This document discusses recommendations for treating hypertension in special populations and situations. It recommends treating hypertension in patients with diabetes or chronic kidney disease to a goal of <130/80 mmHg according to JNC 7 guidelines. It provides guidance on treating hypertension in patients with diabetes, cardiovascular disease, chronic kidney disease, and the elderly. It also covers treating hypertensive emergencies and crises as well as hypertension in other situations such as pregnancy, children, and those with comorbidities like asthma. Drug classes and specific medications are suggested depending on the population and clinical situation.

1. ANTIHYPERTENSIVE DRUGS IN
SPECIAL SITUATIONS

2. CURRENT RECOMMENDATIONS FOR BP GOALS
JNC 7 (Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood) Pressure
 Goal BP <140/90
 Goal with Diabetes or CKD <130/80
http://www.nhlbi.nih.gov/guidelines/hypertension/

3. ANTIHYPERTENSIVES IN
SPECIAL POPULATION

4. SPECIAL POPULATIONS INCLUDE
o Diabetes
o Cardiovascular Disease
oCCF
oIschaemic heart disease
oBradycardia
oPeripheral Vascular disease
o Elderly
o Chronic Kidney Disease
o Hypertensive crisis

5. Other Situations
oChildren and Adolescents
oPregnancy
oHormone replacement therapy
oDyslipidemia
oAsthma and COPD
oCerebrovascular disease
oLiver disease
oGout
oPsoriasis
oScleroderma with Reynaud's phenomenon

6. HYPERTENSION IN DIABETES

7. HYPERTENSION IN DIABETES
 JNC 7 Guidelines say: Treat to <130/80
 Evidence says: No renal or cardiovascular benefit with
lower BP
 ACE/ARB therapy do improve renal outcomes in
patients with proteinuria including microalbuminuria
 New ICSI guideline: <140/85 (consider <130/80 in
patients with proteinuria)
www.icsi.org

8. TREATMENT
CHEP 2012
Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg
with
Nephropathy*
*Urinary albumin to creatinine
ratio > 2.0 mg/mmol in men or
> 2.8mg/mmol in women*
Diabetes
without
Nephropathy**
Isolated
Systolic
Hypertension
Systolic-
diastolic
Hypertension
* based on at least 2 of 3 measurements
A combination of 2 first line drugs may
be considered as initial therapy if the
blood pressure is >20 mmHg systolic
or >10 mmHg diastolic above target
Combinations of an ACEI with an ARB are specifically
not recommended in the absence of proteinuria

9. If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5
ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control
of volume is desired
THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg
DIABETES
with
Nephropathy
ACE Inhibitor
or ARB
IF ACEI and ARB are
contraindicated or not
tolerated,
SUBSTITUTE
• Long-acting CCB or
• Thiazide diuretic
Addition of one or more of
Long-acting CCB or Thiazide
diuretic
3 - 4 drugs combination may
be needed
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
CHEP 2012

10. 1. ACE Inhibitor or ARB or
2. Dihydropyridine CCB or
Thiazide diuretic
IF ACE Inhibitor and ARB and
DHP-CCB and Thiazide are
contraindicated or not
tolerated,
SUBSTITUTE
• Cardioselective BB* or
• Long-acting NON DHP-CCB
More than 3 drugs may be needed to reach target values for diabetic patients
* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol
Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg
Combination of first line
agents
Addition of one or more of:
Cardioselective BB or
Long-acting CCB
Diabetes
without
Nephropathy
DHP: dihydropyridine
Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the
absence of proteinuria
CHEP 2012

11. HYPERTENSION WITH
CARDIOVASCULAR DISEASE

12. HYPERTENSION WITH CO-EXISTING
CARDIOVASCULAR DISEASES
 AHA/ACC Guidelines say: Treat to <130/80
 2010 ICSI guideline: <140/90
 Lower Achieved BP has been associated with no
benefit or worsened outcomes in post hoc analysis
of trials
 INVEST – HTN with DM and CAD
 ONTARGET – HTN with Vascular disease or DM
 I-PRESERVE – HTN with Diastolic CHF
N Engl J Med 2008;359:2456–67, JAMA July 7,2010;304(1)61-68, NEJM 358:1547-1559

13. a) Hypertension with CCF
CHEP 2012
Beta-blockers used in clinical trials were bisoprolol, carvedilol and metoprolol.
If additional therapy is needed:
• Diuretic (Thiazide for hypertension; Loop for volume control)
• for CHF class II-IV or post MI and selected patients with LV
dysfunction (see notes): Aldosterone Antagonist
Systolic
cardiac
dysfunction
• ACEI and Beta blocker
• if ACEI intolerant: ARB
Titrate doses of ACEI or ARB to those used in clinical trials
If ACEI and ARB are contraindicated: Hydralazine and Isosorbide
dinitrate in combination
If additional antihypertensive therapy is needed:
• ACEI / ARB Combination
• Long-acting DHP-CCB (Amlodipine)
Non
dihydropyridine
CCB

14. b) Hypertension with ischaemic heart disease:
• Caution should be exercised when combining a non DHP-CCB and a beta-blocker
• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or
Diltiazem)
• Dual therapy with an ACEI and an ARB are not recommended in the absence of
refractory heart failure
• The combination of an ACEi and CCB is preferred
1. Beta-blocker
2. Long-acting CCB
Stable angina
ACEI are recommended for most
patients with established CAD*
ARBs are not inferior to ACEI in IHD
Short-acting
nifedipine
*Those at low risk with well controlled risk factors may not benefit from ACEI therapy
CHEP 2012

15. c) Hypertension with Bradycardia
 Nifidipine & ACEI are preferable drugs.
 Better to avoid β-blockers, verapamil, diltiazem
d) Hypertension with peripheral vascular disease
 Better to use Ca++ channel blocker & Vasodilators.
Cochrane Review 2009, Goodman Gilman 12th ed

16. HYPERTENSION IN ELDERLY

17. HYPERTENSION IN THE ELDERLY
 JNC7 and other Guidelines say:
Treat to <140/90
 High Risk Conditions:
Treat to <130/80

18. HYVET- HYPERTENSION IN THE VERY ELDERLY
TRIAL
 Only HTN RCT in Patients ≥80 years
 N=3850 mean age 83 years, mean SBP 173 mm
Hg
 Goal SBP<150 mm Hg, mean achieved SBP =143
mm Hg
 Placebo vs perendipril/indapamide
 18 month BP separation = -15/6 mmHg
N Engl J Med 2008; 358(18):1887-98.

19. HYVET RESULTS

20. TREATMENT
 Check and follow BP while standing
 Remember diet/lifestyle changes
 Treat patients with SBP >160 with medications (start with
thiazide or ACE or Ca channel blockers)
 Target BP in those over 80 years: 150
 Recognize that patients with DBP <60 or PP >50 have a
higher risk of CV events, but not clear if this can be
modified

21. HYPERTENSION IN CHRONIC KIDNEY
DISEASE

22. HYPERTENSION IN CKD
 Guidelines say: Treat to <130/80
 Evidence says: No renal or cardiovascular benefit in this
overall group
 Long term renal benefit in patients with proteinuria
(>300mg/dl)
 New ICSI guideline: <140/90, consider <130/80 in patients
with proteinuria

23. Treatment
CHEP 2012
Chronic kidney
disease and
proteinuria *
ACEI/ARB:
Bilateral renal
artery stenosis
ACEI or ARB (if ACEI intolerant)
Combination with other agents
Additive therapy: Thiazide diuretic.
Alternate: If volume overload: loop diuretic
Target BP: < 140/90 mmHg
* albumin:creatinine ratio [ACR] > 30 mg/mmol
or urinary protein > 500 mg/24hr
Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB
Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

24. xxRecurrent stroke
prevention
MI = myocardial infarction; CAD=coronary artery disease; Aldo Ant = aldosterone antagonist.
*Based on benefits from outcome studies or existing guidelines, the compelling indication is managed in
parallel with the BP.
JNC 7. JAMA. 2003;289:2560-2672.
xxChronic kidney disease
xxxxxDiabetes
xxxxHigh CAD risk
xxxPost-MI
xxxxxHeart failure
Aldo AntCCBARBACE
Inhibitor
Beta-
Blocker
Diuretic
Recommended DrugsHigh-Risk Condition
With Compelling
Indication*
JNC 7: COMPELLING INDICATIONS FOR
INDIVIDUAL DRUG CLASSES

25. HYPERTENSIVE CRISIS

26. HYPERTENSIVE CRISIS
 Systolic blood pressure >220 and diastolic >120mmHg.
 HYPERTENSIVE EMERGENCY: is severe hypertension
with acute impairment of an organ system. In these
conditions, the blood pressure (BP) should be lowered
aggressively over minutes to hours.
 HYPERTENSIVE URGENCY: the BP is a potential risk
but has not yet caused acute end-organ damage. These
patients require BP control over several days to weeks.

27.  ACCELERATED HYPERTENSION: recent significant
increase over baseline blood pressure, with vascular
damage on fundoscopic examination, such as flame-
shaped hemorrhages or soft exudates, but without
papilledema.
 Presence of papilledema indicates MALIGNANT
HYPERTENSION.

28. TREATMENT
Weigh benefits of decreasing BP against risks of
decreasing end-organ perfusion. Important steps
include:
- Appropriately evaluating patients with an elevated BP
- Correctly classifying the hypertension
- Determining aggressiveness of therapy
An important point to remember in the management of
the patient with any degree of BP elevation is to "treat
the patient and not the number."

29. TREATMENT
 Initial considerations:
 Place patient who is not in distress in a quiet room and
reevaluate after an initial interview. BP may fall below critical
levels after relaxation without specific treatment.
 Consider the context of the elevated BP (e.g, severe pain)
 Screen for end-organ damage- admit and rapidly lower of BP
using iv meds which depend on the end-organ system
damaged.
 Patients without evidence of end-organ effects may be
discharged with follow–up.

30. DRUGS
 Once the diagnosis of hypertension is made and end-
organ damage confirmed, the BP should be lowered
by about 25% of the mean arterial pressure.
 There are 2 main classes of drugs:
-Vasodilators
-Adrenergic inhibitors

31. VASODILATORS
DRUG DOSAGE ONSET/DU ADV.EFFE
Nitroprusside 0.25-10mcg/kg/min Instant/1-2min. Thiocyanate,
cyanide poisoning
Nitroglycerine 5-100mcg/min 1-5min/3-5min Flushing,headache,
methemoglobin
Nicardipine 5-15mg/hr 5-10min/1-4hr Tachycardia,
flushing. Avoid-heart
failure
Hydralazine 10-20mg 5-15min/3-8hr Flushing,
tachycardia, avoid-
Aortic diss, MI
Enalapril 10-40mg IM,1.25-
5MG1Vq6hr
20-30min/6hr Hypotension,renal
failure, hyperkalemia
Fenoldopam 0.1-0.3mcg/kg/min 5min/10-15min Flushing, headache,
tachycardia

32. DRUG DOSAGE ONSET/DUR ADV.EFF
Labetalol
(a+b blocker)
20-80mgiv bolus
every 10
min,2mg.min iv
infusion
5-10min/3-6hrs Heart block,ortho
hypotension.avoid-
heart failure,asthma
Esmolol
(b-1 selective
blocker)
200-500 mcg/kg/min
for 4min,then 150-
300mcg/kg/min
1-2min/10-20min Hypotension,avoid-
heart failure,asthma
Phentolamine
(a1 blocker)
5-15mg iv 1-2min/3-10min Tachycardia,
flushing, headache
ADRENERGIC INHIBITORS

33. ORAL DRUGS
DRUG DOSAGE ONSET/DURATION ADV. EFF.
CAPTOPRIL
(ACE inhibitor)
6.25-25MG q 6hrs. 15-30min/6 hrs. Hypotension in high
renin states
CLONIDINE
(a2 agonist-centrally
acting)
0.1-0.2 mg hrly,
Upto max 0.8mg in
24hrs.
30-60min/6-12hrs. Sedation,
bradycardia, dry
mouth
LABETALOL 100-200mg q 12hrs 30-120min/8-12hrs Heart failure, heart
block, bronchospasm

34. OTHER SITUATIONS

35. TREATMENT OF HYPERTENSION IN OTHER
SITUATIONS
a) Hypertension in children and adolescent
 Life style modification, if fail - pharmacological therapy
should be started
 Dosage of antihypertensive medication should be smaller
and adjusted very carefully for children.
 ACE inhibitor & A-II receptor blocker should not be used in
pregnant mother
 Use of anabolic steroid for body building & smoking strictly
prohibited.

36. b) Hypertension in Pregnancy
 In the 2nd & 3rd trimester, antihypertensive agents often are not
indicated unless the Diastolic BP exceeds 100 mm Hg.
 Drugs used are methyldopa, Beta-blocker, CCB in order of
preference.
 Hydralazine (Parenteral) & prazosin may be used.
 Should not be used:
ACEI, A-II Receptor blocker, Diuretics, Nitroprusside

37. c) Hypertension with Hormone replacement therapy
 Presence of hypertension is not contraindicated for
post menopausal estrogen replacement therapy.
 Frequent follow up should be advised .

38. D) HYPERTENSION IN DYSLIPIDAEMIA:
 Common co-existence & demand aggressive
management of both conditions.
 High dose thiazides, loop diuretics & beta blockers may
transiently increase total cholesterol, still has significant
reduction CV morbidity & sudden death. So should be
used without hesitation.

39. E) HYPERTENSION WITH ASTHMA & COPD:
 Ca++ channel blocker is the preferable drug.
 ACEI are safe in most patients with asthma.
 A-II receptor blocker may be used if cough is trouble
some problem after using ACEI.
 Contraindications:
β-blocker should not be used in patient with asthma
except in special circumstances.
Goodman Gilman 12th ed

40. F) HYPERTENSION WITH CVD:
Treat extreme BP elevation (systolic
> 220 mmHg, diastolic > 120 mmHg)
by 15-25% over the first 24 hour
with gradual reduction after.
•If eligible for thrombolytic therapy
treat very high BP (>185/110 mmHg)
Acute
ischemic
Stroke
Avoid excessive lowering of BP which can exacerbate ischemia
CHEP 2012

41. G) HYPERTENSION WITH LIVER DISEASE:
All Antihypertensive drugs can be used except methyldopa
H) HYPERTENSION WITH GOUT
All hypertensive drugs can be used
But all Diuretics can increase serum uric acid level. So
diuretics should be avoided if possible.
Contraindications: diuretics

42. I) HYPERTENSION WITH PSORIASIS:
β-Blocker and ACEI aggravate psoriasis. So better to avoid
them.
J) HYPERTENSION WITH SCLERODERMA WITH
REYNAUD'S PHENOMENON
Nifedipine and prostacycline infusion may occasionally
helpful in patient with severe Reynaud's phenomenon.