HYPERTENSION

Dr. Mohib AliJanuary 06, 2015

Definition

• Hypertension is defined as a systolic blood pressure (SBP) of 140

mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or

more on repeated measurement, or taking antihypertensive

medication.

HTN Classification

Blood Pressure Classification

SBP mmHg DBP mmHg

Normal <120 And <80

Pre-Hypertension 120-139 Or 80-89

Stage 1 Hypertension 140-159 Or 90-99

Stage 2 Hypertension -/> 160 Or -/> 100

• Isolated increase in the systolic BP with diastolic BP<90 mm Hg

Class Systolic BP Diastolic BP

Grade 1 140-159 <90

Grade 2 >/- 160 <90

• 90-95% Essential HTN

• 05-10% Secondary

Essential Hypertension

• Multifactorial Aetiology.

– Genetic factors

– Fetal factors

• Environmental factors

– Obesity

– Alcohol intake

– Sodium intake

– Stress

– Smoking

• Insulin resistance

– (Metabolic syndrome)

The majority (80–90%) of patients with hypertension have primary

elevation of blood pressure, i.e. essential hypertension of unknown

cause.

Secondary Hypertension

• Identifiable cause

• Suspected in ;

– Early onset

– First episode over age 50 years

– Those previously well controlled become refractory to treatment

Secondary causes of Hypertension

Endocrine Adrenal Renal Cardiovascular Drugs

• Cushing's syndrome

• Acromegaly

• Thyroid disease

• Hyperparathyroid disease

• Conn's syndrome

• Adrenal hyperplasia

• Phaeochromocytoma

• Diabetic nephropathy

• Chronic glomerulonephritis

• Adult polycystic disease

• Chronic tubulointerstitial nephritis

• Renovasculardisease

• Aortic coarctation

• NSAIDs• Oral

contraceptives• Steroids• Carbenoxalone• Liquorice• Sympathomim

etics• Vasopressin• Monoamine

oxidase inhibitors (with tyramine)

• A 71-year-old woman is reviewed in the clinic. Her blood pressure is

146/ 94 mmHg. This is confirmed on a second reading. what is the

most appropriate next-step?

a) Ask her to come back in 6 months for a blood pressure check

b) Arrange 3 blood pressure checks with the practice nurse over the

next 2 weeks with medical review following

c) Arrange ambulatory blood pressure monitoring

d) Reassure her this is acceptable for her age

e) Start treatment with a calcium channel blocker

Diagnosis Of Hypertension

Investigation of all patients

• Urinalysis for blood, protein and glucose

• Blood urea, electrolytes and creatinine

– Hypokalaemic alkalosis may indicate primary

hyperaldosteronism but is usually due to diuretic therapy

• Blood glucose

• Serum total and HDL cholesterol

• 12-lead ECG (left ventricular hypertrophy, coronary artery disease)

Investigation of selected patients

• Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the

aorta

• Ambulatory BP recording: to assess borderline or ‘white coat’

hypertension

• Echocardiogram: to detect or quantify left ventricular hypertrophy

• Renal ultrasound: to detect possible renal disease

• Renal angiography: to detect or confirm presence of renal artery

stenosis

• Urinary catecholamines: to detect possible phaeochromocytoma

• Urinary cortisol and dexamethasone suppression test: to detect

possible Cushing’s syndrome

• Plasma renin activity and aldosterone: to detect possible primary

aldosteronism

Diagnosis Of HTN

• NICE now recommend ambulatory blood pressure monitoring to aid

diagnosis

• The 2012 NICE guidelines recognize that in the past there was

overtreatment of 'white coat' hypertension. The use of ambulatory

blood pressure monitoring (ABPM) aims to reduce this.

– When ABPM is used, at least two measurements per hour

should be taken during person’s waking hours.

– Use the average value of at least 14 measurements taken during

person’s waking hours to confirm diagnosis of hypertension.

Diagnosis of Hypertension

• If clinic blood pressure is >140/90, offer AMBULATORY BLOOD

PRESSURE MONITORING to confirm diagnosis.

– When ABPM is used, at least two measurements per hour

should be taken during person’s waking hours.

– Use the average value of at least 14 measurements taken during

person’s waking hours to confirm diagnosis of hypertension.

The Oscar 2 monitor.

The ambulatory blood pressure

monitor

Another option is Home Blood Pressure Monitoring

(HBPM). When this is used:

For each blood pressure recording, two consecutive

measurements are taken, at least 1 minute apart and with person

seated,

Blood pressure is recorded twice daily, in morning and evening,

Blood pressure recording continues for at least 4 days, ideally for

7 days.

Measurements on first day are discarded

Average of remaining measurements are used to confirm

diagnosis

• ABPM/HBPM

– <135/85 mmHg = Normal

– >135/85 mmHg = Stage 1 Hypertension

– >150/95 mmHg = Stage 2 Hypertension

• Based on a study examining relationships between clinic BPMs and

ABPM measurements;

– 135/85 ABPM is equivalent to 140/90 clinic BPMs ,

– and 150/95 ABPM is equivalent to 160/100 clinic

NICE Guidelines for Management

Of Hypertension

Importance of lowering blood pressure

• Lowering blood pressure can significantly decrease risk of CV

disease.

– 61 prospective observational trials, nearly 1 million people, age

bands from 40 to 89

– Examined relationship between blood pressure level and 12,000

strokes, 34,000 heart disease events over an average of 13.2

years follow-up

– Reductions in systolic of 20mmHg and diastolic 10mmHg was

associated with reductions in death from stroke and ischemic

heart disease of about one half (~50%)

Importance of lowering blood pressure

• A similar analysis of 9 observational studies looking at relationship

between BP level and strokes/coronary events found:

– Reductions in diastolic BP of 5, 7.5, and 10 mmHg was

associated with reductions in stroke of 34%, 46%, and 56%, and

coronary heart disease of 21%, 29%, and 37%, respectively

Cardiovascular risk assessment

• Important to determine presence of CV disease or high CV risk

states (diabetes or CKD).

• Risk models have been developed for doctors to assess likelihood

of patients developing cardiovascular disease. (10 year risk).

• Factors involved in risk assessment include:

– Gender, age, diabetic status, smoking status, total cholesterol,

HDL cholesterol, and blood pressure.

• Allows for identification of patients under greatest overall risk and

treatment of modifiable risk factors.

Target Organ Damage

• Another important objective in assessing people with suspected

hypertension is ;

– To document presence or absence of target organ damage.

– Examples include:

• Left ventricular hypertrophy, hypertensive retinopathy, and

increased albumin:creatinine ratio (kidney damage)

Target Organ Damage in HTN

AtherosclerosisAneurysmsAortic dissections

Pulmonary oedemaMyocardial infarctionLeft ventricular hypertrophy

HaematuriaUraemiaProteinemia

Haemorrhage / infarctionSeizuresVascular dementia

HaemorrhagesExudatesA-V nippingPapilloedema

Hypertensive retinopathy(Keith-Wagener classification)

• Grade 1– tortuosity of the retinal arteries with increased reflectiveness (silver wiring)

• Grade 2– grade 1 plus the appearance of arteriovenous nipping produced when

thickened retinal arteries pass over the retinal veins

• Grade 3– grade 2 plus flame-shaped haemorrhages and soft (‘cotton wool’) exudates

actually due to small infarcts

• Grade 4– grade 3 plus papilloedema (blurring of the margins of the optic disc)

• Grades 3 and 4 are diagnostic of malignant hypertension.

Grade 4 hypertensive retinopathy

showing swollen optic disc, retinal

haemorrhages

and multiple cotton wool spots

(infarcts)

Central retinal vein thrombosis

showing swollen optic disc and

widespread fundal haemorrhage,

commonly associated with systemic

hypertension

Lifestyle Modifications

• Dietary modifications and exercise

– Low calorie diets have modest effect on BP in overweight

individuals (avg. 5-6 mm Hg).

– Aerobic exercise (brisk walking, jogging, or cycling) for 30-60

min., 3-5 times/week, had small effect on BP (2-3 mm Hg).

• Relaxation therapies

– These activities (stress management, meditation, cognitive

therapy, muscle relaxation) reduce by average of 3-4 mm Hg.

Lifestyle Modifications

• Limit alcohol consumption

– Excessive alcohol consumption is associated with raised blood

pressure, poorer CV and hepatic health.

– Reducing alcohol can lower BP 3-4 mm Hg.

• Limiting excessive consumption of coffee/caffeine (small

benefit).

• Limit dietary sodium intake

– < 6 g/day, modest reduction of 2-3 mm Hg.

• Encourage smoking cessation (reduce risk of

CV/pulmonary disease).

Criteria for starting Antihypertensive drug treatment

• Offer step 1 treatment to people aged under 80 with stage 1

hypertension and one or more of:

• target organ damage

• established cardiovascular disease

• renal disease

• diabetes mellitus

• 10-year cardiovascular risk equivalent to 20% or more.

• Offer step 1 treatment to people of any age with stage 2

hypertension.

• People with newly diagnosed hypertension and a 10-year

cardiovascular disease risk of 20% or higher are offered statin

therapy.

• For people aged under 40 years with stage 1 hypertension and no

evidence of target organ damage, CV disease, renal disease or

diabetes, consider specialist evaluation of secondary causes of

hypertension and more detailed assessment of potential target

organ damage.

Step 1 Treatment

• Patients > 55 years CALCIUM CHANNEL BLOCKER

– Offer to people aged over 55 years and to black people of

African or Caribbean family origin of any age.

– If CCB is not suitable (i.e. edema, intolerance, evidence of heart

failure or risk of heart failure), offer a thiazide-like diuretic over

conventional thiazide diuretics

• Chlorthalidone 12.5-25 mg daily; indapamide 1.5-2.5 mg

once daily

– Calcium Channel Blockers examples—amlodipine, nifedipine,

felodipine, verapamil, diltiazem.

Step 1 Treatment

• Patients < 55 years ACE INHIBITOR or ARB

– Offer people aged under 55 years an ACE inhibitor or a low-cost

ARB.

– If ACE inhibitor is prescribed and is not tolerated (i.e. because of

cough), offer a low-cost ARB.

– ACE inhibitor examples—benazepril , captopril , enalapril ,

fosinopril, lisinopril , quinapril (Accupril), ramipril

– ARB examples—candesartan , irbesartan, losartan, olmesartan,

telmisartan, valsartan

Step 2 Treatment

• ACE inhibitor/ARB + Calcium Channel Blocker

• Offer a CCB in combination with either an ACEI or an ARB.

• If a CCB is not suitable, for example because of oedema or intolerance, or if there is evidence of heart failure or a high risk of heart failure, offer a thiazide-like diuretic.

• For black people of African or Caribbean family origin, consider an ARB in preference to an ACE inhibitor, in combination with a CCB.

• Before considering step 3 treatment, review medication to ensure step 2 treatment is at optimal or best tolerated doses.

Step 3 Treatment

• ACEI/ARB + CCB + Thiazide-like diuretic

– Based on the recommendations and analyses performed in the

first two steps.

– Thiazide diuretic examples: chlorthalidone , indapamide ,

hydrochlorothiazide , metolazone.

Recommendations for Step 4

• Addition of low-dose Spironolactone

– Considered when potassium level is < 4.5 mmol/L

• Potassium, sodium, creatinine : checked 2 weeks after

initiation and periodically thereafter.

• Higher-dose thiazide-like diuretic treatment

– Considered when potassium level is > 4.5 mmol/L

• Other options for add-on therapy: alpha blockers or beta blockers

Blood Pressure Goals

• People aged < 80 years with treated hypertension: <140/90 (home:

135/85)

• People aged > 80 years with treated hypertension: <150/90 (home:

145/85)

• For diabetics it s <140/80 mmHg

• For people with “white coat effect”—difference of 20/10 mmHg

between clinic and average daily reading—consider adjunct

ambulatory or home BP measurement to monitor BP.

All people with Hypertension

Lifestyle Interventions

Criteria for starting Antihypertensive

drug treatment

Antihypertensive drug treatment

Review annually

Antihypertensive drug treatment

People starting antihypertensive drug

treatment

General principles

Blood pressure targets

Patient education & adherence to drug

treatment

Person under age 55

Person aged over 55 or

black person of African or

caribbean family origin of

any age

Person under age 55

Person aged over 55 or black

person of African or caribbean

family origin of any age

Step 1

ACE inhibitor or low cost

Angiotensin 2 receptor blocker

Step 1

Calcium channel blocker

Step 2

ACEI or ARB + CCB

Step 3

ACEI or ARB + CCB + Thiazide-like diuretic

Step 4 Resistant hypertension

ACEI or ARB + CCB + TLDU + consider

further diuretic or alpha-blocker or beta-

blocker

Consider seeking expert advice

Monitor drug treatment

Review annually

The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure (JNC 8) in adults was published in December 2013.

Adults aged > 18 yrs with HTN

Implement lifestyle interventions

(continue throughout management)

Set BP goal & initiate BP lowering medication based on

age, diabetes & CKD

Age > 60 yrs Age < 60 yrs

All ages DM

present, no

CKD

All ages CKD

present with or

without DM

No DM or CKD DM or CKD present

BP goal

SBP <

150mmHg

DBP < 90mmHg

BP goal

SBP <

140mmHg

DBP < 90 mmHg

BP goal

SBP <

140mmHg

DBP < 90mmHg

BP goal

SBP

<140mmHg

DBP < 90mmHg

Initiate thiazide type

DIU or ACEI or ARB or

CCB, alone or in

combination

Initiate thiazide type DIU

or CCB, alone or in

combination

Initiate ACEI or ARB,

alone or in combination

with other drug class

Non Black Black All races

Select a drug treatment titration strategya) Maximize 1st medication before adding second or

b) Add 2nd medication before reaching max. dose of 1st medication orc) Start with 2 medication classes separately or as fixed dose combination

Reinforce medication & lifestyle adherence

For strategies A & B, add & titrate thiazide type DIU or ACEI or ARB

or CCB (use medication class not previously selected & avoid

combined use of ACEI & ARB)

Reinforce medication & lifestyle adherence

Add and titrate thiazide type DIU or ACEI or ARB or CCB (use

medication class not previously selected & avoid combined use of

ACEI & ARB)

Reinforce medication & lifestyle adherence

Add additional medication (e.g. B-blocker, aldosterone antagonist, or

others) and/or refer to physician with expertise in Hypertension

management

At goal BP ?

At goal BP ?

At goal BP ?

At goal BP ?

Continue

current

treatment

&

monitoring

yes

no

yes

yes

yes

no

no

no

Lifestyle modifications

• JNC 8 recommendations to lower BP and decrease cardiovascular

disease risk include the following, with greater results achieved

when 2 or more lifestyle modifications are combined :

• Weight loss (range of approximate systolic BP reduction [SBP],

5-20 mm Hg per 10 kg)

• Limit alcohol intake to no more than 1 oz (30 mL) of ethanol per

day for men or 0.5 oz (15 mL) of ethanol per day for women and

people of lighter weight (range of approximate SBP reduction, 2-

4 mm Hg)

• Reduce sodium intake to no more than 100 mmol/day (2.4 g

sodium or 6 g sodium chloride; range of approximate SBP

reduction, 2-8 mm Hg)

Lifestyle modifications

• Maintain adequate intake of dietary potassium (approximately 90

mmol/day)

• Maintain adequate intake of dietary calcium and magnesium for

general health

• Stop smoking and reduce intake of dietary saturated fat and

cholesterol for overall cardiovascular health

• Engage in aerobic exercise at least 30 minutes daily for most days

(range of approximate SBP reduction, 4-9 mm Hg)

Pharmacologic therapy

• If lifestyle modifications are insufficient to achieve the goal BP, there

are several drug options for treating and managing hypertension.

• Compelling indications may include high-risk conditions such as heart

failure, ischemic heart disease, chronic kidney disease, and recurrent

stroke, or those conditions commonly associated with hypertension,

including diabetes and high coronary disease risk.

Pharmacologic therapy

• Drug intolerability or contraindications may also be factors.

• An angiotensin-converting enzyme (ACE) inhibitor, angiotensin

receptor blocker (ARB), calcium channel blocker (CCB), and beta-

blocker are all acceptable alternative agents in such compelling

cases.

GUIDELINES FOR SELECTING INITIAL DRUG

TREATMENT OF HYPERTENSION

Class of Drug Compelling

Indications

Possible

Indications

Compelling

Contraindi-

cations

Possible

Contraindi-

cations

Diuretics Heart failure

Elderly

patients

Systolic

hypertension

Diabetes Gout Dyslipidemia

β-Blockers Angina

After M.I

Tachyarrhythmi

as

Heart failure

Pregnancy

Asthma and

COPD

Heart block

Dyslipidemia

Athletes and

physically

active patients

Peripheral

vascular

disease

GUIDELINES FOR SELECTING INITIAL DRUG

TREATMENT OF HYPERTENSION

ACE inhibitors Heart failure

Left ventricular

dysfunction

After M.I

Diabetic

nephropathy

Chronic renal

parenchymal

disease

Pregnancy

Hyperkalemia

Bilateral renal

artery stenosis

Angiotensin

receptor

blockers

ACEI

Intolerance

Heart failure

Diabetic

nephropathy

Chronic renal

parenchymal

disease

Pregnancy

Hyperkalemia

Bilateral renal

artery stenosis

Calcium

channel

blocker

Angina

Elderly

patients

Systolic

hypertension

Peripheral

vascular

disease

Heart block Congestive

heart failure

Resistant Hypertension

• Resistant hypertension is defined as the failure to reach

blood pressure control in patients who are adherent to full

doses of an appropriate three-drug regimen (including a

diuretic).

CAUSES OF RESISTANT HYPERTENSION

• Improper BP measurement

• Volume overload & pseudotolerance

– Excess sodium intake

– Volume retention from kidney disease

– Inadequate diuretic therapy

• Associated conditions– Obesity

– Excess alcohol intake

• Identifiable causes of HTN

• Drug-induced or other causes– Nonadherence

– Inadequate doses

– Inappropriate combinations

– NSAIDS ; COX 2 Inhibitors, cocaine, amphetamines, other illicit drugs

– Sympathomimetics(decongestants, anoretics)

– Oral contraceptives

– Adrenal steroids

– Cyclosporine & tacrolimus

– Ertythropoietn

– Licorice (including some chewing tobacco)

– Selected over the counter dietary supplements & medicines (eg, ephedra, ma huang, bitter orange)

Hypertensive Urgencies

• Hypertensive urgencies are situations in which blood pressure must

be reduced within a few hours.

• These include patients with asymptomatic severe hypertension

(systolic blood pressure > 220 mm Hg or diastolic pressure > 125

mm Hg that persists after a period of observation) and those with

optic disk edema, progressive target organ complications, and

severe perioperative hypertension.

Hypertensive Emergencies

• Hypertensive emergencies require substantial reduction of

blood pressure within 1 hour to avoid the risk of serious

morbidity or death.

• Emergencies include ;

– Hypertensive encephalopathy (headache, irritability,

confusion, and altered mental status due to cerebrovascular

spasm)

– Hypertensive nephropathy ( hematuria, proteinuria,and

progressive kidney dysfunction due to arteriolar necrosis and

intimal hyperplasia of the interlobular arteries ),

– Intracranial hemorrhage, aortic dissection, preeclampsia,

eclampsia, pulmonary edema, unstable angina, or

myocardial infarction.

Malignant Hypertension

Malignant hypertension is by historical definition

characterized by encephalopathy or nephropathy with

accompanying papilledema.

Management of hypertension in

pregnancy

• There are three types of hypertension seen in pregnant women:

i. Chronic or pre-existing hypertension

ii. Gestational hypertension

iii. Pre-eclampsia and eclampsia.

• During the normal pregnancy there is a reduction in blood pressure

due to a fall in systemic vascular resistance which is maximal by

weeks 22–24.

• Patients with pre-existing hypertension should discontinue ACE

inhibitors and ARBs which are associated with abnormalities of the

developing fetal renal system.

• The first-line therapy during pregnancy is methyldopa which has no

adverse effects on the fetus although sedating side-effects may limit

up-titration.

• Second-line agents include nifedipine and labetalol.

• The target blood pressure should be <150/100 mmHg.

• Gestational hypertension is a blood pressure of >140/90 mmHg in

the 2nd trimester in a previously normotensive woman.

• These patients should have twice-weekly BP measurements and

urine tested for protein as there is an increased risk of developing

pre-eclampsia

• Patients with moderate hypertension (159–150/109–100 mmHg)

should commence oral labetalol and have blood tests performed

(electrolytes, blood count, liver function tests) and those with severe

hypertension (≥160/110 mmHg) should be admitted to hospital.

• Pre-eclampsia is a multi-system disorder that occurs after 20 weeks’

gestation consisting of:

• Hypertension

• Oedema

• Proteinuria (>0.3 g/24 hours).

• These patients should be admitted and treated for hypertension with

regular BP measurements (4 times daily) and blood tests 2–3/week.

• Patients who progress to eclampsia (convulsions) and/or HELLP

(haemolysis, elevated liver enzymes, low platelet count) syndrome

should be admitted to a critical care unit and may require intravenous

hydralazine, labetalol, and magnesium sulphate (for convulsions) and

prompt delivery.

• Taking at least 30 minutes of regular physical exercise is expected to

have what effect on systolic blood pressure ?

a) An increase of 4-7mmHg

b) No effect expected

c) A reduction of 1-2mmHg

d) A reduction of 4-9mmHg

• What is the target blood pressure for a patient with type 2 diabetes

(assuming no co-morbidities) ?

a) Less than 120/75mmHg

b) Less than 130/80mmHg

c) Less than 140/80mmHg

d) Less than 150/90mmHg

• Which ONE of the following treatments should be used first-line for a

73 year old patient with primary hypertension?

a) Atenolol

b) Indapamide

c) Amlodipine

d) Ramipril

THANK YOU