Htn update
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What’s New in Hypertension-More More More !
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I am a gentle killer All over the world, I am called HYPERTENSION
World Hypertension Day, annually celebrated on May 17th
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Nov 2013
Oct 2011 Oct 2013
2013 20102012
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Dec 2013
Jun 2013
Dec 2013
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Category Systolic Diastolic
Optimal <120 and <80
Normal 120-129 and/or 80–84
High normal 130-139 and/or 85–89
Grade 1 hypertension 140-159 and/or 90-99
Grade 2 hypertension 160-179 and/or 100-109
Grade 3 hypertension ≥180 and/or ≥110
Isolated systolic hypertension
≥140 and <90
Definitions and classification of office BP levels (mmHg)
The blood pressure (BP) category is defined by the highest level of BP, whethersystolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3according to systolic BP values in the ranges indicated
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Factors—other than office BP—influencingprognosis; used for stratification of total CV risk
Risk Factors• Male sex• Age (men ≥55 years; women ≥65
years)• Smoking• DyslipidaemiaTC > 190 mg/dL, and/orLDL >115 mg/dL, and/orHDL: men <40 mg/dL, women < 46
mg/dL, and/orTriglycerides >150 mg/dL
• Fasting plasma glucose 102–125 mg/dL
• Abnormal glucose tolerance test
• Obesity [BMI ≥30 kg/m² (height²)]
• Abdominal obesity (waist circumference: men ≥102
cm;women ≥88 cm) • Family history of premature
CVD (men aged <55 years; women aged <65 years)
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Factors—other than office BP—influencingprognosis; used for stratification of total CV risk
Asymptomatic organ damage
• Pulse pressure (in the elderly) ≥60 mmHg
• ECG :LVH (Sokolow–Lyon index >3.5 mV;RaVL >1.1 mV; Cornell voltage duration product >244 mV x ms), or
• Echo: LVH [LVM index: men >115 g/m²;women >95 g/m² (BSA)]
• Carotid wall thickening (IMT >0.9 mm) or plaque
• Carotid–femoral PWV >10 m/s• Ankle-brachial index <0.9 • CKD with eGFR 30–60
ml/min/1.73 m² (BSA)• Microalbuminuria (30–300
mg/24 h), or albumin–creatinine ratio 30–300 mg/g; (preferentially on morning spot urine)
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Factors—other than office BP—influencingprognosis; used for stratification of total CV risk
Diabetes mellitus
• Fasting plasma glucose ≥126 mg/dL on two repeated measurements, and/or
• HbA1c >7% , and/or• Post-load plasma glucose >198 mg/dL
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Factors—other than office BP—influencingprognosis; used for stratification of total CV riskEstablished CV or renal Disease
• Cerebrovascular disease: stroke; TIA• CHD:MI; angina; revascularization with PCI or CABG• HF, including HF with preserved EF• Symptomatic lower extremities PAD • CKD with eGFR <30 mL/min/1.73m²(BSA); proteinuria (>300 mg/24 h).• Advanced retinopathy: haemorrhages or exudates,
papilledema
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Blood Pressure (mmHg)
High normalSBP 130–139or DBP 85–89
Grade 1 HTSBP 140–159or DBP 90–99
Grade 2 HTSBP 160–179or DBP 100–109
Grade 3 HTSBP ≥180or DBP ≥110
Other risk factors,asymptomatic organ damage or disease
No other RF
1-2 RF
≥3 RF
OD, CKD stage 3 or diabetes
Symptomatic CVD, CKD stage ≥4 or
diabetes with OD/RFs
BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; DBP = diastolic blood pressure; HT = hypertension;OD = organ damage; RF = risk factor; SBP = systolic blood pressure
Total CV RISK
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Stratification of total CV risk in categories of low, moderate, high and very high risk according to SBP and DBP and prevalence of RFs,Asymptomatic OD,diabetes,CKD stage or symptomatic CVD.
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Initiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated(<140/90). (in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)
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Blood Pressure (mmHg)
High normalSBP 130–139or DBP 85–89
Grade 1 HTSBP 140–159or DBP 90–99
Grade 2 HTSBP 160–179or DBP 100–109
Grade 3 HTSBP ≥180or DBP ≥110
Other risk factors,asymptomatic organ damageor disease
No other RF
1-2 RF
≥3 RF
OD, CKD stage 3 or diabetes
Symptomatic CVD, CKD stage ≥4 or
diabetes with OD/RFs
Compelling in
dications
No Compelling indications
Choice of drug treatment
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Any Body Can Dance
A B C D
2013 Indian dance film
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The A,B,C,D drug classes
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Diuretics (thiazides,chlorthalidone and indapamide), beta-blockers,calcium antagonists, ACE inhibitors, and angiotensin receptor blockers are all suitable and recommended for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations with each other
Choice of drug treatmentNo suggestion, all 5 classesNo ranking or classification of preferred drugs
AA BB CC DD
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Possible combinations of classes of antihypertensive drugs
Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination.
DD
AA
AA
CC
BB
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The Joint National Committee (JNC )
JNC 8 Has Finally Arrived
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This JNC 8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from
JNC 7 reasonable.
Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 < 80
Pre – hypertension 120-139 80-90
Hypertension
Stage 1 140 – 159 90 – 99
Stage 2 160 and above 100 and above
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JNC 7 Compelling Indications
† ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.
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Questions guiding the JNC 8 review
This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management. They address thresholds, goals for pharmacologic treatment, and whether particular antihypertensive drugs or drug classes improve important health outcomes compared to others.
1.In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
2.In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
3.In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes?
The answers to these three questions are reflected in 9 recommendations
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Recommendation 1 (Strong recommendation)
Recommendation 2 (Strong recommendation)
Recommendation 3 (Expert opinion)
General population ≥60 years
SBP ≥150 mm Hgor DBP ≥90 mm Hg
SBP <150 mm Hgand DBP <90 mm Hg
General population <60 years DBP ≥90 mm Hg DBP <90 mm Hg
General population <60 years SBP ≥140 mm Hg SBP <140 mm Hg
RecommendationsGoalsBP thresholds
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Recommendation 4 (Expert opinion)
Recommendation 5 (Expert opinion)
Recommendation 6 (Moderate recommendation)
Population with CKD ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
Population with diabetes ≥18 years
SBP ≥140 mm Hgor DBP ≥90 mm Hg
SBP <140 mm Hgand DBP <90 mm Hg
General nonblack population ( ± diabetes )
or
RecommendationsGoalsBP thresholds
Initial treatment
AA CC DDor
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RecommendationsRecommendation 7 (Moderate recommendation)
Recommendation 8 (Moderate recommendation)
Recommendation 9 (Expert opinion)
General ( ± diabetes )
black population or
Population with CKD ≥18 years
Goal BP not reachedwithin a month of treatment
Increase the dose of the initial drug,or add a second drug (from the list provided)
Goal BP not reachedwith 2 drugs
Add and titrate a third drug (from the list provided)Do not use an ACEI and an ARB together in the same patient
Initial treatments
Initial or add-on treatments
Non control strategies
CC DD
AA
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DM CKD
CC DD AA
BB
AA CC DDAlone or in combination
Alone or in combination with other drug class
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Focus on evidence based recommendations Higher target SBP for patients over 60 y/o Limited data to support either 150 or 140
mmHg Removed special lower target BP for those with CKD or DM Liberalized initial drug choices
Major changes from JNC 7
AA CC DD
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Drug Selection in Hypertensive Patients
A. When hypertension is the only or main condition
Patient TypeBlack patients (African ancestry
First Drug Add Second Drug IfNeeded to Achieve
a BP <140/90 mm Hg
If Third Drug is Needed to Achieve
BP of <140/90 mm Hg
All ages
orCC
DD
AA
CC
DD
+
+
Black CD
DD
AA CC
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Drug Selection in Hypertensive Patients
A. When hypertension is the only or main condition
Patient TypeWhite and other non- black Patients
First Drug Add Second Drug IfNeeded to Achieve aBP <140/90 mm Hg
If Third Drug is Needed to Achievea BP of <140/90 mm Hg
Younger than 60
60 y and older
AA
CCDDor AA
CC
DDCC DDor
AA
Also OK AA CC
DD
+
+
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Drug Selection in Hypertensive PatientsB. When hypertension is associated with other conditions
Patient Type First Drug Add Second Drug IfNeeded to Achieve aBP <140/90 mm Hg
If Third Drug is Needed to Achieve a BP of <140/90 mm Hg
Hypertension and diabetes
Note: in black patients,it is acceptable to start with
Hypertension and CKD
AA
CC DD
AA CC DDor
AA
CC
DD
+
+
AA
CC DD or
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Nonblack
Younger than 60
60 y and older
Black
Diabetes Note: in black patients, it is acceptable to start with
CKD
ASH/ISHInitial Drug ChoicesJNC 8
AA CC DD
CC DDAA CC DD
AA
AA
CC DDAA
Also OK
AACC DD
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Take a deep breathTake a deep breath
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Guidelines are meant to “guide” and not to “mandate”
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Population Goal BP,mm Hg
Initial Drug Treatment Options
General nonelderly
<140/90
General elderly <80 yGeneral ≥80 y
<150/90
Diabetes <140/85
CKD <140/90
CKD + proteinuria <130/90
General <60 y <140/90 Nonblack
Black
General ≥60 y <150/90
Diabetes <140/90
CKD 140/90
ESH/E
SCJN
C 8
AA BB CC DD
AA
AA CC DD
CC DD
AA CC DDAA
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AACC
DD
AABB
CCDD
Replaces
As first line drug ESH/ESC2013
ASH/ISH2014
2014“JNC 8”
Beta-blockers Yes No (Step 4)
No (Step 4)
Initial Drug Choices
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DD
AA CC
BB ß-blocker should be included in the regimen if there a compelling indication for a ß-blocker
Possible combinations of ABCD classes
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Lower your number
Lower your risk
Treat patients and not numbers
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New Hypertension Guidelines
Offer Information for Doctors
Around the Globe
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