Download mm Hg

New (1999) WHO-ISH Definitions
and Classification of BP Levels
Category
Systolic BP
(mm Hg)
Diastolic BP
(mm Hg)
Optimal BP
Normal BP
High-Normal
<120
<130
130-139
<80
<85
85-89
Grade 1 Hypertension (mild)
Subgroup: Borderline
Grade 2 Hypertension (moderate)
Grade 3 Hypertension (severe)
140-159
140-149
160-179
>180
90-99
90-94
100-109
>110
Isolated Systolic Hypertension
Subgroup: Borderline
>140
140-149
<90
<90
What is the Goal
of the Practice Guidelines?
To lower blood pressure (BP)
and other risk factors in order to
reduce the risk of cardiovascular
disease (CVD)
Why is Hypertension
Management Needed? (1)
• 600 million hypertensives
in the world
• 3 million die annually as a
direct result of hypertension
Why is Hypertension
Management Needed? (2)
The Rule of Halves
• Only 1/2 have been diagnosed
• Only 1/2 of those diagnosed have been
treated
• Only 1/2 of those treated are adequately
controlled
• Thus, only 12.5% overall are adequately
controlled
Why BP <130/85 mm Hg
and Not <140/90 mm Hg? (1)
• The relationship between CV risk and BP
is continuous
• Today, more than 50% of all hypertensives
have BP >160/90 mm Hg and 75% have BP
>140/90
• The major determinant of the risk reduction
conferred by antihypertensive therapy is the
BP level attained
Why BP <130/85 mm Hg
and Not <140/90 mm Hg? (2)
• In diabetics, there is a clear benefit of
lowering BP <85 mm Hg
• The HOT Study showed that lowering
BP < 85 mm Hg did not increase CV risk
• The goal should be to attain normal BP
(<130/85 mm Hg)
What is High Blood Pressure?
• BP levels are continuously related to
the risk of CVD
• Definition of hypertension or raised
BP is arbitrary
• Even within the normotensive range,
people with the lowest BP levels have
the lowest rates of CVD
Relative Risk of CHD and Stroke in
Relation to Patient’s Usual Diastolic BP
Clinical Evaluation What Should Be Done?
• Confirm elevation of BP
• Exclude or identify secondary causes of
hypertension
• Determine presence of target organ damage
and quantify extent
• Search for other CV risk factors and clinical
conditions that may influence prognosis
and treatment
Multiple BP Measurements
Recommended
Because BP is characterized by large
spontaneous variations, diagnosis
should be based on multiple BP
measurements taken on several
separate occasions
Minimum Routine
Investigations
Clinical and family history
Full physical examination as described in medical
textbooks
Laboratory investigations, including:
–
–
–
urinalyses for blood, protein, and glucose
microscopic examination of the urine
blood chemistry for potassium, creatinine, fasting glucose,
and total cholesterol
Electrocardiography (ECG)
“Isolated” Office Hypertension
In some patients office BP is persistently elevated
whereas daytime BP outside clinic environment is
not. Continuing debate whether “isolated” office
hypertension (“white coat hypertension”) is an
innocent phenomenon or carries an increased risk
of CVD
Ambulatory BP Monitoring
BP values obtained by home measurement or ambulatory
monitoring are several mm Hg lower than office
measurement
Average 24 hour or home BP values around 125/80 mm Hg
= office BP 140/90 mm Hg
Which Factors
Influence Prognosis? (1)
Decisions should not be made on BP alone, but
also on presence of other risk factors, target
organ damage, and concomitant diseases, as
well as on other aspects of patients’ personal,
medical, social, economic, ethnic, and cultural
characteristics
Which Factors
Influence Prognosis? (2)
• Risk factors of CVD
I. Used for risk stratification
II.Other factors adversely influencing
prognosis
• Target organ damage (TOD)
• Associated clinical conditions (ACC)
Which Factors Influence Prognosis? (3)
Risk factors for CVD
I. Used for risk stratification
• Levels of systolic and diastolic blood
pressure (Grades 1-3)
• Men >55 years
• Women >65 years
• Smoking
• Total cholesterol >6.5 mmol/L (250 mg/dl)
• Diabetes
• Family history of premature
cardiovascular disease
Which Factors Influence Prognosis? (4)
Risk factors for CVD
II.Other factors adversely influencing prognosis
• Reduced HDL cholesterol
• Raised LDL cholesterol
• Microalbuminuria in diabetes
• Impared glucose tolerance
• Obesity
• Sedentary lifestyle
• Raised fibrinogen
• High risk socioeconomic group
• High risk ethnic group
• High risk geographic region
Which Factors Influence Prognosis? (5)
Target organ damage (TOD)
• Left ventricular hypertrophy (electrocardiogram,
echocardiogram, or radiogram)
• Proteinuria and/or slight elevation of plasma
creatinine concentration 106-177 mmol/L (1.2-2.0
mg/dl)
• Ultrasound or radiological evidence of
atherosclerotic plaque (carotid, iliac, and femoral
arteries, aorta)
• Generalised or focal narrowing of the retinal
arteries
Which Factors Influence Prognosis? (6)
Associated clinical conditions (ACC)
Cerebrovascular disease
• Ischaemic stroke
• Cerebral haemorrhage
• Transient ischaemic attack (TIA)
Heart disease
•
•
•
•
Myocardial infarction
Angina pectoris
Coronary revascularisation
Congestive heart failure
Which Factors Influence Prognosis? (7)
Associated clinical conditions (ACC)
Renal disease
• Diabetic nephropathy
• Renal failure, plasma creatinine concentration
>177 mmol/L (>2.0 mg/dl)
Vascular disease
• Dissecting aneurysm
• Symptomatic arterial disease
Advanced hypertensive retinopathy
• Haemorrhages or exudates
• Papilloedema
Stratifying Risk - Quantifying Prognosis
Effects of Antihypertensive Treatment
in Randomised Controlled Trials
Management Strategy
Initiate lifestyle measures wherever
appropriate in all patients, including those
who require drug treatment
• Smoking cessation
• Weight reduction
• Moderation of alcohol consumption
• Reduction of salt intake
• Increased physical activity
Principles of Drug Treatment (1)
• Use a low dose of one drug to initiate
therapy
• If good response and tolerability but
inadequate control increase the dose of
the first drug
• If little response or poor tolerability
change to another drug class
Principles of Drug Treatment (2)
• It is often preferrable to add a small
dose of a second drug rather than
increase the dose of the first drug
• Use long-acting drugs providing 24-hour
efficacy on a once daily basis. Improves
adherence to therapy and minimizes BP
variability.
Principles of Drug Treatment (3)
There are six main
drug classes used worldwide diuretics, beta-blockers, ACE
inhibitors, calcium antagonists,
alpha blockers, and angiotensin
II antagonists.
Principles of Drug Treatment (4)
All 6 classes are suitable for the
initiation and maintenance of BP
lowering therapy, but the choice
of drugs will be influenced by cost and
by many factors for special groups
of patients. In some parts of the world,
reserpine and methyldopa are
also used frequently.
Diuretics
Indications
Compelling
Possible
Heart failure
Elderly patients
Systolic hypertension
Diabetes
Contraindications
Compelling
Possible
Gout
Dyslipidaemia
Sexually active
males
Beta-Blockers
Indications
Compelling
Angina
Possible
Heart failure
After myocardial infarct
Tachyarrhythmias
Pregnancy
Diabetes
Compelling
Asthma and
Chronic obstructive
Pulmonary disease
Heart block (AV 2,3)
Possible
Dyslipidaemia
Athletes and
Physically active
Patients
Peripheral
vascular disease
Contraindications
Calcium
Antagonists
Indications
Compelling
Possible
Angina
Elderly patients
Systolic hypertension
Peripheral
Vascular disease
Contraindications
Compelling
Heart block (AV 2,3)
* verapamil or diltiazem
Possible
Heart failure*
ACE Inhibitors
Indications
Compelling
Heart failure
Possible
Left ventricular dysfunct
After myocardial infarct
Diabetic nephropathy
Contraindications
Compelling
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
Possible
ACE inhibitors:
Mech. of eff.: inhibition of the conversion of AT I onto AT II, degradation of bradykine,
decrease of PVR and slight venodilatation

vasokonstriction ATII, secretion of aldosterone -natriuresis

regression of hypertrophia of left ventricle and vessel’s wall
heart insufficiency - mortality rate 20-30 %
glom. pressure - proteinuria during DM nephropatia
- cardioprotective, vasoprotective and renoprotective eff.
AE: hypotension after initial dose, renal impairment (acute renal insufficiency,
hyperkalaemia, dry cough, angioedema
short acting: captoprile - three times a day
medium term: enalaprile - twice a day
long acting: perindoprile, lisinoprile, quinaprile, ramiprile, spiraprile, trandolaprile
Alpha-Blockers
Indications
Compelling
Prostatic Hypertrophy
Possible
Glucose intolerance
Dyslipidaemia
Contraindications
Compelling
Possible
Orthostatic
hypotension
- blockers
Central acting - 2, I1 rec. - decrease of sympatic influence




clonidine - 2,I1-agonist - renal hypertension, !sedation, dyssomnia
methyldopa, guanfacine - 2-rec.
moxonidine, rilmenidine - imidazolin I1 rec.
reserpine -depletion of catecholamines - only in combination - NÚ!!!
Combined - urapidile - block of postsyn. 1-rec., activation of 5-HT1Arec. in CNS
Peripheral -blockers



1
- prazosine, doxazosine, metazosine, terazosine
1+2 - phentolamine - th. of feochromocytoma
+ - labetalol, carvedilol
Angiotensin II
Antagonists
Indications
Compelling
ACE-I cough
Possible
Heart failure
Contraindications
Compelling
Pregnancy
Bilateral renal
Artery stenosis
Hyperkalaemia
Possible
Antagonists of AT II:
Antagonists of AT II




block of AT1 rec.,
regression of hypertr. LV, renoprotective eff.
In AE of ACEI
losartan, valsartan, irbesartan, telmisartan,……
Direct vasodilat. eff.:


hydralazines (endralazine, dihydralazine), minoxidil, sodium nitroprusside
reflex. tachycardia - in combination with -blockers and diuretics
Combination Therapy (1)
In most patients, appropriate
combination therapy produces BP
reductions that are twice as great as
those obtained with monotherapy.
Combination Therapy (2)
Effective drug combinations to treat
hypertension are:
• diuretic and beta-blocker
• diuretic and ACE inhibitor (or
Angiotensin II antagonist)
• calcium antagonist (dihydropyridine)
and beta-blocker
• calcium antagonist and ACE inhibitor
• alpha-blocker and beta-blocker
Other Drugs to Consider
in Hypertension
• Aspirin
• Cholesterol lowering therapy
Treatment Goal
The goal of antihypertensive treatment should
be to achieve “optimal” or “normal” BP in
young, middle-aged, or diabetic subjects
(below 130/85 mm Hg), and at least “highnormal” BP in elderly patients (below 140/90
mm Hg)
How should hypertension
during pregnancy be defined?
Hypertension in pregnancy usually defined
as:



pre-existing chronic hypertension
de novo diagnosed, gestational hypertension or
pre-eclampsia
pre-eclampsia superimposed on chronic
hypertension
Antihypertensive drugs
most widely used acutely
during pregnancy
• Nifedipine
• Labetalol
• Hydralazine
Antihypertensive drugs
most widely used chronically
during pregnancy
• Beta-blockers:
oxprenolol, pindolol, labetalol
atenolol, however, is associated with fetal growth retardation when used long-term throughout pregnancy
• Methyldopa
• Prazosin, hydralazine, nifedipine,
and isradipine
Drugs most widely
avoided during pregnancy
• ACE inhibitors (associated with possible
adverse fetal effects)
• Angiotensin ll antagonists (effects may be
similar to ACE inhibitors)
• Diuretics used infrequently because of
concerns of reducing already compromised
plasma volume
Hypertension
in Type-2 Diabetics (1)
• Diabetes and hypertension are
multiplicative risk factors for CVD
• Absence of hypertension in diabetes is
associated with a better long-term
survival
Hypertension
in Type-2 Diabetics (2)
• Progressive decline in glomerular
function can be slowed with
antihypertensive treatment
• Similar lifestyle measures are
recommended for hypertension and
diabetes
Hypertension
in Type-2 Diabetics (3)
Good evidence for reduction
in CVD events in diabetic patients treated
with antihypertensive
drugs, including diuretics,
and more recently, beta-blockers
and ACE inhibitors
Hypertension
in Type-2 Diabetics (4)
The goal of antihypertensive treatment in
Type-2 diabetics should be to achieve
“optimal” or “normal” BP (that is below
130/85 mm Hg)