HYPERTENSION

Assoc. prof. Lyubomir Kirov, MD, PhD

 IS HYPERTENSION A BIG PROBLEM?

• Hypertension remains the major preventable cause of cardiovascular

disease (CVD) and all-cause death globally and in our continent.

• Based on office BP, the global prevalence of hypertension was estimated

to be 1.13 billion in 2015, with a prevalence of over 150 million in
central and eastern Europe. The overall prevalence of hypertension in
adults is around 30 - 45%, with a global age standardized prevalence of
24 and 20% in men and women, respectively, in 2015.
 IS HYPERTENSION A BIG PROBLEM?

• Hypertension becomes progressively more common with

advancing age, with a prevalence of >60% in people aged
>60 years.

• It is estimated that the number of people with hypertension

will increase by 15–20% by 2025, reaching close to 1.5
billion.
 IS HYPERTENSION A BIG PROBLEM?

• SBP ≥140 mmHg accounts for most of the mortality and disability burden
(≈70%), and the largest number of SBP-related deaths per year are due to
ischaemic heart disease (4.9 million), haemorrhagic stroke (2.0million),
and ischaemic stroke (1.5million)

• increased risk of developing atrial fibrillation (AF) and evidence is

emerging that links early elevations of BP to increased risk of cognitive
decline and dementia
 IS HYPERTENSION A BIG PROBLEM?
• SBP appears to be a better predictor of events than DBP after the age of
50 years

• High DBP is associated with increased CV risk and is more commonly

elevated in younger (<50 years) vs. older patients. DBP tends to decline
from midlife because of arterial stiffening; consequently, SBP assumes
even greater importance as a risk factor from midlife. In middle-aged and
older people, increased pulse pressure (SBP minus DBP values) has
additional adverse prognostic significance.
 PULSE PREASURE

Normal Pulse Pressure

Range: 30-40 mmHg
Causes: Pulse Pressure (>40 mmHg)
1. Pathophysiology in Isolated Systolic Hypertension
1. Suggests reduced large artery vascular compliance
2. Best Blood Pressure marker for cardiovascular risk

2. Causes
1. Isolated Systolic Hypertension
2. Aortic Regurgitation
3. Thyrotoxicosis
4. Patent Ductus Arteriosus
5. Arteriovenous fistula
6. Beriberi heart
7. Aortic Coarctation
8. Anemia
9. Emotional state
 PULSE PREASURE
Normal Pulse Pressure
Range: 30-40 mmHg
Causes: Pulse Pressure (<30 mmHg)
1.Pathophysiology in Hypovolemic Shock
1. Sympathetic response to decreased circulating Blood Volume
2. DBP increase without SBP increase

2.Causes
1. Tachycardia
2. Severe Aortic Stenosis
3. Constrictive Pericarditis
4. Pericardial Effusion
5. Ascites
Curious but not valid and generally accepted
 HYPERTENSION-DEFINITION

Defined as office SBP values ≥140 mmHg and/or diastolic BP (DBP) values ≥90 mmHg,
when treatment of patients (LS change or drugs) with these BP values is beneficial
and outweighs possible risks of that treatment.

This is based on evidence from multiple RCTs.

The same classification is used in younger, middle-aged, and older people, whereas BP
centiles are used in children and teenagers, in whom data from interventional trials are
not available.
OFFICE BLOOD PRESSURE MEASUREMENT- RULES
 BP MEASUREMENT IN SHORT

Routine measurement (follow up)…

Patient should be sitting calm and comfortable, one hand

stretched and supported, the cuff being at the patient’s
heart level.

Patient, sitting with back leaned in the chair, legs not

crossed.

Patient should be at rest at least 1e minute before measuring

BP.
HYPERTENSION- DEFINITION, CLASSIFICATION, ESC/ESH 2018

The classification of blood pressure (BP) and the definition of

hypertension (HTN) remain unchanged in the European
Guideline, 2018.

Measured in the office SBP​​≥140 mmHg and/or DBP≥90mmHg,

which is equivalent to a mean of 24-hour ABPM:
SBP≥130/80mmHg or Home-blood pressure measurement
(HBPM) ≥ 135/85mmHg.
 ABPM & HBPM

ABPM-Ambulatory Blood Pressure Measurement

Performed with the patient wearing a portable BP measuring device for a 24–25 h

period, which records BP values and HR day and night. Then they are analyzed. AHA

guideline 2017- measurement at 15 to 30min. intervals during the day, 15-60min.-

through the night.

HBPM-Home Blood Pressure Measurement.

BP is measured by the patients or a person close to the Pt at least twice daily –in the

morning and the evening (not measured during the night) and registers the measured

values.

HBPM- 3-5, better for 7 days, 3-4 times daily if possible.

 ABPM & HBPM

ABPM-Ambulatory Blood Pressure Measurement

ABPM is a better predictor of HMOD than office BP. Furthermore,

24 h ambulatory BP mean has been consistently shown to have a
closer relationship with morbid or fatal events and it is a
more sensitive risk predictor than office BP of CV outcomes such
as coronary morbid or fatal events and stroke.
 ESC/ESH 2018
Comparison of ambulatory blood pressure monitoring and home blood pressure
monitoring
 DEFINITION OF HTN ACCORFING TO THE OFFICE & OUT-OF-OFFICE BP VALUES-2018

CATEGORY SBP(mmHg) DBP(mmHg)

Office BP ≥140 and/or ≥90

Ambulatory BP

Daytime (or awake) mean ≥135 and/or ≥85

Night time (or asleep) mean ≥120 and/or ≥70

24 – hrs mean ≥130 and/or ≥80

Home BP ≥135 and/or ≥85

 ABPM

KUMAR&CLARK’S CLINICAL MEDICINE

DEFINITIONS AND CLASSIFICATION OF OFFICE BLOOD PRESSURE
LEVELS (MMHG)
 JNC-7 Classifications of HTN
Classification of blood pressure for adults
SBP, systolic blood pressure; DBP, diastolic blood pressure

Blood Pressure SBP DBP

Classification mmHg mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Hypertension

Stage 2 ≥160 or ≥100

Hypertension
 DIAGNOSIS OF HTN

SBP≥140 mmHg and/or DBP ≥90 mmHg.

Screening and diagnosing – BP values, measured in the doctor’s

office.

To verify the diagnosis of hypertension it is recommended to

• do at least two measurements of BP during one and the same

visit and to do this at least at two visits (may be not mandatory
in general practice, have in mind patient’s history, LK).
• ABPM could be used, too but not so often.
 BP MEASUREMENT OUT OR IN THE OFFICE?

IN THE OFFICE - “golden standard” for screening, diagnosing

and follow up of HTN.

OUT-OF-OFFICE – important addition to the standard office

BP measurement.
 BP PATTERNS BASED ON OFFICE AND OUT-OF-OFFICE MEASUREMENTS

Office/Clinic) Home/ABPM

Normotensive No hypertension No hypertension

Sustained hypertension Hypertension Hypertension

Masked hypertension No hypertension Hypertension

White coat Hypertension No hypertension

hypertension
 SPECIFIC INDICATIONS FOR ABPM

Apparent discrepancy between BP values measured at the office and

at home.

Assessment of the level of night lowering of BP („dipping“).

Suspicion for night hypertension or lack of dipping (sleep apnoea,

CKD, diabetic polyneuropathy, orthostatic hypotension, elderly).
Assessment of BP variability.

Treatment control when doctor cannot rely on the accuracy of HBPM.

Wider use of out-of-office BP measurement with ABPM and/or
HBPM, especially HBPM, as an option to confirm the diagnosis of
hypertension, detect white-coat and masked hypertension, and
monitor BP control.
 RESISTANT HYPERTENSION
When the recommended treatment strategy fails to lower office SBP and DBP
values to <140 mmHg and/or <90 mmHg, respectively, and the inadequate
control of BP is confirmed by ABPM or HBPM in patients whose adherence to
therapy has been confirmed.

The recommended treatment strategy should include appropriate lifestyle

measures and treatment with optimal or best-tolerated doses of three or more
drugs, which should include a diuretic, typically an ACE inhibitor or an ARB, and a
CCB. Pseudo-resistant hypertension and secondary causes of hypertension
should also have been excluded.
 DIAGNOSIS OF HTN- HAVE IN MIND THAT…

Orthostatic hypotension

A reduction in SBP of >20mmHg or in DBP of >10mmHg within 3 min of Pt

assuming upright position.

Worsens the for mortality and CV events prognosis.

If the difference between measured values of BP from both arms is >15mmHg

(2018) for SBP and/or >10mmHg for DBP, we should consider any vascular
pathology. Auscultate carotid and renal arteries and refer patient to a consultant.
„DIPPING“ – normal night-time lowering of BP.

„DIPPERS“- night-time lowering of BP >10%, compared to day- time BP values or BP ratio

night/day <0.9. (100/120=0,8)

POSSIBLE CAUSES FOR LACK OF DIPPING:

•Sleep disturbances, obstructive sleep apnoea;

•Obesity, salt overuse from sensitive to it individuals;

•Orthostatic hypotension, autonomous nervous system dysfunction;

•CKD, diabetic neuropathy and elderly.

 Chronic kidney disease (CKD)-KDIGO guidelines

CKD is defined as abnormalities of kidney structure or function, present for >3

months, with implications for health.
Chronic kidney disease (CKD)-KDIGO GUIDELINES
 ESC/ESH 2018
Screening and diagnosis of hypertension.

Measure blood pressure in any patient without

established hypertension at any opportunity (visit). Ask
the patient if he/she has measured high blood
pressure.
 DIAGNOSTIC EVALUATION OF PTs WITH HTN

Evaluation is complex!

BP values, risk factors (RF), asymptomatic or symptomatic organ damage

(OD), DM, CKD, etc.

Detailed personal and family anamnesis is of great importance.

Defining RF other than high BP is extremely important for stratification of

the total CV risk.
PERSONAL AND FAMILY HYSTORY
SECONDARY HTPERTENSION
SECONDARY HTPERTENSION
PERSONAL AND FAMILY HYSTORY
PERSONAL AND FAMILY HYSTORY
Asymptomatic organ damage
ECG showing LVH
Echocardiography
CKD with GFR 30-60 ml/min/1,73 m2
Microalbuminuria (30 - 300 mg/24 hrs.), Albuminuria. Urine
Albumin/Creatinin ratio-UACR ≥ 3.5 mg/mmol (female) или ≥
2.5 mg/mmol (male).

Ankle/brachial index <0,9 indicating an advanced PAD (lower

extremities).
Table 16 The most commonly used simple criteria and recognised cut-off
points for definitions of electro- cardiogram left ventricular hypertrophy

ECG voltage criteria Criteria for LVH

SV1 plus RV5 (Sokolow–Lyon criterion) >35 mm
R wave in aVL >_11 mm
>28 mm (men)
>20 mm (women)

ECG = electrocardiogram; LVH = left ventricular hypertrophy.

a
Sum of limb and precordial lead voltage.
Adapted by L. Kirov
 RENAL FUNCTION

• An alteration of renal function is most commonly detected by an increase

in serum creatinine. This is an insensitive marker of renal impairment
because a major reduction in renal function is needed before serum
creatinine rises.

• Furthermore, BP reduction by antihypertensive treatment often leads to

an acute increase in serum creatinine by as much as 20–30%, especially
with renin-angiotensin system (RAS) blockers, which has a functional basis
and does not usually reflect manifest renal injury, but the long-term clinical
significance is unclear. (ESC/ESH 2018)
 RENAL FUNCTION
• Hypertension is the second most important cause of CKD after diabetes and
also be the presenting feature of asymptomatic primary renal disease.

• The diagnosis of hypertension induced renal damage is based on the finding

of reduced renal function and/or the detection of albuminuria. A progressive
reduction in eGFR and increased albuminuria indicate progressive loss of
renal function. CKD is classified according to estimated GFR.

• Microalbuminuria (30-300 mg/24 hrs.), Albuminuria. Urine

Albumin/Creatinin ratio-UACR ≥ 3.5 mg/mmol (female) или ≥ 2.5 mg/mmol
(male).

• Which is the cause of microalbuminuria in the presence of HTN and DM?

Chronic kidney disease (CKD)-KDIGO GUIDELINES
 EXISTING DISEASES-OD
Diabetes mellitus

FPG≥7.0 mmol/l measured twice and/or

HbA1c ≥6.5 % and/or

GTT>11,0 mmol/l at hour 2

CVD or Renal disease

Brain damage: stroke, TIA

CAD: MI, Stenocardia, AoCbypass, PCA

Heart failure: HFpEF, HFrEF

Symptomatic PAD

CKD and eGFR<30ml/min/1,73 m2; proteinuria (>300 mg/24hrs.)

Advanced retinopathy
RUTINE LABORATORY
INVESTIGATIONS
• Hb and/or Hct (FBC)
• FBG and A1C
• T-Ch, LDL, HDL
• Tg (after a fasting period)
• Serum К and Na
• Uric acid
• Creatinine and eGFR.
• Urine analysis: microscopic
examination, urinary protein by
dipstick test, microalbuminuria
 ECG-12 leads
To assess possible asymptomatic organ damage in
hypertensive Pts it’s recommended:
ECG in all Pts- looking for LVH, LA enlargement,
arrhythmias or concomitant heart disease.
Creatinine and eGFR in all PTs.
Measurement of urine albumin:creatinine ratio is
recommended in all hypertensive Pts. (microalbuminuria)
In all Pts- urinary protein by dipstick test.
Fundoscopy Is recommended in patients with grades 2 or
3 hypertension and all hypertensive patients with
diabetes.
Echocardiography:recommended in hypertensive PTs
when there are ECG abnormalities or signs or symptoms
of LV dysfunction. May be considered when the detection
of LVH may influence treatment decisions
 WHEN TO START TREATMENT?

USE DRUGS TO TREAT, NOT TO FEED!

 WHEN TO START TREATMENT? ESC/ESH 2018
Based on these new data, this Task Force now recommends that lifestyle advice should
be accompanied by BP-lowering drug treatment in patients with grade 1 hypertension
at low–moderate CV risk., I.E…
IF THERE IS HTN BY DEFINITION-DRUG TREATMENT SHOULD BE PRESCRIBED!

“For the purposes of this guideline, the “old” are defined as ≥ 65 years and the “very old”
as ≥80 years.
Discussion about the treatment of ‘the elderly’ or ‘older’ people has been complicated by
the various definitions of older age used in RCTs. For example, older was defined as >60
years in the earliest trials, then as 65, 70, and finally 75 or 80 yrs. in later trials
 ESC/ESH 2018
Classification of hypertension stages according to blood pressure levels, presence of
cardiovascular risk factors, hypertension-mediated
organ damage, or comorbidities.

IF THER’S HTN BY DEFINITION-

PRESCRIBE TREATMENT!
Chronic kidney disease (CKD)-KDIGO GUIDELINES
WHAT’S NEW IN ESC/ESH 2018?
I.E., IN GENERAL POPULATION <65yrs. THE END TARGET IS
SBP 120-129mmHg.
When BP remains uncontrolled with three-drug
THE PREVAILING USE OF TWO DRUG COMBINATION AS A START
combination therapy, the patient is classified as
OF TRATMENT IS COMMON PRACTICE “AT LEAST IN BG”, BECAUSE
having OF resistant hypertension,
THE ALREADY WIDESPREAD assuming
SPC (ARB+HCT; that
ACI+HCT) ON THE
secondaryMARKET,
causes ALSO CCB+D AND EVEN OTHER (TRIPPLE
of hypertension and poor adherence
COMBINATIONS).
to treatment have been excluded, and that the
elevation in BP has been confirmed by repeated office
BP measurement, ABPM, or HBPM. Such patients
should be considered for specialist evaluation.
Additional treatment options include the addition of
low-dose spironolactone (25 - 50 mg daily) or another
additional diuretic therapy higher dose amiloride 10 -
20 mg daily, higher dose thiazide or thiazide-like
diuretics, loop diuretics in patients with significant
renal impairment (eGFR <45 mL/min/m2), beta-
blockers, alpha-blockers, centrally acting agents (e.g.
clonidine), or, rarely, minoxidil.
ANTIHYPERTENSIVE THERAPY IN BULGARIAN PATIENT WITH DIABETES AND HYPERTENSION

L. Kirov1, E. Mushanov1, H. Dimitorv2, N. Ivanova3, B. Georgiev4. 1Medical faculty, Sofi a University,

Sofi a, Bulgaria, 2GP in a solo practice, Veliko Tarnovo, Bulgaria, 3Medical University, Plovdiv, Plovdiv,
Bulgaria, 4National Heart Hospital, Sofi a, Bulgaria

Results: 47% of the included patients were men and 53% - women, mean age 63.5 years old. The mean
blood pressure level was 137.7/86 mmHg and the mean heart rate – 74.5 beats/minute. In the cohort
of hypertensive patients with T2D 44.4% were treated with angiotensin receptor antagonists (ARBs),
39.3% - with ACE-inhibitors, 48.8% - with diuretics, 40.8% - with calcium channel blockers, 52.5 % -
with beta blockers. 38.2% were on fixed dose combinations. The patients with blood pressure below
target levels were treated by 1.73 different drugs, and those not reached the target levels were on
4.39 drugs.

Conclusions: The most used drugs in Bulgarian patients with hypertension and T2D are ARBs and ACE-
inhibitors (84%), followed by beta-blockers (53%), diuretics (49%, mainly in fi xed dose combinations)
and calcium channel blockers.

Journal of Hypertension Vol 35, e-Supplement 2, September 2017

WHAT’S NEW IN ESC/ESH 2018? NEW CONCEPTIONS.
WHEN TO START TREATMENT?

18-79 yrs. ≥80 yrs.

SBP≥140mmHg SBP≥160mmHg
ALL PTs ≥18 г.
DBP≥90mmHg
WHEN TO START TREATMENT?

Change in lifestyle
and drug treatment
immediately in all
Pts.
TARGETS FOR SBP&DBP according to AGE
< 65yrs.

<140/90 mmHg (in all Pts)

<130/80 mmHg (in most Pts)

120-130/80 mmHg (in most Pts)

SBP ≥ 65yrs.

130-139mmHg

DBP in all Pts

< 80 mmHg (in all Pts )

Not recommended DBP< 70 mmHg, except in case of
heart failure, when tratment may achieve much lower
BP levels than recommended BP targets.
CKD-it is recommended to lower SBP to a
range of 130–139 mmHg
 LIFESTYLE CHANGE RECCOMENDATIONS
Salt restriction to <5 g per day is recommended. (1 teaspoon).

It is recommended to restrict alcohol consumption to less than 14 units per week for men &
less than 8 units per week for women. 25ml 40% beverage= 1 unit. Free of alcohol consumption days and avoid
bringing.
Increased consumption of vegetables, fresh fruits, fish, nuts, and unsaturated fatty acids (olive oil). Coffee
consumption is associated with CV benefits. Green and black tea lowers BP. Avoid regular consumption of
sugar-sweetened soft drinks has been associated with overweight, metabolic syndrome, type 2 diabetes, and
higher CV risk.

Body-weight control is indicated to avoid obesity (BMI >30 kg/m2 or waist circumference
>102 cm in men and >88 cm in women), as is aiming at healthy BMI (about 20–25 kg/m2) for people aged over
60 and waist circumference values (<94 cm in men and <80 cm in women)
to reduce BP and CV risk.

Regular aerobic exercise (e.g. at least 30min of moderate dynamic exercise on 5–7 days per week) is
recommended (jogging, cycling, walking, swimming).
Smoking cessation, supportive care, and referral to smoking cessation programs are recommended.
 DRUG TREATMENT-2013

The main mechanism for achieving a beneficial effect is the lowering of BP. The existing risk
factors should be considered but the BP values remain the main basis for initiating treatment!
(2018)

The result for each individual patient is unpredictable and each of the drug classes used has its
advantages and disadvantages.

There is insufficient evidence to impose a universal rating of drugs such as first, second, etc. to
chose in most cases with HTN.
HOW DO WE AFFECT BLOOD PRESSURE USING DRUGS?
 DRUGS FOR THE TREATMENT OF HYPERTENSION
(2013-2018)

5 MAJOR DRUG CLASSES

АСЕІ; ARB; CCB; Diuretics; BB

and other: α - blockers, MRAs, centrally acting agents.

 A B
ACEI ARB
Similar effect on reducing
mortality from major CV events
and all cause death.
Reduce albuminuria to a
greater extent than other
classes as well as the risk of
severe (final stage CKD). Slow
the progression of diabetes-
related or non-diabetic CKD.
Prevention and regression of
LVH and remodeling of small
vessels, as well as the acute
AFib. Appropriate for use after
MI and HFrEF.
BB
Good to use in case of :
symptomatic angina, control of HR,
after MI and as an alternative to
RAS blockers in younger
hypertensive (women) planning
pregnancy or at childbearing age.
The use of BB with a vasodilating
effect is increasing, especially
Nebivolol showing benefits for
central BP, vascular resistance,
endothelial dysfunction, etc. There
is no risk of medication-induced
diabetes and the profile of adverse
effects is better, incl. sexual
function. Metoprolol, Nebivolol,
Carvedilol improve the outcomes in
HF.
C D
CCA DIURETIC
More effective than Much more effective than
BB in reduction of others in the prevention of
stroke, carotid HF.
atherosclerosis, Chlortalidone and
proteinuria and LVH. indapamide are more
effective per milligram than
HCT in lowering the CN and
with longer action. There is
also no evidence of more
side effects.
 A B
ACEI ARB BB
Although A smaller Reduce the risk of stroke to a
small- risk of degree of lesser extent.
angioneurotic refusal of Less effect than RAS blockers in
edema. treatment due LVH reduction, remodeling of
Cough- up to to side effects. small vessels and vessel
30%. stiffens.
The effect in post-MI mortality
in patients without LC
dysfunction is uncertain. Alone,
as well as in combination with
D increase the risk of dru-
induced diabetes (especially in
metabolic s-me).
A less favorable profile of side
effects compared to RAS
blockers.
C D
CCA DIURETIC
Insufficient effect on Thiazide/Thiazide-like: increase
HFrEF. insulin resistance and the risk of
Constopation. new onset of diabetes. This effect
Oedema (around the can be reduced by combination
ankles) with K-sparing D.
If the GFR (eGFR <45 mL/min),
thiazide and thiazide-like D become
less effective. If eGFR is <30 mL/min
they lose effect. In these cases the
choice are loop D.
Indapamid: thiazide-like saluretic effect, vasodilatation, reduces
LVH, does not interfere with lipid and glucose metabolism

Salurerin

Triampur comp.
(T+HCT)

Hurst’s the heart,2017

 DRUGS FOR THE TREATMENT OF HYPERTENSION (2018)

IN GENERAL

• Five major drug classes were recommended for the treatment of hypertension-
ACEI, ARB, BB, CCB and Diuretics (thiazide/thiazidelike as chlortalidone and
indapamide) are proven ability to reduce BP and CV events and are
appropriate for basic antihypertensive treatment strategy.

• The preferred dual combination is ACEI or ARB (RASb) + CCB or D.

Combinations containing drugs from other classes can be used, too.
 WITH WHAT TO TREAT? (2018)

IN GENERAL

• Start with dual drug combination, usually (ACEI or ARB) + CCB or D. Some low- or
moderate-risk patients with grade 1 hypertension may achieve their BP target with
monotherapy, but this is unlikely in patients with an initial SBP >150 mmHg who would
require a BP reduction of ≥20 mmHg. This is the case for most Pts > 80г. or frail. Step 2-
triple combination, usually (ACEI or ARB) + CCB+ D.

• ВВ- it’s possible to be included in each step of treatment when there are specific
indications: i.g. HF, HR control, angina, post-MI, Afib, resistant HTN, young pregnant or
planning pregnancy women.

• Others: in some cases as an additional treatment or in some diseases but rarely.

 WITH WHAT TO TREAT? (2018)

IN GENERAL

• Aspirin is not recommended for primary prevention in hypertensive patients

without CVD. For secondary prevention, the benefit of antiplatelet therapy in
patients with hypertension may be greater than the harm.

• If the usual triple combination does not succeed (ACEI or ARB + CCB+ D)
Spironolacton is added, and if not tolerated another diuretic or rising the dose
of given diuretic or adding BB or alpha blocker.
 WITH WHAT TO TREAT? (2018)

НАЙ-ОБЩО

• Pregnant women- CCB (Nifedipin, Nicardipin), Methyldopa, BB (Labetalol).

• Newly established postpartum hypertension (usually in the first week after

delivery) all drug classes could be used, but Methyldopa should be avoided-
risk of postpartal depression.

• Breastfeeding- All drug classes are are available in low concentration in

mother’s milk except Nifedipin and Propranolol which concentration is equal
to this in mother’s blood.
 WITH WHAT TO TREAT? (2018)

IN GENERAL

• The combination of ACEI+ARB is not recommended.

• Nondihydropyridine CCB (Diltiazem, Verapamil) are not recommended in case

of HFrEF (redused EF), but could be used when HFpEF (preservered EF). alpha
blockers and Central acting agents (e.g. monoxidin) should mot be used, too.

• When eGFR <30 mL/min/1.73 m2 do not apply thiazide and thiazide like
diuretics. If a diuretic is needed, use loop diuretics as their effect is superior to
thiazides.
 WITH WHAT TO TREAT? (2018)

IN GENERAL

• Nondihydropyridine CCB (Diltiazem, Verapamil) in combination with BB is not

recommended as a routine practice.

• In existing HF with oedema, consider adding a loop instead of thiazide or

thiazide like diuretic.

• There is risk of hypokalaemia using Spironolacton especially when eGFR is <45

mL/min/1.72 m2 or К ≥4.5 mmol/L when starting treatment.
 WITH WHAT TO TREAT?(2018)
IN GENERAL

• Always have in mind possible hyperkalaemia after prescribing ACEI, ARB or K

sparing diuretic.

• When treating with ACEI or ARB a rise in the sеrum creatinine and lowering of
the eGFR is possible, but if the rise of creatinine is more than 30% theeGFR
lowering observed a careful evaluation for CKD is needed.

• In Pts with symptomatic angina BB and CCB are preferred. In case of survived
MI RASb and BB are recommended.

• RASb and CCB are more effective in LVH reduction than BB.
TARGETS FOR SBP&DBP according to AGE
Pts < 65yrs.

<140/90 mmHg (in all Pts)

<130/80 mmHg (in most Pts)

120-130/80 mmHg (in most Pts)

SBP in Pts ≥ 65yrs.

130-139mmHg

DBP in all Pts

< 80 mmHg (in all Pts )

Not recommended DBP< 70 mmHg, except in case of
heart failure, when treatment may achieve much lower
BP levels than recommended BP targets.
CKD-it is recommended to lower SBP to a
range of 130–139 mmHg
 Although verapamil and diltiazem are
sometimes used with a beta-blocker
to improve ventricular rate control in
permanent atrial fibrillation, only
dihydropyridine calcium antagonists
should normally be combined with
Combination therapy with two RAAS inhibitors (АСЕI and ARB) is not beta-blockers.
recommended (III A)!
Combination therapy with two antihypertensive drugs in one pill may
be recommended, because reduces the number of pills to be taken
for the day and enhances the adherence to the therapy making it
more convinient (II B).
 DIABETES AND HYPERTENSION

• Prevalence of hypertension is higher among Pts with

diabetes T2, compared to the general population.

• Hypertension itself without existing DM is a prerequisite

and predetermines progression to DM.

• The probability Pts with hypertension to develop DM in

next 5 yrs. is 2.5 fold bigger. (193 [EL 2; PCS];
 BB & Diabetes

• Nebivolol- cardioselective (300 fold higher selective

to β-1 compared to β-2 receptors). In addition to the

selective blocking of β-1 adrenergic receptors, leads
to increased NO production and associated
vasodilatation and antioxidant effect, doesn’t
induce new or augment existing DM, doesn't
interfere lipid or glucose metabolism, doesn’t
cause sexual dysfunction etc.
 HYPERTENSIVE CRISIS

Sudden and abrupt rise of BP:

For SBP> 210 mmHg and for DBP > 120 (130) mmHg.

• CNS symptoms (headache, dizziness, nausea, vomiting, trantient visual disturbances

and/or hypertensive encephalopathy with a probability for loss of consciousness)

• CV disturbances (angina pectoris, conduction and rhythm disturbances, acute MI, acute LV
failure and pulmonary edema);

• Renal symptoms (albuminuria and Er in the urine even acute renal failure with oliguria);
 HYPERTENSIVE CRISIS
Therapeutic approach to hypertensive crisis in general practice
In case of confirmed diagnosis

Clonidine 0.075 – 0.150 mg i.m/ i.v.

or Captopril 6.25 – 50 mg per os
or Nitroglycerin s.l. or sprаy
or Enalapril 1.25 mg/ml i.v.
(Furosemid – i.v., i.m. or per os can be added to treatment)

Threatening or overt disturbances in vital organs’ function?

NO
↓
NO referral to hospital
YES ↓
BP steady lower values
↓
achieved
Refer to hospital ↓
↓ YES
Intensive care ↓
department Check the BP values after
24 hours