1 1 Individualized Therapy forHypertension Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

 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

 Prompt diagnosis  Assess the risk  Achieve target levels of BP  Lifestyle  Combination therapy  Promote adherence

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

ConditionInitiation SBP / DBP mmHg Diastolic ± systolic hypertension  140/90 Isolated systolic hypertension SBP = or >160 Diabetes  130/80 Renal disease (  130/80) Proteinuria >1 g/day (  125/75) Target SBP / DBP mmHg <140/90 <140 <130/80 <125/75

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 minutes of moderate cardiorespiratory activity 4/week or more 3. Reduction in alcohol consumption in those who drink excessively ( ( ≤ 2 drinks/ day) 4.Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25) 5.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

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  Average DBP equal or over 80 mmHg in a patient with diabetes

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

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

CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Resistant Hypertension? 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). 2. Triple or Quadruple Therapy 1. Dual Combination Therapy If partial response to monotherapy

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

Column 1Column 2 Thiazide diuretic Long-acting calcium channel blocker* Beta adrenergic blocker ACE Inhibitor ARB 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)

Column 1Column 2 Thiazide diuretic Long-acting calcium channel blocker* Beta adrenergic blocker ACE Inhibitor ARB 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

Target BP (mm Hg) Number of antihypertensive agents 1 Trial 234 AASKMAP <92 UKPDSDBP <85 ABCDDBP <75 MDRDMAP <92 HOTDBP <80 IDNTSBP <135/DBP <85 ALLHATSBP <140/DBP <90 DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure. Bakris GL et al. Am J Kidney Dis. 2000;36: Lewis EJ et al. N Engl J Med. 2001;345: Cushman WC et al. J Clin Hypertens. 2002;4:

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

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

CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Thiazide diuretic Long-acting DHP CCB Dual combination Triple or Quadruple* combination Lifestyle modification therapy ARB TARGET <140 mmHg Systolic BP * 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).

 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.

 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.

 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.

Saudi Hypertension Management Guidelines 2007  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