In short management of hypertension

1. Presenter
Dr. Md. Shahadad Hossain
Department of Medicine

2. Blood Pressure
It is the lateral pressure exerted by the moving column of
blood on the vessel wall per unit area (sq. mm) by its
contained blood while flowing through it.
Blood pressure = Cardiac Output × Peripheral resistance
Cardiac Output = Stroke Volume × Heart rate
Importance of BP:
 Flow the blood through the circulatory tree
 Provide tissue nutrition for Urine production, Lymph
formation & for Venous return

3. Types of Blood Pressure
 Systolic BP: Maximum pressure during Systole.(100-140 mm
of Hg)
 Diastolic BP: Minimum pressure during Systole (60-90 mm
of Hg)
 Pulse Pressure: Differneces between Systolic BP & Diastolic
BP (
 Mean Arterial Pressure: Diastolic BP+ 1/3rd of Pulse pressure

4. Physiology
 HEART is main organ that regulate the Blood
Pressure, blood pressure in the circulation is
principally due to pumping action of heart
 During each heart beat blood pressure varies between
maximum (systolic) & a minimum (Diastolic)
pressure.

5. Normal Mechanism of maintaining BP
 Nervous Mechanism:
Baroreceptor Mechanism
Chemoreceptor Mechanism
 Hormonal Mechanism:
Renin Angiotensin Aldosterone Mechanism
Vasopressin-Vasoconstictor (ADH)

7. Hypertention
A sustained rise of Systolic BP ≥ 140 mm of Hg &
Diastolic BP ≥ 90 mm of Hg on at least 3 reading under
basal condition without any medication is called
Hypertention.
Aetiology
 Primary
 Secondary

8. 1. Primary :
95% cases a specific underlying cause cannot be found. This
is also known as Essential HTN.
2. Secondary:
 Alcohol
 Obesity
 Pregnancy
 Renal (GN, Renal Vuscular, PKD)
 Endocrine Diseases (Cushing Syndrome,
Pheochromocytoma, Hyperthyroidism)
 Drugs (OCP, Steroids, NSAID, Sympathomimetic)
 Coarcation of Aorta

10. Physiological Variation in Blood Pressure:
 Age
 Sex (Female < 5 mm Hg than Male)
 Body Build: Obese person Systolic BP raised
 Exercise: Rise of Systolic BP
 Posture: On standing, fall of Systlic BP & Rise of Diastolic
BP
 Diurnel variation: Day time 2 o’clock rise, then fall.
 During Sleep: Fall of BP upto 15-20 mm Hg
 After Meal: Rise of BP
 Emotion & Excitement: Systolic BP rises

11.  Pre HTN / High Normal Blood Pressure:
Pre HTN is the term which means BP is recorded with a
Systolic pressure from 120-139 mm of Hg or Disastolic
pressure from 80-89 mm of Hg.
Mx: Lifestyle Modification, HBPM
 White Coat HTN / White Coat Syndrome:
When people exhibit a blood pressure level above normal
range in a clinical settings.
It is believed that the phenomenon is due to anxiety which is
experienced during a clinical visit.

12. Grading of Blood Pressure
Category Systolic BP Diastolic BP
Normal <130 <85
High Normal 130-139 85-89
Grade -1 140-159 90-99
Grade-2 160-179 100-109
Grade-3 ≥180 >110
Isolated Systolic
Grade -1
140-159 <90
Isolated Systolic
Grade-2
≥160 <90

14. Epidemiology of HTN in adult men in 2014

15. History:
 Family history
 Life style ( Exercise, Salt intake, Smoking)
 Drugs
 Alcohol
 Sympmotms of other causes of secondary HTN
( Pheochromocytoma-Paroxysmal Headache, Sweating,
Palpitation)
 Coronary Artery Disease (Angina, Breathlessness)

16. Measurement of Blood Pressure
1. Direct Method: Artery is exposed, U-shaped Mercury
manometer is introduced.
2. Indirect Method:
 Palpatory
 Auscultatory

21. Examination:
 Radio femoral delay (coarcation of Aorta)
 Enlarged Kidney (PKD)
 Abdominal Bruits (Renal artery stenosis)
 Any features of Cushing Syndrome
 Central Obesity & Features of Hyperlipidaemia
 Features of Hypo/Hyperthyroidism
 On Pre cordium examination: features of LVH, Accentuation of
Aortic Component of 2nd HS & 4th HS
 Opthalmoscopy: Hypertensive Retinopathy
 Generalized Atheroma, Aortic aneurysm
 PVD

22. Investigations
 Chest X ray P/A view
 ECG
 Blood Glucose
 TFT
 Lipid Profile
 Blood Urea
 S. Creatinine
In selected patients,
 Echocardiography
 Renal Ultrasound
 Renal Angiography
 Urinary catecholamines
 Dexamethasone Suprresion Test
 Plasma Renin & Aldosterone

23. Complications
 Blood Vessels:
1. Internal lamina thickened
2. Smooth muscle Hypertrophied
3. Fibrous tissue deposited
In small arteries there is
1. Hyaline arterio sclerosis.
2. Narrowing of Lumen ,aneurysm develops
 CNS:
1. Stroke
2. TIA
3. Hypertensive Retinopathy
4. Pappiloedema

24.  Heart:
1. Coronary Artery Disease
2. LVH
3. Atrial Fibrilation
4. LVF
 Kidney:
1. Proteinuria
2. Progressive Renal Failure

25.  Eye: Hypertensive Retinopathy
Grading of Hypertensive retinopathy
Grade 1 Arteriolar thichkening,
tortuosity, increased
reflectiveness ( Silver
wiring)
Grade 2 Grade 1 + Constriction of
vein at arteriolar crossing
(Areriovenous nipping)
Grade 3 Grade 2+ Evidence of Retinal
Ishcaemia( flame shaped or
Blot haemorrhage & cotton
wool exudates)
Grade 4 Grade 3 + Pappiloedema

26. HTN Retinopathy

27.  Malignant or accelerated phase HTN:
HTN + Rapidly progessive end organ damage
1. Microvuscular changes
2. Intravuscular Haemorrage
3. Retinopathy (3/4)
4. Renal dysfunction (proteinuria)
5. HTN encephalopathy
6. Left Ventricular failure.

28. National Guideline for BP Management

29. Goal for BP lowering treatment
Age Target BP level
< 60 year < 140/90 mm of Hg
>60 year < 150/90 mm of Hg
All ages with DM and/or CKD < 140/90 mm of Hg
< 130/80 mm of Hg

30. Recommendations for follow up based on initial blood
pressure measurements for adults
(Modified from JNC-7 report / WHO 2003)
Initial BP (mmHg)
Systolic & Diastolic
Follow up recommended to confirm
Diagnosis and/or review response to
treatment
<130 and <85 Recheck in one year
130-139 and 85-89 Recheck within 3-6 months
140-159 and/or 90-99 Confirm within two months
160-179 and/or 100-109 Evaluate within one month & treat if
confirmed
≥180 and/or ≥ 110 Evaluate and initiate treatment
immediately

31. Non pharmacological Mx
1. Correction of Obesity. Achieving & Maintaining Ideal
body wt.
2. Avoid Alcohol Intake
3. Limiting Salt intake to <5gm/day (1 TSF)
4. Exercise
5. Fruits, Vegetables & High Fibre whole Grain food Intake.
6. Fish rather than Red Meat.
7. Avoid Smoking
8. Avoid fatty food
9. Discourage excessive conjumption of Tea, Coffee,

32. Anti Hypertensive Drugs
 β-blocker:
Cardioselective:
Atenolol, Met0prolol, Bisoprolol, Nevibulol
Cardio Nonselective:
Propanolol ( Indever), Nadolol, Timolol (Nyolol)
 Ca channel blocker:
Dihydropyridine:
Amlodipine, Nimopidine, Nifedipine, Nicardipine
NonDihydropyridine:
Verapamil, Diltiazem,

33.  Diuretics:
Frusemide(Lasix), Hydrochlorthiazide(Acuren),
Spironolactone(Spiretic)
 ACE Inhibitor:
Captopril, Enalapril, Lisinopril
 ARB:
Losartan, Valsartan, Olmesartan.
 α- blocker:
Prazosine, Doxazosine
 Vasodilator:
Hydralazine

34.  Adjuvent therapy:
Lipid Lowering Agent
Aspirin
 Effective Combinations:
ACEi + Diuretics
ARB + Diuretics
Ca Channel Blockers + ACEi / ARB
Ca Channel Blockers + β blockers
β blockers + Diuretics

36. Specific Mx in case of co morbidity
Co morbid condition Drug of choice
HTN with stroke ARB, ACEi, CaCB
HTN with DM 1. ACEi are the drug of choice due to
there Cardiovuscular & Renal protective
effect in DM.
2. ARB
HTN with CKD 1. ACEi which has an anti proteinuric
effect greater than other
hypertensive drug.
2. ARB
HTN with pregnancy 1. I/V hydralazine
2. Tab. α methyl dopa
3. Tab. Nifedipine
4. Tab. Labetolol

37. Hypertensive Emergency
Hypertensive Emergency is characterized by BP is
more then 220/140 mm of Hg complicated by evidence
of impending or progressive Target Organ Dysfunction
such as
1. Hypertensive Encephalopathy
2. Unstable Angina
3. Acute MI
4. Acute LVF
Rx: Parentral Anti Hypertensive
I/V Na Nitroprusside
Nitroglycerine
Enalaprine
Hydralazine hydrochloride

38. THANK YOU

39. Thank You