2. Objectives:
After this session the participant will be able to
•To identify special groups with hypertension
•To institute appropriate management strategies for
hypertension in special groups.
2
3. Special groups
Special groups include:
- Diabetes, hypertension and chronic kidney disease.
- Pregnant women :remains a significantly high population.
- People infected with HIV/AIDs: prevalence is still
persistently high in many parts of sub-Saharan Africa.
- Elderly persons above the age of 80 years: Growing
population of elderly.
- Children under 18yrs: 40% of Africa’s population is under
15yrs.
These groups present unique opportunities and challenges
in Africa and Ethiopia in particular.
3
4. Hypertension and diabetes
•75% of people with diabetes have hypertension
(globally)
•Diabetes in a hypertensive patient is a high added risk
and an indication for referral.
•Other than treatment, intense lifestyle modification
including weight loss and salt reduction should be
instituted.
•Blood pressure goal is <140/90 but can go lower if
desirable.
•Treatment should be started when BP is above target
or patient has proteinuria.
4
5. Hypertension and diabetes (2)
•Lowering BP also exerts a protective effect on
appearance and progression of renal damage.
•Some additional protection can be obtained by use of a
blocker of the renin-angiotensin system
•Microalbuminuria should prompt the use of RAS
blockers irrespective of blood pressure.
•Treatment strategies should consider an intervention
against all CV risk factors, including a statin.
•Because of a great chance of postural hypotension, BP
should be measured in an erect position.
5
6. Hypertension in pregnancy
Hypertension complicates 5 to 7% of all
pregnancies
-Subset of preeclampsia, characterized by new-
onset hypertension, proteinuria and multisystem
involvement, is responsible for:
• Substantial maternal and fetal morbidity
• Is a marker for future cardiac and metabolic disease.
-Preeclampsia and eclampsia are hypertensive
emergencies and should be referred immediately.
6
7. Hypertension in pregnancy:
Classification
A. National high blood pressure education program
working group
- Chronic hypertension
- Preeclampsia – eclampsia
- Preeclampsia superimposed on chronic hypertension.
- Gestational hypertension.
B. 2008 Society of obstetric and gynecology of Canada
_ Preexisting hypertension
_ Gestational hypertension
add ‘with’ Eclampsia
7
8. Who are at risk for preeclampsia?
•Hypertensive disease during a previous pregnancy
•Chronic kidney disease
•Autoimmune disease [SLE, APL syndrome]
•Type 1 or type 2 diabetes
•Chronic hypertension.
Any woman with the above risks refer to high risk
ANC
8
9. Moderate risk for preeclampsia!
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
BMI of 35 kg/m² or more at first visit
Family history of pre-eclampsia
Multiple pregnancy.
9
10. Effects of chronic hypertension on
pregnancy
Premature birth (two thirds); worse with preeclampsia
Intrauterine growth retardation ( one third)
Fetal demise: 2-4 times compared to the general population
- Without preeclampsia (5 per 1,000)
- With preeclampsia (28 per 1,000)
Placental abruption
Caesarian section
- Incidence of these events depend on severity and duration of
hypertension and associated target organ damage
10
11. Effects of pregnancy on hypertension
•Increase in blood volume and decrease in oncotic
pressure-may lead to heart failure
•Physiologic decrease in blood pressure; from 12
wks, peaks at 16-18wks: masks detection of chronic
hypertension
•Progression to preeclampsia and eclampsia
•Peripartum cardiomyopathy
•Renal failure; especially if baseline creatinine >124
µmol/L (divide by 88.42 to change to mg/dl)
i.e. Cr>1.4mg/dl
11
12. Management of pregnancy with
chronic hypertension
Pre-pregnancy advice
- Stop ACE-Inhibitors, ARB’s
- Stop thiazides
- Keep sodium intake low
- Start alternative antihypertensive drugs based on
their side effect profile and teratogenicity
• Limited data on risk for the baby / mother with other drug
classes
12
13. Drugs in pregnancy
•Methyldopa – safe in pregnancy and is time tested
•Labetalol: safe in pregnancy: may lead to small for gestational age (SGA)
when used in mild hypertension
- No difference in outcomes when compared to methyldopa
- Limited experience with B-Blockers
•Calcium channel blockers: safe: limited experience
In emergency:
•IV labetalol, oral methyldopa, oral Nifedipine are indicated. Hydralazine
may be used if no options.
•IV magnesium sulphate is indicated in preeclampsia/eclampsia
•Avoid diuretics unless patient has congestive heart failure or pulmonary
edema.
•Refer patients immediately.
13
14. CASE STUDY 6
Weizero Hadas is a 36 year old housewife. She is 6 months pregnant.
During her second ANC visit, her measurements were as follows:
Weight – 80kg
Height – 160cm
BP – 150/95 mmHg
General examination: Bilateral pitting oedema
Dipstick urinalysis – protein 2+, glucose 3+
Questions:
1. What additional information would you need from Woizero Hadas?
2. How do you interpret her clinical data?
3. What additional investigations would B.W need?
4. What action would you take?
14
15. Case Study 6 Answers
1. What additional information would you need from Weizero Hadas?
Answer:
•Time of first diagnosis of hypertension if previously known
•Past use of antihypertensive medications
•Known history of diabetes, kidney disease, high cholesterol levels
•Symptoms suggestive of heart failure, coronary heart disease, previous stroke or
transient ischemic attack, or peripheral artery disease.
•Personal habits like alcohol drinking, smoking and khat use
•History of hypertension in previous pregnancies
•Use of medications like contraceptives, NSAIDs (like diclofenac, ibuprofen,
indomethacin) and herbal medications
•Family history of hypertension, diabetes, stroke or heart attack
•Past obstetric history
2. How do you interpret her clinical data?
Answer: This is stage 2 hypertension. There is proteinuria, glycosuria and bilateral
pitting oedema which may suggest preeclampsia.
What additional investigations should be done for the patient?
Answer: Blood glucose level, renal function test, serum potassium, total cholesterol
3. What actions would you take?
Answer: As this person has proteinuria and Glucosuria suggesting Preeclampsia and
possible diabetes she needs referral to hospital for further work up and
management.
16. Hypertension and HIV
HIV infection and its treatment are independently
associated with metabolic syndrome
Prolonged treatment with Antiretroviral therapy
(ART) is associated with a higher frequency of
systolic hypertension.
It is also associated with increased risk of
developing hypertension related cardiovascular
complications.
Numerous drug interactions occur as a result of
ART, with the CCB the worst affected of all the
antihypertensive agents.
16
17. Hypertension and HIV (2)
The first line ART regimen is based on Nevirapine
and Efavirenz which promotes the metabolism of
CCB.
Protease inhibitors decrease the metabolism of
CCBs.
It is therefore feasible to avoid the use of CCB in
patients on ART.
The metabolism of β-blockers are inhibited by
Protease inhibitors, the significance of this
interaction is currently of uncertain significance.
Refer all HIV patients newly diagnosed with
hypertension for evaluation.
17
19. Introduction to HTN in Children
•There is increasing evidence that adult HTN
has its antecedents during childhood.
Primary HTN during childhood often tracks
into adulthood.
•Children with BP >90th percentile are 2x at
risk of having HTN as adults.
•Nearly 50% of adults with primary HTN
had a BP >90th percentile as children
19
20. Prevalence of HTN in Children
•Prevalence of HTN in Ethiopia unknown
•About 10% of U.S. youth overall have
prehypertension
•The influence of obesity on elevated BP is
evident in children as young as 2-5 years old.
20
21. Measuring BP
•All children 3 year or older should have
their BP checked during every health care
visit
21
22. Definition of HTN in children
•The definition of HTN in adult is a functional
definition that relates level of BP elevation with
the likelihood of subsequent CV events
•The definition of HTN in children is statistical
rather than functional
•Body size is the most important determinant
of BP in children
•Classification of BP is more accurate when the
values are adjusted for height as well as age
and gender to avoid misclassifying children at
the extremes of normal growth
22
25. HTN in Children and adolescents definition
•Hypertension is defined as average SBP and/or
DBP that is ≥95th percentile for age, sex, and
height on ≥3 occasions.
•Prehypertension is defined as average SBP or
DBP ≥90th percentile but <95th percentile
•In adolescents beginning at age 12 yr ,
prehypertension is defined as BP between
120/80 mm Hg and the 95th percentile.
25
26. Severity Grading
•If BP is ≥95th percentile, then the HTN should
be staged---Stage I
•If BP b/n the 95th and 99th percentile plus 5
mm Hg---Stage II
•If BP above the 99th percentile plus 5 mm Hg---
Severe
26
27. Etiology
•Primary HTN vs Secondary HTN
•Many factors, including heredity, diet, stress,
and obesity, may play a role in the development of
primary HTN
•Secondary HTN is most common in infants and
younger children.
•The younger the child, the higher the BP and the
presence of symptoms related to HTN, the more likely
there will be an underlying secondary cause of
hypertension
27
28. Causes …
•Renal causes
•Vascular causes
•Endocrine
N.B .Secondary hypertension in children is
most commonly caused by renal
abnormalities;
28
29. Clinical feature
•Children with primary HTN are usually
asymptomatic
•In Secondary HTN unless the pressure
has been sustained or is rising rapidly,
hypertension does not usually produce
symptoms.
•clinical manifestations may instead reflect the
underlying disease process, such as growth
failure in children with CKD .
•With substantial HTN: headache, dizziness,
epistaxis, anorexia, visual changes, and seizures
may occur.
29
31. DIAGNOSIS
Once high BP confirmed ,the extent of the
evaluation for underlying causes of hypertension
depends on the type of hypertension that is
suspected.
When secondary hypertension is a strong
consideration ,an extensive evaluation may be
necessary
31
33. Management
The mainstay of therapy for children with
asymptomatic mild hypertension without
evidence of target-organ damage is
therapeutic lifestyle modification with
dietary changes and regular exercise
33
34. Indications for pharmacologic therapy
include
Symptomatic hypertension
Secondary hypertension
Hypertensive target organ damage
Diabetes mellitus
Persistent HTN despite non-
pharmacologic measures
34
36. The goal of therapy for HTN should be to
reduce BP below the 95th percentile,
except in the presence of CKD , diabetes, or
target organ damage: when the goal should
be to reduce BP to < 90th percentile.
36
