Hypertension & Treatment
CME
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Lecture objectives
Outline:
Define hypertension.
Types of hypertension.
Epidemiology of hypertension.
Pathophysiology of hypertension.
Clinical presentation.
Diagnose hypertension.
Manage hypertension.
complications of hypertension .
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Definition of hypertension
Blood pressure (BP) is the pressure exerted by the
blood against the walls of the blood vessels
Hypertension is persistently elevated BP
Multiple occasions or if the patients has
complications of HTN on is on hypertensive
medication
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ACC/AHA 2017
BP CATEGORIZATION
Normal; <120/<80mmHg
Elevated 120-129/<80mmHg
HTN stage 1 is 130-139/80-89mmHg
HTN stage 2 is ≥140/ ≥90mmHg
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ESE/ESH 2013
Optimal <120/<80mmHg
Normal 120-129/80-84mmHg
High normal 130-139/85-89mmHg
Grade 1 HTN 140-159/90-99mmHg
Grade 2 HTN 160-179/100-109mmHg
Grade 3 HTN ≥180/ ≥ 110mmHg
Isolated systolic HTN ≥140/<90 mmHg
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JNC
Category SBP (mmHg) DBP (mmHg)
Normal <120 <80
Pre-hypertension 120 - 139 80 - 89
Stage 1 hypertension 140 - 159 90 - 99
Stage 2 hypertension ≥160 ≥100
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Types of hypertension
1. Essential hypertension.
2. Secondary hypertension.
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Types of hypertension
1. Essential hypertension
Most common-In more than 95% of cases, an
underlying cause cannot be found
Risk factors for
essential hy
pertension
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Proposed mechanisms of essential
hypertension
Vasoconstrictors
Angiotensin II Vasodilators
Blood Volume Catecholamines Pg & Kinins
Na+, Aldosterone
Cardiac Peripheral
BP
Output Resistance
Cardiac Factors
Rate & Contract.. Neural Factors
a Adrenergic – Cons
ß Adrenergic - Dil
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2. Secondary hypertension.
-Due to other causes
In 5-10% of hypertension cases, the
cause is identifiable
Renal causes 80% of all secondary
hypertension(CKD,Renal Artery Stenosis)
Endocrine causes – Conn’s syndrome,
adrenal hyperplasia, phaechromocytoma,
Cushing’s syndrome etc
Drugs and toxins
Pregnancy induced hypertension
Vascular causes -coarctation of aorta,
vasculitis
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DEGREE OF HTN
According to ESH/ESC
◦Mild (Grade 1) = 140-160/90-99
mmHg
◦Moderate(Grade 2)=160-180/100-
109mmHg
◦Severe(Grade 3) ≥180/110 mmHg
Hypertensive agency.
Hypertensive emergency.
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Epidemiology of hypertension
Africa – prevalences 30.8%,sub sah afr 30-
31
Tanzania – 19 in rural, 35 in urban. 70%
among 70+yrs
Hypertension is more prevalent in people of
black race, it starts early and has more
severe course
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RISK FACTORS
NON MODIFIABLE
◦ Age
◦ Sex
◦ Race
◦ Family hx (genetics)
MODIFIABLE
◦ Salt
◦ Cigarate
◦ Alkohol
◦ Exerise
◦ Obesity
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CLINICAL PRESENTATION
Most pts with HTN are asymptomatic
Symptoms and signs develop only with
complication of HTN or in cases of 2 HTN
The only reliable sign of HTN is blood
pressure.
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Diagnosis of hypertension
Someone is labeled hypertensive if
◦ Persistently elevated BP (≥140/90mmHg) in two or more
occasions ,
Taken several weeks apart
Alternatively, 24hr BP measurements
BP measurements should be
◦ In a quite environment
◦ After 5minutes rest
◦ Arm rested at the heart level
◦ At least 2 readings, 5minutes apart
◦ Averaged measurements
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.
Before BP measurements
◦ No vigorous physical activities
◦ Avoid caffeine drinks
◦ Avoid cigarette smoking
Patients should then be classified according
to the level of BP (Use ACC/AHA or ESC/EHA)
or JNC
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Diagnosis of hypertension
Once the dx of HTN has been made, the
following steps should be ordered;
◦Cr, electrolyte, RBG,cholesterol and
fundoscopy in all patients
◦TSH, Renal USS, urinary catecholamines,
VMA, cortisol, serum renin, Aldosterone,
CXR, ECCO; if looking for secondary HTN.
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Management of hypertension
Clinical findings
Careful history taking and physical examination
◦History – a clue to aetiology, family history
of HT and cardiovascular diseases, smoking
status, etc
◦P/E – evidence of target organ damage,
anthropometric measurements (BMI, waist
circumference)
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Management of
hypertension
Investigations: the aim is to look for
◦Target organ damage/involvement (kidneys,
heart, eyes, CNS)
◦Other cardiovascular risk factors (diabetes,
hypercholesterolemia, albuminuria, etc)
◦Look for secondary causes of hypertension
(if suspected)
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Baseline investigations
◦Random blood glucose and/or
HbA1c(<6.5%)
◦Urine analysis and/or urine for
microalbuminuria
◦Electrocardiogram
◦Serum cholesterol
◦Serum creatinine
Depending on the history and P/E
◦Chest x-ray
◦Full blood count
◦Echocardiogram,ECG
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Management of hypertension
Treatment
When to treat the patients?
Treatment consists of two approaches
◦Lifestyle modifications/non pharmacological
◦Drug/pharmacological treatment
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Lifestyle modifications
Patients with mild to moderate(grade 1 and
grade 2) HTN should be given 3 months to
see if they will respond to behavioral
modification first.
If remain >140/90 mmHg they should then
started on anti hypertensive
Pre-hypertension requires health-promoting
lifestyle modifications
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Lifestyle modifications
Reduce salt intake to <6g/day(2-
8mmHg)
Reduce intake of saturated fats
Reduce intake of cholesterol rich foods
Maintain adequate intake of dietary potassium
(vegetables and fruits)
Weight loss to BMI <25kg/m2
Exercise at least 30min/day
Reduce alcohol intake, <21units/wk in men and
<14units/wk in women
Stop smoking
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Lifestyle modifications/non
pharmacological
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Drug/pharmacological
treatment.
Treat pt with severe(grade 3)HTN and or
sign of complication(stroke, CKD,CAD,CCF,
Retinopathy etc) immediately.
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Drug treatment
The goals of therapy
Antihypertensive therapy- is the reduction of long term
cardiovascular diseases/ morbidity and mortality
BP<140/90mmHg and to lower values if to tolerated in
all hypertensive patients
BP<130/80mmHg in diabetics,CKD,and in high or
very high risk parents, such as those with associated
clinical conditions (stroke, myocardial infarction, renal
dysfuction,protenria)
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Drug treatment
In uncomplicated hypertension, a thiazide diuretic,
either alone or combined with drugs from other
classes(ACEI,ARB,BBs,CCBs) , should be used for the
pharmacologic treatment of most cases and very
effective in Africans
In specific high-risk conditions, there are compelling
indications for the use of other antihypertensive drug
classes
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Drug treatment
For patients whose BP is more than 20mmHg above
the systolic BP goal or more than 10mmHg above the
diastolic BP goal, initiation of therapy using 2 agents,
one of which usually will be a thiazide diuretic, should
be considered
Regardless of therapy or care, hypertension will be
controlled only if patients are motivated to stay on
their treatment plan
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Drug treatment
Diuretics
• Thiazide ..hypercalemia, dm
• Loop
• K+ Sparing
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Drug Treatment
Adrenergic blockers/ inhibitors
B-adrenergic blockers
B1- Bisoprolol,Nevivolol,atenolol &
metropolol
B2- Albuterol and salmeterol
Combined alpha 1 and BB (1&2)
Carvedilol
labetalol
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Drug Treatment
Central acting adrenergic antagonist
Clonidine hydrocloride
Methyldopa
Reserpine
Central acting adrenergic antagonist
Prazosin(alpha 1a,1b,1d) and
Bethanidine (beta adrenergic
receptors)
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Drug Treatment
Alpha adrenergic blockers
Doxazosin
Prazosin
Terasosin
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Drug Treatment
Vasodilators
Hydralazing (direct),Doxazosin,Terazosin
CCBs blockers
Amlodipine,Verapamil
Nifedipine,Diltiazemen
ACE inhibitors
Captopril,ramipril
Enapril,lisinopril,
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Drug Treatment
ARBs inhibitors
Losartan
Irbesartan
NB: Do not give ARBs and ACEI as the
combination
ARBs and ACEI is contraindicated in
pregnancy and AKI
Beta blocker are contraindicated for age
>60 yrs as the first line.
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Summary of Stepped Approache
Lifestyle modification
Not at Goal BP
Drug Therapy
Not at Goal BP
Substitute med / add a 2nd med/
increase dose
Not at Goal BP
Continue adding / changing meds until
control
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Drug Tratment
CCBs blokers like nifedipine and
amilodipine are very effective in Africans
and is the good first antihypertensive if you
want to lower blood pressure as in
hypertensive urgency.
DM or CCF and normal or stable creatinine
–respond well to ACEI
CAD- Beta blockers are the best first line
ant hypertensive.
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Drug Treatment
What do if the first drug doesn’t work?
2/3 of the patients with HTN will
require at least two drugs to control
their hypertension and 1/3 will require
3 drugs
Always titrate your first drug to its
maximum dose first before adding
another drug
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Drug Treatments
Monitor for side effects e.g. ACEI
inhibitors, diuretics, beta blockers
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Drug Treatment
Remember:
Most antihypertensive take 2-4 weeks to
reach maximal effects so it is good to wait 1
month before increasing the dose of a
medicine or adding another one.
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Complications of hypertension
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Complications of hypertension
Hypertensive crisis
-Hypertensive emergency
-Hypertensive urgency
In any patient with BP>180/110mmHg with
or without end organ damage
Assess for sign of end organ damage and
consider admission to the hospital
HTN emergency usually does not occur
unless DBP IS >130mmHg
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Complications of hypertension
Urgency is much more common than
emergency
Signs of end organ Damage
Hypertensive encephalopathy(confusion,
headache)
Acute retinal hemorrhage(sudden onset of
blurry vision, massive hemorrhage on
ophthalmoscopy)
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Complications of hypertension
Myocardial ischemia or infarction (chest
pain, ECG changes)
Pulmonary edema(shortness of breath,CXR
with features suggestive of Pulmonary
edema)
Acute kidney injury (recent onset of oliguria
or anuria,elevated creatinine and BUN)
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Complications of hypertension
Treatment of HTN Crisis goal
If hypertensive urgency, aim is to lower
MAP by 25% over 2-3 days using oral
medications. Start with Amilodipine and add
other drugs if necessary
If hypertensive emergency, aim to lower
MAP by 25% over 1-2hrs using iv meds
IV hydralazine drips trited to goal blood
pressure
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Complications of hypertension
Or labetalol drip when available
Once the blood pressure is improves,
transfer the patients to oral medications
NB, when dealing with elderly with
hypertensive crisis the BP should be
lowered slowly to prevent myocardial
infarction and cerebral vascular accidents
like stroke and cerebral infarct.
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Complications of hypertension
Resistant hypertension
BP remains ≥140/90mmHg despite
concurrent use of three antihypertensive
agents of different classes, one of which
should be diuretics.
Prevalence 5-30% of hypertensive
populations.
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Complications of hypertension
True resistant hypertension may
originate from:
Lifestyle factors such as obesity or large
weight gains, excessive alcohol
consumption and high sodium intake
Chronic intake of vassopresors or sodium
retaining substances
Undetected secondary forms of
hypertension
Obstructive sleep apnea
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Complications of hypertension
MANAGEMENT
.Check whether the drugs is included in
the existing regime have any blood
lowering effects, and withdraw those
with minimal or no effects
Mineral corticoid receptor
antagonist,spinorolactone,beta
blockers, centrally acting agents,
alpha-blockers or a direct vasodilators
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Complications of hypertension
Burnt out hypertension
This occurs in patients who have had
severe, long standing HTN, but have
now progresses to CCF(usually with
dilated ventricles) with decreased systolic
function and blood pressure that is now
normal or low
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Follow up
Monthly until the blood pressure goal is
reached
More frequently visits for stages 2 HTN or
with complicating co-morbid conditions
Serum potassium and creatinine should be
monitor at least 1-2 times/year.
After Bp is at goal and stable, follow up
visits can usually be at least 3-6 month
intervals.
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Follow up
Low dose aspirin should be considered only
when blood pressure is controlled
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