2. HYPERTENSION CLASSIFICATION
• Optimal: Systolic lower than 120 mm Hg and diastolic lower than 80 mm Hg
• Normal: Systolic 120-129 mm Hg and/or diastolic 80-84 mm Hg
• High normal: Systolic 130-139 mm Hg and/or diastolic 85-89 mm Hg
• Grade 1: Systolic 140-159 mm Hg and/or diastolic 90-99 mm Hg
• Grade 2: Systolic 160-179 mm Hg or greater and/or diastolic 100-109 mm Hg
• Grade 3: Systolic 180 mm Hg or greater and/or diastolic 110 mm Hg or greater
• Isolated systolic hypertension: 140 mm Hg or greater and diastolic lower than 90 mm
Hg
3. TARGET BL.P.
Issuing Organization Year Population Target Blood Pressure
Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) [5]
2003
All adults except those with diabetes or chronic kidney disease
Adults with diabetes or chronic kidney disease
< 140/90 mm Hg
< 130/80 mm Hg
Eighth Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 8) [88]
2014
Adults age < 60 years and those >18 with diabetes or chronic
kidney disease
Adults age ≥60 years
< 140/90 mm Hg
< 150/90 mm Hg
European Society of Hypertension/European
Society of Cardiology (ESH/ECS) [126] 2013
All adults except those with diabetes
Adults with diabetes
140-150 mm Hg systolic; consider < 140 mm
Hg if the patient is fit and healthy; for ages
≥80 years, the patient's mental capacity and
physical heath should also be considered if
targeting to < 140 mm Hg
< 85 mm Hg diastolic BP
American Heart Association/American College of
Cardiology/American Society of Hypertension
(AHA/ACC/ASH) [130]
2015
Adults ages >80 years
Adults with CAD, except as noted below
Adults with MI, stroke, TIA, carotid artery disease, peripheral
artery disease or abdominal aortic aneurysm
< 150/90 mm Hg
< 140/90 mm Hg
< 130/80 mm Hg
American Heart Association/American College of
9. INITIAL WORKUP
• Urinalysis
• fasting blood glucose
• A1c
• hematocrit
• serum sodium
• potassium
• creatinine
• calcium
• lipid profile following a 9- to 12-hour fast (total cholesterol, high-density
lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL] cholesterol, and
triglycerides).
10. ASSESSMENT OF SUSPECTED SECONDARY CAUSES
• Other studies may be obtained on the basis of clinical findings or in individuals with
suspected secondary hypertension and/or evidence of target-organ disease, such as
complete blood count (CBC), chest radiograph, uric acid, and urine microalbumin.
11. condition Screening Test
Chronic kidney disease Estimated glomerular filtration rate
Coarctation of the aorta Computed tomography angiography
Cushing syndrome; other states of
glucocorticoid excess (eg, chronic steroid
therapy
Dexamethasone suppression test
Drug-induced/drug-related hypertension* Drug screening
Pheochromocytoma 24-hour urinary metanephrine and normetanephrine
Primary aldosteronism, other states of
mineralocorticoid excess
Plasma aldosterone to renin activity ratio (ARR). If
abnormal, refer for further evaluation such as saline
infusion to determine if aldosterone levels can be
suppressed, 24-hour urinary aldosterone level, and
specific mineralocorticoid tests
Renovascular hypertension
Doppler flow ultrasonography, magnetic resonance
angiography, computed tomography angiography
Sleep apnea
Sleep study with oxygen saturation (screening would also
include the Epworth Sleepiness Scale [ESS])
Thyroid/parathyroid disease
Thyroid stimulating hormone level, serum parathyroid
12. EVALUATION OF HYPERTENSIVE EMERGENCIES
• Electrolytes,
• blood urea nitrogen (BUN
• creatinine levels
• . A complete blood cell (CBC) count and smear help exclude microangiopathic anemia.
• Dipstick urinalysis can be used to detect hematuria or proteinuria (renal impairment),
• microscopic urinalysis can be used to detect red blood cells (RBCs) or RBC casts (renal
impairment).
• Optional studies include a toxicology screen, pregnancy test, and endocrine testing.
13. RADIOLOGIC STUDIES
• computed tomographic angiography [CTA]
• magnetic resonance angiography [MRA])
• invasive renal angiography
• Digital subtraction angiography for the evaluation of renal and pulmonary causes of
hypertension, but this modality carries the risk of dye nephropathy and atheroemboli in
patients with diabetes or chronic kidney disease.
• Echocardiography
16. • Lifestyle modifications: greater results achieved when 2 or more lifestyle modifications are
combined :
1. Weight loss helps to prevent hypertension (range of approximate systolic BP reduction
[SBP], 5-20 mm Hg per 10 kg);
2. DASH (Dietary Approaches to Stop Hypertension) diet (range of approximate SBP
reduction, 8-14 mm Hg), which is rich in fruits and vegetables and encourages the use
of fat-free or low-fat milk and milk products.
17. 3. Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium or 6 g sodium
chloride; range of approximate SBP reduction, 2-8 mm Hg)
4. Maintain adequate intake of dietary potassium (approximately 90 mmol/d)
5. Maintain adequate intake of dietary calcium and magnesium for general health
6. Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall
cardiovascular health
7. aerobic exercise at least 30 minutes daily for most days (range of approximate SBP
reduction, 4-9 mm H
19. 1. Diuretics
( Thiazide)
reabsorption of sodium and chloride mostly in the distal tubules. Long-term use of these
drugs may result in hyponatremia.
increase potassium and bicarbonate excretion and decrease calcium excretion and uric
acid retention. Thiazides do not affect normal blood pressure.
20. • Hydrochlorothiazide (Microzide) The usual dose is 12.5 mg given alone or in combination
with other antihypertensives, with a maximum dose of 50 mg daily. Doses greater than 50
mg are associated with hypokalemia.
• Chlorthalidone (Thalitone) initial dosage is 25 mg as a single daily dose
• Metolazone (Zaroxolyn) The initial dosage for hypertension is 2.5 to 5 mg given once
daily.
• Indapamide
21. 2. POTASSIUM-SPARING
• interfere with sodium reabsorption at the distal tubules (primarily in the collecting duct region
of the nephron), decreasing potassium secretion. Potassium-sparing diuretics have a weak
diuretic and antihypertensive effect when used alone.
• Triamterene dose is 100 mg twice daily (maximum dose is 300 mg/d).
• Amiloride (Midamor) dose of 5-10 mg daily in 1-2 divided doses
22. 3. LOOP DIURETICS
• act on the ascending limb of the loop of Henle, inhibiting the reabsorption of sodium and
chloride. The loop diuretics are highly protein-bound and therefore enter the urine
primarily by tubular secretion in the proximal tubule, rather than by glomerular filtration.
• Furosemide (Lasix) The initial dosing recommendations for hypertension are usually 80
mg (divided into 40 mg twice a day).
• Torsemide (Demadex) The initial dose is 5 mg once daily. The dose can be titrated to 10
mg once daily.
• BumetanideThe usual dosage range for bumetanide for hypertension is 0.5-2 mg/day
given once or twice a day. [3]
23. 4. ACEIS
• Angiotensin converting enzyme inhibitors (ACEIs) are the treatment of choice in patients with
hypertension, chronic kidney disease, and proteinuria. ACEIs reduce morbidity and mortality
rates in patients with heart failure, patients with recent myocardial infarctions, and patients
with proteinuric renal disease.
• Fosinopril Initial dose is 5 mg daily up to a maximum of 40 mg daily. May be divided into twice
daily dosing.
• Captopril The initial dose is 25 mg given 2 to 3 times daily. If reduction of blood pressure is
not achieved after 1 or 2 weeks, the dose can be titrated to 50 mg 2 or 3 times daily.
• Ramipril (Altace) the initial dosing recommendation is 2.5 mg daily for patients who are not
receiving a diuretic. Doses can range from 2.5-20 mg/day given once or twice a day.
• Enalapril (Vasotec) The initial dose of enalapril is 5 mg daily. Dosage can range from 10-40
mg/day administered as a single dose or in 2 divided doses
• Lisinopril (Prinivil, Zestril) the initial dose of lisinopril is 10 mg daily. The dosage can range from
20-40 mg/day as a single daily dose.
• Quinapril (Accupril) The initial dose is 10 to 20 mg daily
24. 5. ARBS
• Angiotensin II receptor antagonists or angiotensin receptor blockers (ARBs) are used for
patients who are unable to tolerate ACE inhibitors.
• Losartan (Cozaar) The initial dose is 50 mg daily; however, in patients on diuretic therapy,
the initial dose is 25 mg daily.
• Valsartan (Diovan) The initial dose is 80 or 160 mg once daily when used as monotherapy
in patients who are not volume depleted. The valsartan dose may be increased (maximum
320 mg/day),
• Olmesartan (Benicar) The initial dose is 20 mg daily when used as monotherapy. The dose
may be titrated to 40 mg daily if greater effect is desired.
• Eprosartan (Teveten) The initial dose is 600 mg once daily when used as monotherapy
• Azilsartan (Edarbi) he usual dose is 80 mg once daily. Consider starting with an initial dose
of 40 mg once daily in patients receiving high-dose diuretics.
25. 6. BETA-BLOCKERS, BETA-1 SELECTIVE
• Beta-blockers are generally not recommended as first-line agents for the treatment of
hypertension; however, they are suitable alternatives when a compelling cardiac indication
(eg, heart failure, myocardial infarction, diabetes) is present. Selective beta-blockers
specifically block beta-1 receptors alone, although they can be nonselective at higher
doses.
• Caution should be used in administering these agents in the setting of asthma or severe
chronic obstructive pulmonary disease (COPD), regardless of beta-selectivity profile. In
addition, exacerbations of angina and, in some cases, myocardial infarction have been
reported following abrupt discontinuance of beta-blocker therapy. The doses should be
gradually reduced over at least a few weeks.
26. • Atenolol (Tenormin) The initial dose is 50 mg daily, alone or added to diuretic therapy. If
adequate clinical effect is not seen, the dose can be titrated to 100 mg daily.
• Metoprolol (Lopressor, Toprol XL) The initial dose for metoprolol immediate release is 100
mg daily in single or divided doses, with or without a diuretic (maximum 450 mg/day).
• Propranolol (Inderal LAThe initial dose is 40 mg given twice daily, alone or added to
diuretic therapy. Dose can be titrated based on a patient's clinical response. The
maintenance dose can range from 120-240 mg/day (maximum 640 mg/day).
• Bisoprolol (Zebeta) The initial dose is 5 mg once daily (reduce to 2.5 mg for patients with
bronchospastic disease). The dosage can be titrated to 10 mg/day and then to 20 mg/day
if necessary.
• TimololThe initial dose is 10 mg given twice daily. The total daily dose can be titrated to a
maximum of 30 mg administered in divided doses
27. 7. BETA-BLOCKERS, ALPHA ACTIVITY
• have peripheral vasodilatory effects that act via antagonism of the alpha-1 receptor in
addition to beta-receptors.
• Labetalol (Trandate) The initial dose is 100 mg given twice daily. The dose may be titrated
after 2-3 days in increments of 100 mg twice a day every 2-3 days (maximum 2400
mg/day).
• Carvedilol (Coreg, Coreg CR) The initial dose is 6.25 mg given twice daily. The dose can be
titrated at intervals of 7-14 days to 12.5 mg twice daily, then to 25 mg twice daily as
needed (maximum 50 mg/day).
28. 8. BETA-BLOCKERS, INTRINSIC
SYMPATHOMIMETIC
• Acebutolol (Sectral) Initial dose in uncomplicated, mild to moderate hypertension
is 400 mg daily, or twice-daily dosing may be required for adequate 24-hour
blood pressure control. Optimal response is usually achieved with dosages of 400
to 800 mg/day; however, some patients have been maintained on as little as 200
mg/day.
• PindololThe initial dose is 5 mg twice daily alone or in combination with other
antihypertensive agents.
29. 9. VASODILATORS
• HydralazineInitial dose is 10 mg given 4 times daily for the first 2 to 4 days, then
25 mg 4 times a day for 1 week.
• MinoxidilMinoxidil is indicated in severe hypertension that is symptomatic or
associated with end-organ damage and is not manageable with maximum
therapeutic doses of a diuretic plus 2 other antihypertensives. The initial dose is 5
mg/day as a single dose and can be titrated to 10, 20, and then 40 mg in single or
divided doses as needed (maximum 100 mg/day).
30. 10.CALCIUM CHANNEL BLOCKERS
• Nifedipine (AdalatThe usual dose for nifedipine is 30-60 mg once daily (maximum 90
mg/day); when used for hypertension, nifedipine can be administered to a maximum of
120 mg/day.
• Clevidipine (Cleviprex)
• Amlodipine (Norvasc
• Felodipine (Plendil)
• Diltiazem
• Verapamil
34. 15- OTHER
• Reserpine depleting sympathetic biogenic amines. decrease in peripheral
vascular resistance and a lowering of blood pressure often associated with
bradycardia.
36. SURGICAL INTERVENTION
• renal artery angioplasty with stenting.
• Surgical resection is the treatment of choice for pheochromocytoma and for patients with
a unilateral solitary aldosterone-producing adenoma,
37. This Photo by Unknown Author is licensed under CC BY-NC-ND
