2) Update แนวทางการรักษาโรคความดันโลหิตสูง_นพ.อภิชาต (1)

Office BP treatment targets

General Recommendations

Class Level
A
• The first objective of treatment I A

should be to lower BP to <140/90 B
mmHg in all patients

• Provided that treatment is well I
tolerated treated BP should be

targeted to 130/80 mmHg or lower
in most patients

• A DBP target of <80 mmHg should IIa

be considered for all hypertensive

patients, independent of the level
and risk of comorbidities

Williams, Mancia et al., J Hypertens 2018 / Eur Heart J 2008, in press

Effects of BP Control on CV Outcomes
Regardless of Treatment

Prespecified pooled cohort analysis from ACCOMPLISH
(N=10,705)

Achieved SBP, mmHg

110 to <120 (n=1,329) 130 to <140 (n=3,429)

120 to <130 (n=3,593) ≥ 140 (n=2,354)

Weber MA, et al. Am J Med 2013;126:501-8.

Target Blood Pressure Levels*

Age Hypertension with DM with CKD with CVD Previous

group Only stroke/TIA

18-65 120-130/ 120-130/ 120-130/ 120-130/ 120-130/
years 70-79
70-79 70-79 70-79 70-79
65-79 130-139/
years 70-79 130-139/ 130-139/ 130-139/ 130-139/

≥ 80 130-139/ 70-79 70-79 70-79 70-79
years 70-79
130-139/ 130-139/ 130-139/ 130-139/

70-79 70-79 70-79 70-79

• Average office BP measurement in mmHg

• BP < 120/70 mmHg is not advise

DM = diabetes mellitus, CKD = chronic kidney disease,
CVD = cardiovascular disease. TIA = transient ischemic attack

Target Blood Pressure Levels*

Age Any
group Hypertension

18-65 120-130/
years 70-79

65-79 130-139/
years 70-79

≥ 80 130-139/
years 70-79

• Average office BP measurement in mmHg

Procedures of hypertension treatment in the
absence of compelling indications JSH 2019

Hypertension without compelling indications

STEP 1 One of A, C, and D *

STEP 2 One of A+C, A+D, and C+D*1

(If fixed-dose combination is available, they should be used.)

STEP 3 A+C+D
STEP 4
Resistant hypertension*

Referral to specialists in hypertension
A+C+D+MR antagonist, B-or a -blockers,
and other types of antihypertensive drugs

First-line drugs A : ARBS, ACE inhibitors, C : CCBS
D : Thiazide diuretics

In older patients, administration should be started at half of the standard
dose, and the dose should be increased at 1-3-month intervals

Antihypertensive Medication
Recommendations

Recommendations Strength of Quality of
Recommendations Evidence

Medication to start treatment of I A
hypertension should be selected from
the 5 main groups, that is angiotensin
converting enzyme inhibitors (ACEIs),
angiotensin receptor blockers (ARBs),
beta-blockers, calcium-channel blockers
(CCBs), and diuretics (thiazides and
thiazide-like diuretics)

Antihypertensive Medication
Recommendations

Recommendations Strength of Quality of
Recommendations Evidence

2 types of medications should be started for I A
most patients. May select renin angiotensin
system blockers (ACEIs or ARBs) to be taken
with diuretics or CCBs; however other
combination of medication groups can be
selected as appropriate. For weak elderly
patients, patients with relatively low
starting BP (140-149/90-99 mmHg) and low-
risk patients, only one type of starting
medication should be selected.

Antihypertensive Medication
Recommendations

Recommendations Strength of Quality of
Recommendations Evidence

Medication that is a combination of 2 types in I B
one pill should be selected I A

If 2 types of medications cannot control BP then 3 I B
type of medications should be used. One of the 3 III A
types should be a diuretic (thiazides or thiazide-
like diuretics)

Should add spironolactone, or beta-blocker, or
alpha-blocker, one type at a time in that order if
3 types of medications cannot control BP and if
none of these 3 medications have been taken
prior

Should not co-administer ACEIs with ARBs

Device-based therapies for hypertension

Recommendation Classa Levelb
III B
Use of device-based therapies is not
recommended for the routine
treatment of hypertension, unless in
the context of clinical studies and
RCTs, until further evidence
regarding their safety and efficacy
becomes available.

RCT = randomized controlled trial.
a Class of recommendation.
b Level of evidence

Recommendations for Reducing CV risk
in Hypertensive Patients

Recommendations Strength of Quality of
Recommendations Evidence

Patients should receive risk assessment using I C
Thai CV Risk Score

Patients with ≥ 3 risk factors* or more should I A
receive statin

Patients who smoke should be advised or IA
prescribed medication to stop smoking

Patients with calculated Thai CV Risk Score ≥ IIa C
10% (using blood results) can be considered to
receive statin

Aspirin should not be used as primary III A
prevention for every hypertensive patient

* Risk factors consist of male, over 55 years of age, smoking, left ventricular hypertrophy, a history of prematured CVD in family,
albuminuria, diabetic, or artery disease in other areas, or proportion of total cholesterol/HDL-C from 6 upwards

Types of Medications Prescribed

%

Summary of Adverse Events

%

Overall

HT Drugs: “Rule of TENS”

Baseline
mmHg

–10

–20

–30

One drug for every 10 mmHg reduction in SBP
AA A
10 10 10
AB
10 10
A BB
10 10 10
A BC
10 1010

2018 ESC/ESH Hypertension Guidelines

Core Drug-treatment Strategy for Uncomplicated Hypertension

1 Pill Initial therapy ACEi or ARB + CCB or diuretic Consider monotherapy in low-risk grade 1
hypertension or in very old (>80 years) or frailer
Dual combination
patients

1 Pill Step 2 ACEi or ARB + CCB or diuretic

Triple combination

2 Pill Step 3 Resistant hypertension Consider referral to a specialist centre for
further investigation
Triple combination + Add spironolactone (25-50 mg O.D.)
or other diuretic, alpha-blocker or beta-blocker
spironolactone or other drug

Beta-blockers

Consider beta-blockers at any treatment step, when there is a specific indication
for their use, e.g. hear failure, angina, post-MI, atrial fibrillation or younger

women with, or planning, pregnancy

The core treatment algorithm is also appropriate for patient with hypertension-mediated organ damage,
cerebrovascular disease, diabetes, or PAD

Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2008, in press

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