2. 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
3. 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
6. 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
7.
8. 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
9. 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
10. 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
11. How long to continue lifestyle changes
alone ?
• For low/moderate-risk individuals a few
months
• For higher-risk patients, a few weeks
12. 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.
13.
14. 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)
18. When to start drug Rx
• HIGH N SBP 130-139
DBP 80-89…………TLC, No drugs
• Grade III >180
>110 …..TLC +Immediate drugs
19. ………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
20. 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
21. 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
25. 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 ?
