Hypertension Guidelines: ESH/ESC 2013

Dr. Akshay MehtaNanavati Hospital

Asian Heart Institute

Definitions and classification of office blood pressure levels (mmHg)

Category Systolic Diastolic

Optimal < 120 And < 80

Normal 120-129 And/or 80-84

High normal 130-139 And/or 85-89

Grade 1 hypertension

140-159 And/or 90-99

Grade 2 hypertension

160-179 And/or 100-109

Grade 3 hypertension

> = 180 And/or > = 110

Isolated systolic hypertension

>= 140 and < 90

BP Goals

• all be treated to <140/90 mm Hg

• Except : diabetes (<85 mm Hg diastolic)

• In patients near 80 years age, the systolic blood-

pressure target should be 140 to 150 mm Hg, but

physicians can go lower than 140 mm Hg if the

patient is fit and healthy-mentally & physically

When measuring BP in the office, care should be taken:

Emphasis on ambulatory blood-pressure monitoring (ABPM).

• It provides a large number of measurements

outside the medical environment

• More closely correlated to end-organ damage

and cardiovascular events than office blood-

pressure measurements

Home BP v/s Ambulatory BP

Home BP

• Multiple measurements over

several days, or even longer

periods

• in the individual’s usual

environment

• notes day-to-day BP variability

• cheaper

• more widely available and

• more easily repeatable.

Ambulatory BP

• BP data during routine, day-to-

day activities and

• during sleep

• Waking surge

• quantifies short-term BP

variability

• Correlation with symptoms

• Most accurate

Definitions of hypertension by office and out-of-office blood pressure levels

Category Systolic BP(mmHg)

Diastolic BP (mmHg)

Office BP >= 140 And/or >= 90

Ambulatory BP

Daytime (or awake)

>= 135 And/or >= 85

Nighttime (or asleep)

> = 120 And/or >= 70

24 hour > = 130 And/or >= 80

Home BP >= 135 And/or > = 85

Life style changes

Salt

• A reduction to 5 g per day can decrease systolic blood

pressure about 1 to 2 mm Hg in normotensive individuals and

4 to 5 mm Hg in hypertensive patients, he said.

Wt loss

• Losing about 5 kg can reduce systolic blood pressure by as

much as 4 mm Hg, aerobic endurance training

• can reduce systolic blood pressure 7 mm Hg

How long to continue lifestyle changes alone ?

• For low/moderate-risk individuals a few

months

• For higher-risk patients, a few weeks

When to start drug Rx

Consider BP level and correlate with overall risk:

• cardiovascular risk factors

• overt cardiovascular disease

• asymptomatic organ damage

• diabetes

• chronic kidney disease.

Asymptomatic Target Organ Damage (TOD)

√

√

Pulse pressure ( in the elderly) >= 60 mmHg

Electrocardiograhic LVH( Sokolow-Lyon index > 3.5 mV; RaVL > 1.` mV; Cornell voltage duration product> 244 mV* ms), or

Echocardiographic LVH [ LVM index: men > 115 g/m2; women > 95 g/m2 (BSA)]a

Carotid wall thickening (IMT > 0.9 mm) or plaque

Carotid- femoral PWV > 10 m/s

Ankle- brachial index < 0.9

CKD with Egfr 30-60 ml/min/1.73 m2 (BSA)

Microalbuminuria (30-300 mg/24 h), or albumin- creatinine ratio(30-300 mg/g; 3.4-34 mg/mmol) (preferentially on morning spot urine)

When to start drug Rx ?Correlate BP with Risk

When to start drug Rx ?

When to start drug Rx

• HIGH N SBP 130-139

DBP 80-89…………TLC, No drugs

• Grade III >180

>110 …..TLC +Immediate drugs

………When to start drug Rx• Grade I 140-159 90-99 + no RF….. TLC for mths + RF ….. TLC for wks +CVD or TOD or D/CKD …….TLC + Drugs • Grade II 160-179 100-109 + 2 or more RF… TLC for weeks + CVD/TOD/D/CKD… TLC+Drugs

Combination Rx

• For patients at high risk for cardiovascular events or those

with a markedly high baseline blood pressure

• In those at low or moderate risk for cardiovascular events or

with mildly elevated blood pressure, a single starting agent is

preferred.

• For a high-risk individual, you can't play around with one drug

after another, trying to control blood pressure

Dual renin-angiotensin system (RAS) blockade—ARBs, ACE inhibitors, and direct renin inhibitors

• NO because of concerns of hyperkalemia, low

blood pressure, and kidney failure.

• risk of cancer that has recently been attached

to ARBs has been disproven

Drugs to be preferred in specific conditions

Compelling and possible contra-indications to the use of antihypertensive drugs

Renal Denervation

Renal denervation- ESH/ECS 2013

• Simply labeled as "promising" therapy

• Yet to establish safety and efficacy against the best possible drug regimens

• Will it translate into reductions in cardiovascular morbidity and mortality ?

THANK YOU!!!