This presentation focus on the accurate method of BP measurement as well as the presentation of the latest clinical trials of hypertension management and their impact on recent guidelies

1. Hypertension Management
2017
Dr Monkez M Yousif
Professor of Internal Medicine
Member of AGA, EASL and ISC-Hepatitis WG
Zagazig University
October 16, 2017

2. AGENDA
• Epidemiology of HTN in Egypt
• Accurate diagnosis of HTN
• Presentation of evidence-based threshold and
target BPs.
• Update in Pharmacotherapy.

3. Did you know??
35 000 000
people died from
chronic diseases
in 2005
Preventing
CHRONIC DISEASES
a vital investment

4.  Cardiovascular disease,
mainly heart disease, stroke
 Cancer
 Chronic respiratory diseases
 Diabetes
Chronic diseases
Preventing
CHRONIC DISEASES
a vital investment

5. Causes of chronic diseases
Preventing
CHRONIC DISEASES
a vital investment

6. • One of the key risk factors for cardiovascular
disease is hypertension or raised blood
pressure.
• Hypertension already affects 1.1 billion
people worldwide, leading to heart attacks
and strokes. By 2025, it is estimated over 1.5
billion people will have hypertension.
• Researchers have estimated that raised blood
pressure currently kills nine million people
every year.

7. Epidemiology of Hypertension in
Egypt

8. 1.002.00
2008
2015
55-59 Y 15-59 Y
2008
2015
Prevalence of HTN among adults 15-59
years: EDHS 2008 vs 2015
53.5 % 45.6%
17% 12.8%

9. Awareness of condition and treatment status among
hypertensive women and men age 15-59
EHIS 2015

11. Figure 2
The Lancet 2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8)
Stroke mortality rate in each decade of age versus
usual blood pressure at the start of that decade

12. Figure 4
The Lancet 2002 360, 1903-1913DOI: (10.1016/S0140-6736(02)11911-8)
IHD mortality rate in each decade of age versus usual
blood pressure at the start of that decade

13. CV benefits of treating HTN
Hebert et al, Archives Int Med 1993

14. Hypertension Guidelines

15. 1. Joint National Committee: (JNC VIII): 2014
2. ASH/ISH 2015
3. Australian: 2016
4. Canadian 2017
5. Egyptian: 2014
6. European (ESC/ ESH): 2013
7. Indian: 2007 , 2013
8. Japanese: 2009 , 2014
9. Latin America: 2009, 2017
10. Malaysian: 2008 , 2013
11. NICE (British): 2011
12. Sub-Saharan Africa (SSA): 2014
13. WHO/ISH: 2003
14. South African Hypertension Guideline 2011

16. What is New in Guidelines?

17. • Appropriate methods for making a diagnosis
of hypertension
• Evidence-based threshold and target BPs
• Drug Therapy for HTN

18. Diagnosis of HTN

19. USPSTF Draft Statement, January, 2015:
• “The USPSTF recommends screening for HTN in adults
≥18y old.
• Ambulatory BP monitoring is recommended to
confirm high BP before the diagnosis of HTN, except in
cases for which immediate initiation of therapy is
necessary…
• Good quality evidence suggest that confirmation of
hypertension using home BP monitoring may be
acceptable…
• More research is needed on the best home BP
monitoring protocols for follow-up of elevated office
BP measurements…”
www.uspreventiveservicestaskforce.org/page/Document/RecommendationStatementDraft

20. BP measurement methods
• Office (attended, OBPM)
– Oscillometric (electronic) – preferred method
– Auscultatory (mercury, aneroid)
• Office Automated (unattended, AOBP)
– Oscillometric (electronic)
• Ambulatory blood pressure monitoring (ABPM)
• Home blood pressure monitoring (HBPM)

21. Auscultatory OBPM is inaccurate!
• In the real world, the accuracy of auscultatory
OBPM can be adversely affected by provider,
patient and device factors such as:
– too rapid deflation of the cuff
– digit preference with rounding off of readings to 0 or 5
– also, mercury sphygmomanometers are being phased
out
– and aneroid devices are less likely to remain calibrated
• Consequence: Routine auscultatory OBPMs are
9/6 mm Hg higher than standardized research
BPs (primarily using oscillometric devices)
Myers MG, et al. Can Fam Physician 2014;60:127-32.

22. Automated Office BP Measurement
• Automated office blood pressure (AOBP) is the
preferred method of performing in-office BP
measurement
• More closely approximates ABPM than routine
office BPs (mitigates white coat effect)1-3
• Is more predictive of end organ damage
(LVMI, proteinuria and cIMT), similar to ABPM4-6
1. Beckett L, et al. BMC Cardiovasc Disord 2005;5:18; 2. Myers MG, et al. J Hypertens 2009;27:280-6;
3. Myers MG, et al. BMJ 2011;342;d286;4. Campbell NRC, et al. J Hum Hypertens 2007;21:588-90;
5. Andreadis EA, et al. Am J Hypertens 2011;24:661-6; 6. Andreadis EA, et al. Am J Hypertens 2012;25:969-73.
ABPM = ambulatory blood pressure measurement
LVMI = left ventricular mass index
cIMT = carotid intima media thickness

23. Keys to accurate OBPM
• Use standardized measurement techniques
and validated equipment
• Measurement using electronic (oscillometric)
upperarm devices is preferred over
auscultation
• The first reading should be discarded and the
two averaged.

24. Mean blood pressure* (mmHg)
Centre for Studies
in Primary Care1
ABPM referral
unit2
CAMBO trial3
Routine
manual office BP
151/83 152/87 150/81
Automated
office BP
140/80 132/75 135/77
Awake
ambulatory BP
142/80 134/77 133/74
AOBP Readings are Lower than OBP Readings
and are More Similar to ABP Readings
*The automated office blood pressure (BP) and awake ambulatory BP were similar,
and both were lower than the routine manual BP obtained in community practice.
1. Beckett Let al, BMCCardiovasc.Disord.2005; 5: 18. 2. MyersMGet al, J. Hypertens.2009; 27: 280. 3. MyersMG, et al. BMJ 2011; 342: d286.

25. Correct BP measurement technique

26. Mean Office, Home, Ambulatory
Blood Pressures: Equivalence Numbers
• An office blood pressure of 140/90 mmHg is
comparable to:
Blood Pressure mmHgDescription
135/85Home BP
135/85Daytime Ambulatory BP
130/8024-hour Ambulatory BP
135/85Automated office BP

27. Criteria for the diagnosis of hypertension
and recommendations for follow-up: overview

28. Out-of-Office BP Measurements
• Out-of-office measurement identifies white
coat hypertension and masked hypertension
• ABPM has better predictive ability than OBPM
and is the recommended out-of-office
measurement method
• HBPM has better predictive ability than OBPM
and is recommended if ABPM is not tolerated,
not readily available or due to patient
preference
ABPM = ambulatory blood pressure measurement
HBPM = home BP measurement
OBPM = office BP measurement

29. -0.1 0. 0.1 0.2 0.3 0.4 0.5 0.6
OBP
HBPM
ABPM
Mulè G, et al. J Cardiovasc Risk 2002;9:123-9.
-0.1 0. 0.1 0.2 0.3 0.4 0.5 0.6
OBP
HBPM
ABPM
0. 0.1 0.2 0.3 0.4 0.5
0. 0.1 0.2 0.3 0.4 0.5
SBP
DBP
LVH Albumin excretion ratio
SBP
DBP
Indexes of hypertensive target organ damage Indexes of hypertensive target organ damage
Out-of-Office BP Measurements are
More Highly Correlated With BP-Related Risk

30. Masked Hypertension
BP (mm Hg)
Office BP
Automated office BP
< 140/90
< 135/85
Awake Ambulatory ≥ 135/85
24-hour Ambulatory BP ≥ 130/80
• Definition:
– The term ‘masked hypertension’ is defined as having non-
elevated clinical (office) BP with elevated out-of-clinic
average BP, typically determined by ambulatory BP
monitoring.
• Criteria of Diagnosis

31. 10%
about
in the general
population
30%
about
in treated
hypertensive
patients
diabetes
in patients with
and
higher
chronic kidney
disease patients
One out of three treated hypertensive patients
has masked hypertension
Andalib A, et al. Int Med J 2012;42:260-6
Prevalence of Masked Hypertension

32. 0
5
10
15
20
25
30
35
Normal White coat Uncontrolled Masked
CVeventsper1000patient-year
CV Events
Okhubo T, et al. J Am Coll Cardiol 2005;46;508-15
The Prognosis of White Coat
and Masked Hypertension

33. Clinical and Laboratory Evaluation
Objectives
• Identify high risk patients
– Detect other cardiovascular risk factors.
– Assess target organ damage.
– Diagnose associated cardiovascular or renal
disease.
• Identify secondary causes of hypertension
and comorbid conditions.

34. Laboratory Tests
• Essential (in all patients):
– Urine: dipstick for protein, blood, sugar
– Blood tests: sugar, creatinine
• Recommended (if facilities are available)
– Blood lipid profile: total cholesterol, LDL, HDL, triglycerides
– Uric acid
– Serum potassium
– Hemoglobin
– ECG
– Special investigations in resistant or suspected secondary
forms of hypertension.
– Optic fundus in patients with severe hypertension.

35. Cardiovascular Risk Factors
• DM
• Males >55 years or Females >65 years.
• Total S-Cholesterol> 240 mg/dl, HDL-C <40 mg/dl
or LDL-C >160 mg/dl.
• Cigarette smoking.
• Obesity
• Serum creatinine >2 mg/dl.
• Metabolic syndrome
• Family history of ASCVD in a first degree relative
(parents, siblings or brothers) before the age of
40 years in males and 50 years in females.

36. Silent Target Organ Damage
• Left ventricular hypertrophy (LVH):
– ECG criteria (Sokolow-Lyon SV1+RV5 or V6 > 35 mm,
tall R in AVL> 11 mm) .
– Echo criteria (wall thickness 12 mm or LVMI in males
125 gm/m2 or in females 110 gm/m2 .
• Carotid bruits
• Proteinuria: microalbuminurea 30–300 mg/24 h
• Increased serum creatinine >1.4 mg/dl in
females and >1.5 mg/dl in males
• Optic fundus changes: >grade I retinopathy

37. Cardiovascular Risk Categorization
• Risk Group A (low risk): patients with
– no other cardiovascular risk factors,
– no target organ damage or associated ASCVD.
• Risk Group B (moderate/intermediate risk): patients
with
– additional 1 or 2 risk factors (not including diabetes) but
with no target organ damage or associated ASCVD.
• Risk Group C (high risk): patients with
– diabetes,
– target organ damage or
– associated asymptomatic ASCVD or
– patients with 3 or more risk factors or
– a very high level of a single risk factor.

38. • Risk Group D (very high risk): Patients with
symptomatic established cardiovascular or
renal disease:
– Coronary artery disease (angina, MI, CABG, PCI).
– Cerebrovascular disease (stroke, TIA).
– Peripheral arterial disease.
– Heart failure.
– Abdominal aortic aneurysm.
– Renal failure: serum creatinine >2 mg/dl.

39. Threshold and Target of BP

40. Definitions of hypertension by different types
of blood pressure measurement

41. JNC-7 Treatment Algorithm
Chobanian AV et al. JAMA 2003;289:2560-72.

42. JNC-8 Recommendations
• In patients >60 years of age, start medications
at blood pressure of >150/90mm Hg and treat to
goal of <150/90mm Hg
• In patients >60 years of age, treatment does
not need to be adjusted if achieved blood
pressure is lower than goal and well-tolerated
James PA et al. JAMA 2014;311:507-20.

43. HYVET trial
benefit of target < 150/90 in very elderly

44. VALISH trial
no benefit of target < 140/90 in elderly

45. JATOS trial
Japanese Trial to Assess Optimal SBP

46. JNC-8 Recommendations
• In patients <60 years of age, start
medications at blood pressure of >140/90mm
Hg and treat to goal of <140/90mm Hg
• In all adult patients with diabetes or chronic
kidney disease, start medications at blood
pressure of >140/90mm Hg and treat to goal of
<140/90mm Hg
James PA et al. JAMA 2014;311:507-20.

47. ACCORD Trial
intensive HTN Tx in DM

48. Population SBP DBP
High Risk (SPRINT population) # ≥130 NA
Diabetes ≥ 130 ≥ 80
Moderate* ≥ 140 ≥ 90
Low risk (no TOD or CV risk factors) ≥ 160 ≥ 100
Usual Office BP Threshold Values for
Initiation of Pharmacological Treatment
AOBP = automated office blood pressure
TOD = target organ damage
SBP = systolic blood pressure
DBP = diastolic blood pressure
# Based on AOBP
*AOBP threshold  135/85 mmHg
Hypertension Canada’s 2017 Guidelines

49. Treatment consists of health behaviour ± pharmacological management
Population SBP DBP
High Risk # < 120 NA
Diabetes < 130 < 80
All others* < 140 < 90
Recommended Office BP Treatment Targets
# Based on AOBP
*AOBP threshold  135/85 mmHg

50. New Guideline Post-SPRINT
• For high-risk patients, aged ≥ 50 years, with
systolic BP levels ≥130 mm Hg, intensive
management to target a systolic BP ≤120 mm Hg
should be considered
• Intensive management should be guided by
automated office BP measurements
• Patient selection for intensive management is
recommended and caution should be taken in
certain high-risk groups

51. Average no. of
medications
Intensive care: 2.8
Standard care: 1.8
The SPRINT Research Group, NEJM, Nov 9th, 2015
SPRINT: SBPs Achieved

52. NNT=61
SPRINT Primary Outcome
The SPRINT Research Group, NEJM, Nov 9th, 2015
25% relative risk
reduction (P<0.001) with
intensive treatment,
with the two curves
beginning to separate by
1 year.

53. New Thresholds/Targets for the High-Risk Patient
Post-SPRINT: Who does this apply to?
• There was an increased risk of renal deterioration, potassium
abnormalities and hypotension with intensified therapy
• Patients with one or more clinical indications should consent to
intensive management
Clinical or sub-clinical cardiovascular disease
OR
Chronic kidney disease (non-diabetic nephropathy, proteinuria <1
g/d, *estimated glomerular filtration rate 20-59 mL/min/1.73m2)
OR
†Estimated 10-year global cardiovascular risk ≥15%
OR
Age ≥ 75 years
* Four variable MDRD equation
† Framingham Risk Score, D'Agastino, Circulation 2008

54. New Thresholds/Targets for the High-Risk Patient
Post-SPRINT: Who does this NOT apply to?
Limited or No Evidence:
• Heart failure (EF <35%) or recent MI (within last 3 months)
• Indication for, but not currently receiving, a beta-blocker
• Institutionalized elderly
Inconclusive Evidence:
• Diabetes mellitus
• Prior stroke
• eGFR < 20 ml/min/1.73m2
Contraindications:
• Patient unwilling or unable to adhere to multiple medications
• Standing SBP <110 mmHg
• Inability to measure SBP accurately
• Known secondary cause(s) of hypertension

55. Pharmacologic Therapy of HTN

57. From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Guideline Comparisons of Goal BP and Initial Drug Therapy for Adults With Hypertension

58. Hypertension 2017
What’s new?
• Longer acting (thiazide-like) diuretics are
preferred vs. shorter acting (thiazides)
• Single pill combinations should be used as a
first line treatment (regardless of the extent of
BP elevation)
Leung AA, et al. Hypertension Canada’s 2017 Guidelines. Can J Cardiol. 2017.

59. Longer-acting Diuretics Should be Preferred
(i.e., thiazide-like are preferred to thiazides)
•Longer-acting (thiazide-like):
–chlorthalidone,
–indapamide
•Shorter-acting (thiazides):
–hydrochlorothiazide

60. • Design: Meta-analysis of 21 RCTs of BP lowering comparing
thiazide-type or thiazide-like diuretics vs. placebo or
another antihypertensive on CV events and mortality
• >500,000 person-years of observation combined
• Thiazide-type:
– Hydrochlorothiazide
– Bendrofluazide
– Chlorothiazide
• Thiazide-like:
– Indapamide
– Chlorthalidone
Thiazide-type vs. Thiazide-like Diuretics:
CV Events and Mortality Meta-analysis
Olde Engberink RH. Hypertension 2015;65(5):1033-40

61. Diuretic Type Meta-Analysis vs. Placebo
• Both types of diuretics reduced CV events,
cerebrovascular events, and HF
• Only thiazide-like diuretics additionally reduced
coronary events and all-cause mortality
Event Thiazide-Type Thiazide-Like
CV 0.67 (.56-.81) 0.67 (0.60-0.75)
Coronary 0.81 (0.63-1.05) 0.76 (0.61-0.96)
Cerebrovascular 0.52 (0.38-0.69) 0.68 (0.57-0.80)
Heart Failure 0.36 (0.16-0.84) 0.47 (0.36-0.61)
All-cause Mortality 0.86 (0.75-1.00) 0.84 (0.74-0.96)
Olde Engberink RH. Hypertension 2015;65(5):1033-40

62. • Design: Meta-analysis of 14 RCTs (n=883) comparing HCTZ
vs. indapamide/chlorthalidone on BP reduction
– Compared according to 3 different dose levels: HCTZ 12.5, 25, 50
mg; chlorthalidone 6.25, 12.5, 25 mg; indapamide 1.5, 2, 2.5 mg
• SBP reduction:
– Indapamide vs. HCTZ: −5.1 mmHg (p=0.004)
– Chlorthalidone vs. HCTZ: −3.6 mmHg (p=0.052)
• Metabolic effects:
– No differences between HCTZ vs. indapamide in adverse effects
(K+, Na+, Cr, BG, cholesterol, uric acid); no data for HCTZ vs.
chlorthalidone Roush GC, et al. Hypertension. 2015 May;65(5):1041-6

63. • Meta-analysis
• Used 3 dose levels to try to standardize dosing
– Hydrochlorothiazide (12.5/25/50 mg)
– Chlorthalidone (6.25/12.5/25 mg)
– Indapamide (1.5/2.0/2.5 mg)
– Outcomes:
• BP lowering
• Metabolic
• CV events
Head-to-Head for BP Lowering:
HCTZ vs. Chlorthalidone or Indapamide
Roush GC et al. Hypertension 2015;65:1041-6

64. Summary:
Longer-Acting Diuretics Preferred
• Longer-acting (thiazide-like) diuretics appear
more effective at reducing CV events and SBP
& DBP than shorter-acting (thiazide) diuretics

65. Hypertension 2017
What’s new?
• Longer acting (thiazide-like) diuretics are
preferred
vs. shorter acting (thiazide)
• Single pill combinations should be used as a
first line treatment (regardless of the extent of
BP elevation)

66. TARGET < 140 mmHg systolic AND < 90 mmHg diastolic
First Line Recommandations Circa
1999-2016
Thiazide
diuretic
ACEi
Long-acting
CCB
ARB Beta-
blocker*
*Not indicated as first line therapy for patients over 60 yrs.
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure
is ≥20 mmHg systolic or ≥10 mmHg diastolic above target
Health behaviour management

67. Thiazide/
thiazide-like*
ACEI§ Long-acting
CCB
TARGET <135/85 mmHg (automated measurement method)
ARB § Beta-
blocker†
First Line Treatment of Adults with Systolic/Diastolic
Hypertension Without Other Compelling Indications
Health behaviour management
Single pill
combination**
† BBs are not indicated as first line therapy for age 60 and above
§Renin angiotensin system (RAS) inhibitors are contraindicated in pregnancy and
caution is required in prescribing to women of child bearing potential
* Longer-acting (thiazide-like) diuretics are preferred over shorter-acting (thiazide) diuretics
INITIAL TREATMENT
**Recommended SPC choices are those in which an ACE-I is combined with a CCB,
an ARB with a CCB, or an ACE-I or ARB with a diuretic

68. Advantages of Single Pill Combinations (SPCs)
• SPC therapy is associated with better
adherence
vs. free combinations1
• A regimen featuring initial prescription of SPC
leads to better BP control2
• Initial combination therapy is associated with
↓ risk of CV events than monotherapy3,4
1. Sherrill B, et al. J Clin Hypertens 2011;13:898-909;
2. Feldman RD, et al. Hypertension 2009;53:646-53;
3. Corrao G, et al. Hypertension 2011;58:566-72;
4. Gradman AH, et al. Hypertension 2013;61(2):309-18.

69. Study or Subgroup
Singe Pill Free Equivalent Mean Difference
IV, Random, 95% CI
Mean Difference
IV, Random, 95% CIMean SD N Mean SD N Weight
Naive patients
Brixner 2008 64.2 58.67 1628 57.6 30.21 561 14.2% 6.60 (2.81, 10.39)
Jackson 2008 73.1 35.42 619 60.5 35.42 65 10.3% 12.60 (3.55, 21.65)
Subtotal (95% CI) 2247 626 24.5% 8.13 (3.00, 13.26)
Heterogeneity: Tau2 = 5.47; Chi2 = 1.44, df = 1 (P=0.23); I2 = 30%
Test for overall effect: Z = 3.11 (P=0.002)
Experienced patients
Dickson 2008 58.6 35.42 3363 48.1 35.42 713 14.7% 10.50 (7.64, 13.36)
Dickson-elderly 2008 63.4 29.4 2336 49 23.4 3368 15.2% 14.40 (12.97, 15.83)
Gerbino 2007 87.9 35.42 2839 69.2 35.42 3367 15.1% 18.70 (16.93, 20.47)
Hess 2008 76.9 35.42 7224 54.4 35.42 7225 15.3% 22.50 (21.34, 23.66)
Taylor 2003 80.8 35.42 2754 73.8 35.42 2978 15.1% 7.00 (5.16, 8.84)
Subtotal (95% CI) 18516 17651 75.5% 14.66 (8.97, 20.36)
Heterogeneity: Tau2 = 41.31; Chi2 = 236.93, df = 4 (P0.00001); I2 = 98%
Test for overall effect: Z = 5.05 (P0.0001)
Total (95% CI) 20763 18277 100.0% 13.31 (8.26, 18.35)
Heterogeneity: Tau2 = 42.94; Chi2 = 264.57, df = 6 (P0.00001); I2 = 98%
Test for overall effect: Z = 5.17 (P0.00001)
Test for subgroup differences: Chi2 = 26.20, df = 1 (P0.00001); I2 = 96.2%
Favors free equivalents Favors single pill
-20 -10 0 10 20
SPCs Improve Adherence
Sherrill B, et al. J Clin Hypertens. 2011;13(12):898-909

70. IncrementalSBPreductionratio
observed/expected(additive)
Incremental BP-Lowering Effect at
Standard Doses: Combine or Double?
Wald DS, et al. Am J Med 2009;122:290-300

71. Dose as a proportion of the standard dose
Sideeffectprevalence(%-placeborate)
30
20
10
0
-10
1/4 1/2 1 2 4
30
20
10
0
-10
1/4 1/2 1 2 4
Calcium Channel Blockers Thiazides
At Low Doses the Adverse Effects of Most
Antihypertensives Approach those of Placebo
Law, M R et al. BMJ 2003;326:1427

72. • Cluster randomized controlled trial - hypertension in
family practices
• Simplified algorithm featuring initial therapy with
low-dose antihypertensive single drug combination
vs. conventional guideline-based care
• Low-dose - by splitting usual starting dose in half
• Practitioners randomly assigned to use STITCH care
or usual stepwise management according to CHEP
guidelines
Initial SPC Therapy Improves
BP Control Rates: STITCH Study
Feldman RD, et al. Hypertension 2009;53(4):646-53

73. Absolute difference: 12.0%
95% CI 1.5-22.4%
P = 0.026
Relative difference: 23%
STITCH Study: Results
Feldman RD, et al. Hypertension 2009;53(4):646-53

74. Ross D. Feldman et al. Hypertension. 2009;53:646-653
Copyright © American Heart Association, Inc. All rights reserved.
STITCH-care algorithm

75. Initial Combination Therapy Reduces CV Risk
(observational study)
Corrao G, et al. Hypertension 2011;58(4):566-72

76. Thiazide/
thiazide-like*
ACEI§ Long-acting
CCB
TARGET <135/85 mmHg (automated measurement method)
ARB Beta-
blocker†
First Line Treatment of Adults With Systolic/Diastolic
Hypertension Without Other Compelling Indications
Health behaviour management
Single pill
combination**
† BBs are not indicated as first line therapy for age 60 and above
§Renin angiotensin system (RAS) inhibitors are contraindicated in pregnancy and
caution is required in prescribing to women of child bearing potential
* Longer-acting (thiazide-like) diuretics are preferred over shorter-acting (thiazide) diuretics
INITIAL TREATMENT
**Recommended SPC choices are those in which an ACE-I is combined with a CCB,
an ARB with a CCB, or an ACE-I or ARB with a diuretic

77. Conclusion
• Out of Office BP measurement is more accurate than
In-Office BP measurement.
• Unattended Automated Office Blood Pressure (AOBP)
measurement is the preferred method of performing
in-office BP measurement vs auscultatory
sphygmomanometer method.
• Threshold and Target BPs in eldely patients are
unequivalent in different guidelines.
• Long-acting thiazide-like analogues are preferred than
short-acting thiazides.
• Single pill combinations may (should) be used as a first
line treatment (regardless of the extent of BP
elevation).

78. 78
Monkez M Yousif
From Next time Don’t feel Lonely….cause you have
some friends inside you to take care of yourself……