1. Recent Guidelines for the Management of Arterial Hypertension
Apostolos I. Hatzitolios
Associate Professor of Internal Medicine
1st Propedeutic Department of Internal Medicine
Department of Vascular Diseases and Hypertension
Aristotle University of Thessaloniki, AHEPA Hospital
Thessaloniki, Central Macedonia, HELLAS

2. Diagnosis, regulation and treatment of hypertension in USA
NHANES III (Phase 2)
NHANES III (Phase 1)
51%
73%
68%
31%
55%
54%
10%
29%
27%
Diagnosis
NHANES II
Treatment
Regulation
NHANES
70%
59%
34%
Hypertensive %

3. Guidelines 2007 European Society of Hypertension
European Society of Cardiology
Journal of Hypertension 2007;25:

4. Definitions and Classification of BP Levels (mmHg)
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
and/or
80-84
High Normal
85-89
Grade 1
Hypertension
90-99
Grade 2
Grade 3
≥ 180
≥ 110
Isolated Systolic
≥ 140
< 90

5. Stratification of CV risk in four categories
Blood pressure (mmHg)
Other risk factors, TOD or disease
Normal
SBP or DBP 80-84
High normal
SBP or DBP 85-89
Grade 1 HT
SBP or DBP 90-99
Grade 2 HT
SBP or DBP
Grade 3 HT SBP ≥180 or DBP ≥110
No other risk factors
Average
risk
Low
added risk
Moderate added risk
High added risk
1-2 risk factors
Very high added risk
3 or more risk factors, TOD, DM or MS
Established CV or renal disease

6. High/Very High Risk Subjects
BP ≥ 180 mmHg systolic and/or ≥ 110 mmHg diastolic
High systolic BP > 160 mmHg with low diastolic BP (< 70 mmHg)
≥ 3 cardiovascular risk factors
Diabetes mellitus or Metabolic syndrome
Hypertension Target Organ Damage or Established CV or renal disease

7. High/Very High Risk Subjects
One or more subclinical organ damages:
Electrocardiographic (particularly with strain) or echocardiographic (particularly concentric) LVH
Ultrasound evidence of carotid artery wall thickening or plaque
Increased arterial stiffness
Slight increase in serum creatinine
Reduced estimated glomerular filtration rate or creatinine clearance
Microalbuminuria or proteinuria
Established cardiovascular disease
Heart
Cerebrovascular
Renal
Peripheral artery
Ophthalmic disease

8. Appropriate BP measurement
Allow the patients to relax for several minutes in a quiet place
Take at least two measurements spaced by 1-2 min and additional measurements if the first two are quite different [use phase I and V (disappearance) Korotkoff sounds to identify SBP and DBP]
Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and children
Have the cuff at the heart level
Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one
Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients and in other conditions in which postural hypotension may be frequent or suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)
Measure heart rate (at least 30 sec) after the second measurement in the sitting position

9. Home BP measurements
Self-measurement of BP at home is of clinical value, its prognostic significance is now demonstrated and these measurements should be encouraged in order to:
provide more information on the BP lowering effect of treatment at through and thus on the therapeutic coverage throughout the dose-to-dose time interval
improve patient’s adherence to treatment regimens
On the contrary, Self-measurement of BP should be discouraged when:
it causes anxiety to the patient
it induces self-modification of the treatment regimen

10. Ambulatory BP measurements
Although office BP should be used as reference, 24-h ambulatory BP monitoring may improve prediction of CV risk
Ambulatory BP should be considered, in particular, when:
considerable variability of office BP is found over the same or different visits
high office BP is measured in subjects otherwise at low CV risk
there is a marked discrepancy between BP values measured in the office and at home
there is a resistance to drug treatment
hypotensive episodes are suspected, particularly in elderly and diabetic patients
office BP is elevated in pregnant women and pre-eclampsia is suspected

11. BP thresholds (mmHg) for definition of Hypertension with different types of measurement
SBP
DBP
Office or clinic
140 90
Home 85
24-hour 80
Day
Night
120 70

12. Particular conditions
Isolated office hypertension (White coat hypertension)
Office BP persistently ≥ 140/90 mmHg
Normal daytime ambulatory or home BP < /85
Due to stress and SNS stimulation. CV risk is less than by raised office and ambulatory or home BP
but may be slightly greater than by normotension
Isolated ambulatory hypertension (Masked hypertension)
Office BP persistently normal (< 140/90 mmHg)
Elevated ambulatory (≥ /80 mmHg) or home BP (≥ /85 mmHg)
CV risk is close to that of hypertension. Due to «normal» variation of circadian rhythm, autonomic
nervous system dysfunction, physical or psychological stress, night consumption of alcohol, smoking
and sleep apnea.

13. Guidelines for family and clinical history
Duration and previous level of high BP
Indications of secondary hypertension:
family history of renal disease (polycystic kidneys)
renal disease, urinary tract infection, haematuria, analgesic abuse (parenchymal renal disease)
drug/substance intake, such as: oral contraceptives, liquorice, carbenoxolone, nasal drops, amphetamines, steroids, non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine, cocaine (drug induced hypertension)
episodes of sweating, headache, anxiety, palpitation (phaeochromocytoma)
episodes of muscle weakness and tetany (aldosteronism)

14. Guidelines for family and clinical history
3. Risk factors:
family and personal history of hypertension and CV disease
family and personal history of dyslipidaemia
family and personal history of diabetes mellitus
smoking habits
dietary habits ; lack of physical exercise
obesity
snoring; sleep apnea (information also from partner)
Personality type; stress due to personal, family and environmental factors

15. Guidelines for family and clinical history
4. Symptoms of organ damage:
brain and eyes: headache, vertigo, transient ischemic attacks, sensory or motor deficit , impaired vision
heart: palpitation, chest pain, shortness of breath, swollen ankles
kidneys: thirst, polyuria, nocturia, haematuria
peripheral arteries: cold extremities, intermittent claudication
5. Previous antihypertensive therapy:
Drug(s) used, efficacy and adverse effects

16. Physical examination for secondary hypertension, organ damage and visceral obesity
Signs suggesting secondary hypertension
Features of Cushing syndrome
Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidneys)
Auscultation of abdominal murmurs
(renovascular hypertension)
Auscultation of precordial or chest murmurs; Diminished and delayed femoral pulses femoral BP
(aortic coarctation or aortic disease)

17. Physical examination for secondary hypertension, organ damage and visceral obesity
Signs of organ damage
Brain: murmurs over neck arteries, motor or sensory defects
Retina: fundoscopic adnormalities
Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rates, peripheral oedema
Peripheral arteries: absence, reduction or asymmetry of pulses, cold extremities, ischemic skin lesions
Carotid arteries: systolic murmurs

18. Physical examination for secondary hypertension organ damage and visceral obesity
Evidence of visceral obesity
Body weight
Increased body mass index
[body weight (Kg)/height (m2)]
overweight ≥ 25 Kg/m2; obesity ≥ 30 Kg/m2
Increased waist circumference
(standing position) ♂ > 102 cm; ♀ > 88 cm

19. Laboratory investigations
Routine tests:
Hemoglobin and hematocrit
Fasting plasma glucose
Fasting serum triglycerides
Serum total cholesterol, LDL-cholesterol, HDL-cholesterol
Serum creatinine, potassium, uric acid
Urinalysis (complemented by microalbuminuria dipstick test and microscopic examination)
Estimated creatinine clearance (Cockroft-Gault formula) or glomerular filtration rate (MDRD formula)
Electrocardiogram (ECG)
Thorax X-ray

20. Laboratory investigations
Recommended tests
Echocardiogram
Carotid ultrasound
Quantitative proteinuria (if dipstick test positive)
Ankle-brachial BP index
Fundoscopy
Glucose tolerance test (if fasting plasma glucose > 5,6 mmol/l (102 mg/dL)
Home and 24h ambulatory BP monitoring
Pulse wave velocity measurement (where available)

21. Laboratory investigations
Extended evaluation (domain of the specialist)
Further search for cerebral, cardiac, renal and vascular disease, mandatory in complicated hypertension
Search for suspected secondary hypertension suggested by history, physical examination or routine tests:
measurement of renin, aldosterone,
corticosteroids,
catecholamines in plasma and/or urine;
renal and adrenal ultrasound;
computer-assisted tomography (CT);
magnetic resonance imaging (MRI);
arteriographies

22. Searching for subclinical organ damage
Importance of subclinical organ damage as an intermediate stage in the continuum of vascular disease and as a determinant of total CV risk.
Heart
Electrocardiography should be part of all routine assessment of hypertensives in order to detect LVH, LV strain, ischemic condition and arrhythmias
Echocardiography is recommended whenever a more sensitive detection of LVH is considered useful. Concentric remodeling and hypertrophy carries the worst prognosis, while LV diastolic dysfunction, consists an early ECHO sign, which can be evaluated by Doppler measurement of transmittal velocities.

23. Searching for subclinical organ damage
Blood vessels
Ultrasound scanning of extracranial carotid arteries is recommended in symptomatic carotid stenosis (previous TIA), but also in asymptomatic atherosclerosis suspected by carotid murmurs and reveals vascular hypertrophy, increased IMT, thickening of carotid bifurcation and presence of plaques.
Peripheral large artery stiffening (an important vascular alteration leading to isolated systolic hypertension in the elderly), can be measured by pulse wave velocity. This method might be more widely recommended if its availability were greater.
A low ankle-brachial BP index (<0,9) signals advanced peripheral artery disease

24. Searching for subclinical organ damage
Kidney
Diagnosis of hypertension-related renal damage is based on a reduced renal function or detection of hyperalbuminuria
Measurement of serum creatinine as well as estimation of glomerular filtration rate by specific formulas, should be part of routine procedures, allowing classification of renal dysfunction and respective stratification of CV risk
Presence of urinary protein should be sought in all hypertensives by dipstick. In dipstick negative patients, low grade albuminuria, namely microalbuminuria, should also be determined in spot urine and as ratio to creatinine excretion

25. Searching for subclinical organ damage
Fundoscopy
Examination of eye grounds is recommended only in hypertensive with severe hypertension, since mild retinal changes (grade 1: arteriolar narrowing; grade 2: arteriovenous nipping) appear to be largely non-specific alterations except in young patients
In contrast, grade 3 (hemorrhages and exudates) and 4 (papilloedema) retinal changes, present only in severe hypertension and are associated with an increased CV risk

26. Searching for subclinical organ damage
Brain
Silent brain infarcts, lacunar infarction (small / deep vessel disease), microbleeds and white matter lesions are not infrequent among hypertensives, especially elderly and can be detected by MRI or CT (MRI being generally superior to CT)
Availability and costs do not allow use of these techniques in asymptomatic patients
In elderly hypertensives, cognitive tests (e.g. Mini-mental scale) may also help to detect initial brain deterioration

27. Treatment of hypertension
Non pharmacological
Pharmacological

28. Goals of treatment
Primary goal of treatment is to achieve the maximum reduction in the long-term total risk of CV disease
This requires not only the treatment of raised BP per se, but also of all associated reversible CV risk factors
BP should be reduced at least below 140/90 mmHg and even to lower values, if tolerated, in all hypertensive patients

29. Goals of treatment
Target BP should be at least < 130/80 mmHg in diabetics and in high or very high risk patients, such as those with associated clinical conditions, mainly stroke, myocardial infarction, renal dysfunction. Especially in proteinuria (<125/75 mmHg when >1gr/24h)
Despite the use of combination treatment, reducing SBP to <140 mmHg may be difficult and more so if the target is a reduction to <130 mmHg, moreover while a DBP reduction < 70 mmHg could be not beneficial.
Additional difficulties should be expected in elderly, obese and diabetic patients and in general, in patients with CV damage. In order to more easily achieve goal BP, antihypertensive treatment should be initiated before significant CV damage develops

30. Lifestyle changes
Lifestyle measures should be instituted whenever appropriate, in all patients, including those who require drug treatment, in order to lower BP, to control other risk factors and to reduce the number of doses of antihypertensive drugs to be subsequently administered
Lifestyle measures are also advisable in subjects with high normal BP ( / 85-89) and additional risk factors to reduce the risk of developing hypertension
Lifestyle recommendations should not be given as lip service but instituted with adequate behavioral and expert support and reinforced periodically

31. Lifestyle changes
Lifestyle measures widely recognized to lower BP or CV
risk are:
smoking cessation
weight reduction (and stabilization)
physical exercise
reduction of salt intake
reduction of excessive alcohol intake
increase in fruit and vegetable intake and decrease in saturated and total fat intake (Mediterranean diet)

32. Possible reduction in SBP
Lifestyle changes
Lifestyle changes
Possible reduction in SBP
(mmHg; mean= 38 mmHg)
Weight loss
5-20 mmHg/10Kg
Adoption of DASH diet
8-14 mmHg
Reduction of salt intake
2-8 mmHg
Physical exercise
4-9 mmHg
Reduction of excessive alcohol intake
2-4 mmHg
As long-term compliance with lifestyle measures is low and the BP response highly variable, patients under non pharmacological treatment should be followed-up closely to start drug therapy when needed and timely

33. Initiation of antihypertensive treatment
Other risk factors, Target Organ Damage or disease
Normal
SBP or DBP 80-84
High normal
SBP or DBP 85-89
Grade 1 HT
SBP or DBP 90-99
Grade 2 HT
SBP or DBP
Grade 3 HT SBP ≥180 or DBP ≥110
No other risk factors
No BP intervention
Lifestyle changes for several months then drug treatment if BP uncontrolled
Lifestyle changes for several weeks then drug treatment if BP uncontrolled
Lifestyle changes + immediate drug treatment
1-2 risk factors
Lifestyle changes
>3 risk factors, MS or TOD
Lifestyle changes and consider drug treatment
Lifestyle changes + drug treatment
Diabetes
Established CV or renal disease