensive than individual drugs. nce-daily drugs can be
taken at any time during the day, most usually either in the
morning or in the evening before sleep. !f multiple drugs
are needed, it is possible to divide them between the
morning and the evening.
The choice of drugs will further be influenced by their
availability and affordability. !n many cases, it is
necessary to use whichever drugs have been
provided by government or other agencies. or this
reason, we will only make recommendations for
drug classes, not individ-ual agents, recognizing
that there may be a limited selection of drugs that
can be prescribed by a practitioner. Even among
generic drugs there can be a wide variation in cost.
0ecommendations for drug selection are shown inTable ! '&art 3( for patients whose primary problem
is hypertension, and in Table ! '&art 7(
=fficial +ournal of the American Society of Hypertension! Inc. 6he +ournal of Clinical Hypertension 0
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ASHBISH Hypertension Guidelines D eber et al.
6A'%E I. "rug Selection in Hypertensi7e Patients ith or ithout =ther Maor Conditions
Add Second "rug If
;eeded to Achie7e a
Patient 6ype irst "rug 'P K$)4B24 mm Hg
If 6hird "rug is ;eededto Achie7e a 'P ofK$)4B24 mm Hg
A. hen hypertension is the only or main condition
'lac/ patients African
CC'a or thia8ide diuretic
AR'b or ACE inhibitor
ancestryF? All ages
If una7ailable can add
alternati7e first drug
choiceFhite and other non5blac/
AR'b or ACE inhibitor
CC'a or thia8ide diuretic
Patients?
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cIf eGR K)4 m%Bmin! a loop diuretic eg! furosemide or torsemideF may be needed.
d;ote? If history of myocardial infarction! a b5bloc/er and AR'Bor ACE inhibitor are indicated regardless of blood pressure.
e;ote? If using a diuretic! there is good e7idence for indapamide if a7ailableF.
for patients who have a ma9or comorbidity
associated with their hypertension. The igure
3 displays an algorithm that summarizes the
use of therapy for most patients with
hypertension. The recommendations for particular drug classes are made with the
recognition that sometimes only alternative
drug classes will be available. )owever, most
of the time, the use of any drugs that reduce
blood pressure is more likely to help protect
patients from strokes and other serious events
than giving patients no drug at all.
'RIE C=MME;6S =; "R:GC%ASSES
/ote# There is an assumption, unlessotherwise stated, that all drugs in a class are
similar to each other. We only mention
individual agents if they have an
important property that is not shared by the
others in its class. Table !! provides a list of
commonly used antihypertensive drugs and
their doses.
Angiotensin5con7erting en8yme Inhibitors
These agents reduce blood pressure by
blocking the renin-angiotensin system. They
do this by preventing conversion of
angiotensin ! to the blood pressure-raising
hormone angiotensin !!. They also increase
availability of the vasodilator bradykinin by
block-
ing its breakdown.
Angiotensin-converting enzyme inhibitors arewell tolerated. Their main side effect is cough
'most common in women and in patients of
Asian and African background(. Angioedema
is an uncommon but potentially serious
complication that can threa-
1 6he +ournal of Clinical Hypertension =fficial +ournal of the American Society of Hypertension! Inc.
6A'%E II. "osages of Commonly :sed
Antihypertensi7e "rugs
"aily "osage! mg
%o9 "osage:sual "osage
Calcium channel bloc/ers
;ondihydropyridines
"iltia8em$&4&)4(-4
3erapamil$&4&)4)14"ihydropyridines
Amlodipine&.**$4
elodipine&.**$4Isradipine&.* t9ice*$4 t9ice daily
daily
;ifedipine(4(424;itrendipine$4&4"rugs that target the renin5angiotensin system
Angiotensin5con7erting en8yme inhibitors
'ena8epril*$4)4Captopril$&.* t9ice daily*4$44 t9ice dailyEnalapril*$4)4osinopril$4$4)4%isinopril*$4)4Perindopril))1
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uinapril*$4)4Ramipril&.**$46randolapril$&&1 Angiotensin receptor bloc/ers
A8ilsartan)4
14Candesartan)1(&Eprosartan)44-44144Irbesartan$*4$*4(44%osartan*4*4$44=lmesartan$4&4)46elmisartan)4
)4143alsartan1414(&4"irect renin inhibitor
Alis/iren0*$*4(44"iuretics
6hia8ide and thia8ide5li/e diuretics
'endroflumethia8ide*$4Chlorthalidone$&.*$&.*&*Hydrochlorothia8ide$&.*$&.**4Indapamide$.&*&.*%oop diuretics
'umetanide4.*$urosemide&4 t9ice daily)4 t9ice daily6orsemide*$4Potassium5sparing diuretics
Amiloride**$4Eplerenone&**4$44Spironolactone$&.*&**4
6riamterene$44$44b5'loc/ers
Acebutalol&44&44)44
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ASHBISH Hypertension Guidelines D eber et al.
6A'%E II. ContinuedF
"aily "osage! mg
%o9 "osage:sual "osage
Atenolol&*$44'isoprolol**$4Car7edilol(.$&* t9ice daily-.&*&* t9ice daily%abetalol$44 t9ice daily$44(44 t9ice dailyMetoprolol succinate&**4$44Metoprolol tartrate&* t9ice daily*4$44 t9ice daily;adolol&4)414;ebi7olol&.*
*$4Propranolol)4 t9ice daily)4$-4 t9ice dailya5Adrenergic receptor bloc/ers
"o@a8osin$$&Pra8osin$ t9ice daily$* t9ice daily6era8osin$$&3asodilators! central a5agonists! and adrenergic depleters3asodilators
Hydrala8ine$4 t9ice daily&*$44 t9ice dailyMino@idil&.**$4Central alpha5agonists
Clonidine
4.$ t9ice daily4.$4.& t9ice dailyClonidine patch66S5$! once 9ee/ly66S5$! &! or (!
once 9ee/lyMethyldopa$&* t9ice daily&*4*44 t9ice daily Adrenergic depleters
Reserpine4.$4.$4.&*
All doses are gi7en once5daily unless other9ise specified.
ten airway function, and it occurs most
fre2uently in black patients.
These drugs can increase serum creatinine by
as much as ;8B, but this is usually because
they reduce pressure within the renal
glomerulus and decrease filtration. This is a
reversible change in function and is not
harmful. An even greater increase in
creatinine sometimes occurs when
angiotensin-converting enzyme inhibitors are
combined with diuretics and produce large
blood pressure reductions. Again, this change
is reversible, although it may be necessary to
reduce doses of one or both drugs. !f
creatinine levels increase substantially this
can be caused by concom-itant treatment withnonsteroidal anti-inflammatory drugs or it
may indicate the presence of renal artery
stenosis.
The side effects associated with angiotensin-
convert-ing enzyme inhibitors are generally
not dose-depen-dent, as they occur as
fre2uently at low doses as at high doses. Thus,
it can be perfectly acceptable when using
these agents to start at medium or even high
doses. The one e"ception to this rule is inhyperkal-emia, which may occur more
fre2uently at higher
angiotensin-converting enzyme inhibitor
doses.
These drugs have established clinical outcome
ben-efits in patients with heart failure, post myocardial
=fficial +ournal of the American Society of Hypertension! Inc. 6he +ournal of Clinical Hypertension 2
ASHBISH Hypertension Guidelines D eber et al.
infarction, left ventricular systolic
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dysfunction, and diabetic and nondiabetic
chronic kidney disease.
!n general, angiotensin-converting enzyme
inhibitors are more effective as monotherapy
in reducing blood pressure in white patients
than in black patients, possibly because the
renin-angiotensin system is often less active
in black patients. )owever, these drugs are
e2ually effective in reducing blood pressurein all ethnic and racial groups when combined
with
either calcium channel blockers or diuretics.
*o not combine angiotensin-converting
enzyme inhibitors with angiotensin receptor
blockers1 each of these drug types is
beneficial in patients with kidney disease, but
in combination they may actually
have adverse effects on kidney function.
When starting treatment with an angiotensin-
con-verting enzyme inhibitor, there is a risk of
hypoten-sion in patients who are already
taking diuretics or are on very low-salt diets
or are dehydrated 'eg, laborers in hot climates
and patients with diarrhea(. or patients
taking a diuretic, skipping a dose before
starting the angiotensin-converting enzyme
inhibitor
helps prevent this sudden effect on blood pressure. Angiotensin-converting enzyme
inhibitors must not be used in pregnancy,
especially in the second or third trimesters,
since they can compromise the
normal development of the fetus.
Angiotensin Receptor 'loc/ers
Angiotensin receptor blockers, like
angiotensin-con-verting enzyme inhibitors,
antagonize the renin-angiotensin system.They reduce blood pressure by blocking the
action of angiotensin !! on its AT3 receptor
and thus prevent the vasoconstrictor effects
of this receptor.
The angiotensin receptor blockers are well
toler-ated. %ecause they do not cause cough
and only rarely cause angioedema, and have
effects and benefits similar to angiotensin-
converting enzyme inhibitors, they are
generally preferred over angio-tensin-converting enzyme inhibitors if they are
available and affordable. Gike angiotensin-
convert-ing enzyme inhibitors, angiotensin
receptor blockers can increase serum
creatinine 'see comments about angiotensin-
converting enzyme inhibitors(, but usu-ally
this is a functional change that is reversible
and
not harmful.
These drugs do not appear to have dose-dependent side effects, so it is perfectly
reasonable to start treatment
with medium or even ma"imum approved
doses.
These drugs have the same benefits on
cardiovascular and renal outcomes as
angiotensin-converting
enzyme inhibitors.
Gike angiotensin-converting enzyme
inhibitors, they tend to work better in white
and Asian patients than in black patients, but,
when combined with either calcium channel
blockers or diuretics, they become e2ually
effective in all patient groups.
*o not combine angiotensin receptor blockers
with angiotensin-converting enzyme
inhibitors1 each of these drug types is
beneficial in patients with kidney disease, but
in combination they may actually have
adverse effects on renal events.
When starting treatment with an angiotensin
recep-tor blocker in patients already taking
diuretics, it may be beneficial to skip a dose
of the diuretic to
prevent a sudden fall in blood pressure.
Angiotensin receptor blockers must not be
used in pregnancy, especially in the second or
third trimes-ters, since they can compromise
the normal devel-opment of the fetus.
6hia8ide and 6hia8ide5li/e "iuretics
These agents work by increasing e"cretion of
sodium by the kidneys and additionally may
have some
vasodilator effects.
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linical outcome benefits 'reduction of
strokes and ma9or cardiovascular events( have
been best estab-lished with chlorthalidone,
indapamide, and hydro-chlorothiazide,
although evidence for the first two of
these agents has been the strongest.
hlorthalidone has more powerful effects on
blood pressure than hydrochlorothiazide'when the same doses are compared( and has
a longer duration of
action.
The main side effects of these drugs are
metabolic 'hypokalemia, hyperglycemia, and
hyperuricemia(. The likelihood of these
problems can be reduced by using low doses
'eg, 37.4 mg or 74 mg of hydro-
chlorothiazide or chlorthalidone( or by
combining these diuretics with angiotensin-converting enzyme inhibitors or angiotensin
receptor blockers, which have been shown to
reduce these metabolic changes. ombining
diuretics with potassium-sparing agents
also helps prevent hypokalemia.
*iuretics are most effective in reducing blood
pressure when combined with angiotensin-
convert-ing enzyme inhibitors or angiotensin
receptor block-ers, although they are also
effective when combined with calcium
channel blockers.
/ote# Thiazides plus b-blockers are also aneffective combination for reducing blood
pressure, but since both classes can increase blood glucose concentrations this
combination should be used with caution in
patients at risk for developing diabetes.
Calcium Channel 'loc/ers
These agents reduce blood pressure by
blocking the inward flow of calcium ions
through the G channels
of arterial smooth muscle cells.
There are two main types of calcium channel
blockers# dihydropyridines, such as
amlodipine and nifedipine, which work by
dilating arteries1 and nondihydropyridines,
such as diltiazem and verapa-mil, which
dilate arteries somewhat less but also reduce
heart rate and contractility.
$4 6he +ournal of Clinical Hypertension =fficial +ournal of the American Society of Hypertension! Inc.
ost e"perience with these agents has been
with the dihydropyridines, such as amlodipine
and nifedipine, which have been shown to
have beneficial effects on cardiovascular and
stroke outcomes in hypertension
trials.
The main side effect of calcium channel
blockers is peripheral edema, which is most prominent at high doses1 this finding can
often be attenuated by combining these agents
with angiotensin-convert-ing enzyme
inhibitors or angiotensin receptor block-
ers.
/ondihydropyridine calcium channel
blockers are not recommended in patients
with heart failure, but amlodipine appears to
be safe when given to heart failure patients
receiving standard therapy 'includingangiotensin-converting enzyme inhibitors( for
this
condition.
%ecause the nondihydropyridine drugs,
verapamil and diltiazem, can slow heart rate,
they are some-times preferred in patients with
fast heart rates and even for rate control in
patients with atrial fibrilla-
tion who cannot tolerate b-blockers. /ondihydro-pyridine drugs can also reduce
proteinuria.
alcium channel blockers have powerful
blood pressure-reducing effects, particularly
when com-bined with angiotensin-converting
enzyme inhibitors or angiotensin receptor
blockers. They are e2ually
effective in all racial and ethnic groups.
The dihydropyridine, but not the
nondihydropyri-dine, agents can be safely
combined with b-blockers.
b5'loc/ers
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b-blockers reduce cardiac output and alsodecrease the release of renin from the kidney.
They have strong clinical outcome benefits in
patients with histories of myocardial
infarction and heart failure and are effective
in the management of
angina pectoris.
They are less effective in reducing blood
pressure in black patients than in patients of
other ethnic-
ities.
b-blockers may not be as effective as theother ma9or drug classes in preventing strokeor cardiovascular events in hypertensive
patients, but they are the drugs of choice in
patients with histories of myocar-
dial infarction or heart failure.
any of these agents have adverse effects on
glucose metabolism and therefore are not
recommended in patients at risk for diabetes,
especially in combina-tion with diuretics.
They may also be associated with
heart block in susceptible patients.
The main side effects associated with b- blockers are reduced se"ual function, fatigue,
and reduced e"er-
cise tolerance.
The combined a- and b-blocker, labetalol, iswidely used intravenously for hypertensive
emergencies, and is also used orally for
treating hypertension in pregnant and
breastfeeding women.
ASHBISH Hypertension Guidelines D eber et al.
a5'loc/ers
a-%lockers reduce blood pressure by blockingarte-rial a-adrenergic receptors and thus
preventing the vasoconstrictor actions of
these receptors.
These drugs are less widely used as first-step
agents than other classes because clinical
outcome benefits have not been as well
established as with other agents. )owever,
they can be useful in treating resistant
hypertension when used in combination
with agents such as diuretics, b-blockers, andangio-tensin-converting enzyme inhibitors.
To be ma"imally effective, they shouldusually be combined with a diuretic. $ince a-
blockers can have somewhat beneficial effects
on blood glucose and lipid levels, they can
potentially neutralize some of
the adverse metabolic effects of diuretics.
The a-blockers are effective in treating benign prostatic hypertrophy, and so can be a
valuable part of hypertension treatment
regimens in older men who have this
condition.
Centrally Acting Agents
These drugs, the most well-known of which
are clonidine and a-methyldopa, work primarily by reducing sympathetic outflow
from the central ner-
vous system.
They are effective in reducing blood pressure
in most patient groups.
%othersome side effects such as drowsiness
and dry mouth have reduced their popularity.
Treatment with a clonidine skin patch causes
fewer side effects than the oral agent, but the
patch is not always
available and can be more costly than the
tablets. !n certain countries, including the
Inited $tates,
a-methyldopa is widely employed for treatinghyper-tension in pregnancy.
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"irect 3asodilators
%ecause these agents, specifically hydralazine
and mino"idil, often cause fluid retention and
tachycar-dia, they are most effective in
reducing blood
pressure when combined with diuretics and b-
blockers or sympatholytic agents. or thisreason, they are now usually used only as
fourth-line or later
additions to treatment regimens.
)ydralazine is the more widely used of these
agents. The powerful drug mino"idil is
sometimes used by specialists in patients
whose blood pressures are difficult to control.
luid retention and tachycardia are fre2uent
problems with mino"idil, as well as unwanted
hair growth 'particularly in women(.
urosemide is often re2uired to cope with the
fluid retention.
Mineralocorticoid Receptor Antagonists
The best known of these agents is
spironolactone. Although it was originally
developed for the treat-ment of high
aldosterone states,