CME INDIA Presentation by Dr. A. Muruganathan, MD, Former Emeritus Professor – The Tamil Nadu Dr. M. G. R Medical University, Chairman IMA Hypertension Standing Committee, Member Tamil Nadu Medical Council, International advisor for Royal College of Physicians Glasgow, International member of the medical education board of RCP Glasgow. Advisory Council member of National Board of Examination (NBE), Director – Hold Medical Academy, Imm. Past Governor – American College of Physicians (ACP) India Chapter, Dean – Indian College of Physicians (ICP): 2016 – 2017, President – Hypertension Society of India (HSI): 2015 – 2016, President – Association of Physicians of India (API): 2013 – 2014 BC ROY Awardee, Tichur, TN.

Presentation based on guest lecture at 1st Physical CME Deoghar by CME INDIA on 09-12-2023.

What is New in Hypertension Management?

Hypertension: A quadruple paradox

  1. Easy to diagnose BUT often remains undetected.
  2. Simple to treat BUT often remains untreated.
  3. Important risk factor for cardiovascular morbidity and mortality.
  4. Despite availability of potent drugs, BUT often treatment with all is ineffective.

Reduce the tremendous disease burden associated with this HTN

  • Hypertension is a global health challenge, with a high prevalence, low control rates, and an associated high morbidity and mortality.
  •  The early introduction of combination therapy is now recommended in the guidelines of several major hypertension societies and organizations not only in high-risk individuals and those with moderate-to-severe hypertension but also more recently to most persons with newly diagnosed hypertension.
  • The goal of such an approach is to control nocturnal hypertension, time at target ,24 BP CONTROL and to rapidly increase the control rate of hypertension and reduce the tremendous disease burden associated with this disease.

Stages of HTN

  • In addition to grades of hypertension, which are based on BP values, we also distinguish stages of hypertension as follows:
  • Stage 1: Uncomplicated hypertension (i.e., without HMOD or established CVD, including CKD stage 1 and 2).
  • Stage 2: Presence of HMOD or CKD grade 3 or diabetes.
  • Stage 3: Established CVD or CKD stages 4 or 5.
What is New in Hypertension Management?

Ref. (ESC-2023)2

Home blood pressure monitoring (HBPM)

  • It offers several advantages as a method for obtaining blood pressure readings outside of clinical settings, reflecting the individual’s typical environment. Widely accepted for long-term use, HBPM is a cost-effective approach.
  • HBPM has shown superior predictive capabilities for hypertensive-mediated organ damage (HMOD), cardiovascular outcomes, and mortality when compared to office BP measurements.
  • To ensure accuracy, HBPM should be performed using validated automated upper arm cuff devices following established protocols (www.stridebp.org).
  • Devices with automated storage and averaging capabilities, as well as connectivity for data transfer, are preferred for physician evaluation. Measurement conditions and posture should align with those recommended for office BP measurements (OBPM). Notably, HBPM tends to lack the white-coat effect, resulting in values generally lower than office BP values, with the difference diminishing as office BP decreases.
  • Despite its advantages, HBPM has limitations, including the need for patient training, potential inaccuracies of devices, induced anxiety, and the risk of overly frequent measurements leading to unnecessary treatment modifications by the patient.

Selected standard laboratory tests for work-up of hypertensive patients

Hemoglobin and/or hematocrit
Fasting blood glucose and HbA1c
Blood lipids: total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides
Blood potassium and sodium
Blood uric acid
Blood creatinine (and/or cystatin C) for estimating GFR with eGFR a formulas
Blood calcium
Urine analysis (first voided urine in the morning), multicomponent dipstick test in all patients, urinary albumin/creatinine ratio, microscopic examination in selected patients.
ECG/Echocardiography

Exercise and BP

  • According to a consensus document of the European Association of Preventive Cardiology, a BP above 220 mmHg in male and 200 mmHg in female measured at peak exercise during cycle ergometry warrants further clinical evaluation including ABPM.
  • Two interesting recent findings are:
    • The BP response to submaximal exercise may have a greater prognostic significance than BP measured at peak.
    • Exercise hypotension may also be a sign of an underlying CV disease.

What is the Office BP thresholds for initiation of drug treatment

  • In general, the consensus among guidelines is that patients with grade 1 hypertension and low-to-moderate cardiovascular (CV) risk (i.e., those without established cardiovascular disease (CVD), diabetes, chronic kidney disease (CKD), or hypertensive-mediated organ damage (HMOD)) may initially focus on lifestyle modifications. Lifestyle interventions typically include dietary changes, increased physical activity, weight management, and reduction of alcohol and sodium intake.
  • However, the initiation of drug treatment for patients with grade 1 hypertension and low-to-moderate CV risk may be considered based on individual patient factors and preferences. Some guidelines may suggest a trial period of lifestyle modifications before introducing pharmacological interventions, while others may emphasize the importance of promptly addressing hypertension through medication, especially if lifestyle changes alone prove insufficient in achieving blood pressure (BP) goals.
  • It is crucial for healthcare providers to assess each patient’s overall CV risk profile, considering factors such as age, sex, smoking status, family history, and comorbidities.
In patients 18 to 79 years, the recommended office threshold for initiation of drug treatment is 140 mmHg for SBP and/or 90 mmHg for DBP. (I A)
In patients ≥80 years, the recommended office SBP threshold for initiation of drug treatment is 160 mmHg. (I B)
However, in patients ≥80 years a lower SBP threshold in the range140 – 159 mmHg may be considered. (II C)
The office SBP and DBP thresholds for initiation of drug treatment in frail patients should be individualized. (I C)
In adult patients with a history of CVD, predominantly CAD, drug treatment should be initiated in the high-normal BP range (SBP≥130 or DBP ≥80 mmHg
What is New in Hypertension Management?

Drug classes for BP-lowering therapy. (a) Use of Diuretics: Consider transition to Loop Diuretic if eGFR is between 30 to 45 ml/min/1.73 m2. If eGFR <30 ml/ min/1.73 m 2 use Loop Diuretic. (b) Non-DHP CCB should not be combined with BB. (c) BB should be used as guideline directed medical therapy in respective indications or considered in several other conditions. Start with dual combination therapy including a RAS-blocker (either ACEi or ARB) plus a T/TL Diuretic or a CCB is recommended (thick blue lines). Triple therapy includes a combination of the three classes as indicated by the blue lines (ESC-2023)2

Compelling contraindications and conditions requiring cautious use of BP-lowering drugs

What is New in Hypertension Management?

(Ref-2)

General recommendations for antihypertensive drug treatment

  • BP lowering should be prioritized over the selection of specific antihypertensive drug classes because treatment benefit largely originates from BP reduction. (I A)
  • Five major drug classes including ACEis, ARBs, BBs, CCBs, and Thiazide/Thiazide-like diuretics have effectively reduced BP and CV events in RCTs. These drugs and their combinations are recommended as the basis of antihypertensive treatment strategies. (I A)
  • Initiation of therapy with a two-drug combination is recommended for most hypertensive patients. Preferred combinations should comprise a RAS blocker (either an ACE inhibitor or an ARB) with a CCB or Thiazide/Thiazide-like diuretic. Other combinations of the five major drug classes can be used. (I A)
  • Initiation with monotherapy should be considered in patients with:
  • Grade 1 hypertension and low-risk if BP is only marginally elevated (less than 150 mmHg SBP and 95 mmHg DBP)
  • High-normal BP and very high CV risk
  • Frailty and/or and advance age.
  • If BP is not controlled with the initial two-drug combination by using the maximum recommended and tolerated dose of the respective components, treatment should be increased to a three-drug combination, usually a RAS blocker + CCB + Thiazide/Thiazide-like diuretic. (I A)
  • If BP is not controlled with a three-drug combination by using the maximum recommended and tolerated dose of the respective components, it is recommended to extend treatment according to the recommendations for true resistant hypertension. (I A)
  • The use of single pill combinations (SPCs) should be preferred at any treatment step, i.e., during initiation of therapy with a two-drug combination and at any other step of treatment. (I B)
  • BBs should be used at initiation of therapy or at any treatment step asGDMT, examples:
  • Heart failure with reduced ejection fraction HFrEF
  • Anti-ischemic therapy in chronic coronary syndromes
  • Heart rate control in atrial fibrillation
  • BBs can be considered in the presence of several other conditions in which their use can be favorable (I C)
  • The combination of two RAS blockers is not recommended due to increased risk of adverse events, in particular AKI.

What is Quadpill Concept?

  • The concept of the quadpill represents an innovative therapeutic strategy aimed at enhancing blood pressure (BP) control while concurrently improving tolerability. This approach involves utilizing combinations of low or ultralow doses of recommended antihypertensive drugs. By doing so, the potential to effectively reduce elevated BP is maintained, while minimizing the occurrence of side effects.
What is New in Hypertension Management?

1. Flack JM et al. Vascular Health and Risk Management 2011:7 777–787, 2. Kochar M et al. AJH 1999;12:797–805, 3. Kuo S et al. AJH 2003; 16:623–628, 4. Kurtz TW et al. Vasc Health Risk Manag. 2012; 8: 133–143, 5. Oparil S et al.  J Clin Hypertens. 2001;3:283–291, 318, 6. Wang HY et al. Arzneimittelforschung. 2008;58(10):505-9

Reduction of early morning BP surge

What is New in Hypertension Management?

Combination Therapy

  • Beyond the additive and/or synergistic effect on blood pressure when two complementary classes of antihypertensive agents are used in combination, these agents can assist in blunting or mitigating the side effects of each other, as well. For example, the use of a renin-angiotensin- aldosterone system inhibitor can reduce the pedal edema often experienced with calcium channel blockers.

OSA and CPAP

  • Patients that may benefit more from CPAP treatment have been reported to be younger than 60 years, with an uncontrolled BP before treatment initiation and with severe oxygen desaturation at baseline.
  • The BP-lowering effect of CPAP can be seen also in patients with resistant hypertension, and it has been found to be almost double for the nighttime than to the daytime BP, due to reduced sleep segmentation and improved intermittent hypoxia.
  • Reduction of arterial stiffness, decrease of high-sensitive C-reactive protein, plasma cortisol and noradrenaline levels have also been associated with use of CPAP

Uric Acid and Hypertension

  • Among ARBs, losartan has been shown to reduce serum urate levels through an uricosuric effect, with some favorable implications for CV outcome.
  • Together with CCBs, losartan has also been shown to reduce the incidence of gout in hypertensive patients, regardless of the BP level, in a large nested case–control study.
  • In line with other guidelines, these guidelines suggest to prescribe diuretics with caution in patients with gout but not to avoid them if diuretics are needed to achieve BP control.
  • In general, physicians should try to use lower doses of diuretics because the effect of these drugs on serum uric acid is dose-related.

COPD

  • A systematic review and meta-analysis of 49 studies involving more than 670 000 patients indicated that treatment of patients with COPD and CVD with both ß1-selective and nonselective BBs significantly lowered heart rate (about 8 bpm) and reduced all-cause mortality as compared with COPD patients with no BB treatment.
  • Additionally, use of ß1-selective BBs, but not of nonselective ones, reduced CODP exacerbations.
  • Thus, in COPD patients, hypertension and CVD should be treated, if tolerated with more ß1-selective BBs, to reduce both mortality and COPD exacerbation

Hypertension management in pregnancy

In women with hypertensive disorders in pregnancy, initiation or intensification of drug treatment is recommended when SBP is ≥ 140 mmHg and/or DBP ≥ 90 mmHg.
(I C)
In women with pre-existing hypertension (with or without superimposed pre-eclampsia), BP should be lowered to a target below 140/90 mmHg. (I A)
In women with gestational hypertension (with or without pre- eclampsia), BP should be lowered to a target below 140/90 mmHg. (I C)
In women with hypertensive disorders in pregnancy, too marked BP-lowering should be avoided. On-treatment DBP <80 mmHg is not recommended. (III C)
Labetalol a and α-methyl-DOPA are the first choice BP-lowering agents for hypertensive disorders in pregnancy unless contraindicated. (I B)
Extended-release nifedipine is recommended as an alternative BP-lowering agent during pregnancy. (I B)
Up-titration of monotherapy may precede any combination drug treatment. (II C)
Combination drug treatment between labetalol, extended- release nifedipine, or α-methyldopa may be reasonable to achieve the desirable BP target after the failure of up-titrated monotherapy. (II C)
ACE inhibitors, ARBs, or direct renin inhibitors are not recommended during pregnancy. (III C)
Aspirin (100-150 mg, at bedtime, weeks 11-35) should be administered in pregnant women at high or moderate risk of pre- eclampsia. (I A)
Severe hypertension (≥160/110 mmHg) in a pregnant woman requires prompt hospital admission. (I C)
In pre-eclampsia with severe features, magnesium sulfate should be administered immediately. (I C)
HBPM can be a reasonable alternative to conventional office BP measurement to detect new-onset hypertension in women at risk for pre-eclampsia without pre-existing hypertension. (II B)
HBPM can be a reasonable alternative to conventional office BP measurement to achieve BP control in women with gestational or pre-existing hypertension.

CME INDIA Tail Piece

1st Physical CME at Holy City Deoghar on 09/12/2023

What is New in Hypertension Management?

References:

  1. Neutel J, Smith DH. J Clin Hypertens. 2003;1:58–63, 2. Williams B et al. Journal of Human Hypertension 2009;23:610–619, 3. McInnes G. Journal of the American Society of Hypertension 2(4) (2008) S16 –S22
  2. Mancia G, Kreutz R, Brunström M, Burnier et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023 Dec 1;41(12):1874-2071. doi: 10.1097/HJH.0000000000003480. Epub 2023 Sep 26. PMID: 37345492.
  3. Flack JM et al. Vascular Health and Risk Management 2011:7 777–787, 2. Kochar M et al. AJH 1999;12:797–805, 3. Kuo S et al. AJH 2003; 16:623–628, 4. Kurtz TW et al. Vasc Health Risk Manag. 2012; 8: 133–143, 5. Oparil S et al.  J Clin Hypertens. 2001;3:283–291, 318, 6. Wang HY et al. Arzneimittelforschung. 2008;58(10):505-9


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