Approach to hypertension

1. APPROACH TO
HYPERTENSION

2. Definition
The 2017
ACC–AHA
Hypertension
Guideline
Systolic blood pressure of 130 mm Hg or more
Diastolic blood pressure of 80 mm Hg or more
blood-pressure target to less than 130/80 mm Hg.
Isolated systolic hypertension is defined as a blood pressure ≥130 mmHg systolic and <80 mmHg
diastolic, and
Isolated diastolic hypertension is defined as a blood pressure <130 mmHg systolic and ≥80
mmHg diastolic.

3. Global Cardiovascular disease crisis
Hypertension an important risk factor for
myocardial infarction (MI), heart failure (HF),
stroke, and cardiovascular disease (CVD),
accounting for 41% of all CVD deaths.

6. 0
10
20
30
40
50
60
70
80
90
100
0
50
100
150
200
250
Cumulative
%
Number
of
people
(millions)
India – More People with HTN than Any Other
Country
WHO. Global Status Report on noncommunicable diseases 2014.
Top 30 countries, world, 2014

8. Classification of Hypertension

10. Causes of Hypertension
Types Of Hypertension
Primary/Essential HTN Secondary HTN

11. Primary Hypertension
• Formerly called "essential"
hypertension
• result of numerous genetic
and environmental factors
Risk Factors for Primary Hypertension
• Obesity
• High alcohol intake
• High salt intake - >3 g/day [sodium chloride]
• Age
• Sedentary lifestyle
• Family History
• Twice as common in subjects who have
one or two hypertensive parents

12. SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION
• Prescription or over-the-counter medications
• Oral contraceptives, particularly those containing higher doses of estrogen
• Nonsteroidal antiinflammatory agents (NSAIDs), particularly chronic
• Antidepressants, including tricyclic antidepressants, selective serotonin reuptake inhibitors, and monoamine oxidase
inhibitors
• Corticosteroids, including both glucocorticoids and mineralocorticoids
• Decongestants, such as phenylephrine and pseudoephedrine
• Erythropoietin
• Atypical antipsychotics, including clozapine and olanzapine
• Angiogenesis inhibitors, such as bevacizumab
• Tyrosine kinase inhibitors, such as sunitinib and sorafenib
• Primary kidney disease – Both acute and chronic kidney disease
• Primary aldosteronism – mineralocorticoid excess, primarily aldosterone, should be suspected in any patient
with the triad of hypertension, unexplained hypokalemia, and metabolic alkalosis.
• Renovascular hypertension – Renovascular hypertension is often due to fibromuscular dysplasia in younger
patients and to atherosclerosis in older patients.
• Obstructive sleep apnea
• Pheochromocytoma – rare cause - patients paroxysmal hypertension
• Cushing's syndrome

13. BLOOD PRESSURE
MEASUREMENT

15. Office-based blood pressure measurement
• Checklist for
accurate
measurement of
blood pressure
Step 1:
Properly
prepare the
patient
1.Have the patient relax, sitting in a chair (feet on floor, back
supported) for >5 minutes.
2.The patient should avoid caffeine, exercise, and smoking for at
least 30 minutes before measurement.
3.Ensure patient has emptied their bladder.
4.Neither the patient nor the observer should talk during the rest
period or during the measurement.
5.Remove all clothing covering the location of cuff placement.
6.Measurements made while the patient is sitting or lying on an
examining table do not fulfill these criteria.

16. Step 2: Use proper technique for BP
measurements
Use a BP
measurement
device that has
been validated,
and ensure that
the device is
calibrated
periodically.*
Support the
patient's arm
(eg, resting on a
desk).
Position the
middle of the
cuff on the
patient's upper
arm at the level
of the right
atrium (the
midpoint of the
sternum).
Use the correct
cuff size, such
that the bladder
encircles 80% of
the arm, and
note if a larger-
or smaller-than-
normal cuff size
is used.
Either the
stethoscope
diaphragm or
bell may be
used for
auscultatory
readings.

17. Step 3: Take the proper measurements
At the first visit, record BP in both arms. Use the arm that gives the higher reading for subsequent
readings.
Separate repeated measurements by 1 to 2 minutes.
For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to estimate
SBP. Inflate the cuff 20 to 30 mmHg above this level for an auscultatory determination of the BP level.
For auscultatory readings, deflate the cuff pressure 2 mmHg per second, and listen for Korotkoff sounds.
1.Use an average of ≥2 readings obtained on ≥2 occasions to estimate the individual's level of BP.

18. Ambulatory blood pressure monitoring
Preferred method for confirming the diagnosis of
hypertension and white coat hypertension
ABPM records the blood pressure at preset intervals (usually
every 15 to 20 minutes during the day and every 30 to 60
minutes during sleep).
Only method of blood pressure measurement that can
reliably obtain nocturnal readings.
ABPM should be considered in the following circumstances:
●Suspected episodic hypertension (eg, pheochromocytoma)
●Determining therapeutic response (ie, blood pressure control)
in patients who are known to have a substantial white coat
effect)
●Hypotensive symptoms while taking antihypertensive
medications
●Resistant hypertension
●Autonomic dysfunction
●Suspected masked hypertension

19. Complications of
Hypertension

20. Target
organ
Damage

21. Evaluation of hypertension
• The extent of target-organ damage, if any
• The presence of established cardiovascular or kidney disease
• The presence or absence of other cardiovascular risk factors
• Lifestyle factors that could potentially contribute to hypertension
• Potential interfering substances (eg, chronic use of NSAIDs, oral contraceptives)

22. Laboratory tests for primary hypertension

23. Important aspects of the physical examination
in the hypertensive patient

24. Nonpharmacologic interventions for treatment of
hypertension
Nonpharmacologic
intervention
Dose Approximate impact Reference
Weight loss • Best goal - ideal body
weight
• aim for at least a 1 kg
reduction in weight for
adults who are
overweight.
Expect about 0.5 to 1
mmHg for every 1 kg
reduction in weight.
-5 mmHg
Stevens VJ et al. Weight loss
intervention in phase 1 of the
Trials of Hypertension
Prevention. The TOHP
Collaborative Research Group.
Arch Intern Med. 1993.
Dietary salt restriction Optimal goal is <1500
mg/day
-5 to -6 mmHg He FJ, et al. Effect of longer term
modest salt reduction on blood
pressure: Cochrane systematic review
and meta-analysis of randomised
trials. BMJ. 2013 Apr.
Moderation in alcohol
intake
Men: ≤2 drinks daily.
Women: ≤1 drink
daily.
-4 mmHg Forman JP et al.Diet and
lifestyle risk factors associated
with incident hypertension in
women. JAMA. 2009 Jul.

25. Nonpharmacologic interventions for treatment of
hypertension
Nonpharmacologic
intervention
Dose Approximate
impact
Reference
DASH diet – The
Dietary Approaches
to Stop Hypertension
• Consume a diet rich in fruits,
vegetables, whole grains, and low-fat
dairy products, with reduced content
of saturated and total fat
-11 mmHg
Physical activity • Aerobic – atleast 90 min/week
• Dynamic resistance - 90 to 150
minutes/week. 6 exercises, 3
sets/exercise, 10 repetitions/set.
-5 to -8 mmHg
Whelton PK,et al
ACC/AHAGuideline for the
Prevention, Management of
High Blood Pressure in Adults:
2018 Jun
Potassium
supplementation
• Aim for 3500 to 5000 mg/day –
preferably dietry, Contraindicated in
CKD
-4 mmHg Whelton PK,et al
ACC/AHAGuideline for the
Prevention, Management of
High Blood Pressure in Adults:
2018 Jun

26. Pharmacotherapy

32. Followup

33. Considerations for individualizing
antihypertensive therapy

35. • A 56-year-old woman presents for elevated blood pressure, which was noted at a job-site
screening. She has gained 9.1 kg during the past 5 years and takes naproxen
sodium (at a dose of 250 mg daily) for joint pain. She has never smoked, and she
consumes one or two alcoholic drinks daily. Both of her parents received a diagnosis
of hypertension in their 50s. On examination, the blood pressure is 162/94 mm Hg
in both arms while the patient is seated and 150/96 mm Hg while the patient is standing. The body-mass index
(the weight in kilograms divided by the square of the
height in meters) is 29. Her examination is notable only for abdominal obesity without
bruits or masses. The serum level of sodium is 138 meq per liter, potassium 3.8 meq
per liter, calcium 9.4 mg per deciliter (2.35 mmol per liter), fasting glucose 105 mg
per deciliter (5.8 mmol per liter), and creatinine 0.8 mg per deciliter (71 μmol per liter).
Urinalysis is negative. How would you further evaluate and treat this patient?

36. • initiate single-agent therapy for her stage 2 hypertension and encourage lifestyle changes
• sodium restriction, weight reduction,and discontinuation of contributing medications
• attention to the lipid profile and glucose level is also warranted
• follow-up blood-pressure and electrolyte measurements in 3 to 4 weeks
• Dose increases and additional medications may be needed
• regular visits during dose adjustment, combined with home blood-pressure measurement
• Once her blood pressure is at goal (<130/80 mm Hg), I would recommend follow-up at 3-month
interval

37. • Thank you