Transcript management of hypertension - King Saud University Medical

MANAGEMENT
OF
HYPERTENSION
DR. HUSSEIN SAAD (MRCP)
A S S I S TA N T P R O F E S S O R
C O N S U LTA N T FA M I LY M E D I C I N E
COLLEGE OF MEDICINE
KING SAUD UNIVERSITY
EPIDEMIOLOGY
■ In developed and developing countries alike,
Essential Hypertension affects 25-35% of the adult
population. Up to 60-70% of those beyond the
seventh decade of life.
■ Each increment of 20 mm Hg in systolic blood
pressure or 10 mm Hg in diastolic blood
pressure doubles the risk of cardiovascular
disease events independent of other factors.
Prevalence of Hypertension in Obese and
non-Obese Saudis
The study group: 14.805
males: 6225
females: 8580
The age: 14 – 70 years
Non-obese prevalence: 4.8 %
2.8 %
Obese prevalence:
8%
8%
males
females
males
females
Mohsen A El-Hazmi, Saudi Medical Journal 2001; vol 22 (1): 44-48
Hypertension among attendants of primary health care
centers in Al-Qassim region
Saudi Arabia. Khalid A,et al Saudi Med J 2001; Vol. 22 (11) 960-963
The study sample: 1114
The prevalence: 30 %
Higher in: ● Age > 40 years
● Overweight and obese people
● illiteracy
Awareness: 20 % 0f hypertensive women
25 % of hypertensive men
EPIDEMIOLOGY
In the Framingham Heart Study:
◊ Those below
Age of 55 diastolic Bp is
the strongest predictor of cardiovascular risk
◊
Above 55 years, diastolic Bp was negatively
related to the risk of coronary events, so the
pulse pressure became superior predictor to
the systolic Bp.
What happens to blood pressure with aging?
• Systolic pressure increases with age
• Diastolic pressure increases with age but peaks between 55 and 60 years then
starts to decrease.
• Arterial stiffness: cause of elevated systolic and lower diastolic pressure
with aging
Systolic
95
Systolic pressure (mm Hg)
Diastolic pressure (mm Hg)
Diastolic
90
85
80
4
3
75
2
70
1
65
175
•
165
study
155
• Study
cohort with
deaths, myocardial
infarctions and
congestive heart
failures excluded
145
135
125
115
105
Age (y)
Age (y)
BP values over lifetime period in population studies
Franklin SS, Fustin W 4th, Wong ND, et al. Circulation. 1997;96:308-315.
Entire cohort
Pulse Pressure and Total Mortality
P<0.00001
45
40
event rate %
35
30
25
20
15
10
5
0
< 25
30
40
50
60
> 65
pulse pressure (mm Hg)
Mitchell, G.F. & Pfeffer, M.A., Curr Opin Cardiol 1999; 14: 361-9
Pulse Pressure and Coronary Risk
3.0
CHD hazard ratio
2.5
2.0
1.5
1.0
0,5
60
70
80
90
100
110
diastolic blood pressure (mm Hg)
Franklin, S.S. et al., Circulation 1999; 100: 354-60
Are we achieving adequate control
Up to 65% of Americans with hypertension do not
achieve adequate blood pressure control.
The World Health Organization now projects that by
2030, ischemic heart disease and stroke will become
the second and third leading causes of death
worldwide.
Trends in awareness, treatment, and
control of high BP in adults ages 18 -74
National Health and Nutrition Examination Survey, Percent
II
III (Phase 1 III (Phase 2
(1976- 80) 1988- 91)
1991- 94) 1999- 00
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
DIAGNOSIS
Two or more elevated
readings are obtained on at
least two visits over a period
of one to several weeks.
Blood Pressure Assessment:
Patient preparation and posture
Standardized technique:
Posture
The patient should be calmly
seated with his or her back well
supported and arm supported at
the level of the heart.
His or her feet should touch the
floor and legs should not be
crossed.
Definitions and classification of blood pressure
2007 guidelines for the management of arterial hypertension
The task force for the management of arterial hypertension of the
European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC)
S Y S TO L I C
OPTIMAL
<120
NORMAL
120–129
HIGH NORMAL
130–139
GRADE 1 HTN
140–159
GRADE 2 HTN
160–179
GRADE 3 HTN
180
And
And/or
And/or
And/or
And/or
And/or
D I A S TO L I C
<80
80–84
85–89
90–99
100–109
11 0
Dr. HUSSEIN SAAD
Definitions and classification of blood pressure
2007 guidelines for the management of arterial hypertension
The task force for the management of arterial hypertension of the
European Society of Hypertension (ESH) and of the European
Society of Cardiology (ESC)
I S O L AT E D S Y S T O L I C H T N
≥140
AND
S Y S TO L I C
G R A D E 1 I S O L AT E D H T N
G R A D E 2 I S O L AT E D H T N
G R A D E 3 I S O L AT E D H T N
140–159
160–179
180
<90
D I A S TO L I C
And
And
And
<90
<90
<90
Dr. HUSSEIN SAAD
Diagnosis
If the clinic blood pressure is 140/90 mmHg or
higher, offer ambulatory blood pressure
monitoring (ABPM) to confirm the diagnosis of
hypertension.
Diagnosis
When using the following to confirm diagnosis, ensure:
ABPM:
at least two measurements per hour during the person’s
usual waking hours, average of at least 14 measurements to
confirm diagnosis
HBPM:
two consecutive seated measurements, at least 1 minute
apart
blood pressure is recorded twice a day for at least 4 days and
preferably for a week
measurements on the first day are discarded
average value of all remaining is used.
Home measurement of blood pressure
Morning and Evening,
period.
for an initial 7-day
Which patients?
 For the diagnosis of hypertension
 Suspected non adherence
 White coat hypertension
 Masked hypertension
Average BP equal to or over 135/85
mmHg should be considered elevated
Suggested use of ABPM in the Management of
Hypertension
Office BP > 140/90 mmHg
in low risk patients (with no target-organ disease)
Perform ABPM
Mean awake BP
Less than 135/85 mmHg
Follow-up with periodic home-BP
measurement
Mean awake BP
equals or over 135/85 mmHg
Life style Modification
Initiate antihypertensive therapy
ABPM: Ambulatory Blood Pressure Monitoring BP: Blood
Pressure
Adapted from White W, NEJM 348:24, June 12, 2003
ABPM
Measurement
method
Threshold for Stage 1 Threshold for Stage 2
hypertension
hypertension
Clinic BP 140/90mmHg
Ambulatory BP
135/85mmHg
160/100mmHg
150/95mmHg
ABPM has to be considered:
 Suspected white coat hypertension
 Suspected episodic hypertension
 Hypertension resistant to increasing
medication
 Hypotensive symptoms while taking
antihypertensive medications
Blood Pressure Measurement
 Patients should be seated with back supported and arm
bared and supported.
 Measurements should begin after at least 5 minutes of
rest.
 Appropriate size of Cuff. Why?
Update in NICE 2011
Stage 1 hypertension:
 Clinic blood pressure (BP) is 140/90 mmHg or
higher and
 ABPM or HBPM average is 135/85 mmHg or higher.
Stage 2 hypertension:
 Clinic BP 160/100 mmHg is or higher and
 ABPM or HBPM daytime average is 150/95 mmHg
or higher.
Severe hypertension:
 Clinic BP is 180 mmHg or higher or
 Clinic diastolic BP is 110 mmHg or higher.
White-Coat Hypertension
is it Innocent?
 Raised clinic blood pressure in the presence of a normal
daytime ambulatory blood pressure.
 Results of Event-Based Studies have shown that the
risk of cardiovascular disease is lower in patients with
white-coat hypertension.
 Check for any Metabolic risk factor, if present you have
to start medication.
BENEFITS OF LOWERING BLOOD
PRESSURE
 The Clinical Trials had shown:
Reduction in • STROKE 35 – 40 %
• MI
20 – 25 %
• HEART FAILURE > 50%
Microvascular remodelling leads
to capillary rarefaction
Increase in wall
to lumen ratio
Normotensive
Decreased lumen
Functional
occlusion
Rarefaction
Endothelial dysfunction, Mechanical trauma,
Release of growth factors,
Proliferation of smooth muscle cells
Levy BI. J Hypertens. 2006;24(suppl 5):6-9.
HYPERTENSIVE
Risk Factors
 Smoking
 Dyslipidaemia
 Diabetes Mellitus
 Obesity
 Age older than 60 years
 Sex (men or postmenopausal women)
 F.H. of cardiovascular disease
How to approach a patient with
Hypertension ?
 Medical History
 Physical Examination
 Routine Laboratory Tests
 Optional Tests
 Non-Pharmacological
Treatment
 Drug Treatment
Patient Evaluation
Evaluation of patients with documented HTN has
three objectives:
1. Assess lifestyle and identify other CV risk factors
or concomitant disorders that affects prognosis
and guides treatment.
2. Reveal identifiable Causes of high BP.
3. Assess the presence or absence of Target Organ
Damage and CVD.
MEDICAL HISTORY
 Patient History of Cardiovascular
Disease
 Current and Previous Medications
 Smoking
 Lifestyle Factors
 Family History
PHYSICAL EXAMINATION
 Blood Pressure (Readings ?)
 Height, Weight and Pulse
 Exam. Of Neck, Heart, Lungs,
Abdomen and Extremities
 Funduscopic Examination
(Arterial narrowing “copper wiring”,
A-V nipping, Flame shaped haemorrhages,
Soft exudates, Papilloedema)
ROUTINE LAPORATORY TESTS
 CBC
 Urine Analysis and Microalbuminuria
 Urea , Creatinine, Electrolytes, Uric Acid
and Calcium
 Fasting Plasma Glucose
 Lipid Profile (T.ch, Trig, LDL and HDL)
 ECG
 Chest X-ray ??
Who should be screened for causes of secondary
hypertension?
Target Organ Damage
 Heart
Left ventricular hypertrophy
 Angina or prior myocardial infarction
 Heart failure
 Brain
 Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy

High/Very high risk subjects
► BP 180 mmHg systolic and/or 110 mmHg diastolic
► Systolic BP > 160 mmHg with low diastolic BP (<70
mmHg)
► Diabetes mellitus
► Metabolic syndrome
► ≥ 3 cardiovascular risk factors
High/Very high risk subjects
One or more of the following subclinical organ
damages:
► ECG with LVH and strain
► Echo. of concentric LVH
► U/S evidence of carotid artery wall thickening or
plaque
► Moderate increase in serum creatinine
► Reduced creatinine clearance
► Microalbuminuria or proteinuria
► Established cardiovascular or renal disease
OPTIONAL TESTS
 24-hour Urinary Protein
 Creatinine Clearance
 Echocardiography
 Ultrasonography
 Thyroid Stimulating Hormone
 24-hour Urinary Vanyl Mandelic Acid
 24-hour Urinary Catechleamines
 24-hour Urinary Free Hydrocortisol
What is the goal of management of
hypertension?
Treating (Non-Diabetic) SBP and DBP to targets
that are < 140 / 90 is associated with decrease
in CVD Complications.
Hansson et al, Principal results of the Hypertension Optimal treatment,
HOT Study Group, Lancet 1998; 351: 1755 – 62.
The Target for Blood pressure Control
 < 140/80 mmHg for people with diabetes .
 Limited data suggest possible worsening of
both renal and CVD outcomes if systolic blood
pressure is lowered to < 110 mmHg.
GUIDELINES: JNC 7 & ESH/ESC 2007,
BHS 2004, Canada 2010 &NICE 2011
1. All support combination therapy +++
2. Support initiation of therapy with drug
combinations
3. Approve low-dose fixed combinations for
initiation of therapy
CLASSES OF ANTIHYPERTENSIVE
DRUGS
■ BETA BLOCKERS
• Atenolol
• Bisoprolol
• Carvedilol
■ ACE Inhibitors
• Captopril
• Lisinopril
• Enalapril
Angiotensin-receptor blocker
ARB therapy may cut the risk of Alzheimer's disease
(AD) by reducing amyloid deposition in the brain.
890 hypertensive patients with available brain autopsy
data.
The risk for AD was 24% lower in those prescribed
ACE inhibitor.
Ihab Hajjar, MD, and colleagues from University of Southern California
Archives of Neurology, September 13, 2012
CLASSES OF
ANTIHYPERTENSIVE DRUGS
Angiotensin II Receptor Blockers
• Losartan
• Candesartan
• Valsartan
• Irbesartan
■ Calcium Channel Blockers ( Long Acting)
• Nifedipine Retard
• Amlodipine
• Felodipine
■ Diuretics ( Thiazides, Indapamide SR)
■ Vasodilators
Aged under
55 years
Aged over 55
years or black
person of any age
C2
A
A+
C2
A+C+D
Resistant hypertension
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
NICE 2011
Step 1
Step 2
Step 3
Step 4
Key
A – ACE inhibitor or lowcost angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic
Updated Guideline issued by NICE 2011
In hypertensive patients aged 55 or older or black
patients of any age:
 The first choice for initial therapy should be either
a calcium-channel blocker or
a Thiazide-type diuretic.
 If a third drug is needed an ACE inhibitor or
ARB is a choice.
NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary
care, 2011. www.nice.org.uk
Updated Guideline issued by NICE 2011
In hypertensive patients younger than 55, the first
choice for initial therapy should be:
 An ACE inhibitor (or an ARB if an ACE inhibitor is
not tolerated).
 Adding an ACE inhibitor to a calcium-channel
blocker or a diuretic (or vice versa are logical
combinations).
NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary
care, 2011. www.nice.org.uk
Updated Guideline issued by NICE 2011
Beta-blockers may be considered in younger
people, particularly:
 Those with an intolerance or contraindication to ACE
inhibitors and ARB or
 Child-bearing potential or
 People with evidence of increased sympathetic
drive.
NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary
care, 2011. www.nice.org.uk
Updated Guideline issued by NICE 2011
If therapy is initiated with a beta-blocker and a second
drug is required, add a calcium-channel blocker
rather than a Thiazide-type diuretic to reduce the
patient’s risk of developing Diabetes.
 NICE clinical guideline 34, Hypertension: management of hypertension
in adults in primary care, 2011. www.nice.org.uk
Summary: Treatment of Systolic-Diastolic Hypertension
without Other Compelling Indications
TARGET <140/90 mmHg
Lifestyle modification
Initial therapy
Thiazide
diuretic
CONSIDER
• Nonadherence
• Secondary HTN
• Interfering drugs or
lifestyle
• White coat effect
ACEI
ARB
Long-acting
CCB
A combination of 2 first line drugs may
be considered as initial therapy if the
blood pressure is >20 mmHg systolic or
>10 mmHg diastolic above target
Betablocker*
Dual Combination
Triple or Quadruple
Therapy
*Not indicated as first
line therapy over 60 y
CANADIAN 2010
Treatment Algorithm for Isolated Systolic Hypertension
without Other Compelling Indications
TARGET <140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
diuretic
ARB
CANADIAN 2010
Long-acting
DHP CCB
Treatment of Systolic-Diastolic Hypertension without
Diabetic Nephropathy
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
Diabetes
without
Nephropath
y
1. ACE Inhibitor or ARB or
DHP: dihydropyridine
IF ACE Inhibitor and ARB and
DHP-CCB and Thiazide are
contraindicated or not
tolerated,
SUBSTITUTE
• Cardioselective BB* or
• Long-acting NON DHP-CCB
2. Thiazide diuretic or
Dihydropyridine CCB
Combination of first line
agents
Addition of one or more of:
Cardioselective BB or
Long-acting CCB
Combinations of an ACE Inhibitor with an ARB are
specifically not recommended in the absence of
proteinuria
More
than 3 drugs BB:
may Acebutolol,
be needed toAtenolol,
reach target
values ,for
diabetic
* Cardioselective
Bisoprolol
Metoprolol
patients
CANADIAN 2010
Treatment of Hypertension in association with
Diabetes Mellitus: Summary
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
with
Nephropathy
ACE
Inhibitor
or ARB
Diabetes
1. ACEInhibitor or
ARB
without
Nephropath
y
A combination of 2 first line
drugs may be considered as
initial therapy if the blood
pressure is >20 mmHg systolic
or >10 mmHg diastolic above
target
or
2. Thiazide
diuretic or DHPCCB
> 2-drug
combinations
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria
More than 3 drugs may be needed to reach target values for diabetic patients
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should
be substituted for a thiazide diuretic if control of volume is desired
CANADIAN 2010
A meta-analysis of 94,492 patients with hypertension
treated with beta blockers to determine the risk of newonset diabetes mellitus.
S. Bangalore et. Al. American journal of cardiology,
may 2007.
■ Β blockers are associated with an increased
r i s k f o r n e w - on s e t D M b y 2 2 %.
■ No benefit for the end point of death or mi.
■ I n c r e a s e d r i s k f o r s t r o k e b y 1 5 %.
■ This risk was greater in patients with higher
baseline BMI and higher baseline FPG.
DR. HUSSEIN SAAD
Relative risks of drugs (Base Case Studies)
Outcome
Thiazides
D
C C blockers
C
B. Blockers
B
ACEi / ARB
A
Unstable
Angina
0.893
0.881
0.984
0.970
MI
0.780
0.796
0.855
0.816
Diabetes*
0.985
0.808
1.137
0.720
Stroke*
0.690
0.656
0.851
0.731
Heart Failure
0.530
0.731
0.761
0.642
Death
0.910
0.883
0.939
0.902
NICE GUIDELINES 2006
Dr. HUSSEIN SAAD
Evidence of use of B Blockers
Conditions
Weak to
None
Hypertension (uncomplicated)
√
Some
Evidence
Heart Failure
Acute Coronary Syndrome
Strong
Evidence
√
√
Post MI
√
Stable Angina without MI
√
Perioperative (non
cardiac)
√
HOCM
√
Source: Cardiosource , 2008 American College of Cardiology
There is a paucity of data or an absence of evidence
to support the use of beta-blockers as Monotherapy
or as First-line agents in uncomplicated HTN.
► Given the risk of stroke.
► Lack of cardiovascular morbidity and mortality
benefit.
► Numerous adverse effects.
► Lack of regression of target end-organ effects of
hypertension (e.g., left ventricular hypertrophy and
endothelial dysfunction).
DIURETICS
■ Meta-analysis of all RCTs support diuretics as
first line agent.
■ 62 clinical trials including 192, 478 patients clearly
supports using Diuretics as first line treatment for
HTN including those with Diabetes, co-existing risk
factors for CVD and asymptomatic LVH.
■ Dose of Diuretic cannot be higher than an
equivalent dose of 25 mg HCZ.
Jama 2003; 289:2534-44
ANTIPLATELET AGENTS for HYPERTENSION
Primary Prevention:
For patients with elevated blood pressure and no
cardiovascular disease, ASA cannot be
recommended since the magnitude of benefit is
negated by a harm of similar magnitude.
(ARI 0.6 %, NNH 167 for 3.8 years)
Database of Systematic Reviews, Cochrane Library, Issue 2, 2005.Chichester, UK.
INITIAL DRUG CHOICES
■ Isolated Systolic Hypertension:
● Thiazides
● Calcium Channel Blockers ( Long Acting )
■ Peripheral Arterial
Disease
● Calcium Channel Blockers ( Long Acting )
INITIAL DRUG CHOICES
■ Heart Failure:
• ACE Inhibitors
• Angiotensin II Receptor Blockers
• Diuretics
• B-Blockers
■ IHD and MI:
• B-Blockers
• ACE Inhibitors / Angiotensin II Receptor Blockers
• Calcium Antagonists ( Diltiazem )
B.P. and DIABETES MELLITUS
 Diabetic patients with Bp
> 140/80 are candidate for
antihypertensive treatment.
 Patients should be checked to confirm the presence
of hypertension.
 Proceed to:
● Behavioral Approach / Lifestyle Modific.
● Drug Treatment
B.P. and DIABETES MELLITUS
Drug Treatment
● ACE Inhibitors
● Angiotensin II Receptor blockers
■ In Microalbuminuria and Nephropathy
lower Bp to ≤ 140/80
Hypertension in High Risk Patients: Number
of Agents Required to Achieve BP Goal
UKPDS (<85 mm Hg,
diastolic)
MDRD (92 mm Hg, MAP)
HOT (<80 mm Hg, diastolic)
AASK (<92 mm Hg, MAP)
RENAAL (<140/90 mm Hg)
IDNT (135/85 mm Hg)
1
2
3
Number of BP Medications
4
UKPDS=United Kingdom Prospective Diabetes Study; MDRD=Modification of Diet in Renal Disease;
HOT=Hypertension Optimal Treatment; AASK=African American Study of Kidney Disease;
RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan
Diabetic Nephropathy Trial; MAP=mean arterial pressure.
Bakris et al. Am J Kidney Dis. 2000;36:646-661; Brenner et al. N Engl J Med.
2001;345:861-869; Lewis et al. N Engl J Med. 2001;345:851-860.
Lifestyle modifications to prevent and
manage hypertension
Approximate
SBP Reduction
Weight reduction Maintain normal body
weight (body mass index 18.5–24.9 kg/m2).
5–20
mmHg/10kg
Adopt DASH eating plan Consume a diet rich 8–14 mmHg
in fruits, vegetables, and low fat dairy products
with a reduced content of saturated and total
fat.
Dietary sodium reduction Reduce dietary
sodium intake to no more than 100 mmol per
day (2.4 g sodium or 6 g sodium chloride).
2–8 mmHg
Physical activity Engage in regular aerobic
4–9 mmHg
physical activity such as brisk walking (at least
30 min per day, most days of the week).
DASH, Dietary Approaches to Stop Hypertension; SBP, systolic blood pressure
For overall cardiovascular risk reduction, stop smoking.
WCH
 White coat hypertension is defined when a
patient has a persistently elevated clinic BP
≥ 140/90 and a normal HBPM or ABPM day
time average, i.e. <135/85
 White coat hypertension is present in as many
as 25% of patients, possibly leading to:
 Incorrect diagnosis of hypertension.
 Diagnosis of uncontrolled hypertension (receive
inappropriate dose titrations or additional
antihypertensive agents)
 Resistant hypertension, with a reported prevalence of
37 to 44 % in some studies.
JNC-8 Recommendations
 In patients >60 years of age, start medications at blood
pressure of >150/90mm Hg and treat to goal of
<150/90mm Hg
 In patients >60 years of age, treatment does not need to
be adjusted if achieved blood pressure is lower than goal
and well-tolerated
James PA et al. JAMA 2014;311:507-20.
JNC-8 Recommendations
 In patients <60 years of age, start medications at blood
pressure of >140/90mm Hg and treat to goal of
<140/90mm Hg
 In all adult patients with diabetes or chronic kidney
disease, start medications at blood pressure of
>140/90mm Hg and treat to goal of <140/90mm Hg
James PA et al. JAMA 2014;311:507-20.
BP Goal
JNC-7
JNC-8
Comparisons to
ASH/ISH ESC/ES CHEP
Other Guidelines
H
Age < 60 <140/90
<140/90
<140/90
<140/90
<140/90
Age 6079
<140/90
<150/90
<140/90
<140/90
<140/90
Age 80+
<140/90
<150/90
<150/90
<150/90
<150/90
Diabetes <130/80
<140/90
<140/90
<140/85
<130/80
CKD
<140/90
<140/90
<130/90
<140/90
<130/80
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
JNC-7
JNC-8
ASH/ISH
ESC/ESH
CHEP
Comparisons to Other Guidelines
Non-black
(no DM or
CKD)
Thiazide
Thiazide,
ACEI,
ARB, CCB
<60:ACEI,
ARB
>60:CCB,
thiazide
Thiazide,
Thiazide,
ACEI,
ACEI, ARB
ARB, CCB, (BB if <60)
BB
Black (no
DM or
CKD)
Thiazide
Thiazide,
CCB
Thiazide,
CCB
Thiazide,
Thiazide,
ACEI,
ARB (BB if
ARB, CCB, <60)
BB
Diabetes
ACEI,
CCB,
ARB, CCB, thiazide
BB,
thiazide
CKD
ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB ACEI, ARB
ACEI,
ACEI, ARB ACEI,
ARB, CCB,
ARB, CCB,
thiazide
thiazide
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
Case 1
A 49 year old lady, a known case of OA of knees,
incidentally discovered to have high Bp in two visits,
156 / 106 and 164 / 100 respectively.
 What is the target of Bp for this lady?
 What additional history you need from this lady?
 What investigations are you going to request?
 Mention one medication are you going to start with?
Case 2
Abdullah a 53-year old man presents to your clinic to
be control his blood pressure. He is regular on Atenolol
50 mg OD for the last 3 years.
PMH is unremarkable.
FH: his father is hypertensive.
Bp:162/98
P. 62/m
BMI 31
O/E: nothing is significant apart from A-V nipping on
retinal examination.
 What is your comment on his medication based on
guidelines?
 What action plan are you going to take?
 Non-pharmacological management is an important aspect,
Explain.
Case 3
Saleh a 64-year old man who is a known case of
hypertension, came for follow up. He is regular on
Hydrochlorthiazide 25mg daily. BP is 176 / 82.
On reviewing his file the BP is ranging from
162 / 76 to 180 / 88
 U and E: within normal
 FBS:
6.4 mmol/L 2hpp: 9.56 mmol/L
 ECG:
LVH
 What is/are the diagnosis of Saleh?
 Based on evidence, which medication of choice are you going
to choose?
Case 4
Mofleh a 55 year old man, who is a known case of
diabetes on insulin. He came for routine follow up.
BP: 154 / 106
P. 92 / min.
BMI 33
O/E:* reduced sensation to pin pricks in lower
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Limb up to the middle of his legs.
* Funduscopy: background retinopathy
24hr urine for protein :
o.438 gm
urea :
8.7 mmol/L
( 2.5 – 6.4 )
creatinine: 144 mmol/L
( 62 – 115 )
sodium : 138 mmol/L
( 135 – 145 )
potassium : 4.7 mmol/L
( 3.5 – 5.1 )
ECG :
LVH and inverted T waves in V4,5 and 6
What problems mofleh has?
What is your target(s) for this case?
What medication are you going to give?