A detailed presentation on hypertension and its management

1. SAFA JEHANGIR KHAMISA
MANAGEMENT OF HYPERTENSION
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2. Course Outline
Lesson 1. Introduction
Lesson 2. Diagnosis
Lesson 3. Types of Hypertension
Lesson 4. Complications
Lesson 5. Treatment
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3. 3
Introduction to Hypertension: Hypertension, or high blood pressure, is a condition in
which the force of blood against the walls of the arteries is too high. It can lead to serious health
problems, such as heart disease and stroke if left untreated.
Symptoms
• Headaches
• Shortness of breath
• Nosebleeds
Causes
◦ Smoking
◦ Being overweight or obese
◦ Lack of physical activity
Risk Factors
Age
Family history
Obesity
Physical Inactivity

4. 4
Types of Hypertension
Essential hypertension
95%
No underlying cause
Secondary hypertension
Underlying cause

5. 5
Causes of Secondary Hypertension
• Renal
– Parenchymal
– Vascular
– Others
• Endocrine
• Miscellaneous
• Unknown

6. TEACH A COURSE 6
Diseases Attributable to Hypertension
HYPERTENSION
Gangrene of the
Lower Extremities
Heart
Failure
Left Ventricular
Hypertrophy Myocardial
Infarction
Coronary Heart
Disease
Aortic
Aneurysm
Blindness
Chronic
Kidney Failure Stroke Preeclampsia/
Eclampsia
Cerebral
Hemorrhage
Hypertensive
encephalopathy

7. TEACH A COURSE 7
Who are at risk ?
• Advancing Age
• Sex (men and postmenopausal women)
• Family history of cardiovascular disease
• Sedentary lifestyle & psycho-social stress
• Smoking, High cholesterol diet, Low fruit consumption
• Obesity
• Co-existing disorders such as diabetes, and hyperlipidemia
• High intake of alcohol

8. 8
SO, WHAT DOES A
PATIENT FEEL?

9. TEACH A COURSE 9
Clinical Manifestation
• No specific complains or manifestations other than elevated systolic and/or diastolic
BP (Silent Killer )
• Morning occipital headache
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision

10. Diagnosing Hypertension Based on AHA Guidelines
Measuring
Blood
Pressure
• Measure blood pressure in a quiet, private room. The
patient should sit supported, feet flat, and arm at heart
level.
• Choose the correct cuff size for accuracy.
• Take two readings at a one-minute interval and average
them for diagnosis.
• ABPM is necessary for diagnosing hypertension along
with clinical blood pressure measurements. Meeting these
criteria using ABPM confirms hypertension.
• A 24-hour mean of ≥125 mmHg systolic or ≥75 mmHg
diastolic
• Daytime (awake) mean of ≥130 mmHg systolic or ≥80
mmHg diastolic
• Nighttime (asleep) mean of ≥110 mmHg systolic or ≥65
mmHg diastolic
Diagnosis
• If the average of the two readings is:
• Less than 120/80 mm Hg: Normal blood pressure
• Systolic between 120 and 129 mm Hg and diastolic below 80
mm Hg: Elevated blood pressure
• Between 130/80 mm Hg and 139/89 mm Hg: Stage 1
hypertension
• 140/90 mm Hg or higher: Stage 2 hypertension
• A diagnosis can be made, without further confirmatory
readings, when a patient presents with hypertensive urgency or
emergency.
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11. TEACH A COURSE 11
CLASSIFICATION

12. 12
White Coat vs Masked Hypertension
White coat hypertension — White coat hypertension is defined as
blood pressure that is consistently elevated by office readings but
does not meet diagnostic criteria for hypertension based upon out-
of-office readings.
Masked hypertension — Masked hypertension is defined as blood
pressure that is consistently elevated by out-of-office measurements
but does not meet the criteria for hypertension based upon office
readings.

13. 13
EVALUATION
History — The history should search
for those facts that help to determine
the presence of aggravating factors
(including prescription medications,
nonprescription NSAIDs, and alcohol
consumption), the duration of
hypertension, previous attempts at
treatment, the extent of target-organ
damage, and the presence of other
known risk factors for cardiovascular
disease.
Physical examination — The main
goals of the physical examination are
to evaluate for signs of end-organ
damage, for established
cardiovascular disease, and for
evidence of potential causes of
secondary hypertension. The physical
examination should include the
underutilized but important
funduscopic examination to evaluate
for hypertensive retinopathy.
Laboratory testing

14. 14
Laboratory Testing
 Electrolytes (including calcium) and serum creatinine (to calculate the estimated glomerular filtration rate)
 Fasting glucose
 Urinalysis
 Complete blood count
 Thyroid-stimulating hormone
 Llipid profile
 Electrocardiogram
 Calculate 10-year atherosclerotic cardiovascular disease risk
Additional tests — Additional tests may be indicated in certain settings:
●Urinary albumin to creatinine ratio. Increased albuminuria is recognized as an independent risk factor for cardiovascular disease; it should be
performed in all patients with diabetes or chronic kidney disease.
●Echocardiography is a more sensitive means of identifying the presence of left ventricular hypertrophy (LVH)

15. HOW
TO
TREAT
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16. Treatment overview
GOALS OF
THERAPY
LIFESTYLE
MODIFICATION
PHARMACOLOGICAL
TREATMENT
16
ALGORITHM FOR
TREATMENT
FOLLOW UP AND
MONITORING

17. 17
Blood pressure goals (targets) — The ultimate goal of
antihypertensive therapy is a reduction in cardiovascular events

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Lifestyle Modification
Weight Loss
Limited alcohol intake
Potassium supplementation: preferably by
dietary modification, unless contraindicated by
the presence of chronic kidney disease or the
use of drugs that reduce potassium excretion.
Exercise
Dietary salt restriction
DASH Diet*
*The DASH dietary pattern
is consequently rich in
potassium, magnesium,
calcium, protein, and fiber
but low in saturated fat,
total fat, and cholesterol

19. TEACH A COURSE 19
MODIFICATION APPROXIMATE SBP REDUCTION (Range)
Weight reduction 5–20 mmHg / 10 kg weight loss
Adopt DASH eating plan 8–14 mmHg
Physical activity 4–9 mmHg
Dietary sodium reduction 2–8 mmHg
Moderation of alcohol
consumption
2–4 mmHg

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Drug Therapy
Class of drug Example Initiating dose Usual Maintenance Dose
Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.
-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.
Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.
channel
blockers
-blockers prazosin 2.5 mg o.d 2.5-10mg o.d.
ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.
Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.
receptor blockers

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Beta Blockers
Example: Atenolol, Metoprolol, nebivolol
1. Block 1 receptors on the heart
2. Block 2 receptors on kidney and inhibit release of renin
3. Decrease rate and force of contraction and thus reduce cardiac output
4. Drugs of choice in patients with co-existent coronary heart disease
Side effects:
1. lethargy, impotency, bradycardia
2. Not safe in patients with co-existing asthma and diabetes
3. Have an adverse effect on the lipid profile

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Calcium Channel Blockers
Example: Amlodipine
1. Block entry of calcium through calcium channels
2. Cause vasodilation and reduce peripheral resistance
3. Drugs of choice in elderly hypertensives and those with co-existing asthma
4. Neutral effect on glucose and lipid levels
Side effects
1. Flushing
2. Headache
3. Pedal edema

24. 24
ACE Inhibitors
Example: Ramipril, Lisinopril, Enalapril
•Inhibit ACE and formation of angiotensin II and block its effects
•Drugs of choice in co-existent diabetes mellitus, Heart failure
Side effects:
•Dry cough
•Hypotension
•Angioedema

25. TEACH A COURSE 25
Angiotensin II Receptor Blockers
Example: Losartan
•Block the angiotensin II receptor and inhibit effects of angiotensin II
•Drugs of choice in patients with co-existing diabetes mellitus
Side effect:
•Hypotension

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Diuretics
Example: Hydrochlorothiazide
1. Acts by decreasing blood volume and cardiac output
2. Decrease peripheral resistance during chronic therapy
3. Drugs of choice in elderly hypertensives
Side effects:
1. Hypokalemia
2. Hyponatremia
3. Hyperlipidemia
4. Hyperuricemia (hence contraindicated in gout)
5. Hyperglycemia (hence not safe in diabetes)
6. Not safe in renal and hepatic insufficiency

27. TEACH A COURSE 27
Alpha Blockers
Example: prazosin
• Block -1 receptors and cause vasodilation
• Reduce peripheral resistance and venous return
• Exert beneficial effects on lipids and insulin sensitivity
• Drugs of choice in patients with co-existing BPH
Side effect:
Postural hypotension

28. Algorithm for
Treatment
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29. 29
When there is no compelling reason we initiate therapy with
these four classes of antihypertensives:
• Thiazide-like diuretics
• Long-acting calcium channel blockers (most often a dihydropyridine such
as amlodipine)
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin II receptor blockers (ARBs)

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Considerations for
individualizing
antihypertensive
therapy
Indication or contraindication Antihypertensive drugs
Compelling indications (major improvement in outcome independent of blood pressure)
Heart failure with reduced ejection
fraction
ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist*
Post myocardial infarction ACE inhibitor or ARB, beta blocker, aldosterone antagonist
Proteinuric chronic kidney disease ACE inhibitor or ARB
Angina pectoris Beta blocker, calcium channel blocker
Atrial fibrillation rate control Beta blocker, nondihydropyridine calcium channel blocker
Atrial flutter rate control Beta blocker, nondihydropyridine calcium channel blocker
Likely to have a favorable effect on symptoms in comorbid conditions
Benign prostatic hyperplasia Alpha blocker
Essential tremor Beta blocker (noncardioselective)
Hyperthyroidism Beta blocker
Migraine Beta blocker, calcium channel blocker
Osteoporosis Thiazide diuretic
Raynaud phenomenon Dihydropyridine calcium channel blocker
Contraindications
Angioedema Do not use an ACE inhibitor
Bronchospastic disease Do not use a non-selective beta blocker
Liver disease Do not use methyldopa
Pregnancy (or at risk for) Do not use an ACE inhibitor, ARB, or renin inhibitor (e.g., aliskiren)
Second- or third-degree heart block
Do not use a beta blocker, nondihydropyridine calcium channel blocker unless a
functioning ventricular pacemaker
Drug classes that may have adverse effects on comorbid conditions
Depression Generally avoid beta blocker, central alpha-2 agonist
Gout Generally avoid loop or thiazide diuretic
Hyperkalemia Generally avoid aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor
Hyponatremia Generally avoid thiazide diuretic
Renovascular disease Generally avoid ACE inhibitor, ARB, or renin inhibitor

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CHOICE OF DRUG

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Combination Therapy - Single-agent therapy will not adequately control blood pressure in most
patients whose baseline systolic blood pressure is 15 mmHg or more above their goal.
Combination therapy with drugs from different classes has a
substantially greater blood pressure-lowering effect than
doubling the dose of a single agent, often with a reduction in
side effects seen with a higher dose of monotherapy.
Long-acting ACE inhibitor or ARB + a long-acting
dihydropyridine calcium channel blocker.
OR
an ACE inhibitor or ARB + thiazide diuretic can also be used but
may be less beneficial when hydrochlorothiazide is used.
ACE inhibitors and ARBs should not be used together.

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If blood pressure remains high despite use of two
antihypertensive medications:
Use ACE inhibitor or ARB in
conjunction with both a
long-acting
dihydropyridine calcium
channel blocker and a
thiazide-like diuretic
(chlorthalidone preferred).
*If a long-acting
dihydropyridine calcium
channel blocker is not
tolerated due to leg
swelling, a non-
dihydropyridine calcium
channel blocker (i.e.,
verapamil or diltiazem) may
be used instead.
*If a thiazide-like diuretic is
not tolerated or is
contraindicated, a
mineralocorticoid receptor
antagonist (i.e.,
spironolactone or
eplerenone) may be used.
If the above drug classes
cannot be used due to
intolerance or
contraindication, a beta
blocker, alpha blocker, or
direct arterial vasodilators
present other options.
Generally, concomitant use
of beta blockers and non-
dihydropyridine calcium
channel blockers should be
avoided.
Patients not controlled on a
combination of three
antihypertensive
medications that are taken
at reasonable doses and
that include a diuretic are
considered to have drug-
resistant hypertension
(once nonadherence and
white coat effect have been
eliminated as possibilities).

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Resistant Hypertension
Many patients who appear to have resistant hypertension actually have pseudo resistance rather than true resistance. Pseudo resistance results
from some or all of the following problems:
Inaccurate blood pressure measurement (e.g., use of an inappropriately small blood pressure cuff, not allowing a patient to rest quietly before taking
readings)
Poor adherence to blood pressure medications
Poor adherence to lifestyle and dietary approaches to lower blood pressure
Suboptimal antihypertensive therapy, due either to inadequate doses, an inappropriate drug combination, or exclusion of a diuretic from the
antihypertensive regimen
White coat hypertension
One or more of the following issues may contribute to true resistant hypertension:
Extracellular volume expansion
Increased sympathetic activation
Ingestion of substances that can elevate the blood pressure, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or stimulants
Secondary or contributing causes of hypertension

35. TEACH A COURSE 35
Urgency vs. Emergency
Hypertensive Urgency
Blood pressure reading of 180/110 or higher without signs of organ damage.
Hypertensive urgency is a condition in which blood pressure is
severely elevated, but there are no signs of organ damage.
Symptoms may include severe headache, shortness of breath,
or nosebleeds. Treatment typically involves the use of
medications to lower blood pressure over a period of hours to
days.
Hypertensive Emergency
Blood pressure reading of 180/120 or higher with signs of organ damage.
Hypertensive emergency is a condition in which blood pressure
is severely elevated and there are signs of end-organ damage.
Symptoms may include chest pain, shortness of breath,
seizures, or confusion. Treatment typically involves the use of
medications to lower blood pressure immediately, often in an
intensive care setting.
Prevention and Management
The best way to prevent hypertensive urgency
and emergency is to manage blood pressure.
For those with a history of high blood pressure,
it is important to monitor blood pressure
regularly and seek medical attention if readings
are consistently high.

36. Q) Lifestyle intervention for management of hypertension
includes all except:
a) Regular aerobic activity 30 min /day
b) Salt intake to <6 gm./day
c) Attain and maintaining BMI >25k/m2
d) Diets rich in fruits and vegetables and restricted content of
saturated fats
e) Moderation of alcohol consumption

37. Q) Lifestyle intervention for management of hypertension
includes all except:
a) Regular aerobic activity 30 min /day
b) Salt intake to <6 gm./day
c) Attain and maintaining BMI >25k/m2
d) Diets rich in fruits and vegetables and restricted content of
saturated fats
e) Moderation of alcohol consumption

38. Q) Safest drug for hypertension in pregnancy is:
a) ACE inhibitors
b) Angiotensin receptor blockers
c) Diuretic
d) Methyldopa

39. Q) Safest drug for hypertension in pregnancy is:
a) ACE inhibitors
b) Angiotensin receptor blockers
c) Diuretic
d) Methyldopa

40. Q) The first line antihypertensive in diabetic
patients is:
a) Diuretics
b) Angiotensin converting enzyme inhibitors
c) Beta blockers
d) Calcium channel blockers

41. Q) The first line antihypertensive in diabetic
patients is:
a) Diuretics
b) Angiotensin converting enzyme inhibitors
c) Beta blockers
d) Calcium channel blockers

42. 42
Discontinuing therapy
Some patients with stage 1
hypertension are well controlled,
often on a single medication.
After a period of years, the question
arises as to whether antihypertensive
therapy can be gradually diminished
or even discontinued.
After discontinuation of treatment, a
substantial proportion of patients
remain normotensive for at least one
to two years, a larger fraction of
patients do well with a decrease in
the number and/or dose of
medications taken.
More gradual tapering of drug dose is
indicated in well-controlled patients
taking multiple drugs.
Abrupt cessation of some
antihypertensive drugs, especially
higher doses of short-acting beta
blockers (such as propranolol) or the
short-acting alpha-2 agonist
(clonidine) can lead to a potentially
fatal withdrawal syndrome. Gradual
discontinuation of these agents over
a period of weeks should prevent this
problem.

43. Summary
Hypertension is a major cause of
morbidity and mortality and needs
to be treated.
It is an extremely common
condition; however, it is still under-
diagnosed and undertreated
Hypertension is easy to diagnose
and easy to treat
Aim of the management is to save
the target organ from damage and
to maintain the patients’ quality of
life
Life-style modification should
always be encouraged in all
Hypertensive patients
Here is what we should take away from today
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44. References
1.Muntner P, Carey RM, Gidding S, et al. Potential US Population
Impact of the 2017 ACC/AHA High Blood Pressure Guideline.
Circulation 2018; 137:109.
2.Yoon SS, Gu Q, Nwankwo T, et al. Trends in blood pressure
among adults with hypertension: United States, 2003 to 2012.
Hypertension 2015; 65:54.
3.https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2014_na
mcs_web_tables.pdf.
4.Whelton PK, Carey RM, Aronow WS, et al. 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults: A Report of the
American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines. Hypertension 2018; 71:e13.
5.Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH
Guidelines for the management of arterial hypertension. Eur
Heart J 2018; 39:3021.
6.Unger T, Borghi C, Charchar F, et al. 2020 International Society
of Hypertension global hypertension practice guidelines. J
Hypertens 2020; 38:982.
7.Hypertension in adults: Diagnosis and management. National In
stitute for Health and Care Excellence (NICE). http://www.nice.org.
uk/guidance/ng136 (Accessed on October 23, 2020).
8.Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance
of usual blood pressure to vascular mortality: a meta-analysis of
individual data for one million adults in 61 prospective studies.
Lancet 2002; 360:1903.
9.Muntner P, Shimbo D, Carey RM, et al. Measurement of Blood
Pressure in Humans: A Scientific Statement From the American
Heart Association. Hypertension 2019; 73:e35.
10.Stergiou GS, Palatini P, Parati G, et al. 2021 European Society
of Hypertension practice guidelines for office and out-of-office
blood pressure measurement. J Hypertens 2021; 39:1293.
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45. Thank You!