Definition of hypertension

  • hypertension is defined as office SBP values ≥ 140 mmHg and/or diastolic BP (DBP) values ≥ 90 mmHg (ESC 2018)
  • this is based on evidence from multiple RCTs that treatment is beneficial in patients with these BP levels

Hypertension and the risk of stroke

  • arterial hypertension is the major cardiovascular risk factor
  • treatment of hypertension reduces the risk of stroke and cerebrovascular mortality and slows the progression of potential carotid stenosis
  • the benefit is also present in people > 80 years of age (HYVET trial)
  • in stroke prevention, it is the absolute value of the blood pressure reduction that is important, not the type of antihypertensive drug
    • BP control must be consistent to reduce the risk of vascular events  [Towfighi, 2014]
  • BP lowering in stroke prevention is also beneficial in normotensive patients (HOPE, PROGRESS trials)
  • according to the SPRINT  trial, CV risk reduction is more pronounced with a target SBP < 120 mm Hg compared to SBP < 140 mm Hg
    • other recent trials also support target systolic BP < 120 mm Hg (ACCORD BP, RESPECT, and ESPRIT)
PROGRESS trial
HOPE trial

Blood pressure classification

  • it is recommended that BP be classified as optimal, normal, high–normal, or grades 1–3 hypertension, according to office BP (ESC 2018 I/A)
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Diagnostic evaluation

  • the purpose of the clinical evaluation is to:
    • determine the diagnosis and grade of hypertension
    • screen for potential secondary causes of hypertension
    • identify factors potentially contributing to the development of hypertension (lifestyle, concomitant medications, or family history),
    • identify concomitant CV risk factors (including lifestyle and family history)
    • identify comorbidities
    • establish whether there is evidence of hypertension-mediated organ damage (HMOD) or existing cardiovascular, cerebrovascular, or renal disease

Cut-offs for diagnosis of hypertension

Definition of hypertension according to different methods of BP measurement
Category Systolic BP (mmHg) Diastolic BP (mmHg)
Office BP
≥ 140 ≥ 90
ABPM, daytime mean
≥ 135 ≥ 85
ABPM, nighttime mean
≥ 120 ≥ 70
ABPM, 24h mean ≥ 130 ≥ 80
HBPM (home measurement)
≥ 135 ≥ 85
all hypertensive patients
in selected patients
medical history and physical examination
HBPM, ABPM
office BP measurement
ABI
urine analysis: microscopic examination; urinary protein by dipstick test or, ideally, albumin: creatinine ratio fundoscopy
fasting blood glucose and glycated HbA1c
microalbuminuria detection
Na, K, urea, uric acid
echocardiography
liver function tests carotid ultrasound
creatinine and eGFR abdominal ultrasound and Doppler studies
CBC cognitive function testing
lipids (total cholesterol, LDL, HDL, triglycerides)
12-lead ECG

Blood pressure measurement techniques

  • a sphygmomanometer is a device used to measure blood pressure
  • it consists of:
    • an inflatable rubber cuff (of proper size)
    • the machine that records the pressure
    • the mechanism for inflation (manually operated bulb+valve or an  electrically operated pump)
  • manual vs. digital
    • manual (stethoscope using the auscultatory technique)
      • aneroid (mechanical types with a dial) – may require calibration checks
      • mercury (gold standard) – the pressure is indicated by a column of mercury; it does not require recalibration and has high accuracy
    • digital (oscillometric)
      • may use manual or automatic inflation, but both types are electronic, easy to operate without training, and can be used in noisy environments
      • calibration is also a concern
Digital manometer
Manual aneroid manometer
Digital manometer
Manual mercury manometer
Office BP measurement
  • the auscultation method is more accurate than the oscillometric method
  • adequate cuff size is required (the cuff’s bladder length should be at least equal to 80% of the upper arm circumference )
    • arm circumference < 35 cm – cuff 16×30 cm  (for most patients)
    • arm circumference 35-44 cm – cuff 16×36 cm
    • arm circumference > 45 cm – cuff 16×42 cm
  • the cuff should be positioned at heart level, with the back and arm supported to avoid muscle contraction and isometric exercise-induced increases in BP
  • the patient should be seated comfortably for 5-10 min before beginning BP measurements; the forearm is loosely supported at heart level
  • measure BP on both arms at the first visit
    • use the arm with the higher readings as the reference
  • three BP measurements should be recorded, 1–2 min apart; BP is recorded as the average of the last two BP readings
    • additional measurements are suggested only if the first two readings differ by >10 mmHg
  • auscultatory methods use phase I (appearance) and V (sudden reduction/disappearance) Korotkoff sounds to identify SBP and DBP, respectively
    • in patients with high cardiac minute volume or peripheral vasodilation, Korotkov sounds are sometimes audible down to 0 mm Hg (infinite tone phenomenon). In these situations, we read the diastolic BP as phase IV Korotkov phenomena (sudden attenuation of the sound)
  • measure BP 1 min and 3-5 min after standing from a sitting position in all patients at the first visit to exclude orthostatic hypotension
  • lying and standing BP measurements should also be considered in subsequent visits in the elderly, those with diabetes, and other conditions in which orthostatic hypotension is common
  • record the heart rate and use pulse palpation to exclude arrhythmia
Ambulatory BP Monitoring (ABPM)

Indication for 24h Holter monitoring

  • increased BP variability
  • discrepancies between home and office BP (white coat phenomenon)
  • masked hypertension – higher home BP and normal office BP
  • treatment resistance
  • suspected episodes of hypotension (especially in the elderly and diabetics)
  • elevated BP in pregnancy and suspected eclampsia

Normal BP

  • 24-hour average BP  ≤ 130/80 mm Hg
  • daily average ≤135/85 mm Hg
  • nighttime average BP ≤ 120/70 mm Hg
Home BP Monitoring (HBPM)
  • improves patient cooperation and compliance, reduces the effect of white coat syndrome, reveals daytime BP fluctuations
  • measurement technique:
    • rest 5-10 minutes before measurement + no major physical activity 30 minutes before measurement
    • sitting upright, feet on the floor, uncrossed
    • arms supported on a table at heart level
    • 2 measurements 1 minute apart, morning and evening
    • record the results in the BP diary

Cardiovascular risk assessment

  • hypertension rarely occurs in isolation and often clusters with other CV risk factors such as dyslipidemia and glucose intolerance (metabolic syndrome)
  • the metabolic risk factor clustering has a multiplicative effect on CV risk
  • CV risk assessment with the SCORE system (i.e., the likelihood of a person developing a CV event over a defined period) is recommended for hypertensive patients who are not already at high or very high risk due to established CVD, renal disease, or diabetes, a markedly elevated single risk factor (e.g., cholesterol), or hypertensive LVH

Management

Target BP values

  • the general principle is to initiate pharmacologic antihypertensive treatment in all patients with SBP 140 mmHg or DBP ≥90 mmHg
  • target BP value for people at particular risk (including a history of stroke/TIA, diabetes, CKD): < 130/80 mmHg (shift to< 120 mm Hg can be expected)
    • supported by data from a large meta-analysis of RCTs  [Katsanos, 2016]
    • in patients with increased vascular risk, initiate therapy at BP > 130 mmHg!
  • in patients with steno-occlusive carotid disease or advanced arteriolopathy, BP should be lowered slowly and cautiously because of the increased risk of hypoperfusion (individual BP target around 135-139/85-89 mmHg )
  • the effect of therapy does not depend on the antihypertensive agent but on the blood pressure achieved
    • when choosing a drug, consider comorbidities, interactions, and patient preferences
ESC guidelines 2018
  • the first objective is to lower BP to <140/90 mmHg
    • high normal BP (130139/8589 mmHg) – drug treatment may be considered when CV risk is very high due to established CVD, especially in CAD
  • patients <65 years of age:  SBP should be lowered to 120–129 mmHg in most patients if tolerated
    • SPRINT, ACCORD BP, RESPECT, and ESPRIT trials suggest target SBP < 120 mm Hg!
  • patients >65 years: target SPB 130–139 mmHg
  • patients >80 years: target SPB 130–139 mmHg if tolerated
  • target DPB <80 mmHg should be considered for all hypertensive patients, regardless of risk level and comorbidities
WHO guidelines 2022
 

Lifestyle modification and treatment of other vascular risk factors

→ screening and management of other modifiable vascular risk factors

Antihypertensive drugs

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