Individualized Therapy for Hypertension

1. Individualized Therapy for Hypertension Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847 1

2. To describe the "stepwise approach" to therapy. To discuss: 1. The evidence for the role of lifestyle changes 2. The indications, contraindications and side effects of various antihypertensive classes Objectives

3. Prompt diagnosis • Assess the risk • Achieve target levels of BP • Lifestyle • Combination therapy • Promote adherence Important Messages for the Management of Hypertension

4. Treat Hypertension in the Context of Overall Cardiovascular Risk 1. Global cardiovascular risk should be assessed. 2. In the absence of data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds. 3. Shared decision-making may improve the effectiveness of preventive health interventions. Counting risk factors underestimates the risk

5. Threshold for Initiation of Treatment and Target Values

6. management of hypertension

7. 1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet 2. Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week or more 3. Reduction in alcohol consumption in those who drink excessively ( ( ≤ 2 drinks/ day) Weight loss (≥ 5 Kg) in those who are over weight (BMI>25) Waist Circumference < 102 cm for men < 88 cm for women 5. In individuals considered salt-sensitive, such as:Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day 6. Smoke free environment Lifestyle Recommendations

8. Lifestyle:

9. Strongly consider prescription if: • Average DBP equal or over 90 mmHg • Hypertensive Target-organ damage (or CVD) • Independent cardiovascular risk factors: • Elevated systolic BP • Cigarette smoking • Abnormal lipid profile • Strong family history of premature CV disease • Truncal obesity • Sedentary Lifestyle Indications for Pharmacotherapy • Average DBP equal or over 80 mmHg in a patient with diabetes

10. NO YES Treatment in the absence of compelling indication Individualized Treatment (with compelling indications) Choice of Pharmacological Treatment Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions?

11. Treatment of Adults with Systolic-Diastolic Hypertension without Other Compelling Indications

12. ARB ACE-I monotherapy TARGET <140 mm Hg systolic and < 90 mmHg diastolic INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification therapy Beta-blocker* Thiazide Long-acting CCB * No longer preferred as routine initial therapy

13. 1. Dual Combination Therapy • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? • Resistant Hypertension? 2. Triple or Quadruple Therapy Combination Therapy If partial response to monotherapy If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

14. TARGET <140 mm Hg systolic and < 90 mmHg diastolic Lifestyle modification therapy Long-acting CCB Beta-blocker* Thiazide diuretic ACE-I ARB Dual Combination • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? Triple or Quadruple Therapy Summary * Not indicated as first line therapy over 60

15. Useful Dual Combinations For additive hypotensive effect in dual therapy Combine an agent from Column 1 with any in Column 2 * Caution should be exercised when using a non DHP-CCB and a beta-blocker (ACE=Angiotensin Converting Enzyme, ARB=Angiotension Receptor Blocker)

16. Useful Triple Therapy Combinations For additive hypotensive effect in triple therapy Combine 2 agents from one Column with any in the other Column * Caution should be exercised when using a non DHP-CCB and a beta-blocker

17. Specific drugs for specific patients

18. Multiple Antihypertensive Agents Are Needed to Achieve Target BP UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 AASK MAP <92 IDNT SBP <135/DBP <85 ALLHAT SBP <140/DBP <90 Number of antihypertensive agents Trial Target BP (mm Hg) 1 2 3 4 DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure. Bakris GL et al. Am J Kidney Dis. 2000;36:646-661. Lewis EJ et al. N Engl J Med. 2001;345:851-860. Cushman WC et al. J Clin Hypertens. 2002;4:393-405.

19. pharmacological treatment for hypertensive patients withother compelling indications

20. Individualized treatment • Compelling indications: • Smoking • Ischemic Heart Disease • Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI • Left Ventricular Systolic Dysfunction • Cerebrovascular Disease • Left Ventricular Hypertrophy • Non Diabetic Chronic Kidney Disease • Renovascular Disease • Diabetes Mellitus • With Diabetic Nephropathy • Without Diabetic Nephropathy • Global Vascular Protection for Hypertensive Patients • Statins • Aspirin

21. According to JNC7:

22. Treatment for Isolated Systolic Hypertension without Other Compelling Indications

23. Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB Treatment Algorithm TARGET <140 mmHg Systolic BP INITIAL TREATMENT AND MONOTHERAPY

24. Summary TARGET <140 mmHg Systolic BP Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB Dual combination • CONSIDER • Nonadherence? • Secondary HTN? • Interfering drugs or lifestyle? • White coat effect? *If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). Triple or Quadruple* combination

25. Thiazide - type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. • Certain high-risk conditions are compelling indications for other drug classes. • Most patients will require two or more antihypertensive drugs to achieve goal BP. • If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic. Important Points: (JNC7)

26. The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated. • Motivation improves when patients have positive experiences with, and trust in, the clinician. • Empathy builds trust and is a potent motivator. • The responsible physician’s judgment remains paramount. Important Points: (JNC7)

27. According to JNC7:

28. CVD risk has now replaced CHD risk (to include strokes) The current CVD risk threshold is >20% over 10 years (equivalent to CHD risk of 15%) Current advice from the BHS is to prescribe a statin in all patients with hypertension and a CVD risk of 20% or greater. Unless contra-indicated low dose aspirin should be considered in patients over 50 with a CVD risk of >20% when the blood pressure is controlled. CVD risk has implications regarding levels to treat. Hypertension and CVD risk

29. Specialist referral is indicated if there is a possible underlying cause or presenting as: • sudden onset • worsening of hypertension • resistance to multi-drug regimen three or more drugs • Hypertension diagnosed in young age ( < 35 years) • persistent noncompliance When to refer? Saudi Hypertension Management Guidelines 2007

30. Thank u