2. BP classification
BP Classification SBP mmHg* DBP mmHg
Lifestyle
Modification
Drug
Therapy**
Normal <120 and <80 Encourage No
Prehypertension 120-139 or 80-89 Yes No
Stage 1
Hypertension
140-159 or 90-99 Yes
Single
Agent
Stage 2
Hypertension
≥ 160 or ≥ 100 Yes Combo
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3. BP RECORDING
Method Brief Description
In-office
Two readings, 5 minutes apart. Sitting in chair.
Confirm elevated reading in contralateral arm.
Self-measurement
Provides information on response to therapy.
May help improve adherence to therapy and
evaluate “white-coat” HTN.
Ambulatory BP
monitoring
Indicated for evaluation of “white-coat” HTN.
Can be used to confirm self-measurement when
inconsistent with in-office measurement.
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6. 3. Malignant hypertension
Accelerated hypertension is characterized by
greatly elevated BP with evidence of vessel
damage.
Damage to optic fundus
Renal damage: haemeturia, proteinuria and
impaired renal function
Hypertensive encephalopathy: confusion,
headache, visual loss and coma.
4. White coat hypertension
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7. Regulation of BP
MAP is the average of blood pressure over a cardiac
cycle and is determined by the cardiac output
(CO), systemic vascular resistance (SVR), and central
venous pressure (CVP)):
MAP= CO × SVR
Baro receptor reflex
NO
ANP
Bradykinin,
ADH,
Endothelins-vasoconstriction-
bosentan, sitaxentan or ambrisentan.
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9. 11/14/2022
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Bradykinin is an inflammatory mediator. It is
a peptide that causes blood vessels to dilate
(enlarge), and therefore causes blood
pressure to fall.
ACE inhibitors, which are used to lower blood
pressure, increase bradykinin (by inhibiting its
degradation), further lowering blood pressure.
Bradykinin dilates blood vessels via the
release of prostacyclin, nitric oxide,
and Endothelium-Derived Hyperpolarizing
Factor.
10. Management of hypertension
Diagnosis of BP
Assessment of hypertensive patient can be
done by physical examination of patient eg
abdominal bruits, palpable kidneys.
Lab analysis
Contributory factors: salt intake, smoking,
alcohol, obesity etc
End organ damage: examination of optic fundi
to detect retinal changes, ECG analysis.
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11. BP Classification SBP mmHg* DBP mmHg
Lifestyle
Modification
Drug
Therapy**
Normal <120 and <80 Encourage No
Prehypertension 120-139 or 80-89 Yes No
Stage 1
Hypertension
140-159 or 90-99 Yes
Single
Agent
Stage 2
Hypertension
≥ 160 or ≥ 100 Yes Combo
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15. Dietary Approaches to
Stop Hypertension
Lowers systolic BP
in normotensive
patients by an
average of 3.5 mm
Hg
In hypertensive
patients by 11.4 mm
Hg
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
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18. Class Examples Major adverse
effects
Notes
Diurteics Thiazide, loops Hypokalemia,
gout, glucose
intolerance,
uremia,
dehydration
Cheap, , long term
metabolic effects,
especially for elderly and
patient that had cardiac
failure. first line therapy
β-blockers Atenelol,
propranolol,
metoprolol
Tiredness, reduced
exercise tolerance,
bradycardia,
wheezing, cardiac
failure, impotence
Cheap, effective,
adverse effects common,
first line therapy
Calcium
antagonists:
dihydroperidine
s
Nifedipine,
amolodipine
Flushing, edema,
postural
hypotension,
headache
More expensive, not well
tolerated, low incidences
of MI and stroke, used
for patient with ischemic
heart disease or
diabetes
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19. Class Examples Major adverse
effects
Notes
Calcium channel
antagonists
Veapamil,
diltiazem
Bradycardia, heart
block
Well tolerated, for
patient who cant
tolerate β
blockers. Caution
needed when
used with β
blockers
ACE inhibitors Captopril, enalpril,
lisinopril, ramipril
Cough, rash, taste
disturbance, renal
failure,
angioedema
Expensive, cough,
limit to those with
diabetes and
cardiac failure.
Angiotensin II
antagonists
Losartan ,
valsartan
irbesartan
Renal failure,
headache
More expensive,
especially for
patients in whom
ACE inhibitor
indicated is not
tolerated.
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20. Class Examples Major adverse
effects
Notes
α blockers Prazocin,
doxazocin
Edema, postural
hypotension
More expensive, adv
effects common, long
term efficacy is poor,
less effective than
thiazide in preventing
heart failure and
combined
cardiovascular out
comes. Second line
Centrally acting
vasodilators
Methyl dopa,
moxonidine
Tiredness,
depression
Poorly tolerated, used
in severe
hypertension, third
line
Direct acting vaso
dilators
Monoxidil,
nitro
prusside,
Edema, postural
hypotension ,
headache
Poorly tolerated. used
in severe
hypertension, third
line
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21. Thiazide Diuretics
• Drug of choice for last 3 decades
• Normotensive: no effect
• Mechanism: inhibit Na- /K/Cl- pumps in the distal tubule
• Examples: Hydrocholorthiazide 12.5-25 mg daily, Chlorthalidone 12.5-50 mg daily
• Reduces plasma and ECF vol.
• Compensatory mechanisms develop.
• Fall in BP is maintained by slowly developing reduction in tpr.
• BP fall happens over 4 weeks (10 mm Hg). Chronic treatment has no effect on CO or HR,
but tpr is reduced.
• No postural hypotension.
• Effective first line agent and provides synergistic benefit
• As single agent more effective (in 30% cases)
• Uses- Edema, HT, Dibetes insipedus, Hypercalciurea.
• Contra- Diabetes, Hypokalemia, Hearing loss, Hyperuricaemia.
• Not useful in low GFR pateints
22. Loop diuretics
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Furosemide: strong diuretic but weaker
antihypertensive than thiazide.
Short duration: 4-6.
The tpr is not reduced.
Electrolyte imbalance
Indicated in hypertension when thiazide are
ineffective, CHF is present, resistance in co
regime, marked fluid retention.
25. Diuretic treatment for
hypertensives
Elderly
Low renin
hypertension
Systolic BP
Obese
Renal disease with
Na+ retention
Low cost
Young active
Diabetic
Gout or family
history of gout
Abnormal lipid
profile
Pregnancy induced
hypertension
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Suitable for To be avoided
26. Beta blockers: With/without internal
sympathomimetic activity
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Mild hypertensives
Effect is maintained over 24 hrs
Nonselective (β1+ β2)
Without intrinsic sympathomimetic activity eg
propranolol, sotalol, nadolol and timolol.
Some blockers exhibit internal sympathomimetic
activity eg oxprenolol, pindolol and alprenolol.
With additional α blocking property: Labetalol
Cardioselective (β1): atenolol, metoprolol,
acebutolol
27. Effect on heart
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B1 selective
Without sympathomimetic activ
Rate, force, C.O, CHF, O2, ang
With sympathomimetic activity,
bradycardia is not seen
28. Effect on blood vessels
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B1 selective
Without sympathomimetic activity
(Re reversal of vasomotor reversal),
Increased TPR ,
With sympathomimetic activity
30. Metabolic effects
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Effect on lipid metabolism: Ppnl blocks
lipolysis
Effect on blood glucose: Ppnl inhibits
glycogenolysis, long-term induces
carbohydrate intolerance by reducing insulin
release
31. Disadvantages: prototype-Ppnl
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Can precipitate CHF
Can complicate asthma
Worsens chronic obstructive lung disease
Plasma lipid profile is altered on long term use
Carbohydrate tolerance is impaired in prediabetics
Withdrawal should be gradual
Is contraindicated in sick sinus or partial heart
block
Cold hands and feet worsening of peripheral
vascular disease
Night mares, forgetfulness and rarely
hallucinations
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Ppnl: well absorbed after oral administration,
but has low BA due to high first pass
metabolism in liver. Lipophilic and penetrates
into brain.T1/2: 3-6 hrs
Dose: 10 -160 mg BD
33. Cardioselective beta blockers
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Atenolol, metoprolol, acebutolol
More specific for β1 than β2.
Less interference with carbohydrate
metabolism,
Low incidence of cold hands and feet
No deleterious effect on blood lipid profile
Less liable to impair exercise capacity.
34. Acting on both alpha and beta
receptor
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Labetalol
There are 4 stereoisomers of labetalol each of
which has a distinct profile of action on subtypes α
and β receptors.
Agonist on β 2, antagonist on β1and α1.
It has 1/3 less potency than Ppnl for β1and 5 times
more potent in blocking β than α.
It has less agonistic activity on β1 but is β 2 agonistic
activity.
Side effect is postural hypotension.
Start with 50 mg BD
35. Alpha blockers
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egs Prazosin, Terazosin
It is a competitive antagonist of α1 receptor.
Dilates both resistance and capacitance vessels.
Initiating dose is 0.5 mg at bedtime followed by 10 mg
(max). An oral dose produces peak fall in BP after 4-5
hrs and effect lasts for 12 hr.
It improves carbohydrate metabolism
Has favorable effect on lipid profile
Helps left ventricular failure by reducing preload and
afterload.
36. Beta adrenergic blockers
Angina or post MI
Co-existing
tachycardia
Tense young patients
Non obese, high renin
hypertensive
Low cost
pregnancy
CHF
Bradycardia
Asthma
Diabetic
Abnormal lipid
profile
elderly
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Suited for To be avoided
40. Angiotensin inhibitors
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First choice in all grades of essential hypertension
20% of high BP cases has high plasma renin
ACE inhibitors: Captopril, enalapril, lisinopril etc.
They mainly act by inhibiting the peripheral
resistance.
Does not have any sympathomimetic activity.
Used in nephropathy (with or with out BP).
Captopril dose : 75-150 mg tab, T1/2: 2.2, BA:
65%.
Enalpril T1/2: 11hrs, lisinopril T1/2: 12 hr
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Severe hypotension may occur in patients with
hypovolemia,
hyperkalemia,
dry cough
rashes
Contraindicated in pregnancy due to
hypotensive effect on fetus, anuria and renal
failure.
42. Angiotensin receptor inhibitors
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Losartan and Valsartan were the first marketed
blockers of AT1 receptors.
Candesartan, eposartan, telmisartan,
irbesartan
They do not have any effect on bradykinin.
More selective for angiotensin effects than
ACEI.
Side effects similar as ACEI
Dose : losartan: 50mg/day. Peak effect at 3-6
weeks.
43. Treatment choice
High renin release
Young pateints
Diabetes
Angina and post MI
cases
CHF
gout
Renal stenosis
Pregnancy
High salt intake
With diuretic therapy
Preexisting dry
cough
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Suited for
Avoided
44. Calcium Channel blockers
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They decrease peripheral resistance.
No effect on heart.
Onset is quick.
Monotherapy is effective
Do not impair physical capacity.
No sedation or other CNS effect.
Not contraindicated in asthma, angina.
Do not affect male sexual function.
No deleterious effect on plasma lipid profile
No effect on fetus.
Tend to increase HR and CO by reflex mechanism
Nifidipine exhibits short half life therefore used for emergency
treatment
45. Vasodilators
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Hydralazine, diazoxide, minoxidil
Vasodilatation , reduces TPR, significant
decrease in diastolic BP,
Reflex rise in BP observed.
Hydralazine, Well absorbed orally, peak occurs
in 1-2 hrs. Hypotensive effect lasts for 12 hrs
46. Special patient groups
Diabetes: ACE inhibitors along with calcium
channel blockes, β blockers, α blockers and
thiazides.
Target BP < 130/80 or 125/75 < in diabetic
nephropathy.
Renal disease: ACE Inhibitors, diuretics should
not be used.
Pregnancy: Pre-eclampsia, BP above 135/85
Drugs contraindicated: diuretics, ACE Inhibitors,
Reserpine, Non Selective β Blockers: Ppnl
Safer drugs: Hydralazine, methyldopa,
dihydropyridine CCB, prazosin, clonidine,
atenolol, pindolol
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47. Treatment for hypertensive
management
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Admission to ICU
Continuous recording of BP, bodyweight and
fluid intake and output.
Parental preparations are used to lower BP
(within few hrs) followed by oral
antihypertensive therapy.
Sodium nitroprusside, nitroglycerin, labetalol,
calcium channel blockers, hydralazine.