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Individualized Therapy
for
Hypertension
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 –1 Fax: 4970847
1
OBJECTIVES


To describe the "stepwise approach" to therapy.
To discuss:
1. The evidence for the role of lifestyle changes
2. The indications, contraindications and side
effects of various antihypertensive classes
IMPORTANT MESSAGES FOR THE
MANAGEMENT OF HYPERTENSION
 Prompt
diagnosis
 Assess the risk
 Achieve target levels of BP


Lifestyle
Combination therapy
 Promote
adherence
TREAT HYPERTENSION IN THE CONTEXT OF
OVERALL CARDIOVASCULAR RISK
1. Global cardiovascular risk should be assessed.
2. In the absence of data to determine the accuracy of
risk calculations, avoid using absolute levels of
risk to support treatment decisions at specific risk
thresholds.
3. Shared decision-making may improve the
effectiveness of preventive health interventions.
Counting risk factors underestimates the risk
THRESHOLD FOR INITIATION OF TREATMENT
AND TARGET VALUES
Condition
Initiation
Target
SBP / DBP mmHg
SBP / DBP mmHg
 140/90
<140/90
SBP = or >160
<140
 130/80
<130/80
Renal disease
( 130/80)
<130/80
Proteinuria >1 g/day
( 125/75)
<125/75
Diastolic ± systolic hypertension
Isolated systolic hypertension
Diabetes
MANAGEMENT OF HYPERTENSION
LIFESTYLE RECOMMENDATIONS
1.
2.
3.
Healthy diet; High in fresh fruits, vegetables and low fat dairy
products, low in saturated fat and salt in accordance with the DASH
diet
Regular physical activity: optimum 30-60 minutes of moderate
cardiorespiratory activity 4/week or more
Reduction in alcohol consumption in those who drink excessively (
( ≤ 2 drinks/ day)
4.
Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25)
5.
Waist Circumference
< 102 cm for men
< 88 cm for women
5.
In individuals considered salt-sensitive, such as: Canadians of
African descent, age over 45, individuals with impaired renal
function or with diabetes. Restrict salt intake to less than 100
mmol/day
6.
Smoke free environment
LIFESTYLE:
INDICATIONS FOR PHARMACOTHERAPY
Strongly consider prescription if:



Average DBP equal or over 90 mmHg
Hypertensive Target-organ damage (or CVD)
Independent cardiovascular risk factors:







Elevated systolic BP
Cigarette smoking
Abnormal lipid profile
Strong family history of premature CV disease
Truncal obesity
Sedentary Lifestyle
Average DBP equal or over 80 mmHg in a patient with diabetes
CHOICE OF PHARMACOLOGICAL
TREATMENT
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO
Treatment in the
absence of compelling
indication
YES
Individualized
Treatment
(with compelling indications)
TREATMENT OF ADULTS WITH
SYSTOLIC-DIASTOLIC
HYPERTENSION WITHOUT OTHER
COMPELLING INDICATIONS
MONOTHERAPY
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
ACE-I
ARB
Longacting
CCB
Betablocker*
* No longer preferred as routine initial therapy
COMBINATION THERAPY
If partial response to monotherapy
1. Dual Combination Therapy
CONSIDER
2. Triple or Quadruple Therapy
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse
effects, other classes of antihypertensive drugs may be combined
(such as alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
SUMMARY
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification
therapy
Thiazide
diuretic
ACE-I
ARB
Long-acting
CCB
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Dual Combination
Triple or Quadruple
Therapy
* Not indicated as first line therapy over 60
Betablocker*
USEFUL DUAL COMBINATIONS
For additive hypotensive effect in dual therapy
Combine an agent from
Column 1 with any in Column 2
Column 1
Column 2
• Thiazide diuretic
• Beta adrenergic blocker
• Long-acting calcium
channel blocker*
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
(ACE=Angiotensin Converting Enzyme, ARB=Angiotension Receptor Blocker)
USEFUL TRIPLE THERAPY
COMBINATIONS
For additive hypotensive effect in triple therapy
Combine 2 agents from one Column with any in
the other Column
Column 1
Column 2
• Thiazide diuretic
• Beta adrenergic blocker
• Long-acting calcium
channel blocker*
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
SPECIFIC DRUGS FOR SPECIFIC PATIENTS
MULTIPLE ANTIHYPERTENSIVE AGENTS
ARE NEEDED TO ACHIEVE TARGET BP
Trial
Number of antihypertensive agents
Target BP (mm Hg) 1
2
3
4
ALLHAT SBP <140/DBP <90
UKPDS
DBP <85
ABCD
DBP <75
MDRD
MAP <92
HOT
DBP <80
AASK
MAP <92
IDNT
SBP <135/DBP <85
DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.
Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
Lewis EJ et al. N Engl J Med. 2001;345:851-860.
Cushman WC et al. J Clin Hypertens. 2002;4:393-405.
PHARMACOLOGICAL TREATMENT FOR
HYPERTENSIVE PATIENTS WITH OTHER
COMPELLING INDICATIONS
Individualized treatment

Compelling indications:
•
•
•
•
•
•
•
•

Diabetes Mellitus
•
•

Smoking
Ischemic Heart Disease
Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Left Ventricular Systolic Dysfunction
Cerebrovascular Disease
Left Ventricular Hypertrophy
Non Diabetic Chronic Kidney Disease
Renovascular Disease
With Diabetic Nephropathy
Without Diabetic Nephropathy
Global Vascular Protection for Hypertensive Patients
•
•
Statins
Aspirin
ACCORDING TO JNC7:
TREATMENT FOR ISOLATED
SYSTOLIC HYPERTENSION WITHOUT
OTHER COMPELLING INDICATIONS
TREATMENT ALGORITHM
TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
diuretic
ARB
Long-acting
DHP CCB
SUMMARY
TARGET <140 mmHg Systolic BP
Lifestyle modification
therapy
Thiazide
diuretic
ARB
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
Dual combination
Triple or Quadruple*
combination
Long-acting
DHP CCB
*If blood pressure is still not
controlled, or there are
adverse effects, other
classes of antihypertensive
drugs may be combined
(such as alpha blockers,
centrally acting agents, or
nondihydropyridine calcium
channel blocker).
IMPORTANT POINTS: (JNC7)

Thiazide - type diuretics should be initial drug therapy for
most, either alone or combined with other drug classes.

Certain high-risk conditions are compelling indications for
other drug classes.

Most patients will require two or more antihypertensive
drugs to achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two
agents, one usually should be a thiazide-type diuretic.
IMPORTANT POINTS: (JNC7)
The most effective therapy prescribed by the
careful clinician will control HTN only if
patients are motivated.
 Motivation improves when patients have
positive experiences with, and trust in, the
clinician.
 Empathy builds trust and is a potent motivator.
 The responsible physician’s judgment remains
paramount.

ACCORDING TO JNC7:
HYPERTENSION AND CVD RISK





CVD risk has now replaced CHD risk (to include strokes)
The current CVD risk threshold is >20% over 10 years
(equivalent to CHD risk of 15%)
Current advice from the BHS is to prescribe a statin in all
patients with hypertension and a CVD risk of 20% or greater.
Unless contra-indicated low dose aspirin should be considered
in patients over 50 with a CVD risk of >20% when the blood
pressure is controlled.
CVD risk has implications regarding levels to treat.
WHEN TO REFER?
Specialist referral is indicated if there is a 
possible underlying cause or presenting as:
• sudden onset 
• worsening of hypertension 
• resistance to multi-drug regimen three or 
more drugs
• Hypertension diagnosed in young age ( < 35 
years)
• persistent noncompliance 
Saudi Hypertension Management Guidelines 2007
THANK U