1. HYPERTENSIONUp to date K.Premmatat M.D.

2. Overview • Epidermiology • Pathophysiology • Classification & Definition • Secondary hypertension , white – coat hypertension , masked hypertension • Role of HBPM • Patient assessment & risk factors • Treatments

3. What is the estimated prevalence of hypertension in Thailand ?

5. Magnitude of the hypertension

6. Rule of halves • Only ½ have been diagnosed. • Only ½ of those diagnosed have been treated. • Only ½ of those treated are adequately controlled.

9. Pathophysiology Salt ,RAAS , Intravascular volumes Autonomic nervous system (NE,E,DA)

10. Complications • Atherosclerotic event • CAD (coronary artery disease) • CVA (Cerebral vascular accident) • PAD (Peripheral artery disease) • CKD (Chronic kidney disease) • Retina

11. Population Based Strategy for Hypertension Reduction. Graph depicts Systolic Blood pressure distributions in a population with a change in Blood pressure and the % reduction in mortality associated with this. JNC-7; 2003.

12. Classification & Definition • JNC 7 • 2013 ESH/ESC • NICE guidance UK • Essential (Primary) • Secondary • White – coat • Masked

13. JNC 7

14. 2013 ESH/ESC

15. NICE guidance UK • 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.

16. Secondary hypertension • Renal • Parenchymal disease (DN , AGN , CGN) • Renal cysts (Polycystic kidney disease) • Renal tumor(including rennin - secreting tumor) • Obstructive uropathy • Primary sodium retention (Liddle syndrome) • Renal artery stenosis • Arteriosclerotic • Fibromuscular dysplasia

17. Secondary hypertension • Adrenal • Primary aldosteronism • Cushing syndrome • Pheochromocytoma • Congenital adrenal hyperplasia • Licorice • Aortic coarctation • Obstructive sleep apnea • Preeclampsia / eclampsia

18. Secondary hypertension • Neurogenic • Polyneuritis (Acute porphyria , lead poisoning) • Acute increased ICP • Acute spinal cord dissection • Endocrine • Hyper/ hypothyroidism • Hypercalcemia (Hyperparathyroidism) • Acromegaly , carcinoids • Medications  steriod , estrogen (high dose) , TCAs , decongestant , NSAIDs , MAOI , nicotine , cocaines , EPOs

19. When we should think for secondary hypertension ? • History & physical examinations • Hypertension in the young • Refractory hypertension • Uncontrolled hypertension • First diagnosis hypertension in patient > 55 year old

22. White – coat hypertension Masked hypertension • White – coat hypertension • Grade I hypertension in the office but normal at home. • High office BP in individuals without asymptomatic organ damage and at low total CV risk. • Masked hypertension • High normal BP in the office but hypertension at home. • Normal office BP in individuals with asymptomatic organ damage or at high total CV risk.

23. HMBP (Home blood pressure monitoring)

24. HMBP (Home blood pressure monitoring) • Indication • Suspicious white – coat , masked hypertension • Considerable variability of office BP over the same or different visits • Autonomic, postural, post-prandial, siesta- and drug-induced hypotension • Elevated office BP or suspected pre-eclampsia in pregnant women • Identification of true and false resistant hypertension

25. ESC 2013

26. Patient assessment & risk factorsTreatments • Level of BP • Risk factors • Target organ damaged

27. Level of BP

28. Risk factors

29. Target organ damaged

31. Investigations

32. Investigations

35. Treatments • Goal of treatments • Line of management • - Life – style modification • - Drug • - Compelling indication • - Special conditions • Follow up

36. Goal of treatments • JNC 7 • Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. • NICE • 140/90 mmHg in people aged under 80 • 150/90 mmHg in people aged 80 and over • 130/80 mmHg in people who have diabetes , CKD • 125/75 mmHg in people who have proteinuria >= 1 g/day

37. ESC 2013

38. Goal of treatments • ESC 2013 • All  140/90 mmHg • Except • DM  140/85 mmHg • Elderly > 80 year olds  DM 140-150/90 mmHg NON - DM 140-150/85 mmHg

40. Line of management LSM – Life - style modifications • JNC , NICE , ESC  SAME

42. Life - style modifications • DASH (Dietary approachs to stop hypertension) • Aerobic exercise • Avoid tobacco , Alcohol drinking (male < 2 drink/day = beer 720 ml , female < 1drink/day ) • Restrict salt • Weight reduction

43. Lifestyle Modification

46. Drugs • Diuretic • Beta – blocker • ACEI • ARB • CCB • Alpha – blocker • Aldosterone – antagonists eg. Spironolactone , eplerenone • Direct vasodilatoreg. Hydralazine , minoxidill • Sympatholytic drug eg. clonodine

47. Without Compelling Indications With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Algorithm for Treatment of Hypertension JNC7 Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices

48. Aged over 55 years or black person of African or Caribbean family origin of any age Summary of antihypertensive drug treatment (NICE) Aged under55 years Step 1 C A Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic Step 2 A + C Step 3 A + C + D Resistant hypertension A + C + D + consider further diureticor alpha- or beta-blocker Consider seeking expert advice Step 4

49. ESC