Essential Hypertension management and treatment

1. KGMU 2011
Fabio Grubba

2.  Essential hypertension or idiopathic
hypertension is the form
of hypertension that by definition, has no
identifiable cause.
 Hypertension can increase the risk
of cerebral, cardiac, and renal events.

3.  US national institute of health –JNC guide
lines for hypertension
 JCN-7 Joint national committee on
prevention , detection, evaluation, and
treatment of High blood pressure
 JCN-8

4.  BP mm/hg
 Lower than 120/80 NORMAL
 120-139/80-89 PREHYPERTENSION
 140-159/90-99 STAGE 1 Hypertension
 Above 160/100 STAGE 2 Hypertension
American Heart Association

5.  Stage I Hypertension. systolic pressure 140 to 159 mm
Hg and or diastolic pressure measurements 90-99 mm Hg. Tachycardia
 Stage II Hypertension. Stage II systolic elevation (160 to 179 mm
of Hg) and or diastolic pressure (100 to 109 mm Hg).
Symptoms are the same as noted in Stage I. Stage I and II hypertension
may be treated no pharmacologically with diet
and exercise or pharmacologically with antihypertensive medications.
 Stage III Hypertension. persistent elevation (systolic >180mm Hg; diast
olic >110mm Hg) with target end organ Damage.
This stage is often treated immediately with
antihypertensive medications.
 Hypertensive urgency is a condition of persistent elevation in blood
Pressure . symptoms of dizziness, chest pain, or confusion.
 Hypertensive crisis is similar condition,however the patient has sympt
oms of target end organ damage.
 ESH (European society of cardiology)

6.  Labile hypertension: AP are sometimes but
not always in the hypertensive range
 Accelerated Hypertension: Significant
increase of pressure that previous
Hytpertensive levels (Vascular damage)
 White coat hypertension:Persistent higher
but only in doctors presence
 Isolated Systolic Pressure:Related with
patients above 50 Years of age caused by
arterial stiffness

7.  Family history
 Obesity
 Advanced age
 Inactivity
 Cigarette smoking
 Excessive salt consumption
 Excessive alcohol consumption

8.  Abnormal Na transport: Na-K pump (Na+, K+-ATPase)
is defective or inhibited intracellular Na = cell sensitive
to sympathetic stimulation
 Sympathetic nervous system:Sympathetic
stimulation increases BP
 Renin-angiotensin-aldosterone system
 Vasodilator deficiency:Deficiency of a vasodilator
(eg, bradykinin, nitric oxide)
 Pathology and complications: No pathologic changes
occur early in hypertension.
 Most of the patients with essential hypertension have
the normal cardiac output but raised peripheral
resistance

9.  Hypertension is usually asymptomatic until
complications develop in target organs
 Dizziness, flushed facies, headache, fatigue,
epistaxis, and nervousness are not caused by
essential hypertension.
 ONLY Severe hypertension can cause severe
cardiovascular, neurologic, renal, and retinal
symptoms (eg, symptomatic coronary
atherosclerosis, HF, hypertensive
encephalopathy, renal failure).

10.  Multiple measurements of BP to confirm
 Urinalysis and urinary albumin:creatinine ratio
 Renal ultrasonography if creatinine increased
 Blood tests: Fasting lipids, creatinine, K
 Evaluate for aldosteronism if K decreased
 ECG: If left ventricular hypertrophy, consider
echocardiography
 Sometimes thyroid-stimulating hormone
measurement

11.  BP must be measured twice—first with the
patient supine or seated, then after the
patient has been standing for ≥ 2 min—on 3
separate days.
 Classification BP (mm Hg)
 Normal: < 120/80
 Pre-hypertension: 120–139/80–89
 Stage 1: 140–159 (systolic) or 90–99
(diastolic)
 Stage 2: ≥ 160 (systolic) or ≥ 100 (diastolic)

12.  Weight loss and exercise
 Smoking cessation
 Diet: Increased fruits and vegetables,
decreased salt, limited alcohol
 Drugs if BP is initially high (> 140/90 mm Hg)
or unresponsive to lifestyle modifications

14.  Lifestyle recommendations include regular
aerobic physical activity :at least 30 min/day;
 weight loss to a body mass index of 18.5 to 24.9;
 smoking cessation;
 a diet rich in fruits, vegetables, and low-fat dairy
products with reduced saturated and total fat
content;
 dietary sodium[Na + ] of < 2.4 g/day (< 6 g NaCl);
 and alcohol consumption of ≤ 1 oz/day in men
and ≤ 0.5 oz/day in women

15.  If systolic BP remains > 140 mm Hg or
diastolic BP remains > 90 mm Hg after 6 or
more years of lifestyle modifications, antihy
 For most hypertensive patients, one drug,
usually a thiazide-type diuretic, is given
initially. pertensive drugs are required.
 Low-dose aspirin (81 mg once/day) appears
to reduce incidence of cardiac events in
hypertensive patients

16. •Some antihypertensives are
contraindicated in certain disorders
like β-blockers in asthma
• OR indicated particularly for certain
disorders as β-blockers or Ca channel
blockers for angina pectoris
•ACE inhibitors or angiotensin II
receptor blockers for diabetes
•When a single drug is used, black
men may respond best to a Ca
channel blocker (eg, diltiazem).
• Thiazide-type diuretics appear to
be particularly effective in
people > 60 and in blacks.

17.  Diuretics: modestly reduce plasma volume and reduce vascular
resistance, possibly via shifts in Na from intracellular to extracellular loci.
 These drugs are the least expensive initial therapy
Main are thiazide-type diuretics, loop diuretics, and K-sparing diuretics.
 Loop diuretics are used to treat hypertension only in patients who have
lost > 50% of kidney function.
 Thiazide-type diuretics are most commonly used. In addition to other
antihypertensive effects, they cause vasodilation as long as intravascular
volume is normal.
 Thiazide-type diuretics can increase serum cholesterol slightly (mostly
low-density lipoprotein) and also increase triglyceride levels,
 All diuretics except the K-sparing distal tubular diuretics cause significant
K loss.

18.  β−Blockers: These slow heart rate and reduce
myocardial contractility, thus reducing BP.
 All β-blockers are similar in antihypertensive efficacy.
In patients with diabetes, chronic peripheral arterial
disease, or COPD, a cardioselective β-blocker
 acebutolol, atenolol, betaxolol,bisoprolol, metoprolol)
 cardioselective β-blockers are contraindicated in
patients with asthma or in patients with COPD with a
prominent bronchospastic component.
 β-Blockers have CNS adverse effects (sleep
disturbances, fatigue, lethargy) and exacerbate
depression

20.  Ca channel blockers: are potent peripheral vasodilators
and reduce BP by decreasing TPR;
 they sometimes cause reflexive tachycardia.
 Nondihydropyridines,verapamil,anddiltiazem
 slow the heart rate, decrease atrioventricular conduction,
and decrease myocardial contractility.
 Long-acting nifedipine,verapamil,ordiltiazem,is used to
treat hypertension,
 but short-acting nifedipine and diltiazem are associated
with a high rate of MI and are not recommended.
 A Ca channel blocker is preferred to a β-blocker in patients
with angina pectoris and a bronchospastic disorder, with
coronary spasms

22.  ACE inhibitors: These drugs reduce BP by interfering
with the conversion of angiotensin I to angiotensin II
 and by inhibiting the degradation of bradykinin,
 thereby decreasing peripheral vascular resistance
without causing reflex tachycardia.
 These drugs reduce BP in many hypertensive patients,
regardless of plasma renin activity.
 these drugs provide renal protection, they are the
drugs of choice for patients with diabetes and may be
preferred for blacks.
 A dry irritating cough is the most common adverse
effect

24.  Adrenergic modifiers: This class includes
central α2-agonists, postsynaptic α1-blockers,
and peripheral-acting adrenergic blockers.
 α 2-Agonists:
methyldopa, clonidine,guanabenz, guanfacine
 stimulate α2-adrenergic receptors in the brain
stem and reduce sympathetic nervous activity,
lowering BP.
 Because they have a central action, they are
more likely than other antihypertensives to
cause drowsiness, lethargy, and depression; they
are no longer widely used.

26.  Direct vasodilators: These drugs work
directly on vessels, independently of the
autonomic nervous system.
 but has more adverse effects, including
Na and water retention and hypertrichosis,
which is poorly tolerated by women.

28.  Age,sex,alcohol intake,blood serum
cholesterol,glucose intolerance and weight
 Hypertension is a progressive and lethal
disease with not treated properly
 Untreated hypertension is associated with
shortening of life by 10 till 20.
 Nearly 30 % of patients acquires
atherosclerosis complication
 More than 50 % will have a end organ
damage

29.  IMC lower than 25 always
 Limit salt , caffeine and alcohol excessive
consumption
 Exercise regularly

30.  The ultimate public health goal of antihypertensive therapy is to reduce the morbidity and
mortality from cardiovascular and renal events. It is well established that lowering BP reduces
cardiovascular risk. Study has estimated the absolute benefit associated with a 12-mm Hg
reduction in systolic BP over 10 years.
 For the patient with stage 1 hypertension (systolic BP 140-159 mm Hg and/or diastolic BP 90-
99 mm Hg) and additional cardiovascular risk factors, one death would be prevented for every 11
patients treated. In the presence of cardiovascular disease with target organ damage, only nine
patients would require BP reduction to prevent a death.
 Evidence exists that treating systolic BP and diastolic BP to a target below 140/90 mm Hg is
associated with reduction in cardiovascular disease complications.
 Data now support treatment to a BP goal below 130/80 mm Hg in patients with hypertension,
diabetes mellitus, or renal disease.
 Hypertension is an important modifiable risk factor. Although a majority of patients with
hypertension remain asymptomatic, a careful early evaluation identifies those with or at risk for
target organ damage
 The effective management of hypertension is therefore an important primary health care
objective in managing cardiovascular and renal disease.
 The majority of patients with uncontrolled hypertension are older adults with isolated stage 1 or 2
systolic hypertension, most of whom have access to and regular visits with their health care
providers.

31. 1. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/arterial-
hypertension/
2. Pickering TG, Miller NH, Ogedegbe G, et al: American Heart Association; American Society of
Hypertension; Preventive Cardiovascular Nurses Association: Call to action on use and
reimbursement for home blood pressure monitoring: A joint scientific statement from the
American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular
Nurses Association. Hypertension. 2008, 52: (1): 10-29.
3. Guyton AC. Blood pressure control—Special role of the kidneys and body fluid. Science. 1991,
252: 1813-1816.
4. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/
5. http://www.merckmanuals.com/professional/cardiovascular_disorders/hypertension/overview
_of_hypertension.html
6. http://www.mayoclinic.com/health/high-blood-pressure/DS00100
7. http://www.google.com/#sclient=psy-
ab&hl=en&source=hp&q=hypertension+JNC&pbx=1&oq=hypertension+JNC&aq=f&aqi=g4&aq
l=1&gs_sm=e&gs_upl=4063l5601l1l5820l4l4l0l0l0l0l1665l1665l8-
1l1l0&bav=on.2,or.r_gc.r_pw.,cf.osb&fp=2196ee66493014b2&biw=1920&bih=979
8. http://en.wikipedia.org/wiki/Hypertension
9. http://www.ash-us.org/