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Lecture 1

Diagnosing and Managing Hypertension


According to Guidelines
IS MY PATIENT HYPERTENSIVE?

Definition, Diagnosis and Grade

of Hypertension

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IS MY PATIENT HYPERTENSIVE?

Definition of
hypertension

Office BP ≥ 140/90 mmHg

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Office BP ≥140/90 mmHg (newly diagnosed)

≥180/110 mmHg 140-159/90-99 mmHg

Hypertension confirmed
Recheck BP in a few
weeks or months
Or
No 160-179/100-109 mmHg
Do HBPM

Recheck BP in a few
days or weeks

HBPM = Home Blood Pressure monitoring


Classification of office blood pressurea and definitions of
hypertension grade

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


IS MY PATIENT HYPERTENSIVE?

2013 ESH/ESC

o BP should be measured daily on at least 3–4 days and


preferably on 7 consecutive days in the mornings as
well as in the evenings.

o Two measurements per occasion taken 1–2 min apart

o Home BP is the average of these readings, with


exclusion of the first monitoring day.

Mancia G, et al. J Hypertens 2013;31:1281–1357


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IS MY PATIENT HYPERTENSIVE?

Category Systolic BP Diastolic BP


Office BP ≥140 and/or ≥90
Ambulatory BP
Daytime (or awake) ≥135 and/or ≥85
Nighttime (or asleep) ≥120 and/or ≥70
24-h ≥130 and/or ≥80
Home BP ≥135 and/or ≥85

Mancia G, et al. J Hypertens 2013;31:1281–1357


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WHAT INVESTIGATIONS ARE
NECESSARY FOR PATIENTS
WITH HYPERTENSION?

[Investigation for hypertension mediated organ damage (HMOD) and

compelling indications]

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COMPELLING INDICATIONS
IN HYPERTENSION

 Heart failure

 Post-myocardial infarction

 High coronary disease risk/angina pectoris

 Diabetes

 Chronic kidney disease

 Recurrent stroke prevention


Chobanian AV, et al. Hypertension. 2003;42:1206–1252
Mancia G, Fagard R, et al. J Hypertens 2013, 31:1281–1357
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Hypertension mediated organ
Damage (HMOD)

Organ Organ damage

Heart Left ventricular hypertrophy

Carotid wall thickening (IMT >0.9 mm) or


Brain
plaque

Kidney Albuminuria

Vascular Pulse wave velocity

Mancia G, Fagard R, et al. J Hypertens 2013, 31:1281–1357


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Routine tests
Haemoglobin and/or haematocrit
Fasting plasma glucose
Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein
cholesterol
Fasting serum triglycerides
Serum creatinine (with estimation of GFR)
Urine analysis: microscopic examination; urinary protein by dipstick test; test for
microalbuminuria
12-lead ECG
Intima media thickness
Pulse wave velocity

Mancia G, et al. J Hypertens 2013;31:1281–1357


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WHAT IS
THE BLOOD PRESSURE TARGET
FOR MY PATIENTS?

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First objective is to reduce BP to 130-139/80-89 mm Hg
3 months after drug treatment initiation

If tolerated

Age <65 years Age ≥65 years


Target 120-129/70-79 mm Hg Target 130-139/70-79 mm Hg

SBP should not <120 mm Hg

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


ALL PATIENTS NEED
TO ADOPT LIFESTYLE CHANGES

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LIFESTYLE CHANGES
Salt restriction to 5–6 g per day

Moderation of alcohol consumption to no more than 20–30 g of


ethanol per day in men and to no more than 10–20 g of ethanol per
day in women

Increased consumption of vegetables, fruits, and low-fat dairy


products

Reduction of weight to BMI of <23,5 kg/m2 and of waist


circumference to <90 cm in men and <80 cm in women*

Regular exercise, i.e. at least 30 min of moderate dynamic exercise


on 5 to 7 days per week

Advice to quit smoking


Mancia G, et al. J Hypertens 2013;31:1281–1357.
*Inoue S. WHO International Obesity Task Force 2000.
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WHEN SHOULD I
INITIATE DRUG TREATMENT?

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Initiation of drug treatment

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


Office blood pressure thresholds for treatment

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


SHOULD I START DRUG TREATMENT
WITH ONE OR A COMBINATION OF
DRUGS?

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Most hypertensive patients should initiate treatment
with a single pill combination comprising two
antihypertensive drugs

EXCEPT

Monotherapy is indicated for:


• Low-risk patients with grade 1 hypertension whose
SBP is <150 mm Hg
• Very high risk patients with high normal BP
• Frail older patients

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


WHAT ARE THE PREFERRED DRUGS
FOR MY PATIENTS?

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Preferred drugs for
uncomplicated hypertension, DM,
Stroke/TIA, PAD, or with HMOD,

DM = diabetes mellitus
TIA = transient ischemic attack
PAD = peripheral artery disease
HMOD = hypertension mediated organ damage
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Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339
PREFERRED DRUGS

Preferred drugs for chronic

kidney disease

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Hypertension and CKD

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


PREFERRED DRUGS

Preferred drugs for coronary

artery disease

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Hypertension and CAD

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


PREFERRED DRUGS

Preferred drugs for heart failure

with reduced ejection fraction*

* EF ≤40%
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Hypertension and HFrEF

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


PREFERRED DRUGS

Preferred drugs for atrial

fibrillation

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Hypertension and atrial
fibrillation

Williams B, et al. Eur Heart J 2018. doi:10.1093/eurheartj/ehy339


WHEN SHOULD I REFER MY
HYPERTENSIVE PATIENTS TO A
SPECIALIST?

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WHEN TO REFER

Extended evaluation (mostly domain of the specialist)

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


mandatory in resistant and complicated hypertension

Search for secondary hypertension when suggested by history,


physical examination, or routine and additional tests.

28 Mancia G, et al. J Hypertens 2013; 31: 1281–1357


WHEN TO REFER
 postural hypotension persists (If the systolic blood
pressure falls by 20 mmHg or more when the person
is standing)
 accelerated hypertension, that is, blood pressure
usually higher than 180/110 mmHg with signs of
papilloedema and/or retinal hemorrhage
 suspected phaeochromocytoma (labile or postural
hypotension, headache, palpitations, pallor and
diaphoresis)
 Consistent inter-arm differences of over 20/10 mmHg
 younger people (i.e. <40years) with uncomplicated
stage 1 hypertension
 Abdominal bruit

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