Haerani Rasyid,Syakib Bakri

Sub Bagian Ginjal & Hipertensi

Bagian / SMF Ilmu Penyakit Dalam
RS UNIVERSITAS HASANUDDIN

 Continuing Medical
Implementation

Blood Pressure Measurement (1)

Office Blood Pressure
Allow the patient to sit quietly for several minutes
Patients should be seated with back supported and arm bared and
supported.
Patients should refrain from smoking or ingesting caffeine for 30
minutes prior to measurement.
Use a validated device
Take at least two measurements spaced by 1-2 min
Use a standard bladder (12-13 x 35 cm), but a larger one for
bigarms
Have the cuff at the heart level
Deflate the cuff slowly (2 mmHg/s)
Measure BP also in standing position in elderly and diabetic patients
Measure BP in the both arms

Blood Pressure Measurement (2)

Home Blood Pressure
Pro :
More information for the doctors decision
Improved patients adherence to treatment
Con :
May cause anxiety
May induce self-modification of treatment

RECOMMENDED BLOOD PRESSURE

MEASUREMENT TECHNIQUE
2.2.

The
Thecuff
cuffmust
mustbe
belevel
levelwith
withheart.
heart.
IfIfarm
circumference
exceeds
arm circumference exceeds 33
33cm,
cm,
aalarge
largecuff
cuff must
mustbe
beused.
used.
Place
Placestethoscope
stethoscopediaphragm
diaphragmover
over
brachial
artery.
brachial artery.

1.1.
The
Thepatient
patientshould
should
be
relaxed
be relaxedand
andthe
the
arm
must
be
arm must be
supported.
supported.
Ensure
Ensureno
notight
tight
clothing
constricts
clothing constricts
the
thearm.
arm.

3.3.

Stethoscope

Mercury
machine

Continuing Medical
Implementation

The
Thecolumn
columnofof
mercury
mercurymust
mustbe
be
vertical.
vertical.
Inflate
Inflatetotoocclude
occludethe
the
pulse.
Deflate
at
2
pulse. Deflate at 2toto
33mm/s.
mm/s.Measure
Measure
systolic
(first
systolic (firstsound)
sound)
and
anddiastolic
diastolic
(disappearance)
(disappearance)toto
nearest
nearest 22mm
mmHg.
Hg.

Classification of Blood Pressure for Adults

(JNC 7, May 2003)

Systolic
Normal

<120

Diastolic
And <80

Prehypertension 120 139 Or

80 89

Stage 1

140 - 159 Or

90 99

Stage 2

> 160

> 100

Or

Definitions and Classification

of BP Levels (mmHg)
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

Consequences of Uncontrolled
Blood Pressure

Stroke, hemorrhage
LVH, CHD, CHF
Renal failure
Peripheral vascular disease
Retinopathy

Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment
of High Blood Pressure (JNC VI). Arch Intern Med. 1997;157:2413-2446.

Tissue injury (MI, Stroke, Renal

insufficiency, peripheral arterial
insufficiency)

Atherothrombosis and
progressive CV
disease

Pathologic remodeling

Early tissue
dysfunction

Target organ
damage

Oxidative &
mechanical stress

End-organ failure
(CHF, ESRD)

Inflammation

Smooking,
Dyslipidemia,
Diabetes

Hypertension

Death

Hypertension perceived as simply a

disease of numbers

Hypertension
Its More Than Just Blood Pressure
Hypertension Syndrome
A Complex inherited syndrome of cardiovascular risk factors

Characteristics of the
Hypertension Syndrome
Increased blood pressure
Dyslipidemia
Insulin resistance, tendency to glucose
intolerance
Truncal Obesity
Microalbuminuria, early changes in renal
functional reserve
Increase activity of vascular coagulation factors
Reduced arterial compliance
Hypertrophy and altered diastolic function of
left ventricle

High Blood Pressure is a Late

Manifestation of the Hypertension
Syndrome

Neutel JM et all, Am J Hepertens, 1999; 12:215-223

Change in the management of cardiovascular diseases

from the traditional approach of managing multiple
independent risk factors(silos approach) to a new
paradigm of integrated identification and management of
all risk factors contributing to the risk of cardiovascular
disease (global approach).

Excess
Sodium
intake

Renal
Sodium
retention

Fluid
Volume

Fewer
Nephrons

Genetic
Alteration

Stress

Decreased
Filtration
surface

Sympathetic
Nervous
system
overactivity

ReninAngiotensin
Excess

Obesity

Cell
Membrane
Alteration

Endothelial
factors

Hyperinsulinemia

Venous
constriction
Contractility

Preload

BLOOD PRESSURE

Hypertension

=
=

Functional
Structural
Constriction hypertrophy

CARDIAC OUTPUT

PERIPHERAL RESISTANCE

Increased CO

and/or

Increased PR

Autoregulation

Diagnostic Evaluation
Aims
Establishing BP values
Identifying secondary causes of hypertension

Searching for:
a) other risk factors;
b) subclinical organ damage;
c) concomitant diseases;
d) accompanying CV and renal complications.

Particular conditions
Isolated office hypertension (White coat hypertension)

Office BP persistently 140/90 mmHg

Normal daytime ambulatory or home BP < 130-135/85

Due to stress and SNS stimulation. CV risk is less than by raised office and ambulatory or home BP
but may be slightly greater than by normotension

Isolated ambulatory hypertension (Masked hypertension)

Office BP persistently normal (< 140/90 mmHg)

Elevated ambulatory ( 125-130/80 mmHg) or home BP ( 130-135/85 mmHg)

CV risk is close to that of hypertension. Due to normal variation of circadian rhythm, autonomic
nervous system dysfunction, physical or psychological stress, night consumption of alcohol, smoking
and sleep apnea.

Guidelines for family and clinical history

1.

Duration and previous level of high BP

2.

Indications of secondary hypertension:

family history of renal disease (polycystic kidneys)

renal disease, urinary tract infection, haematuria, analgesic abuse

(parenchymal renal disease)

drug/substance intake, such as: oral contraceptives, liquorice,

carbenoxolone, nasal drops, amphetamines, steroids, non-steroidal antiinflammatory drugs, erythropoietin, cyclosporine, cocaine (drug induced
hypertension)

episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma)

episodes of muscle weakness and tetany (aldosteronism)

Guidelines for family and clinical history

3. Risk factors:
family and personal history of hypertension and CV disease
family and personal history of dyslipidaemia
family and personal history of diabetes mellitus
smoking habits
dietary habits ; lack of physical exercise
obesity
snoring; sleep apnea (information also from partner)
Personality type; stress due to personal, family and
environmental factors

Guidelines for family and clinical history

4. Symptoms of organ damage:
brain and eyes: headache, vertigo, transient ischemic attacks,
sensory or motor deficit , impaired vision
heart: palpitation, chest pain, shortness of breath, swollen
ankles
kidneys: thirst, polyuria, nocturia, haematuria
peripheral arteries: cold extremities, intermittent claudication
5. Previous antihypertensive therapy:
Drug(s) used, efficacy and adverse effects

Physical examinations
1. Signs suggesting secondary hypertension
2. Signs of organ damage
3. Evidence of visceral obesity.

Physical examination for

secondary hypertension, organ damage and visceral obesity
Signs suggesting secondary hypertension
Features of Cushing syndrome
Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidneys)
Auscultation of abdominal murmurs
(renovascular hypertension)
Auscultation of precordial or chest murmurs; Diminished and delayed
femoral pulses femoral BP
(aortic coarctation or aortic disease)

Physical examination for

secondary hypertension, organ damage and visceral obesity
Signs of organ damage
Brain: murmurs over neck arteries, motor or sensory defects
Retina: fundoscopic adnormalities
Heart: location and characteristics of apical impulse, abnormal
cardiac rhythms, ventricular gallop, pulmonary rates, peripheral
oedema
Peripheral arteries: absence, reduction or asymmetry of pulses, cold
extremities, ischemic skin lesions
Carotid arteries: systolic murmurs

Physical examination for secondary hypertension

organ damage and visceral obesity
Evidence of visceral obesity
Body weight
Increased body mass index
[body weight (Kg)/height (m2)]

overweight 25 Kg/m2; obesity 30 Kg/m2

Increased waist circumference
(standing position) > 90 cm; > 80 cm

Laboratory investigations
Routine tests:

Hemoglobin and hematocrit

Fasting plasma glucose
Fasting serum triglycerides
Serum total cholesterol, LDL-cholesterol, HDL-cholesterol
Serum creatinine, potassium, uric acid

Urinalysis (complemented by microalbuminuria dipstick test and

microscopic examination)
Estimated creatinine clearance (Cockroft-Gault formula) or glomerular
filtration rate (MDRD formula)

Electrocardiogram (ECG)
Thorax X-ray

Laboratory investigations
Recommended tests
Echocardiogram
Carotid ultrasound
Quantitative proteinuria (if dipstick test positive)
Ankle-brachial BP index
Fundoscopy
Glucose tolerance test (if fasting plasma glucose > 5,6 mmol/l
(102 mg/dL)

Home and 24h ambulatory BP monitoring

Pulse wave velocity measurement (where available)

Laboratory investigations
Extended evaluation (domain of the specialist)

Further search for cerebral, cardiac, renal and vascular disease,

mandatory in complicated hypertension

Search for suspected secondary hypertension suggested by history,

physical examination or routine tests:

measurement of renin, aldosterone,

corticosteroids,

catecholamines in plasma and/or urine;

renal and adrenal ultrasound;

computer-assisted tomography (CT);

magnetic resonance imaging (MRI);

arteriographies

Searching for subclinical organ damage

Importance of subclinical organ damage as an intermediate stage in the
continuum of vascular disease and as a determinant of total CV risk.

Heart
Electrocardiography should be part of all routine assessment of
hypertensives in order to detect LVH, LV strain, ischemic condition
and arrhythmias
Echocardiography is recommended whenever a more sensitive
detection of LVH is considered useful. Concentric remodeling and
hypertrophy carries the worst prognosis, while LV diastolic
dysfunction, consists an early ECHO sign, which can be evaluated by
Doppler measurement of transmittal velocities.

Searching for subclinical organ damage

Blood vessels

Ultrasound scanning of extracranial carotid arteries is recommended in

symptomatic carotid stenosis (previous TIA), but also in asymptomatic
atherosclerosis suspected by carotid murmurs and reveals vascular
hypertrophy, increased IMT, thickening of carotid bifurcation and
presence of plaques.

Peripheral large artery stiffening (an important vascular alteration

leading to isolated systolic hypertension in the elderly), can be
measured by pulse wave velocity. This method might be more widely
recommended if its availability were greater.
A low ankle-brachial BP index (<0,9) signals advanced peripheral artery
disease

Searching for subclinical organ damage

Kidney

Diagnosis of hypertension-related renal damage is based on a reduced renal

function or detection of hyperalbuminuria

Measurement of serum creatinine as well as estimation of glomerular

filtration rate by specific formulas, should be part of routine procedures,
allowing classification of renal dysfunction and respective stratification of CV
risk

Presence of urinary protein should be sought in all hypertensives by dipstick.

In dipstick negative patients, low grade albuminuria, namely microalbuminuria,
should also be determined in spot urine and as ratio to creatinine excretion

Searching for subclinical organ damage

Fundoscopy

Examination of eye grounds is recommended only in hypertensive with

severe hypertension, since mild retinal changes (grade 1: arteriolar
narrowing; grade 2: arteriovenous nipping) appear to be largely nonspecific alterations except in young patients

In contrast, grade 3 (hemorrhages and exudates) and 4 (papilloedema)

retinal changes, present only in severe hypertension and are associated
with an increased CV risk

Searching for subclinical organ damage

Brain

Silent brain infarcts, lacunar infarction (small / deep vessel disease),

microbleeds and white matter lesions are not infrequent among
hypertensives, especially elderly and can be detected by MRI or CT (MRI
being generally superior to CT)

Availability and costs do not allow use of these techniques in asymptomatic

patients

In elderly hypertensives, cognitive tests (e.g. Mini-mental scale) may also

help to detect initial brain deterioration

Initiation of antihypertensive treatment

Other risk
factors, Target
Organ Damage or
disease

No other risk
factors

1-2 risk
factors
>3 risk
factors, MS
or TOD

Normal

High normal

Grade 1 HT

Grade 2 HT

SBP 120-129 or
DBP 80-84

SBP 130-139 or
DBP 85-89

SBP 140-159 or
DBP 90-99

SBP 160-179 or
DBP 100-109

No BP intervention

Lifestyle changes
for several months
then drug treatment
if BP uncontrolled

Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled

Lifestyle
changes +
immediate drug
treatment

Lifestyle changes

Lifestyle changes

Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled

Lifestyle changes
for several weeks
then drug treatment
if BP uncontrolled

Lifestyle
changes +
immediate drug
treatment

Lifestyle changes

Lifestyle changes
and consider drug
treatment

Lifestyle changes +
drug treatment

Lifestyle changes +
drug treatment

Lifestyle
changes +
immediate drug
treatment

Lifestyle changes +
immediate drug
treatment

Lifestyle changes +
immediate drug
treatment

Lifestyle
changes +
immediate drug
treatment

No BP intervention

Diabetes

Lifestyle changes

Lifestyle changes +
drug treatment

Established
CV or renal
disease

Lifestyle changes +
immediate drug
treatment

Lifestyle changes +
immediate drug
treatment

Grade 3 HT
SBP 180 or
DBP 110

II. Criteria for the diagnosis of hypertension and recommendations for follow-up

Elevated Out of
the Office BP
measurement

Hypertension Visit 1
BP Measurement,
History and Physical
examination

Elevated Random
Office BP
Measurement

Hypertension Visit 2
Target Organ Damage
or Diabetes
or Chronic Kidney Disease
or BP >180/110?

Hypertensive
Urgency /
Emergency

Yes

Diagnosis
of HTN

No
BP: 140-179 / 90-109

Clinic BPM

ABPM (If available)

Home BPM (If available)

II. Criteria for the diagnosis of hypertension and recommendations for follow-up

Elevated Out of
the Office BP
measurement

Elevated Random
Office BP
Measurement
Hypertension Visit 1
BP Measurement,
History and Physical
examination

Hypertensive
Urgency /
Emergency

Diagnostic tests ordering

at visit 1 or 2
Hypertension Visit 2
within 1 month

BP >140/90 mmHg and

Target organ damage or
Diabetes or Chronic Kidney
Disease or BP >180/110?

No

BP: 140-179 / 90-109mmHg

Yes

Diagnosis
of HTN

II. Criteria for the diagnosis of hypertension and recommendations for follow-up

BP: 140-179 / 90-109

Clinic BP

ABPM (If available)

Home BPM

Hypertension visit 3
>160 SBP
or >100
DBP
<160 /
100

Diagnosis
of HTN

or

ABPM or
HBPM

Awake BP
<135/85
and
24-hour
<130/80

Awake BP
>135 SBP or
>85 DBP or
24-hour
>130 SBP or
>80 DBP

Continue to
follow-up

Diagnosis
of HTN

Hypertension visit 4-5

>140 SBP
or
>90 DBP
< 140 /
90

Diagnosis
of HTN

Continue to
follow-up

< 135/85

>135/85

or

Continue
to followup

Diagnosis
of HTN

Patients with high normal blood pressure (clinic SBP 130-139 and/or DBP 85-89) should be
followed annually.

II. Criteria for the diagnosis of hypertension and recommendations for follow-up
Diagnosis of hypertension

Non Pharmacological treatment

With or without Pharmacological treatment

Are BP readings below target during 2 consecutive visits?

Yes
Follow-up at 3-6
month intervals *

* Consider Home blood pressure

measurement in hypertension
management, to assess for the
presence of masked hypertension or
white coat effect and to enhance
adherence.

No
Symptoms, Severe
hypertension, Intolerance
to anti-hypertensive
treatment or Target Organ
Damage

Yes
More frequent
visits *

No
Visits every 1
to 2 months*

Treatment of Hypertension????
Non-farmakologik
Farmakologik
JNC VII 2004: berjenjang dan
compelling indications
BHS-NICE 2006 : terapi sekuensial
Pengobatan awal dan kombinasi :
ESH-ESC 2009, CHEP 2009, JHS 2009

Modifikasi gaya hidup untuk pengendalian

Hipertensi
Modifikasi

Rekomendasi

Penurunan Tekanan Darah

Sistolik kurang lebih

Menurunkan berat
badan

Pelihara berat badan normal

(BMI 18.5-24.9)

5-20 mm Hg utk setiap

penurunan 10 kg BB

Menjalankan menu
DASH

Konsumsi makanan kaya buah,

sayur, susu rendah lemak dan
rendah lemak jenuh

8-14 mm Hg

Mengurangi asupan
garam/sodium

Kurangi natrium sampai tidak

2-8 mm Hg
lebih dari 2.4 g/hari atau NaCl 6
g/hari

Meningkatkan aktifitas
fisik

Berolahraga erobik teratur

seperti misalnya berjalan kaki
(30 men/hari 4-5 hari
seminggu)

4-9 mm Hg

Kurangi konsumsi
alkohol

Batasi konsumsi alkohol,jangan

lebih dari 2 /hari utk pria dan 1
/hari utk perempuan.

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

DASH diet
Dietary

Approaches to Stop
Hypertension.
Was an 11 week trial.
Differences from the food pyramid:
An increase of 1 daily serving of
veggies and increase of 1-2 servings of
fruit inclusion of 4-5 servings of
nuts,seeds, and beans.

Tips for Reducing Sodium

Buy

fresh, plain frozen or canned no

added salt veggies.
Use fresh poultry, lean meat, and fish.
Use herbs, spices, and salt-free
seasonings at the table and while
cooking.
Choose convenience foods low in salt.
Rinse canned foods to reduce sodium.

Maintain Healthy Weight

Blood

pressure rises as weight rises.

Obesity is also a risk factor for heart
disease.
Even a 10# weight loss can reduce
blood pressure.

Be Physically Active
Helps

lower blood pressure and lose/

maintain weight.
30 minutes of moderate level activity on
most days of week. Can even break it
up into 10 minute sessions.
Use stairs instead of elevator, get off
bus 2 stops early, Park your car at the
far end of the lot and walk!

Limit Alcohol Intake

Alcohol raises blood pressure and can
harm liver, brain, and heart
What counts as a drink?
12 oz beer
5 oz of wine
1.5 oz of 80 proof whiskey
Quit

Smoking

When to initiate Antihypertensive

Therapy?

Initiation of antihypertensive treatment

ESH/ESC/ISH, based on

Total level of cardiovascular risk and level of systolic and

diastolic Blood Pressure

JNC-7, based on
Level of systolic and diastolic BP

JNC 7 Algorithm for Treatment of Hypertension

Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mm Hg)
(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling
Indications

Stage 1 Hypertension
(SBP 140-159 or DBP 90-99 mm Hg)
Thiazide-type diuretics for most
May consider ACEI, ARB, BB, CCB,
or combination

With Compelling
Indications

Stage 2 Hypertension

(SBP 160 or DBP 100 mm Hg)

2-drug combination for most (usually
thiazide-type diuretic and
ACEI, ARB, BB, or CCB)

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved
Consider consultation with hypertension specialist

Chobanian et al. JAMA. 2003;289:2560-2572.

Drug(s) for the compelling

indications
Other antihypertensive drugs (diuretic,
ACEI, ARB, BB, CCB)
as needed

Indication

Drug choice

Compelling indications
Diabetes with proteinuria
Non-diabetic renal failure
with proteinuria
Congestive heart failure

Isolated systolic
hypertension
Myocardial infarction

ACEi / ARBs esp. type 1 DM

ACEi / ARBs

ACEi, diuretic
Diuretic (preferred),
Long-action CCB
Beta-blocker (no ISA),
ACEi if systolic dysfunction

Indication

Drug choice

May have favourable effect on co-morbid conditions

Angina pectoris

Beta-blocker, calcium blocker

Atrial fibrillation, tachycardia

Beta-blocker, calcium blocker

Diabetes with proteinuria

Calcium blocer (non-DHP)

Dyslipidemia

Alpha blocker

Congestive heart failure

Carvedilol, losartan

Osteoporosis

Thiazide diuretic

Adapted from the Sixth Report of the Joint National Committee on detection, Evaluation and Diagnos
High Blood Pressure (JNC VI). ArchIntern Med 1997; 157:2413.

Contraindications

Drug

Bcronchospastic disease

Beta Blocker

Depression

Reserpine

Liver disease

Methyldopa

Pregnancy

ACEi, ARBs

Second or third degree

heart block

Beta-blocker, CCB (nonDHP)

Contraindications

Drug

May have adverse effect on comorbid condition

Depression

Beta-blocker, central alpha

agonist

Diabetes Mellitus

Beta-blocker, high dose diuretic

Gout

Diuretic

Liver disease

Labetalol

Renovascular disease

ACEi, ARBs

Adapted from the Sixth Report of the Joint National Committee on detection, Evaluation and Diagnosis of High Blood
Pressure (JNC VI). ArchIntern Med 1997; 157:2413.

The BHS Recommendations for a Simplified Approach to Blood

Pressure Lowering Therapy
Older (e.g. 60 yr)

Younger (e.g. <60 yr)

Step 1

A
(ACE or AII)

(or B)

C or D

(b-blocker)

CCB

Diuretic

Step 2

A (or B)

C or

Step 3

A (or B)

Step 4

Add either a-blocker or loop

diuretic or spironolactone

Resistant
Hypertension

A:
B:
C:
D:

ACE inhibitor or angiotensin receptor blocker

b-blocker
Calcium Channel Blocker
Thiazide Diuretic

D
D

The BHS recommendations for combining blood

pressure-lowering drugs

Step 1

Step 2

Step 3

Step 4

<55 years

55 years or black
patients at any age

C or D
A

or

Add: further diuretic therapy or alpha-blocker or beta-blocker

Consider seeking specialist advice

A: ACE inhibitor or ARB, if ACE inhibitor intolerant C:

Calcium-channel blocker
D: Diuretic (thiazide)
BHS, British Hypertension Society; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker

2006 update

National Collaborating Centre for Chronic Conditions. Hypertension: management in

adults in primary care: partial update. London: Royal College of Physicians, 2006

2007 ESH/ESC Guidelines

Diuretics

AT1-receptor
blockers

-blockers

a1-blockers

CCBs

ACE inhibitors

NICE CLINICAL GUIDELINE 2011

NICE CLINICAL GUIDELINE

2011

3
0
0 Recommendations for Follow-up
Diagnosis of hypertension

Non Pharmacological treatment

With or without Pharmacological treatment

Are BP readings below target during 2 consecutive visits?

Yes
Follow-up at 3-6
month intervals

No
Symptoms, Severe
hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes
More frequent
visits

Continuing Medical
Implementation
Canadian Hypertension Education Program Recommendations

No
Monthly visits

52

PLAN OF ACTION

CONFIRM
DIAGNOSIS

CONFIRM OF
TARGET ORGAN
INVL
- KIDNEY
- DM
- HEART

PLAN OF TREATMENT
- CHOICE OF DRUG
- CHOICE OF COMBINATION
TARGET BP

WHICH DRUG
SHOULD BE USE
- Diuretic
- BBlocker
- ACE-I
- ARB
- CCB
-

M
O
N
I
T
O
R
I
N
G

Lifestyle modification

Not a Goal BP
<140/90 mmHg or < 130/80 mmHg for those with Diabetes
or Chronic Kidney Disease

Initial Drug Choises

Hypertension With
Compeling Indication

Hypertension Without
Compeling Indication

Stage 1 Hypertension
SBP 140-150 mmHg
DBP 90-99 mmHg
Thiazide type diuretics for most
May Consider ACEI, ARB,BB, CCB
Or Combination

Stage 2 Hypertension
SBP > 160 mmHg
DBP > 100 mmHg
2 Drug Combination foir Most
Usualy Thiazide Type diuretic
And ACEI or ARB or
BB or CCB

Drug For the Compeling

indication
Other anti Hypertensive drugs
DiureticsAnd ACEI or ARB or
BB or CCB as needed

Not a Goal BP
Optimize dosages or Add Additional drugs until Goal BP is achived
Consider Consultation With Hypertension SDpecialistl

Algoritthm for Treatment of Hypertension JNC VII,2003

GO ALS OF TREATMENT
Is to achieve the maximum reduction in the total
risk of Cardiovascular morbidity
and
mortality

Main classes of
antihypertensive drugs
Diuretics
Inhibit the reabsorption of salts and water from kidney
tubules into the bloodstream

Calcium-channel antagonists

Inhibit influx of calcium into cardiac and smooth

muscle

Beta-blockers

Inhibit stimulation of beta-adrenergic receptors

Angiotensin-converting enzyme (ACE) inhibitors

Inhibit formation of angiotensin II

Angiotensin II receptor blockers (ARBs)

Inhibit binding of angiotensin II to type 1 angiotensin
II
Receptors

Vasodilators
Direct renin inhibitors

Control of Blood Pressure and

Antihypertensive Sites of Action
BP is controlled
via changes in

Sympathetic
Stimulation

Cardiac
output
Vasomotor
Sympathetic
tone
Stimulation
Plasma
volume

1 3
Heart

12
Sympathetic
Stimulation

Precapillary Arteriole
(Resistance Vessels)

1
4

b-Blockers
a1-Blockers

Vasodilators

ACE Inhibitors
AT1-RA

Diuretics

12

Renin
Activates

3
Kidney

Postcapillary Venules
(Capacitance Vessels)

Angiotensin
Activates

Aldosterone

Sympathetic
Stimulation