1 1 individualized therapy forhypertension introduction to primary care: a course of the center of...
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1 1
Individualized TherapyIndividualized Therapyfor for
HypertensionHypertension
Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847
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To describe the "stepwise approach" to therapy.
To discuss: 1. The evidence for the role of lifestyle
changes 2. The indications, contraindications
and side effects of various antihypertensive classes
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Prompt diagnosis Assess the risk Achieve target levels of BP
Lifestyle Combination therapy
Promote adherence
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1. Global cardiovascular risk should be assessed.
2. In the absence of data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds.
3. Shared decision-making may improve the effectiveness of preventive health interventions.
Counting risk factors underestimates the risk
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Condition Initiation
SBP / DBP mmHg
Diastolic ± systolic hypertension 140/90
Isolated systolic hypertension SBP = or >160
Diabetes 130/80
Renal disease ( 130/80)
Proteinuria >1 g/day ( 125/75)
Target
SBP / DBP mmHg
<140/90
<140
<130/80
<130/80
<125/75
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1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet
2. Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week or more
3. Reduction in alcohol consumption in those who drink excessively ( ( ≤ 2 drinks/ day)
4. Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25)
5. Waist Circumference< 102 cm for men< 88 cm for women
5. In individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day
6. Smoke free environment
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Strongly consider prescription if: Average DBP equal or over 90 mmHg Hypertensive Target-organ damage (or
CVD) Independent cardiovascular risk
factors: Elevated systolic BP Cigarette smoking Abnormal lipid profile Strong family history of premature CV disease Truncal obesity Sedentary Lifestyle Average DBP equal or over 80 mmHg in a patient with diabetes
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Associated risk factors?or
Target organ damage/complications?or
Concomitant diseases/conditions?
IndividualizedTreatment
(with compelling indications)
YES
Treatment in theabsence of compelling
indication
NO
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INITIAL TREATMENT AND MONOTHERAPY
* No longer preferred as routine initial therapy
Beta-blocker*
Long-actingCCB
Thiazide ACE-I ARB
Lifestyle modificationtherapy
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
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CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or lifestyle?• White coat effect?• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
2. Triple or Quadruple Therapy
1. Dual Combination Therapy
If partial response to monotherapy
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* Not indicated as first line therapy over 60
CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
Dual Combination
Triple or Quadruple Therapy
Lifestyle modificationtherapy
Thiazidediuretic ACE-I Long-acting
CCBBeta-
blocker* ARB
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
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Column 1 Column 2
• Thiazide diuretic
• Long-acting calcium channel blocker*
• Beta adrenergic blocker
• ACE Inhibitor
• ARB
For additive hypotensive effect in dual therapy Combine an agent from Column 1 with any in Column 2
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
(ACE=Angiotensin Converting Enzyme, ARB=Angiotension Receptor Blocker)
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Column 1 Column 2
• Thiazide diuretic
• Long-acting calcium channel blocker*
• Beta adrenergic blocker
• ACE Inhibitor
• ARB
For additive hypotensive effect in triple therapy Combine 2 agents from one Column with any in the other Column
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
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Target BP (mm Hg)Number of antihypertensive agents
1Trial 2 3 4
AASK MAP <92
UKPDS DBP <85
ABCD DBP <75
MDRD MAP <92
HOT DBP <80
IDNT SBP <135/DBP <85
ALLHAT SBP <140/DBP <90
DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure. Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.Lewis EJ et al. N Engl J Med. 2001;345:851-860.Cushman WC et al. J Clin Hypertens. 2002;4:393-405.
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Individualized treatment Compelling indications:
• Smoking• 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
Diabetes Mellitus• With Diabetic Nephropathy• Without Diabetic Nephropathy
Global Vascular Protection for Hypertensive Patients• Statins• Aspirin
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INITIAL TREATMENT AND MONOTHERAPY
Thiazide diuretic
Long-actingDHP CCB
Lifestyle modificationtherapy
ARB
TARGET <140 mmHg Systolic BP
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CONSIDER
• Nonadherence?• Secondary HTN?• Interfering drugs or
lifestyle?• White coat effect?
Thiazide diuretic
Long-actingDHP CCB
Dual combination
Triple or Quadruple* combination
Lifestyle modificationtherapy
ARB
TARGET <140 mmHg Systolic BP
*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).
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Thiazide - type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
Certain high-risk conditions are compelling indications for other drug classes.
Most patients will require two or more antihypertensive drugs to achieve goal BP.
If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.
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The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.
Motivation improves when patients have positive experiences with, and trust in, the clinician.
Empathy builds trust and is a potent motivator.
The responsible physician’s judgment remains paramount.
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CVD risk has now replaced CHD risk (to include strokes)
The current CVD risk threshold is >20% over 10 years (equivalent to CHD risk of 15%)
Current advice from the BHS is to prescribe a statin in all patients with hypertension and a CVD risk of 20% or greater.
Unless contra-indicated low dose aspirin should be considered in patients over 50 with a CVD risk of >20% when the blood pressure is controlled.
CVD risk has implications regarding levels to treat.
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Saudi Hypertension Management Guidelines 2007
Specialist referral is indicated if there is a possible underlying cause or
presenting as: •sudden onset •worsening of hypertension •resistance to multi-drug regimen
three or more drugs •Hypertension diagnosed in young age
( < 35 years) •persistent noncompliance
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