Htn update
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The document discusses new guidelines for hypertension from organizations like JNC 8, ESC, and ASH/ISH. The guidelines stratify total cardiovascular risk and recommend treatment thresholds and goals based on risk factors. For general patients under 60, treatment is recommended for those with systolic BP over 140 or diastolic over 90. The guidelines also recommend initial treatment options including ACE inhibitors, calcium channel blockers, thiazide diuretics, and others. The guidelines aim to provide evidence-based recommendations for hypertension treatment worldwide while allowing flexibility based on individual patient characteristics. Overall, the focus is on improving health outcomes through treating patients and controlling blood pressure levels rather than rigidly adhering to specific numbers.
![Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
Risk FactoRs
• Male sex
• Age (men ≥55 years; women ≥65
years)
• Smoking
• Dyslipidaemia
TC > 190 mg/dL, and/or
LDL >115 mg/dL, and/or
HDL: men <40 mg/dL, women < 46
mg/dL, and/or
Triglycerides >150 mg/dL
• Fasting plasma glucose 102–
125 mg/dL
• Abnormal glucose tolerance
test
• Obesity [BMI ≥30 kg/m²
(height²)]
• Abdominal obesity
(waist circumference: men ≥102
cm;women ≥88 cm)
• Family history of premature
CVD (men aged <55 years;
women aged <65 years)](https://image.slidesharecdn.com/htnupdate-140429065444-phpapp01/85/Htn-update-10-320.jpg)
![Factors—other than office BP—influencing
prognosis; used for stratification of total CV risk
asymptomatic oRgaN Damage
• Pulse pressure (in the
elderly) ≥60 mmHg
• ECG :LVH (Sokolow–Lyon
index >3.5 mV;RaVL >1.1 mV;
Cornell voltage duration
product >244 mV x ms), or
• Echo: LVH [LVM index: men
>115 g/m²;women >95 g/m²
(BSA)]
• Carotid wall thickening (IMT
>0.9 mm) or plaque
• Carotid–femoral PWV >10 m/s
• Ankle-brachial index <0.9
• CKD with eGFR 30–60
ml/min/1.73 m² (BSA)
• Microalbuminuria (30–300
mg/24 h), or albumin–
creatinine ratio 30–300 mg/g;
(preferentially on morning spot
urine)](https://image.slidesharecdn.com/htnupdate-140429065444-phpapp01/85/Htn-update-11-320.jpg)
Htn update
- 3. What’s New in Hypertension- More More More !
- 4. I am a gentle killer All over the world, I am called HYPERTENSION World Hypertension Day, annually celebrated on May 17th
- 5. Nov 2013 oct 2011 oct 2013 2013 20102012
- 6. Dec 2013 JuN 2013 Dec 2013
- 8. Category Systolic Diastolic Optimal <120 and >80 Normal 120-129 and/or 80–84 High normal 130-139 and/or 85–89 Grade 1 hypertension 140-159 and/or 90-99 Grade 2 hypertension 160-179 and/or 100-109 Grade 3 hypertension ≤180 and/or ≤110 Isolated systolic hypertension ≤140 and >90 Definitions and classification of office BP levels (mmHg) The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated
- 10. Factors—other than office BP—influencing prognosis; used for stratification of total CV risk Risk FactoRs • Male sex • Age (men ≥55 years; women ≥65 years) • Smoking • Dyslipidaemia TC > 190 mg/dL, and/or LDL >115 mg/dL, and/or HDL: men <40 mg/dL, women < 46 mg/dL, and/or Triglycerides >150 mg/dL • Fasting plasma glucose 102– 125 mg/dL • Abnormal glucose tolerance test • Obesity [BMI ≥30 kg/m² (height²)] • Abdominal obesity (waist circumference: men ≥102 cm;women ≥88 cm) • Family history of premature CVD (men aged <55 years; women aged <65 years)
- 11. Factors—other than office BP—influencing prognosis; used for stratification of total CV risk asymptomatic oRgaN Damage • Pulse pressure (in the elderly) ≥60 mmHg • ECG :LVH (Sokolow–Lyon index >3.5 mV;RaVL >1.1 mV; Cornell voltage duration product >244 mV x ms), or • Echo: LVH [LVM index: men >115 g/m²;women >95 g/m² (BSA)] • Carotid wall thickening (IMT >0.9 mm) or plaque • Carotid–femoral PWV >10 m/s • Ankle-brachial index <0.9 • CKD with eGFR 30–60 ml/min/1.73 m² (BSA) • Microalbuminuria (30–300 mg/24 h), or albumin– creatinine ratio 30–300 mg/g; (preferentially on morning spot urine)
- 12. Factors—other than office BP—influencing prognosis; used for stratification of total CV risk Diabetes mellitus • Fasting plasma glucose ≥126 mg/dL on two repeated measurements, and/or • HbA1c >7% , and/or • Post-load plasma glucose >198 mg/dL
- 13. Factors—other than office BP—influencing prognosis; used for stratification of total CV risk EstablishEd CV or rEnal disEasE • Cerebrovascular disease: stroke; TIA • CHD:MI; angina; revascularization with PCI or CABG • HF, including HF with preserved EF • Symptomatic lower extremities PAD • CKD with eGFR <30 mL/min/1.73m²(BSA); proteinuria (>300 mg/24 h). • Advanced retinopathy: haemorrhages or exudates, papilledema
- 14. Blood Pressure (mmHg( High normal SBP 130–139 or DBP 85–89 Grade 1 HT SBP 140–159 or DBP 90–99 Grade 2 HT SBP 160–179 or DBP 100–109 Grade 3 HT SBP ≥180 or DBP ≥110 Other risk factors, asymptomatic organ damage or disease No other RF 1-2RF ≤3RF OD, CKD stage 3 or diabetes Symptomatic CVD, CKD stage ≥4 or diabetes with OD/RFs BP = blood pressure; CKD = chronic kidney disease; CV = cardiovascular; CVD = cardiovascular disease; DBP = diastolic blood pressure; HT = hypertension; OD = organ damage; RF = risk factor; SBP = systolic blood pressure Total CV RISK
- 15. Stratification of total CV risk in categories of low, moderate, high and very high risk according to SBP and DBP and prevalence of RFs,Asymptomatic OD,diabetes,CKD stage or symptomatic CVD.
- 16. Initiation of lifestyle changes and antihypertensive drug treatment. Targets of treatment are also indicated(<140/90). (in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)
- 17. Blood Pressure (mmHg( High normal SBP 130–139 or DBP 85–89 Grade 1 HT SBP 140–159 or DBP 90–99 Grade 2 HT SBP 160–179 or DBP 100–109 Grade 3 HT SBP ≥180 or DBP ≥110 Other risk factors, asymptomatic organ damage or disease No other RF 1-2RF ≤3RF OD, CKD stage 3 or diabetes Symptomatic CVD, CKD stage ≥4 or diabetes with OD/RFs Com pelling indications No Compelling indications Choice of drug treatment
- 18. Any Body Can Dance A B C D 2013 Indian dance film
- 19. The A,B,C,D drug classes
- 20. Diuretics (thiazides,chlorthalidone and indapamide), beta-blockers,calcium antagonists, ACE inhibitors, and angiotensin receptor blockers are all suitable and recommended for the initiation and maintenance of antihypertensive treatment, either as monotherapy or in some combinations with each other Choice of drug treatment No suggestion, all 5 classes No ranking or classification of preferred drugs AA BB CC DD
- 21. Possible combinations of classes of antihypertensive drugs Green continuous lines: preferred combinations; green dashed line: useful combination (with some limitations); black dashed lines: possible but less well-tested combinations; red continuous line: not recommended combination. DD AA AA CC BB
- 23. The Joint National Committee (JNC ) JNC 8 Has Finally Arrived
- 24. This JNC 8 guideline has not redefined high BP, and considers the 140/90 mm Hg definition from JNC 7 reasonable. Category SBP (mm Hg) DBP (mm Hg) Normal < 120 < 80 Pre – hypertension 120-139 80-90 Hypertension Stage 1 140 – 159 90 – 99 Stage 2 160 and above 100 and above
- 25. JNC 7 Compelling Indications † ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.
- 26. Questions guiding the JNC 8 review This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management. They address thresholds, goals for pharmacologic treatment, and whether particular antihypertensive drugs or drug classes improve important health outcomes compared to others. 1.In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes? 2.In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes? 3.In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific health outcomes? The answers to these three questions are reflected in 9 recommendations
- 27. Recommendation 1 (Strong recommendation) Recommendation 2 (Strong recommendation) Recommendation 3 (Expert opinion) General population ≥60 years SBP ≥150 mm Hg or DBP ≥90 mm Hg SBP <150 mm Hg and DBP <90 mm Hg General population <60 years DBP ≥90 mm Hg DBP <90 mm Hg General population <60 years SBP ≥140 mm Hg SBP <140 mm Hg Recommendations GoalsBP thresholds
- 28. Recommendation 4 (Expert opinion) Recommendation 5 (Expert opinion) Recommendation 6 (Moderate recommendation) Population with CKD ≥18 years SBP ≥140 mm Hg or DBP ≥90 mm Hg SBP <140 mm Hg and DBP <90 mm Hg Population with diabetes ≥18 years SBP ≥140 mm Hg or DBP ≥90 mm Hg SBP <140 mm Hg and DBP <90 mm Hg General nonblack population ( ± diabetes ) or Recommendations GoalsBP thresholds Initial treatment AA CC DDor
- 29. Recommendations Recommendation 7 (Moderate recommendation) Recommendation 8 (Moderate recommendation) Recommendation 9 (Expert opinion) General ( ± diabetes ) black population or Population with CKD ≥18 years Goal BP not reached within a month of treatment Increase the dose of the initial drug, or add a second drug (from the list provided) Goal BP not reached with 2 drugs Add and titrate a third drug (from the list provided) Do not use an ACEI and an ARB together in the same patient Initial treatments Initial or add-on treatments Non control strategies CC DD AA
- 30. DM CKD CC DD AA BB AA CC DD Alone or in combination Alone or in combination with other drug class
- 31. Focus on evidence based recommendations Higher target SBP for patients over 60 y/o Limited data to support either 150 or 140 mmHg Removed special lower target BP for those with CKD or DM Liberalized initial drug choices Major changes from JNC 7 AA CC DD
- 33. Drug Selection in Hypertensive Patients A. When hypertension is the only or main condition Patient Type Black patients (African ancestry First Drug Add Second Drug If Needed to Achieve a BP <140/90 mm Hg If Third Drug is Needed to Achieve BP of <140/90 mm Hg All ages or CC DD AA CC DD + + Black CD DD AA CC
- 34. Drug Selection in Hypertensive Patients A. When hypertension is the only or main condition Patient Type White and other non- black Patients 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 Younger than 60 60y and older AA CC DD or AA CC DD CC DDor AA Also OK AA CC DD + +
- 35. Drug Selection in Hypertensive Patients B. When hypertension is associated with other 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 and diabetes Note: in black patients, it is acceptable to start with Hypertension and CKD AA CC DD AA CC DDor AA CC DD + + AA CC DDor
- 36. Nonblack Younger than 60 60y and older Black Diabetes Note: in black patients, it is acceptable to start with CKD ASH/ISH Initial Drug ChoicesJNC 8 AA CC DD CC DD AA CC DD AA AA CC DD AA Also OK AA CC DD
- 37. Take a deep breathTake a deep breath
- 38. Guidelines are meant to “guide” and not to “mandate”
- 39. Population Goal BP, mm Hg Initial Drug Treatment Options General nonelderly >140/90 General elderly <80 y General ≥80 y >150/90 Diabetes >140/85 CKD >140/90 CKD + proteinuria >130/90 General <60 y >140/90 Nonblack Black General ≥60 y >150/90 Diabetes >140/90 CKD 140/90 ESH/ESC JNC8 AA BB CC DD AA AA CC DD CC DD AA CC DD AA
- 40. AA CC DD AA BB CC DD Replaces As first line drug ESH/ESC 2013 ASH/ISH 2014 2014 “JNC 8” Beta-blockers Yes No (Step 4( No (Step 4( Initial Drug Choices
- 41. DD AA CC BB ß-blocker should be included in the regimen if there a compelling indication for a ß-blocker Possible combinations of ABCD classes
- 42. Lower your number Lower your risk Treat patients and not numbers
- 45. New Hypertension Guidelines Offer Information for Doctors Around the Globe
Editor's Notes
- #27: RAAS and angiotensin II are activated in the insulin resistance state, and RAAS inhibition has effects on insulin action and secretion. Indeed, the vasodilation induced by ACE inhibitors could improve the blood circulation in skeletal muscles, thus favoring peripheral insulin action, but also in the pancreas, promoting insulin secretion. Preserving cellular potassium and magnesium pools by blocking the aldosterone effects could also improve both cellular insulin action and insulin secretion. However, besides these classical effects, new mechanisms have been recently suggested. A direct effect of the inhibition of angiotensin and/or of the enhancement of bradykinin on various steps of the insulin cascade signaling has been described as well as an increase in GLUT4 glucose transporters after RAS inhibition. Furthermore, it has been demonstrated that angiotensin II inhibits adipogenic differentiation of human adipocytes and, therefore, it has been hypothesized that RAS blockade may prevent diabetes by promoting the recruitment and differentiation of adipocytes. In conclusion, numerous physiological and biochemical mechanisms could explain the protective effect of RAS inhibition against the development of type 2 diabetes in individuals with arterial hypertension or congestive heart failure. What might be the main mechanism in the overall protection effect of ACEIs or ARBs remains an open question.
- #28: A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009. A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users. The primary end point was the cumulative incidence of new-onset diabetes mellitus.
- #29: A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009. A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users. The primary end point was the cumulative incidence of new-onset diabetes mellitus.
- #30: A total of 4071 individuals, with hypertension or normotensives, and without previous history of diabetes mellitus were investigated between January 2004 and September 2009. A subgroup of 1856 hypertensive patients who had at least one additional cardiovascular risk factor took part in the treatment analysis. To adjust for potential cofounders, a propensity score matched analysis was performed using the logistic regression model. The population was finally divided as follows: 321 patients for ACE inhibitor users and 321 patients for ARB users. The primary end point was the cumulative incidence of new-onset diabetes mellitus.