1. HYPERTENSION

2. SOME PRELIMINARY DEFINITIONS
Blood pressure (BP), sometimes referred to as arterial blood pressure, is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs.
When used without further specification, "blood pressure" usually refers to the arterial pressure of the systemic circulation.
During each heartbeat, blood pressure varies between a maximum (systolic) and a minimum (diastolic) pressure. The blood pressure in the circulation is principally due to the pumping action of the heart.
 Differences in mean blood pressure are responsible for blood flow from one location to another in the circulation. The rate of mean blood flow depends on the resistance to flow presented by the blood vessels.
Mean blood pressure decreases as the circulating blood moves away from the heart through arteries and capillaries due to viscous losses of energy. Mean blood pressure drops over the whole circulation, although most of the fall occurs along the small arteries and arterioles.

3. SOME PRELIMINARY DEFINITIONS
Mean arterial pressure
The mean arterial pressure (MAP) is a term used in medicine to describe an average blood pressure in an individual.
The mean arterial pressure (MAP) is the average over a cardiac cycle and is determined by the cardiac output (CO), systemic vascular resistance (SVR), and central venous pressure (CVP)
CALCULATION : 1/3 (SBP + 2 DBP)
MAP is considered to be the perfusion pressure seen by organs in the body.
It is believed that a MAP that is greater than 60 mmHg is enough to sustain the organs of the average person. MAP is normally between 70 to 110 mmHg
If the MAP falls below this number for an appreciable time, vital organs will not get enough Oxygen perfusion, and will become ischemic.

4. SOME PRELIMINARY DEFINITIONS
Normal blood pressure
< 120/80 mmHg
Pre hypertension
or mmHg
Stage 1 hypertension:
Clinic blood pressure (BP) is 140/90 mmHg or higher and
ABPM ( ambulatory blood pressure monitoring) or HBPM ( home bpm) 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 systolic BP is 180 mmHg or higher or
Clinic diastolic BP is 110 mmHg or higher.
White-coat effect:
A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis
NOTES FOR PRESENTERS:
Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
White-coat effect A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis
Additional information:
Only use the hyperlinks if you arrived at this slide from a case. If you are reading this slide as part of your general introduction please ignore the hyperlinks in the boxes.

5. Aims of the talk To diagnose hypertension To treat hypertension Why ?
Who ?
When ?
How ?
To what extend treat hypertension ?

6. Second part : special issues in HPT
Primary HPT
Secundary HPT
HPT and Diabetes Mellitus
HPT in Pregnancy
Resistant HPT
New insights in HPT

8. Case scenario 1 : Mary Presentation
38 year old, attending for routine appointment about her contraception, for which she uses a diaphragm.
Medical history
From her records you notice that Mary’s blood pressure has increased since her last check twelve months ago. She does not smoke, drinks units of alcohol a week and has no notable medical history.
On examination
Mary’s first clinic blood pressure measurement is 158/94 mmHg. Her heart rate is 72 beats per minute and regular
You are considering a diagnosis of hypertension and therefore take another reading in Mary’s other arm. There is no notable difference between readings.
Next steps for diagnosis
Question 1.1
What would you do next?
NOTES FOR PRESENTERS:
Presentation
Mary is 38 years old. She is attending for a routine appointment.
Medical history
From her records you notice that Mary’s blood pressure has increased since her last check.
She does not smoke and has no notable medical history.
On examination
Mary’s first clinic blood pressure measurement is 158/94 mmHg. Her heart rate is 72 beats per minute and regular
Please note: when using automated devices to measure blood pressure, palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery.
You are considering a diagnosis of hypertension and therefore take another reading in Mary’s other arm. There is no notable difference between readings.
Next steps for diagnosis
Question 1.1
What would you do next?

9. Definitions Stage 1 hypertension:
Normal blood pressure
< 120/80 mmHg
Pre hypertension
or mmHg
Stage 1 hypertension:
Clinic blood pressure (BP) is 140/90 mmHg or higher and
ABPM ( ambulatory blood pressure monitoring) or HBPM ( home bpm) 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 systolic BP is 180 mmHg or higher or
Clinic diastolic BP is 110 mmHg or higher.
White-coat effect:
A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis
NOTES FOR PRESENTERS:
Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM) average blood pressure is 135/85 mmHg or higher.
Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.
Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher or clinic diastolic blood pressure is 110 mmHg or higher.
White-coat effect A discrepancy of more than 20/10 mmHg between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis
Additional information:
Only use the hyperlinks if you arrived at this slide from a case. If you are reading this slide as part of your general introduction please ignore the hyperlinks in the boxes.

10. Case scenario 1 : Mary
Answer 1.1 You would take Mary’s blood pressure a third time during the consultation. Question 1.2 The third reading is 149/93 mmHg. You suspect hypertension – what would you do next?
NOTES FOR PRESENTERS:
Relevant recommendations
Because automated devices may not measure blood pressure accurately if there is pulse irregularity (for example, due to atrial fibrillation), palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery. [new 2011] [1.1.2]
When considering a diagnosis of hypertension, measure blood pressure in both arms.
– If the difference in readings between arms is more than 20 mmHg, repeat the measurements.
– If the difference in readings between arms remains more than 20 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading. [new 2011] [1.2.1]
If blood pressure measured in the clinic is 140/90 mmHg or higher:
– Take a second measurement during the consultation.
– If the second measurement is substantially different from the first, take a third measurement.
Record the lower of the last two measurements as the clinic blood pressure. [new 2011] [1.2.2]
Question 1.2
The third reading is 149/93 mmHg. You suspect hypertension – what would you do next?

11. Case scenario 1 : Mary Answer 1.2
Organise for Mary to receive ambulatory blood pressure monitoring (ABPM) through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for
target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy).
coexisting disorders
Move to the next slide for a lists of tests and further investigations
NOTES FOR PRESENTERS:
Answer 1.2
You organise for Mary to receive ABPM through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Move to the next slide a lists of tests and further investigations and the relevant recommendations
Relevant recommendations
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] [KPI] [1.2.3]
When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] [1.2.9]
While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see recommendation 1.3.3) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool1 (see recommendation 1.3.2) [New 2011] [1.2.6]

12. How should the Blood Pressure be Measured?
In the Clinic
By the doctor?
By a nurse?
By an automated device?
Outside the Clinic
Home monitoring?
Ambulatory monitoring?

13. The White Coat Effect in the Real World (Little et al, BMJ 2002; 325: 254)
173 hypertensive patients in 3 general practices in the UK
Clinic (MD and RN), self-monitoring, and ABPM
White coat effect estimated as difference between other measures of BP and daytime BP: ABPM
Physician 19/11 mmHg
Nurse /8 mmHg
Nurse /6 mmHg
Self-monitoring in clinic 10/13 mmHg
Self-monitoring at home 5/6 mmHg

14. 24 Hour Ambulatory Monitoring

16. Home monitoring should be recommended for all patients
Prospective Studies Showing that Home BP Predicts CV Morbidity Better than Clinic BP
Author Year Population N Comments
Imai Population ABP & HBP predict, not CBP
Bobrie Treated HBP predicts, not CBP
Sega Population HBP predicts better than CBP
Home monitoring
should be recommended
for all patients

17. A Diagnosis of Hypertension
based exclusively on Physician readings is no longer acceptable
Measurement error
Small number of readings
Effects of recent activities
Expense & Inconvenience
White coat effect

18. Case scenario 1 : Mary Answer 1.2
Organise for Mary to receive ambulatory blood pressure monitoring (ABPM) through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for
target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy).
coexisting disorders
Move to the next slide for a lists of tests and further investigations
NOTES FOR PRESENTERS:
Answer 1.2
You organise for Mary to receive ABPM through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Move to the next slide a lists of tests and further investigations and the relevant recommendations
Relevant recommendations
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] [KPI] [1.2.3]
When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] [1.2.9]
While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see recommendation 1.3.3) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool1 (see recommendation 1.3.2) [New 2011] [1.2.6]

19. Case scenario 1 : Mary Answer 1.2 (continued)
test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
examine the fundi for the presence of hypertensive retinopathy
arrange for a 12-lead electrocardiograph or an echocardiography to be performed
NOTES FOR PRESENTERS:
Answer 1.2 continued
You would:
test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
examine the fundi for the presence of hypertensive retinopathy
arrange for a 12-lead electrocardiograph to be performed.
Relevant recommendations
For all people with hypertension offer to:
arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011] [1.3.3]

20. JNC 7 Recommendations for Routine Work-up of Hypertensive Patients
Routine Tests
Electrocardiogram
Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR, and calcium
Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides
Optional tests
Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

21. Case scenario 1 : Mary Answer 1.2
Organise for Mary to receive ambulatory blood pressure monitoring (ABPM) through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for
target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy).
coexisting disorders
Move to the next slide for a lists of tests and further investigations
NOTES FOR PRESENTERS:
Answer 1.2
You organise for Mary to receive ABPM through your GP practice. If you are responsible for setting up the monitoring device, you ensure that at least two measurements per hour are taken during Mary’s usual waking hours (for example, between 8 am and 10 pm). You would use the average value of at least 14 measurements taken during Mary’s usual waking hours to confirm a diagnosis of hypertension.
At the same time you would also carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy). Move to the next slide a lists of tests and further investigations and the relevant recommendations
Relevant recommendations
If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. [new 2011] [KPI] [1.2.3]
When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person’s usual waking hours (for example, between 08:00 and 22:00). Use the average value of at least 14 measurements taken during the person’s usual waking hours to confirm a diagnosis of hypertension. [new 2011] [1.2.9]
While waiting for confirmation of a diagnosis of hypertension, carry out investigations for target organ damage (such as left ventricular hypertrophy, chronic kidney disease and hypertensive retinopathy) (see recommendation 1.3.3) and a formal assessment of cardiovascular risk using a cardiovascular risk assessment tool1 (see recommendation 1.3.2) [New 2011] [1.2.6]

22. Overlap of Four Common Conditions
Obesity
SMOKING
Hypertension
Diabetes
Sleep Disordered Breathing

23. Case scenario 1 : Mary
Answer 1.2 (continued) You would also carry out a formal assessment of cardiovascular risk (Mary’s clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67). Additionally, you would also ascertain information about lifestyle in areas such as diet, exercise, alcohol, smoking and caffeine consumption and dietary sodium intake and offer appropriate lifestyle advice. Record the results of all investigations and assessment in Mary’s notes.
NOTES FOR PRESENTERS:
Answer 1.2 continued
You would also carry out a formal assessment of cardiovascular risk (Mary’s clinic blood pressure must be used in the calculation of cardiovascular risk) using a cardiovascular risk assessment tool, in line with Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67).
Additionally, you would also ascertain information about lifestyle in areas such as diet, exercise, alcohol, smoking and caffeine consumption and dietary sodium intake and offer appropriate lifestyle advice
Records the results of all investigations and assessment in Mary’s notes.
Relevant recommendations
Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67). [1.3.2] [2008]
Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension. [2004] [1.4.1]
Ascertain people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004] [1.4.2]
Related recommendations
See lifestyle intervention recommendations – 1.4.9
Additional information
The BHS have developed a section of their website to assist in the setting up and management of an Ambulatory Blood Pressure Monitoring clinic.

24. Comparison of a Sample of Global Coronary and Cardiovascular Risk Scores
Framingham
SCORE
PROCAM (Men)
Reynolds (Women)
Reynolds (Men)
Sample size
5345
205,178
5389
24,558
10,724
Age, range (y)
30 to 74; M:49
19 to 80; M:46
35 to 65; M:47
>45; M:52
>50; M:63
Mean follow-up (y) 12 13 10
10.2
10.8
Risk factors
considered
Age, sex, total
cholesterol, HDL
cholesterol,
smoking, systolic
blood pressure,
antihypertensive
Medications
Age, sex, total-
HDL cholesterol
ratio, smoking,
systolic blood
pressure
Age, LDL
family history,
diabetes,
triglycerides
Age, HbA1C (with
diabetes), smoking,
systolic blood pressure,
total cholesterol, HDL
cholesterol, hsCRP,
parental history of MI
at <60 y of age
Age, systolic blood
pressure, total
cholesterol, smoking,
hsCRP, parental history
of MI at <60 y of age
Endpoints
CHD (MI and
CHD death)
Fatal CHD
Fatal/nonfatal
MI or sudden
cardiac death
(CHD and CVD
combined)
MI, ischemic stroke,
coronary
revascularization,
cardiovascular death
MI, stroke, coronary
URLs for risk
calculators
hin.net/atpiii/calcul
ator.asp?usertype=
prof 
ore.org/pages/welc
ome.aspx 
taskforce.com/co
ronary_risk_asse
ssment.html
kscore.org/   
Note: Table 2 in full-text Guideline

25. JNC 7: CVD Risk Factors Hypertension* Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.

26. Case scenario 1 : Mary
Question 1.3 You identify her dietary sodium intake is greater than recommended levels. NICE PH25 on prevention of cardiovascular disease recommends that as part of preventing cardiovascular disease at a population level there should be a reduction in salt intake. By 2015 an adults maximum intake of salt per day should not exceed 6g and by 2025 this should be reduced to 3g What advice would you offer?
NOTES FOR PRESENTERS:
Question 1.3
You identify her dietary sodium intake is greater than recommended levels. NICE PH25 on prevention of cardiovascular disease recommends that as part of preventing cardiovascular disease at a population level there should be a reduction in salt intake. By 2015 an adults maximum intake of salt per day should not exceed 6g and by 2025 this should be reduced to 3g. Additionally, Mary’s exercise patterns are not in line with national guidance. (For the Chief Medical Office current recommendations for physical activity see UK physical activity guidelines)
What advice would you offer?

27. Case scenario 1 : Mary
Answer 1.3 You would advise that healthy diet and regular exercise can reduce blood pressure. You would also encourage her to keep her dietary sodium intake low as this can reduce blood pressure.
NOTES FOR PRESENTERS:
Answer 1.3
You would advise that healthy diet and regular exercise can reduce blood pressure. You would also encourage her to keep her dietary sodium intake low as this can reduce blood pressure. You should also inform her about local initiatives
Relevant recommendations
Ascertain people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004] [1.4.2]
Encourage people to keep their dietary sodium intake low, either by reducing or substituting sodium salt, as this can reduce blood pressure. [2004] [1.4.6]
A common aspect of studies for motivating lifestyle change is the use of group working. Inform people about local initiatives by, for example, healthcare teams or patient organisations that provide support and promote healthy lifestyle change. [2004] [1.4.9]

29. Dietary Approaches to Stop Hypertension (DASH)

30. Case scenario 1 : Mary
Question 1.4 The result of Mary’s ABPM shows daytime average blood pressure of 145/92 mmHg. What would your diagnosis and your next steps be?
NOTES FOR PRESENTERS:
Question 1.4
The result of Mary’s ABPM shows daytime average blood pressure of 145/92 mmHg.
What would your diagnosis and your next steps be?

31. Case scenario 1 : Mary
Answer 1.4 This result shows that Mary has stage 1 hypertension. If you had not already done so (answer 1.2), you would estimate cardiovascular risk and offer tests for target organ damage. You would use the results of the cardiovascular risk assessment to discuss prognosis and healthcare options with Mary. Continue to ascertain information about her lifestyle in order to provide tailored lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake) and exercise and alcohol consumption. See the definitions slide for ABPM diagnosis criteria
NOTES FOR PRESENTERS: Answer 1.4
This result shows that Mary has stage 1 hypertension.
If you had not already done so (answer 1.2), you would:
test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip
take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol
examine the fundi for the presence of hypertensive retinopathy
arrange for a 12-lead electrocardiograph to be performed.
You would use the results of the cardiovascular risk assessment to discuss prognosis and healthcare options with Mary.
Continue to ascertain information about her lifestyle in order to provide tailored lifestyle advice in accordance with the guideline on areas such as diet (including sodium and caffeine intake) and exercise and alcohol consumption.
See slide 3 for ABPM diagnosis criteria
Relevant recommendations:
Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension, both for raised blood pressure and other modifiable risk factors. [2004] [1.3.1]
Estimate cardiovascular risk in line with the recommendations on Identification and assessment of CVD risk in ‘Lipid modification’ (NICE clinical guideline 67). [1.3.2] [2008] (Clinic blood pressure measurements must be used in the calculation of cardiovascular risk.)
For all people with hypertension offer to:
arrange for a 12-lead electrocardiograph to be performed. [2004, amended 2011] [1.3.3]
Lifestyle advice should be offered initially and then periodically to people undergoing assessment or treatment for hypertension. [2004] [1.4.1]
Ascertain people's diet and exercise patterns because a healthy diet and regular exercise can reduce blood pressure. Offer appropriate guidance and written or audiovisual materials to promote lifestyle changes. [2004] [1.4.2]
See lifestyle interventions recommendations – 1.4.9

32. JNC 7: Target Organ Damage
Heart
Left ventricular hypertrophy
Angina or myocardial infarction
Atrial fibrillation
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

33. LEFT VENTRICULAR HYPERTROPHY
The Sokolow-Lyon index:
S in V1 + R in V5 or V6 (whichever is larger) ≥ 35 mm (≥ 7 large squares)
R in aVL ≥ 11 mm
Left axis deviation (QRS of -30° or more)

34. Retina Normal and Hypertensive RetinopathyB C
Normal Retina B
Hypertensive Retinopathy
A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro Strokes)

35. Stage I- Arteriolar Narrowing

36. Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking
AV Nicking

37. Stage III- Hemorrhages (H), Cotton Wool Spots and Exudats (E)

38. Stage IV- Stage III+Papilledema

39. Case scenario 1 : Mary Question 1.5
The results of the investigations for target organ damage and formal assessment of cardiovascular risk are:
no evidence of target organ damage
10-year cardiovascular risk less than 20%.
Nothing abnormal was detected in the other investigations you organised.
What is your next step and what treatment and follow up would you offer?

40. Case scenario 1 : Mary
Answer 1.5 (continued) Mary does not have target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater, therefore you would not offer antihypertensive drug treatment. You would continue to provide further tailored lifestyle advice (recommendation – 1.4.9) periodically in accordance with the NICE clinical guideline. The NICE clinical guideline recommends that you would provide Mary with an annual review of care to monitor blood pressure, provide her with support and discuss her lifestyle and symptoms.
NOTES FOR PRESENTERS:
Answer 1.5 (continued)
Mary does not have target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 20% or greater, therefore you would not offer antihypertensive drug treatment.
You would continue to provide further tailored lifestyle advice (recommendation – 1.4.9) periodically in accordance with the NICE clinical guideline. The NICE clinical guideline recommends that you would provide Mary with an annual review of care to monitor blood pressure, provide her with support and discuss her lifestyle and symptoms.
Relevant recommendations
Provide an annual review of care to monitor blood pressure, provide people with support and discuss their lifestyle, symptoms and medication. [2004] [1.7.3]
See recommendations to for lifestyle interventions

41. Aims of the talk To diagnose hypertension To treat hypertension Why ?
Who ?
When ?
How ?
To what extend treat hypertension ?

42. Goals of Treatment
Treating SBP and DBP to targets that are <140/90 mmHg
Patients with diabetes or renal disease, the BP goal is <130/80 mmHg
The primary focus should be on attaining the SBP goal.
To reduce cardiovascular and renal morbidity and mortality

43. Benefits of Treatment
Reductions in stroke incidence, averaging 35–40 percent
Reductions in MI, averaging 20–25 percent
Reductions in HF, averaging >50 percent.

44. Treatment guidelines (ESH/ESC 2007)
Average risk
Low added risk
Moderate added risk
High added risk
Very high added risk
ESH – ESC Guidelines Committee. J Hypertens 2007; 25: 1105–1187

45. Care pathway CBPM ≥140/90 mmHg & ABPM/HBPM ≥ 135/85 mmHg
Stage 1 hypertension
CBPM ≥160/100 mmHg & ABPM/HBPM ≥ 150/95 mmHg
Stage 2 hypertension
Care pathway
If target organ damage present or 10-year cardiovascular risk > 20%
Offer antihypertensive drug treatment
Consider specialist referral
If younger than 40 years
Offer lifestyle interventions
NOTES FOR PRESENTERS. Key priority recommendations are identified with [KPI] in these notes
Step 1 treatment:
Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011] [1.6.6]
Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011] [1.6.7]
Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age. If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.8] [KPI]
If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.9] [KPI]
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011] [1.6.10] [KPI]
Related recommendations:
Recommendations and have not been updated and reviewed since ‘Hypertension’ (NICE clinical guideline 34, 2006).
Step 2 treatment
If blood pressure is not controlled by step 1 treatment, offer step 2 treatment with a CCB in combination with either an ACE inhibitor or an *ARB. [new 2011] [1.6.13]
If a CCB is not suitable for step 2 treatment, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011] [1.6.14]
For black people of African or Caribbean family origin, consider an ARB* in preference to an ACE inhibitor, in combination with a CCB. [new 2011] [1.6.15]
*Choose a low-cost ARB
Additional information: the pathway above focuses on stage 1 and 2 hypertension. For the full care pathway see page 35 of the NICE guideline.
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

46. Case scenario 1 : Mary
Question 1.6 If Mary had been eligible to receive antihypertensive drug treatment, what should you consider when prescribing antihypertensive drugs for a woman of child-bearing potential?
NOTES FOR PRESENTERS:
Question 1.6
If Mary had been eligible to receive antihypertensive drug treatment, what should you consider when prescribing antihypertensive drugs for a woman of child-bearing potential?

47. Normal Blood Pressure Regulation
Hydraulic equation:
Blood Pressure = Cardiac output (CO) X Resistance to passage of blood through precapillary arterioles (PVR)
Physiologically CO and PVR is maintained minute to minute by – arterioles (1) postcapillary venules (2) and Heart (3)
Kidney is the fourth site – volume of intravascular fluid
Baroreflex, humoral mechanism and renin-angiotensin- aldosterone system regulates the above 4 sites
All antihypertensives act via interfering with normal mechanisms

48. The Renal response
Long-term blood pressure control – by controlling blood volume
Reduction in renal pressure - intrarenal redistribution of pressure and increased absorption of salt and water
Decreased pressure in renal arterioles and sympathetic activity – renin production – angiotensin II production
Angiotensin II:
Causes direct constriction of renal arterioles
Stimulation of aldosterone synthesis – sodium absorption and increase in intravascular blood volume

49. Antihypertensive Drugs
Diuretics:
Thiazides: Hydrochlorothiazide, chlorthalidone
High ceiling: Furosemide
K+ sparing: Spironolactone, triamterene and amiloride
MOA: Acts on Kidneys to increase excretion of Na and H2O – decrease in blood volume – decreased BP
Angiotensin-converting Enzyme (ACE) inhibitors:
Captopril, lisinopril., enalapril, ramipril and fosinopril
MOA: Inhibit synthesis of Angiotensin II – decrease in peripheral resistance and blood volume
Angiotensin (AT1) blockers:
Losartan, candesartan, valsartan and telmisartan
MOA: Blocks binding of Angiotensin II to its receptors

50. Antihypertensive Drugs
ß-adrenergic blockers:
Non selective: Propranolol (others: nadolol, timolol, pindolol, labetolol)
Cardioselective: Metoprolol (others: atenolol, esmolol, betaxolol)  
MOA: Bind to beta adrenergic receptors and blocks the activity
Calcium Channel Blockers (CCB):
Verapamil, diltiazem, nifedipine, felodipine, amlodipine, nimodipine etc.
MOA: Blocks influx of Ca++ in smooth muscle cells – relaxation of SMCs – decrease BP
ß and α – adrenergic blockers:
Labetolol and carvedilol
α – adrenergic blockers:
Prazosin, terazosin, doxazosin, phenoxybenzamine and phentolamine
MOA: Blocking of alpha adrenergic receptors in smooth muscles - vasodilatation

51. Antihypertensive Drugs –
Centrally acting: Clonidine, methyldopa
MOA: Act on central α2A receptors to decrease sympathetic outflow – fall in BP
K+ Channel activators:
Diazoxide, minoxidil, pinacidil and nicorandil
MOA: Leaking of K+ due to opening – hyper polarization of SMCs – relaxation of SMCs
Vasodilators:
Arteriolar – Hydralazine (also CCBs and K+ channel activators)
Arterio-venular: Sodium Nitroprusside

52. Starting treating HPT Step 1 treatment:
Offer people aged under 55 years step 1 antihypertensive treatment with an angiotensin-converting enzyme (ACE) inhibitor or a low-cost angiotensin-II receptor blocker (ARB). If an ACE inhibitor is prescribed and is not tolerated (for example, because of cough), offer a low-cost ARB. [new 2011]
Do not combine an ACE inhibitor with an ARB to treat hypertension. [new 2011]
Offer step 1 antihypertensive treatment with a calcium-channel blocker (CCB) to people aged over 55 years and to black people of African or Caribbean family origin of any age.
If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic. [new 2011]

53. Second part : special issues in HPT
Primary HPT
Secundary HPT
HPT and Diabetes Mellitus
HPT in Pregnancy
Resistant HPT
New insights in HPT

54. Types of Hypertension Primary HTN: also known as essential HTN.
accounts for 95% cases of HTN.
no universally established cause known.
Secondary HTN:
less common cause of HTN ( 5%).
secondary to other potentially rectifiable causes.

55. Primary HPT
Pathogenesis — The pathogenesis of primary hypertension (formerly called "essential" hypertension) is poorly understood. A variety of factors have been implicated, including:
Increased sympathetic neural activity, with enhanced beta-adrenergic responsiveness
Increased angiotensin II activity and mineralocorticoid excess.
Hypertension is about twice as common in subjects who have one or two hypertensive parents and multiple epidemiologic studies suggest that genetic factors account for approximately 30 percent of the variation in blood pressure in various populations
Reduced adult nephron mass may predispose to hypertension, which may be related to genetic factors, intrauterine developmental disturbance (eg, hypoxia, drugs, nutritional deficiency), and post-natal environment (eg, malnutrition, infections).

56. Causes of Secondary HTN
Common
Intrinsic renal disease
Renovascular disease
Mineralocorticoid excess
Sleep Breathing disorder
Uncommon
Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism

57. Secondary HTN-Clues in Medical History
Onset: at age < 30 yrs ( Fibromuscular dysplasia) or > 55 (atherosclerotic renal artery stenosis), sudden onset (thrombus or cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation (pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and daytime sleepiness (sleep disorders)

58. Secondary HTN-clues on Exam
Pallor, edema, other signs of renal disease.
Abdominal bruit especially with a diastolic component (renovascular)
Truncal obesity, purple striae, buffalo hump (hypercortisolism)

59. Secondary HTN-Clues on Routine Labs
Increased creatinine, abnormal urinalysis ( renovascular and renal parenchymal disease)
Unexplained hypokalemia (hyperaldosteronism)
Impaired blood glucose
( hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)

60. Renal Parenchymal Disease
Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of renal disease
Multifactorial cause for HTN including disturbances in Na/water balance, vasopressors/ prostaglandins imbalance
Renal disease from multiple etiologies.

61. Renovascular HTN
Atherosclerosis 75-90% ( more common in older patients)
Fibromuscular dysplasia 10-25% (more common in young patients, especially females)
Other
Aortic/renal dissection
Takayasu’s arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation

62. Fibromuscular Dysplasia, before
and after PTRA
Atherosclerotic RAS before and after stent
Safian & Textor. NEJM 344:6;

63. Renovascular hypertension (RVH)
Case presentation
59 yo male , no medical past history
Acute loin pain and headaches
BP : 180/100,bilateral; PR 88 rr
Acute renal failure:
s.creatinine: 1.13>1.75mg/ dl
microhematuria

64. Renovascular hypertension (RVH)
Risk factors:
no family history for HTN or CVD
Obesity
Heavy smoker

65. Renovascular hypertension (RVH)
Ultrasound of kidneys : symetric , normal size and shape, no uromechanical obstruction

66. Renovascular hypertension (RVH)
One year later: non optimal blood pressure on 3 medications : 160/90 HCTZ+ACEI+BB
Renal dysfunction: s.creatinine 1.41mg/dl
New US

67. Renovascular hypertension (RVH)
DMSA RENAL SCAN

68. Atherosclerotic renal artery stenosis – do we really know what to do?

69. Treatment decisions for management of renal artery stenosis must take into account the likelihood of:
1- Blood pressure reduction,
2- Renal preservation,
3- or Both

70. RENOGRAM WITH ACE-INHIBITOR
DUPLEX-KIDNEY US
MR ANGIOGRAPHY
SPIRAL CT ANGYOGRAPHY
GOLD STANDARD: RENAL ARTERIOGRAPHY

71. Renin-Angiotensin System
Angiotensinogen
RAS
Renin
Angiotensin I
Captopril
ACE
Angiotensin II
Aldosterone Vasoconstriction
HTN

72. Effect of RAS on GFR

73. Captopril Renal Scan MAG 3

77. Renal revascularization is favored in patients who have:
1- Bilateral renal artery stenosis and a serum creatinine level 1.5 mg/dL,
2- Unilateral renal artery stenosis and fractional GFR 40%,
3- ACE inhibitor–induced renal failure,
4- Hypertensive crisis, and
5- Nonischemic pulmonary edema.
Medical therapy is favored over renal revascularization in patients with:
1-Unilateral renal artery stenosis and serum creatinine level 2.5mg/dL,
2- Renal length 7 cm,
3- Proteinuria 1 g/d,
4- Severe diffuse intrarenal vascular disease, and target kidney renal resistance 80, all of which provide evidence of underlying advanced nephropathy.

78. Mineralocorticoid excess

80. Cardiovascular Events and Primary Aldosteronism
Rate of Cardiovascular Events and Cardiac Structure in Primary Aldosteronism
Primary Aldo (n=124)
Essential HTN (n=465)
Odds ratio (95% CI)
p value
Stroke (%)
12.9
3.4
4.2 ( )
< 0.001
Myocardial infarction (%)
4.0
0.6
6.5 (1.5–27.4)
< 0.005*
Atrial fibrillation
7.3
12.1 ( )
<0.0001*
Echo LVH (%) 34 24
1.6 ( )
< 0.01
EKG LVH (%) 32 14
2.9 ( )
*Fisher exact test.
CI = confidence interval; LVH = left ventricular hypertrophy
Milliez P et al. J Am Coll Cardiol 2005; 45(8):

81. Case Detection Higher prevalence: Young age of HBP onset
Severe refractory HBP
FH of PA or CVA <40 y/o
Hypokalemia

82. Prevalence of Primary Aldosteronism in Hypertensive Patients
14 ―
12 ―
10 ―
8 ―
6 ―
4 ―
2 ―
0 ―
Normal Stage 1 Stage Stage 3
1.55
1.99
13.2
8.02
Mosso L et al. Hypertension 2003; 42(2):

83. Screening for PA : ARR Aldosterone / PRA > 30 / 1
Aldosterone >15 ng% (36% may have levels 9-16 ng%)
24 hour urine: Aldosterone > 12 mcg/day with sodium > 200 meq /day

84. PA : Confirmation Saline Suppression Test (>6 ng/dL)
Florinef Suppression Test ( >6ng/dL)
24 hr urine aldosterone on high salt diet >12 mcg

85. Subtypes of Primary Aldosteronism
May be treated surgically for cure
Aldosterone-producing adenoma (APA)
Primary (unilateral) adrenal hyperplasia
Aldosterone-producing adrenocorticoid carcinoma
Should always be treated medically
Idiopathic hyperaldosteronism (BAH)
Glucocorticoid-remediable aldosteronism (FH-1)
FH-2

86. New insights in HPT
Renal Denervation

87. Renal Sympathetic Activation: Efferent Nerves Kidney as Recipient of Sympathetic Signals
Renal Efferent
Nerves
↑ Renin Release  RAAS activation
↑ Sodium Retention
↓ Renal Blood Flow 87 87

88. Renal Sympathetic Activation: Afferent Nerves Kidney as Origin of Central Sympathetic Drive
Vasoconstriction
Atherosclerosis
Hypertrophy
Arrhythmia
Oxygen Consumption
Sleep Disturbances
Insulin
Resistance
Renal Afferent
Nerves
↑ Renin Release  RAAS activation
↑ Sodium Retention
↓ Renal Blood Flow 88 88

89. Renal Nerve Anatomy Nerves arise from T10-L2
The nerves arborize around the artery and primarily lie within the adventitia
Vessel
Lumen
Media
Adventitia
Renal Nerves 89 89 89 89

90. Renal Nerve Anatomy Allows a Catheter-Based Approach
Spacing of e.g. 5 mm.
Renal artery access via standard interventional technique
4-6 two-minute treatments per artery
Proprietary RF generator
Automated
Low power
Built-in safety algorithms 90 90

91. Symplicity HTN-2: Lancet Conclusions
Catheter-based renal denervation, done in a multicentre, randomised trial in patients with treatment-resistant essential hypertension, resulted in significant reductions in BP.
The magnitude of BP reduction can be predicted to affect the development of hypertension-related diseases and mortality
The technique was applied without major complications.
This therapeutic innovation, based on the described neural pathophysiology of essential hypertension, affirms the crucial relevance of renal nerves in the maintenance of BP in patients with hypertension.
Catheter-based renal denervation is beneficial for patients with treatment-resistant essential hypertension.
Symplicity HTN-2 Investigators. Lancet. 2010;376: 91