Approach & Management
- Dr.Mohammed Sadiq Azam M .D.
Department of Medicine,
Prof Siraj’s Unit (M – 1)
Deccan College of Medical Sciences
Hypertension( HTN) is the most common primary
35 million office visits are as the primary diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be as much as
7.1 million deaths per year may be attributable to
A systolic blood pressure (SBP) ≥ 140mmHg
A diastolic (DBP) ≥ 90 mmHg.
Based on the average of two or more properly
measured, seated BP readings.
On each of two or more office visits.
Accurate Blood Pressure
The equipment should be regularly inspected and validated.
The operator should be trained and regularly retrained.
The patient must be properly prepared and positioned and
seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.
Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.
At least two measurements should be made
and the average recorded.
Clinicians should provide to patients their
specific BP numbers and the BP goal of
Follow-up based on initial BP measurements for
*Without acute end-organ damage
SBP >120 mmHg and <139mmHg and/or
DBP >80 mmHg and <89 mmHg.
Prehypertension is not a disease category
rather a designation for individuals at high risk
of developing HTN.
Individuals who are prehypertensive are not candidates
for drug therapy, BUT,
Should be firmly and unambiguously advised to practice
Those with pre-HTN, who also have diabetes or kidney
disease, drug therapy is indicated IF a trial of lifestyle
modification fails to reduce their BP to 130/80 mmHg or
Not distinguished as a separate entity as far as
management is concerned.
SBP should be primarily considered during treatment
and not just diastolic BP.
Systolic BP is more important cardiovascular risk factor
after age 50.
Diastolic BP is more important before age 50.
Severe elevated BP in the upper range of
stage II hypertension.
Without progressive end-organ dysfunction.
Examples: Highly elevated BP without severe
headache, shortness of breath or chest pain.
Usually due to under-controlled HTN.
Severely elevated BP (>180/120mmHg).
With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
Acute left ventricular failure with pulmonary edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm
Types of Hypertension
Also known as essential
Less common cause
Accounts for 95% cases of
of HTN ( 5%).
Secondary to other
No universally established
Secondary HTN - Clues in Medical
Onset: at age < 30 yrs ( Fibromuscular dysplasia) or
> 55 (athelosclerotic renal artery stenosis), sudden
onset (thrombus or cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and daytime
sleepiness (sleep disorders)
Secondary HTN - clues on
Pallor, edema, other signs of renal disease.
Abdominal bruit especially with a diastolic
Truncal obesity, purple striae, buffalo hump
Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of renal
Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins imbalance
Renal disease from multiple etiologies.
Atherosclerosis 75-90% ( more common in older
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Post transplantation stenosis
Prolonged Uncontrolled HTN
Changes in the vessel wall leading to vessel
trauma and arteriosclerosis throughout the
Complications arise due to the “target organ”
dysfunction and ultimately failure.
Damage to the blood vessels can be seen on
CVS (Heart and Blood Vessels)
Effects On CVS
Ventricular hypertrophy, dysfunction and
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and
Effects on The Kidneys
Glomerular sclerosis leading to impaired kidney
function and finally end stage kidney disease.
Ischemic kidney disease especially when renal
artery stenosis is the cause of HTN
Stroke, intracerebral and subaracnoid
Cerebral atrophy and dementia
Retinopathy, retinal hemorrhages and
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to
extraoccular muscle paralysis and
Retina Normal and Hypertensive
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
(1) To assess lifestyle and identify other
cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD
(1) Cardiovascular Risk
Obesity (body mass index ≥30 kg/m2)
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)
(2) Identifiable Causes of
Drug-induced or related causes
Chronic kidney disease
Chronic steroid therapy and Cushing’s
Coarctation of the aorta
Thyroid or parathyroid disease
(3) Target Organ Damage
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Angina/MI Stroke: Complications of HTN,
Angina may improve with b-blokers
Asthma, COPD: Preclude the use of bblockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia : Suggest renal
Claudication: May be aggravated by bblockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May
have been due to HTN
Family history of DM : Patient may
also be Diabetic
Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
High alcohol: A cause of HTN
High salt intake: Advice low salt intake
Appropriate measurement of BP in both arms
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
Palpation of the thyroid gland.
Thorough examination of the heart and
Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Lower extremities for edema and pulses
Blood glucose (FPG/PPG) and hematocrit; serum
potassium, creatinine ( or estimated GFR), and
HDL cholesterol, LDL cholesterol, and triglycerides.
Urinary albumin excretion or Spot Albumin/creatinine
Goals of Treatment
Treating SBP and DBP to targets that are <140/90
Patients with diabetes or renal disease, the BP goal is
The primary focus should be on attaining the SBP
To reduce cardiovascular and renal morbidity and
Benefits of Treatment
Reductions in stroke incidence,
averaging 35–40 percent
Reductions in MI, averaging 20–25
Reductions in HF, averaging >50 percent.
Lifestyle Changes Beneficial in Reducing
Decrease time in sedentary behaviors such as
watching television, playing video games, or spending
Increase physical activity such as walking, biking,
aerobic dancing, tennis, soccer, basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.
Dietary Approach to Stop Hypertension
As effective as one medication