![Stroke or TIA
Don’t start drug in first week after acute stroke
Clinical judgement should be used in very high SBP
Start drug treatment even SBP is in the 140–159
mmHg
SBP goal of <140 mmHg ]
Drug of choice : ACE inhibitors, diuretics](https://image.slidesharecdn.com/htguidelinemx97-160828124734/85/HT-guideline-management97-57-320.jpg)
HT guideline management97
- 2. Contents Lifestyle interventions Criteria for starting antihypertensive drug treatment Blood pressure targets Patients education and adherence to drug treatment
- 3. Reference
- 4. Lifestyle interventions Weight reduction Diet and exercise Relaxation Reduce alcohol consumption and stop smoking Discourage excessive consumption of caffeine Low sodium diet
- 5. Weight reduction Weight circumference Men < 90 cm Women < 80 cm BMI 22.5 – 25 kg/m2 Orlistat Bariatic surgery
- 7. Low salt diet < 2,300 mg/day NaCl <6g/day
- 8. Moderate alcohol consumption Men 2 drink (20-30g/day) Women 1 drink (10-20g/day)
- 9. Stop smoking Nicotine replacement therapy Bupropion Varenicline Motivational interview
- 10. Exercise Preventing cardiovascular disease 50-70% max HR 70-85% max HR Maximum HR = 220 - age
- 12. Criteria for starting antihypertensive drug treatment JNC 8 Age ≥ 60 years BP ≥ 150/90 mmHg Age < 60 years BP ≥ 140/90 mmHg Diabetes BP ≥ 140/90 mmHg CKD BP ≥ 140/90 mmHg
- 13. SBP ≥ 160 mmHg or DBP ≥100 mmHg
- 15. Criteria for starting antihypertensive drug treatment NICE guideline Age < 80 years old with stage 1 HT with target organ damage established cardiovascular disease renal disease Diabetes 10-year cardiovascular risk equivalent to 20% or greater. Any age with stage 2 HT BP ≥ 140/90 at clinic Or BP ≥ 135/85 at home BP ≥ 160/100 at clinic Or BP ≥ 150/95 at home
- 16. Choosing antihypertensive drug treatment Offer drugs taken only once a day Prescribe non-proprietary drugs where these are appropriate and minimise cost. Do not combine ACEI and ARB
- 18. SBP >160 mmHg and/or DBP >100 mmHg
- 19. 2 3 4
- 21. Treatment steps for hypertension Beta-blockers may be considered in younger people : •intolerance or contraindication to ACEI and ARB or •women of child-bearing potential or •increased sympathetic drive
- 22. If a CCB is not suitable •Edema •intolerance •evidence of heart failure •high risk of heart failure offer a thiazide-like diuretic. (Chlortalidone or indapamide)
- 23. If a CCB is not suitable •offer a thiazide-like diuretic. (Chlortalidone or indapamide) For black people of African or Caribbean family origin, •ARB in preference to an ACE inhibitor in combination with CCB If initiated with a beta-blocker and a second drug is required •CCB is better than a thiazide-like diuretic to reduce risk of developing diabetes
- 24. If clinic BP > 140/90 mmHg after optimal or best tolerated doses of an •ACE inhibitor or an ARB plus a •CCB plus a •diuretic Resistant HT •consider adding a fourth antihypertensive drug and/or seeking expert advice.
- 25. If serum K ≤ 4.5 mmol/l •low-dose spironolactone (25 mg once daily) If serum K > 4.5 mmol/l •higher-dose thiazide-like diuretic If further diuretic therapy is not tolerated, or is contraindicated or ineffective, •consider an alpha- or beta- blocker. Monitor •serum Na •Serum K •renal function within 1 month & repeat as required thereafter.
- 28. Blood pressure targets < 80 years Clinic BP < 140/90 mmHg Home BP < 135/85 mmHg ≥ 80 years Clinic BP < 150/90 mmHg Home BP < 145/85 mmHg JNC 8 (2014) < 60 years BP < 140/90 mmHg ≥ 60 years BP < 150/90 mmHg
- 30. Antihypertensive drugs Beta-blockers Diuretics Calcium antagonists Angiotensin-converting enzyme inhibitors Angiotensin receptor blockers Renin inhibitors Alpha blockers Vasodilators
- 31. RE Jackson, MC Bellamy, antihypertensive drugs, BJA education, 14 January 2015 http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku061
- 37. Renin inhibitors Aliskiren Great use if combine with HCTZ or ARB Cough, Angioedema
- 39. Diuretics Furosemide Bumetanide Thiazide -- HCTZ Thiazide like -- Indapamide -- Chlortalidone Epithelial sodium channel blockers -- Amiloride -- Triamterene Aldosterone antagonist -- Spinorolactone -- Eplerenone
- 40. Thiazide VS thiazide like diuretics Rik H.G. Olde E, Wijnanda JF, Bas VB, Lizzy MB, Liffert V, Bert-JH. Effects of Thiazide-Type and Thiazide-Like Diuretics on Cardiovascular Events and Mortality, American Heart Association,2015. TL diuretics resulted in a 12% additional risk reduction for cardiovascular events (P=0.049) and a 21% additional risk reduction for heart failure (P=0.023) when compared with TT diuretics.
- 41. Beta-blockers
- 42. Alpha blockers Doxazosin Prazosin Terazosin
- 43. Vasodilators Hydralazine Minoxidil Sodium nitroprusside
- 51. White coat hypertension Without additional risk factors Lifestyle changes only + close F/U With a higher CV risk because of metabolic derangements or asymptomatic OD drug treatment + addition to lifestyle changes
- 52. Masked hypertension Lifestyle modification + antihypertensive drug treatment
- 53. Isolated systolic hypertension Start with diuretics or DHP or CCB
- 54. Elderly Patients with SBP ≥160 mmHg Reduce SBP to 140 – 150 mmHg In fit elderly patients <80 years old Start drug at SBP values ≥140 mmHg Target SBP <140 mmHg if treatment is well tolerated. All hypertensive agents are recommended and can be used in the elderly, Diuretics and CCB may be preferred in isolated systolic hypertension.
- 55. Diabetes Start drug treatment when SBP is ≥140 mmHg. SBP goal <140 mmHg DBP goal <85 mmHg. All classes of antihypertensive agents are recommended RAS blockers may be preferred, especially in the presence of proteinuria or microalbuminuria.
- 56. CKD Lowering SBP to <140 mmHg If overt proteinuria is present, SBP values <130 mmHg RAS blockers are more effective in reducing albuminuria than other antihypertensive agents Combination of two RAS blockers is not recommended Aldosterone antagonists is not recommended
- 57. Stroke or TIA Don’t start drug in first week after acute stroke Clinical judgement should be used in very high SBP Start drug treatment even SBP is in the 140–159 mmHg SBP goal of <140 mmHg ] Drug of choice : ACE inhibitors, diuretics
- 58. Coronary heart disease SBP goal <140 mmHg Recent myocardial infarction beta-blockers are recommended Diuretics, beta-blockers, ACE inhibitors, angiotensin receptor blockers, and/or mineralocorticoid receptor antagonists are recommended in patients with heart failure or severe LV dysfunction to reduce mortality and hospitalization.
- 59. Resistant hypertension Resistance to treatment when lifestyle modification + 3 antihypertensive drugs (include diuretics) fail to reach goal of SBP < 140 mmHg, DBP < 90 mmHg Consider stopping all current drugs and restart with a simpler treatment regimen under close medical supervision Mineralocorticoid receptor antagonists (amiloride) and alpha-1-blocker (doxazosin) should be considered Invasive procedures renal denervation and baroreceptor stimulation
- 60. Renovascular hypertension RAS blockers cannot be used in bilateral renal artery stenosis or in unilateral artery stenosis with evidence of functional importance by ultrasound examinations or scintigraphy.
- 61. Primary aldosteronism the treatment of choice is unilateral laparoscopic adrenalectomy mineralocorticoid receptor antagonists is indicated in patients with bilateral adrenal disease (idiopathic adrenal hyperplasia and bilateral adenoma
- 62. Pregnancy Start when BP ≥140/90 mmHg with Gestational hypertension (with or without proteinuria) Pre-existing hypertension with the superimposition of gestational hypertension Hypertension with asymptomatic OD or symptoms at any time during pregnancy Methyldopa, labetalol and nifedipine Beta-blockers and diuretics should be used with caution ACE inhibitors, ARBs, renin inhibitors are contraindated
- 63. JNC8 NICE ESC
Editor's Notes
- #5: Moderate alcohol consumption Do not offer calcium, magnesium or potassium supplements as a method of reducing blood pressure
- #6: waist circumference(,102 cm for men and ,88 cm for women) more recent meta-analysis concluded that mortality was lowest in overweight subjects
- #7: Dietary Approaches to Stop Hypertension โดยเนน้อาหารประเภทผกั5ส่วนต่อวนั(ผกั1ส่วนมีปริมาณเท่ากบัผกัดิบประมาณ2ทพัพี [1ถว้ยตวง]หรือผกัสุก1ทพัพี[1/2ถว้ยตวง])ผลไม้4ส่วนต่อวนั (ผลไม้1ส่วนมีปริมาณเท่ากบั ผลไมห้ นั่ พอดีคาประมาณ 6-8 ชิ้น หรือผลไมเ้ป็นผลขนาดกลาง 1 ผล หรือผลไมเ้ป็นผลขนาดเล็ก 2-4 ผลหรือปริมาณผลไมท้่ีวางเรียงช้นัเดียวบนจานรองกาแฟไดพ้อดี1จาน)นมไขมนัต่าและผลิตภณัฑ์ นมไขมนัต่า2-3ส่วนต่อวนัธญัพืชถวั่เปลือกแขง็7ส่วนต่อวนั
- #8: รณรงค์6 g ต่อวันต่อคนในปี 2015 และลดเหลือ 3 g by 2025 low-salt รณรงค์ให้ขายถูกกว่าเกลือปกติ การลดโซเดียม ใช้ได้ดีในพวกคนดำ คนแก่ เบาหวาน metabolic syndrome โรคไต, การจำกัดเกลือสามารถช่วยลดโดสและจำนวนยาลดความดันได้ด้วย
- #9: ดึื่มเหล้ามากเกิน เพิ่มความดัน และเพิ่ม risk stroke No studies have been designed to assess the impact of alcohol reduction on CV endpoints. แต่ไม่มีงานวิจัยไหนบอกได้ว่าลด CV risk
- #10: หมอสละเวลา 3-5 นาที คุยกับคนไช้ บุหรี่ไปกระตุ้น central nervous system ภายใน 15 นาทีหลังสูบบุหรี่ ทำให้ความดันสูง Smoking : powerful risk factor of CV risk
- #11: Moderate: can talk but cannot sing , เดินเร็ว ว่ายน้ำเร็ว ปั่นจักรยานอยู่กับที่แบบไม่ฝืด ตัดหญ้า เต้นแอโรบิกเบาๆ Viforous: can’t say more than few words at a time ออกกำลังกายต่อเนื่องในโรงยิม ปั่นจักรยานอยู่กับที่แบบฝืด ปั่นจักรยานแข่งขัน The activity can be in 1 session or several sessions lasting 10 minutes or more.
- #13: if pharmacologic treatment for high BP results in lower achieved SBP (eg, &lt;140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted
- #15: ของปี 2007 Recommended a lower threshold for antihypertensive drug in patients with diabetes, previous CVD or CKD even when BP was in the high normal range (130 – 139/85 – 89 mmHg). งานวิจัย บอกว่า Ramipril or valsatan not improve morbidity and mortality
- #17: Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher) the same treatment as people with both raised systolic and diastolic blood pressure
- #19: A ยาตัวแรก ให้ max dose เริ่มยาตัวที่ 2 ให้ max dose ให้ยาตัวที่ 3 titrate ถึง max dose B เริ่มยาตัวแรก ยังไม่ถึง max ให้เพิ่มยาตัวที่ 2 แล้ว titrate ยา 2 ตัวให้ถึง max dose แล้วค่อย add ตัวที่ 3 titrate ถึง max dose C เริ่มยา 2 ตัวพร้อมกันเลย แล้วค่อย เพิ่มยาตัวที่ 3 ถ้าคุมไม่ดี experts บางคนแนะนำว่าให้ใช้เฉพาะคนไข้ SBP &gt;160 or DBP &gt; 100 หรือ SBPมากกว่า goal 20 DBP &gt; goal 10
- #22: ACEI ห้ามสั่งคู่กับ ARB ถ้าให้ ACEI แล้ว SE เยอะ เช่น ไอมาก ให้ ARB (low cost) แพ้ยา หรือมี ข้อห้ามในการให้ Contraindication : pregnancy, แพ้ยา , Use with caution: renal insuf ใช้ได้ถึง Cr 3 Impaired renal function Aortic valve stenosis or cardiac outflow obstruction Hypovolemia or dehydration Hemodialysis with high-flux polyacrylonitrile membranes http://www.aafp.org/afp/2002/0801/p461.html Common adverse drug reactions include: hypotension, cough, hyperkalemia, headache, dizziness, fatigue, nausea, and renal impairment.[13][14] ACE inhibitors might increase inflammation-related pain, perhaps mediated by the buildup of bradykinin that accompanies ACE inhibition.
- #23: แต่ถ้าใครกิน thiazide อยู่แล้ว และ stable and control BP ได้ดี ก็ให้กินของเก่าไปค่ะ
- #24: Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses.
- #26: Use particular caution in people with a reduced eGFR because they have an increased risk of hyperkalaemia. ถ้ายัง control ไม่ได้ ก็ consult NICE has published interventional procedures guidance on percutaneous transluminal radiofrequency sympathetic denervation of the renal artery for resistant hypertension with special arrangements for clinical governance, consent, and audit or research. NICE has published interventional procedures guidance that implanting a baroreceptor stimulation device for resistant hypertension should be used only in the context of research.
- #27: Thai guideline
- #30: Guideline thai ใช้อันนี้
- #32: เส้นประ verapamil and diltiazem ลด heart rate ได้ด้วย
- #35: Vsmc : vascular smooth muscle
- #36: ACE: angiotensin converting enzyme ARB : Angiotensin II receptor blockers Negative feedback จาก ACEI ARB ทำให้ renin ทำงานมากขึ้น
- #37: S
- #38: Renin inhibitor ยากลุ่มใหม่ รองรับโดย FDA ปี 2007 ซึ่งไปออกฤทธิ์ที่ Renin ซึ่งเป็น Rate limiting step ACEI ทำให้เกิดการคั่งของ Ang I และอาจเปลี่ยนไปเป็น Ang II ด้วย pathway อื่น เช่น chymase and chymotrypsin-like angiotensin-generating enzyme ARBs, angiotensin II levels จะสูงขึ้น และจะไปแย่งจับ Ang II receptor ก็ยังไป stimulate aldosterone จาก adrenal gland ได้ direct renin inhibition (DRI) จะลดการสะสมของ precursor ทำให้สามารถลด breakthrough effect ได้ Negative feedback จาก ACEI ARB ทำให้ renin ทำงานมากขึ้น
- #40: Loop diuretics : ป้องกันดูดกลับของ Na K 2Cl more effective ในคนที่ renal insufficiency เพิ่มการสร้าง prostaglandin ทำให้ vasodilation และเพิ่ม blood supply ไปไต ดั้งนั้น NSAID ซึ่ง block COX pathway ทำให้ลด efficacy ของ loop diuretics Furosemide Bumetanide Ethacrynic acid Torsemide
- #41: Sulfonamide diuretics with no chemical of thiazide: Chlortalidone or indapamide,
- #44: lower the blood pressure by decreasing total peripheral resistance. mix between arteriolar and venous dilatation
- #51: Thai guideline
- #57: Spironolactone , the risk of excessive reduction in renal function and of hyperkalaemia. Loop diuretics should replace thiazides if serum creatinine is 1.5 mg/dL or eGFR is ,30 mL/min/1.73 m2.
- #58: All drug regimens are recommended
- #60: R/O (i) persistence of an alerting reaction to the BP-measuring procedure, with an elevation of office (although not of out-of-office) BP, (ii) use of small cuffs on large arms, with inadequate compression of the vessel and (iii) pseudo-hypertension Spironolactone even at low doses (25 – 50 mg/day)
- #63: Beta-blockers (possibly causing foetal growth retardation if given in early pregnancy) and diuretics (in pre-existing reduction of plasma volume) should be used with caution n emergency (pre-eclampsia), intra- venous labetalol is the drug of choice with sodium nitroprusside or nitroglycerin