Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
1 1

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To describe the "stepwise approach" to therapy.
To discuss:
1. The evidence for the role of lifestyle changes
2. The indications, contraindications and side effects of various antihypertensive classes

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Lifestyle
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Combination therapy
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TREAT HYPERTENSION IN THE CONTEXT OF
OVERALL CARDIOVASCULAR RISK
1. Global cardiovascular risk should be assessed.
2. In the absence of data to determine the accuracy of risk calculations, avoid using absolute levels of risk to support treatment decisions at specific risk thresholds.
3. Shared decision-making may improve the effectiveness of preventive health interventions.
Counting risk factors underestimates the risk

THRESHOLD FOR INITIATION OF TREATMENT
AND TARGET VALUES
Condition Initiation
SBP / DBP mmHg
Diastolic
± systolic hypertension

140/90
Isolated systolic hypertension
Diabetes
Renal disease
Proteinuria >1 g/day
SBP = or >160

130/80
(
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130/80)
(

125/75)
Target
SBP / DBP mmHg
<140/90
<140
<130/80
<130/80
<125/75

1.
Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with the DASH diet
2.
3.
Regular physical activity: optimum 30-60 minutes of moderate cardiorespiratory activity 4/week or more
Reduction in alcohol consumption in those who drink excessively (
( ≤ 2 drinks/ day)
4.
Weight loss (
≥ 5 Kg) in those who are over weight (BMI>25)
5.
Waist Circumference
< 102 cm for men
< 88 cm for women
5. In individuals considered salt-sensitive, such as: Canadians of
African descent, age over 45, individuals with impaired renal function or with diabetes. Restrict salt intake to less than 100 mmol/day
6.
Smoke free environment

INDICATIONS FOR PHARMACOTHERAPY
Strongly consider prescription if:

Average DBP equal or over 90 mmHg
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Hypertensive Target-organ damage (or CVD)
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Independent cardiovascular risk factors:
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Elevated systolic BP
Cigarette smoking
Abnormal lipid profile
Strong family history of premature CV disease
Truncal obesity
Sedentary Lifestyle
 Average DBP equal or over 80 mmHg in a patient with diabetes

CHOICE OF PHARMACOLOGICAL
TREATMENT
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO YES
Treatment in the absence of compelling indication
Individualized
Treatment
(with compelling indications)

TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide ACE-I ARB
Longacting
CCB
* No longer preferred as routine initial therapy
Betablocker*

COMBINATION THERAPY
If partial response to monotherapy
1. Dual Combination Therapy
2. Triple or Quadruple Therapy
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined
(such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification therapy
Thiazid e diuretic
ACE-I ARB
Long-acting
CCB
Betablocker*
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
Dual Combination
Triple or Quadruple
Therapy
* Not indicated as first line therapy over 60

For additive hypotensive effect in dual therapy
Combine an agent from
Column 1 with any in Column 2
Column 1
• Thiazide diuretic
• Long-acting calcium channel blocker*
Column 2
• Beta adrenergic blocker
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
(ACE=Angiotensin Converting Enzyme, ARB=Angiotension Receptor Blocker)

For additive hypotensive effect in triple therapy
Combine 2 agents from one Column with any in the other Column
Column 1
• Thiazide diuretic
• Long-acting calcium channel blocker*
Column 2
• Beta adrenergic blocker
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker

SPECIFIC DRUGS FOR SPECIFIC PATIENTS

MULTIPLE ANTIHYPERTENSIVE AGENTS
ARE NEEDED TO ACHIEVE TARGET BP
Trial Target BP (mm Hg) 1
Number of antihypertensive agents
2 3 4
ALLHAT SBP <140/DBP <90
UKPDS DBP <85
ABCD
MDRD
HOT
AASK
IDNT
DBP <75
MAP <92
DBP <80
MAP <92
SBP <135/DBP <85
DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.
Bakris GL et al. Am J Kidney Dis.
2000;36:646-661.
Lewis EJ et al. N Engl J Med.
2001;345:851-860.
Cushman WC et al. J Clin Hypertens . 2002;4:393-405.

PHARMACOLOGICAL TREATMENT FOR
HYPERTENSIVE PATIENTS
COMPELLING INDICATIONS

Individualized treatment
 Compelling indications:
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•
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Smoking
Ischemic Heart Disease
Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI
Left Ventricular Systolic Dysfunction
Cerebrovascular Disease
Left Ventricular Hypertrophy
Non Diabetic Chronic Kidney Disease
Renovascular Disease
 Diabetes Mellitus
•
•
With Diabetic Nephropathy
Without Diabetic Nephropathy
 Global Vascular Protection for Hypertensive Patients
•
•
Statins
Aspirin

TREATMENT ALGORITHM
TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy
Thiazide diuretic
ARB
Long-acting
DHP CCB

TARGET <140 mmHg Systolic BP
Lifestyle modification therapy
Thiazide diuretic
CONSIDER
• Nonadherence?
• Secondary HTN?
• Interfering drugs or lifestyle?
• White coat effect?
ARB
Long-acting
DHP CCB
Dual combination
Triple or Quadruple* combination
* If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined
(such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).

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Thiazide - type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
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Certain high-risk conditions are compelling indications for other drug classes.
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Most patients will require two or more antihypertensive drugs to achieve goal BP.
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If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

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The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.
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Motivation improves when patients have positive experiences with, and trust in, the clinician.
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Empathy builds trust and is a potent motivator.
The responsible physician’s judgment remains paramount.

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CVD risk has now replaced CHD risk (to include strokes)
The current CVD risk threshold is >20% over 10 years
(equivalent to CHD risk of 15%)
Current advice from the BHS is to prescribe a statin in all patients with hypertension and a CVD risk of 20% or greater.
Unless contra-indicated low dose aspirin should be considered in patients over 50 with a CVD risk of >20% when the blood pressure is controlled.
CVD risk has implications regarding levels to treat.

Specialist referral is indicated if there is a possible underlying cause or presenting as:
• sudden onset
• worsening of hypertension
• resistance to multi-drug regimen three or more drugs
• Hypertension diagnosed in young age ( < 35 years)
• persistent noncompliance
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Saudi Hypertension Management Guidelines 2007