2) Update แนวทางการรักษาโรคความดันโลหิตสูง_นพ.อภิชาต (1)

Predictive Power of Systolic BP on Cardiovascular Mortality

Systolic BP (mmHg) Diastolic BP (mmHg)

<140 1 1.5 2 2.5 <90
140–159 Relative risk 90–99
≥100
160–179
≥180

0.5 0.5 1 1.5 2 2.5

Relative risk

Prognosis Prognosis Prognosis Prognosis
better worse better worse

Alli et al. Arch Intern Med 1999;159:1205–12

Key Messages

 For persons over age 50, SBP is a more important than DBP as CVD risk factor.

Hypertension Diagnosis in Different Measurement
Methods

Category SBP and/or DBP
Office BP measurement (mmHg) (mmHg)

≥ 140 ≥ 90

HBPM ≥ 135 and/or ≥ 85

ABPM

Average of daytime BP ≥ 135 and/or ≥ 85

Average of nighttime BP ≥ 120 and/or ≥ 70

Average of BP in a day ≥ 130 and/or ≥ 80

SBP = systolic blood pressure, DBP = diastolic blood pressure, HBPM = home blood pressure
monitoring, ABPM = ambulatory blood pressure monitoring

Only relying on manual office blood pressures misses out on white coat and
masked hypertension

200

Ambulatory BP mmHg 180 Masked hypertension
160 Hypertension

140 Normotension White Coat 135
120 Hypertension 200

100 120 140 160 180
100

Manual Office BP mmHg

From Pickering, Hypertension 1992

The prognosis of masked hypertension

Prevalence is approximately 10% in hypertensive patients.

CV events per 1000 patient-year 35

CV Events
30

25

20

15

10
5

0 White coat Uncontrolled Masked
24/656 41/462 236/3125
Normal
23/685

Bobrie et al. JAMA 2004;291:1342-9

Salt Intake and 3 types of Masked Hypertension

Kario K. Circulation 2018;137:543-545.

10-year follow up data from Ohasama Study

The Risk of Masked Hypertension

CVD Mortality Stroke CVD Mortality/Stroke

Relative Hazard (95% CI) 2.83
2.17
(0.73-3.21)
(0.95-3.72)1.00 1.07
(1.04-3.61)
(0.58-
2.07)
(1.31-3.60)
(1.77-4.54)
(0.76-2.14)
(1.38-3.29)
(1.49-3.41)
3 2.13 2.26
2 1.88 1.94
1.28
1.54 1.00
1.00

1

Events/ 21/739 11/170 14/221 21/202 36/739 12/170 26/221 38/202 49/739 21/170 36/221 46/202
Patients N-BP WC-HT M-HT S-HT N-BP WC-HT M-HT S-HT N-BP WC-HT M-HT S-HT

J am Coll Cardiol 2005;46:508-515.

เปรียบเทยี บผลความแตกต่างของความดันโลหติ วัดทีบ่ ้านและทคี่ ลินิกจากการศึกษา 18 รายงาน แกน
นอนแสดงระดับของความดันโลหติ systolic ทวี่ ัดจากคลินิก

แสดง white-coat effect ทเี่ กิดขึน้ ตอนแพทยเ์ ข้าเยยี่ มผ้ปู ่ วย

ค่าความดัน mean arterial pressure ค่า heart rate

Grassi G, et al. Circulation 1999;100:222.

PAMELA study

Pressioni Arteriorse Monitorate E Loro Associazioni

Kaplan-Meier curves แสดงการรอดชวี ติ เปรียบเทยี บกลุ่มผู้ป่ วยทมี่ ีความดนั โลหติ ปกต,ิ white-coat hyper-
tension และ sustained hypertension

วนิ ิจฉัยจาก clinic BP เทียบกับ 24 hour BP วินิจฉัยจาก clinic BP เทียบกับ home BP

Hypertension 2006;47:846.



Untreated WCH and CV Events

Study, Year Total HR (95% CI)
participants, n

Verdecchia et al, 1994 1392 1.17 (0.25-5.33)
Fagard et al, 2005 352 1.00 (0.35-2.90)
Pierdomenico et al, 2008 0.97 (0.38-2.46)
Mancia et al, 2013 2037 1.45 (0.28-7.51)
Sung et al, 2013 1589 5.59 (1.22-25.55)
Asayama et al, 2014 1257 1.20 (0.93-.54)
Stergiou et al, 2014 8237 1.42 (1.06-1.91)
Banegas et al, 2018 6458 1.96 (1.22-3.15)
63,910 1.36 (1.03-2.00)
Overall (I2 = 0.0%; P = 0.379)

0.2 0.5 1.0 2.0 5.0

Ann Intern Med. DOI: 10.7326/M19-0223.

Ten-year age- and sex-adjusted odds ratios (ORs) of new-onset SHT in
WCHT and MHT vs true normotension (NT) at entry

Mancia G et al. Hypertension 2009;54:226-232

Hypertension Diagnostic Algorithm

Average office BP (on the same visit)

≥ 130/80 ≥ 140/90 ≥ 160/100 ≥ 180/110
Definite HT
High normal BP Possible HT Probable HT Yes

No TOD / CVD / DM / high CV risk* No
No
HBPM/ABPM HBPM/ABPM or
HBPM/ABPM or Serial OBPM
Serial OBPM 2 visits within 1 mo.
2 visits within 3 mo.

High: Masked HT High: Definite HT
Normal: Normotension Normal (HBPM/ABPM): White-coat HT

*10-year Thai CV risk score > 10 %
Home Blood Pressure Monitoring (HBPM) : การวัดความดันโลหติ ดว้ ยเครอ่ื งชนิดพกพาทบ่ี ้าน
Ambulatory Blood Pressure Monitoring (ABPM) : การวัดความดนั โลหติ ดว้ ยเครอ่ื งชนิดตดิ ตัวพร้อมวัดอัตโนมัติ
Office Blood Pressure Monitoring (OBPM) : การวัดความดันโลหติ ในสถานพยาบาล
High BP: HBPM/daytime ABPM ≥ 135/85 mmHg or serial OBPM ≥ 140/90 mmHg

Recommendations for Additional Investigations on Patients
with Hypertension

Recommendations Strength of Quality of
Recommendations Evidence

Heart I B
I B
12-lead electrocardiogram in every IIb B
patient.

Echocardiogram

− For patients whose
electrocardiogram is abnormal or in
cases with suspected heart disease

− For patients who are suspected of
having left ventricular hypertrophy

Recommendations for Additional Investigations on
Patients with Hypertension

Recommendations Strength of Quality of
Recommendations Evidence

Arteries IIb B

− Carotid artery ultrasound is IIb B
recommended for patients whose IIb B
carotid bruit can be heard, those
with cerebrovascular disease or
patients with artery diseases in
other parts of the body

− Pulse wave velocity (PWV)

− Ankle brachial index (ABI)

Recommendations for Additional Investigations on
Patients with Hypertension

Recommendations Strength of Quality of
Recommendations Evidence

Kidneys I B
I B
− Creatinine and estimated glomerular I A
filtration rate (eGFR)
IIa C
− Measurement of urine albumin

− Microalbumin level in urine for patients
with DM

− Kidney ultrasound and Doppler in patients
with kidney disease, with albumin in urine
or suspected of HT from renal artery
stenosis

Recommendations for Additional Investigations on
Patients with Hypertension

Recommendations Strength of Quality of
Recommendations Evidence

Eyes I C
− Retina examination in patients with very IIa B
high BP (SBP ≥ 180 mmHg or DBP ≥ 110
mmHg) or those with comorbid DM

Brain
− CT scan or MRI of the brain for patients
with neurological symptoms or cognitive
disorders

Recommendations for HBPM

Recommendations Strength of Quality of
Recommendations Evidence

Measurement Methods I B
A. Measure BP in a seated position, with both

feet placed on the ground and start
measuring after at least 2-minute sit-down
B. Measure BP two episodes per day, in the
morning and in the evening. Measure BP
twice in each episode, each time 1 minute
apart.

#For Diagnosis The measurement should

be done for 7 consecutive days or at least 3
days per week

Recommendations for HBPM

Recommendations Strength of Quality of
Recommendations Evidence

C. For the morning episode, one should I B
measure BP within 1 hour after waking up
and having urinated. This is preferably done
before having breakfast and before taking
antihypertensives (if any).

D. For the night episode, one should measure
BP before bedtime

Recommendations for HBPM

Recommendations Strength of Quality of
Recommendations Evidence

Since HBPM can predict CVD I B
complications better than office BP
measurement, the readings from HBPM
are to be prioritized if they conflict with
readings from office BP. Additional
ambulatory blood pressure monitoring
(ABPM) can be considered when
necessary

Clinical use of Home Blood Pressure Monitoring

Measurement Before each visit to the health professional:
protocol • 3 – 7-day monitoring in the morning (before drug intake if

Interpretation treated) and the evening.
• Two measurements on each occasion after 5 min sittng rest and 1

min between measurements.
Long-term follow-up of treated hypertension:
• 1 – 2 measurements per week or month.

• Average home blood pressure after excluding readings of the first
day ≥ 135 or 85 mmHg indicates hypertension.

J Hypertens 2020;38:982–1004

Patterns of Disrupted Diurnal BP
Variation identified by ABPM

Nocturnal Increased absolute level of night-time blood pressure
hypertension : Associated with increased cardiovascular risk - may
indicate obstructive sleep apnea
Morning surge :
Excessive blood pressure elevation rising in morning
Definitions, thresholds ,and prognostic impact debatable

*The classic definition of nondipping (nocturnal blood pressure fall <10% or night/day ratio >0.9)
may be criticized because ‘reduced dipping’ is in effect a form of ‘nondipping’.

J Hypertens 2013;31:1731-68.

Patterns of Disrupted Diurnal BP
Variation identified by ABPM

Dipping : Nocturnal blood pressure fall >10% of daytime values or

Night/day blood pressure ratio <0.9 and >0.8 – normal
diurnal blood pressure pattern

Reduced dipping : Nocturnal blood pressure fall from 1 to 10% of daytime

values or

Night/day blood pressure ratio <1 and>0.9 – reduced
diurnal blood pressure pattern

Non dipping and No reduction or increase in nocturnal blood pressure or
rising :
Night/day ratio ≥1 – associated with poor cardiovascular

risk

Extreme dipping : Marked nocturnal blood pressure fall >20% of daytime
values or
Night/day ratio <0.8 – debatable cardiovascular risk

*The classic definition of nondipping (nocturnal blood pressure fall <10% or night/day ratio >0.9)
may be criticized because ‘reduced dipping’ is in effect a form of ‘nondipping’.

J Hypertens 2013;31:1731-68.

No. of risk factors in patients withMost Patients With Hypertension Have Additional Risk Factors
hypertension
0 5 10 15 20 25 30 35 40
Patients (%)

Mancia et al. J Hypertens 2004;22:51−7

THAI CV RISK SCORE

Without Laboratory Test

Thai CV Risk Score Waist circumference 20-60 inches

Age 35-70 Height 130-200
Sex M/F centimeters
Smoking Y/N
DM Y/N With Laboratory Test
SBP 80-200
Total Cholesterol 150-280

LDL Cholesterol 40-220

HDL Cholesterol 30-70

Thai CV Risk Score

Age (35-70 years) + -
Sex Female Male
Smoking Yes
Diabetes No Yes
Systolic BP (80-200 mmHg) No
- +

Non-Laboratory Test - +
- +
Waist Circumference (20-60 inches)
Height (130-200 cms)

Laboratory Test - +
- +
Total Cholesterol (150-280 mg/dl) - +
LDL-Cholesterol (40-220 mg/dl)
HDL-Cholesterol (30-70 mg/dl)

Thai CV Risk Score
Interpretation and Suggestion

Predicted 10-year Risks Interpretation Action
<10 percent Low Risk General Advise
General Advise
10 – <20 percent Medium Risk See Physician
20 – 30 percent High Risk

2o 1o Prevention 1. Thai CV Risk Score Risk of CVD in 10 years
<10% = Low risk

10-19% = Moderate risk
>20% = High risk

2. Sub Clinical ASCVD (Moderate to High Risk)
Atherosclerotic plaque
High Coronary Calcium Score (>300 Agatston units)
Ankle-brachial index < 0.9

3. Clinical ASCVD (High Risk)

Comparison Between EGAT Risk Scores (with and without blood test)
and the Framingham CVD Score in Predicting 17-year CVD events in
EGAT 1

17-year CV Risk (%) 25 Actual event
20 EGAT score with blood test
15 EGAT score without blood test
10 Framingham CVD risk score

5

0 Second Third Fourth Fifth
First

Quintile of predicted risk based on original Framingham heart score

Int J Epidemiol. 2012;41:359-365.

THAI CV RISK SCORE

Moderate-to-High Risk Detection Performance

Thai CV Without Lipid vs Thai CV With Lipid (n=2820)

Thai CV Risk Score

Without Lipid Low Risk <10% Low Risk <10% Moderate to High Risk
Profile (n=2,457) (n=2,775) ≥10% (n=45)
0
2,457
45
Moderate to High Risk ≥10% 318
(n=363)

Agreement 88.72%, p<0.001

Moderate to High Risk= 363 Moderate to High Risk= 45

318 45

Office BP treatment targets Class Level
I A
General Recommendations I A

• The first objective of treatment should be to IIa B
lower BP to <140/90 mmHg in all patients

• Provided that treatment is well tolerated treated
BP should be targeted to 130/80 mmHg or lower
in most patients

• A DBP target of <80 mmHg should 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

BP Reductions of

Nonpharmacological Interventions

Intervention Dose Reduction in SBP
(mmHg)
Weight loss Aim for at least 1-kg reduction in body weight for most adults who are overweight.
HT Normal BP
Expect ~1 ​mmHg reduction for every 1-kg reduction in body weight. 5 2–3

DASH dietary pattern Diet rich in fruits, vegetables, whole grains, low-fat dairy products, with reduced content of 11 3

saturated and total fat. 5–6 2–3
4–5 2
Dietary sodium Optimal goal <1500 m​ g/day. Aim for at least 1000 ​mg/day reduction in most adults
5–8 2–4
Dietary potassium Approximately 3500–5000 ​mg/day. 42
Physical Activity 54
Aerobic 90–150 m​ in/week at 65–75% of max heart rate 43
Dynamic resistance 90–150 ​min/week; 6 exercises, 3 sets/exercise, 10 repetitions/set
Isometric resistance 4 ×​ ​2 ​min (hand grip), 1 m​ in rest between exercises; 3 sessions/week for 8–10 week duration
Alcohol consumption In individuals who drink alcohol, reduce to: Men ​≤ ​2 drinks daily, Women ≤​ 1​ drink daily (~12 oz.
beer, 5 oz. of wine, or 1.5 oz. distilled spirits)

คาํ แนะนําการปรับวถิ กี ารดาํ เนินชีวติ
วธิ ีการที่แนะนํา รายละเอียด
การจาํ กดั เกลือในอาหาร ลดการเติมเกลือขณะเตรียมอาหารและขณะรับประทาน
Healthy diet เพิม่ อาหารธญั พืช, ผลไม,้ ผกั , ผลิตภณั ฑน์ มไขมนั ต่าํ
ผกั ใบเขียว และ beetroot จะมี nitrates สูง, avocados, nuts, seeds, legumes และเตา้ หูจ้ ะมี แมกนีเซียม, แคลเซียมและโพแทสเซียมสูง
Healthy drinks ลดการรับประทานไขมนั อ่ิมตวั , น้าํ ตาล
Moderate alcohol consumption ลด trans fat
การลดน้าํ หนกั กาแฟ ชา ชาเขียว น้าํ ทบั ทิม น้าํ beetroot และโกโก้
การงดสูบบุหรี่ ผชู้ ายไมเ่ กิน 2 standard drinks ผหู้ ญิงไม่เกิน 1.5 standard drink (1 standard drink มี alcohol 10 กรัม)
การออกกาํ ลงั ควรดูแล abdominal obesity เป็นพิเศษ waist-to-height ratio ควรจะนอ้ ยกวา่ 0.5
ลดความเครียด เพื่อลดความเสี่ยงตอ่ CVD, COPD และมะเร็ง
สมุนไพรนานาชนิด ออกกาํ ลงั ไดท้ ้งั aerobic หรือ resistance exercise
หลีกเลี่ยง air pollution และ อุณหภูมิท่ีเยน็ มาก อาจมีผลช่วยลดความดนั โลหิตได้
ไมแ่ นะนาํ
มีหลกั ฐานชดั เจนเกี่ยวกบั air pollution ท่ีอาจเพิม่ ความดนั โลหิตในระยะยาว

Recommendations for adequate daily sodium intake

Age Adequate Upper Limit 2,300 mg sodium (Na)
Intake (mg) = 100 mmol sodium (Na)
19-50 (mg) = 5.8 g of salt (NaCl)
51-70 1500 2300 = 1 level teaspoon of
71 and over 2300 table salt
1300 2300

1200

• 80% of average sodium intake is in processed foods
• Only 10% is added at the table or in cooking

Institute of Medicine, 2003

เคร่ืองปรุงรส ปริมาณโซเดยี ม
ต่อ 1 ช้อนโต๊ะ
นํ้าปลา
ซีอิ้ว 1345 มิลลิกรมั
ซอสถวั่ เหลือง
ซอสหอยนางรม 1225 มิลลิกรมั
นํ้าจิ้มไก่ 1225 มิลลิกรมั
ซอสพริก 530 มิลลิกรมั
ซอสมะเขือเทศ 385 มิลลิกรมั
ผงชรู ส 205 มิลลิกรมั
ซปุ ก้อน 140 มิลลิกรมั
เกลือ ( 1 ช้อนชา ) 163 มิลลิกรมั
176 มิลลิกรมั
2400 มิลลิกรมั

Sodium Content in Street Foods

โครงการโซเดียมและโซเดียมคลอไรดใ์ นอาหาร Street Foods โดย ดร.เนตรนภิส วฒั นสุชาติ https://www.facebook.com/diabeteshealthcareTH/photos/a.1670987076257225/2177684042254190/?type=3&theater

Factors that could predict high salt intake

Factors Multivariate analysis

Adjusted OR 95% CI p-value

Graduated from university of higher 2.42 1.37-4.26 <0.01*

Estimated CCr (> 60 ml/min/1.73 m2) 4.00 2.11-7.58 <0.01*

Knew that salt could increase BP level 2.88 1.39-5.96 <0.01*

OR= odd ratio, 95% CI = 95% confidence interval CCR – Creatinine clearance, BP = blood pressure
* p-value considered significant at < 0.05

Buranakitjaroen P, J Med Assoc Thai 2013;96(suppl. 2):S1-S8.







ยาหรือสารทเี่ พม่ิ ระดบั ความดนั โลหิต
ชื่อยาหรือสารทเี่ พมิ่ ความดนั โลหิต รายละเอยี ด

NSAIDs celecoxib เพิ่มความดนั โลหิตได้ ≤3/1 มม.ปรอท
NSAIDs อื่นเพ่ิม 3/1 มม.ปรอท
aspirin ไม่เพิ่มความดนั โลหิต
NSAIDs มีผลตา้ นฤทธ์ิ RAAS inhibitors และตา้ นฤทธ์ิ beta blockers

ยาคุมกาํ เนิด ยาขนาดสูง (>50 µg estrogen และ 1-4 µg progestin) เพิ่มความดนั โลหิตได้ 6/3 มม.ปรอท

Antidepressants SNRI เพมิ่ 2/1 มม.ปรอท
SSRI ไม่เพิ่มความดนั โลหิต
Tricyclic Antidepressant เพิ่มความดนั โลหิต

Acetaminophen ถ้าใช้ทุกวนั เป็นประจาํ เพิ่มความเสี่ยงต่อการเป็นความดนั โลหิตสูง 1.34 เท่า

ยาอ่ืน ๆ steroids, antiretroviral therapy, sympathomimetics (pseudoephedrine, cocaine, amphetamines), ยารักษาไม
เกรน, serotonergics, recombinant human erythropoietin, calcineurin inhibitors, antiangiogenesis และ kinase
inhibitors

สมุนไพรและสารอ่ืน ๆ แอลกอฮอล,์ Ma-huang, โสม, ชะเอม, St. John’s Wort, Yohimbine

RAAS : renin angiotensin aldosterone system
SNRI : selective norepinephrine and serotonin reuptake inhibitors SSRI : selective serotonin reuptake inhibitors

JACC 2020;75:320-32

JACC 2020;75:320-32

JACC 2020;75:320-32

2018 ESC/ESH Hypertension Guidelines

Classification of HT stages according to BP levels, presence of CV
risk factors, HMOD, or comorbidities

Hypertension Other risk BP (mmHg) grading
factors
disease High-normal Grade 1 Grade 2 Grade 3
staging
SBP 130-139 SBP 140-149 SBP 160-179 SBP ≥ 180
DBP 85-89 DBP 90-99 DBP 100-109 DBP ≥ 110

Stage 1 No other risk factors Low risk Low risk Moderate risk High risk
(uncomplicated) High risk
1 or 2 risk factors Low risk Moderate risk Moderate-
Stage 2 high risk High risk
(asymptomatic
≥ 3 risk factors Low-moderate Moderate- High risk High-very
disease) risk high risk high risk

HMOD, CKD grade 3, Moderate- High risk High risk
high risk
or diabetes mellitus

without organ
damage

Stage 3 Symptomatic CVD, Very high risk Very high risk Very high risk Very high risk

(symptomatic CKD grade ≥ 4, or
disease)
diabetes mellitus
with organ damage

HMOD = Hypertension-Mediated Organ Damage
Williams, Mancia et al., J Hypertens 2018 and Eur Heart J 2008, in press

Initiation of BP-lowering treatment

(lifestyle changes and medication) at different initial office BP levels

High normal BP Grade 1 hypertension Grade 2 hypertension Grade 3 hypertension
BP 130-139/85-89 BP 140-159/90-99 BP 160-179/100-109 BP ≥ 180/110

Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice

Consider drug Immediate drug Immediate drug Immediate drug
treatment in very treatment in high or treatment in all
treatment in all
high risk very high risk patients (I,A)
patients (I,A)
patients with patients with CVD,
CVD, especially renal disease or TOD

CAD ( IIb,A) (I,A)

Drug treatment in Aim for BP control Aim for BP control
moderate risk within 3 months within 3 months
patients without

CVD, renal disease or
HMOD after 3-6

months of lifestyle
intervention if BP not

controlled(I,A)

Office BP Thresholds for Drug Treatment

Age group Office SBP treatment threshold (mmHg) Office DBP

treatment

threshold
(mmHg)

HT + Diabetes + CKD + CAD + Stroke/TIA

18 - 65 years >140 >140 >140 >140a >140a >90
>140 >140 >140 >140a >140a >90
65 - 79 years >160 >160 >160 >160 >160 >90
>90 >90 >90 >90 >90
>80 years

Office DBP
treatment
threshold
(mmHg)

BP = blood pressure; CAD = coronary artery disease; CKD = chronic kidney disease; DBP = diastolic blood pressure; SBP =
systolic blood pressure; TIA = transient ischaemic attack.
aTreatment may be considered in these very high-risk patients with high–normal SBP (i.e. SBP 130–140 mmHg).