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CV 5
mortality 4
risk
3
2
1
0
115/75 135/85 155/95 175/105
SBP/DBP (mm Hg)
–20
20%–30%
–40 30%–40% 30%–40%
–60
Can we do better?
–80
–100
CV=cardiovascular.
Neal B et al. Lancet. 2000;356:1955–1964.
BP Differences of 10 mmHg Are Associated With Up to a
40% Effect on CV Risk
–5 0 5 10 15 20 25
Difference (reference treatment minus experimental treatment) in Systolic BP (mmHg)
Greater differences in BP reduction mean greater reductions in the risk of cardiovascular mortality.
BP, blood pressure
Staessen JA et al. Hypertension Research. 2005;28:385-407.
Scope to be discussed
• Burden of illness high blood pressure
• Impact of reducing BP in hypertension
• Classification of high BP
• When to start antihypertensive treatment
• How to treat
• What the BP target acheived
Definition and Classification of Hypertension
Definition and classification of hypertension: JNC VII
3 or more risk Lifestyle Drug treatment Drug treatment Drug treatment Immediate drug
factors, target changes and lifestyle and lifestyle and lifestyle treatment and
changes changes changes lifestyle changes
organ damage, or
diabetes
Associated clinical Drug treatment Immediate drug Immediate drug Immediate drug Immediate drug
conditions and lifestyle treatment and treatment and treatment and treatment and
changes lifestyle lifestyle changes lifestyle changes lifestyle changes
changes
* Risk of developing a major cardiovascular event (fatal and nonfatal stroke, and
myocardial infarction)
SBP, systolic blood pressure 2003 WHO/ISH statement on hypertension. J Hypertens 2003;21:1983-1992
Scope to be discussed
• Burden of illness high blood pressure
• Impact of reducing BP in hypertension
• Classification of high BP
• When to start antihypertensive treatment
• What the BP target acheived
• How to treat
Treatment guidelines
Consider:
Untreated BP level
Presence or absence of TOD and risk factors
Choose between:
BP, blood pressure; TOD, target organ damage ESH/ESC Guidelines 2003. J Hypertens 2003;21:1011-1053
Choice of antihypertensive therapy:
ESH/ESC 2003
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
SBP, systolic blood pressure; DBP, diastolic blood pressure; ACE-I,
angiotensin-converting enzyme inhibitor; ARB, angiotensin II JNC VII. JAMA 2003;289:2560-2572
receptor blocker; BB, beta-blocker; CCB, calcium-channel blocker
Algorithm of HT Treatment (ACC/AHA)
Hypertension treatment strategy: WHO/ISH 2003
Step 1 A or B C or D
Step 2 A (or B) + C or D
Step 3
A + C + D
Step 4
Resistant Add: either alpha-blocker or spironolactone or other diuretic
hypertension
“2007 Guidelines for the management of hypertension” J Hypertens. 2007;25:1105–1187.J Hypertens. 2009;27:2121-2158.
History of antihypertensive drugs
• Diuretics
– Inhibit the reabsorption of salts and water from kidney
tubules into the bloodstream
• Calcium-channel antagonists
– Inhibit influx of calcium into cardiac and smooth muscle
• Beta-blockers
– Inhibit stimulation of beta-adrenergic receptors
• Angiotensin-converting enzyme (ACE) inhibitors
– Inhibit formation of angiotensin II
• Angiotensin II receptor blockers (ARBs)
– Inhibit binding of angiotensin II to type 1 angiotensin II
receptors
Comparisons to Other Guidelines
BP Goal JNC-7 JNC-8 ASH/ISH ESC/ESH CHEP
Diabetes ACEI, ARB, CCB, ACEI, ARB, ACEI, ARB ACEI, ARB,
CCB, BB, thiazide CCB, CCB,
thiazide thiazide thiazide
CKD ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
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