What’s New in Hypertension-More More More !

I am a gentle killer All over the world, I am called HYPERTENSION

World Hypertension Day, annually celebrated on May 17th

Nov 2013

Oct 2011 Oct 2013

2013 20102012

Dec 2013

Jun 2013

Dec 2013

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

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)

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)

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

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

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

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.

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.)

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

Any Body Can Dance

A B C D

2013 Indian dance film 

The A,B,C,D drug classes

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

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

The Joint National Committee (JNC )

JNC 8 Has Finally Arrived

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

JNC 7 Compelling Indications

† ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.

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

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

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

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

DM CKD

CC DD AA

BB

AA CC DDAlone or in combination

Alone or in combination with other drug class

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

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

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

+

+

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

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

Take a deep breathTake a deep breath

Guidelines are meant to “guide” and not to “mandate”

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

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

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

Lower your number

Lower your risk

Treat patients and not numbers

New Hypertension Guidelines

Offer Information for Doctors

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