17 Agustus 2008

Comprehensive Evaluation in
Cardiovascular Risk for Patients with
Hypertension in Accordance with the
Latest Guideline
By
Dr H Aulia Syawal SpJP-K,FIHA, FAsCC
Senior Consultant Cardiologist Siloam Sriwijaya Hospital Palembang
PALEMBANG CARDIOLOGY UPDATE X
Aston Hotel June 28-29th 2019
OUTLINE
• Introduction
• Definition : white coat HT, masked HT
• BP measurement : office based, ABPM, Home BP
• Primary HT : pathophysiology , risk factor
• Secondary or contributing causes
• HMOD ( Hypertension Mediated Organ Damage )
• Making diagnosis : screening, diagnosis
• Evaluation : history, physical exam, Lab : additional, testing for secondary
HT
• Treatment : non and pharmacology ; target BP, resistant HT, HT urgency
and emergency
 Hypertension Remains a Leading Cause of Mortality
Annually over 7 million deaths world-wide associated with hypertension

The global incidence of hypertension will

• As populations age and adopt more sedentary exceed 29% by 2025
2000
Population with hypertension (%)
lifestyles, the worldwide prevalence of 30
2025
hypertension will continue to rise towards 1.5
billion by 2025 28

• Elevated BP is the leading global contributor to 26

premature death, accounting for almost 10 million
deaths in 2015, 4.9 million due to ischaemic heart 24
Overall Males Females
disease and 3.5 million due to stroke. Kearney et al. Lancet 2005;365:217–23

Uncontrolled BP results in >40,000 major CV

• Less than 50% of hypertensive patients in US events per year in the USA
receive therapy. In Canada and Europe Major cardiovascular events/year*
approximately 66-75% were untreated4 50 000
DBP/SBP uncontrolled
• Approximately 70% of patients do not reach BP 40 000 DBP uncontrolled

goals. Physicians require better agents and targeted 30 000

SBP uncontrolled

approaches4 20 000
1. Cohen JD. Manag Care 2009;18:51–8; 10 000
2. Lawes et al. Lancet 2008;371:1513–8;
3. Kearney et al. Lancet 2005;365:217–23; 0
4. Wolf-Maier et al. Hypertension 2004;43:10–17. Medicated Unmedicated Total
Flack et al. Managed Care Interface 2002, Nov 28-36
 More Than 80% of Hypertensive Patients Have Additional
Comorbidities

Men Women

≥ Four Comorbidities:
8% ≥ Four
None • Obesity None 12%
19% • Glucose intolerance 17%
Three • Hyperinsulinemia Three
22% • Reduced HDL-C 20%
• Elevated LDL-C
One One
26%
• Elevated TG 27%
Two • LVH Two
25% 24%

>50% have 2 or more comorbidities

Kannel WB. Am J Hypertens. 2000:13:3S-10S.

Definition of Hypertension
Definition
• White Coat Hypertension : BP is consistently elevated by office readings
but does not meet diagnostic criteria for hypertension based upon out-
of-office readings.
• Masked Hypertension : BP is consistently elevated by out-of-office
measurements but does not meet the criteria for hypertension based
upon office readings.
Classification of office blood pressure and definitions of hypertension grade
Pathophysiology
Common causes of secondary hypertension
 Hypertension and total cardiovascular risk assessment
Factors influencing cardiovascular risk in patients with hypertension
Factors influencing cardiovascular risk in
patients with hypertension
Factors influencing cardiovascular risk in
patients with hypertension
Ten year CardioVascular Risk categories
(Systematic COronary Risk Evaluation system)
Classification of hypertension stages according to blood pressure,
cardiovascular risk factors, HMOD, or comorbidities.
Screening of Hypertension
ACC/AHA 2017 AND ESC 18 guidelines that all individuals 18 years or older
should be screened for elevated blood pressure
• Further BP recording is indicated, at least every 5 years if BP remains
optimal.
• Further BP recording is indicated, at least every 3 years if BP remains
normal.
• If BP remains high–normal, further BP recording, at least annually, is
recommended.
• In older patients (> 50 years), more frequent screening of office BP should
be considered for each BP category because of the steeper rise in SBP with
ageing
CLINICAL EVALUATION AND ASSESSMENT OF HYPERTENSION MEDIATED ORGAN
DAMAGE IN PATIENTS WITH HYPERTENSION

• establish the diagnosis and grade of hypertension,

• screen for potential secondary causes of hypertension,
• identify factors potentially contributing to the development of
hypertension (lifestyle, concomitant medications or family history );
• identify concomitant cardiovascular risk factors (including lifestyle
and family history);
• identify concomitant diseases and establish any evidence of HMOD
or existing cardiovascular, cerebrovascular and renal disease.
Medical history
• Time of the first diagnosis of hypertension, including records of any previous
medical screening, hospitalization
• Record any current and past BP values, current and past antihypertensive
medications
• Family history of hypertension, CVD, stroke, or renal disease
• Lifestyle evaluation, including exercise levels, body weight changes, diet history,
smoking history, alcohol use, recreational drug use, sleep history and impact of
any treatments on sexual function
• History of any concomitant cardiovascular risk factors, details and symptoms of
past and present comorbidities
• Specific history of potential secondary causes of hypertension
• History of past pregnancies and oral contraceptive use, menopause and hormone
replacement
• Use of liquorice, Use of drugs that may have a pressor effect
 Physical examination
Body habitus Signs of HMOD Secondary hypertension

• Weight and • Neurological examination and cognitive • Skin inspection: cafe-au-lait patches of
height measured status neurofibromatosis
on a calibrated • Fundoscopic examination for (pheochromocytoma)
scale, with hypertensive retinopathy • Kidney palpation for signs of renal
calculation of • Palpation and auscultation of heart and enlargement in polycystic kidney
BMI carotid arteries disease
• Waist • Palpation of peripheral arteries • Auscultation of heart and renal arteries
circumference • Comparison of BP in both arms (at least for murmurs or bruits indicative of
once) aortic coarctation, or renovascular
hypertension
• Comparison of radial with femoral
pulse: to detect radio-femoral delay in
aortic coarctation
• Signs of Cushing’s disease or acromegaly
• Signs of thyroid disease
Diagnosis of hypertension should be based on:

• Repeated office BP measurements on more than one visit, except

when hypertension is severe (e.g. grade 3 and especially in high-risk
patients).
• Out-of-office BP measurement with ABPM and/or HBPM, provided
that these measurements are logistically and economically feasible.
Protokol Pengukuran Tekanan Darah Klinis*
• Pasien istirahat awal 5 menit/10 menit pasca olahraga, dlm keadaan tenang,tdk
menahan b.a.k /b.a.b, tdk konsumsi obat adrenergik/kafein/rokok, tdk bicara.
Posisi duduk/berbaring lengan setinggi jantung
• Ukuran manset yg sesuai: p=80-100% LLA, l=40% LLA ( p=35cm, l=13cm ), pompa
>30 mmHg di atas bunyi Korotkov hilang ( >180mmHg ), turunkan dng kecepatan
3mmHg/detik
• Pasien baru diukur kedua lengan- ambil sisi dng TD yg lebih tinggi, ( beda kedua
lengan <15 mmHg ). Ukur 3x berturut2 selang 1 menit atau lebih banyak bila
selisih diantara pengukuran>10mmHg. Untuk menyingkirkan Hipotensi Ortostatik
, ukur 1 menit dan 3 menit setelah berdiri.

*)Konsensus Penatalaksanaan Hipertensi 2019 - Perhimpunan Dokter Hipertensi Indonesia / InaSH Februari 2019
 Exception for diagnosis of hypertension
• Patients with Hypertensive Urgency or Emergency ( BP ≥180/≥120)
• Patients with an initial screening BP ≥160/≥100 mmHg and have also
already a known target organ damage (eg.left ventricular hypertrophy
[LVH], hypertensive retinopathy, ischemic cardiovascular disease
 Assessment of Hypertension-Mediated
Organ Damage
Routine laboratory tests More detailed screening
for HMOD
Hemoglobin and/or hematocrit Echocardiography cardiac structure and function
Fasting blood glucose and glycated HbA1c Carotid ultrasound presence of carotid plaque or stenosis
Blood lipids: total cholesterol, LDL cholesterol, Abdominal ultrasound renal size and structure, abdominal aorta
HDL cholesterol, triglyceride and Doppler studies for evidence of aneurysmal dilatation,
adrenal glands, Renal artery Doppler
studies
Blood potassium and sodium, uric acid, PWV index of aortic stiffness
creatinine, Liver function, urinalysis
Basic screening ABI evidence of LEAD
Blood creatinine and eGFR, alb; creatinine ratio Cognitive function cognition in patients with symptoms
testing
Fundoscopy Brain imaging ischemic or hemorrhagic brain injury
12-lead ECG
When to refer a patient with hypertension
for hospital-based care
1. Patients suspected of secondary hypertension
2. Younger patients (<40 years) with grade 2 or more severe hypertension
in whom secondary hypertension has exactly been excluded
3. Patients on treatment of resistant hypertension
4. Patients in whom more detailed assessment of HMOD might influence
the decision of treatment
5. Patients with sudden onset of hypertension whose BP has previously
been normal
6. Other clinical circumstances in which consideration for more evaluation
by specialist is required.
TREATMENT OF HYPERTENSION
• 10 mmHg reduction in SBP or a 5mmHg reduction in DBP is
associated with significant reductions in all major cardiovascular
events by 20%, all-cause mortality by 10–15%, stroke by 35%,
coronary events by 20%, and heart failure by 40%
 Lifestyle interventions for patients with
hypertension or high-normal BP
Class Level
Salt restriction to < 5 g per day is recommended I A
It is recommended to restrict alcohol consumption to < 14 units per week for men and < 8 units per I A
week for women
Increased consumption of vegetables, fresh fruits, fish, nuts, unsaturated fatty acids (olive oil); low I A
consumption of red meat; and consumption of low-fat dairy products are recommended
Body weight control is indicated to avoid obesity (BMI > 30 kg/m2, or waist circumference > 102 cm in I A
men and > 88 cm in women) and aim for healthy BMI (about 20–25 kg/m2) and waist circumference
values (< 94 cm in men and < 80 cm in women) to reduce BP and cardiovascular risk.
Regular aerobic exercise (e.g. > 30 min of moderate dynamic exercise on 5–7 days per week) is I A
recommended
Smoking cessation and supportive care and referral to smoking cessation programmes are I B
recommended
It is recommended to avoid binge drinking. III A
 Initiation of hypertension treatment according to office BP
Recommendation Class Level
In patients with high–normal BP (130–139/85–89 mmHg):
• Lifestyle changes are recommended I A
• Drug treatment may be considered when their cardiovascular risk is very IIb A
high due to established CVD, especially CAD
In patients with grade 1 hypertension:
• Lifestyle interventions are recommended to determine if this will normalize II B
BP I A
• at low–moderate-risk and without evidence of HMOD, BP-lowering drug
treatment is recommended if the patient remains hypertensive after a I A
period of lifestyle intervention.
• at high risk or with evidence of HMOD, prompt initiation of drug treatment
is recommended simultaneously with lifestyle interventions
Prompt initiation of BP-lowering drug treatment is recommended in patients I A
with grade 2 or 3 hypertension at any level of CV risk, simultaneously with the
initiation of lifestyle changes
 Initiation of hypertension treatment according to office BP

Recommendation Class Level

In fit older patients with hypertension (even if aged > 80 years), BP-lowering A
drug treatment and lifestyle intervention are recommended when SBP is >
160 mmHg
BP-lowering drug treatment and lifestyle intervention are recommended for I A
fit older patients (> 65 years but not > 80 years) when SBP is in the grade 1 IIb A
range (140–159 mmHg), provided that treatment is well tolerated
Withdrawal of BP-lowering drug treatment on the basis of age, even when A
patients attain an age of > 80 years, is not recommended, provided that
treatment is well tolerated
 Drug treatment strategy for hypertension
Recommendation Class Level
Among all antihypertensive drugs, ACE inhibitors, ARBs, beta-blockers, CCBs, and I A
diuretics (thiazides and thiazide-like drugs such as chlorthalidone and indapamide)
have demonstrated effective reduction of BP and cardiovascular events in RCTs, and
thus are indicated as the basis of antihypertensive treatment strategies
Combination treatment is recommended for most hypertensive patients as initial I A
therapy. Preferred combinations should comprise a RAS blocker (either an ACE
inhibitor or an ARB) with a CCB or diuretic. Other combinations of the five major
classes can be used
It is recommended that beta-blockers are combined with any of the other major drug
classes when there are specific clinical situations, e.g. angina, post-myocardial
infarction, heart failure, or heart rate control
It is recommended to initiate an antihypertensive treatment with a two-drug I B
combination, preferably in an SPC. Exceptions are frail older patients and those at low
risk and with grade 1 hypertension (particularly if SBP is < 150 mmHg)
 Drug treatment strategy for hypertension
Recommendation Class Level
It is recommended that if BP is not controlled with a two-drug I A
combination, treatment should be increased to a three-drug
combination, usually a RAS blocker with a CCB and a
thiazide/thiazide-like diuretic, preferably as an SPC
It is recommended that if BP is not controlled with a three-drug I B
combination, treatment should be increased by the addition of
spironolactone or, if not tolerated, other diuretics such as
amiloride or higher doses of other diuretics, a beta-blocker, or an
alpha-blocker
The combination of two RAS blockers is not recommended III A
treatment strategy for uncomplicated hypertension
Office blood pressure treatment target range
 Resistant Hypertension
Recommendations Class Level
It is recommended that hypertension be defined as resistant to treatment (i.e. resistant
hypertension) when:
• Optimal doses (or best-tolerated doses) of an appropriate therapeutic strategy, which
should include a diuretic (typically an ACE inhibitor or an ARB with a CCB and a
thiazide/thiazide-type diuretic), fails to lower clinic SBP and DBP values to < 140 mmHg I C
and/or < 90 mmHg, respectively; and
• The inadequate control of BP has been confirmed by ABPM or HBPM; and
• After exclusion of various causes of pseudo-resistant hypertension (especially poor
medication adherence) and secondary hypertension.
Recommended treatment of resistant hypertension is:
• Reinforcement of lifestyle measures, especially sodium restriction
• Addition of low-dose spironolactonec to existing treatment
I B
• Or the addition of further diuretic therapy if intolerant to spironolactone, with either
eplerenone,c amiloride,c a higherdose thiazide/thiazide-like diuretic, or a loop diuretic
• Or the addition of bisoprolol or doxazosin
Hypertensive emergencies requiring immediate blood
pressure lowering with intravenous drug therapy

X
X

X
 Drug types, doses, and characteristics for treatment of hypertension emergencies

#
`
Follow Up
• it is important to revisit the patient at least once within the first 2
months to evaluate the effects on BP and assess possible side effects
until BP is under control.
• Elevated blood pressure at control visits should always lead
physicians to search for the cause(s), particularly the most common
ones such as poor adherence, persistence of a white-coat effect, and
occasional or more regular consumption of salt, drugs, or substances
that raise BP or oppose the antihypertensive effect of treatment (e.g.
alcohol or nonsteroidal anti-inflammatory
• the treatment regimen should be up titrated in a timely fashion
 Summary
• Hypertension is defined as an office SBP at least 140 and/or DBP at least
90mmHg, which is equivalent to a 24 h ABPM average of at least 130/80
mmHg, or a HBPM average at least 135/85mmHg.
• The importance of cardiovascular risk assessment using SCORE system and
detection of HMOD should be planned as part of risk assessment in
hypertensive patient
• Treatment of hypertension: importance of lifestyle interventions
• A simplified drug treatment algorithm, start treatment in most patients
with two drugs, not one, in a single-pill-combination strategy to treat
hypertension