SHREE BAJRANGDASBAPA

AROGYADHAM
Dr. Deepak Munshi – MD Physician
SESSION 1
WHAT IS HYPERTENSION?
 What is Blood Pressure?

◻ It is the lateral pressure exerted by

the flowing blood on the walls of the
blood vessels (arteries)

 Systolic Blood Pressure (SBP):

Pressure during the ventricular
Systole Normal Blood pressure
<120/80 mm Hg
 Diastolic Blood Pressure (DBP):
Pressure during the ventricular
Diastole
 Hypertension

• Doubles the risk of CV diseases, including CHD, ischemic

and hemorrhagic stroke, renal failure, and peripheral
arterial disease

• Often associated with additional CV disease risk factors

• Large segments of the hypertensive population are either

untreated or inadequately treated.

Eur Heart J. 2013 Jul;34(28):2159-219.

Classification of office BP levels (mmHg)

Eur Heart J. 2013 Jul;34(28):2159-219.

 Diagnostic evaluation

Initial evaluation of a patient with hypertension

Confirm the diagnosis of hypertension

Assess CV risk & organ damage (OD)

Concomitant clinical conditions

Eur Heart J. 2013 Jul;34(28):2159-219.

 Diagnostic evaluation

➢ BP measurement

➢ Medical history including family history

➢ Physical examination

➢ Laboratory investigations

➢ Further diagnostic tests

Eur Heart J. 2013 Jul;34(28):2159-219.

BP measurement
 Office blood pressure measurement

‘Gold standard’ for screening, diagnosis and

management of hypertension

Eur Heart J. 2013 Jul;34(28):2159-219.

Precautions while measurement of BP

Eur Heart J. 2013 Jul;34(28):2159-219.

Precautions while measurement of BP

Eur Heart J. 2013 Jul;34(28):2159-219.

 Out-of-office blood pressure
• Advantages
❑ Provides a large number of BP measurements away from the
medical environment
❑ More reliable assessment of actual BP than office BP.

• Assessed by Ambulatory Blood Pressure Monitoring (ABPM) & Home

Blood Pressure Monitoring (HBPM) usually by self-measurement.

• Several studies have shown that hypertensive patients LVH and OD

correlate with ambulatory BP more closely than with office BP

Eur Heart J. 2013 Jul;34(28):2159-219.

 Definitions of hypertension
Office & out-of-office BP levels

Eur Heart J. 2013 Jul;34(28):2159-219.

 Average daytime, night-time &
24-hour blood pressure

• Most commonly used variables in clinical practice

• Calculated from the BP diary

Prognostic significance
• 24-h average BP has been consistently shown to have a stronger
relationship with morbid or fatal events than office BP
• Night-time BP is a stronger predictor than daytime BP
• The night–day ratio is a significant predictor of clinical CV
outcomes
• Incidence of CV events is higher in patients with a lesser drop in
nocturnal BP than in those with greater drop

Eur Heart J. 2013 Jul;34(28):2159-219.

 White-coat hypertension

• Isolated office hypertension

• Prevalence 13%

• Office BP is usually higher than BP measured out of the office

• Due to alerting response, anxiety or a conditional response to the

unusual situation

• BP normal or high out of the office, either on ABPM or HBPM.

• Risk factors: age, female sex and non-smoking

Eur Heart J. 2013 Jul;34(28):2159-219.

 Masked hypertension

• Isolated ambulatory hypertension

• Prevalence 13%
• BP may be normal in the office and abnormally high out of the
medical environment
• Risk factors: younger age, male gender, smoking, alcohol
consumption, physical activity, exercise-induced, anxiety, job stress,
obesity, diabetes, family history of hypertension
• Largely undetected and untreated
• Asymptomatic organ damage
• Incidence of CV events is about two times higher

Eur Heart J. 2013 Jul;34(28):2159-219.

 Isolated systolic hypertension

• Until the 1980’s DBP was assumed to be the most relevant for
prognosis of hypertensive patients.
• There was a radical change in thinking based on epidemiological
studies which led to recognition of elevated SBP
• JNC-VII and WHO/ISH guidelines: BP >140/<90 mm Hg
• More common in elderly subjects, since SBP rise with advancing age
whereas DBP usually levels off
• NHANES III: ISH is the most prevalent type of untreated
hypertension >60 years of age.
• Substantial health care problem as the target BP is very difficult to
attain by drug therapy.

http://www.apiindia.org/pdf/medicine_update_2012/hypertension_02.pdf
 Prehypertension

• JNC VII- SBP: 120 to 139 mmHg or DBP: 80 to 89 mmHg

• Often associated with multiple additional CV risk factors, such as
obesity, DM, dyslipidemia
• Evidence of organ damage
• Decrease average life expectancy by as much as five years
Management
– Nonpharmacological treatment with lifestyle modifications
– Pharmacological therapy : for patients with co-morbidities such
as DM, CKD, CAD.

http://www.apiindia.org/pdf/medicine_update_2012/hypertension_01.pdf
Medical history
 Symptoms

• Headache generally occurs only in patients with severe hypertension.

• “Hypertensive headache" occurs in the morning and is localized to the

occipital region.

Nonspecific symptoms such as

• Dizziness
• Palpitations
• Easy fatigability
• Impotence

Longo DL et al. Harrison's™ Principles of Internal Medicine Eighteenth Edition

History of risk factors

Eur Heart J. 2013 Jul;34(28):2159-219.

 History and symptoms of
organ damage & CV disease

Eur Heart J. 2013 Jul;34(28):2159-219.

Physical examination
 Physical examination
• On at least one occasion, BP needs to be measured at both arms and
differences between the two arms in SBP >20 mmHg and/or in DBP
>10 mmHg—if confirmed—should trigger further investigations of
vascular abnormalities

• All patients should undergo auscultation of the carotid arteries, heart

and renal arteries.

• Murmurs should suggest further investigation (carotid ultrasound,

echocardiography, renal vascular ultrasound, depending on the
location of the murmur).

Eur Heart J. 2013 Jul;34(28):2159-219.

 Physical examination

• Height, weight, and waist circumference should be measured with

the patient standing, and BMI calculated

• In all patients, heart rate should be measured while the patient is at

rest

• An increased heart rate indicates an increased risk of heart disease

• An irregular pulse should raise the suspicion of atrial fibrillation

Eur Heart J. 2013 Jul;34(28):2159-219.

Signs of organ damage

Eur Heart J. 2013 Jul;34(28):2159-219.

Evidence of obesity

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Laboratory investigations
 Laboratory investigations
Provide evidence for the presence of additional risk factors,
searching for secondary hypertension and looking for OD

Eur Heart J. 2013 Jul;34(28):2159-219.

Laboratory investigations

Eur Heart J. 2013 Jul;34(28):2159-219.

CASE BASED MANAGEMENT
OF HYPERTENSION
 Case study: Mrs. XYZ

◻ A 58-year-old female presented with h/o of feeling tired

and fatigued
◻ She also complains to headaches in the evenings
◻ She had tried using local oil massages for the hair but has
not got any relief
◻ She has no significant past medical history
◻ Her father was died due to MI
◻ On review of systems, she indicates no weight change,
chest pain, dyspnoea, syncope or palpitations
Case study continue…

On examination:
◻ Pulse rate: 86 bpm at rest

◻ Blood pressure (BP): 155/92 mm Hg sitting with no

orthostatic drop on standing

◻ no heart murmur

◻ no abnormal breath sounds

◻ no cyanosis or clubbing
Case study continue…
Laboratory investigation
 LDL 120 mg/dl; HDL 38 mg/dl; Triglycerides 198 mg/dl
 FBG 115 mg/dl, PPG 150 mg/dl, HbA1c 5.5%
 Urine analysis
■ Specific gravity 1.010, pH 6.0, no protein, no blood, no
nitrite and negative leukocyte esterase.
■ Microscopic examination: no cells, casts or crystals.
■ Serum creatinine: 0.8 mg/dL
■ Estimated glomerular filtration rate (eGFR): is 100
mL/min/1.73m2 for body surface area.
Question
◻ What should be the next line of management
a) Therapeutic life style changes
b) Start Anti-hypertensive medication
c) Repeat BP measurement
d) Nothing
Diagnosis of High Blood Pressure

◻ Take two to three blood pressure readings each at

three or more separate appointments before
diagnosing high blood pressure

◻ To prepare for the test, patient

 Should not smoke cigarettes or take coffee for 30
minutes prior to the test.
 Must go to the bathroom before the test.
 Sit for 5 minutes before the test.
Make a more accurate diagnosis of HTN in
view of new recommendations

2015 recommendations from the U.S. Preventive

Services Task Force and the Canadian
Hypertension Education Program (CHEP) –

To routinely incorporate out-of-office BP

measurement in all patients to confirm the diagnosis
of hypertension
Effectively use home BP monitoring (HBPM) for
your patients

Should be considered for patients with hypertension, particularly

those with:
• Diabetes mellitus (Grade D);
• CKD (Grade C);
• Suspected nonadherence (Grade D);
• Demonstrated white coat effect (Grade C);
• BP controlled in the office but not at home (masked
hypertension) (Grade C).

CHEP 2015
Goal Of Treatment

◻ Achieve and maintain goal BP

◻ Adherence to treatment

◻ Reduce CV and renal morbidity and mortality

◻ Monitoring of anti-hypertensive drug side effect

What is the BP that you aim in this 58 years
old non DM, non IHD female (mmHg)

1) 140/90

2) 120/80

3) 130/85

4) 150/ 90
JNC 8: Recommendations
JNC 8: Recommendations
Which is the best class of anti-HT agent needed to treat her HT

 Beta-blockers
 Alpha Blockers
 ARBs
 ACE
Choice of drug treatment

There is no ‘fixed rule’ as to which drug to start a particular

patient on
◻ Choice is best ‘individualized’ based on:

◻ Type and severity of hypertension

◻ Age

◻ Presence of co-morbid medical conditions

◻ Cost/economics
First line therapy medication
Co-morbid Conditions and Choice of Drugs in
Hypertension

Diabetes/Chronic Renal Disease ACEIs or ARBs

Stroke ACEIs ± Diuretics

IHD/Angina β-blockers
CCBs (long-acting)

Post-AMI/Heart Failure β-blockers and ACEIs

Elderly/Isolated Systolic Diuretics or CCBs

Hypertension

The JNC 7 Report. JAMA. 2003; 289: 2560-2571

What will be the best treatment for HT ?

 Telmisartan
 Atenolol
 Propranolol
 Amlodipine
Use of β-blocker in the management of HTN

JNC 8 recommendation
◻ The panel did not recommend β-blockers for the

initial treatment of hypertension

◻ in one study compared to use of an ARB, β-blockers use
resulted in a higher rate of the primary composite
outcome of
 Cardiovascular death
 Myocardial infarction
 Stroke
Calcium Channel Blockers
◻ Advantages:
 Unlike diuretics no adverse metabolic effects but mild
adverse effects like – dizziness, fatigue etc.
 Do not compromise haemodynamics – no impairment
of work capacity
 No sedation or CNS effect
 Can be given to asthma, angina and PVD patients
 No renal and male sexual function impairment like β-
blocker
 Minimal effect on quality of life
Major drawbacks of Dihydropyridine CCBs

1. Reflex Tachycardia
2. Edema
3. Renal Non-protection
4. No effect on proteinuria
Telmisartan- Advantages

◻ Longer elimination half-life of 24 hrs

◻ High affinity towards AT1 receptor (telmisartan >
olmesartan > candesartan > valsaratan > losartan)
◻ Very slow dissociation rate
These unique properties of Telmisartan ensure
improved 24- hr control of blood pressure as compared
to other ARBs
Telmisartan-
Unique property of activating PPAR- γ

Improves insulin sensitivity

Decreases adipocyte cell size
Decrease hepatic fat storage

• Decreased serum glucose and serum triglyceride levels, and

increased glucose uptake
•These effects improve metabolic syndrome and reduce the
risk of atherosclerosis
 Place of Telmisartan 80mg for the reduction of CV
morbidity

◻ Telmisartan is indicated* for the reduction of CV morbidity in

patients with
1. manifest atherothrombotic cardiovascular disease
(history of coronary heart disease or stroke, or peripheral
vascular disease) or
2. diabetes with documented target organ damage

◻ Because telmisartan’s unique pharmacology leads to proven

differences in organ protection a class effect cannot be assumed

* EMEA: European Medicines Agency

Bakris G, et al. Telmisartan is more effective than losartan in reducing proteinuria in patients with diabetic
nephropathy. Kidney Int 2008:74:364–369.
 Telmisartan

◻ SAFETY PROFILE
 Tolerability profile similar to placebo
 Mild and transient side effects-
■ headache,giddiness and fatigue

 Better tolerated than ACE inhibitors

■ lower incidence of cough

 Better tolerated than Amlodipine-

■ No Edema,flushing or reflex tachycardia.
Mrs. XYZ…3 years later….
◻ She is now 61 yrs of age
◻ Had gone for a medical check up as she had chest
pain
◻ Pulse rate: 90 bpm at rest
◻ Blood pressure (BP): 160/98 mm Hg
◻ ECG: Normal
◻ X-ray:Normal
Case study continue…

Laboratory investigation
 LDL 190 mg/dl; HDL 35 mg/dl; Triglycerides 250
mg/dl
 FBG 110 mg/dl, PPG 140 mg/dl, HbA1c 6%
 Urine analysis
■ Normal except
■ Urine Albumin-to-Creatinine Ratio (UACR)- 35mg/g
BP Control at 3 years

◻ One drug 27%

◻ Two or more drugs 73%

KEY QUESTIONS
1. How and when should you titrate or add additional
agents?

2. When should you start with more than one drug?

How and when should you titrate or add additional
agents?

◻ Any schedule for dose titration is arbitrary and based on the

pharmacodynamics and pharmacokinetics of the individual
drugs used.

◻ We would generally recommend titration of drugs that are not

given at full dose after 1-4 weeks, or adding additional drugs
for those patients not at goal blood pressure.

◻ The speed with which this is undertaken depends on the stage

of BP (relative risk) and the clinician’s judgment of the impact
of co-morbidity and other CV risk factors (absolute risk).
Which is the most scientific
combination ?

1) ARB , CCB, DIURETIC.

2) ARB , BB , DIURETIC.

3) ACE,ARB, DIURETIC.

4) BB, CCB , DIURETIC.

 A

D C
 JNC 8: Recommendation

If goal BP is not reached within a month of treatment, increase

the dose of the initial drug or add a second drug from one of the
classes (thiazide-type diuretic, CCB, ACEI, or ARB).

If goal BP cannot be reached with 2 drugs, add and titrate a third

drug.
If goal BP cannot be reached using the above drug class or because
of a contraindication or the need to use more than 3 drugs to reach Grade E
goal BP, antihypertensive drugs from other classes can be used.

Referral to a hypertension specialist indicated for patients in whom

goal BP cannot be attained using the above strategy or for the
management of complicated patients for whom additional clinical
consultation is needed.
 JNC 8: Recommendation

Aged 18 years or older with CKD and hypertension, initial

(or add-on) antihypertensive treatment should include an
ACEI or ARB to improve kidney outcomes
Grade B
This applies to all CKD patients with hypertension regardless
of race or diabetes status

CKD patients with and without proteinuria using ACEIs or

ARBs showed evidence of improved kidney outcomes in
both groups
Question
◻ What else should add in the management of this
patient
 Aspirin
 Rosuvastatin 10mg
 Rosuvastatin 20mg
 Rosuvastatin + Fenofibrate
2013 ACC/AHA Guidelines on the Assessment
of Atherosclerotic Cardiovascular Risk:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Stone NJ, et al
4 major statin treatment groups

◻ People with clinical ASCVD

◻ People age > 21 yrs with LDL-C levels of 190
mg/dL or more
◻ Diabetes (Type I/II), age 40-75 and LDL-C 70-189
mg%
◻ People without diabetes, age 40-75, LDLC 70-189
mg% and 10 yr ASCVD risk of 7.5% or higher
What is clinical ASCVD ??
◻ Coronary artery disease or peripheral artery disease
diagnosed by invasive /CT angiography
◻ Acute coronary syndromes
◻ Coronary or other arterial revascularization
◻ Stroke or TIA
◻ PVD presumed to be atherosclerotic
 Take home

◻ Take your to establish diagnosis of HTN (Home readings,

ABPM)
◻ Whenever possible, Impliment Life style change without
Pharmacotherapy, conitnue home monitoring.
◻ User friendly, pocket friendly prescriptions.
◻ Low dose synergistic combinations.
◻ Ensure adherence.
◻ Aim at 140/90, 150/90 as of now.
◻ Periodic checks of Biochemistry/End organs to break the
chain of HTN- Disease- Events
THANK YOU