.

Figure 1. Coronary heart disease (A) and stroke (B) mortality rate in each decade of age
versus usual BP at the start of that decade.

Franco V et al. Circulation 2004;109:2953-2958

Copyright American Heart Association

2 5
30 (2
10/5 .)
SBP DBP
BP <140/90 mmHg
chronic kidney disease diabetes BP goal
<130/80 mmHg (<125/75 mmHg proteinuria >1 gm/day)

Isolated Systolic HT (ISH) SBP >140 DBP <90 mmHg.

Isolated Office HT (white-coat HT) home BP <135/85
Masked HT ; no office HT but home BP > 135/85
Orthostatic hypotension ; SBP <20 mmHg.
BP >20/10 mmHg. Refer
BP

2 2-4 (
BP >180/110 mmHg. BP >140/90 +
SCORE >5)

Category

SBP

DBP

Optimal

<120

and

<80

Normal
High normal
Grade 1 hypertension
(mild)

120-129
130-139
140-159

and/or
and/or
and/or

80-84
85-89
90-99

Grade 2 hypertension
(moderate)

160-179

and/or

100-109

Grade 3 hypertension
(severe)
Isolated systolic
hypertension

>180

and/or

>110

>140

and

<90


HT
SBP

DBP

Office or clinic

140

90

24-hour

125-130

80

Day

130-135

85

Night

120

70

Home

130-135

85

2-3 /
white-coat effect

presence progression organ damage

(office BP values)

Awareness ( )
Treatment (/)
( )
Patient history of cardiovascular disease
Family history (HT, CVD, sudden death) 65 55
Lifestyle factors (alcohol, smoking, exercise, stress, diet)

(90 . 80 .)
Funduscopic examination

Examination of the neck, heart, lungs, abdomen, and extremities
Neurological assessment

Fasting plasma glucose*

Hemoglobin and hematocrit
Lipid profile (Total chol, TG,
HDL) 12 *
Urine dipstick and sediment

Creatinine*
EKG
Uric acid
Potassium*


(Secondary hypertension)

<25 >55
20/10 .
( nocturia
)
>180/110 mmHg
3 (resistant HT)

(sudden onset of hypertension)

Echocardiogram

Carotid ultrasound
Glucose tolerance test
Microalbuminuria
24 hr-proteinuria
Ankle brachial index (ABI)

carotid bruit, amaurosis fujax, stroke
FPG 110-125 mg/dl
Diabetes mellitus
Urine protein dipstick positive
Claudication, Diabetes mellitus

 Cardiovascular Risks
Major Risk Factors:
Smoking

ESH 2007

Family history of CVD or sudden

death male <55 female <65 years
Diabetes mellitus
FBS > 126 mg/dl or 2 hr.GTT >
198 mg/dl

*Glucose tolerance test

Fasting plasma glucose 102-125 ./

.+

* CVD 2003 ESH / ESC Guidelines

+ metabolic syndrome

 Cardiovascular Risks
Major Risk Factors:

ESH 2007

Age male >55 female >65

Total cholesterol >240 mg/dl or LDLchol >160 mg/dl
HDL-chol male <40 mg/dl or female <45
mg/dl

*Total cholesterol >190 ./.

*LDL-cholesterol >115 ./.
*HDL-cholesterol : <40 ./

. ; <46 ./.+

* CVD 2003 ESH / ESC Guidelines

+ metabolic syndrome

 Cardiovascular Risks
Major Risk Factors:

ESH 2007

BMI >25 kg/m2 or sedentary lifestyle

* pulse pressure (
)

*Triglyceride >150 ./.+

* :>90 . ; >80

. +
* CVD 2003 ESH / ESC Guidelines
+ metabolic syndrome

 Target Organ Damage (Subclinical OD)

Target Organ Damage
Left ventricular
hypertrophy
Nephropathy

/
CXR, EKG
Echocardiographic LVH (LVMI >125 /
2 ; >110 /2)
Microalbuminuria 30-300 mg/day
albumin-creatinine ratio : >22 ./
; >31 ./

 Target Organ Damage (Subclinical OD)

Target Organ Damage
Retinopathy
Atherosclerotic plaque
(aorta, carotid, coronary,
iliac, femoral arteries)

/
Fundoscopy grade 3-4
X-ray, ultrasound
carotid wall (IMT >0.9 .)
plaque
*Carotid-femoral pulse wave velocity >12 ./

*Ankle/Brachial BP index <0.9

Clinical Cardiovascular Disease

(Associated clinical condition-ACC)
Diabetes mellitus

FBS >126 mg/dl

Postload plasma glucose >200 ./.
HbA1C > 6.5

Stroke and TIA, RIND

Heart diseases (CAD, MI,
CABG, PCI, CHF)

CXR, EKG

Clinical Cardiovascular Disease

(Associated clinical condition-ACC)
Chronic kidney disease (Cr >1.3-1.5
mg/dl in male or >1.2-1.4 mg/dl in
female, Creatinine clearance <60
dl/min, albuminuria >300 mg/day or
proteinuria >500 mg/day
*Estimate GFR creatinine
clearance <60 ./

Creatinine, urine
microalbuminuria, UA

Cockroft-Gault formula Ccr

(ml/min) = (140-age yrs) (wt
kg) x 0.85 ()/ 72 x Scr
(mg/dl)

* CVD 2003 ESH / ESC Guidelines

(optional)

Clinical Cardiovascular Disease

(Associated clinical condition-ACC)
Peripheral arterial disease
Advanced HT retinopathy
hemorrhage exudates,
papilledema (grade 3-4)

Ankle-Brachial Index <0.9

Stratification of Risk to Quantify Prognosis

low 15- moderate 20- high 30- very high in10 yrs.
Blood pressure (mmHg)

Other RF
OD or
Disease

High normal
SBP 130-139
or DBP 85-89

Grade 1
SBP 140-159
or DBP 90-99

Grade 2
Grade 3
SBP 160-179
SBP > 180
or DBP 100-109 or DBP > 110

No other RF

Average

Average

Low

Moderate

High

1-2 RF

Low

Low

Moderate

Moderate

Very High

> 3 RF, MS,

OD or DM

Moderate

High

High

High

Very High

Established
CV or renal
disease

Very High

Very High

Very High

Very High

Very High

Initiation of Antihypertensive
Treatment
Blood pressure (mmHg)
Grade 2:
SBP 160-179
or DBP 100-109

Other RF Normal:
OD and Dis.SBP 120-129

High normal:
SBP 130-139
or DBP 85-89

Grade 1:
SBP 140-159
or DBP 90-99

No other RF No BP
intervention

No BP
intervention

Lifestyle changes forLifestyle changes forLifestyle changes

several m.
several wks.
+ Immediate
drug Rx
then drug Rx if
then drug Rx if
BP uncontrolled
BP uncontrolled

Lifestyle
change

Lifestyle
change

Lifestyle changes forLifestyle changes forLifestyle changes

several wks.
several wks.
+ Immediate
drug Rx
then drug Rx if
then drug Rx if
BP uncontrolled
BP uncontrolled

Lifestyle
change

Lifestyle changes
and consider
drug Rx

or DBP 80-84

1-2 RF

> 3 RF, MS
or OD

DM

Lifestyle
changes

Established Lifestyle changes

CV or renal + Immediate
drug Rx
disease

Grade 3:
SBP > 180
or DBP > 110

Lifestyle changes
Lifestyle
changes
+ Immediate
Lifestyle change
+
drug Rx
+
drug Rx
drug Rx
Lifestyle changes
Lifestyle change
+ Immediate
+ drug Rx
drug Rx
Lifestyle changes Lifestyle changes Lifestyle changes Lifestyle changes
+ Immediate
+ Immediate
+ Immediate
+ Immediate
drug Rx
drug Rx
drug Rx
drug Rx

BMI 18.5-24.9 kg/m2

Waist circumference <90 cm
(male) <80 cm.(female)
Dietary

Approach to
Stop HT
(DASH)

SBP
5-20 mmHg/ 10 kg
reduction
8-14 mmHg.

SBP
2-8 mmHg.

Na <2.4 gm/day or
NaCl <6 gm/day
aerobic exercise 30 /
4-9 mmHg.
3-5 /
alcohol male <2 drink/day (ethanol 30 gm, Beer 2-4 mmHg.
720 ml, Wine 300 ml, Whiskey 90 ml)
female <1 drink/day

Total chol <190 mg/dl LDL-chol

<115 mg/dl
CVD Total chol
<175 mg/dl LDL-chol <100 mg/dl

Fasting plasma glucose >126 mg/dl

Random plasma glucose >200 mg/dl


108 mg/dl (6.0 mmol/l)

2-4 HbA1C 3-6

 Metabolic Syndrome

>130/85 mmHg
>90 . >80 . (asia)
fasting blood glucose >100 mg/dl (AHA) > 110
mg/dl (IDF)
triglyceride > 150 mg/dl
HDL <40 mg/dl <46 mg/dl
3/5


Class
Favoring use
Thiazide
CHF, Elderly, ISH
Loop diuretic Renal insufficiency,
CHF
Aldosterone CHF, post MI,
antagonist

Contraindication
Compelling
Possible
Gout
Pregnancy

Renal failure,
hyperK


Class
Beta-blocker

Favoring use
Compelling
Possible
CAD, post MI, CHF, 2nd-3rd AV
PAD, glucose
tachyarrhythmias,
block,
intolerance,
pregnancy
asthma,
athletics
COPD
Dihydropyridine Elderly, ISH, CAD,
Tachyarrhythm
Ca antagonist PAD, carotid
ias, CHF
atherosclerosis,
pregnancy


Class
Verapamil,
diltiazem
CCB
ACEI

Favoring use
Compelling
CAD, carotid
2nd-3rd AV block,
atherosclerosis,
CHF
PSVT
CHF, post MI, LV
Pregnancy,
dysfunction, non-DM bilateral renal
nephropathy, type I
artery stenosis,
DM nephropathy,
hyperK
proteinuria

Possible


Class

Favoring use

Compelling

Possible

Type II DM nephropathy, Pregnancy, bilateral

DM
renal artery
microalbuminuria,
stenosis, hyperK
proteinuria, LVH,
ACEI cough
Alpha blocker BPH, hyperlipidemia
Orthostatic
CHF
hypotension
ARB


Class

Favoring use

Compelling

Possible

Alpha
agonist

Hepatotoxic,
Withdrawal
syndrome

Reserpine

Depression, active
peptic ulcer

guidelines isolated
systolic HT (ISH) diuretic Calcium
antagonist




<140/90 .

, TOD, CVD


postural hypotension
80
cardiovascular morbidity CHF

ACEI ARB
RAS
drug combination
monotherapy

orthostatic hypotension

Microalbuminuria (MAU) 24 .
30 to 300mg/L
high normal
Albumin/creatinine ratio (ACR)
microalbuminuria ACR 2.5 mg/mmol () 3.5
mg/mmol ()

statin


/ (stroke)

stroke TIA
stroke
<130/80 .
high normal BP
combination
ACEI ARB
BP acute stroke
stroke

(MI) BB, ACEI

ARB MI




BP <130/80 .

thiazide loop diuretic

BB, ACEI, ARB aldosterone
CA

diastolic heart failure


Atrial fibrillation (AF)

AF AF
CVD 2-5
embolic stroke
anticoagulant anticoagulant
SBP >140 .

2
1.) BP <130/80 .
<120/75 proteinuria >1 /
proteinuria ARB ACEI 2

statin
CVD

ACEI ARB
teratogenic effect
estrogen
, stroke MI
progestogen

(Hormone replacement therapy - HRT)

HRT ,
, stroke,
thromboembolism, ,
HRT

SBP 140-149 .
DBP 90-95 . gestational hypertension (
proteinuria) BP >140/90 .
SBP >170 . DBP >110 .

methyldopa, CA BB drug of choice
aspirin pre-eclampsia


Metabolic syndrome (MS)

MS
subclinical organ damage ambulatory BP
home BP


RAS CA


()

, cocaine,
glucocorticosteroid, NSAID
Obstructive sleep apnea
Secondary hypertension
Irreversible organ damage
Volume overload ,
, Na , hyperaldosteronism


( )

Isolated office (white coat) hypertension

cuff
Pseudohypertension ( )

Carotid bruit
Headache, sweating, and palpitations
Cushingoid body habitus
Persistent or severe elevation

Loud snoring, obesity, gasping, and

daytime sleepiness

Carotid stenosis
pheochromocytoma
Cushing's disease
Consider medications, illicit drug
use, and excessive alcohol use
sleep apnea

Abnormal creatinine or severe

hypertension
Hypokalemia
Thyroid abnormality
Upper but not lower extremity
hypertension
Carotid bruit

renovascular disease, chronic kidney
disease
primary aldosteronism
hyperthyroidism
coarctation of aorta
Carotid stenosis