Management of hypertension by Dr. Basil Tumaini, presented at Kilema hospital in Moshi District Council.

1. MANAGEMENT
OF
HYPERTENSION
Dr. Basil B. Tumaini, MD
May 2013

2. OBJECTIVES
Promote the prevention of hypertension &
cardiovascular diseases
Increase awareness & detection of HTN
Increase the proportion of HTN Pts on
treatment & effectively treated to optimal
BP levels
Reduce the total cardiovascular risk
Improve compliance to treatment
May 2013 2HTN management, Dr. Basil Tumaini

3. IMPLEMENTATION
A protocol for HTN management should
cover:
Screening, evaluation & follow up policy
Essential & cost-effective investigations
Non-pharmacological measures
Essential drug policy
Public health education policy
May 2013 3HTN management, Dr. Basil Tumaini

4. BP Measurement
Mercury sphygmomanometers
Aneroid sphygmomanometers
Electronic sphygmomanometers
May 2013 4HTN management, Dr. Basil Tumaini

5. Mercury sphygmomanometers
Are the standard.
May 2013 5HTN management, Dr. Basil Tumaini

6. Aneroid sphygmomanometers
May 2013 6HTN management, Dr. Basil Tumaini

7. Electronic sphygmomanometers
Always purchase equipment from reliable
manufacturer.
May 2013 7HTN management, Dr. Basil Tumaini

8. Electronic sphygmomanometers
Gaining popularity for home monitoring
Take average of three recordings
They act as a guide
Should be calibrated vs. a mercury
sphygmomanometer if used in a clinical
setting
Use only those whose accuracy has been
certified
May 2013 HTN management, Dr. Basil Tumaini 8

9. CUFF SIZE
Always use appropriate cuff size
The bladder should encircle & cover two-
thirds of the length of the arm
May 2013 HTN management, Dr. Basil Tumaini 9
ARM
CIRCUMFERENCE
RECOMMENDED CUFF
SIZE
16 – 21 cm Child
22 – 26 cm Small adult
27 – 34 cm Adult
35 – 44 cm Large adult
45 – 52 cm Adult thigh

10. Regular calibration
For aneroid and electronic equipment
Every 6 months
Against a mercury manometer
May 2013 HTN management, Dr. Basil Tumaini 10

11. POSTURE
Patient sitting up on a chair or lying
supine quietly for about 5 minutes
Standing pressures are important for
elderly, diabetics, those on diuretics &
sympatholytics
Read immediately and 2 minutes after
standing
May 2013 HTN management, Dr. Basil Tumaini 11

12. Technique & Performance 1
Proper cuff placement
The midline of the bladder should be over
the brachial artery
The lower edge of the cuff should be 2 cm
above the antecubital fossa
Feel the radial pulsation
May 2013 HTN management, Dr. Basil Tumaini 12

13. Technique & Performance 2
Inflate the cuff quickly to 70mm Hg then
increase gradually by 10mm Hg to the
disappearance of radial pulsation (SBP)
Inflate the bladder quickly to a pressure of
20mm Hg above the systolic BP
Auscultate with a bell over brachial artery
Deflate bladder at a rate of about 3 mm
Hg per pulse beat
May 2013 HTN management, Dr. Basil Tumaini 13

14. Technique & Performance 3
Systolic pressure is at the first appearance
(phase 1) of Korotkoff sounds (SBP)
Diastolic pressure is at the disappearance
(phase 5) of Korotkoff sounds (DBP)
May 2013 HTN management, Dr. Basil Tumaini 14

15. Variables that may affect
measured BP value
Food intake esp. Caffeine-containing
beverages
Cigarette smoking
Strenuous exercises within the last hour
Stressful situations e.g., meetings, phones
Use of drugs e.g., nasal decongestants,
some cough syrups
May 2013 HTN management, Dr. Basil Tumaini 15

16. Errors in BP measurement may
occur due to
Improper arm position
Observer error
White-coat hypertension
Wrong rate of cuff inflation or deflation
Failure to recognise auscultatory gap
Technical causes
May 2013 HTN management, Dr. Basil Tumaini 16

17. Classification of BP/HTN
(WHO/ISH)
CATEGORY SBP mm Hg DBP mm Hg
Optimal BP < 120 < 80
Normal BP < 130 < 85
High-normal BP 130 - 139 85 - 89
Grade I - Mild 140 - 159 90 - 99
Subgroup - borderline 140 - 149 90 - 94
Grade II - Moderate 160 - 179 100 - 109
Grade III - Severe ≥ 180 ≥ 110
Isolated systolic
subgroup: borderline
> 140 > 90 < 99
May 2013 HTN management, Dr. Basil Tumaini 17

18. Natural history of HTN 1
BP increases with age
Due to decreased arterial compliance
Pulse pressure widens
SBP increases
DBP decreases
Malignant HTN occurs in 1% of untreated
hypertensives
May 2013 HTN management, Dr. Basil Tumaini 18

19. Natural history of HTN 2
HTN has few symptoms
Principally related to target organ damage
(TOD) rather than elevated BP
May 2013 HTN management, Dr. Basil Tumaini 19

20. Major consequences of HTN
Accelerated
atherosclerosis
CAD
Ischemic stroke
Ischemic nephropathy
PAD
Retinopathy
Hemodynamic
complications
Heart failure
Haemorrhagic stroke
Aortic dissection
Encephalopathy
May 2013 HTN management, Dr. Basil Tumaini 20
Death

21. HTN in African populations
Most are salt sensitive (2/3)
High prevalence of HTN
Accelerated rates of complications: stroke,
heart disease, ESRD
Increased incidence of nephrosclerosis
Reduced ANP, increased Endothelin-1
May 2013 HTN management, Dr. Basil Tumaini 21

22. Aims of clinical & lab.
evaluation of hypertensives
Confirm chronic elevation of BP
Staging of hypertension
Exclude/identify secondary causes of HTN
Determine presence of TOD
Determine presence of other
cardiovascular risk factors
These may influence treatment and
prognosis
May 2013 HTN management, Dr. Basil Tumaini 22

23. Recommended lab. Tests1 (where available)
To assess presence of TOD
Serum creatinine
BUN
Urinalysis for protein and cells
ECG
Echocardiography
May 2013 HTN management, Dr. Basil Tumaini 23

24. Recommended lab. Tests2 (where available)
To assess presence of cardiovascular
risk factors
FBG
Serum cholesterol – total, HDL, LDL
May 2013 HTN management, Dr. Basil Tumaini 24

25. Additional tests
CXR
Serum calcium, uric acid /electrolytes
May 2013 HTN management, Dr. Basil Tumaini 25

26. Approach to treatment in HTN
Identify the major risk factors
MODIFIABLE
Smoking
Obesity
Hypo dynamism
DM
Alcohol abuse
Hyperlipidaemia
LVH
NON-MODIFIABLE
Age
Sex
Strong family history
of CVS diseases
May 2013 HTN management, Dr. Basil Tumaini 26

27. BP reduction goals
Reduce DBP to < 85 mm Hg
Reduce SBP to < 140 mm Hg
May 2013 HTN management, Dr. Basil Tumaini 27

28. Aims of the treatment protocol
Reduce CV risk associated with HTN
(stroke, MI, sudden death)
Reduce risk from co-existing risk factors
(DM, hypercholesterolemia, smoking,
obesity)
Improve quality of life
Encourage a healthy lifestyle
Use therapeutic agents wisely
May 2013 HTN management, Dr. Basil Tumaini 28

29. Treatment options
Non-drug therapy of HTN
Drug treatment for HTN
May 2013 HTN management, Dr. Basil Tumaini 29

30. Non-drug therapy of HTN 1
Has potential to lower BP
Can prevent development of HTN
Can reduce other CV risk factors
Reduce need for antihypertensive drugs
Maximise efficacy of antihypertensive
drugs
May 2013 HTN management, Dr. Basil Tumaini 30

31. Non-drug therapy of HTN 2
Weight reduction if obese
Salt restriction (< 6 mg per day)
Alcohol moderation
(< 21U/w M; < 14U/w F)
Increase regular physical activity: brisk
walk or swim for 30 – 45 min, 3-4 times
per week (avoid strenuous exercises &
isometric exercises e.g., weight lifting)
May 2013 HTN management, Dr. Basil Tumaini 31

32. Non-drug therapy of HTN 3
Increase fruit, vegetables, fish intake
Increase dietary: potassium, calcium
Decrease: saturated fats, cholesterol
Stop smoking
Reduce stress
May 2013 HTN management, Dr. Basil Tumaini 32

33. PATIENT EDUCATION
The core of successful management
Stress that HTN management is for life
Stress lifestyle modification
Both verbal and written information
May 2013 HTN management, Dr. Basil Tumaini 33

34. Drug treatment for lowering BP
Major drug groups
Diuretics
Beta-blockers
Calcium antagonists
ACE inhibitors
Angiotensin II antagonists
Alpha-adrenergic blockers
May 2013 HTN management, Dr. Basil Tumaini 34

35. PRINCIPLES OF DRUG
TREATMENT 1
Initiate therapy with a low dose of a
particular agent
If tolerable but no adequate control
achieved, increase the dose of the same
drug.
If still poor response or poor tolerance,
change to another drug class
May 2013 HTN management, Dr. Basil Tumaini 35

36. PRINCIPLES OF DRUG
TREATMENT 2
It may be preferable to add a small dose of
another class of drugs rather than increase
the dose of the first drug
Use optimal drug combinations
Achieves optimal BP control while
minimizing side effects
E.g., diuretic+B-blocker; diuretic+ACE
inhibitor; B-blocker + calcium antagonist
May 2013 HTN management, Dr. Basil Tumaini 36

37. PRINCIPLES OF DRUG
TREATMENT 3
Long-acting, sustained-release
preparations (OD) improve compliance
All drug classes (!) are suitable for the
initiation and maintenance of HTN
therapy
May 2013 HTN management, Dr. Basil Tumaini 37

38. CHOICE OF
ANTIHYPERTENSIVES
Socio-economic factors
External funding
Cost
CVS risk profile of the individual patient
Presence of TOD, clinical CVS disease
Presence of renal disease & DM
Other co-existing disorder
Available evidence
May 2013 HTN management, Dr. Basil Tumaini 38

39. CLASS OF
DRUGS
COMPELLING
INDICATIONS
POSSIBLE
INDICATIONS
COMPELLING
CONTRA-
INDICATIONS
POSSIBLE
CONTRA-
INDICATIONS
Diuretics HF
Elderly
Systolic HTN
DM Gout Dyslipidaemia
Sexually
active males
ß-blockers Angina
AMI
Tachyarrhythmia
HF
Pregnancy
DM
Asthma
Heart block
PVD
Dyslipidaemia
Calcium
antagonist
Angina
Systolic HTN
Elderly Pts
PVD Heart block HF
ACE
inhibitors
HF
LV dysfunction
After MI
DM nephropathy
Pregnancy
Hyperkalaemia
BRAS
α- blockers
Angiotensin II
antagonists
BPH
ACE inhibitor
cough
Glucose
intolerance
Dyslipidaemia
HF
Pregnancy
Hyperkalaemia
BRAS
Orthostatic
hypotension
May 2013 HTN management, Dr. Basil Tumaini 39

40. Risk factors used for
risk stratification
Levels of SBP & DBP (grade I-3)
Men > 55 years
Women > 65 years
Smoking
Total cholesterol > 6.5 mmol/L
DM
Family history of premature CV death
May 2013 HTN management, Dr. Basil Tumaini 40

41. Additional risk factors
influencing prognosis
Low HDL cholesterol
High LDL cholesterol
Microalbuminuria in DM
IGT
Obesity
Lack of physical exercise
High fibrinogen, homocystein
May 2013 HTN management, Dr. Basil Tumaini 41

42. Associated clinical conditions
(ACC)
CVD: ischemic/haemorrhagic stroke, TIA
Heart disease: MI, Angina pectoris,
coronary revascularisation
Renal disease: RF, DM nephropathy
Vascular diseases: dissecting aneurysm,
symptomatic PVD, advanced HTN
retinopathy
May 2013 HTN management, Dr. Basil Tumaini 42

43. Stratifying Risk
BP mm Hg SBP 140-159
DBP 90-99
SBP 160-179
DBP 100-109
SBP ≥ 180
DBP ≥ 110
No other risk
factors
Low risk Medium risk High risk
1-2 risk factors Medium risk Medium risk Very high risk
≥3 risk factors
TOD or DM
High risk High risk Very high risk
ACC Very high risk Very high risk Very high risk
May 2013 HTN management, Dr. Basil Tumaini 43

44. Management Strategy
Very high
risk
High risk Medium risk Low risk
Begin drug
treatment
Begin
drug
treatment
Monitor BP & other risk
factors for 3-6 months
Monitor BP & other
risk factors for 6-12
months
SBP ≥ 140
or
DBP ≥ 90
SBP <140
or
DBP < 90
SBP ≥ 150
or
DBP ≥ 95
SBP < 150
or
DBP < 95
Begin
drug
treatment
Continue
monitoring
Begin
drug
treatment
Continue
monitoring
May 2013 HTN management, Dr. Basil Tumaini 44

45. Follow-up 1
During evaluation and stabilisation of Rx
Should be frequent
Monitor & encourage compliance with life
style changes & drug therapy
Stress that BP management is a life-long
undertaking
May 2013 HTN management, Dr. Basil Tumaini 45

46. Follow-up 2
Contents in follow-up clinics
Measurement of BP incl. Orthostatic BP
Assessment of possible side effects, e.g.,
dizziness, sexual dysfunction, oedema,
palpitations, cough, bronchospasms
Investigations: BUN, serum creatinine,
BG, electrolytes (esp. For Pts on diuretics
& ACE inhibitors)
May 2013 HTN management, Dr. Basil Tumaini 46

47. Management of high BP in
special situations
Hypertensive crisis
Childhood HTN
HTN in pregnancy
HTN in type II DM
May 2013 HTN management, Dr. Basil Tumaini 47

48. Hypertensive crisis
Syndrome of acute severe hypertension
Hypertensive urgency: no associated TOD
Hypertensive emergency: with associated
TOD
May 2013 HTN management, Dr. Basil Tumaini 48

49. Hypertensive urgencies
Hospitalisation & careful monitoring
Aim to lower BP within 24 hrs with oral
agents
Commonly used drugs:
Captopril 25 mg repeat 4-6 hourly
Nifedipine caps (SL liquid extract) 10 mg
4-6 hourly
Others: Labetalol, Prazocin
May 2013 HTN management, Dr. Basil Tumaini 49

50. Hypertensive emergencies 1
Admit in ICU
Aim is to lower BP gradually but not
necessarily to normal levels
Rapid reductions in aortic dissection,
hypertensive encephalopathy, APO
Vasodilators are preferred agents
May 2013 HTN management, Dr. Basil Tumaini 50

51. Hypertensive emergencies 2
DRUG DOSE ONSET OF
ACTION
COMMENTS
Hydrallazine 5-10 mg IV or IM 10-20 min Drug of choice for
eclampsia
Avoid in acute
coronary syndrome
Nitroglycerin
(GT)
5-100μg/min infusion 1-3 min Drug of choice in
angina or MI
Nitroprusside 0.25-1 mg/kg/min IV 30 sec – 1 min Drug of choice for
hypertensive
encephalopathy, LVF,
aortic dissection
Labetalol 20-80mg IV bolus 5-10 min Avoid in asthma,
heart block, CCF
May 2013 HTN management, Dr. Basil Tumaini 51

52. Childhood hypertension 1
HTN def. in children is based on normal
distribution of SBP & DBP for children
of comparable age, weight and height
Use correct size of the cuff
Can be essential or secondary HTN
May 2013 HTN management, Dr. Basil Tumaini 52

53. Childhood hypertension 2
Essential HTN:10-20% of hypertensive
children<10yrs old & 35% for adolescents
Secondary HTN associated with renal &
vascular causes
E.g., coarctation of the aorta, congenital
renal malformations, PKD, renal artery
stenosis
May 2013 HTN management, Dr. Basil Tumaini 53

54. Childhood hypertension 3
Symptoms
Mild BP elevation: no specific symptoms
Severe HTN: headaches, epistaxis,
dizziness, blurred vision, nausea, mental
status changes, seizures, irritability or
lethargy
May 2013 HTN management, Dr. Basil Tumaini 54

55. Hypertension in pregnancy
Drugs preferred: Nifedipine,
Methyldopa, Hydrallazine, Labetalol
Drugs avoided: ACE inhibitors &
Angiotensin II antagonists(foetal effects);
diuretics (accentuating compromised
plasma volume)
May 2013 HTN management, Dr. Basil Tumaini 55

56. Hypertension in type 2 DM
High risk for CVD
Multiple risk factors for atherosclerosis
(HTN, obesity, hyperlipidaemia)
BP reduction aims: <130/80 mm Hg
Drugs: ACE inhibitors, Angiotensin II
antagonists, Diuretics, some ß-blockers
May 2013 HTN management, Dr. Basil Tumaini 56

57. Some drugs and dose schedules1
CATEGORY DRUG DOSE
Diuretics Bendrofluazide 2.5 – 5 mg OD
Hydrochlorothiazide 12.5-50 mg OD
Frusemide 20-320 mg OD
Spironolactone 25-100 mg OD
ß-blocker Propranolol 40-320 mg BD
Atenolol 25-100 mg OD
Labetalol 200-1200 mg QID
Calcium channel
blocker
Nifedipine 20-120 QID
Amlodipine 2.5-10 mg OD
ACE inhibitors Captopril 12.5-150 mg QID
Enalapril 2.5-40 mg OD
May 2013 HTN management, Dr. Basil Tumaini 57

58. Some drugs and dose schedules2
CATEGORY DRUG DOSE
Centrally acting Methyldopa (pregnancy) 500 mg – 3 g BD
Direct Vasodilator Hydrallazine PO 25-100 mg TDS
Hydrallazine IV/IM 5-10 mg
Angiotensin II
blocker
Lorsatan 25-50 mg OD
May 2013 HTN management, Dr. Basil Tumaini 58

59. THANKS TO YOU ALL
TIBA ELIMU
UTAFITI
May 2013 HTN management, Dr. Basil Tumaini 59

60. Reference
Association of Physicians Guidelines for the
management of hypertension in Tanzania
May 2013 HTN management, Dr. Basil Tumaini 60