6. SBP ≥140 mmHg
with DBP <90
mmHg
Common after 50
years old
non-pharmacological and aim for adoption of
healthy living.
Isolated Systolic Hypertension
Isolated Office
(White Coat)
Hypertension
Masked
Hypertensio
n
Elevated Clinic BP Normal
Normal Home
BP
Elevated
8. History
Duration and level of elevated BP
if known
Symptoms of
Secondary causes of hypertension
Target organ complications
Risk factor
Dietary history
Drug history (OTC / traditional
/complementary medicine
Lifestyle factors
9. Physical examination
General examination including
height, weight and waist
circumference
Measure BP appropriately
Fundus examination
Examination for carotid bruit,
abdominal bruit, presence of
peripheral pulses and radio-
femoral delay
CVS:cardiomegaly, signs of
heart failure and aortic
regurgitation
P/A: renal masses/bruit and
aortic aneurysm
CNS: stroke
Signs of endocrine disorders
(e.g. Cushing syndrome,
acromegaly and thyroid
disease)
10. Investigation
Full blood count
Blood glucose
Renal function tests
(creatinine, eGFR, serum
electrolytes)
Lipid profile (total
cholesterol, HDL
cholesterol, LDL cholesterol
and triglycerides)
Urinalysis (dip stick:
albuminuria/microalbuminuri
a & microscopic
haematuria)
Electrocardiogram (ECG)
Chest x ray
16. Pharmacological therapy
At risk hypertension
that failed non-
pharmalogical
method
Medium/high CV
risk
SBP >160 and/or
DBP >100 mmHg
Start monotheraphy for
stage1
Combination therapy
for stage 2 and above /
Stage 1 with medium
risk
If ineffective, consider
increasing dose /add
another /substitute
drug
Measure the BP at the
same time each day.
WHEN TO TREAT : GUIDELINES
17. 1) A or C or D
2) If target not reached,
A+C or A +D
3) If target not reached,
A+C+D
ACE inhibitor or ARB
Calcium-channel
blocker
thiazide Diuretic
STARTING
REGIMENS
Group Target BP
<80 y/o <140/90
>80 y/o <150/90
High risk <130/80
18. 3-6 monthly stage I (mild)
hypertension with low
global CV risk
BP well-controlled for
>1 year on the same
medication at the same
dosage
Agree to be followed-up
at least 3-6 monthly
motivated to adopt
healthy living
Follow up Step down therapy
25. Hypertensive
Urgency
Severe increase in
BP which is not
associated with
acute end organ
damage/complicatio
n
damage/complicatio
n
Aka accelerated
/malignant
hypertension
26.
27. Hypertensive Emergency
Severe elevation of blood pressure associated
with new or progressive end organ
damage/complication
Eg. acute heart failure, dissecting aneurysm,
acute coronary syndromes, hypertensive
encephalopathy, acute renal failure,
subarachnoid haemorrhage and/or intracranial
haemorrhage
28.
29. Pg 1.26 sarawak
Drug
s
Dose Remarks
Labetolol
20 mg injected slowly for at least 2 min; followed by 40-80 mg every
10 min.
Max: 200 mg
Caution in heart
failure.
Nitroglycerin
e
Initial: 5-25 mcg/min.
Usual range: 10-200 mcg/ min; up to 400 mcg/min
in some cases.
Preferred in ACS and
acute pulmonary oedema.
Isoke
t
IV infusion 2-20 mg/hr, titrate based on target BP. Preferred in ACS
Hydralazin
e
Initial: 5-10 mg via slow inj, may repeat after 20-30 min.
Alternatively, as a continuous infusion, initial
dose of 0.2-0.3 mg/min.
Maintenance: 0.05-0.15 mg/min.
Caution in ACS, CVA and dissecting
aneurysm.
Unpredictable BP-lowering effects.
Nicardipin
e
Slow IVI at an initial rate of 5 mg/hr. Increase infusion rate as
necessary, up to max 15 mg/hr.
Consider reducing to 3 mg/hr
after response is achieved.
Caution in acute heart failure and
coronary ischaemia.
Esmolol
Loading dose of 80 mg over 15-30 sec, followed by an infusion of
150 mcg/kg/min, may increase to 300 mcg/kg/min if necessary.
Used in perioperative situations and
tachyarrhythmias.
Sodium
Nitroprusside
Initial: 0.3-1.5 mcg/kg/min, adjust gradually
as needed. Usual: 0.5-6 mcg/kg/min. Max rate: 8 mcg/kg/min,
discontinue if there is no response after 10 mins. May continue for a
few hr if there is response.
Caution in heart failure.
Require intraarterial blood pressure
monitoring. Lower dosing adjustmen
required for elderly and those alread
receiving antihypertensives.
34. Hypertension in Elderly
Respond to non-
pharmacological treatment
Drug dosage—Monotherapy
‘start low and go slow’
Treat when SBP>160
Age Target SBP
>80 <150
65- 80 <140
35. BP > 140/90mmHg
despite good medication
adherence while on
three or four anti-
hypertensive agents in
adequate doses.
Exclude secondary
causes
Spirinolactone is the
preferred 4th drug
BP are not
controlled after ≥5
antihypertensives
Beta blocker/ alpha
blocker or centrally
acting
Resistant Hypertension Refractory Hypertension
39. Reference
Clinical Practical Guideline, Management of
Hypertension, 5th edition, 2018
Eighth Joint National Committee Guidelines for
Management of Hypertension , 2014
Editor's Notes
33.6% in 2011 to 35.3% in 2015
2diag:3 undiag
More in rural, males.
Higher chance of mi, g\heart failure, stroke,kidney dis
Sbp rises through age, dbp after 50 years old
). Prognosis of masked hypertension is worse than isolated office hypertension.12
To exclude secondary causes of hypertension/presence of target organ damage or complication/assess lifestyle and identify other cardiovascular risk factors coexisting condition that affect prognosis and guide treatment
1kg =1 SBP, alc: 5-10mmHg
<5g salt or 2g K =8sbp/3dbp
150min of moderate aerobic exercise
When to choose : health , side effect, admin, cost, disorder
Stage 1 start monotherapy
S2, combination therapy
To refer when severe/ resistanr/ secondary/ onset TOD
side effects of the centrally acting agents include
drowsiness, dry mouth, headache, dizziness and mood change.
Rebound hypertension in clonidine
Reduce SBP to less than 140 mmHg during the first hour for patients with severe preeclampsia or eclampsia, and pheochromocytoma crisis. For patients with aortic dissection reduce SBP to less than 120 mmHg.
Labetolo n nicardipine is preferred, easy titrate n minimal vasodilation on cerebral perfusion
Within day to week after stroke,decrease in bp occur
Compliance, proper measurement, not white coat, combo drug ( ARS, CCB, diuretic), not on OCP, steroid tht may antagonisee antiHPT
Candidate for intervention/procedure based
