Transcript Therapeutic Options in Hypertension

Therapeutic Options in
Hypertension
Non-pharmacologic
approaches
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Awareness, Treatment and Control of
High Blood Pressure in Canada
16%
42%
23%
19%
Patients unaware of their high blood pressure
42%
Aware but not treated and not controlled
19%
Treated but not controlled
23%
Treated and controlled
16%
Adapted from: Am J Hypertens 1997; 10:1097-1102.
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Lifestyle Modification for
Hypertension
• Lose Weight (BMI  25)
• Limit alcohol < 2
drinks/day
• Increase aerobic activity
• Reduce sodium intake
• Maintain K, Ca, Mg
• Smoking cessation
• Reduce intake of fats for
overall health
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Timing the Initiation
of Therapy
• Confirm diagnosis
• Assess risk
• Identify target organ damage
–
–
–
–
Retinopathy
Nephropathy
Vasculopathy-bruits or reduced ABI or pulses
S4 or LVH
• Exclude secondary causes
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3
0
0
High blood pressure vs Hypertension
Office Diagnosis of Hypertension: Summary
Visit 1
180
105
90
History-taking,
physical examination
Visit 2
Visit 3
140
- Hypertensive
urgency?
- Target organ
damage or
BP >180/105?
(Visit 3)
Hypertension
diagnosis
confirmed
Visit 4
Visit 5
Blood pressure
measurement
every year
BP >threshold
for initiation of
treatment
No
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Canadian Hypertension Education Program Recommendations
Yes
Validated technique and
BP measurement device
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2
3
0
0
Impact of High-Normal Blood Pressure on the Risk of
Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE
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Canadian Hypertension Education Program Recommendations
N Engl J Med 2001;345:1291-7
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2
3
0
0 Treat Hypertension in the Context of Overall
Cardiovascular Risk
Grade 1
Grade 2
Grade 3
SBP 140-159 or
DBP 90-99
(mild hypertension)
SBP 160-179 or
DBP 100-109
(moderate hypertension)
SBP ? 180
or DBP ? 110
(severe hypertension)
Low risk
Medium risk
High risk
Medium risk
Medium risk
V high risk
III. 3 risk factors or
TOD or De novo
diabetes
High risk
High risk
V high risk
IV. ACC or Diabetes
V high risk
V high risk
V high risk
Other Risk Factors &
Disease History
I. No other risk
factors
II. 1-2 risk factors
Risk strata (typical % 10 year risk of stroke, myocardial infarction or death)
<15%
15-20%
20-30%
 30%
Adapted from WHO/ISH Recommendations on Hypertension. Chalmers J et al. J Hyper 1999;17:151-85.
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Timing the Initiation
of Therapy
• Initiate therapy in High Risk and Very
High Risk immediately & f/u monthly till
2 visits at target
• Initiate therapy in Medium Risk after
diet/lifestyle trial ~ 3 months & f/u 1-2
monthly
• Initiate therapy in Low Risk after
diet/lifestyle trial ~ 6 months & f/u 3-6
monthly
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0
20 Threshold for Initiation of Treatment and
Target Values
Condition
Initiation
Target
SBP / DBP mmHg
SBP / DBP mmHg
 140/90
<140/90
Isolated systolic hypertension
SBP >160
<140
Home BP measurement
(no diabetes, renal disease or
proteinuria)
( 135/85)
<135/85
 130/80
<130/80
Renal disease
( 130/80)
<130/80
Proteinuria >1 g/day
( 125/75)
<125/75
Diastolic ± systolic hypertension
Diabetes
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When you come to a fork in the
road…
….take it.
Yogi Berra
Choice of Anti-hypertensive Therapy
 Guidelines
 Efficacy
 Tolerability
 Safety
 Specific indications
 Contra-indications
 Outcome
 Cost
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Hypertension Evidence
The Gold standard
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