INDIVIDUALISED THERAPY FOR HYPERTENSION

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Individualized Therapy for Hypertension
Introduction to Primary Care a course of the
Center of Post Graduate Studies in FM
PO Box 27121 Riyadh 11417 Tel [phone] Fax
4970847
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Objectives

• To describe the "stepwise approach" to therapy.
• To discuss
• 1. The evidence for the role of lifestyle
  changes
• 2. The indications, contraindications and
  side effects of various antihypertensive classes

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Important Messages for the Management of
Hypertension

• Prompt diagnosis
• Assess the risk
• Achieve target levels of BP
• Lifestyle
• Combination therapy
• Promote adherence

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Treat Hypertension in the Context of Overall
Cardiovascular Risk
1. Global cardiovascular risk should be
assessed. 2. In the absence of data to determine
the accuracy of risk calculations, avoid using
absolute levels of risk to support treatment
decisions at specific risk thresholds. 3. Shared
decision-making may improve the effectiveness of
preventive health interventions.
Counting risk factors underestimates the risk
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Threshold for Initiation of Treatment and Target
Values
Condition Initiation
SBP / DBP mmHg
Diastolic systolic hypertension ? 140/90
Isolated systolic hypertension SBP or gt160
Diabetes ? 130/80
Renal disease (? 130/80)
Proteinuria gt1 g/day (? 125/75)
Target
SBP / DBP mmHg
lt140/90
lt140
lt130/80
lt130/80
lt125/75
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management of hypertension
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Lifestyle Recommendations
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Lifestyle
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Indications for Pharmacotherapy

• Strongly consider prescription if
• Average DBP equal or over 90 mmHg
• Hypertensive Target-organ damage (or CVD)
• Independent cardiovascular risk factors
• Elevated systolic BP
• Cigarette smoking
• Abnormal lipid profile
• Strong family history of premature CV disease
• Truncal obesity
• Sedentary Lifestyle

• Average DBP equal or over 80 mmHg in a patient
  with diabetes

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Choice of Pharmacological Treatment
Associated risk factors? or Target organ
damage/complications? or Concomitant
diseases/conditions?
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Treatment of Adults with Systolic-Diastolic
Hypertension without Other Compelling Indications
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monotherapy
TARGET lt140 mm Hg systolic and lt 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Beta-blocker
Long-acting CCB
Thiazide
No longer preferred as routine initial therapy
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Combination Therapy
If partial response to monotherapy
If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
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Summary
Not indicated as first line therapy over 60
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Useful Dual Combinations
For additive hypotensive effect in dual therapy
Combine an agent from Column 1 with any in
Column 2
Column 1 Column 2
Thiazide diuretic Long-acting calcium channel blocker Beta adrenergic blocker ACE Inhibitor ARB
Caution should be exercised when using a non
DHP-CCB and a beta-blocker (ACEAngiotensin
Converting Enzyme, ARBAngiotension Receptor
Blocker)
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Useful Triple Therapy Combinations
For additive hypotensive effect in triple therapy
Combine 2 agents from one Column with any in the
other Column
Column 1 Column 2
Thiazide diuretic Long-acting calcium channel blocker Beta adrenergic blocker ACE Inhibitor ARB
Caution should be exercised when using a non
DHP-CCB and a beta-blocker
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Specific drugs for specific patients
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Multiple Antihypertensive Agents Are Needed to
Achieve Target BP
Number of antihypertensive agents
Target BP (mm Hg)
Trial
1
2
3
4
DBP, diastolic blood pressure MAP, mean arterial
pressure SBP, systolic blood pressure. Bakris
GL et al. Am J Kidney Dis. 200036646-661. Lewis
EJ et al. N Engl J Med. 2001345851-860. Cushman
WC et al. J Clin Hypertens. 20024393-405.
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pharmacological treatment for hypertensive
patients with other compelling indications
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• Individualized treatment
• Compelling indications
• Smoking
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment
  Elevation-MI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
• Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
• Global Vascular Protection for Hypertensive
  Patients
• Statins
• Aspirin

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According to JNC7
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Treatment for Isolated Systolic Hypertension
without Other Compelling Indications
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Treatment Algorithm
TARGET lt140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
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Summary
TARGET lt140 mmHg Systolic BP
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting DHP CCB
Dual combination

• CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?

If blood pressure is still not controlled, or
there are adverse effects, other classes of
antihypertensive drugs may be combined (such as
alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
Triple or Quadruple combination
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Important Points (JNC7)

• Thiazide - type diuretics should be initial drug
  therapy for most, either alone or combined with
  other drug classes.
• Certain high-risk conditions are compelling
  indications for other drug classes.
• Most patients will require two or more
  antihypertensive drugs to achieve goal BP.
• If BP is gt20/10 mmHg above goal, initiate therapy
  with two agents, one usually should be a
  thiazide-type diuretic.

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Important Points (JNC7)

• The most effective therapy prescribed by the
  careful clinician will control HTN only if
  patients are motivated.
• Motivation improves when patients have positive
  experiences with, and trust in, the clinician.
• Empathy builds trust and is a potent motivator.
• The responsible physicians judgment remains
  paramount.

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According to JNC7
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Hypertension and CVD risk

• CVD risk has now replaced CHD risk (to include
  strokes)
• The current CVD risk threshold is gt20 over 10
  years (equivalent to CHD risk of 15)
• Current advice from the BHS is to prescribe a
  statin in all patients with hypertension and a
  CVD risk of 20 or greater.
• Unless contra-indicated low dose aspirin should
  be considered in patients over 50 with a CVD risk
  of gt20 when the blood pressure is controlled.
• CVD risk has implications regarding levels to
  treat.

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When to refer?

• Specialist referral is indicated if there is a
  possible underlying cause or presenting as
• sudden onset
• worsening of hypertension
• resistance to multi-drug regimen three or more
  drugs
• Hypertension diagnosed in young age ( lt 35
  years)
• persistent noncompliance

Saudi Hypertension Management Guidelines 2007
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