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Updated management of Hypertension

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Updated management of Hypertension

  1. 1. Updated Management of Hypertension Presented by Dr. Abdullah Al Mamun Intern Doctor Shaheed Syed Nazrul Islam Medical College Hospital Kishoreganj
  2. 2. Prevalance of Hypertension In Bangladesh The overall prevalence of hypertension is 26.4 %, and the prevalence is higher in women (32.4 %) than men (20.3 %).
  3. 3. Hypertension Definition: Hypertension may be defined as persistent elevation of systolic blood pressure of 140 mm-Hg or greater and/or diastolic blood pressure of 90 mm-Hg or greater or on anti- hypertensive drug.
  4. 4. Risk Factors Major risk factors: • Increasing age • Male gender • Family history • Genetic abnormalities • Hyperlipidemia • Cigarette smoking • Diabetes
  5. 5. Risk Factors Minor risk factors • Obesity • Physical inactivity • Stress • Post menopausal oestrogen deficiency • High carbohydrate intake • Alcohol
  6. 6. Classification of Hypertension • A) Essential Hypertension (90-95%) • B) Secondary Hypertension (05-10%)  CKD  Glomerulonephritis  Thyrotoxicosis  Hypothyroidism Alcohol  Obesity  Pre-eclampsia Cushing syndrome Renal artery stenosis
  7. 7. Classification of Hypertension Category Systolic Diastolic Optimal blood pressure <120 <80 Normal blood pressure <130 <85 High normal blood pressure 130-139 85-89 Grade 1 Hypertension(mild) 140-159 90-99 Grade 2 Hypertension (moderate) 160-179 100-109 Grade 3 Hypertension (severe) ≥ 180 ≥ 110 Isolated Systolic HTN (grade 1) 140-159 <90 Isolated Systolic HTN (grade2) ≥ 160 <90 ** according to British hypertensive society
  8. 8. Category Systolic Diastolic Optimal <120 and <80 Pre-hypertension 120-139 and/or 80-89 Stage 1 Hypertension 140-159 and/or 90-99 Stage 2 Hypertension 160-179 and/or 100-109 Stage 3 Hypertension ≥180 and/or ≥110 Isolated Systolic HTN ≥140 and <90 Classification of Hypertension **According to national guideline for Hypertension in Bangladesh
  9. 9. Stage 03 Hypertension Stage 03 can be divided in three categories 1. Severe HTN: BP>180/110 mmHg without symptoms or acute signs of organ damage 2. Hypertensive urgencies: BP> 180/110mmHg with symptoms of modest organ damage 3. Hypertensive emergencies: BP> 220/140 mmHg with life threatening organ dysfunction
  10. 10. Severe HTN without symptoms or signs of organ damage It may be due to • Abrupt withdrawal of prior therapy • Acute pain • Emotional distress
  11. 11. Hypertensive urgency Patient may be associated with  Severe headache Shortness of breath  Oedema  Target organ damage  Cardiovascular disease
  12. 12. Hypertensive Emergency BP> 220/140 with evidence of impending or progressive target organ damage such as  Hypertensive encephalopathy  Severe shortness of breath  Prolonged chest pain/ unstable angina  Acute MI  Acute LVF with pulmonary oedema
  13. 13. Resistant Hypertension It may be defined as high BP that remains uncontrolled despite treatment with at least three anti hypertensive agents at highest tolerated dose ( ARB/ ACE inhibitors + CCB+ Thiazide diuretics) ** Pseudo-resistant HTN should be excluded
  14. 14. Fates of untreated HTN Uncontrolled or poorly controlled HTN may leads to • Myocardial Infarction • Acute & chronic heart failure • Stroke • Left ventricular hypertrophy • Chronic kidney disease • Hypertensive retinopathy • Peripheral vascular disease.
  15. 15. Diagnosis of Hypertension History:  Duration, age of onset & previous levels of BP  Family history  Lifestyle ( exercise, salt intake, smoking habit)  Previous antihypertensive therapy  Drugs or alcohol intake  Symptoms suggestive secondary causes of HTN  Symptoms of concomitant disease (DM, Renal disease, gout)
  16. 16. Diagnosis of Hypertension Physical Examination:  Two or more BP measurements separated by two minutes with the patient either supine or seated.  Measurement of on both arms  Assessment of presence of signs suggest of target organ damage  Assessment of signs suggestive secondary HTN
  17. 17. Diagnosis of Hypertension Physical Examination:  radio-femoral delay : coarctation of aorta  enlarged kidney: polycystic kidney disease  Abdominal bruits: renal artery stenosis  Characteristic features of Cushing syndrome
  18. 18. Diagnosis of Hypertension Investigations  Urinalysis for blood protein & glucose  Blood glucose  ECG  Random total cholesterol  S. Creatinine  S. Electrolyte  Chest X-ray: cardiomegaly, Heart failure, Coarctation of aorta  Echocardiogram: Left ventricular hypertrophy  For detection of secondary causes of HTN several other investigations may be needed.
  19. 19. Hypertension in Special situation Hypertension in elderly: Special features of HTN in elderly:  Pseudo hypertension  Isolated systolic HTN more common  White-coat HTN is also more common  Postural hypotension & hypertension are commonly seen  Co-morbidities are common  Adverse effect of drugs are more possible
  20. 20. Hypertension in Special situation Hypertension in pregnancy: It may be 1. Gestational HTN: New HTN (≥ 140/90 mmHg) developed after 20 weeks of pregnancy which may be normalized within 06 weeks of delivery a) Pre eclampsia: HTN with protenuria after 20 weeks of pregnancy b) Eclampsia: Pre-eclampsia complicated with convulsion/coma
  21. 21. Hypertension in Special situation Hypertension in pregnancy: 2. Chronic HTN: Elevated BP (≥ 140/90 mmHg) diagnosed before pregnancy or developed during pregnancy before 20 weeks & after delivery its persists 3. Pre eclampsia/eclamsia superimposed on chronic HTN
  22. 22. Hypertension in Special situation Hypertension in DM The HTN in DM study group reported a 39% prevalence of HTN among newly diagnosed patient & in approximately half of them the elevated BP predated the onset of microalbuminuria. HTN should be detected & treated early in the course of DM to prevent cardiovascular disease & to delay progression of renal disease & diabetic retinopathy.
  23. 23. Hypertension in Special situation Hypertension in stroke: HTN is the most common & very important risk factor for any type of stroke. Incidence of stroke is three times higher in persons with stage 2 or stage 3 HTN.
  24. 24. Hypertension in Special situation HTN in stroke Target BP: • In Ischemic stroke: MAP-(105-110 mmHg) • But if target organ involvement than (90-95mmHg) • In Subarachnoid hemorrhage : 5mmHg more than ischemic stroke • In Intra-cerebral hemorrhage: 5mmHg less than Ischemic stroke
  25. 25. Hypertension in Special situation Hypertension in Renal disease • Hypertension is one of the common cause of CKD • It’s also a complication of CKD • Approximately 50-75% of patients with CKD have HTN
  26. 26. Hypertension in Special situation Hypertension in cardiovascular disease: • Ischemic heart disease is the most commonest form of target organ damage associated with HTN. • Heart failure in the form of systolic or diastolic ventricular dysfunction results primarily from systolic HTN & IHD.
  27. 27. Management of Hypertension • Target Blood pressure level Conditions Target BP Age < 60 years < 140/90 mmHg Age ≥ 60 years < 150/90 mmHg All Ages with DM < 140/90 mmHg DM with presence of protenuria 1g/24 hours 125/75 mmHg All Ages with CKD < 130/80 mmHg
  28. 28. Management of Hypertension • Non-Pharmacological Management • Pharmacological Management
  29. 29. Non Pharmacological Management/ Lifestyle Modifications Achieving & Maintaining ideal weight Limiting total salt intake < 5gm/day  Taking healthy diet  Regular moderate intensity physical activity Avoiding tobacco use  Avoiding or limiting alcohol intake
  30. 30. Pharmacological Management Age <55 years Age > 55 years ACEI/ ARB CCB ACEI/ARB+ CCB + Diuretics+ Further diuretic/ Alpha blockers/ Beta blockers ACEI/ ARB+ CCB ACEI/ARB+ CCB + Diuretics Step 01 Step 02 Step 03 Step 04 ACEI- Angiotensin Coverting Engyme Inhibitos ARB: Angiotensin Receptor Blocker CCB: Calcium Channel Blocker
  31. 31. Class Conditions in favour Compelling contraindication Possible Contraindication Diuretics (Thiazide & Thiazide like) Heart Failure, Elderly patient, IHF Gout Pregnancy Diuretics (loop) Renal insufficiency, Heart Failure Pregnancy Diuretics (Anti- aldosterone) Heart Failure, Post MI, Resistant HTN Renal failure, Hyperkalemia CCB ( long acting only) Elderly patients, ISH, Angina pectoris, PVD, Atherosclerosis, Pregnancy Tachyarrythmia, Heart failure CCB (Verapamil, Diltiazem) Angina Pectoris, Atherosclerosis, SVT AV block, Heart failure Constipation
  32. 32. Class Conditions in favour Compelling contraindication Possible Contraindication ACE inhibitor HF, Left ventricular dysfunction, Post MI, Non- diabetic nephropathy, Type- 1 diabetic nephropathy, Prevention of diabetic microalbuminuria, proteinuria Pregnancy, Hyperkalamia, Bilateral renal artery stenosis, Angioneurotic oedema ARB Type 2 diabetic nephropathy, Type 2 diabetic microalbuminuria, Non-diabetic nephropathy, LVH, ACE inhibitor intolerance, High CV risk Pregnancy, Hyperkalamia, Bilateral renal artery stenosis, Beta blockers Angina pectoris, Post MI, Heart failure Ashthma, COPD, AV block, pregnancy PVD, bradycardia, Glucose intolerance, Metabolic syndrome, Physically active patients
  33. 33. Pharmacological Management Ideal drug for treatment of HTN Must be efficacious  Minimum side effects Able to prevent complications Easy to use Affordable
  34. 34. Stage 1 HTN: If there is no target organ damage Observation for 03-06 months Lifestyle modification+ 02 monthly visits If not controlled- Monotherapy+ Follow up after 06 weeks  If patient shows response but target BP is not achieved: Increase dose of initial drug/ Add another drug  If patient does not show response or does not tolerate: Substitute the drug with another class
  35. 35. Combinations Comments ACE inhibitors + Diuretics Appropriate for concurrent Heart Failure. DM & Stroke ARB + Diuretics Appropriate for concurrent Heart Failure & DM CCB+ ACE inhibitors Appropriate for concurrent Dyslipidemia & DM CCB+ ARB Appropriate for concurrent Dyslipidemia & DM CCB+ Beta-blockers Cheap, appropriate for concurrent CHD Beta blockers+ Diuretics Appropriate for elderly patient, cost effective Stage 2 HTN: Combination Therapy is recommended
  36. 36. Severe HTN without symptoms or signs of organ damage Management: • Immediate normalization of BP not necessary • Usually appropriate to prescribe two drug therapy • Counsel the patient on the importance of long term BP control • Schedule follow up within one week or less
  37. 37. Hypertensive urgency Management: • Admission in hospital • Measurement of BP after 30 minutes of bed rest • BP should be controlled by oral/ parenteral anti-hypertensive agents • In most patients it is possible to avoid parenteral therapy and bring BP under control with bed rest & oral therapy • Initial aim for reduction of 25% BP over 24 hours but not lower than 160/90 mmHg • Orally Captopril 25 mg or labetalol 200-400 mg could be used
  38. 38. Hypertensive Emergency Management:  Admission on ICU for continuous monitoring of BP & parenteral administration of Anti-hypertensive  Initial goal to reduce mean arterial blood pressure no more than 25% within minutes to 01 hour)  Then if stable, BP should be reduce up to 160/100 within next 02-06 hours  If this level of BP is well tolerated & the patient is clinically stable gradual reduction of BP within 24-48 hours
  39. 39. Treatment of Isolated Systolic HTN • If Systolic BP < 160 regular monitoring is required • If systolic BP is >160 mm Hg, the form of drug therapy now is low-dose diuretics or dihydropyridine calcium-channel blockers.
  40. 40. Treatment of Secondary HTN
  41. 41. Resistant Hypertension Management: – Spironolactone 25/50 mg once daily as fourth agent if blood potassium level<4.5 mmol/L – If Spironolactone contraindicated or not well tolerated Amiloride/ Alpha-blockers/ Direct vasodilators are other options – Combined alpha & beta blocker can be used
  42. 42. Hypertension in Elderly Management:  Step 01- Calcium channel blocker ( if not suitable thiazide or thiazide like diuretics)  Step 02- if not controlled ACEI or ARB should be added  Step 03- if not controlled thiazide or thiazide like diuretics should be added as third drug  Step 04- If still not controlled its need to be treated as resistant HTN
  43. 43. HTN in Pregnancy Specific Management: Gestational HTN:  Tab. Methyl dopa 250-500 mg 08/12 hourly  Tab. Labetalol 100 mg 08/12 hourly  Tab Nifedipine 10-20 mg 12 hourly Severe Pre-eclampsia:  IV Hydralazine bolus/infusion  IV labetalol  Anti convulsant therpy for prevention of convulsion
  44. 44. HTN in Stroke • If the patient is not known hypertensive & BP is < 180/110 mmHg it’s better to wait for 5-7 days • If there is target organ damage antihypertensive should start immediately but slowly build up dose for gradual reduction of BP • If there is severe HTN (>220/120 mmHg) immediate reduction is necessary but not more than 20% in 1st 24 hours. Preferred agents are IV labetalol, Nitroprusside, Hydralazine, Nicardipine. Sublingual Nifedipine is not recommended • If patient is known hypertensive & on drug or not than either treatment should be start or previous medication should be continued.
  45. 45. HTN in Stroke Selection of drug: Always oral agents are preferred except severe HTN. According to priority 1. ARB 2. ACEI 3. CCB 4. Alpha blocker 5. Beta blocker 6. Diuretics ( Hyponatremia should be excluded)
  46. 46. HTN in DM Management: – ACEI is the drug of choice – If not tolerated ARB should consider – Diuretics can be added when mono therapy is not adequate but higher dose may decrease insulin responsiveness – Dihydropyridine CCB has good role in reducing proteinuria in diabetic nephropathy – Beta blocker & alpha blockers are used when others could not control BP but it should be use cautiously as it may produce many side effects
  47. 47. HTN in Kidney Disease o In management of HTN in renal disease control of BP & Proteinuria are the most important factors. ACEI & ARB have greater anti-proteinuric effect than other anti- hypertensive. o S. creatinine should be checked within first two weeks of therapy, If there is persistent rise of S.creatinine of 30% from baseline within 02 months ACEI / ARB should be stopped. o In case of High S. Creatinine level loop diuretics are preferred o CCB (Diltiazem/ Verapramil) have anti-proteinuric effect. Combination of ACEI & CCB is more anti-proteinuric.
  48. 48. HTN in coronary artery disease Drugs of choice: • Stable Angina pectoris: Beta blockers • unstable angina/MI: Beta blockers & ACEI • Post MI: ACEI, Beta blocker, aldosterone antagonist
  49. 49. HTN in Heart Failure Treatment includes Thiazide & loop diuretics as well as beta blockers, ACEI, ARB & anti aldosterone on top of diuretics. CCB should be avoided.
  50. 50. Management of HTN before surgery  Elective surgery: If the BP is <180/100 mmHg, operation should not delayed. if the BP is ≥ 180/100mmHg operations should be delayed with reduction of blood pressure by suitable anti-hypertensive.  Emergency Surgery: If the BP is >180/110 mmHg I/V antihypertensive drugs such as labetolol or hydralazine need to use to decrease blood pressure prior to initiating anaesthesia.