Hypertension

[Link] Khassawneh M.D

consultant Family
medicine/Geriatric
medicine and chronic
diseses
1) Essential HTN applies to more than 95% of cases of
HTN.
also called: essential hypertension or idiopathic
hypertension.

It has no known underlying cause; it is a multifactorial

aetiology:
- Genetic component
- Obesity
- High salt intake
- Excess alcohol intake
- The metabolic syndrome

2) Secondary hypertension accounts for 5% of cases.

This is the result of a specific and potentially treatable
cause
DefinitionS:

ACC/AHA classification
Hypertension is a risk factor for:
o coronary artery disease (CAD)
o heart failure
o chronic kidney disease
o stroke
o intracerebral hemorrhage
o transient ischemic attack (TIA)
o peripheral arterial disease (PAD)
o aortic regurgitation
o atrial flutter
o mild cognitive impairment (MCI)
 Diagnosis :

Blood pressure can be measured via the following strategies:

❖ Office-based BP measurements
❖ Out-of-office based BP measurements
Office-based BP measurements may be automated or manual.

The diagnosis should not be made on a single office visit. Usually 2–3 office
visits at 1–4-week intervals (depending on the BP level) are required to
confirm the diagnosis of hypertension.

The diagnosis might be made on a single visit, if BP is ≥180/110 mm Hg and

there is evidence of cardiovascular disease (CVD).

The proper measurement of office-based BP requires attention to all of the

following:
- Time of measurement
- Type of measurement device
- Cuff size
- Patient position
- Cuff placement
- Technique of measurement
- Number of measurements
Out-of-office BP measurements is often necessary for the accurate
diagnosis of hypertension and for treatment decisions.
About 10%–30% of subjects attending clinics due to high BP have
white coat hypertension

1) 24-hour ambulatory blood pressure monitoring [ABPM]

This is more reproducible than office measurements meeting one or
more of these criteria using ABPM qualifies as hypertension:
- A 24-hour mean of 130/80 mmHg or above
- Daytime (awake) mean of 135/85 mmHg or above
- Nighttime (asleep) mean of 110/65 mmHg or above

2) Home BP monitoring :
To establish the diagnosis of hypertension, you should obtain at least
12 to 14 measurements with both morning and evening
measurements taken over a period of one week
Following the documentation of hypertension, a detailed history should
extract the following information:
1) Exclusion of secondary causes of hypertension
- Early or late onset of HTN (<20, >50).
- History of tachycardia, sweating and headache.
- Past or family history of renal disease.
- Resistant HTN in a compliant patient.
- Symptoms of sleep apnea.
- History of amphetamine, cocaine, or alcohol abuse, Use of OCP, NSAID,
corticosteroids.
- History of hirsutism or easy bruising
2) Extent of end-organ damage (e.g, heart, brain, kidneys, eyes)
- Heart: left ventricular hypertrophy, angina/previous myocardial
infarction, previous coronary revascularization, and heart failure
- Brain: stroke or transient ischemic attack, dementia
- Chronic kidney disease
- Peripheral arterial disease
- Retinopathy
3) Assessment of patients’ cardiovascular risk status
❑ More than 50% of hypertensive patients have additional cardiovascular risk
factors
❑ The presence of one or more additional cardiovascular risk factors proportionally
increases the risk of coronary, cerebrovascular, and renal diseases in
hypertensive patients.
- Hypertension
- Diabetes mellitus
- Obesity (BMI ≥30 kg/m2)
- Tobacco use
- Elevated LDL cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol,
- Age greater than 55 years for men or greater than 65 years for women
- Estimated glomerular filtration rate less than 60 mL/min
- Microalbuminuria
- Family history of premature cardiovascular disease (men < 55 years; women < 65
years)
- Lack of exercise
Laboratory Investigations and ECG

Routine lab tests are recommended before beginning treatment of high

blood pressure to determine organ or tissue damage or other risk factors.
These lab tests include:
Blood tests: Sodium, potassium, serum creatinine and estimated
glomerular filtration rate (eGFR), lipid profile and fasting glucose.
Urine test: Dipstick urine test.
12-lead ECG: Detection of atrial fibrillation, left ventricular hypertrophy
(LVH), ischemic heart disease.
Other tests may be ordered based on clinical findings:
if coarctation of aorta suspected - computed tomography (CT)
angiography, echocardiography, or magnetic resonance imaging
(MRI)
if Cushing syndrome suspected - dexamethasone suppression test or
24-hour urinary free cortisol
if parathyroid disease suspected - serum parathyroid hormone
if pheochromocytoma suspected - plasma or urinary
metanephrines
if primary aldosteronism suspected - plasma aldosterone and
plasma renin activity
if renovascular hypertension (renal artery stenosis) suspected -
duplex ultrasonography, CT angiography, or magnetic resonance
angiography (MRA)
if sleep apnea suspected - sleep study or nocturnal pulse oximetry
if thyroid disease suspected - thyroid-stimulating hormone (TSH)
management of HTN:

Pharmacological measures

Non-pharmacological measures
Lifestyle modification alone effectively controls about 10% of patients
Pharmacological treatment:
JNC8 recommendations:

In the general population aged ≥60 years, initiate

pharmacologic treatment to lower blood pressure
(BP) at systolic blood pressure (SBP) ≥150 mm Hg or
diastolic blood pressure (DBP) ≥90 mm Hg and treat to
a goal SBP <150 mm Hg and goal DBP <90 mm Hg.
 2

In the general population <60 years, initiate

pharmacologic treatment to lower BP at SBP ≥140
mm Hg and treat to a goal SBP <140 mm Hg.

In the general population <60 years, initiate

pharmacologic treatment to lower BP at DBP ≥90
mm Hg and treat to a goal DBP <90 mm Hg.
 3

In the population aged ≥18 years with chronic

kidney disease (CKD), initiate pharmacologic
treatment to lower BP at SBP ≥140 mm Hg or DBP
≥90 mm Hg and treat to goal SBP <140 mm Hg and
goal DBP <90 mm Hg.
 4

In the population aged ≥18 years with DM, initiate

pharmacologic treatment to lower BP at SBP ≥140
mm Hg or DBP ≥90 mm Hg and treat to a goal SBP
<140 mm Hg and goal DBP <90 mm Hg.
 5
In the general nonblack population, including those with
diabetes, initial antihypertensive treatment should
include a thiazide-type diuretic, calcium channel
blocker (CCB), angiotensin-converting enzyme inhibitor
(ACEI), or angiotensin receptor blocker (ARB).
The JNC 8 panel does not recommend first-line therapy
with beta-blockers and alpha-blockers
Before receiving alpha-blockers, betablockers, or any of
several miscellaneous agents, under the JNC 8
guidelines, patients would receive a dosage adjustment
and combinations of the 4 first-line therapies.
 6

In the general black population, including those

with diabetes, initial antihypertensive treatment
should include a thiazide-type diuretic or CCB.
 7
In the population aged ≥18 years with CKD, initial
(or add-on) antihypertensive treatment should
include an ACEI or ARB to improve kidney
outcomes.
This applies to all CKD patients with hypertension
regardless of race or diabetes status.
One exception to the use of ACE inhibitors or ARBs
in protection of kidney function applies to patients
over the age of 75 years, thiazide-type diuretics or
CCBs are an acceptable alternative to ACEIs or
ARBs.
 8
Attain and maintain goal BP
✔ If goal BP is not reached within a month of treatment, increase the
dose of the initial drug or add a second drug from one of the
classes in recommendation 5 (thiazide-type diuretic, CCB, ACEI, or
ARB)
✔ Assess BP and adjust the treatment regimen until goal BP is reached
✔ If goal BP cannot be reached with 2 drugs, add and titrate a third
drug from the list provided
✔ Do not use an ACEI and an ARB together
✔ Referral to a hypertension specialist may be indicated for patients
in whom goal BP cannot be attained using the above strategy or
for the management of complicated patients for whom additional
clinical consultation is needed.
Several medications are now designated as later-line
alternatives, including the following:
beta-blockers,
alphablockers,
central alpha2/-adrenergic agonists (eg, clonidine),
direct vasodilators (eg, hydralazine),
loop diruretics (eg, furosemide),
aldosterone antagoinsts (eg, spironolactone),
peripherally acting adrenergic antagonists (eg, reserpine).
Each of the antihypertensive therapy classes is roughly
equally effective in lowering the blood pressure, producing a
good antihypertensive response in 30 to 50 percent of
patients. However, wide interpatient variability as many
patients will respond well to one drug but not to another.

The major determinant of reduction in cardiovascular risk in

both younger and older patients with hypertension, not the
choice of antihypertensive drug (assuming that the patient
does not have an indication for a particular drug).

At the same level of blood pressure control, most

antihypertensive drugs provide the same degree of
cardiovascular protection.
INITIAL MONOTHERAPY

Initial monotherapy is successful in many patients with mild primary

hypertension.
- Mild HTN = when the current BP is < 20/10 mmHg above our goal BP.

- Add on therapy: if despite maximum dose of single agent our current BP is >
10/5 mmHg above our goal BP, the patient require a second agent.
SEQUENTIAL MONOTHERAPY

The main idea here is that you change the medication instead of
adding a new agent.

There are no strict guidelines as to how to perform sequential

monotherapy, although the following approach is reasonable:
The BP response to initial monotherapy should be assessed in 4-6 weeks → if
there is an inadequate response, the dose can be increased and the
blood pressure response assessed after another 4-6 weeks period → if after
a single dose increase fails to produce an adequate blood pressure
response, we switch to a different agent.

This process of trying to find the one drug to which the patient is most
responsive may minimize side effects, maximize patient compliance.
However, over time, more than one drug will be needed in many
patients who are initially controlled.
COMBINATION THERAPY

Administering two drugs as initial therapy should be

considered when the BP is > 20/10 mmHg above goal.
Given the preference for an ACE inhibitor/ARB plus a
dihydropyridine CCB in patients requiring combination
therapy.
 Examples MOA Effect Compelling indication Contraindications Side effects

Vasodilation
Heart Failure Dry Cough
Reduce aldosterone Pregnancy
Inhibit AC enzyme, Diabetes (type 1 or 2) Angioedema
ACEIs Captopril Enalapril … secretion Bilateral renal artery
decrease Angiotension II *Post MI Hyperkalemia
Increase bradykinin (side stenosis
*Chronic renal disease Fatigue
effects)

Losartan
Block the angiotension II Same as ACEIs but no The same as ACEIs except Same As ACEIs but with no
ARBs valsartan Same As ACEIs
receptor increase bradykinin only DM type 2 not 1 cough
candesartan

Hypokalemia
Hypomagnesima
Hydrochlorothiazide Block Na/cl transpoter in Dieresis Gout
Thiazides Heart Failure Hyperuricemia
Chlorothalidone distal tubules Vasodilation Used with caution in DM
Hyper glycemia
Impotence

Non : block calcium

Non: vasodilation
channels of cardiac and
Non – dihydropyridines Decrease CO by direct heart Constipation
vascular muscles The non dihydro:
(verapamil , diltiazem) effect Edema
CCBs Angina Heart failure
Dihydropyridine Excessive hypotension
Dihydropyridine: selective AV block
(amlodipine, nifedipine) Dihydropyridine: Non dihydro
for vascular muscle calcium
Vasodilation
channels

Bradycardia
MI Asthma hypotension
Angina COPD Fatigue
Cardioselective (atenolol , Inhibit sympathetic cardiac
B - Blockers Decrease CO Heart Failure (only certain DM Vivid dreams
metoprolol) stimulation
drugs : metoprolo, Heart failure (except the Cold hands
carvidolol, labetolol) aforementioned 3 drugs) Psychosis
Sexual dysfunction
 Screening:

❖ We start screening for high blood pressure in adults aged 18

years or older.
❖ Adults aged 18 to 39 years with normal blood pressure who do
not have other risk factors should be rescreened every 3 to 5
years.
❖ Adults aged ≥ 40 years and persons at increased risk for high
blood pressure should be screened annually.( Persons at
increased risk include those who have high-normal blood
pressure, those who are overweight or obese, and African
Americans.)
THANK YOU