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Mansoura University -  Faculty of  Medicine Mansoura – Manchester  Programme for Medical Education Semester **   7 *****

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The information included in this presentation are not the only source for this topic and you should explore other valuable references in order to satisfy the ILOs of this topic.

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Contact:  e-mail: mahfouzessams@gmail.com Mobile: 01223948086 Academic hours:

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Definition and classification of HTN BP measurement  Aetiology  of HTN Patient evaluation  History  Physical examination Investigations  Risk stratification

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Aims of HTN  treatment Value of BP control  BP targets  Main treatment items  When and how to start treatment  Hypertensive emergencies

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To know the definition and classification of HTN To master the best techniques of BP measurement  To learn the most important causes of HTN To know how to evaluate hypertensive patient  To be trained how to risk stratify patient with HTN

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To know the objectives of HTN treatment  Health value of HTN control  How to start treatment according to patient CV risk Drug combinations and when to use  How to deal with HTN emergencies

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ESC Hypertension Guidelines 2018  www.escardio.org ACC/AHA Hypertension guidelines 2017  www.acc,org

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By Essam  Mahfouz, MD Professor of Cardiology, Mansoura University

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Hypertension is defined as Increase of blood pressure > 140/90 Resistant hypertension is defined as persistently elevated BP in spite of use of triple antihypertensive including diuretics for > 2 months Malignant hypertension is an old term that means diastolic BP> 130 + papilledema &/or retinal  Hge

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Category Systolic BP mm Hg  Diastolic BP mm Hg Optimal  < 120 <80 Normal  120-129 80-84 High normal 130-139 85-89 Grade 1 140-159 90-99 Grade 2 160-179 100-109 Grade 3 >180 > 110 Isolated systolic HTN >140 <90

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Methods Office or routine measurement Home  measurement (HBPM) Self-measurement Family member measurement  Ambulatory BP  monitoring (ABPM)  Apparatus: Mercury sphygmomanometers most common Aneroid  sphygmomanometers Digital  apparatus Doppler sphygmomanometers

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Technique  and precautions:  The BP is measured in sitting position, in the basal condition from the right arm that is supported at the heart level No smoking, tea, or coffee one hour before measurement  Supine and standing measure is taken if orthostatic HTN is suspected as in diabetic, elderly & patients with autonomic dysfunction Appropriate size cuff that cover 2/3 of the arm circumference and ½ of its length   Rapidly inflate the cough and release pressure gradually to detect the phases of 	 Korotkoff  sounds I ( 1 st  tapping sound) to V (Complete disappearance of sound) that represent the SBP & DBP respectively  Take the mean of 2 readings

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Staight back
chair
Arm resting
on table
Center of cuff
at heart line
Feet flat on
floor
Group

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160
120
80
40
Arterial
pulse
tracing
occluded;
no flow
Artery
compressed;
blood flow
audible
Artery not
compressed;
flow free
and audible
Effect of cuff
on arterial flow
Silence
Systolic
pressure
Sounds of
turbulent flow
Diastolic
pressure
Silence
Auscultatory
findings

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Definitions of HTN by office and out-of-office blood pressure levels

Category Systolic BP(mmHg) Diastolic  BP (mmHg) Office BP >= 140 And/or >= 90 Ambulatory BP Daytime (or awake) >= 135 And/or >= 85 Nighttime (or asleep) >  = 120 And/or >= 70 24 hour > = 130 And/or >= 80 Home BP >= 135 And/or > = 85

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White coat HTN: Refer to abnormal increase in BP when measured in the clinic than when measured in the home  Masked HTN: Refer to higher BP Reading in the home than that in the office  Both conditions are important to catch during management of HTN Use of home BP Measurement or ambulatory BP monitoring is helpful for detection of these conditions

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Primary or essential 90-95% Unknown etiology Usually start at early middle age > 40 year May be familial with multifactorial inheritance A role of hyperactivity of sympathetic nervous system and renin angiotensin aldosterone system and high salt intake are blamed for its pathogenesis  Secondary HTN Renal HTN Reno vascular e.g. renal artery stenosis   Parenchymal renal disease Endocrine HTN: Adrenal Cushing syndrome, primary  aldosteronism ,  pheochromocytoma  and renin producing tumors Diabetes mellitus  Thyroid disease hyper sometimes hypothyroidism Acromegaly

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Hyperparathyroidism  Mechanical  coarctation  of aorta Neurogenic Increased ICT Poliomyelitis  Drug induced: Contraceptive pills Corticosteroid Non-steroidal anti-inflammatory drugs Liquorice Monamine  oxidase inhibitor withdrawal  Cyclosporine  Pregnancy related: Toxemia of pregnancy Other  causes

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Evaluation of patients with documented hypertension has three objectives: To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment  To reveal identifiable causes of high BP  To assess the presence or absence of target organ damage and CVD. The data needed are acquired through medical history, physical examination, routine laboratory tests, and other diagnostic procedures.

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In patient with non-complicated HTN General examination  Pulse & BP Body  wt , BMI and waist circumference  Local cardiac examination LVH Heart sounds and murmurs

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Signs suggesting secondary  HTN  Features of Cushing syndrome. Skin stigmata of neurofibromatosis ( pheochromocytoma ). Palpation of enlarged kidneys (polycystic kidney). Auscultation of abdominal murmurs ( reno -vascular hypertension). Auscultation of precordial or chest murmurs (aortic  coarctation  or aortic disease). Diminished and delayed femoral and reduced femoral blood pressure (aortic  coarctation , aortic disease ).

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Signs of Target  organ damage Brain: murmurs over neck arteries, motor or sensory defects. Retina:  funduscopic  abnormalities. Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary  rales , dependent edema. Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities,  ischemic  skin lesions .

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Routine tests Plasma glucose  & HbA1c Serum total cholesterol Serum high-density lipoprotein (HDL)-cholesterol Fasting serum triglycerides Serum uric acid Serum creatinine Serum potassium Hemoglobin and hematocrit Urinalysis Electrocardiogram

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Recommended tests Echocardiogram CXR Ex ECG and  Holter  monitoring  Carotid (and femoral) ultrasound C-reactive protein Microalbuminuria  (essential test in diabetics ) Quantitative proteinuria (if dipstick test positive) Funduscopy  (in severe hypertension )

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Extended  evaluation (domain of the specialist) Complicated hypertension: tests of cerebral, cardiac and renal function Search for secondary hypertension: measurement of renin, aldosterone, corticosteroids,  catecholamines ; arteriography; renal and adrenal ultrasound; Computer-assisted tomography (CAT); brain magnetic resonance imaging

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Blood Pressure (mmHg)
Other risk factors,
asymptomatic organ damage
or disease
No other RF
1-2 RF
23 RF
OD, CKD stage 3 or diabetes
Symptomatic CVD, CKD stage 24 or
diabetes with OD/RFs
High normal
SBP 130-139
or DBP 85-89
Low risk
Low to
Moderate risk
Moderate to
high risk
Very high risk
Grade I HT
SBP 140-159
or DBP 90—99
Low risk
risk
Moderate to
high risk
High risk
Very high risk
Grade 2 HT
SBP 160-179
or DBP 100-109
Moderate risk
Moderate to
high risk
High Risk
HVI risk
Very high risk
Grade 3 HT
SBP 2180
or DBP 2110
High risk
Hi*l risk
Hi*l risk
High to
very high risk
Very high risk
BP = 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.

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Prognostic factors used in risk stratification

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Relief of symptoms Prevention of complications and target organ damage Improve quality of life Improve mortality

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2018 ESC/ESH Hypertension Guidelines
Risk reduction (0/0) by 10 mmHg SBP reduction
at initial SBP of 130-139 mmHg (RCTs)
CHD +
Stroke *
Major CV events *
All-cause mortality *
* All statistically significant
-12
— 27
-25
-13
-11
• ESC
Ettehad et al., Lancet 2015; 387: 957
Williams, Mancia et al., J Hycærtens 2018 and Eur Heart J 2018, in press

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Average Percent Reduction 	Stroke incidence 	35–40%   	 	Myocardial infarction 	20–25%  	Heart failure	50%

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all be treated to <140/90 mm Hg   Except : diabetes (<85 mm Hg diastolic) In patients near 80 years age, the systolic blood-pressure target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy-mentally & physically

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Life style modifications Diagnosis and treatment of the cause in secondary HTN Drug therapy Treatment in special situations Elderly  Children  Diabetics Chronic kidney disease

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Including the following: Diet: Weight  reduction  Salt restriction the degree depends on the severity of HTN High K and  Ca  intake  Exercise and increase physical activity  STOP Smoking and alcohol intake Relaxation therapy

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Lifestyle Modifications3 (LM)
Modification
Reduce weight
Adopt DASH*5
eating plan
Lower sodium
intake6
Physical activity
Moderation
of alcohol
consumption
Recommendation
Maintain normal body weight (body mass index 18.5-24.9 kg/m2)
Approximate
SBP Reduction
(Range)"
5-20 mm Hg/10 kg
Consume a diet rich in fruits, vegetables, and low-fat dairy products with a
8-14 mm Hg
reduced content of saturated and total fat
a. Consume no more than 2,400 mg of sodium/day;
b. Further reduction of sodium intake to 1,500 mg/day is desirable since
it is associated with even greater reduction in BP; and
2-8 mm Hg
c. Reduce intake by at least 1 ,000 mg/day since that will lower BP, even
if the desired daily sodium intake is not acheived
Engage in regular aerobic physical activity such as brisk walking (at least
30 min per day, most days of the week)
Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine,
or 3 oz 80-proof whiskey) per day in most men, and to no more than
1 drink per day in women and lighter weight persons
4-9 mm Hg
2-4 mm Hg

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Consider BP level and correlate with overall risk: C ardiovascular  risk factors O vert  cardiovascular disease A symptomatic  organ damage D iabetes C hronic  kidney disease.

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O ESC
Table 19.
Summary of office blood
pressure thresholds for treatment
Office SBP treatment threshold (mmHg)
Age group
Hypertension
Diastolic
treatment
+ Stroke/
Threshold
18-65 years
65-79 years
2 80 years
Diastolic
treatment
threshold
(mmHg)
2 140
2 140
2 160
2 90
Diabetes
2 140
2 140
2 160
2 90
+ CKD
2 140
2 140
2 160
2 90
+ CAD
2 140a
2 140a
2 160
290
TIA
2 140a
2 140a
2 160
2 90
(mmHg)
2 90
2 90
2 90
rruy be in very with (i.e. SBP
2018 ESC/ESH Guidelr•s for the man.ment Of hypertension
Euro*an Heart Ryurnal (2018) doi:IO.1Ø3/eurhe.rtVehy339
Journal of Hypertension (2018) de:10.

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2018 ESC/ESH Hypertension Guidelines
Office BP treatment targets in hypertensive patients -
General Recommendations
e The first objective of treatment should be to lower
BP to < 140/90 mmHg in all patients
e Provided that treatment is well tolerated treated BP
should be targeted to 130/80 mmHg or lower in
most patients
Class / Level
IA
IA
• ESC
Williams, Mancia et al., J Hycærtens 2018 and Eur Heart J 2018, in press

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Table 23.
Office blood pressure treatment
target range
Office SBP treatment target ranges (mmHg)
Age group
18—65 years
65-79 years
2 80 years
DBP treatment
target range
(mmHg)
Hypertension
Diabetes
Target to 130 Target to 130
+ CKD
+ CAD
+ Stroke/
TIA
Target to Target to 130Target to 130
or lower if
tolerated
Not <120
Target to
<140 to 130
if tolerated
Target to
€140 to 130
if tolerated
< 80 to 70
or lower if
tolerated
Not <120
Target to
<140 to 130
if tolerated
Target to
<140 to 130
if tolerated
<80t070
<140 to 130
if tolerated
Target to
<140 to 130
if tolerated
Target to
€140 to 130
if tolerated
< 80 to 70
or lower if
tolerated
Not <120
Target to
<140 to 130
if tolerated
Target to
<140 to 130
if tolerated
< 80 to 70
or lower if
tolerated
Not <120
Target to
<140 to 130
if tolerated
Target to
€140 to 130
if tolerated
< 80 to 70
OESC
axon n SXi&
DBP
treatment
target
ra nge
(mmHg)
€80 to 70
€80 to 70
70
2018 EWES" GuiQEr.s for the management of arterial
European Heart (2018)
Journal Hypertension (2018)

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First line drugs: Diuretics especially thiazide  ACE Inhibitor & ARBs Calcium channel blockers Second  line  drugs B-Blockers  Alfa  2 blockers  Centrally acting drugs  alfa -methyl  dopa Direct vasodilators hydralazine,  minoxidil Other anti-adrenergic drugs reserpine,  guanithidine ,  alfa  1 blockers Others

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Core drug-treatment strategy
for uncomplicated hypertension and most patients
with HMOD, cerebrovascular disease, or PAD
1
Ipil
Initial therapy
Dual combination
step 2
Triple combination
step 3
Triple combination
• spironolactone
or other drug
ACEI or ARB + CCB or diuretic
ACEI or ARB + CCB + diuretic
Resistant hypertension
Add spironolactone (25-50 mg O.d.) or other
diuretic, alpha-blocker or beta-blocker
@ESC
Consider monotherapy in
low-risk grade 1 hypertension
or in very old (280vears)
or frailer patients
Consider referal to a specialist
centre for further investigation
Consider beta-blockers at any treatment step, when there is a
pecific indication for their use, e.g. heart failure, angina, post-MI,
atrial fibrillation, Or younger women with, Or planning pregnancy
21
Williams B. Mancia G et al. Eur Heart J (2018); dci:lO.
ams B, Marxia G et al. J Hypertens (2018);
• hypertension-mediated organ damage; PAD • peripheral arterial disease

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dose Trade name Generic name  Thiazide and thiazide like 25-50mg Hygertone Chlorothalidone 25-50 esidrex hydrochlorothazide 1.5mg natrilex Indapamide   Loop  diuretics 40-80 mg Lasix  Furosmide   5-20 mg Examide   Torsemide   K-retaining diuretics 25-100 mg Aldactone   Spironolactone 5 mg  Midamor   Amiloride

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Generic name  Trade name  Dose  Captopril  Capoten   25-150mg Enalapril   Ezapril   5-40  mg Lisinopril   Zestril  10-40 mg Ramipril   Tritace   2.5-10 mg Prindopril   Coversyl   5-10mg Fosinopril   Monopril   10-40 mg

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Generic  name  Trade name  Dose  Losartan  Cozaar   50-100 mg Valsartan  Tareg   80-320 mg Candisartan   Atacand   8-32mg Irbesartan   Approval  150-300mg

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Generic  name  Trade name  Dose  Nifidepine   Adalate  or epilate  10-40 mg Amlodopine   Norvasc  5-20 mg Verapamil   Isoptin   80-240 mg Deltiezem   Altiezem     120-240mg

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 ESC Hypertension Guidelines 2018  www.escardio.org ACC/AHA Hypertension guidelines 2017  www.acc,org  

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