Look ! Is it necessary to discuss HTN ?

Is it necessary to take medication regularly if I am not having any symptoms?Yes Sir, = you must take .Hypertension is a silent killer.Left untreated cause multiple organ damage.

Begins at 115/75 mmHg, CVD risk X2 for each ↑ of 20/10 mmHg.

Is it necessary to take medication regularly if I am not having any symptoms?Yes Sir, = you must take .Hypertension is a silent killer.Left untreated cause multiple organ damage.

Begins at 115/75 mmHg, CVD risk X2 for each ↑ of 20/10 mmHg.

Each 2 mmHg rise in SBP is associated with increased risk of mortality:- 7% from heart disease - 10% from stroke.

•BP OF 140/90 MM HG OR MORE .

•EPIDEMIOLOGIC DATA SHOWING CONTINUOUS POSITIVE RELATIONSHIPS BETWEEN THE RISK OF CAD AND STROKE DEATHS WITH BP VALUES AS LOW AS 115/75 MM HG

•THIS ARTIFICIAL DICHOTOMY BETWEEN “HYPERTENSION” AND “NORMOTENSION” CAN DELAY MEDICAL TREATMENT UNTIL VASCULAR HEALTH HAS BEEN IRREVERSIBLY COMPROMISED .

• FOR CERTAIN HIGH-RISK PATIENTS, TREATMENT THRESHOLD HAS BEEN LOWERED TO 130/80 MM HG .

•BP OF 140/90 MM HG OR MORE .

•EPIDEMIOLOGIC DATA SHOWING CONTINUOUS POSITIVE RELATIONSHIPS BETWEEN THE RISK OF CAD AND STROKE DEATHS WITH BP VALUES AS LOW AS 115/75 MM HG

•THIS ARTIFICIAL DICHOTOMY BETWEEN “HYPERTENSION” AND “NORMOTENSION” CAN DELAY MEDICAL TREATMENT UNTIL VASCULAR HEALTH HAS BEEN IRREVERSIBLY COMPROMISED .

• FOR CERTAIN HIGH-RISK PATIENTS, TREATMENT THRESHOLD HAS BEEN LOWERED TO 130/80 MM HG .

Definition

JNC-7: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The Guidelines,2003

JNC-7: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure The Guidelines,2003

JNC6: published 1997JNC 5: published 1992JNC 4: published 1988JNC 3: published 1984JNC 2: published 1980JNC 1: published 1976

JNCNICE GuidelineCanadian GuidelineATP Guideline

Where to start? What are the guides?

What is latest?

NICE GUIDELINES 2011 UPDATE

ForewordForeword

PreventionDetection, Evaluation Treatment DASH Eating Plan Your Guide to Lowering High Blood Pressure Reference Card from the JNC 7 for clinicians; Blood Pressure Wallet Card for patients; Palm application of the JNC 7 recommendations.

Busy Clinician’s job became easy.Busy Clinician’s job became easy.

JNC -7 GUIDELINES

Clips from JNC-7

66 chapters31 tables17 figures

66 chapters31 tables17 figures

age >50yrs, SBP >140 mmHg is a more important CVD risk than DBP.Begins at 115/75 mmHg, CVD risk X2 for each ↑ of 20/10 mmHg.Normotensive at 55 years of age-90% lifetime risk of developing HTN.Prehypertensive indiv.-BP=120-139/80-89mmHg→LSM.Uncomplicated hypertension-Thiazide diuretic alone/ combined with drugs.Compelling indications Goal in BP ↓: essential <140/90 mmHg and <130/80 mmHg for patients with diabetes and chronic kidney disease. BP is >20 mmHg above the SBP goal or 10 mmHg above the DBP goal, initiation of therapy using two agents, 1st thiazide then ……..other class.Motivation to stay on their treatment plan. Positive experiences, trust & empathy → patient motivation and satisfaction. Physician’s judgment remains paramount

age >50yrs, SBP >140 mmHg is a more important CVD risk than DBP.Begins at 115/75 mmHg, CVD risk X2 for each ↑ of 20/10 mmHg.Normotensive at 55 years of age-90% lifetime risk of developing HTN.Prehypertensive indiv.-BP=120-139/80-89mmHg→LSM.Uncomplicated hypertension-Thiazide diuretic alone/ combined with drugs.Compelling indications Goal in BP ↓: essential <140/90 mmHg and <130/80 mmHg for patients with diabetes and chronic kidney disease. BP is >20 mmHg above the SBP goal or 10 mmHg above the DBP goal, initiation of therapy using two agents, 1st thiazide then ……..other class.Motivation to stay on their treatment plan. Positive experiences, trust & empathy → patient motivation and satisfaction. Physician’s judgment remains paramount

JNC-7 only a guide

ALLHAT TRIAL IS THE BASIS FOR JNC-7

SALIENT FEATURES

ALLHAT TRIAL:

Implications• Diuretics should be the drug of choice for first step

therapy

• For the patient who cannot take a diuretic CCB’s and ACEI’s may be considered.

• Most patients require more than one drug. Diuretics should generally be part of the antihypertensive regimen.

• Lifestyle advice should also be provided.

• Diuretics should be the drug of choice for first step therapy

• For the patient who cannot take a diuretic CCB’s and ACEI’s may be considered.

• Most patients require more than one drug. Diuretics should generally be part of the antihypertensive regimen.

• Lifestyle advice should also be provided.

ALLHAT

JNC -7 GUIDELINES

SELECTIVE ANTIHYPERTENSIVE THERAPY FOR WOMEN?

• No evidence to suggest that women respond differently to antihypertensive therapy than men

• Diuretics may be particularly useful• Adverse effects are more troublesome

– ACE inhibitor cough 3 times more common– Dihydropyridine CCB edema more common– Hirsutism with minoxidil intolerable

• Treatment outcomes are probably similar

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

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

ACTUAL SHOW BEGINS NOW