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Hypertension

&
Update Management
Presented by:
DR. ..

Hypertension
most important preventable contributors to disease and
death.
Nearly 1 in 3 adults has high blood pressure, which
increases the risks of-

Stroke (No. 1 Mortality in Bangladesh)


Heart failure,
Heart attack,
Kidney failure
And death
JAMA Published online December 18,2013

High Blood Pressure:


Global Burden

High Blood Pressure is the number one killer and


leading cause of risk for death. 30% of global
mortality in world wide.
More then quarter of the world adult population
suffering from hypertension. This figure will raise to
30% in 2025.
9.4 million people die every year.
Over 1 billion people have high blood pressure
affected in every year.

Regional Burden:
One in every 10 deaths in South-East Asia region.
It kills 1.5 Million people in this region each year.
Approximately one third of the adult population in the South-East
Asia region has hypertension.

Bangladesh Situation:
32.9% of adult population never measured BP
(44.5/22.8= Male/Female).
54.7% Measured not diagnosed (44.7/63.3 = M/F).
12.5% Measured and diagnosed (10.9/13.9 = M/F).

Among Them:
30.3% had normal Blood pressure with healthy life style.
17.6% had normal BP with anti hypertensive medication.
30.7% on medication but still hypertension.
21.4% was hypertensive but not taking medicine.
Classification of hypertension:

Classification of hypertension:

According to JNC-7 (joint National committee on prevention


classification of hypertension for Age 18 yr or Above.
Category

Systolic Bp mm Hg

Diastolic BP mm Hg

Normal

<120

<80

Pre-hypertension

120-139

80-89

Stage- 1
hypertension

140-159

90-99

Stage- 2
hypertension

160

100

Isolated systolic hypertension 140 or diastolic hypertension


90

Aetiologicaly two forms of high blood pressure:


i) Essential hypertension (Primary)
ii) Secondary hypertension.

Essential (Primary) hypertension:


About 90-95% of cases are primary hypertension. Pathogenesis is not clearly
known. There are many multifactors relation to essential hypertension.

Risk factors for primary hypertension


Genetic factors approx. 30%.
Excessive salt intake (>5-8 gm. / daily)
Aging.
Sex; male predominant.
Mental stress.
Obesity (Body mass index > 25)
Excess alcohol intake & smoking.
Lack of physical exercise.
Fast food & Excess animal fat taking.
Insulin resistance which in a syndrome X or metabolic syndrome.
Recent studies Low birth weight is a risk factor adult essential hypertension.

Secondary hypertension: About 5-10% secondary hypertension.


Renal diseases: CKD. Glomerulonephritis, polycystic kidney disease.
Pregnancy ( Eclamsia)

Endocrine diseases: Cushing syndrome, Hypothyroidism, Throtioxicosis,


coarctation of aorta, Acromegaly, Hyperaldosteronism

Drugs: Oral contraceptivs-oestrogen


Anabolic steraids
Corticosteroid.
Non-steroidal anti-intlammatory drugs- Cerbenoxotone.

The sign & Symptoms of high blood pressure


Uncomplicated hypertension usually occurs without any symptoms.
Hypertension is called silent killer.
Some people with uncomplicated hypertension may produce early
morning headaches dizzincss, shortness of breath, bleeding nose,
blurred version.
When complicated hypertension occurs like heart failure: Heart
attack, malignant hypertension then produce symptomes.

Investigation:
For all Patients:
X-ray chest (PAV) Cardiomegaly, Heart failure sign
ECG LVH, Ischaemia
Echo Concentric hypertrophy, Aorata dilated, LV dilated, Diastolic
dysfunction.
Urine for routine test : proteinuria
Serum Creatinine, Blood Urea.
Lipid Profile
Serum Electrolytes
RBS

Investigation of Selected patients:


Renal Ultrasound Detected for Reenal Disease
Urinary catecholamine
Urinary cortisone & Dexamethasone suppressing test.
Plasma rennin activity & aldosterone
CT Scan, MRI
Renal Angiography

WHOs Guidelince for treatment of hypertention:


Six drugs are Reconmmended:
Diuretics - Hydrochlorothiazide, chorthalidone, Indepamide.
2) ACEI Captopril, Ramipril, Perindopril, Benzapril.
3) ARB Losarten, valsartan, Irbrasartan, Telmisartan olmesartan (Olsart).
4) Beta-Blocker Atenolal, Metoprolol, Bisoprolol, Propanonal, Nebivolol
5)CCB:
1)

a) Dihydrophridine- Amlodepine, Nefidipine (Long acting)


b) Non Dihydropyridine : Deltizem & Varapramil (Shrot & Long acting)
6) Alpha Blocker : Prazosin, Tetrazosin.
Dihydrophridine
Alpha Methyldopa (only for pregnancy Hypertension).
New, 4th Generation CCB (L & N type CCB): Cilnidipine (Cildip)

Comparison with Amlodipin


Parameter

Amlodipine

Cilnidipine

Ca-Channel
Blockade

Only L-type

Both L & N-Type

Ankle edema

Up to 64%

No or Less chance

Reflex Tachycardia

Frequently
happens

Suppress
tachycardia

Protective Effect

No

Cardioprotective,
Neuroprotective,
Renoprotective,

Insulin Sensitivity

No

Has

End Organ

Has no protective
role

Protect end organ


from vascular
damage

Mangement of Blood pressure for adults aged 18 years


or Older
BP

SBP mm. Hg

DBP mm Hg

Life style
Modification

Drug Therapy

Normal

120

80

Encourage

No

Pre-Hypertension

120-139

80-89

Yes

No

Stage 1
Hypertension

140-159

90-99

Yes

Yes

Stage 2
Hypertension

160 or

100

Yes

Yes

Stage 1 Drug Treatment:


Without Complication
Thiazide Type Diuretic for most Patients may
consider or ACEI, ARB, BB, CCB Single or
Combination.

With Complication
Drugs: Diuretics, ACEI, ARB, BB, CCB As
needed.

Stage 2 Drug Treatment:


Without Complication
Two drug Combination for most patients
usually
Thiazide Diuretics or ACEI, ARB, BB, CCB
Combination.

With Complication
Drugs: Diuretics, ACEI, ARB, BB, CCB As
needed.

NB: If BP is more then 20/10mm Hg Above


initialy Two Drugs Theraphy Used.

Recommended Drugs for Complication:


Hypertension with complication

Diuretics

BB

ACEI

ARB

CCB

Aldosterone
Antagonist

Heart Failure

Myocardial infraction

High Coronary Risk Disease

Diabetics

Chronic kidney Disease

Recurrent Stroke Prevention

In Patients with Hypertension BP goal is <130/80 mm Hg Accroding to


JNC-7

JNC 8
2014 Evidence-Based Guidelines for the
Management of High Blood Pressure in
Adults
JAMA. 2014;311(5):507-520
December 18, 2013

2014 Hypertension Guideline JNC-8


Guideline
2014 Hypertension
Guideline JNC-8

Populatin

Goal BP mm Hg

Initial Drug
Treatment Options

General 60 y

< 150/90

Nonblack: Thiazidetype diuretic, ACEI,


ARB or CCB

General < 60 y

<140/90

Black: thizide-type
diuretic or CCB

Diabetes

<140/90

Thiazide-type
diuretic, ACEI, ARB
or CCB

CKD no proteinuria

<140/90

ACEI or ARB

CKD + Proteinuria

<130/90

ACEI or ARB

HTN Goal

16

JNC 8: Drug Treatment


Thresholds and Goals
Age > 60 years
Systolic:
Threshold > 150 mmHg
Goal < 150 mmHg
LOE: Grade A

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A

JNC 8: Drug Treatment


Thresholds and Goals
Age < 60 yo
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages 18-39

JNC 8: Drug Treatment


Thresholds and Goals
Age > 18 yo with CKD or DM
JNC 7: < 130/80 (MDRD NEJM 1994)
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade E

ACEIs and ARBs should not be used in combination

Comparison of Recent
Guideline Statements
JNC 8

ESH/ESC

AHA/ACC

ASH/ISH

>140/90

>140/90 <80 yr
>150/90 >80 yr

>140/90
Threshold
for Drug Rx

>140/90 < 60 yr Eldery SBP >160


>150/90 >60 yr Consider SBP
140-150 if <80 yr

B-blocker
First line Rx

No

Yes

No

No

Initiate Therapy
w/ 2 drugs

>160/100

"Markedly
elevated BP"

>160/100

>160/100

Goal BP
Group

BP Goal (mm Hg)


DM*

General

CKD**

JNC 8:

<60 yr: <140/90


>60 yr: <150/90

< 140/90

< 140/90

ESH/ESC:

< 140/90

< 140/85

< 140/90

Elderly

140-150/90
(<80 yr: SBP<140)

ASH/ISH

< 140/90
>80 yr: <150/90

AHA/ACC

< 140/90

*ADA: < 140/80 or lower

(SBP < 130 if proteinuria)


< 140/90

< 140/90

(Consider < 130/80 if proteinuria)


< 140/90

< 140/90

**KDIGO: <140/90 w/o albuminuria


<130/80 if >30 mg/24hr

Life Style Modification:


01

Weight Reduction

Recommendation : Normal body Weight maintain body


mass index (18.5 24.9 kg/ m) <25

02

Dietary approaches to
stop HTN

Diet rich in fruits vegetables, low fat diet avoid animal


fat.

03

Dietary sodium reduction

Daily sodium intake 2-4 gm.

04

Physical Activity

Regular Physical actively Daily walking 40 min to 1


Hours.

05

Stop Smoking

Avoid Tabacco

06

Moderation of Alocohol
Consumption

Limit consumption of Alcohol Not more than 2 drinks /


Day man.
I drink per day in women
wine 05 oz, Beer 12 oz, Whiske 1 oz.
Avoiding Alcohol totally will be the best

07

Avoid Tension, Anxity

08

Regular check up Blood


Pressure

09

Regular taking
hypertension drug.

10

Control blood pressure

Complications:
Hypertension is the most important risk factor for death.

Heart : 20-25% Heart disease occurs from hypertension


Lt. Ventricular hypertrohpy
Heart failure
i) Systolic dysfunction
ii) Diastolic dysfunction
Stable Angina
Myocardial infraction
Unstable Angina.

Brain:

Cerebro Vascular Disease:


Stroke (35-40% ooccurs from hypertension) :
i) Haemorrhagic stroke
Atheroembolic
stroke
Kidney:ii)Nephropathy,
CKD.
TIA
Dementia
Eye: Retinopathy
Encephalopathy
i) Hemorrhages & exudates
ii) Pappilloedema
Peripheral arterial disease.

Hypertensive Emergency:
Require immediate blood pressure reduction within minute to
an hour up to 140/90 mm Hg. Not necessary to normal.
i) Hypertension Encephalopathy,
ii) Acute aortic dissection.
iii) Acute Mi, Unstable Angina.
iv) Acute LVF, Pulmonary oedema.
v) Post coronary artery bypass with hypertension.
vi) Strokes
vii) Eclampsia
Treatment: Drug used short acting Nifedipine, Captopril by
mouth or sublingually, I/V Nitroglycerin, Sodium Nitroprusside.

Hypertensive Urgencies
Required Blood Pressure reduction with 12-24 hr to up to
140/90 mm Hg. Not necessary to normal level.
i) Severe systolic hypertension >200 mm Hg. Or severe
Diastolic hypertension >120 mm Hg. Without complication.
ii) Malignant hypertension without complication.
iii) Pre-operative hypertension.
Hypertensive Encephalopathy:
Severe hypertension systolic BP 210 or Diastolic 120
mm Hg. Associated with Headache, Drowsiness, Vision
disorder, Nausea & Vomiting. Symptoms are collectively
referred to as hypertensive encephalopathy.

White Coat Hypertension


When blood pressure is elevated only in doctors office &
may have normal blood pressure out side the physicians
office is called White Coat Hypertension
Resistant Hypertension:
Resistant hypertension is the failure to reach goal BP in
patients who are adhering to full doses of three drug
regimen that includes a Diuretics.
Malignant Hypertension: Severe hypertension systolic BP
210 or Diastolic pressure 120 mm Hg. With
pappilloedema.
Accelerated Hypertension: Severe hypertension with the
Fundus shows retinal haemorrhages or exudates

Fixed-dose combinations
Single-pill combinations of two antihypertensive
drugs, known as fixed-dose combinations, are now
widely available, often combining an ACEI or an
ARB as agents that target the reninangiotensin
system (RAS) with either a thiazide diuretic or a
CCB.
At low doses, fixed-dose combinations may have
greater efficacy and better tolerability than the
respective high-dose monotherapies
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Combination therapy
The rationale behind combination therapy,
using two or more drugs with different and
complementary mechanisms of action, is the
potential to improve BP control by the
combined effects and, by allowing lower
doses of the drugs, to reduce unwanted
side-effects.
29

Olmesartan/amlodipine combination
therapy
ARB Olmesartan is of interest since it has been
shown in pharmacodynamic studies to produce a
strong level
of
AT1 receptorproduces
blockade in robust
relation to
dose
Olmesartan
antihypertensive
efficacy over 24 hours, the daytime, night-time,
and end-of dosing interval periods relative to
losartan, candesartan or valsartan monotherapy,
and was at least as efficacious as irbesartan.
Clinical data suggest that olmesartan may
protect against end-organ damage and, in this
regard, renoprotective and anti-atherosclerotic
effects have been reported in clinical and
experimental
Am J Hypertens. 2007;20(8):907916
studies.
Clin Pharmacol Ther. 2005;78(5):501507
J Hypertens. 2010;28(3): 520526

Conclusion
For all persons with hypertension, the potential
benefits of a healthy diet, weight control, and
regular exercise cannot
be overemphasized. These lifestyle treatments have
the potential to improve BP control and even reduce
medication needs.
Although the authors of this hypertension guideline
did not conduct an evidence review of lifestyle
treatments in patients taking and not taking
antihypertensive
medication,
wesupport
the
recommendations of the 2013 Lifestyle Work Group.

Take home massage


Healthy diet
Weight
control
Regular
exercise
Regular Medication
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Conclusion

Morbidity and mortality associated with Hypertension

related complications is high, because of patient and


doctors related pitfalls
So, we should properly address the pitfalls and try to

minimize the hypertension related complications

Thanks for your attention

35

Acknowledgements
Courtesy by:

Opsonin Pharma Ltd.


Medical Services Department

Calnor
Amlodipine+Olmesartan

Cildip
Cilnidipine

Ref: Vascular Health and Risk Management 2011:7 183192


& JNC-8 & Website

Olsart
Olmesartan