HIGHLIGHT UPDATE HYPERTENSION

GUIDELINES

ENDAH DEWATI KARTIKA SARI, MD

1. Mozaffarian D, et al. Heart Diiisease and Strokke Statistics-2015 Update.AHA
Circulation.2015;;131:29-322.
2. Thayer C,et al. Hypertension diagnosisand treatment guideline.Group
Health.2014:1-19
HYPERTENSION COMPLICATIONS
Blood Pressure Reduction Of 2 mmHg
Reduces The Risk Of CV Events by 7–10%
•Meta-analysis of 61 prospectiv
• Observational studies
•• 1 million adults
7% reduction in risk
of ischaemic heart
disease mortality
2 mmHg
decrease in
mean SBP

10% reduction in risk

of stroke mortality
 ADA AHA/ACC

JNC ASH/ISH

NICE HYPERTENSION ISHIB

GUIDELINES
NHLBI NKF

CHEP
ESC ISH
PA James et al. “JNC-8.” JAMA 2014:311:507.
Comparison of Current Recommendations With JNC 7
Guidelines
Topic JNC VII Guideline Hipertensi 2014
Methodology Nonsystematic literature review Critical questions and review
by expert committee including a criteria defined by expert panel
range of study designs with input from methodology team
Recommendations based on Initial systematic review by
consensus methodologist restricted to RCT
evidence
Subsequent review of RCT
evidence and recommendations
by the panel according to a
standardized protocol
Definitions Defined hypertension and Definitions of hypertension and
prehypertension prehypertension not addressed,
but thresholds for pharmacologic
treatment were defined
Treatment Goals Separate treatment goals defined Similar treatment goals defined for
for “uncomplicated” hypertension all hypertensive populations
and for subsets with various except when evidence review
comorbid conditions (diabetes and supports different goals for a
CKD) particular subpopulation
Lifestyle recommendations Recommended lifestyle Lifestyle modifications
modifications based on literature recommended by endorsing the
review and expert opinion evidence-based
Recommendattions of the
Drug therapy Recommended 5 classes to be
considered as initial therapy but
recommended thiazide-type
diuretics as initial therapy for
most petients without compelling
indication for another class.
Specified particular
antihypertensive medication
classes for patients with
compelling indications, ie,
diabetes, CKD, heart failure,
myocardial infarction, stroke,
and high CVD risk
Included a comprehensive table
of oral antihypertensive drugs
including names and usual dose
ranges
Recommended selection among
4 specific medication classes
(ACEI or ARB CCB or diuretics)
and doses based on RCT
evidnce
Recommended specific
medication classes based on
evidence review for racial, CKD,
and diabetic subgroups
Panel created a table of drugs
and doses used in the outcome
trials
Scope of topics Addressed multiple issues (blood Evidence review of RCTs
pressure measurements addressed a limited number of
methods, patient evaluation questions, those judged by the
components, secondary in panel to be of highest priority
special populations) based on
literature review and expert
opinion
Review process prior to Reviewed by the National High Reviewed by experts including
publication Blood Pressure Education those affiliated with professional
Program Coordinating and public organizations and
Committee, a coalition of 39 federal agencies; no official
major professional, public, and sponshorship by any
voluntary organizations and 7 organization should be inferred
federal agencies
Abbreviations : ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker;
CCB, calcium channel blocker; CKD, chronic kidney disease, JNC, Joint national Committee; RCT,
randomized controlled trial

PA James et al. “JNC-8.” JAMA 2014:311:507.

RECOMMENDATIONS FOR
MANAGEMENT OF HYPERTENSION (1)
RECOMMENDATION STRENGTH OF
RECOMMENDATION
Recommendation 1 Grade A
Populasi usia ≥60 tahun, mulai terapi farmakologi
TDS≥150 mmHg, TDD≥90 mmHg
Corollary Recommendation Grade E
Populasi usia≥60 tahun, jika terapi farmakologi
mengakibatkan penurunan TD lebih rendah (<140/90)
& pengobatan ditoleransi dengan baik tanpa efek
samping, teruskan pengobatan.Pada usia ini TD<140
tidak lebih baik dibanding 140-160
Recommendation 2 Grade A (30-59 tahun)
Populasi usia<60 tahun, terapi farmakologi bila TDD≥90 Grade E (18-29 tahun)
mmHg..Target TDD<90 mmHg
RECOMMENDATIONS FOR
MANAGEMENT OF HYPERTENSION (2)
RECOMMENDATION STRENGTH OF
RECOMMENDATION
Recommendation 3 Grade E
Populasi usia <60 yrs, terapi farmacologi bila
SBP ≥140 mmHg.Target SBP<140 mmHg
Recommendation 4 Grade E
Populasi usia ≥18 yrs dengan CKD, terapi
farmacologi bila SBP ≥140 mmHg or DBP ≥90
mmHg . Target SBP <140 mmHg dan DBP <90
mmHg
Recommendation 5 Grade E
Populasi usia ≥18 dengan DM, terapi
farmacologi bila SBP ≥140 mmHg atau DBP ≥ 90
mmHg. Target SBP<140 and DBP <90
RECOMMENDATIONS FOR
MANAGEMENT OF HYPERTENSION (3)
RECOMMENDATION STRENGTH OF
RECOMMENDATION
Recommendation 6 Grade B
Pada populasi non black , termasuk dg DM,
initial anti HTN treatment : a thiazide type
diuretic, CCB, ACEI or ARB
Recommendation 7 Grade B ( No DM)
Populasi kulit hitam, termasuk dg DM, initial Grade C ( DM)
anti HT: thiazide-type diuretic or CCB
Recommendation 8 Grade B
Populasi usia ≥18 dg CKD dan HTN, initial (or
add on) anti HTN : ACEI or ARB utk
memperbaiki kidney outcomes. Tanpa melihat
ras atau status DM
RECOMMENDATIONS FOR
MANAGEMENT OF HYPERTENSION (4)
RECOMMENDATION STRENGTH OF
RECOMMENDATION

Recommendation 9 Grade E
• Tujuan treatment HTN adalah untik mencapai dan
mempertahankan target BP
• Jika target BP tidak tercapai dlm 1 bl, naikkan dosis
atau tambahkan 2nd 1 obat dr rekomendasi 6
(thiazide-type diuretic, CCB, ACEI, or ARB)
• Jika target BP tidak tercapai dg 2 obat, tambah dan
titrasi obat 3rd . Do not use an ACEI and an ARB
together
• Jika target BP tidak dapat tercapai dg obat-obat pada
recommendasi 6 krn kontraindikasi atau butuh >3
obat, obat antiHT dari kelas lain bias digunakan.
• Referral kepada hypertension specialist jika BP tidak
tercapai atau untuk management komplikasi.
2014 HYPERTENSION GUIDELINE
MANAGEMENT ALGORYTHM
 STRATEGIES TO DOSE
ANTIHYPERTENSIVE DRUGS

STRATEGY DESCRIPTION
A Start one drug, titrate to maximum dose, and then add a second
drug

B Start one drug and then add a second drug before achieving
maximum dose of the initial drug

C Begin with 2 drugs at the same time, either as 2 separate pills or

a single pill combinationn
Perbedaan 201 Hypertension guidelines (JNC 8)
dengan panduan hipertensi lainnya

NICE 2011 ESC 2013 ASH/ISH AHA/ACC/ CHEP 2014

2014 CDC 2013 2013 Hypertens
ion
guidelines
(JNC 8)
Definisi >140/90 >140/90 >140/90 >140/90 >140/90 Tiddak
Hipertensi menuliska
(mmHg) n
Ambang 140/90 140/90 140/90 140/90 140/900 >60th:
memulai >80 th: 150/90
terapi 150/90 <60 th:
(mmHg) 140/90
Beta Tidak Ya Tidak Tidak Ya, pada Tidak
bloker pasien<60
sebagai th
obat lini
pertama
Perbedaan 201 Hypertension guidelines (JNC 8)
dengan panduan hipertensi lainnya
NICE 2011 ESC 2013 ASH/ISH AHA/ACC/ CHEP 2014
2014 CDC 2013 2013 Hypertens
ion
guidelines
(JNC 8)
Terapi Tidak Pasien 160/100 160/100 TDS>20 160/100
kombinasi menyebut dengan TDD>10
(mmHg) kan tekanan Dari target
darah
sangat
<150tingg
Target <80 <140/90 <140/90 <140/90 <80 th: >60th:
tekanan th:<140/9 <80 th: >80 th: Lansia 140/90 150/90
darah 0 150/90 <150 dapat ≥80 th: <60 th:
≥80th: >80 th: lebih 150/90 140/90
<150 150-140 tinggi
 Perbedaan 201 Hypertension guidelines (JNC
8) dengan panduan hipertensi lainnya

NICE 2011 ESC 2013 ASH/ISH AHA/ACC/ CHEP 2014

2014 CDC 2013 2013 Hypertens
ion
guidelines
(JNC 8)
Target Tidak Dapat
tekanan dituliskan lebih
darah rendah
pada dari target
pasien populasi
dengan umum
penyakit
penyerta :
DM
CKD <140/85 <140/90 <130/80 <140/90
CKD+prot <140/90 <140/90 <140/90
einuria <130/90
 Diagnostic evaluation
Office blood pressure measurement (1)

• Validated ausculatory or oscillometric semiautomatic

sphygmomanometers
• Measurement at the upper arm is preffered and
cuff/bladder dimensions should be adapted to the arm
circumference
• At least two BP measurement are taken, spaced 1-2 min
apart, after the patient has been sitting for 3-5 min, with
additional measurement if the first two are quite different.
• Automated recording of multiple BP reading with the
patient seated inn an isolated room
 Diagnostic evaluation
Office blood pressure measurement (2)
• In case of a consistent systolic BP difference of>10 mm
Hg between arms, the arm with the higher BP values
should be used.
• BP is taken 1 and 3 min after standing in elderly subjects,
diabetic patients and in other conditions in which orthostatic
hypotension may be frequent or suspected. Orthostatic
hypotension is defined as a reduction in SBP of ≥ 20
mmHg or in DBP ≥10 mmHg within 3 min of standing.
• Heart rate should be assessed after the 2nd BP
measurement.
DIAGNOSTIC EVALUATION
OUT-OF-OFFICE
MEASUREMENT :
AMBULATORY AND HOME
BLOOD PRESSURE
 ESH-ESC recommendations
Out-of-office BP should be
considered to confirm the diagnosis
of hypertension, identify the type IIa B
of hypertension, detect
hypotensive episodes, and
maximize prediction of CV risk
For out-of-ooffice BP
measurements, ABPM or HBPM may
be considered depending on IIb C
indication, availibility, ease, cost of
use and, if appropriate, patient
preference

Mancia G, et al. J Hypertens. 2013; 3: 1281-1357.

 Diagnostic evaluation
Out-of-office measurement (2)

• The major advantage : more reliable assessment of

the actual BP than office BP
• It’s commonly assessed by ambulatory or home BP
monitoring, usually by self-measurement
• Interpretation of the result should take into account
that the reproducibility of out-of-office BP is
reasonably good for 24-h, day and night BP averages,
but less for shorter periods within the 24-h and for
more complex and derived indice.
 Diagnostic evaluation
Out-of-office measurement (1)

• ABPM & HBPM should be regarded as

complementary
• Office BP is usually higher than ambulatory and
home BP
• Cut-off values for the definition of hypertension are
different for office and out-of-office BP
 Out of Office BP – Methodological Aspects
ABPM Home BP
• Measurement extended to 24-25 • To be measured on at least 3-4 days
hours (included the night) (preferably 7 days)
• Difference from operator – • Morning / evening values (quiet
measured BP to be checked environment)
• Measurements to be made at same • Values to be reported in
frequency (e.g. Every 20 min) during standardized loggbook but storage in
day and night memory device
• Excessive intervals to be avoided • Possible advantage of
telemonitoring
• Recording satisfactory
• Data interpretation always by
• At least 70% of BPs during daytime
physician
and night-time periods should be
satisfactory

2013 ESH/ESC Guidelines for the management of arterial hypertension

Diagnostic evaluation ABPM : Derived variables

• Night –to-day BP ratio : ratio between average

night-time BP and average day-time BBP.
• Night-time dipping pattern :

Category Night/day ratio

Absence of dipping >1.0
Mild dipping >0.9 and ≤ 1.0
Dipping >0.8 and ≤ 0.9
Extreme dipping ≤0.8
 Diagnostic evaluation Ambulatory BP

1. Relation with organ damage & prognostic

significance

2. Prognostic significance of daytime and night-time BP

• The night-time BP is a stronger predictor of
morbiidiity and morrtality than daytime BP
• With regard to the dipping pattern, the incidence
of CV events is higher in patients with a lesser or
no drop in night time BP than in those with a
greater drop.
 Diagnostic evaluation HBPM : Relation with
organ damage and prognostic significance

• Home BP is more closely related to hypertension induced

orggan damage.

• In primary care and in hypertensive patients indicate that

the prediction oc CV morbidity and mortality is significantlyy
better with home BP than with office BP

• Home BP is at least as well correlated with organ

damage than ambulatory BP, and that the prognostic
significance of home BP is similar to that of ambulatory BP
after adjuustment for age and gender.
 Diagnostic evaluation
White-coat and masked
hypertension
 Diagnostic evaluation WCHT
 Factors related to WCHT :
• Higher prevalence : older age, female, non-smoking,
no organ damage, grade 1 hypertension
• Lower prevalence : repeated office BP measurements
by nurse or another healthcare provider , grade 3
hypertension

 To be confirmed within 3—6 months.

 Compared with true normotension, out-of-office BP is

higher, organ damage and metabolic risk factor may be
more frequent, and the risk of new-onset diabetes and
progression to sustained hypertension may be increased.
 Diagnostic evaluation Masked HT

• The condition is frequently aasociated with other

risk factors, organ damage, increase risk of diabetes
and sustained hypertension.

• The incidence of CV events is higher than in true

normotension about two times and is similar to the
incidence in sustteined hypertension.
 Clinical Indications for out-of-office BP
Out-of-office BP is an important adjunct to office BP
The choice between ABPM & HBPM will depend on indication,
availability, ease, cost of use and, if appropriate, patient preference
To confirm borderline or abnormal findings on HBPM with ABPM,
which is currently considered the reference for out-of-office BP, with
the additional advantage of providing night-time

Conventional office BP measurement currently remains

the gold standart for screening, diagnosis and
management of hypertension
 White coat vs masked hypertension

White coat Masked

• Clinic BP > ambulatory • Clinic BP < ambulatory

BP BP
• More common in women • Associated with
and elderly increased left ventricular
• Increased adverse effect mass, arterial stiffness,
of antihypertensive and carotid intimal
medication media thickness
• Strong predictor of CV
morbidity and mortality

Mancia G, De Backer G, Dominiczak A, et al. Eur Heart J. 2007;28(12):1462–1536. Chrysant SG. Curr Hypertens Rep. 2000;2(4):412–417.
O’Brien E. Hot Topics Hypertens. 2011; 4(12):7–23. Mancia G, Facchetti R, Bombelli M, Grassi G, Sega R. Hypertension. 2006;47(5):846–853.
Sega R, Trocino G, Lanzarotti A, et al. Circulation. 2001;104(12):1385–1392. Ormezzano O, Baguet JP, Francois P, Quesada JL, Pierre H, Mallion JM.
Clin Auton Res. 2004;14(3):160–166. Pierdomenico SD, Lapenna D, Bucci A, et al. Am Heart J. 2005;149(5):934–938.
 Clinical Indications for out-of-office BP
measurement for Diagnostic Purposes
Clinical Indications for HBPM or ABPM
• Suspicion of white-coat hypertension
 Grade 1 hypertension in the office
 High office BP in ndividuals without ymptomatic organ damaged and at
low total CV riskk
• Suspicion of masked hypertension :
 High normal BP in the office
 Normal office BP in individuals with asympyomatic organ damage or at
high total CV risk
• Identification of whit-coat effect in hypertensive patients
• Considerable variability of office BP over the same or different visits
• Autonomic postural post-prandial, siesta and drug-induced hypotension
• Elevated office BP or suspected pre-eclampsia in pregnant women
• Identification of true and false resistant hypertension
Specific Indications for ABPM

• Marked discordance between office BP and home BP

• Assessment of dipping status

• Suspicion of nocturnal hypertension or absence of

dipping, such as in patients with sleep apneu, chronic
kidney disease or diabetes

• Assessment of BP variability
 Classification of dipping in blood pressure is based on the
American Heart Association's calculation, using systolic blood
pressure (SBP)

DIP ={ 1-SBP sleeping } x 1oo%

SBP waking
Range Class
<0% Reverse Dipper
0% - 10% Non-Dipper
10% - 20% Dipper
>20% Extreme Dipper

Dippers have significantly lower all-cause mortality than non-dippers or reverse

dippers. As a result, "... ambulatory blood pressure predicts mortality significantly
better than clinic blood pressure
 RECOMMENDATION (1)
Automated office blood pressurre is now
recommended as the preferred method of measuring
in-office BP.
A serum lipid panel ( consisting of total cholesterol, LDL,
HDL, and TG ) fasting and nonfasting collections are now
considered acceptable.
Indivdual with secondary hypertension arising from primary
A serum lipid panel ( consisting of total cholesterol, LDL,
HDL, and TG ) fasting and nonfasting collections are now
considered acceptable.
Indivdual with secondary hypertension arising from primary
omated office blood pressurre is now recommended as the
preferred method of measuring in-office BP.
 RECOMMENDATION (2)
Increase dietary potassium to reduce blood pressure in
those who are not at high risk for hyperkalemia.
In selected high-risk patients, intensive blood pressure
reduction to a target SBP<120 mm Hg should be
considered to decrease the risk of CV events

In hypertensive individuals with uncomplicated, staable

angina pectoris, either a beta-blocker or calcium channel
blocker may be considered for initial therapy
 BP measurement methods

1. Office (attended, OBPM)

1. Oscillometric (electronic) – preferred method
2. Auscultatory (mercury, aneroid)
2. Office Automated (unattended, AOBP)
1. Oscillometric (electronic)
3. Ambulatory blood pressure monitoring (ABPM)
4. Home blood pressure monitoring (HBPM)
 New 2015 Recommendation:
BP Measurement
Office BP measurement (OBPM):
Measurement using electronic (oscillometric) upper arm
devices is preferred to auscultatory devices (Grade C).

Auscultatory (mercury, aneroid) Oscillometric (electronic)

 BP measurement methods
Office Automated (unattended, AOBP)
Oscillometric (electronic)
Out of office BP measurement methods:
Ambulatory (ABPM)
Out of office BP measurement methods:
Home (HBPM)
 Out-of-office BP Measurements

• ABPM has better predictive ability than OBPM and is

the recommended out-of-office measurement method.
• HBPM has better predictive ability than OBPM and is
recommended if ABPM is not tolerated, not readily
available or due to patient preference.
• Identifies white coat hypertension (as well as
diagnosing masked hypertension))
Only relying on office pressures misses out on
white coat and masked hypertension
200
Ambulatory BP mmHg

180
Masked True
Hypertension Hypertension
160

140 135
White Coat
120 Normotension
Hypertension

100
100 120 140 160 180 200
Manual Office BP mmHg

From Pickering et al. Hypertension 2002;40:795-796

 Summary of evidence
• Out-of-office is needed to identify white coat
hypertension (and to rule out masked hypertension)
• ABPM has better predictive ability than OBPM
• HBPM has better predictive ability than OBPM
 Criteria for the diagnosis of hypertension
and recommendations for follow-up: summary

Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation
ABPM: Ambulatory Blood Pressure Measurement
AOBP: Automated Office Blood Pressure
HBPM: Home Blood Pressure measurement
OBPM: Office Blood Pressure measurement
 SUMMARY (1)
• JNC 8 has not redefined high BP, and the panel
believes that the 140/90 mm Hg definition from JNC 7
remains reasonable.

• The relationship between BP and risk is linear down

to very low BP, but the benefitt of treating to these
lower levels with antihyppertensive drugs is not
established.

• Lifestyle medication have the potential to improve BP

control and even reduce medication needs.
 SUMMARY (2)
• Blood Pressure Control involves not just Clinic
Blood Pressure but also Ambulatory Blood
Pressure and Home Blood Pressure
•
• Out of Office BP Measurements
• benefit in giving us an estimate of the TRUE blood pressure
• could be used in diagnosis , therapy and predicting prognosis
in our patients
• indispensable technique in the management of hypertension,
is included in most HT guidelines

AS-2015
The guidelines are not a substitute for clinical
judgment, and decisions about care must
carefully consider and incorporate the clinical
characteristics, and circumstances of each
individual patient.