I am a gentle killerAll over the world, I am called HYPERTENSION

World Hypertension Day, annually celebrated on May 17th

Statement of Need

“My greatest challenge as a doctor in the management of

patients with hypertension is……………”

Please write down your answer to the following:

When to begin treatment,How low to aim for, and Which antihypertensive medications to use.

Evidence-Based Cardiology Consult

Highes

t LOE

Lowes

t LOE

Levels Of Evidence Pyramid

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

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)

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)

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

Established 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

High risk

Moderate risk

Low 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

Any Body Can Dance

A B C D

2013  2014

Any Body Can DanceAny Body Can Dance 2

The A,B,C,D drug classes

Diuretics (thiazides,chlorthalidone and indapamide), beta-blockers,calcium antagonists, ACE inhibitors, and ARBs 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 classes

No 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 )

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

Hypertension

Heart Failure

Coronary Heart Disease

Diabetes

Chronic Kidney Disease

JNC 7 Compelling Indications

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

Compelling Indicator: Heart FailureACE-I (or ARB) is indicated in nearly all patients with LV systolic dysfunction. ACE-I (or ARB) should be titrated to target HF doses, even if BP is low, as long as the patient does not become symptomatic or develop impaired renal perfusion.

Beta Blockers in nearly all patients with LV systolic dysfunction .Titrate to target HF doses.

Consider spironolactone after the patient is placed on the maximum doses of ACE-I and beta-blocker,especially if Class III or IV

Diuretics (usually loop) are often required for fluid management

Compelling Indicator : Chronic Kidney DiseaseACE-I and ARB’s can slow

progression of kidney disease.

A limited increase in serum creatinine of as much as 30% above baseline with ACE-I or ARB is acceptable and not a reason to withhold treatment, unless hyperkalemia develops.

A limited increase in serum creatinine of as much as 30% above baseline with ACE-I or ARB is acceptable and not a reason to withhold treatment, unless hyperkalemia develops.

In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²) higher doses of loop diuretics may be needed in combination with other drug classes.

In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²) higher doses of loop diuretics may be needed in combination with other drug classes.

Stages of Chronic Kidney DiseaseTwo Screening Tests

•eGFR

•ACR–Albumin/Creatinine ratio

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(irrespective of

race or diabetes)

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

Black CD

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

JNC 8 :Relaxing blood pressure goals

Higher real-world blood pressures

This is akin to the “speed limit rule”—people are more likely to hover above target,no matter what the target is.

ESH/ESC BP-lowering drugs recommended when total cardiovascular risk is high because of organ damage, diabetes, cardiovasculardisease, or chronic kidney disease

JNC 8 BP-lowering drugs recommended to lower BP <140 mm Hg systolic and 90 mm Hg diastolic in patients aged <60 years ,and <150 mm Hg systolic and 90 mm Hg diastolic in patients aged >60 years

Recommendation in patients with grade I hypertension (BP 140–159 mm Hg systolic or 90–99 mm Hg diastolic)

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

One Size Does Not Fit All.

New hypertension guidelines:

One size fits most?

New hypertension guidelines:

One size fits most?

?

Lower

your

num

ber

Lower

your

risk

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

The JNC 8 : Nine recommendations

AACC

DD

AABB

CCDD

Replaces

As first line drug 2013 “ESH/ESC”

2014 “ JNC 8 ”

Beta-blockers Yes No (Step 4)

Initial Drug Choices

DD

AA CC

BBß-blocker should be included in the regimen if there a compelling indication for a ß-blocker

Possible combinations of ABCD classes

Angina PectorisPost-MI

Heart FailureAtrial Fib.

Aortic Aneurysm