Hypertension

Hawler Medical University

College of Medicine
Department:
Silent killer
! Headache
! Stroke
! Heart attack
! Sudden death
! Medications long term SE
! Erectyle dysfunction
 Hypertension
by
Dr. Mariwan H. Saka
Lecturer
Internal Medicine
MBChB FICMS ( Medicine )
H.D. in Interventional Cardiology
College of Medicine
Hawler Medical University
At the end of session student should be able to
discuss the following

! Definition
! Etiology and prevalence
! Measurement of BP
! Assessment / approach
! Target organ damage (HMOD) ,clinical and subclinical
! Investigations
! Management
ESH Working Group on blood pressure monitoring.
European Society of Hypertension practice
guidelines for home blood pressure monitoring. J
Hum Hypertens. 2010;24:779-85.

6
Hypertension and total

cardiovascular risk assessment
! Its reversible risk factor for myocardial infarction, stroke, heart failure,
atrial fibrillation, aortic dissection, and peripheral arterial disease,
increased risk of cognitive decline and dementia
! SBP appears to be a better predictor of events than DBP after the
age of 50 years. High DBP is associated with increased CV risk and
is more commonly elevated in younger (<50 years) vs. older patients.
! In middle-aged and older people, increased pulse pressure(the
difference between SBP and DBP values) has additional adverse
prognostic significance
Definition
! hypertension’ is defined as the level of BP at which the benefits
of treatment (either with lifestyle interventions or drugs)
unequivocally outweigh the risks of treatment, as documented
by clinical trials

! Hypertension is defined as office SBP values >_140 mmHg

and/or diastolic BP (DBP) values >_90 mmHg. This is based
on evidence from multiple RCTs that treatment of patients with
these BP values is beneficial
Prevalence
! 1.13 billion in 2015….. 1.5 billion in 2025
! in adults is around 30 - 45%, across the world,
irrespective of income status,
! Gender and age 30 50 75
! prevalence of >60% in people aged >60 years.
! Western countries
! Erbil
 Prevalence of Hypertension and
Associated Factors Among Adult
Population of Erbil city: A Household
Survey

By:
Nazar P. Shabila
Sherzad A. Shabu
Mariwan H. Saka
Prevalence of HTN
Etiology
Essential HTN 95% Secondary HTN
Multifactorial alcohol
race obesity
genetic pregnancy
environmental factors renal disease
high salt endocrine
heavy alcohol drugs
inactivity neurogenic
IUGR coarctation of aorta
stress ?
 Most patients have overlapping 

CV Risk Factors
Dyslipidaemics:
➢ 48% have hypertension
➢ 14% have type 2 diabetes
Hypertension ➢ 35% are overweight/obese

Dyslipi-
 Type 2
HTN was found in: daemia
➢82% of those with CKD
➢77% of those with DM
➢74% in those with PAD
➢73% of those with CHD
➢71% in those with CHF
➢62% in those with MetS
➢70% in those with stroke
➢52% in those with
Diabetes
Diabetes:
➢60% have hypertension
➢60% have hyperlipidemia
➢90% are overweight/ obese
Wong ND et al. Arch Intern Med
 Classification of Blood Pressure (Office BP*)
Category Systolic (mmHg) Diastolic (mmHg)

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 systolicoffice
*Conventional hypertension
BP rather than unattended ≥ 140 and < 90
office BP 17
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guidelines ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
Definition of hypertension according to office*, ambulatory, and
home blood pressure levels

Category SBP DBP ( mmHg)

( mmHg)

Office BP* ≥ 140 and/or ≥ 90

Ambulatory BP
Daytime (or awake) mean ≥ 135 and/or ≥ 85

Night-time (or asleep) mean ≥ 120 and/or ≥ 70

24-h mean ≥ 130 and/or ≥ 80

*Conventional office BP rather than unattended
Home BP mean
office BP. ≥ 135 and/or ≥ 85
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guidelines ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
Nocturnal BP dipping
! Recognised reasons for an absence of nocturnal BP dipping are sleep
disturbance, obstructive sleep apnoea, obesity, high salt intake in salt-
sensitive subjects, orthostatic hypotension, autonomic dysfunction, CKD,
diabetic neuropathy, and old age
! The night-to-day ratio is also a significant predictor of outcome, and
patients with a reduced nighttime dip in BP (i.e. <10% of the daytime
average BP or a night-to-day ratio >0.9) have an increased cardiovascular
risk. Moreover, in those in whom there is no night-time dip in BP or a
higher night-time than daytime average BP, there is a substantially
increase in risk.Paradoxically, there is also some evidence of increased
risk in patients who have extreme dipping of their night-time BP
Hemodynamic Subtypes
1- Systolic Hypertension in Young Adults
17-25
2- Diastolic Hypertension in Middle Age
30-50
3- Isolated Systolic Hypertension in Older
Adults > 55
4- Combined classic essencial
Measurment
! Rest for 5 min
! Sitting position postural elderly, DM, Parkinson
! Clothes ,Smoking, Coffee, Urine, Morning
! Position of stethoscope
! Auscultatory gap 1st by palpation
! 2 measure if 1st abnormal 5min apart
! Both sides ,diff >15 mmHg) is associated with an increased CV risk, use the higher
value
! Record the HR, palpate the. pulseresting HR is an independent predictor of CV
morbid or fatal events
! 3 separate occasion
! Home & ambulatory
! labile , refractory , symptomatic hypot. ,WCH Masked, Nocturnal
Screening and Diagnosis of
Hypertension
Normal High-Normal
Optimal
BP BP 130-139/ Hypertensio
BP 120-129/ 85-89 n 140/90
<120/80 80-84

Consider Out-of-office
masked BP
hypertension measurement
(ABPM or
HBPM)
Use either to
confirm diagnosis

R e p e a t Out-of-office BP
Repeat BP at Repeat BP at Repeat BP at visits for measurement
least every 5 least every 3 least office BP (ABPM or HBPM)
years years annually measuremen
t

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www.escardio.org/ Williams B, Mancia G et al. Eur Heart J (2018); doi:10.1093/eurheartj/
guidelines ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
 Personal History:
Risk factors for
hypertension
Risk factors
Family
Family & personal
and personal history
history of HTN, CVD,
of hypertension, CVD, Stroke , Renal
stroke, or renal disease
Disease

Family
Smokingand personal history of associated risk factors (e.g. familial
history
hypercholesterolaemia)
Smoking History
Alcohol consumption
Dietary history and salt intake
Alcohol Consumption
History
Lack ofof erectileexercise/sedentary
physical dysfunction lifestyle

History of Erectile Dysfunction

Previous hypertension in pregnancy/pre-eclampsia
Sleep history, snoring, sleep apnoea (information also from
2018 ESC/ESH Guidelines for the management of arterial
partner)
www.escardio.org/ Williams B, Mancia G et al. Eur
hypertension Heart JHeart
European (2018); doi:10.1093/eurheartj/
Journal (2018) doi:10.1093/
guidelines ehy339 Williams B, Mancia G et
eurheartj/ehy339al. J Hypertens (2018); doi:10.1097/
Previous HTN in Pregnancy/Preeclampsia
HJH0000000000001940
European Journal of Hypertension (2018) doi:10.1097/HJH.
HMOD (TOD)
 Personal History:
History and symptoms of HMOD/
CVD
History and symptoms of HMOD, CVD, stroke, and renal disease
Brain and eyes: headache, vertigo, syncope, impaired vision, TIA, sensory or
Braindeficit,
motor & Eye: headache,
stroke, vertigo, syncope,
carotid revascularization, impaired
cognitive vision,
impairment, or TIA,
sensory
dementia or
(in motor deficit , stroke, carotid revascularization,
the elderly)
cognitive impairment ,dementia(elderly)

Kidney: thirst, polyuria, nocturia, haematuria, urinary tract infections

Heart: chest pain, shortness of breath, oedema, myocardial infarction,
coronary revascularization, syncope, history of palpitations, arrhythmias
(especially AF), heart failure
Kidney: polyuria, thirst, nocturia, hematuria, UTI

Peripheral arteries: cold extremities, intermittent claudication, pain-

free walking distance, pain at rest, peripheral revascularization
2018 ESC/ESH Guidelines for the management of arterial
www.escardio.org/ Williams B, Mancia G et al. Eur
hypertension Heart JHeart
European (2018); doi:10.1093/eurheartj/
Journal (2018) doi:10.1093/
guidelines ehy339 Williams eurheartj/ehy339
B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
European Journal of Hypertension (2018) doi:10.1097/HJH.
Physical examination
! Accurate assessment of BP
! General appearance
! Fundoscopy
! Neck
! Heart
! Lungs
! Abdomen
! Extremities
! Neurological
Routine work-up for evaluation of hypertensive
patients

Routine laboratory tests

Haemoglobin and/or haematocrit
CBC
Fasting
FBS, blood glucose and
HbA1c
HbA1c lipids: total cholesterol, low-density lipoprotein cholesterol, high-density
Blood
Lipid profile
lipoprotein cholesterol
Blood triglycerides Blood
Serum electrolyte
Serum
Blood creatinine
potassium
uric acid andand eGFR
sodium
Uric acic
LFT
Blood creatinine and eGFR
Blood liver
Urine function
analysis tests
, microscopic examination , depstick protien
Urine analysis:
Ideally albumin:microscopic examination;
creatinine ratio urinary protein by dipstick test or,
ideally, albumin:creatinine ratio
12-lead ECG
Abdominal US: Kidnye size, CKD, Aorta, Adrenal gland
2018 ESC/ESH Guidelines for the management of arterial 8
www.escardio.org/ Williams B, Mancia G et al. Eur
hypertension Heart JHeart
European (2018); doi:10.1093/eurheartj/
Journal (2018) doi:10.1093/
guidelines ehy339 Williams eurheartj/ehy339
B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
European Journal of Hypertension (2018) doi:10.1097/HJH.
 New-onset or uncontrolled hypertension in adults

Conditions
• Drug-resistant/ induced hypertension
• Abrupt onset of hypertension
• Onset of hypertension at <30 y
• Exacerbation of previously controlled hypertension
• Disproportionate TOD for degree of hypertension
• Accelerated/ malignant hypertension
• Onset of diastolic hypertension in older adults (age ≥65 y)
• Unprovoked or excessive hypokalemia

Yes No

Screen for Screening not

secondary hypertension indicated
(Class I) (No Benefit)
(see Table 13)

Positive
screening test

Yes No

Refer to clinician with Referral not

specific expertise necessary
(Class IIb) (No Benefit)

Colors correspond to Class of Recommendation in Table 1 .

TOD indicates target organ damage (e.g., cerebrovascular disease,
hypertensive retinopathy, left ventricular hypertrophy, left ventricular dysfunction,
heart failure, coronary artery disease, chronic kidney disease, albuminuria,
peripheral artery disease).
 Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
 Assessment of hypertension-mediated organ damage (HMOD)
Basic screening tests for Indication and interpretation
HMOD

12-lead ECG Screen for LVH and other possible cardiac

abnormalities and to document heart rate
and cardiac rhythm.
Urine albumin:creatinine To detect elevations in albumin excretion
indicative of possible renal disease.
ratio
More detailed screening for HMOD
Blood creatinine and eGFR To detect possible renal disease.

Carotid ultrasound To detect

To determine the presence
hypertensive of carotid
retinopathy,
Fundoscopy plaque or stenosis, particularly in patients
especially in patients with grade 2 or 3
with cerebrovascular
hypertension. disease or vascular
disease elsewhere.

Echocardiography To evaluate cardiac

2018
Williams B, Mancia
structure
ESC/ESH Guidelines
G et al. Eur
and
for the management
Heart JHeart
(2018);
of arterial
doi:10.1093/eurheartj/ 9
www.escardio.org/
guidelines
function,
ehy339when
Williamsthis information
B, Mancia G et al. J Hypertenswill
hypertension European
eurheartj/ehy339
Journal (2018) doi:10.1093/
(2018); doi:10.1097/
influence treatment decisions.
HJH0000000000001940
European Journal of Hypertension (2018) doi:10.1097/HJH.
 Assessment of hypertension-mediated organ damage (HMOD)

More detailed screening for HMOD Indication and interpretation

PWV An index of aortic stiffness and underlying

arteriosclerosis.
ABI Screen for evidence of PAD.

Cognitive function testing To evaluate cognition in patients with

symptoms suggestive of cognitive impairment.

Brain imaging To evaluate the presence of ischaemic or

haemorrhagic brain injury, especially in
patients with a history of cerebrovascular
disease or cognitive decline.
2018 ESC/ESH Guidelines for the management of arterial 11
www.escardio.org/ Williams B, Mancia G et al. Eur
hypertension Heart JHeart
European (2018); doi:10.1093/eurheartj/
Journal (2018) doi:10.1093/
guidelines ehy339 Williams eurheartj/ehy339
B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
European Journal of Hypertension (2018) doi:10.1097/HJH.
Treatment
! Non drug life style modification
! Drug
choice of treatment
unfavourable combination
! Emergency treatment
EOD
Malignant ( accelerated ) HTN
! Refractory HTN
! Adjuvant therapy
aspirin ,statin TOD, comorbidity, 10 yr CVR >15%
 Managing CV risk beyond BP
People with any of the following: Recommendations Clas Lev
•Documented CVD, clinical or unequivocal sa elb
on imaging
–Clinical CVD includes; acute myocardial
infarction, acute coronary syndrome, CV risk assessment with the I B
coronary or other arterial SCORE system is recommended
Very revascularisation, stroke, TIA, aortic Recommendatio Clas Leve
aneurysm, PAD for hypertensive patients who
high
risk –Unequivocal documented CVD on imaging are not already at high or very ns s l
includes: For patients at low–moderate CV IIa C
significant plaque (i.e. ≥ 50% stenosis) on high risk due to established risk, statins should be considered
angiography or ultrasound. It does not include CVD, renal disease, or diabetes to achieve an LDL-C value of < 3.0
increase in carotid intima-media thickness
•Diabetes mellitus with target organ damage mmol/L (115 mg/dL)
, e.g. proteinuria or a with a major risk factor
such as grade 3 hypertension or
hypercholesterolaemia. Antiplatelet therapy, in particular I A
•Severe CKD (eGFR < 30 mL/min/1.73 m2) low- dose aspirin, is recommended
•A calculated 10-year SCORE of ≥ 10% for secondary prevention in
For patients at very high CV I B hypertensive patients
risk, statins are recommended
People with any of the following: to achieve LDL-C levels of < Aspirin is not recommended for III A
•Marked elevation of a single risk factor, 1.8 mmol/L primary prevention in
particularly cholesterol > 8 mmol/L (> 310 (70 mg/dL), or a reduction of hypertensive patients without
mg/dL), e.g. familial hypercholesterolaemia, ≥ 50% if the baseline LDL-C is CVD
grade 3 hypertension 1.8–3.5 mmol/L (70–135 mg/
a Class of
•Grade 3 hypertension (blood pressure ≥ recommendation.
High 180/110 mmHg) dL) b Level of evidence.
risk •Most other people with diabetes mellitus
(except some young people with type 1 For patients at high CV risk, I B
diabetes mellitus and without major risk statins are recommended to
factors, that may be moderate risk) achieve an LCL-C goal of < 2.5
•Hypertensive LVH mmol/L (100 mg/dL), or a
•Moderate CKD eGFR 30–59 mL/min/1.73 m2)
•A calculated 10-year SCORE of 5–10% reduction of ≥50% if the
baseline LDL- C is 2.6–5.2
mmol/L (100–200 mg/dL)

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www.escardio.org/ Patients at very high or high CV risk do not need formal risk
guidelines assessment
Office Blood Pressure Thresholds for Treatment

Grade Grade Grade

High normal Hypertension
1 Hypertension
2 Hypertensio
3
BP130-139 /
BP BP 140-159 / BP 160-179 /
85-89 n
90-99 100-109 BP ≥180 / 110

Lifestyle Advice Lifestyle Advice Lifestyle Advice Lifestyle Advice

Consider Drug Immediate Drug Immediate Immediate

Treatment in very Treatment in high or Drug Drug
high risk patient very high risk patients Treatment in Treatment in
with CVD, especially with CVD, CKD or all patients all patients
CAD HMOD
IIB
11
Drug Treatment in
Aim for BP Aim for BP
low moderate risk
control within 3 control within
patients without
months 3 months
CVD,
CKD or HMOD
after 3-6 months of
l i f e s t y l e
intervention if BP
not controlled
www.escardio.org/ Williams B, Mancia G et al. Eur Heart J (2018); doi:10.1093/eurheartj/
guidelines ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HJH0000000000001940
 Drug treatment strategy for hypertension
Recommendations Class Level

Among all antihypertensive drugs, ACE inhibitors, ARBs, I A

beta-blockers, CCBs, and diuretics (thiazides and thiazide-
like such as chlortalidone and indapamide) have
demonstrated effective reduction of BP and CV events in
RCTs, and thus are indicated as the basis of antihypertensive
treatment strategies.
Combination treatment is recommended for most I A
hypertensive patients, as initial therapy. Preferred
combinations should comprise a RAS blocker (either an ACE
inhibitor or an ARB) with a CCB or diuretic. Other
combinations of the five major classes can be used.
It is recommended that beta-blockers are combined with I A
any of the other major drug classes when there are specific
clinical situations, e.g. angina, post-myocardial infarction, 36
heart failure, or heart-rate controlWilliams
www.escardio.org/ B, Mancia G et al. Eur Heart J (2018); doi:10.1093/eurheartj/
ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
guidelines
HJH0000000000001940
 Core drug-treatment strategy
for uncomplicated hypertension and most
patients with HMOD, cerebrovascular disease,
diabetes, or PAD
Consider monotherapy in
Initial therapy low-risk grade 1
1 Dual ACEI or ARB + CCB or hypertension
pill combination or in very old (≥80years)
diuretic or frailer patients

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guidelines eurheartj/ehy339
Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HMOD = hypertension-mediated organ damage; PAD = peripheral arterial HJH0000000000001940
 Core drug-treatment strategy
for uncomplicated hypertension and most
patients with HMOD, cerebrovascular disease,
diabetes, or PAD
Consider monotherapy in
Initial therapy low-risk grade 1
1 Dual ACEI or ARB + CCB or hypertension
pill combination or in very old (≥80years)
diuretic or frailer patients

Step 2
1 Triple combination ACEI or ARB + CCB +
pill
diuretic

38
www.escardio.org/ Williams B, Mancia G et al. Eur Heart J (2018); doi:10.1093/
guidelines eurheartj/ehy339
Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HMOD = hypertension-mediated organ damage; PAD = peripheral arterial HJH0000000000001940
 Core drug-treatment strategy
for uncomplicated hypertension and most
patients with HMOD, cerebrovascular disease,
diabetes, or PAD
Consider monotherapy in
Initial therapy low-risk grade 1
1 Dual ACEI or ARB + CCB or hypertension
pill combination or in very old (≥80years)
diuretic or frailer patients

Step 2
1 Triple combination ACEI or ARB + CCB +
pill
diuretic
Step 3 Resistant hypertension
Triple combination Consider referal to a
2 + spironolactone Add spironolactone (25-50 mg o.d.) or specialist centre for further
pills or other drug other diuretic, alpha-blocker or beta- investigation
blocker

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www.escardio.org/ Williams B, Mancia G et al. Eur Heart J (2018); doi:10.1093/
guidelines eurheartj/ehy339
Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
HMOD = hypertension-mediated organ damage; PAD = peripheral arterial HJH0000000000001940
 Core drug-treatment strategy
for uncomplicated hypertension and most
patients with HMOD, cerebrovascular disease,
diabetes, or PAD
Consider monotherapy in
Initial therapy low-risk grade 1
1 Dual ACEI or ARB + CCB or hypertension
pill combination or in very old (≥80years)
diuretic or frailer patients

Step 2
1 Triple combination ACEI or ARB + CCB +
pill
diuretic
Step 3 Resistant hypertension
Triple combination Consider referal to a
2 + spironolactone Add spironolactone (25-50 mg o.d.) or specialist centre for further
pills or other drug other diuretic, alpha-blocker or beta- investigation
blocker
Beta-blockers
Consider beta-blockers at any treatment step, when there
is a specific indication for their use, e.g. heart failure,
angina, post-MI, atrial fibrillation, or younger women with,
or planning pregnancy
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HMOD = hypertension-mediated organ damage; PAD = peripheral ehy339 Williams B, Mancia G et al. J Hypertens (2018); doi:10.1097/
arterial disease HJH0000000000001940
2018 ESC/ESH Hypertension Guidelines Presentation at the ESH Meeting, Barcelona June 9th,

First step combination treatment in some specific conditions 2018

1- Diabetes: RAS blocker+CCB or D (IA)

2- CAD: BB or CCB+RAS blocker (IA) CKD:RAS blocker+ CCB or D(loop D)

3- Cerebrovascular Disease: RAS Blocker+CCB or D(IA)

4- AF: BB and/or nondihCCB (IIaB)

5- Hf(r/p*EF):RAS blocker+BB,D+Antialdo (IA)(*IIaB)

6- COPD: RAS blocker+CCB

7- LEAD: RAS blocker+CCB or D (*BB may be considered)

8- Blacks: D+CCB (IB)

 Hypertension Treatment Algorithms for Specific Co-morbidities

Hypertension and Coronary Artery Hypertension and Chronic Kidney

Disease Disease

Hypertension and Heart Hypertension and Atrial

Failure Fibrillation

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HJH0000000000001940
 Device-based therapies for hypertension

Recommendations Class Level

Use of device-based therapies is not recommended III B

for the routine treatment of hypertension, unless in
the context of clinical studies and RCTs, until further
evidence regarding their safety and efficacy becomes
available.

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2018 ESC/ESH Hypertension Guidelines

Hypertension (HT) in specific circumstances

Resistant Hypertension /Secondary Obstructive pulmonary disease

Hypertension Heart disease
Hypertensive Urgencies / Emergencies • CAD
White Coat Hypertension • LVH / HFrEF/HFpEF
Cerebrovascular disease and cognition
Masked Hypertension Young adults
Atrial fibrillation and other arrhythmias
Older patients
Vascular disease
Women / Pregnancy / Oral contraception /
Hormone-replacement therapy Valvular disease and aortopathy
Different ethnic groups Sexual dysfunction
Diabetes mellitus Cancer therapy
Chronic kidney disease Perioperative management

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2018, in press
 Hypertensive emergencies

Severe blood pressure elevation

Acute hypertension- No acute hypertension-

mediated organ damage mediated organ damage present
present
Uncontrolled
Hypertensive emergency hypertension

Adjust treatment
Hospitalizatio without
hospitalization;
n secure
follow up to reach target
BP

Intracranial
Acute Encephalopathy Acute CAD, acute Acute Severe
hypertensive haemorrage heart failure aortic preeclampsia/HELLP
microangiopathy and stroke diseases syndrome, eclampsia

2018 ESC/ESH Guidelines for the management of arterial

www.escardio.org/ hypertension European Heart Journal (2018) doi:10.1093/
guidelines Journ eurheartj/ehy339 of Hypertension (2018) doi:10.1097/
Europea HJH.0000000000001940 T Kahan 2018
Diagnosis and Management of a Hypertensive Crisis

Colors correspond to Class of Recommendation in Table 1.

*Use drug(s) specified in Table 19.
†If other comorbidities are present, select a drug specified in Table 20.
BP indicates blood pressure; DBP, diastolic blood pressure; ICU, intensive care unit;
and SBP, systolic blood pressure.
 Colors correspond to Class of Recommendation in Table 1.
BP indicates blood pressure; DBP, diastolic blood pressure; IV, intravenous; and SBP, systolic
blood pressure.
 Colors correspond to Class of Recommendation in Table 1.
DBP indicates diastolic blood pressure; SBP, systolic blood pressure; and TIA, transient
ischemic attack.
 Hypertensive emergencies requiring
immediate BP lowering with intravenous
drug therapy

2018 ESC/ESH Guidelines for the management of arterial

www.escardio.org/ hypertension European Heart Journal (2018) doi:10.1093/
guidelines eurheartj/ehy339
EuropeaJournal of Hypertension (2018) doi:10.1097/HJH. T Kahan 2018
 Drug Onset of Duration of Dose Contraindications Adverse effects
action action
Esmolol 1–2 min 10–30 min 0.5–1 mg/kg as bolus; 50–300 mg/kg/min as Second or third-degree AV Bradycardia
continuous infusion block, systolic heart failure,
asthma, bradycardia
Metoprolol 1–2 min 5–8 h 15 mg i.v., usually given as 5 mg i.v., and Second or third-degree AV Bradycardia
repeated at 5 min inter- vals as needed block, systolic heart failure,
asthma, bradycardia
Labetalol 5–10 min 3–6 h 0.25–0.5 mg/kg; 2–4 mg/min until goal BP is Second or third-degree AV Bronchoconstriction, foetal
reached, there- after 5–20 mg/h block; systolic heart failure, bradycardia
asthma, bradycardia
Fenoldopam 5–15 min 30–60 min 0.1 mg/kg/min, increase every 15 min until Caution in glaucoma
goal BP is reached
Clevidipine 2–3 min 5–15 min 2 mg/h, increase every 2 min with 2 mg/h until Headache, reflex
goal BP tachycardia
Nicardipine 5–15 min 30–40 min 5–15 mg/h as continuous infu- sion, starting Liver failure Headache, reflex
dose 5 mg/h, increase every 15–30 min with tachycardia
2.5 mg until goal BP, thereafter decrease to 3
mg/h

Nitroglycerine 1–5 min 3–5 min 5–200 mg/min, 5 mg/min increase every 5 min Headache, reflex
tachycardia
Nitroprusside Immediate
AV = atrioventricular; 1–2 min
BP = blood pressure; 0.3–10 mg/kg/min, increase by
i.v. = intravenous. Liver/kidney failure (relative) Cyanide intoxication
0.5 mg/kg/min every 5 min until goal BP
Enalaprilat 5–15 min 4–6 h 0.62–1.25 mg i.v. History of angioedema
Urapidil 3–5 min 4–6 h
... 5–40 mg/h as
12.5–25 mg as bolus injection;
..
continuous infusion ....
Clonidine 30 min 4–6 h ....
150–300 mg i.v. over 5–10 min Sedation, rebound
.... hypertension
.
Phentolamine 1–2 min 10–30 min 0.5–1 mg/kg bolus injections OR 50–300 mg/ Tachyarrhythmias, chest
2018 ESC/ESH Hypertension
Guidelines

10-year CV risk categories (SCORE system)

Very high risk People with any of the following:
Documented CVD, either clinical or unequivocal on imaging.
Clinical CVD includes; acute myocardial infarction, acute coronary syndrome, coronary or other arterial
revascularization, stroke, TIA, aortic aneurysm, PAD.
Unequivocal documented CVD on imaging includes: significant plaque (i.e. ≥ 50% stenosis) on
angiography or ultrasound. It does not include increase in carotid intima-media thickness.
Diabetes mellitus with target organ damage, e.g. proteinuria or a with a major risk factor such as
grade 3 hypertension or hypercholesterolaemia
Severe CKD (eGFR < 30 mL/min/1.73 m2)
A calculated 10-year SCORE of ≥ 10%

High risk People with any of the following:

Marked elevation of a single risk factor, particularly cholesterol > 8 mmol/L (> 310 mg/dL)
e.g. familial hypercholesterolaemia, grade 3 hypertension (BP ≥ 180/110 mmHg)
Most other people with diabetes mellitus (except some young people with type 1 diabetes mellitus and
without major risk factors, that may be moderate risk)
Hypertensive LVH
Moderate CKD (eGFR 30–59 mL/min/1.73 m2)
A calculated 10-year SCORE of 5–10%

Moderate risk People with:

A calculated 10-year SCORE of 1% to < 5% Grade 2 hypertension
Many middle-aged people belong to this category

Low risk People with:

Williams, 10-year
A calculated Mancia et al., J Hypertens
SCORE of <2018
1%and Eur Heart J 2018, in press
Blood Pressure Variability 

and Its Determinants

!Behavioural Determinants
!Nicotine
!Alcohol
!Caffeine/coffee , tea green and black
!Physical inactivity
!Diets F/V , citrate, Salt, Calories
!Genetic Determinants
Antihypertensives
! Thiazide & other diuretics
! B blockers
! ACEI
! ARB
! Calcium channel blockers
! Vasodilators
! Centrally acting drugs
Approach to HTN
! Confirm HTN asymptomatic ?
! Headache ???
! Exclude secondary HTN young
! Other risk factors
! Complication (HMOD)
! Comorbidity
! Life style modefication ↑ K ,↑Ca, ↓Na
! Choice of therapy
Resistant Hypertension
!Failure of diastolic blood pressure to fall below
90 mm Hg despite the use of three or more
drugs, including a diuretic
!Pseudoresistance WCH, Elderly
!Nonadherence to Therapy
!Drug-Related Causes
!Associated Conditions
!Secondary Hypertension
!Volume Overload
Meta-analyses of RCTs shown that a 10 mmHg reduction in SBP or a
5 mmHg reduction in DBP is associated with 


! significant reductions in all major CV events by 20%

! all-cause mortality by 10 - 15%
! stroke by 35%
! coronary events by 20%
! heart failure by 40%.
! These relative risk reductions are consistent, irrespective of
baseline BP within the hypertensive range, the level of CV risk,
comorbidities (e.g. diabetes and CKD), age, sex, and ethnicity
Questions
How you manage
! 28 years old man presented with HTN
! 40 years old lady with HTN & migraine
! 70 years old man with BPH & asthma
THANK
YOU