DR.

YASIR NOOR
MASTER IN FAMILY MEDICINE AND COMMUNITY HEALTH
FACULTY OF MEDICINE
UNIVERSITY OF SUIZ CANAL
 Objective

• Definition
• Epidemiology
• Classification, Diagnosis and Types
• Risk factor
• Causes
• BP Measurement Technique
• Screening
• Prevention
• Management
 DEFINITION OF HTN

Hypertension is defined as persistent

elevation of SBP ≥ 140mm Hg and/ or DBP ≥
90mm Hg in patients not on
antihypertensive medication

(at least 3 reading of high BP)

 DEFINITION OF HTN

Persistent SBP and or DBP levels above which

harm and significant increment of morbidity
and mortality are observed if left untreated.

SHAMS 2018
 EPIDEMIOLOGY
Hypertension is the most widespread risk factor of CVD around the
.world
‫ سنة وما‬18 ‫ في الفئة العمرية من‬%15,2 ‫معدل االنتشار في المملكة العربية السعودية‬
‫فوق‬
About 1.1 million Saudi men and 0.8 million Saudi women are
.hypertensive

• The global prevalence of raised blood pressure was around 24.1%

in men and 20.1% in women in 2015.
• The number of adults with raised blood pressure increased from
594 million in 1975 to 1.13 billion in 2015, with the increase
largely in low- and middle-income countries
 CLASSIFICATION OF HTN
1/ Normal : systolic <120 AND diastolic <80 mmHg
2/ Pre hypertension : systolic 120 – 139 OR diastolic 80 – 89
mmHg
3/ GRAD 1 : systolic 140 to 159 AND/OR diastolic 90 to 99
mmHg
GRADE 2 : systolic 160 to 179 AND/OR diastolic 100 to 109
mmHg
GRADE 3 : systolic 180 mmHg OR higher AND/OR diastolic 110
mmHg OR higher.
Immediate RX
SHAMS 2018
 CLASSIFICATION OF HTN

NORMAL SBP < 120 mmHg AND DBP < 80 mmHg

ELEVATED SBP 120 – 129 mmHg AND DBP < 80 mmHg

STAGE 1 SBP 130 - 139 mmHg OR DBP 80 - 89 mmHg

STAGE 2 SBP ≥ 140 mmHg OR DBP ≥ 90 mmHg

In patients not on antihypertensive medication

ACC\ AHA 2017

 DIAGNOSIS OF HTN

≥ 60 YEARS AGE PATIENTS

• SBP ≥ 150 mmHg
• DBP ≥ 90 mmHg
< 60 YEARS AGE PATIENTS
• SBP ≥ 140 mmHg
• DBP ≥ 90 mmHg
In patients not on antihypertensive medication

JNC 8
 DIAGNOSIS OF HTN

• BP 180/110 OR Higher = HTN

• Confirm with
• 1/ ABPM (Ambulatory.. preferred)
Daytime mean 135/85 or Higher
24 hrs mean 130/80 or Higher
• 2/ HBPM (Home) mean of 130/80 or Higher

SHAMS 2018
 DIAGNOSIS OF HTN

• SHAMS 2018
• BP less than 180/110
• NO DIABETES
1/ AOBP (automated office) 135/85 OR Higher
2/ Non AOBP 140/90 OR Higher
SUSPECTED , NEEDS CONFIRMATION
 DIAGNOSIS OF HTN
• BP less than 180/110
• W ITH DIABETES
AOBP OR NON AOBP 130/80 OR Higher
SUSPECTED NEEDS CONFIRMATION
THEN
confirm both with and without DM by :
1/ ABPM Daytime mean 135/85 OR Higher

24 hr measures mean 130/80 OR Higher

2/ HBPM mean measures 135/80 OR Higher

IF readings are below above mentioned this is
WHITE COAT HTN
SHAMS 2018
 Types of HTN
• Isolated systolic hypertension
• Masked hypertension (isolated ambulatory)
• Resistant HTN
• White coat HTN
• Urgency HTN
• Emergency HTN (Malignant and Accelerated
HTN)
 Isolated systolic HTN
Systolic of 140 or higher with normal diastolic
BP
 Age group below 80 years 140 mm HG or
higher
 Age group 80 years and older 150 mm HG or
higher
 White coat HTN

• White coat HTN is defined as an elevated BP in

the office at repeated visits, while it is normal
out of the office, using either ABPM or HBPM.

).
 RESISTANT HYPERTENSION

• Resistant Hypertension (RH) can be defined as

office BP above goal of 140/90 mm Hg
despite implementing lifestyle modification and
3 drugs therapy, one of them is a diuretic in
optimal doses.
• Recently the definition was expanded to
include those patients whose BP is controlled
on 4 or more drugs
SHAMS 2018
 Masked hypertension
(isolated ambulatory)

• Masked HTN is defined as normal BP in the

office at repeated visits and elevated out of
the office, either on ABPM or HBPM.
• Possible causes: anxiety, stress.

SHAMS 2018
 HTN urgency
SBP ≥ 180, DBP ≥ 110
Asymptomatic
Not acute
No end organ damage EOD
 HTN emergency
SBP ≥ 180 mmhg and/or DBP ≥ 110 mmhg *
Acute end organ damage EOD *
Requires immediate treatment
TYPES OF HTN emergency
Accelerated HTN \1
Malignant HTN \2
They have similar therapies and outcomes
 Malignant HTN
• Presentation of acute very high BP with multi
organ damage. Stage III or IV retinopathy is
common in this group. It is considered as a
hypertensive emergency.
 Accelerated HTN

Rapidly rising BP of ≥ 180\110, IF left untreated

can cause end organ damage (EOD)
 Postural hypotension
• Postural hypotension (falls or postural
dizziness)
• Person either supine or seated.
• Measure blood pressure again with the
person standing for at least 1 minute prior to
measurement
 Postural hypotension
Systolic BP falls by 20 mmHg or more OR diastolic
fall by 10 mmHg when the person is standing
THEN :
 Review medication
 Measure subsequent blood pressures with the
person standing
 Consider referral to specialist care if symptoms of
postural hypotension persist.
 Risk factors
:Non- modifiable risk factors *
Age: chance increases with age, men more common at 45
yrs. Women at 65 yrs.
As mentioned above: Sex
Family hx
blacks more than whites:Race
Genetic factors
Family history of an overt CVD disease or death of first
degree relative from a cardiac event CVD (men < 55
.women < 65)
CKD CRP >1 mg/dl
 :modifiable risk factors

Dietary habits (Excess Consumption of Sodium Chloride,

(Potassium,Calcium,Magnesium
Dyslipidaemia TG >250 mg/dl(6.5 mmol/L), LDL C>155 mg/dl(4
mmol/L), HDLC < 40 mg/dl(1mmol/L) in men,< 50 mg\dl(1.3
mmol/L) in women
DM
Obesity BMI 30 kg\m2 or more
Physical inactivity
Alcohol consumption
Smoking
.Personality of patient and social environment
???Causes of HTN
 CAUSES of HTN

•Secondary 10%
•Renal disease
•Aortic coarcitation
•Drugs (steroid, stimulant

•Primary 90 %. oral contraceptive pills)

•Endocrine
1.Hypo and hyper thyroidism
2.Hyperparathroidism due to hyper calcaemia
3.Cushing syndrome.
4.Pheochromocytoma.
5.Primary aldosteronism.

(essential X) •Obstuctive sleep apnea(OSA) 50% of HTN

patients have OSA‫انقطاع النفس النومي السريري‬
•OSA is associated with resistant HTN and vise
versa
 :Primary & secondary
Hypertension onset at young age Onset in older age (40s & 50s)

Rapid onset of severe hypertension Gradual onset

Lack of family history Family history (1st degree relatives)

clinical (signs and symptoms ) and associated with obesity.

laboratory evidence of secondary causes

Resistant hypertension Lack of severe end-organ damage

More severe chronic end-organ damage Lack of clinical (signs and symptoms ) and
Grade III/IV retinopathy, LVH/CHF, CKD laboratory evidence of secondary causes
 BP MEASUERMENT
TECHNIQUE

• The patient should sit quietly for at least

5 minutes with the arm exposed and
supported at the level of the heart, and the
back resting against a chair and both feet on
the floor.

• Ideally patient should not exercised or

consumed caffeine or smoked tobacco within
30 minutes before testing.
BP MEASUERMENT TECHNIQUE
• Use the proper cuff size.
• blood pressure is checked in both arms
• Calibrated ‫ & معيارية‬validated ‫حيحة‬M‫ ص‬device.
 BP MEASUERMENT
TECHNIQUE
• Use radial pulse obliteration pressure to
estimate the systolic BP, inflate 20-30 mmHg
above that level, then deflate by 2-3 mmHg\
second
• SBP as first Korotkoff sound and DBP as
disappearance of all Korotkoff sounds
• Provide patients the SBP/DBP readings both
verbally and in writing.
 SCREENING FOR HTN
SHAMS 2018 GUIDELINES
 Blood pressure should be measured in each
visit to the clinic for all adults 18 yrs and older

 Children aged 3 years and older should have

their BP measured during every healthcare
visit, especially with the growing prevalence of
obesity in children
 Screening intervals
Screening is recommended
• annually for adults aged 40 years or older
• At any age for those who are at increased risk
of high BP including those who have high-
normal BP(130–139/85–89 mm Hg) and those
who are overweight or obese.
SHAMS 2018
 Screening intervals

• Adults aged 18–39 years with normal BP

(<130/85 mm Hg) who do not have other risk
factors should be re-screened every 3–5 years

SHAMS 2018
 SCREENING FOR HTN
SHAMS 2018 GUIDELINES
• Follow the proper technique of blood
pressure measurement.
 SCREENING FOR HTN
• The U.S. Preventive Services Task Force
(USPSTF)

recommends screening for high blood

pressure in adults aged 18 years and older.
(This is a grade "A" recommendation)
• The American Academy of Family Physicians
( AAFP)
• strongly recommends screening adults aged
18 years and older for hypertension.

• The American Heart Association (AHA)

Similar recommendations have been issued for
adults beginning at age 20 years and older.
TARGETS BASED ON CO-MORBIDTIES
SHAMS 2018
TARGET COMORBIDITY
140/90 Age less than 80 yrs
150/90 Age more than 80 yrs

140/90 DM
140/90 CKD WITHOUR PROTEIUREA
130/80 CKD WITH PROTEIUREA

140/90 IHD
140/90 CHF
140/90 OLD STROKE
 HYPERTENSION PREVENTION

• Primary prevention through advocating a

healthy life style and controlling other CV risk
factors.

• BP should be measured periodically, and

lifestyle counseling should be offered
accordingly by a trained healthcare
professional.
 PREVENTION
Impact of lifestyle therapies on blood pressure in
hypertensive patients

Effect Target Intervention

mm HG reduction 2.5− 5.8 mg/day 1500< Sodium reduction

mm Hg reduction 5.9 − 7.2 kg 4.5 Weight loss

mm Hg 5.5−/11.4− DASH Diet Dietary pattern

mm Hg 7.5−/10.3− times/week 3 Exercise

mm Hg 2.3−/4.6 − drinks/day 2.7 Alcohol intake

Management
 MANAGEMENT
• GOALS OF TREATMENT
• Primary goal is to achieve the maximum reduction in
total risk of cardiovascular and renal morbidity and
mortality (Grade A).
• This requires two steps:
1. Reducing BP to the target level
2. Controlling all other reversible cardiovascular risk
factors e.g. diabetes, smoking, obesity,
Dyslipidaemia, physical inactivity, unhealthy diet,
alcoholism and stress.
 ..… Approach

History

Physical
management
examination

investigation
 ‫اهداف التقييم االكلينيكي للمريض‬
‫القياس الصحيح لضغط الدم لعمل التشخيص‬ ‫•‬
‫التعرف على عوامل الخطورة‬ ‫•‬
‫تقييم االمراض المصاحبة للضغط‬ ‫•‬
‫تشخيص المضاعفات‬ ‫•‬
‫التعرف على االسباب الثانوية الرتفاع ضغط الدم ( العمر المبكر‪,‬‬ ‫•‬
‫االستجابة الضعيفة للعالج‪ ,‬حدوث المضاعفات‪ ,‬عدم وجود تاريخ‬
‫اسري‪ ,‬نتائج الفحوصات التي ترجح االسباب الثانوية)‪.‬‬
‫يتم ذلك من خالل التاريخ المرضي والكشف السريري‬
‫والفحوصات المخبرية واإلشعاعية الالزمة‬

‫‪44‬‬
 HISTORY
• ASK THE PT ABOUT HIS / HER

IDEA
CONCERN
EXPECTATION
EFFECT
 History-1
• General medical history; allergies, surgeries,
…etc.
• Hypertension: duration , medications.
• Personal history of DM, Dyslipidaemia, CAD.
• Family history of hypertension, CAD,
Dyslipidaemia, DM.
• Style of living: occupation, smoking,
activities, eating habits.

46
 History-2

• Palpitations ,sweating, tremors;

pheochromocytoma.
• Weight gain; cushings, hypothyroid.
• Weight loss; hyperthyroid, DM and
pheochromocytoma.
• Renal stones; Hyperparathyroidism, CKD.
• Symptoms of TOD related to organ.
47
 History-3
• Drug history :
– NSAID.
– Steroids; oral contraceptive pill, corticosteroids.
– Nasal decongestants-ephedrine.
– Appetite Supressants-phenylpropanolamine.
– Street drugs; cocaine.
– Tricyclic antidepressants.
– Erythropoietin.
– Cyclosporine and Tacrolimus.
– Alcohol.
– Drug withdrawal; Clonidine, Beta-blockers.
– Licorice.
– Herbs ( dietary supplements).

48
 Examination-1
• General medical examination.
• BP; at the first visit, in both arms, if discrepancy
think of Coarcitation, dissection. BP in lower limb;
discrepancy suggests Coarcitation.
• Pulse; at first visit, compare R & L arm, any radio-
femoral delay.
• Weight, Height, BMI, Waist Circumference.

49
 Examination-2
• Neck; raised JVP.
• Heart ; displaced apex, normal sounds, added
sounds, murmur.
• Lung ; check for any rales or wheezes.
• Abdomen; masses, striae .
• Lower limbs; swellings, trophic changes,
pulses.
• Fundus examination.
50
 Laboratory Investigation
1/ Basic
• CBC.
• Urine analysis.
• Blood chemistry; electrolytes, sugar, lipids, creatinine and eGFR.
• ECG.
• Thyroid-stimulating hormone TSH
2/ Optional
• urinary albumin to creatinine ratio
• Uric acid
• Echocardiogram

51
 The BP target

<140/90 mm Hg for most patients with HTN.

NON-PHARMACOLOGICAL APPROACH

• Summary of Recommendations:
• Weight reduction to ideal body weight
• Adopt DASH dietary plan
• Restrict sodium intake to <1500 mg/day (1/2
to 3/4 teaspoon)
• Regular moderate-intensity physical activity
• Smoking cessation
 Principles of drug treatment
SHAMS 2018

1. Hypertension without any compelling indications

(Target BP <140/90 mm Hg)

 Thiazide diuretics, ACEI, ARBS, or long-acting

dihydropyridine CCBs (Amlodipine) are considered first-
line antihypertensive agents. Combination of first line
agents.

 2-3 agents should be considered if SBP ≥20 mmHg or

DBP ≥10 mmHg above target or in patients at high CV-R.
 Principles of drug treatment
SHAMS 2018

• Combination of ACEI and ARBs is

contraindicated.
• ACEI and ARBs are potential teratogens.
Avoid use in pregnancy, and use with caution
for females of child bearing potential
 Principles of drug treatment
SHAMS 2018

• Isolated systolic hypertension without other

compelling indications (target BP for age <80
years is <140 mm Hg; for age ≥80 years, the
target systolic BP is <150 mm Hg) GIVE
Thiazide/ thiazide-like diuretics, ARBs, or long-
acting dihydropyridine CCBs.
For isolated diastolic HTN follow the same
treatment isolated systolic HT in addition to
ACEIs
 Principles of drug treatment
SHAMS 2018

WITH Diabetes Mellitus (Target BP <140/90; however,

<130/80 may be warranted)
A- Diabetes mellitus with microalbuminuria , renal
disease, CVD, or additional CV risk factors GIVE ACE
inhibitors or ARBs.
• Addition of long-acting dihydropyridine CCBs is preferred
over Thiazide/ Thiazide like diuretics (Indapamide).
• A loop diuretic (furosemide) could be considered in
hypertensive CKD patients with extracellular fluid
overload.
 Principles of drug treatment
SHAMS 2018

B- Diabetes mellitus without microalbuminuria

or other co morbidities: GIVE
ACE inhibitors, ARBs, long-acting
dihydropyridine CCBs or Thiazide/Thiazide-
like diuretics.
• Combination of ACEI with CCB is preferred
over combination with Thiazide /Thiazide-
like diuretic.
 Principles of drug treatment
SHAMS 2018

• Cardiovascular Disease (Target <140/90 mm Hg):

• a- Coronary artery disease GIVE
ACE inhibitors or ARBs; ßBs and LA-DHP-CCBs for
• patients with stable angina. When combination therapy
is being used for high risk patients, an ACE inhibitor with
dihydropyridine CCB (e.g. Amlodipine) is preferred.
• Avoid short-acting nifedipine.
• Combination of an ACEI with an ARB is contraindicated.
Exercise caution when lowering SBP to target if DBP is
≤60 mm Hg.
 Principles of drug treatment
SHAMS 2018

• b- Recent myocardial infarction GIVE

• ßBs and ACE inhibitors (ARBs if ACE inhibitor
intolerant).
• Long-acting CCBs if ßB contraindicated or not
effective.
• Nondihydropyridine CCBs (Verapamil/
diltiazem) should not be used with
concomitant heart failure.
 Principles of drug treatment
SHAMS 2018

• Heart failure
ACE inhibitors (ARBs if ACE inhibitor intolerant)
and BBs.

• Aldosterone antagonists may be added for

patients with recent cardiovascular
hospitalization, acute myocardial infarction.
 Principles of drug treatment
SHAMS 2018

• Non-diabetic chronic kidney disease—Target

<140/90 mm Hg:
• Nondiabetic chronic kidney disease with
proteinuria GIVE
ACEI (ARBs if ACE Intolerant).

• Diuretics as additive therapy. Combinations

with other agents may be used.
 Principles of drug treatment
SHAMS 2018

• To achieve optimal blood pressure targets:

• Multiple drugs are often required to reach
target levels, especially in patients with type
2 diabetes
• Low doses of multiple drugs may be more
effective and better tolerated than higher
doses of fewer drugs
 Principles of drug treatment
SHAMS 2018

 Reassess patients with uncontrolled blood

pressure at least every 2 months

 The most preferable combinations are ACEIs

or ARBs plus LA-DHP-CCBs and/or thiazide
diuretics as required
Chronic Management
Initial Approach to Very High Blood Pressure in PHC:
 Antihypertensive Medication Adherence
Strategies
In adults with hypertension to improve
adherence.
• Once daily dosing rather than multiple times
daily is beneficial.
• Use of combination pills can be useful.
 Hypertensive Crises- Urgencies

• For adults without a compelling condition, SBP should

be reduced by no more than 25% within the first hour;
Then, if stable, to 160/100 mm Hg within the next 2 to 6
hours;
Then cautiously to normal during the following 24 to 48
hours.
• Intensify antihypertensive therapy.

ACC\ AHA 2017

 Hypertensive Crises—Emergencies

• In adults with a hypertensive emergency,

admission to an intensive care unit is
recommended for continuous monitoring of
BP and target organ damage and for
parenteral administration of an appropriate
agent .

ACC\ AHA 2017

ACC\ AHA THERAPY RECOMMENDATIONS

• Pregnant women or are who are planning to

become pregnant, should be transitioned to
methyldopa, nifedipine, and/or labetalol during
pregnancy
• Pregnant women with hypertension should not
be treated with ACE inhibitors, ARBs, or direct
rennin inhibitors

ACC\ AHA 2017

 Home BP measurements(BPHM)

At least 2 readings morning before taking

.medications and evening for one week

.Value of BP 135/85 or higher is diagnostic

 Ambulatory BP measurements( ABPM)

Obtain readings every 15 to 30 mins during

the day and every 15 mins to 1 hour during
.the night
diagnostic values
awakening hours mean BP of 135\85 or higher
asleeping hours of 120\70 or more
 Special Considerations
• When using thiazide or thiazide type diuretic
monitor for hyponatremia and hypokalaemia,
uric acid (ACUTE GOUT) and calcium levels.
• Do not use ARBS in combination with ACE
inhibitors or direct rennin inhibitor.
 Special Considerations
• Avoid routine use with beta blockers because
of increased risk of bradycardia and heart
block.
• Do not use CCB in patients with HFrEF.
 Special Considerations
• Beta blockers are not recommended as first-
line agents unless the patient has IHD or HF.
• Bisoprolol and metoprolol succinate are
preferred inpatients with HFrEF.
• Avoid abrupt cessation
 Special Considerations
Diuretics :
Aldosterone antagonists e.g. Spironalactone
(K+ sparing diuretic) :
• These are preferred agents in primary
aldosteronism and resistant hypertension.
• Avoid use with K+ supplements and other K+
sparing diuretics with significant renal
dysfunction.
 Special Considerations
JNC 7
• low-dose aspirin therapy should be considered
only when [blood pressure] is controlled
because of the increased risk of hemorrhagic
stroke when the hypertension is not
controlled.
 Special Considerations
Vit D AND HTN
• The results of a meta-analysis indicated that
supplementation with vitamin D does not lower blood
pressure in the general population.

• Prev Chronic Dis 2020;17:190307. DOI: 

http://dx.doi.org/10.5888/pcd17.190307 A CDC Journal
Dongdong Zhang, MD1; Cheng Cheng, MD2; Yan Wang, MD1; Hualei Sun,
MD1; Songcheng Yu, MD1; Yuan Xue, MD1; Yiming Liu, MD1; Wenjie Li,
MD, PhD1; Xing Li, MD1
Recommendations for Management of Hypertension JNC8

Recommendation 1
SUMMARY
≥60 YEARS BP TREATMENT TARGET< 150/90
(Strong Recommendation – Grade A)
Recommendations for Management of Hypertension JNC8

Recommendation 2
SUMMARY
<60 YEARS DIASTOLIC BP TREATMENT TARGET
LESS THAN 90
(For ages 30-59 years, Strong Recommendation –
Grade A; For ages 18-29 years, Expert Opinion
– Grade E)
Recommendations for Management of Hypertension JNC8

Recommendation 3
SUMMARY
<60 years, TREATMENT GOAL FOR SYSTOLIC BP
<140mmHg. (Expert Opinion – Grade E)
Recommendations for Management of Hypertension JNC8

Recommendation 4
SUMMARY
≥18 years with chronic kidney disease (CKD)
TREATMENT GOAL FOR BP <140/90 mmHg.
(Expert Opinion – Grade E)
Recommendations for Management of Hypertension JNC8

Recommendation 5
SUMMARY
18 years with DM GOAL FOR BP <140/90
mmHg. (Expert Opinion – Grade E)
Recommendations for Management of Hypertension JNC8

Recommendation 6
SUMMARY
Nonblack population, including those with
diabetes, treatment should include a thiazide
-type diuretic, (CCB), OR (ACEI) OR (ARB).
(Moderate Recommendation – Grade B)
Recommendations for Management of Hypertension JNC8

Recommendation 7
SUMMARY
Black population, including those with diabetes:-
treatment should include a thiazide -type
diuretic or CCB. (For general black population:
Moderate Recommendation –Grade B; for
black patients with diabetes: Weak
Recommendation – Grade C)
Recommendations for Management of Hypertension JNC8

Recommendation 8
SUMMARY
18 years with CKD, initial (or add-on) treatment
should include an ACEI or ARB to improve
kidney outcomes.
This applies to all CKD patients with hypertension
regardless of race or diabetes status. (Moderate
Recommendation – Grade B)
Recommendation 9
SUMMARY
• START WITH ONE DRUG, goal, if not achieved within one
month increase the dose of the initial drug or add a
second drug (Thiazide-type diuretic, CCB, ACEI, or ARB).
• If goal still not achieved add a third drug.
• Do not use an ACEI and an ARB together in the same
patient
• If goal not achieved refer the patient to HTN specialist.
(Expert Opinion – Grade E)
ACC\ AHA THERAPY RECOMMENDATIONS

• For initiation of antihypertensive drug

therapy, first-line agents include:-

Thiazide diuretics, CCBs, and ACE inhibitors or

ARBs.
ACC\ AHA THERAPY RECOMMENDATIONS

• Start with 2 first-line agents of different

classes, either as separate agents or in a
fixed-dose combination in adults with Stage 2
hypertension
• An average BP more than 20/10 mm Hg
above their BP target.
ACC\ AHA THERAPY RECOMMENDATIONS

• Initiation of antihypertensive drug therapy

with a single antihypertensive drug is
reasonable in adults with stage 1
hypertension and BP goal <130/80 mm Hg
with dosage titration and sequential addition
of other agents to achieve the BP target
ACC\ AHA THERAPY RECOMMENDATIONS

In adults with DM and hypertension

• antihypertensive drug treatment should be
initiated at a BP of 130/80 mm Hg or higher with
a treatment goal of less than 130/80 mm Hg.
• all first-line classes of antihypertensive agents
(i.e., diuretics, ACE inhibitors, ARBs, and CCBs)
are useful and effective.
• ACE inhibitors or ARBs may be considered in the
presence of albuminuria (11, 12).
 :References

UpToDate
JNC8

SHAMS
Saudi Hypertension ( NICE 2013
Management Guidelines
)Synopsis2018 ACC\ AHA
2017
thank you