Hypertension guideline by Munchukorn

1. Management in
Hypertension
Munchukorn Leelatanon, MD

2. Contents
Lifestyle interventions
Criteria for starting antihypertensive drug
treatment
Blood pressure targets
Patients education and adherence to drug
treatment

3. Reference

4. Lifestyle interventions
 Weight reduction
 Diet and exercise
 Relaxation
 Reduce alcohol
consumption and stop
smoking
 Discourage excessive
consumption of caffeine
 Low sodium diet

5. Weight reduction
Weight circumference
 Men < 90 cm
 Women < 80 cm
BMI 22.5 – 25 kg/m2
Orlistat
Bariatic surgery

6. Diet control
Mediterranean diet
DASH diet

7. Low salt diet
< 2,300 mg/day
 NaCl <6g/day

8. Moderate alcohol
consumption
Men 2 drink (20-30g/day)
Women 1 drink (10-20g/day)

9. Stop smoking
Nicotine replacement therapy
Bupropion
Varenicline
​​Motivational interview

10. Exercise
Preventing cardiovascular
disease
50-70%
max HR
70-85%
max HR
Maximum HR = 220 - age

11. Effectiveness of lifestyle
modification

12. Criteria for starting antihypertensive
drug treatment
JNC 8
 Age ≥ 60 years
 BP ≥ 150/90 mmHg
 Age < 60 years
 BP ≥ 140/90 mmHg
 Diabetes
 BP ≥ 140/90 mmHg
 CKD
 BP ≥ 140/90 mmHg

13. SBP ≥ 160 mmHg or
DBP ≥100 mmHg

15. Criteria for starting antihypertensive
drug treatment
NICE guideline
 Age < 80 years old with stage 1 HT with
 target organ damage
 established cardiovascular disease
 renal disease
 Diabetes
 10-year cardiovascular risk equivalent to 20% or
greater.
 Any age with stage 2 HT
BP ≥ 140/90 at clinic
Or
BP ≥ 135/85 at home
BP ≥ 160/100 at clinic
Or
BP ≥ 150/95 at home

16. Choosing antihypertensive
drug treatment
Offer drugs taken only once a day
Prescribe non-proprietary drugs where these are
appropriate and minimise cost.
Do not combine ACEI and ARB

17. Treatment steps
for hypertension
1

18. SBP >160 mmHg
and/or
DBP >100 mmHg

19. 2
3
4

21. Treatment steps
for hypertension
Beta-blockers may be
considered in younger people :
•intolerance or contraindication
to ACEI and ARB or
•women of child-bearing potential
or
•increased sympathetic drive

22. If a CCB is not suitable
•Edema
•intolerance
•evidence of heart failure
•high risk of heart failure
offer a thiazide-like diuretic.
(Chlortalidone or indapamide)

23. If a CCB is not suitable
•offer a thiazide-like diuretic.
(Chlortalidone or indapamide)
For black people of African or
Caribbean family origin,
•ARB in preference to an ACE
inhibitor in combination with CCB
If initiated with a beta-blocker
and a second drug is required
•CCB is better than a thiazide-like
diuretic to reduce risk of
developing diabetes

24. If clinic BP > 140/90 mmHg after
optimal or best tolerated doses of
an
•ACE inhibitor or an ARB plus a
•CCB plus a
•diuretic
Resistant HT
•consider adding a fourth
antihypertensive drug and/or
seeking expert advice.

25. If serum K ≤ 4.5 mmol/l
•low-dose spironolactone (25
mg once daily)
If serum K > 4.5 mmol/l
•higher-dose thiazide-like
diuretic
If further diuretic therapy is not
tolerated, or is contraindicated
or ineffective,
•consider an alpha- or beta-
blocker.
Monitor
•serum Na
•Serum K
•renal function
within 1 month
& repeat as
required
thereafter.

28. Blood pressure targets
< 80 years
 Clinic BP < 140/90 mmHg
 Home BP < 135/85 mmHg
≥ 80 years
 Clinic BP < 150/90 mmHg
 Home BP < 145/85 mmHg
JNC 8 (2014)
< 60 years
 BP < 140/90 mmHg
≥ 60 years
 BP < 150/90 mmHg

30. Antihypertensive drugs
 Beta-blockers
 Diuretics
 Calcium antagonists
 Angiotensin-converting enzyme inhibitors
 Angiotensin receptor blockers
 Renin inhibitors
 Alpha blockers
 Vasodilators

31. RE Jackson, MC Bellamy, antihypertensive drugs, BJA education, 14 January 2015
http://bjaed.oxfordjournals.org/content/early/2015/06/03/bjaceaccp.mku061

32. Calcium channel blocker

35. Renin inhibitors
ACE
inhibitors
ARB
Aldosterone
antagonists
SE: hyperkalemia, hypotension

36. http://my-lifespan.com/coverex.html

37. Renin inhibitors
 Aliskiren
 Great use if combine with
HCTZ or ARB
Cough, Angioedema

39. Diuretics
Furosemide
Bumetanide
Thiazide
-- HCTZ
Thiazide like
-- Indapamide
-- Chlortalidone
Epithelial sodium
channel blockers
-- Amiloride
-- Triamterene
Aldosterone
antagonist
-- Spinorolactone
-- Eplerenone

40. Thiazide VS thiazide like diuretics
Rik H.G. Olde E, Wijnanda JF, Bas VB, Lizzy MB, Liffert V, Bert-JH. Effects of Thiazide-Type and Thiazide-Like Diuretics
on Cardiovascular Events and Mortality, American Heart Association,2015.
TL diuretics resulted in a 12% additional risk reduction for cardiovascular
events (P=0.049) and a 21% additional risk reduction for heart failure
(P=0.023) when compared with TT diuretics.

41. Beta-blockers

42. Alpha blockers
 Doxazosin
 Prazosin
 Terazosin

43. Vasodilators
 Hydralazine
 Minoxidil
 Sodium nitroprusside

49. Contraindications

51. White coat hypertension
Without additional risk factors
 Lifestyle changes only + close F/U
With a higher CV risk because of metabolic
derangements or asymptomatic OD
 drug treatment + addition to lifestyle changes

52. Masked hypertension
Lifestyle modification + antihypertensive drug
treatment

53. Isolated systolic hypertension
Start with diuretics or DHP or CCB

54. Elderly
 Patients with SBP ≥160 mmHg
 Reduce SBP to 140 – 150 mmHg
 In fit elderly patients <80 years old
 Start drug at SBP values ≥140 mmHg
 Target SBP <140 mmHg if treatment is well tolerated.
 All hypertensive agents are recommended and
can be used in the elderly,
 Diuretics and CCB may be preferred in isolated
systolic hypertension.

55. Diabetes
Start drug treatment when SBP is ≥140 mmHg.
SBP goal <140 mmHg
DBP goal <85 mmHg.
All classes of antihypertensive agents are
recommended
RAS blockers may be preferred, especially in the
presence of proteinuria or microalbuminuria.

56. CKD
Lowering SBP to <140 mmHg
If overt proteinuria is present, SBP values <130
mmHg
RAS blockers are more effective in reducing
albuminuria than other antihypertensive agents
Combination of two RAS blockers is not
recommended
Aldosterone antagonists is not recommended

57. Stroke or TIA
Don’t start drug in first week after acute stroke
 Clinical judgement should be used in very high SBP
Start drug treatment even SBP is in the 140–159
mmHg
SBP goal of <140 mmHg ]
Drug of choice : ACE inhibitors, diuretics

58. Coronary heart disease
SBP goal <140 mmHg
Recent myocardial infarction beta-blockers are
recommended
Diuretics, beta-blockers, ACE inhibitors,
angiotensin receptor blockers, and/or
mineralocorticoid receptor antagonists are
recommended in patients with heart failure or
severe LV dysfunction to reduce mortality and
hospitalization.

59. Resistant hypertension
 Resistance to treatment when lifestyle modification + 3
antihypertensive drugs (include diuretics) fail to reach
goal of SBP < 140 mmHg, DBP < 90 mmHg
 Consider stopping all current drugs and restart with a
simpler treatment regimen under close medical
supervision
 Mineralocorticoid receptor antagonists (amiloride) and
alpha-1-blocker (doxazosin) should be considered
 Invasive procedures
 renal denervation and
 baroreceptor stimulation

60. Renovascular hypertension
RAS blockers cannot be used in bilateral renal
artery stenosis or in unilateral artery stenosis with
evidence of functional importance by
ultrasound examinations or scintigraphy.

61. Primary aldosteronism
the treatment of choice is unilateral
laparoscopic adrenalectomy
mineralocorticoid receptor antagonists is
indicated in patients with bilateral adrenal
disease (idiopathic adrenal hyperplasia and
bilateral adenoma

62. Pregnancy
 Start when BP ≥140/90 mmHg with
 Gestational hypertension (with or without proteinuria)
 Pre-existing hypertension with the superimposition of
gestational hypertension
 Hypertension with asymptomatic OD or symptoms at any time
during pregnancy
 Methyldopa, labetalol and nifedipine
 Beta-blockers and diuretics should be used with caution
 ACE inhibitors, ARBs, renin inhibitors are contraindated

63. JNC8
NICE
ESC