Arterial Hypertension

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Arterial Hypertension
Presented By Dr Emami
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• hypertension is the most common reason for
  office visits of non-pregnant adults to
  physicians in the United States and for use of
  prescription drugs.

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• Despite the prevalence of hypertension and its
  associated complications, control of the disease
  is far from adequate .
• Data from NHANES show that only 45 percent of
  persons with hypertension have their blood
  pressure under control, defined as a level below
  140/90 mmHg

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DEFINITIONS

• Hypertension was defined as a blood pressure
  140/90 mmHg
• Normal BP systolic lt120 mmHg and diastolic lt80
• Prehypertension systolic 120-139 mmHg or
  diastolic 80-89
• Hypertension
•         Stage 1 systolic 140-159 mmHg or
  diastolic 90-99 mmHg
•         Stage 2 systolic 160 or diastolic 100
  mmHg

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• Isolated systolic hypertension
• isolated diastolic hypertension
• These definitions apply to adults on no
  antihypertensive medications and who are not
  acutely ill.
• If there is a disparity in category between the
  systolic and diastolic pressures, the higher
  value determines the severity of the hypertension.

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• ESSENTIAL (PRIMARY) HYPERTENSION
• Pathogenesis  is poorly understood.
• Increased sympathetic neural activity, with
  enhanced beta-adrenergic responsiveness.
• Increased angiotensin II activity and
  mineralocorticoid excess.
• Hypertension is about twice as common in subjects
  who have one or two hypertensive parents
• genetic factors account for approximately 30
  percent of the variation in blood pressure in
  various populations
• Reduced adult nephron mass may predispose to
  hypertension, which may be related to genetic
  factors, intrauterine developmental disturbance
  (eg, hypoxia, drugs, nutritional deficiency)

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Risk factors

• Race
• salt intake increased salt intake is a necessary
  but not sufficient cause for hypertension.
• excess alcohol intake
• Obesity is associated with an increased
  prevalence and incidence of hypertension
• Physical inactivity
• Dyslipidemia may also be associated with the
  development of hypertension, and is independent
  of obesity

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• COMPLICATIONS The likelihood of developing the
  complications varies with the blood pressure. The
  increase in risk begins as the blood pressure
  rises above 110/75 mmHg in all age groups.
• In older patients, systolic pressure and perhaps
  pulse pressure are more powerful determinants of
  risk than diastolic pressure .

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Screening

•   The optimal interval for screening for
  hypertension is not known.
• guidelines on screening for high blood
  pressure recommend screening every two years
  for persons with systolic and diastolic
  pressures below 120 mmHg and 80 mmHg,
  respectively
• and yearly for persons with a systolic
  pressure of 120 to 139 mmHg or a diastolic
  pressure of 80 to 89 mmHg

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DX

• In the absence of end-organ damage, the diagnosis
  of mild hypertension should not be made until the
  blood pressure has been measured on at least
  three to six visits, spaced over a period of
  weeks to months.
• the blood pressure drops by an average of 10 to
  15 mmHg between visits one and three in patients
  who appear to have mild hypertension on a first
  visit to a new doctor, with a stable value not
  being achieved until more than six visits in some
  cases
• Thus, many patients considered to be hypertensive
  at the initial visit are in fact normotensive.

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• Technique of blood pressure measurement in the
  diagnosis of hypertension

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•  Correct measurement and interpretation of the
  blood pressure is essential in the diagnosis and
  management of hypertension.
• Proper BP machine calibration, training of
  personnel, positioning of patient, and selection
  of cuff size are all essential.

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• TIME OF MEASUREMENT  For the diagnosis of
  hypertension, multiple readings should be taken
  at various times.
• Extraneous variables that can influence the BP
  should be avoided in the 60 minutes prior to
  evaluation. These include food intake, strenuous
  exercise ,smoking, and the ingestion of caffeine.
• Smoking transiently raises the BP thus, the
  office BP may underestimate the usual BP in a
  heavy smoker who has not smoked for more than 30
  minutes before the measurement is made.
• Caffeine intake can raise the BP acutely,
• Taking the BP in a cool room (12ºC or 54ºF) or
  while the patient
• is talking can raise the measured value by as
  much as 8 to 15
• mmHg.

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• TYPE OF MEASUREMENT DEVICE 
• Mercury sphygmomanometers provide the most
  accurate
• measurement of BP.
• Aneroid sphygmomanometers, which are used in
  many offices,
• should be checked against a mercury device since
  the air gauge may be in error.
• Automated oscillometric BP measuring devices are
  increasingly being used in medical offices, and
  for home monitoring. The readings are typically
  lower than BP obtained with the auscultatory
  method..
• The disadvantages are that the oscillometric
  method has somewhat greater inherent error and
  epidemiologic data are based on auscultatory
  methods.
• advantages are that observer error and training
  are minimal.

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• CUFF SIZE  Use of a proper-sized cuff is
  essential. If too small a cuff is used, can lead
  to overestimation of the systolic pressure by as
  much as 10 to 50 mmHg in obese patients.
• The length of the BP cuff bladder should be 80
  percent, and the width at least 40 percent of the
  circumference of the upper arm.
• This width recommendation cannot be practically
  maintained in obese patients.

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• PATIENT POSITION  The BP is ideally taken in the
  sitting
• position with the back supported
• Supine values tend to be slightly different,
• Supine and standing measurements should always
  be taken in the
• elderly to detect postural hypotension
• The arm should be supported at the level of the
  heart.
• The mercury manometer should be visible but does
  not have to be
• at the level of the heart
• The patient should sit quietly for five minutes
  before the BP is
• measured .
• Even under optimal conditions, many patients are

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• CUFF PLACEMENT  The blood pressure cuff should
  be placed with the bladder midline over the
  brachial artery pulsation, with the arm without
  restrictive clothing (the patient's sleeve should
  not be rolled up as this may act as a tourniquet)
• If possible, the lower end of the blood pressure
  cuff should be two to three centimeters above the
  antecubital fossa to minimize artifactual noise
  related to the stethoscope touching the cuff.

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• TECHNIQUE OF MEASUREMENT  The cuff should be
• inflated to a pressure approximately 30 mmHg
  greater
• than systolic, as estimated from the
  disappearance of the
• pulse in the brachial artery by palpation
• The auscultatory gap is associated with increased
  arterial
• stiffness and carotid atherosclerosis it may
  therefore
• identify patients at increased risk of
  cardiovascular
• disease
• Once the cuff is adequately placed and inflated,
  the
• following steps should be followed

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• Neither the patient nor the observer should talk
  during the
• measurement
• The BP should be taken with the patient's arm
  supported at the
• level of the heart.
• The mercury manometer should be visible but does
  not have to be at
• the level of the heart
• The stethoscope should be placed lightly over the
  brachial artery,
• since the use of excessive pressure can increase
  turbulence and delay
• the disappearance of sound. The net effect is
  that the diastolic
• pressure reading may be artifactually reduced by
  up to 10 to 15 mmHg
• The cuff should be deflated slowly at a rate of 2
  to 3 mmHg per
• heartbeat

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• The systolic pressure is equal to the pressure at
  which the brachial pulse can first be palpated .
• or the pressure at which the pulse is first heard
  by auscultation (Korotkoff phase I).
• As the cuff is deflated below the systolic
  pressure, the pulse continues to be heard until
  there is abrupt muffling (phase IV) and,
  approximately 8 to 10 mmHg later, disappearance
  of sound (phase V)
• The diastolic pressure is generally equal to
  phase V

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• the point of muffling should be used in those
  patients in whom there is more than a 10 mmHg
  difference between phases IV and V
• This can occur in children, and in high-output
  states such as thyrotoxicosis, anemia, and aortic
  regurgitation.

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• The BP should be measured initially in both
  arms .If there is a
• disparity due to a unilateral arterial lesion,
  the arm with higher
• pressure should be used.
• The BP should be taken at least twice on each
  visit, with the
• measurements separated by one to two minutes to
  allow the
• release of trapped blood.
• If the second value is more than 5 mmHg
  different from the first,
• continued measurements should be made until a
  stable value is
• attained.

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• Leg blood pressure  There are occasional
  patients
• in whom the blood pressure needs to be measured
  in the
• legs. The classic example is with suspected
  coarctation
• of the aorta in which there is an arm-to-leg
  gradient.
• Blood pressure should be taken in the leg among
  women
• with breast cancer who have undergone bilateral
• axillary lymph node dissection,
• If there has been unilateral axillary node
  dissection, it is
• recommended that the BP should always be taken in
  the
• contralateral arm.

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• The principles of blood pressure measurement in
  the leg are similar to the arm.
• An appropriate-sized thigh cuff is essential.
• The systolic pressure in the leg in normal
  subjects is usually 10 to 20 percent higher than
  that in the brachial artery.

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• Wrist blood pressure  may be more practical in
• obese people, since wrist diameter is not
  significantly
• affected.
• Systolic BP rises, and diastolic BP falls, in
  more distal
• arteries.
• In the wrist, the hydrostatic pressure related
  to the lower
• position of the wrist relative to the heart can
  result in a
• further false elevation of BP.
• This can be minimized by taking the BP with the
  wrist kept
• at the level of the heart.

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MULTIPLE BLOOD PRESSURE MEASUREMENTS

•  in the absence of end-organ damage, the
  diagnosis of
• mild hypertension should not be made until the
  blood
• pressure has been measured on at least two
  additional
• visits, spaced over a period of one week or more
  .
• Sequential studies have shown that the BP drops
  by an
• average of 10 to 15 mmHg between the first and
  third
• visits in newly diagnosed patients with a stable
  value
• not being achieved until more than six visits in
  some cases
• Thus, many patients considered to be hypertensive
  at the
• initial visit are in fact normal.

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What is White Coat HTN?
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• in patients diagnosed as being hypertensive on a
  first
• visit to a new physician, there is a mean 15 and
  7 mmHg
• fall in the systolic and diastolic BP,
  respectively, by the
• third visit with some patients not reaching a
  stable value
• until the sixth visit
• Thus, it has been recommended that a patient with
  mild
• to moderate elevation in BP should not be
  diagnosed
• with hypertension unless the BP remains elevated
  after three
• to six visits, unless there is evidence of
  ongoing end-organ
• damage.
• the prevalence of white coat hypertension ranges
  from 10 to
• more than 20 percent, and appears to be higher
  in children and
• the elderly

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• White coat hypertension can also be seen in
  patients with apparently resistant hypertension
• The likelihood of normal ambulatory pressures is
  low (less than 5 percent) in patients with office
  diastolic pressures 105 mmHg but such patients
  may still have a white coat effect underestimates
  the efficacy of therapy

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• the optimal approach to patients with white coat
  hypertension is uncertain.
• If therapy is withheld because of a normal
  ambulatory BP, careful monitoring is still
  indicated for the possible development of
  worsening hypertension or of end-organ damage,
  while the patient is encouraged to modify
  unhealthy lifestyle habits.

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ABPM
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• INTERPRETATION OF ABPM  One of the unresolved
• issues in ambulatory monitoring is the definition
  of what
• constitutes normal and elevated blood pressure
• Most experts agree that 24 hour blood pressure
  lt130/80
• mmHg is probably normal, and 135/85 mmHg is
• probably abnormal
• A daytime ambulatory average BP below 135/85 is
• normotension.

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INDICATIONS FOR ABPM

• Suspected white coat hypertension
• Suspected episodic hypertension (eg,pheo)
• Hypertension resistant to increasing medications
• symptoms while taking antihypertensive
  medications
• Autonomic dysfunction
• To establish nondipper status or nocturnal
  hypertension
• Large variations in self-measured blood pressure
  values

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PROGNOSTIC VALUE OF ABPM

• Prediction of cardiovascular risk  the risk of
  hypertensive
• cardiovascular complications (including both the
  
• development and regression of LVH with treatment)
  
• correlates more closely with 24-hour or daytime
  ABPM than
• with the office pressure
• However, the difference in prognostic accuracy
  between
• ABPM and office readings might be diminished by
• obtaining repeated BP measurements during the
  same visit,
• or by measuring BP in a standardized fashion with
  
• appropriate equipment

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Blood Pressure During Sleep and on Awakening
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Normal Pattern

• The usual fall in BP at night is largely the
  result of sleep and inactivity rather than the
  time of day
• Whereas the nocturnal fall averages approximately
  15 in those who are active during the day, it is
  only about 5 in those who remain in bed for the
  entire 24 hours
• The usual falls in BP and heart rate that occur
  with sleep reflect a decrease in sympathetic
  nervous tone.
• In healthy young men, plasma catecholamine levels
  fell during rapid-eye-movement sleep, whereas
  awakening immediately increased epinephrine, and
  subsequent standing induced a marked increase in
  norepinephrine

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Associations with Nondipping

• Older age (Staessen et al., 1997)
• Cognitive dysfunction (Van Boxtel et al., 1998)
• Diabetes (Björklund et al., 2002)
• Obesity (Kotsis et al., 2005)
• African Americans (Jehn et al., 2008) and
  Hispanics (Hyman et al., 2000)
• Impaired endothelium-dependent vasodilation
  (Higashi et al., 2002)
• Elevated levels of markers of cellular adhesion
  and inflammation (Von Känel et al., 2004)
• Left ventricular hypertrophy (Cuspidi et al.,
  2004)
• Intracranial hemorrhage (Tsivgoulis et al., 2005)
• Loss of renal function (Fukuda et al., 2004)
• Mortality from cardiovascular disease (Redon
  Lurbe, 2008)

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Nocturnal blood pressure and nondippers  

• The average nocturnal BP is approximately 15
  percent lower than
• daytime values in both normals and hypertensive
  patients
• Failure of the BP to fall by at least 10 percent
  during sleep is
• called nondipping.
• Independent of the degree of hypertension,
  nondipping is a risk
• factor for the development of LVH as well as HF
  and other
• cardiovascular complications
• Nondipping has also been associated with
  microalbuminuria and
• faster progression of nephropathy in patients
  with diabetes
• mellitus.
• nondipping may be a risk factor for decline in
  GFR, and ESRD
• and death among patients with CKD

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HOME BP MEASUREMENTS

•  In view of the cost and limited availability of
  ambulatory monitoring, increasing attention is
  being given to home
• Such self-recorded casual BP measurements taken
  at home or daytime or work correlate more closely
  with the results of 24-hour ambulatory monitoring
  than with the BP taken in the office.
• home BP measurements may be more predictive of
  adverse outcomes (eg, stroke, end-stage renal
  disease) than clinic blood pressures
• patient self-monitoring of BP at home may improve
  BP control, especially if combined with
  behavioral interventions

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• HBPM should become a routine component of BP
  measurement in the majority of patients with
  known or suspected hypertension.

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• Two to three readings should be taken while the
  subject is resting in the seated position, both
  in the morning and at night, over a period of 1
  W .
• A total of 12 readings are recommended for
  making clinical decisions.
• The target HBPM goal for treatment is less than
  135/85 mm Hg

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• Use a 7-day measurement period with two to three
  measurements each morning and two to three
  measurements in the evening at prestipulated
  times (an average of 12 morning and 12 evening
  measurements).
• Exclude the first-day measurements from the
  analyses to remove the alerting reaction.

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• It is recommended that the BP should be regularly
  measured (by either the patient or other person)
  at work and at home
• In addition to improved control of the BP,
  potential advantages of home BP monitoring
  include identification of white coat
  hypertension, assessment of the response to
  antihypertensive medications, and improvement in
  patient compliance.

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• The potential problems with outpatient BP
  measurements can be minimized by providing
  adequate training, and periodically checking the
  machine for accuracy .
• As with ambulatory monitoring, the BP taken by
  the patient varies widely during the day, being
  influenced by factors such as stress
  (particularly at work), smoking, caffeine intake,
  natural circadian variation, and exercise .
• Thus, multiple readings should be taken to
  determine the average level.

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• The timing of antihypertensive medications must
  also be considered.
• With short-acting drugs (eg, captopril,
  atenolol), the BP may fall to normal or even
  below normal one to two hours after therapy and
  then gradually increase to elevated levels until
  the next dose is taken.
• This problem can be minimized by having the
  outpatient BP measured 30 to 60 minutes before
  taking medications, preferably in the early
  morning to assess for possible inadequate
  overnight BP control.

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•  
• the BP should be measured at roughly the same
  time each day and the relation to meals and
  medications noted.
• The patient should be instructed to wait to
  measure the BP if they have recently eaten a meal
  or exercised.

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• Cuff inflation hypertension  A possible problem
  with
• self-measurement of BP is that the muscular
  activity
• used to inflate the cuff can acutely raise the
  BP by as
• much as 12/9 mmHg, an effect called cuff
  inflation
• hypertension that dissipates within 5 to 20
  seconds (average 7 seconds . )
• Thus, inflating the cuff to at least 30 mmHg
  above systolic and then allowing the
  sphygmomanometer to fall no more than 2 to 3 mmHg
  per heartbeat is desirable both for accurate
  measurement and to permit this exertional effect
  to disappear

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• If the blood pressure is taken at home to
  establish the diagnosis of hypertension or to
  assess blood pressure control, the optimal
  schedule is unclear.
• at least 12 to 14 measurements should be
  obtained, with both morning and evening
  measurements taken over seven workdays

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Should we recommend home-self measurement?

• Advantages
• Disadvantages
• Goal

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Initial evaluation for HTN
1- Staging of the BP 2- Assessment of the
patients overall cardiovascular risk 3- Detection
of clues indicating potential identifiable causes
of HTN that require further evaluation
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Staging of the BP
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Accurate assessment of BP
Office BP? The united states preventive services
taskforce recommends measuring BP at each office
visit for patients over the age of 21

• Is accurate BP measurement important?
• Time of measurement
• Patient position
• Cuff type and size
• technique of measurement

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• How many readings and visits are needed to
  diagnose HTN?
• Measuring in one arm versus two
• Measuring seated versus supine
• Using large versus small cuff
• Using mercury versus aneroid
  sphygmomanometer
• Korotkoff phase IV versus phase V for DBP

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Evaluation

• - History
• - Physical examination
• - Laboratory testing   Hematocrit
  Urinalysis routine blood chemistries
  Glucose Creatinine electrolytes

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• Fasting (9 to 12 hours) lipid profile
  - Total cholesterol - HDL-cholesterol -
  Triglycerides
•  - Electrocardiogram

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Follow up
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Who should be treated?
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WHEN SHOULD DRUG THERAPY BE STARTED?
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• Before addressing the question, When should drug
  therapy be started? one caveat must always be
  recalled An initially elevated BP, above 140 mm
  Hg systolic or 90 mm Hg diastolic, must always be
  remeasured at least three times over at least 4
  weeks to ensure that hypertension is present.
• Only if the level is very high (gt180/110 mm Hg)
  or if symptomatic target organ damage is present
  should therapy be begun before the diagnosis is
  carefully established.

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• 2014 Evidence-Based Guideline for the anagement
• of High Blood Pressure in Adults
• Report From the Panel Members Appointed
• to the Eighth Joint National Committee (JNC 8)

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Recommendation 1

• In the general population aged 60 years or older,
  initiate pharmacologic treatment to lowerBP at
  systolic blood pressure (SBP) of 150 mmHg or
  higher or diastolic blood pressure (DBP) of
  90mmHg orhigher and treat to a goal SBP lower
  than 150mmHg and goal DBP lower than 90mmHg.

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• These members concluded that the evidence
• was insufficient to raise the SBP target from
  lower than 140 to lower than 150 mm Hg in
  high-risk groups, such as black persons, those
  with CVD including stroke, and those with
  multiple risk factors.
• The panel agreed that more research is needed to
  identify optimal goals of SBP for patients with
  high BP

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Recommendation 2

• In the general population younger than 60 years,
  initiate pharmacologic treatment to lower BP at
  DBP of 90 mm Hg or higher and treat to a goal DBP
  of lower than 90mmHg.

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Recommendation 3

• In the general population younger than 60 years,
  initiate pharmacologic treatment to lower BP at
  SBP of 140 mm Hg or higher and treat to a goal
  SBP of lower than 140mmHg

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Recommendation 4

• In the population aged 18 years or older with
  CKD, initiate pharmacologic treatment to lower BP
  at SBPof 140mmHg or higher or DBP of 90mmHg or
  higher and treat to goal SBP of lower than 140mm
  Hg and goal DBP lower than 90mmHg.

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• this recommendation applies to individuals
  younger than 70 years with an estimated GFR or
  measured GFR less than 60 mL/min/1.73 m2 and in
  people of any age with albuminuria defined as
  greater than 30 mg of albumin/g of creatinine at
  any level of GFR.

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Recommendation 5

• In the population aged 18 years or older with
  diabetes, initiate pharmacologic treatment to
  lower BP at SBP of 140mmHg or higher or
• DBP of 90 mm Hg or higher and treat to a goal SBP
  of lower than 140mmHg and goal DBP lower than
  90mmHg.

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Recommendation 6

• In the general nonblack population, including
  those with diabetes, initial antihypertensive
  treatment should include a thiazide-type
  diuretic,
• calcium channel blocker (CCB), angiotensin-convert
  ing enzyme inhibitor (ACEI), or angiotensin
  receptor blocker (ARB).

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• Each of the 4 drug classes recommended by the
  panel in recommendation 6 yielded comparable
• effects on overall mortality and
  cardiovascular, cerebrovascular, and kidney
  outcomes,
• with one exception heart failure.
• Initial treatment with a thiazide-type diuretic
  was more effective than a CCB or ACEI, and an
  ACEI was more effective than a CCB in improving
  heart failure outcomes

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• The panel also acknowledged that the evidence
• supported BP control, rather than a specific
  agent used to achieve that control, as themost
  relevant consideration for this recommendation.

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• The panel did not recommend ß-blockers for the
  initial treatment of hypertension because in one
  study use of ß-blockers resulted in a higher rate
  of the primary composite outcome of
  cardiovascular death,myocardial infarction, or
  stroke compared to use of an ARB, a finding that
  was driven largely by an increase in stroke

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• a-Blockers were not recommended as first-line
  therapy because
• in one study initial treatment with an
  a-blocker resulted in worse cerebrovascular,
  heart failure, and combined cardiovascular
  outcomes than initial treatment with a diuretic

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• Similar to those for the general population, this
  recommendation applies to those with diabetes
  because trials including participants with
  diabetes showed no differences in major
  cardiovascular or cerebrovascular outcomes from
  those in the general population

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Recommendation 7

• In the general black population, including those
  with diabetes, initial antihypertensive treatment
  should include a thiazide-type diuretic or CCB

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Recommendation 8

• In the population aged 18 years or older with CKD
  and hypertension, initial (or add-on)
  antihypertensive treatment should include
• An ACEI orARB to improve kidney outcomes.
• This applies to all CKD patients with
  hypertension regardless of race or diabetes
  status.

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• The evidence is moderate that treatment with an
  ACEI or ARB improves kidney outcomes
• for patients with CKD.
• This recommendation applies to CKD patients
• with and without proteinuria, as studies
  using ACEIs or ARBs showed evidence of improved
  kidney outcomes in both groups.

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• This recommendation is based primarily on kidney
  outcomes because there is less evidence favoring
  ACEI or ARB for cardiovascular outcomes in
  patients with CKD.
• Neither ACEIs nor ARBs improved cardiovascular
  outcomes for CKD patients compared with a
  ß-blocker or CCB.

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• Recommendation8 applies to adults aged 18 years
  or older with CKD, but there is no evidence to
  support renin-angiotensin system inhibitor
  treatment in those older than 75 years.
• Although treatment with an ACEI or ARB may be
  beneficial in those older than 75 years, use of a
  thiazide-type diuretic or CCB is also an option
  for individuals with CKD in this age group.

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• Use of an ACEI or an ARB will commonly increase
  serum creatinine and may produce other metabolic
  effects such as hyperkalemia, particularly in
  patients with decreased kidney function.
• Although an increase in creatinine or potassium
  level does not always require adjusting
  medication, use of renin-angiotensin system
  inhibitors in theCKDpopulation requires
  monitoring of electrolyteand serum creatinine
  levels, and in some cases, may require reduction
  in dose or discontinuation for safety reasons.

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Recommendation 9

• The main objective of hypertension treatment is
  to attain and maintain goal BP. If goal BP is not
  reached within a month of treatment, increase the
  dose of the initial drug or add a second drug
• from one of the classes in recommendation 6
  (thiazide-type diuretic, CCB, ACEI, or ARB).
• The clinician should continue to assess BP and
  adjust the treatment regimen until goal BP is
  reached.

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• If goal BP cannot be reached with 2 drugs, add
  and titrate a third drug from the list provided.
• Do not use an ACEI and an ARB together in the
  same patient.
• If goal BP cannot be reached ,using the drugs in
  recommendation 6 because of a contraindication or
  the need to use more than 3 drugs to reach goal
  BP, antihypertensive drugs from other classes can
  be used.
• Referral to a hypertension specialist may be
  indicated for patients in whom goal BP cannot be
  attained using the above strategy or for the
  management of complicated patients for whom
  additional clinical consultation is needed

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