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M3 - Hypertension

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This document discusses hypertension (high blood pressure) including its definition, prevalence in India, risk factors, types, symptoms, pathophysiology, complications, and management. Some key points: - Hypertension is defined as blood pressure above 120/80 mmHg. In India, about 30% of people have hypertension. - It can be primary (essential) or secondary to other causes. Risk factors include age, diet, activity levels, family history, weight, and other medical conditions. - Hypertension often causes no symptoms but can lead to heart, brain, kidney and other organ damage if uncontrolled. - Management involves lifestyle changes and medication, starting with lifestyle alone or a single drug and progressing to multiple

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Hypertension & Mx of Hypertension 1 | P a g e What is Blood Pressure? When heart beats, it pumps blood round the body and maintains the circulation. As the blood moves, it exerts force against the sides of the blood vessels. The strength of this force is called the blood pressure (figure 1). What is hypertension? A sustained elevation in arterial blood pressure above the normal value of <120mm Hg of systolic blood pressure and <80mm Hg of diastolic blood pressure (figure 2). Burden of Hypertension in India: Overall prevalence for hypertension in India was 29.8%. About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for hypertension. One-tenth of rural and one-fifth of urban Indian hypertensive population have their BP under control. BP is categorized as per the American Heart Association (AHA) as in figure 3: Figure 1 shows blood pressure force Figure 2 shows blood vessel in high blood pressure Figure 3 shows blood pressure category as per AHA Basics on Hypertension
Hypertension & Mx of Hypertension 2 | P a g e BP Measurement Techniques (Table 1): Types of Hypertension: The two major types are: Primary or essential hypertension that has no known cause, is diagnosed in the majority of people. Among the factors that have been intensively studied are Renin angiotensin aldosterone system Sympathetic nervous system Salt intake Obesity and Insulin resistance Secondary hypertension is often caused by reversible factors, like pregnancy, drug induced, kidney disease, endocrine gland disorders and is sometimes curable. White-coat hypertension In-clinic BP is consistently elevated, though ABPM readings are normal. The anticipation of BP measurement alters reaction leading to increase in BP. Prevalence increases with age and may be a precursor of sustained hypertension. Risk factors: Increasing age of people Smoking Excess salt in diet Lack of physical activity Family history of hypertension Excess body weight Diabetes Mellitus Chronic kidney disease Excess stress Symptoms: Figure 4 shows types of hypertension
Hypertension & Mx of Hypertension 3 | P a g e Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. Some with high blood pressure report headaches (particularly at the back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes. ESSENTIAL HYPERTENSION: Patho-physiology (Figure 5) RAAS: Renin angiotensin aldosterone system: The reninangiotensinaldosterone system (RAAS) is a hormone system that regulates blood pressure and fluid balance. When renal blood flow is reduced, juxtaglomerular cells in the kidneys convert the prorenin already present in the blood into renin and secrete it directly into the circulation. Plasma renin then carries out the conversion of angiotensinogen released by the liver to angiotensin I. Angiotensin I is subsequently converted to angiotensin II by the enzyme angiotensin- converting enzyme found in the lungs. Angiotensin II is a potent vaso-active peptide that causes blood vessels to constrict, resulting in increased blood pressure. Angiotensin II also stimulates the secretion of the hormone aldosterone from the adrenal cortex. Aldosterone causes the tubules of the kidneys to increase the reabsorption of sodium and water into the blood, while at the same time causing the excretion of potassium (to maintain electrochemical balance). This increases the volume of extracellular fluid in the body, which also increases blood pressure.
Hypertension & Mx of Hypertension 4 | P a g e Figure 6 shows Renin- angiotensin-aldosterone system pathway If the reninangiotensinaldosterone system is abnormally active, blood pressure will be too high. There are many drugs that interrupt different steps in this system to lower blood pressure. These drugs are one of the main ways to control high blood pressure (hypertension), heart failure, kidney failure, and harmful effects of diabetes. Figure 7 shows RAAS involvement in development and progression of HTN complications. Complications: Heart related:
Hypertension & Mx of Hypertension 5 | P a g e o Left ventricular hypertrophy, coronary heart disease, heart failure Kidney related: o Renal failure Brain related: o Stroke o Transient Ischemic Attacks Eye related: o Retinopathy Blood vessels related: o Peripheral vascular disease o Antihypertensive Drugs: Drugs that decreases cardio output or peripheral vascular resistance or both. o Goals of Therapy: Blood pressure target values for treatment of hypertension Table 2: Goal of antihypertensive therapy. Figure 8 shows antihypertensive drugs action Mx of Hypertension
Hypertension & Mx of Hypertension 6 | P a g e o Hypertension management strategies as per the JNC 8 guidelines Figure 9 shows 2014 hypertension guideline management algorithm
Hypertension & Mx of Hypertension 7 | P a g e Table 3: Strategies to Dose Antihypertensive Drug: Strategy Description Details A Start one drug, titrate to maximum dose, and then add a second drug If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum recommended dose to achieve goal BP If goal BP is not achieved with the use of one drug despite titration to the maximum recommended dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the maximum recommended dose of the second drug to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP B Start one drug and then add a second drug before achieving maximum dose of the initial drug Start with one drug then add a second drug before achieving the maximum recommended dose of the initial drug, then titrate both drugs up to the maximum recommended doses of both to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination. Some committee members recommend starting therapy with 2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose.
Hypertension & Mx of Hypertension 8 | P a g e Figure 10: 2013 American Society of Hypertension (ASH) /ISH Hypertension Guidelines Table 4: Drug Selection in Hypertensive Patients With or Without Other Major conditions Patient Type First Drug Add Second Drug If Needed to Achieve a BP <140/90 mm Hg If Third Drug is Needed to Achieve a BP of <140/90 mm Hg
Hypertension & Mx of Hypertension 9 | P a g e A. When hypertension is the only or main condition Black patients (African ancestry): All ages CCBa or thiazide diuretic ARBb or ACE inhibitor (If unavail-able can add alter-native first drug choice) Combination of CCB + ACE inhibitor or ARB + thiazide diuretic White and other non- black Patients: Younger than 60 ARBb or ACE inhibitor CCBa or thiazide diuretic Combination of CCB + ACE inhibitor or ARB + thiazide diuretic White and other non- black patients: 60 y and older CCBa or thiazide diuretic (Although ACE inhibitors or ARBs are also usually effective) ARBb or ACE inhibitor (or CCB or thiazide if ACE inhi-bitor or ARB used first) Combination of CCB + ACE inhibitor or ARB + thiazide diuretic B. When hypertension is associated with other conditions Hypertension and diabetes ARB or ACE inhibitor Note: in black patients, it is acceptable to start with a CCB or thiazide CCB or thiazide diuretic. Note: in black patients, if starting with a CCB or thiazide, add an ARB or ACE inhibitor The alternative second drug (thiazide or CCB) Hypertension and chronic kidney disease ARB or ACE inhibitor Note: in black patients, good evidence for renal protective effects of ACE inhibitors CCB or thiazide diuretic c The alternative second drug (thiazide or CCB) Hypertension and clinical coronary artery disease d -Blocker plus ARB or ACE inhibitor CCB or thiazide diuretic The alternative second step drug (thiazide or CCB)
Hypertension & Mx of Hypertension 10 | P a g e Hypertension and stroke history e ACE inhibitor or ARB Thiazide diuretic or CCB The alternative second drug (CCB or thiazide) Hypertension and heart failure Patients with symptomatic heart failure should usually receive an ARB or ACE inhibitor + b-blocker + diuretic + spironolactone regardless of blood pressure. A dihydropyridine CCB can be added if needed for BP control. ESC guideline 2013 Target BP is <140/90 mmHg with few exceptions. Target BP is <140/85 mmHg in diabetes. In elderly patients the target systolic BP is 140-150 mmHg, but <140 mmHg may be considered in fit elderly. In individuals older than 80 years it is recommended to reduce systolic BP to 140- 150 mmHg if they are in good physical and mental condition. Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors and angiotensin receptor blockers (ARBs) are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in combination therapy. Some agents should be considered as the preferential choice in specific conditions, such as: Recent myocardial infarction (beta-blocker, ACE-inhibitor, ARB); Heart failure (diuretic, beta-blocker, ACE-inhibitor, ARB, mineralocorticoid receptor antagonist); Diabetes or renal dysfunction (ACE-inhibitor, ARB); Pregnancy (methyldopa, labetalol, nifedipine)
Hypertension & Mx of Hypertension 11 | P a g e Table 5: Comparison of guidelines JNC-8 ASH/ISH AHA/ACC Published on 18th Dec 2013 19th Dec 2013 21st Nov 2013 Target goal For general patients including DM/CKD <140/90 <140/90 <140/90 Lower targets may be appropriate for LVD, LVH, DM, CKD For Elderly people 150/90(60 yrs) 150/90(80 yrs) Lower targets for the Elderly Treatment preference General <60 yrs Initiate Thiazide-type Diuretic or ACEI or ARB or CCB For uptitration, any possible combination from above (avoid ACEI+ARB) Stage 1 HT: ACEI or ARB (If needed, add CCB or Thiazide-type Diuretic) Stage 1 HT: Thiazide for most patients or ACEI, ARB, CCB, (or combination, if uncontrolled) Stage 2 HT: ACEI or ARB + CCB or Thiazide-type Diuretic Stage 2 HT: Thiazide with ACEI / ARB/ CCB, or ACEI with CCB General 60 yrs Same as above Stage 1: CCB or Thiazide (If needed, add ACEI or ARB) Same as Above Hypertension with Diabetes Same as above ACEI or ARB If needed add CCB or thiazide-type diuretic ACEI or ARB, thiazide, BB, calcium channel blocker Hypertension with CKD ACEI or ARB alone Or in combination with other ACEI or ARB If needed add CCB or thiazide-type diuretic ACEI or ARB
Hypertension & Mx of Hypertension 12 | P a g e drug class Hypertension with CAD --- 硫-Blocker plus ARB or ACE inhibitor If needed add CCB or thiazide-type diuretic 硫-Blocker, ACEI Hypertension with stroke --- ACE inhibitor or ARB If needed add CCB or thiazide-type diuretic Thiazide, ACEI. Hypertension with HF --- ARB or ACE inhibitor+ 硫 - blocker+ diuretic+ spironolactone regardless of blood pressure ACEI or angiotensin- receptor blocker (ARB), BB, aldosterone antagonist, thiazide;

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M3 - Hypertension

  • 1. Hypertension & Mx of Hypertension 1 | P a g e What is Blood Pressure? When heart beats, it pumps blood round the body and maintains the circulation. As the blood moves, it exerts force against the sides of the blood vessels. The strength of this force is called the blood pressure (figure 1). What is hypertension? A sustained elevation in arterial blood pressure above the normal value of <120mm Hg of systolic blood pressure and <80mm Hg of diastolic blood pressure (figure 2). Burden of Hypertension in India: Overall prevalence for hypertension in India was 29.8%. About 33% urban and 25% rural Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. Only 25% rural and 38% of urban Indians are being treated for hypertension. One-tenth of rural and one-fifth of urban Indian hypertensive population have their BP under control. BP is categorized as per the American Heart Association (AHA) as in figure 3: Figure 1 shows blood pressure force Figure 2 shows blood vessel in high blood pressure Figure 3 shows blood pressure category as per AHA Basics on Hypertension
  • 2. Hypertension & Mx of Hypertension 2 | P a g e BP Measurement Techniques (Table 1): Types of Hypertension: The two major types are: Primary or essential hypertension that has no known cause, is diagnosed in the majority of people. Among the factors that have been intensively studied are Renin angiotensin aldosterone system Sympathetic nervous system Salt intake Obesity and Insulin resistance Secondary hypertension is often caused by reversible factors, like pregnancy, drug induced, kidney disease, endocrine gland disorders and is sometimes curable. White-coat hypertension In-clinic BP is consistently elevated, though ABPM readings are normal. The anticipation of BP measurement alters reaction leading to increase in BP. Prevalence increases with age and may be a precursor of sustained hypertension. Risk factors: Increasing age of people Smoking Excess salt in diet Lack of physical activity Family history of hypertension Excess body weight Diabetes Mellitus Chronic kidney disease Excess stress Symptoms: Figure 4 shows types of hypertension
  • 3. Hypertension & Mx of Hypertension 3 | P a g e Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. Some with high blood pressure report headaches (particularly at the back of the head and in the morning), as well as lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision or fainting episodes. ESSENTIAL HYPERTENSION: Patho-physiology (Figure 5) RAAS: Renin angiotensin aldosterone system: The reninangiotensinaldosterone system (RAAS) is a hormone system that regulates blood pressure and fluid balance. When renal blood flow is reduced, juxtaglomerular cells in the kidneys convert the prorenin already present in the blood into renin and secrete it directly into the circulation. Plasma renin then carries out the conversion of angiotensinogen released by the liver to angiotensin I. Angiotensin I is subsequently converted to angiotensin II by the enzyme angiotensin- converting enzyme found in the lungs. Angiotensin II is a potent vaso-active peptide that causes blood vessels to constrict, resulting in increased blood pressure. Angiotensin II also stimulates the secretion of the hormone aldosterone from the adrenal cortex. Aldosterone causes the tubules of the kidneys to increase the reabsorption of sodium and water into the blood, while at the same time causing the excretion of potassium (to maintain electrochemical balance). This increases the volume of extracellular fluid in the body, which also increases blood pressure.
  • 4. Hypertension & Mx of Hypertension 4 | P a g e Figure 6 shows Renin- angiotensin-aldosterone system pathway If the reninangiotensinaldosterone system is abnormally active, blood pressure will be too high. There are many drugs that interrupt different steps in this system to lower blood pressure. These drugs are one of the main ways to control high blood pressure (hypertension), heart failure, kidney failure, and harmful effects of diabetes. Figure 7 shows RAAS involvement in development and progression of HTN complications. Complications: Heart related:
  • 5. Hypertension & Mx of Hypertension 5 | P a g e o Left ventricular hypertrophy, coronary heart disease, heart failure Kidney related: o Renal failure Brain related: o Stroke o Transient Ischemic Attacks Eye related: o Retinopathy Blood vessels related: o Peripheral vascular disease o Antihypertensive Drugs: Drugs that decreases cardio output or peripheral vascular resistance or both. o Goals of Therapy: Blood pressure target values for treatment of hypertension Table 2: Goal of antihypertensive therapy. Figure 8 shows antihypertensive drugs action Mx of Hypertension
  • 6. Hypertension & Mx of Hypertension 6 | P a g e o Hypertension management strategies as per the JNC 8 guidelines Figure 9 shows 2014 hypertension guideline management algorithm
  • 7. Hypertension & Mx of Hypertension 7 | P a g e Table 3: Strategies to Dose Antihypertensive Drug: Strategy Description Details A Start one drug, titrate to maximum dose, and then add a second drug If goal BP is not achieved with the initial drug, titrate the dose of the initial drug up to the maximum recommended dose to achieve goal BP If goal BP is not achieved with the use of one drug despite titration to the maximum recommended dose, add a second drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB) and titrate up to the maximum recommended dose of the second drug to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP B Start one drug and then add a second drug before achieving maximum dose of the initial drug Start with one drug then add a second drug before achieving the maximum recommended dose of the initial drug, then titrate both drugs up to the maximum recommended doses of both to achieve goal BP If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose to achieve goal BP C Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination Initiate therapy with 2 drugs simultaneously, either as 2 separate drugs or as a single pill combination. Some committee members recommend starting therapy with 2 drugs when SBP is >160 mm Hg and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg above goal and/or DBP is >10 mm Hg above goal. If goal BP is not achieved with 2 drugs, select a third drug from the list (thiazide-type diuretic, CCB, ACEI, or ARB), avoiding the combined use of ACEI and ARB. Titrate the third drug up to the maximum recommended dose.
  • 8. Hypertension & Mx of Hypertension 8 | P a g e Figure 10: 2013 American Society of Hypertension (ASH) /ISH Hypertension Guidelines Table 4: Drug Selection in Hypertensive Patients With or Without Other Major conditions Patient Type First Drug Add Second Drug If Needed to Achieve a BP <140/90 mm Hg If Third Drug is Needed to Achieve a BP of <140/90 mm Hg
  • 9. Hypertension & Mx of Hypertension 9 | P a g e A. When hypertension is the only or main condition Black patients (African ancestry): All ages CCBa or thiazide diuretic ARBb or ACE inhibitor (If unavail-able can add alter-native first drug choice) Combination of CCB + ACE inhibitor or ARB + thiazide diuretic White and other non- black Patients: Younger than 60 ARBb or ACE inhibitor CCBa or thiazide diuretic Combination of CCB + ACE inhibitor or ARB + thiazide diuretic White and other non- black patients: 60 y and older CCBa or thiazide diuretic (Although ACE inhibitors or ARBs are also usually effective) ARBb or ACE inhibitor (or CCB or thiazide if ACE inhi-bitor or ARB used first) Combination of CCB + ACE inhibitor or ARB + thiazide diuretic B. When hypertension is associated with other conditions Hypertension and diabetes ARB or ACE inhibitor Note: in black patients, it is acceptable to start with a CCB or thiazide CCB or thiazide diuretic. Note: in black patients, if starting with a CCB or thiazide, add an ARB or ACE inhibitor The alternative second drug (thiazide or CCB) Hypertension and chronic kidney disease ARB or ACE inhibitor Note: in black patients, good evidence for renal protective effects of ACE inhibitors CCB or thiazide diuretic c The alternative second drug (thiazide or CCB) Hypertension and clinical coronary artery disease d -Blocker plus ARB or ACE inhibitor CCB or thiazide diuretic The alternative second step drug (thiazide or CCB)
  • 10. Hypertension & Mx of Hypertension 10 | P a g e Hypertension and stroke history e ACE inhibitor or ARB Thiazide diuretic or CCB The alternative second drug (CCB or thiazide) Hypertension and heart failure Patients with symptomatic heart failure should usually receive an ARB or ACE inhibitor + b-blocker + diuretic + spironolactone regardless of blood pressure. A dihydropyridine CCB can be added if needed for BP control. ESC guideline 2013 Target BP is <140/90 mmHg with few exceptions. Target BP is <140/85 mmHg in diabetes. In elderly patients the target systolic BP is 140-150 mmHg, but <140 mmHg may be considered in fit elderly. In individuals older than 80 years it is recommended to reduce systolic BP to 140- 150 mmHg if they are in good physical and mental condition. Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors and angiotensin receptor blockers (ARBs) are all suitable for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in combination therapy. Some agents should be considered as the preferential choice in specific conditions, such as: Recent myocardial infarction (beta-blocker, ACE-inhibitor, ARB); Heart failure (diuretic, beta-blocker, ACE-inhibitor, ARB, mineralocorticoid receptor antagonist); Diabetes or renal dysfunction (ACE-inhibitor, ARB); Pregnancy (methyldopa, labetalol, nifedipine)
  • 11. Hypertension & Mx of Hypertension 11 | P a g e Table 5: Comparison of guidelines JNC-8 ASH/ISH AHA/ACC Published on 18th Dec 2013 19th Dec 2013 21st Nov 2013 Target goal For general patients including DM/CKD <140/90 <140/90 <140/90 Lower targets may be appropriate for LVD, LVH, DM, CKD For Elderly people 150/90(60 yrs) 150/90(80 yrs) Lower targets for the Elderly Treatment preference General <60 yrs Initiate Thiazide-type Diuretic or ACEI or ARB or CCB For uptitration, any possible combination from above (avoid ACEI+ARB) Stage 1 HT: ACEI or ARB (If needed, add CCB or Thiazide-type Diuretic) Stage 1 HT: Thiazide for most patients or ACEI, ARB, CCB, (or combination, if uncontrolled) Stage 2 HT: ACEI or ARB + CCB or Thiazide-type Diuretic Stage 2 HT: Thiazide with ACEI / ARB/ CCB, or ACEI with CCB General 60 yrs Same as above Stage 1: CCB or Thiazide (If needed, add ACEI or ARB) Same as Above Hypertension with Diabetes Same as above ACEI or ARB If needed add CCB or thiazide-type diuretic ACEI or ARB, thiazide, BB, calcium channel blocker Hypertension with CKD ACEI or ARB alone Or in combination with other ACEI or ARB If needed add CCB or thiazide-type diuretic ACEI or ARB
  • 12. Hypertension & Mx of Hypertension 12 | P a g e drug class Hypertension with CAD --- 硫-Blocker plus ARB or ACE inhibitor If needed add CCB or thiazide-type diuretic 硫-Blocker, ACEI Hypertension with stroke --- ACE inhibitor or ARB If needed add CCB or thiazide-type diuretic Thiazide, ACEI. Hypertension with HF --- ARB or ACE inhibitor+ 硫 - blocker+ diuretic+ spironolactone regardless of blood pressure ACEI or angiotensin- receptor blocker (ARB), BB, aldosterone antagonist, thiazide;