52. Cardiovascular risk category of hypertension Blood pressure （ mmHg ） Grade 1(SBP 140 ～ 159 or DBP 90 ～ 99) Grade 2(SBP 160 ～ 179 or DBP 100 ～ 109) Grade 3(SBP ≥180 or DBP ≥110) No other risk factors Low-risk Medium-risk High-risk 1 ～ 2 risk factors Moderate-risk Medium-risk Very High-risk 3 or more risk factors ， or diabetes ， or target organ damage High-risk High-risk Very High-risk complications Very High-risk Very High-risk Very High-risk
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59. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
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69. Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension > 160 or > 100 Yes Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
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72. Other medications for hypertensive patients Primary prevention ( 1 ) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) ( 2 ) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l ( 3 ) Vitamins—no benefit shown, do not prescribe
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74. Targets for lipid lowering Ideal - TC<4.0mmol/l or LDL <2.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater ‘ Audit’ - TC <5.0mmol/l or LDL <3.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater Lipid targets
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78. ESH - ESC Guidelines, J Hypertens 2008 -BP < 140/90 mmHg in all hypertensive patients < 130/80 mmHg in hypertensive patients with diabetes or renal disease -Control of all cardiovascular risk factors Goals of treatment
These data are taken from a meta-analysis of 61 prospective observational studies on deaths from vascular disease among subjects without vascular disease at baseline. The results demonstrated that the relationship of stroke mortality (left panel) and ischemic heart disease (IHD) mortality (right panel) to usual BP is strong and direct at all ages. As highlighted on the following slide, each difference of 20 mmHg in usual systolic BP is associated with a two-fold difference in the risk of stroke mortality and IHD mortality (between ages 40–69 years). The annual absolute difference in risk is greater in old age. Reference Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.
Trials have shown that BP lowering can produce rapid reductions in cardiovascular disease risk. In fact, even a 2 mmHg decrease in systolic BP would result in approximately 7% lower mortality risk from ischemic heart disease and a 10% lower mortality risk from stroke. Reference Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.
