ALGORITHM IN HYPERTENSION

LUSIANI , MD

CARDIOVASCULAR DIVISION, INTERNAL MEDICINE DEPARTMENT

FACULTY OF MEDICINE, UNIVERSITY OF INDONESIA

PIT PDUI

Guidelines for Hypertension

NICEESH

ASH/ISHJNC 7, JNC 8

NICE Guideline 2011

Care pathway

CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg

Stage 2 hypertension

Consider specialist referral

Offer antihypertensive drug treatment

Offer lifestyle interventions

If younger than 40 years

If target organ damage present or 10-year cardiovascular risk > 20%

Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

Offer patient education and interventions to support adherence to treatment

CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg

Stage 1 hypertension

Heartscore.org

Step 4

Summary of antihypertensive drug treatment

Aged over 55 years or black person of African or Caribbean family origin of any age

Aged under

55 years

C2A

A + C2

A + C + D

Resistant hypertension

A + C + D + consider further diuretic3, 4 or alpha- or

beta-blocker5

Consider seeking expert advice

Step 1

Step 2

Step 3

KeyA – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic

10

European Society of Hypertension (ESH) 2013

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

CV Risk Stratification

2013 ESH/ESC Guidelines for the management of arterial hypertension

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

2013 ESH/ESC

Guidelines for the

management of

arterial hypertensi

on

2013 ESH/ESC Guidelines for

the management

of arterial hypertension.

Journal of Hypertension

2013, 31:1281–1357

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

Monotherapy vs Combination

Recommendations

SBP goal for “most”•Patients at low–moderate CV risk•Patients with diabetes•Consider with previous stroke or TIA•Consider with CHD•Consider with diabetic or non-diabetic CKD

<140 mmHg

SBP goal for elderly•Ages <80 years•Initial SBP ≥160 mmHg

140-150 mmHg

SBP goal for fit elderlyAged <80 years

<140 mmHg

SBP goal for elderly >80 years with SBP•≥160 mmHg

140-150 mmHg

DBP goal for “most” <90 mmHg

DB goal for patients with diabetes <85 mmHg

Blood pressure goals in hypertensive patients

2013 ESH/ESC Guidelines for the management of arterial hypertension. Journal of Hypertension 2013, 31:1281–1357

2013 ESH/ESC Guidelines for

the management

of arterial hypertension.

Journal of Hypertension

2013, 31:1281–1357

2013 ESH/ESC Guidelines for

the management

of arterial hypertension.

Journal of Hypertension

2013, 31:1281–1357

ASH / ISH 2013

Michael A. Weber, MD et al. Clinical Practice Guidelines for the Management of Hypertension in the CommunityA Statement by the American Society of Hypertension and the International Society of Hypertension. The Journal of Clinical Hypertension

Michael A. Weber, MD et al. Clinical Practice Guidelines for the Management of Hypertension in the CommunityA Statement by the American Society of Hypertension and the International Society of Hypertension. The Journal of Clinical Hypertension

Michael A. Weber, MD et al. Clinical Practice Guidelines for the Management of Hypertension in the CommunityA Statement by the American Society of Hypertension and the International Society of Hypertension. The Journal

of Clinical Hypertension

Michael A. Weber, MD et al. Clinical Practice Guidelines for the Management of Hypertension in the CommunityA

Statement by the American Society of Hypertension and the International Society

of Hypertension. The Journal of Clinical Hypertension

JNC 8 2013

Paul A. James, MD; Suzanne Oparil, MD; et al.2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). jama.2013.284427

Paul A. James, MD; Suzanne Oparil, MD; et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). jama.2013.284427

Paul A. James, MD; Suzanne Oparil, MD; et al.2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults, Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). jama.2013.284427

Prehypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg)

Not at Goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease)

With Compelling Indications

Prehypertension

Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg)

Thiazide-type diuretics for most; may consider ACEI, ARB, BB, CCB, or combination.

Stage 2 Hypertension (SBP 160 or DBP 100 mm Hg)

2-drug combinations for most(usually thiazide-type diuretics andACEI, or ARB, or BB, or CCB).

Drug(s) for compelling indications

Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB)as needed.

LIFESTYLE MODIFICATIONS

If not at goal BP, optimize dosages or add additional drugs until goal BP is achieved. Consider consultation with hypertension specialist.

Without Compelling Indications

JNC 7

Which guidelines should we use?

JNC VII vs JNC VIII

THANK YOU