Hypertension Update 2014 :When to begin treatment, How low to aim for, and Which antihypertensive medications to use.

2. I am a gentle killer All over the world,
I am called HYPERTENSION
World Hypertension Day,
annually celebrated on May 17th

3. Statement of Need
Please write down your answer to the following:
“My greatest challenge as a doctor in the
management of patients with hypertension
is……………”
When to begin treatment,
How low to aim for, and
Which antihypertensive medications to use.

4. Evidence-Based Cardiology Consult

5. Highest LOE Lowest LOE
Levels Of Evidence Pyramid

9. Nov 2013
oct 2011 oct 2013
2013 2012 2010

10. JuN 2013
Dec 2013
Dec 2013

12. Definitions and classification of office BP levels (mmHg)
Category Systolic Diastolic
Optimal <120 and 80>
Normal 120-129 and/or 84–80
High normal 130-139 and/or 89–85
Grade 1 hypertension 140-159 and/or 90-99
Grade 2 hypertension 160-179 and/or 100-109
Grade 3 hypertension 180≤ and/or 110≤
Isolated systolic
hypertension
140≤ and 90>
The blood pressure (BP) category is defined by the highest level of BP, whether
systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3
according to systolic BP values in the ranges indicated

14. Risk FactoRs
• Male sex
• Age (men ≥55 years; women ≥65
years)
• Smoking
• Dyslipidaemia
TC > 190 mg/dL, and/or
LDL >115 mg/dL, and/or
HDL: men <40 mg/dL, women < 46
mg/dL, and/or
Triglycerides >150 mg/dL
• Fasting plasma glucose 102–
125 mg/dL
• Abnormal glucose tolerance
test
• Obesity [BMI ≥30 kg/m²
(height²)]
• Abdominal obesity
(waist circumference: men ≥102
cm;women ≥88 cm)
• Family history of premature
CVD (men aged <55 years;
women aged <65 years)

15. asymptomatic oRgan
damage
• Pulse pressure (in the
elderly) ≥60 mmHg
• ECG :LVH (Sokolow–Lyon
index >3.5 mV;RaVL >1.1 mV;
Cornell voltage duration
product >244 mV x ms), or
• Echo: LVH [LVM index: men
>115 g/m²;women >95 g/m²
(BSA)]
• Carotid wall thickening (IMT
>0.9 mm) or plaque
• Carotid–femoral PWV >10 m/s
• Ankle-brachial index <0.9
• CKD with eGFR 30–60
ml/min/1.73 m² (BSA)
• Microalbuminuria (30–300
mg/24 h), or albumin–
creatinine ratio 30–300 mg/g;
(preferentially on morning spot
urine)

16. diabetes mellitus
• Fasting plasma glucose ≥126 mg/dL on two
repeated measurements, and/or
• HbA1c >7% , and/or
• Post-load plasma glucose >198 mg/dL

17. established cV
or Renal disease
• Cerebrovascular disease: stroke; TIA
• CHD:MI; angina; revascularization with PCI or CABG
• HF, including HF with preserved EF
• Symptomatic lower extremities PAD
• CKD with eGFR <30 mL/min/1.73m²(BSA);
proteinuria (>300 mg/24 h).
• Advanced retinopathy: haemorrhages or exudates,
papilledema

18. (Blood Pressure (mmHg
High normal
SBP 130–139
or DBP 85–89
Grade 1 HT
SBP 140–159
or DBP 90–99
Grade 2 HT
SBP 160–179
or DBP 100–109
Grade 3 HT
SBP ≥180
or DBP ≥110
,Other risk factors
asymptomatic organ
damage or disease
No other RF
RF 1-2
RF 3≤
OD, CKD stage 3 or
diabetes
,Symptomatic CVD
CKD stage ≥4 or
diabetes with OD/RFs
Total CV RISK
BP = blood 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

19. High risk
Moderate risk
Low risk

20. Stratification of total CV risk in categories of low, moderate, high and very high
risk according to SBP and DBP and prevalence of RFs , asymptomatic OD , diabetes ,
CKD stage or symptomatic CVD.

21. Initiation of lifestyle changes and antihypertensive drug treatment.
Targets of treatment are also indicated(<140/90).
(in patients with diabetes, the optimal DBP target is between 80 and 85 mmHg.)

22. (Blood Pressure (mmHg
High normal
SBP 130–139
or DBP 85–89
Grade 1 HT
SBP 140–159
or DBP 90–99
Grade 2 HT
SBP 160–179
or DBP 100–109
Grade 3 HT
SBP ≥180
or DBP ≥110
,Other risk factors
asymptomatic organ
damage
or disease
No other RF
RF 1-2
RF 3≤
OD, CKD stage 3 or
diabetes
,Symptomatic CVD
CKD stage ≥4 or
diabetes with OD/RFs
Compelling indications
No Compelling indications

23. Any Body Can Dance 2
2014 Any Body Can Dance
2013
Any Body Can Dance
A B C D

24. The A,B,C,D drug classes

25. AA B C DD
Choice of drug treatment
No suggestion, all 5 classes
No ranking or classification of preferred
drugs
Diuretics (thiazides,chlorthalidone and
indapamide), beta-blockers,calcium antagonists,
ACE inhibitors, and ARBs are all suitable and
recommended for the initiation and maintenance of
antihypertensive treatment, either as monotherapy or
in some combinations with each other

26. Possible combinations of classes of
antihypertensive drugs
DD
AA
Green continuous lines: preferred combinations;
green dashed line: useful combination (with some limitations);
black dashed lines: possible but less well-tested combinations;
red continuous line: not recommended combination.
AA
C
B

28. The Joint National Committee (JNC )

29. This JNC 8 guideline has not redefined high BP,
and considers the 140/90 mm Hg definition from
JNC 7 reasonable.
Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 < 80
Pre – hypertension 120-139 80-90
Hypertension
Stage 1 140 – 159 90 – 99
Stage 2 160 and above 100 and above

30. Hypertension
Heart Failure
Coronary Heart Disease
Diabetes
Chronic Kidney
Disease

31. JNC 7 Compelling Indications
† ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker;Aldo
ANT, aldosterone antagonist; BB, beta-blocker; CCB, calcium channel blocker.

32. Compelling Indicator: Heart Failure
ACE-I (or ARB) is indicated in nearly all patients
with LV systolic dysfunction.
ACE-I (or ARB) should be titrated to target HF doses,
even if BP is low, as long as the patient does not
become symptomatic or develop impaired renal
perfusion.
Beta Blockers in nearly all patients with LV
systolic dysfunction .Titrate to target HF doses.
Consider spironolactone after the patient is placed on the maximum
doses of ACE-I and beta-blocker,especially if Class III or IV
Diuretics (usually loop) are often required
for fluid management

33. Compelling Indicator : Chronic Kidney Disease
ACE-I and ARB’s can slow
progression of kidney disease.
A limited increase in serum creatinine of as much
as 30% above baseline with ACE-I or ARB is
acceptable and not a reason to withhold
treatment, unless hyperkalemia develops.
A limited increase in serum creatinine of as much
as 30% above baseline with ACE-I or ARB is
acceptable and not a reason to withhold
treatment, unless hyperkalemia develops.
In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²)
higher doses of loop diuretics may be needed in
combination with other drug classes.
In CKD stages 4 and 5 (eGFR<30 mL/min/per 1.73m²)
higher doses of loop diuretics may be needed in
combination with other drug classes.

34. Stages of Chronic Kidney Disease
Two Screening Tests
•eGFR
•ACR
–Albumin/
Creatinine ratio

36. Questions guiding the JNC 8 review
This hypertension guideline focuses on 3 questions related to high blood pressure (BP) management.
They address thresholds, goals for pharmacologic treatment, and whether particular
antihypertensive drugs or drug classes improve important health outcomes compared to others.
1.In adults with hypertension, does initiating antihypertensive pharmacologic
therapy at specific BP thresholds improve health outcomes?
2.In adults with hypertension, does treatment with antihypertensive
pharmacologic therapy to a specified BP goal lead to improvements in health
outcomes?
3.In adults with hypertension, do various antihypertensive drugs or drug classes
differ in comparative benefits and harms on specific health outcomes?
 The answers to these three questions are reflected in 9 recommendations

37. Recommendations
Recommendation 1
(Strong recommendation)
General population
≥60 years
Recommendation 2
(Strong recommendation)
Recommendation 3
(Expert opinion)
BP thresholds Goals
SBP ≥150 mm Hg
or DBP ≥90 mm Hg
SBP <150 mm Hg
and DBP <90 mm Hg
General population
<60 years DBP ≥90 mm Hg DBP <90 mm Hg
General population
<60 years SBP ≥140 mm Hg SBP <140 mm Hg

38. Recommendations
Recommendation 4
(Expert opinion)
Population with CKD
≥18 years
Recommendation 5
(Expert opinion)
Recommendation 6
(Moderate recommendation)
BP thresholds Goals
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
Population with diabetes
≥18 years
SBP ≥140 mm Hg
or DBP ≥90 mm Hg
SBP <140 mm Hg
and DBP <90 mm Hg
General nonblack
population ( ± diabetes )
Initial treatment
AA or
CC or DD

39. Recommendations
Recommendation 7
(Moderate recommendation)
Initial treatments
General ( ± diabetes )
black population or
Recommendation 8
(Moderate recommendation)
Population with CKD
≥18 years(irrespective of
race or diabetes)
Recommendation 9
(Expert opinion)
Goal BP not reached
within a month of treatment
C DD
Initial or add-on treatments
AA
Non control strategies
Increase the dose of the initial drug,
or add a second drug (from the list provided)
Goal BP not reached
with 2 drugs
Black CD
Add and titrate a third drug (from the list provided)
Do not use an ACEI and an ARB together in the same patient

40. DM CKD
C DD AA
BB
AA C DD
Alone or in combination
Alone or in
combination with
other drug class

41. Major changes from JNC 7
 Focus on evidence based recommendations
 Higher target SBP for patients over 60 y/o
Limited data to support either 150 or 140 mmHg
 Removed special lower target BP
for those with CKD or DM
 Liberalized initial drug choices
AA C DD

42. JNC 8 :Relaxing blood pressure goals
Higher real-world blood pressures
This is akin to the “speed limit rule”—
people are more likely to hover above target,no matter
what the target is.

43. Recommendation in patients with grade I hypertension
(BP 140–159 mm Hg systolic or 90–99 mm Hg diastolic)
ESH/ESC BP-lowering drugs recommended when total
cardiovascular risk is high because of organ
damage, diabetes, cardiovascular
disease, or chronic kidney disease
JNC 8 BP-lowering drugs recommended to lower BP
<140 mm Hg systolic and 90 mm Hg diastolic in
patients aged <60 years ,and <150 mm Hg systolic
and 90 mm Hg diastolic in patients aged >60 years

44. Guidelines are meant to “guide”
and not to “mandate”

45. One Size Does Not Fit All.
New hypertension
New hypertension
guidelines:
guidelines:
One size fits most?
One size fits most?
?

46. Lower your risk
Lower your number

47. Population ,Goal BP
mm Hg
Initial Drug Treatment Options
General nonelderly 140/90>
General elderly <80 y
General ≥80 y 150/90>
Diabetes 140/85>
CKD 140/90>
CKD + proteinuria 130/90>
General <60 y 140/90> Nonblack
Black
General ≥60 y 150/90>
Diabetes 140/90>
CKD 140/90
ESH/ESC
JNC 8
AA B C DD
AA
AA C DD
C DD
AA C DD
AA

48. The JNC 8 : Nine recommendations

49. AA
C
Initial Drug Choices
DD
AA
B
C
DD
Replaces
As first line drug 2013
”ESH/ESC“
JNC 8 “ 2014
”
Beta-blockers Yes (No (Step 4

50. Possible combinations of ABCD classes
DD
AA C
B
ß-blocker should be
included in the
regimen if there a
compelling indication
for a ß-blocker
Angina Pectoris
Post-MI
Heart Failure
Atrial Fib.
Aortic Aneurysm