management of systemic hypertension update 2012

Lifestyle change: exercise Exercise should be prescribed as an adjunctive to pharmacological therapy Should be prescribed to reduce blood pressure Type C ardiorespiratory Activity TL: 2

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Definition and Classification of HTN

3

TL: Mancia G et al European Heart Journal June 11, 2007

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Threshold of HTN definition based on

technique of measurement

4

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 Blood acid uric

 Creatinemia; eGFR (Cockcroft-Gault)

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Laberatory examinations (2)

6

 Laboratory check of necessity

 Echocardiography

 Carotid ultra sound

 Urine microalbumine/ urine creatinine

 Pulse wave velocity

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Blood pressure targets

TL: 2012 Canadian Hypertension Education Program (CHEP)

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• Dietary and soluble fibre

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Benefits of natri reduction/ Canada

REDUCTION IN AVERAGE DIETARY SODIUM FROM

ABOUT 3500 MG TO 1700 MG

 1 million fewer hypertensives

 5 million fewer physicians visits a year for hypertension

 Health care cost savings of $430 to 540 million per year

related to fewer office visits, drugs and laboratory costs for hypertension

 Improvement of the hypertension treatment and control

rate

 13% reduction in CVD

 Total health care cost savings of over $1.3 billion/year

Penz ED, Cdn J Cardiol 2008 Joffres MR_CJC_ 23(6) 2007.

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Meta analysis of benefits of natri

reduction

The Cochrane Library 2006;3:1-41

Average Reduction of sodium in

mg/day

1800 mg/day

2300 mg/day

Hypertensives Reduction of BP 5.1 / 2.7 mmHg

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Source of ingested natrium

1 12% natural content of foods

2 “Hidden“ sodium: 77% from processing of food -manufacturing and restaurants

3 “Conscious“ sodium: 11% added at the table (5%) and in cooking (6%)

J Am College of Nutrition 1991;10:383-93

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Lifestyle change: exercise

Exercise should be prescribed as an adjunctive to pharmacological

therapy

Should be prescribed to reduce blood pressure

Type C ardiorespiratory Activity

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Lifestyle change: reduction of body weight

Height, weight, and waist circumference (WC) should be measured and body

mass index (BMI) calculated for all adults.

CMAJ 2007;176:1103-6

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Iliac crest

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Lifestyle change: alcohol

Low risk alcohol consumption

Women: maximum of 9 standard drinks/week

Men: maximum of 14 standard drinks/week

0-2 standard drinks/day

A standard drink is about 142 ml or 5 oz of wine (12% alcohol) 341 mL or 12

oz of beer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).

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Aerobic exercise 120-150 min/week -4.9 / -3.7

Dietary patterns Hypertensive DASH diet

-11.4 / -5.5

749-751

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or Concomitant diseases/conditions?

Individualized Treatment

(and compelling indications)

YES

Treatment in the absence of compelling indications for specific

therapies

NO

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Majority of patients needs > 1 drug to attain

target of BP

0 1 2 3 4 5

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• White coat effect

Dual Combination

Triple or Quadruple Therapy

Lifestyle modification

Thiazide diuretic ACEI

Long-acting CCB

blocker*

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• White coat effect

Thiazide diuretic Long-acting

*If blood pressure is still not controlled, or there are adverse effects, other classes of

antihypertensive drugs may be combined (such as ACE

inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker)

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Treatment of HTN on patients combined

with ischemic heart disease

 Caution should be exercised when combining a non DHP-CCB and a beta-blocker

 If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem)

• Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure

• The combination of an ACEi and CCB is preferred

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy

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Treatment of HTN on patients with

recent acute myocardial infarction

Long-actingDihydropyridine CCB*

Beta-blocker and ACEI or ARB

Recent myocardial infarction

Heart Failure

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

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left ventricular systolic dysfunction

Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol

If additional therapy is needed:

• Diuretic (Thiazide for hypertension; Loop for volume control)

• for CHF class III-IV or post MI: Aldosterone Antagonist

Systolic cardiac dysfunction

• ACEI and Beta blocker

• if ACEI intolerant: ARB Titrate doses of ACEI or ARB to those used in clinical trials

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide dinitrate

in combination

If additional antihypertensive therapy is needed:

• ACEI / ARB Combination

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cerebro vascular disease

Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA

An ACEI / diuretic combination is preferred

Stroke TIA

Combinations of an ACEI with an ARB are not recommended

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Treatment of HTN on diabetic patients

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

> 2-drug combinations

ACE Inhibitor

or ARB

without Nephropathy

1 ACEInhibitor or ARB

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MRC Working Party MRC trial of treatment of mild hypertension: 1985 Jul 13;291(6488):97-104.

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Algorithm for management of elderly HTN patients

(The 2011 ACC/AHA Recommendation) (1)

30

TL: Aronow WS et al J Am coll Cardiol 2011; 57: xxx- xx

Principles of Hypertension Treatment Target systolic blood pressure is ≤ 140 mmHg in patients aged 55 to 79

Target systolic blood pressure is ≤ 140 mmHg in patients ≥ aged 80+

Achieved values < 140 mmHg for those aged ≤ 79 are appropriate;

but for those aged ≥ 80, 140 to 145 mmHg, if tolerated, can be acceptable

Lifestyle Modilications

Not at Target Blood Pressure

Initial Drug Choices

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TL: Aronow WS et al J Am coll Cardiol 2011; 57: xxx- xx

Without Compelling Indications With Compelling Indication

Majority will require at least two medications to reach goal

if at least 20 mmHg above target Initial combinations should be considered The combination of amlopidine with an RAS blocker may be preferred to a diuretic combination, though either is acceptable

Compelling Indication Heart Failure

Post myocardial infarction CAD or High CVD risk Angina Pectoris Aortopathy/ Aortic Aneurysm

Diabetes Chronic kidney disease Recurrent stroke prevention Early demenia

Initial therapy Options* THIAZ, BB, ACEI, ARB, CA, ALDO ANT

BB, ACEI, ALDO ANT, ARB THIAZ, BB, ACEI, CA

BB, CA

BB, ARB, ACEI, THIAZ, CA

ACEI, ARB, CA, THIAZ, BB ACEI, ARB

THIAZ, ACEI, ARB, CA Blood pressure control

* Combination therapy

Not at Target Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved

Refer to a clinical hypertension specialist if unable to achieve control

Algorithm for management of elderly HTN patients

(The 2011 ACC/AHA Recommendation) (2)

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The 2011 CHEP recommendations of

HTN in stroked patients (1)

32

Ischemic stroke without fibrinolytic:

 In acute stroke do not lowering BP

 If too severe BP (eg: syst BP > 220 mmHg or diast BP > 120 mmHg: reduce ≤ 25% existing

BP level in 24 hours)

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Leonardi-Bee, J et al Stroke 2002;33:1315-1320

Proportion of patients who died within 14 days (solid lines) or were dead or

dependent at 6 months (dashed lines) by baseline SBP

33

The 2011 CHEP recommendations of

HTN in stroked patients (2)

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The 2011 CHEP

recommendations on drugs

combination

34

HTN associaled with diabetes mellitus

ACE –I or ARB combined with DHP calcium

antagonists better than ACE- I+ Diuretic.

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New points of NICE Guideline for

1. No difference in HTN drugs leetween > 80 year old patients and

55-80 years old patients

2. HTN patients < 55 years old: begin with A (ACE-I or ARB)

3. HTN patients ≥ 55 years old: begin with Calcium antagonists

4. Diuretic: choosing between chlorthalidone or indapamide

5. Step 2 of drugs combination: ACE-I or ARB + DHP calcium

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New points in 2012 CHEP

recommendation

equal importance in diagnosis and management

kidney disease BP target < 140/90 mmHg

anti- aldosterone

TL: CHEP 2012 Recommendations www hypertension.ca. 36

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Single pill combination-based

treatment improves blood pressure

control rates

37

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STITCH Study : cluster randomization

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STITCH: Primary Outcome

Proportion of Practice at BP Target

p = 0.03

52.7 64.7

Absolute Difference in BP control rate = 12%

39

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New technique in the

management of resistant

hypertension

40

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41

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Algorithm of study

TL: Symplicity HTN-2 Investigators, Lancet 2010; 376: 1903-1909

42

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Renal denervation system

43

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Results after 6 months

44

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Kidney biomarker changes/ renal

denervation therapy compared with placebo

45

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 Not only BP level, other risk factors management

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