Hypertension is a major global health problem affecting over 1 billion people worldwide. The document discusses hypertension guidelines including the JNC 8 guideline which recommends treating to a blood pressure goal of less than 150/90 mmHg for those aged 60 and older and less than 140/90 mmHg for those under 60. It provides recommendations on initial treatment options and adding additional drugs. The document also discusses special situations and management of hypertension in various comorbid conditions. Hypertensive emergencies require rapid parenteral treatment in a hospital to reduce blood pressure in a controlled manner to prevent end organ damage.

1. Respected teachers, colleagues and trainees

2. Warm welcome you all

3. • Dr. Rajat SR Biswas, MD
• Resident Physician

4. - Hypertension Basics
- Some recommendations
&
- Some special situations

5. Hypertension : Problem Magnitude
 Hypertension( HTN) is the most common primary diagnosis.
 Worldwide prevalence estimates for HTN may be as much as 1
billion.
 Prevalance of HTN in Bangladesh from different studies-
14.6% to 19%

6. Global Mortality 2000:
Hypertension is the major risk factor
Adapted from Ezzati et al. Lancet 2002;360:1347-1360.
Attributable mortality in millions (total: 55 861 000)
Developing regions
Developed regions
0 87654321
7.6 million deaths

7. Systemic hypertension
• long-lasting, usually permanent increase of systolic and
diastolic blood pressure
primary (essential) hypertension – unknown cause;
usually coincidence of more factors – neural,
hormonal, kidney dysfunction, ...
secondary (symptomatic) hypertension – symptom
(sign) of other disease

8. Isolated systolic hypertension
 increased systolic blood pressure at normal or
decreased diastolic BP
 pseudohypertension ← rigid arteries in old age
“white coat hypertension “ – induced by stress at physical
examination
„masked hypertension“ - false finding of normal blood
pressure during the examination; opposite of white
coat hypertension

14. Types of Hypertension
• Primary HTN:
• Also known as essential
HTN.
• Accounts for 95% cases of
HTN.
• No universally established
cause known.
• Secondary HTN:
• Less common cause
of HTN ( 5%).
• Secondary to other
potentially rectifiable
causes.

15. Causes of Secondary HTN
• Common
• Intrinsic renal disease
• Renovascular disease
• Mineralocorticoid
excess (Primary
Aldosteronism)
• Sleep Breathing
disorder
• Uncommon
• Pheochromocytoma
• Glucocorticoid excess
(Cushing’s Syndrome)
• Coarctation of Aorta
• Hyper/hypothyroidism

17. Secondary hypertension

18. New Guidelines for Hypertension
 National Institute for Health and Clinical Excellence (NICE), 2011
 Kidney Disease: Improving Global Outcome (KDIGO), 2012
 European Society of Hypertension/European Society of Cardiology,
(ESH/ESC), 2013
 American Diabetes Association (ADA), 2014
 American Society of Hypertension and the International Society of
Hypertension (ASH/ISH), 2014
 Eighth Joint National Committee (JNC8), 2013 - Evidence Based
Guideline

19. JNC-8 Guideline
 The new guidelines emphasize control of
systolic blood pressure (SBP) and diastolic
blood pressure (DBP) with age- and
comorbidity-specific treatment cutoffs.
 It also introduce new recommendations
designed to promote safer use of angiotensin
converting enzyme inhibitors (ACEIs) and
angiotensin receptor blockers (ARBs).

20. Comparison of JNC Guidelines
JNC7
 Nonsystematic literature review
and expert opinion
 Range of study designs
 No grading system for
recommendations
 Recommendations:
 Lifestyle modifications
 Initial therapy for HTN
 Compelling indications
 Addressed secondary HTN
and resistant HTN
JNC8
 Systematic review
 Randomized, controlled trials
(RCT) only
 Graded recommendations
 Recommendations:
 No specific lifestyle
recommendations
 Initial therapy for HTN
 Racial, CKD, and diabetic
subgroups addressed
 Addressed three key questions

21. This JNC8 guideline has not redefined high BP,
and considers the 140/90 mm Hg definition from
JNC 7 reasonable.
It offers clinicians an analysis of what is known and
not known about BP treatment thresholds, goals,
and drug treatment strategies to achieve those
goals.
However these recommendations are not a
substitute for clinical judgment, and decisions
about care must carefully consider and
incorporate the clinical characteristics and
circumstances of each individual patient.

22. Recommendations

23. Concerning thresholds and goals.
Recommendations 1 -5

24.  General population aged 60 years or older
Recommendation 1
SBP ≥150 mmHg
Or
DBP ≥ 90mmHg
Goal of Treatment :
SBP <150 mmHg
OR
DBP of < 90mmHg.
Initiate Treatment at :

25.  General population < 60 years
Recommendation 2
Initiate Treatment at : DBP ≥ 90mmHg
Goal of Treatment : DBP of < 90mmHg.

26.  General population < 60 years
Recommendation 3
SBP ≥ 140 mmHg
Goal of Treatment : SBP of < 140 mmHg.
Initiate Treatment at :

27.  Population aged 18 years or older with CKD
Recommendation 4
Initiate Treatment at:
SBP ≥ 140 mmHg
Or
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHg
Or
DBP < 90 mmHg

28.  Population aged 18 years or older with
diabetes
Recommendation 5
Initiate Treatment at:
SBP ≥ 140 mmHg
Or
DBP ≥ 90 mmHg
Goal of Treatment :
SBP < 140 mmHg
Or
DBP < 90 mmHg

29. Concerning selection of
antihypertensive drugs.
Recommendations6,7,8

30. Recommendation 6
 In General nonblack population, including those
with diabetes
 Initial antihypertensive treatment should include any
of the following:
 A thiazide-type diuretic
 Calcium channel blocker (CCB)
 Angiotensin-converting enzyme inhibitor (ACEI) or
 Angiotensin receptor blocker (ARB).

31. Recommendation 7
 In general black population, including those
with diabetes:
 Initial antihypertensive treatment should
include :
 Thiazide-type diuretic
 CCB.

32. Recommendation 8
 Population aged 18 years or older with CKD
and hypertension
 Initial (or add-on) antihypertensive treatment
should include an ACEI or ARB to improve
kidney outcomes.
 This applies to all CKD patients with
hypertension regardless of race or diabetes
status.

33. Recommendation 9
 The main objective of hypertension treatment is to
attain and maintain goal BP.
 If goal BP is not reached within a month of
treatment:
 increase the dose of the initial drug OR
 Add a second drug from one of the classes in
recommendation 6 (thiazide-type diuretic, CCB, ACEI, or
ARB).
 The clinician should continue to assess BP and
adjust the treatment regimen until goal BP is
reached.

34. Opinion for starting & adding drugs
.
Recommendation 9

35. Recommendation 9
 If goal BP cannot be reached with 2 drugs:
 Add and titrate a third drug from the list provided.
 Do not use an ACEI and an ARB together in the
same patient.
 If goal BP cannot be reached using the drugs in
recommendation 6 because of a contraindication or
the need to use more than 3 drugs to reach goal BP:
antihypertensive drugs from other classes can be
used.

36.  For patients in whom goal BP cannot be attained
using the above strategy OR
 The management of complicated patients for
whom additional clinical consultation is needed.
 Referral to a hypertension specialist may be
indicated
Recommendation 9

37. Drug choice in some special
situations

38. Benefits of Treatment
• Reductions in stroke incidence, averaging 35–40
percent
• Reductions in MI, averaging 20–25 percent
• Reductions in HF, averaging >50 percent.

40. Hypertension in elderly
• Benefit of Rx are much greater in older people than
young.
• Commonly isolated systolic hypertension
• Drug of choice:
~Thiazide like diuretics
~CCBs

41. Hypertension in young
• Diastolic HTN more common
• 2nd HTN also more common
• Drug of choice:
~ ACEIs
~ARBs

42. Hypertension with Heart failure
• Asymptomatic with demonstrable ventricular dysfunction:
~ACEIs
~BBs
• Symptomatic ventricular dysfunction OR
End stage heart failure:
~Aldosterone blocker with Loop diuretics
~ACEIs
~ARBs
• AVOID CCBS

43. Hypertension with IHD
 Stable angina:
~BBs
~CCBs
 Acute coronary syndrome:
~BBs
~ACEIs
 Post MIs:
~ACEIs
~BBs
~Aldosterone antagonists

44. Hypertension with LVF
• Diuretics & ACEIs
• All anti-hypertensive drugs except direct vasodilators eg.
Hydralazine
• I/V nitroglycerine in Acute LVF

45. Hypertension with bradycardia
• Nifidipine & ACEIs
preferable
• Avoid :
~BBs
~Rate limiting CCBs

46. Hypertension with DM
• Preferable:
~ACEIs or ARBs
• Others:
~CCBs
~Thiazide
~BBs
• Combination of 2 or more drugs preferred

47. Hypertension with metabolic syndrome
• BBs & Thiazides avoided as they aggravate DM &
Dyslipidemia

48. Hypertensive with CKD
• Favorable drugs:
~ACEIs
~ARBs
* F/U with S. Creatinine level(upto 35% rise acceptable)
• Advanced renal disease: add loop diuretics
• A-blockers , CCBs

49. Hypertension with ischemic stroke
 Not to lower the BP in 1st
week unless
~ Malignant HTN
~ Myocardial Ischaemia
~ Thrombolytic therapy
with BP> 185/110
 Recurrent stroke
prevention:
~ACEIs
~Thiazide

50. Hypertension with hemorrhagic stroke
• Lower the mean arterial
BP < 130 mm Hg
• Use non-vasodilating I/V
drugs eg. Labetalol,
nicardipine, esmolol.

51. Hypertension in surgical patients
• In elective surgery
effective BP control.
• In older pts B-blockers
are beneficial.
• Discontinue ACEIs &
ARBs 24 prior to non-
cardiac surgery.

52. Hypertension in surgical patients
• In urgent surgery I/V
nitroprusside, nicardipine,
labetelol.
• Intra-operative coronary
ischaemia  GTN
• Intra-operative
tachycardia  BBs.
• Post-operative volume
overload  frusemide.

53. Hypertension with OCP
• 2-3 times more in woman taking OCP esp in obese and
elderly
• Stop OCP BP returns to normal within few months in
most cases
• If BP doesn’t normalize or OCP has to be taken then
start anti-HTN drugs
• POP are recommended for hypertensive female.

54. Hypertension with HRT
• Hypertension is not a contraindication for post
menopausal HRT
• Frequent F/U should be advisedc
• Selective Ostrogen receptor modulator are preferred

55. Pheochromocytoma
• To prepare the patient for surgery, for a minimum of 6
weeks to allow restoration of normal plasma volume.
• The most useful drug is α-blocker phenoxybenzamine
(10-20 mg orally 6-8-hourly).
• If α-blockade produces a marked tachycardia, then a β-
blocker (e.g. propranolol) or combined α- and β-
antagonist (e.g. labetalol) can be added.
• On no account should the β-antagonist be given before
the α-antagonist, as it may cause a paradoxical rise in
blood pressure due to unopposed α-mediated
vasoconstriction.

56. • During surgery sodium nitroprusside and the short-acting
α-antagonist phentolamine are useful in controlling
hypertensive episodes which may result from
anaesthetic induction or tumour mobilisation.
• Post-operative hypotension may occur and require
volume expansion and, very occasionally, noradrenaline
(norepinephrine) infusion.
• This is uncommon if the patient has been prepared
adequately with phenoxybenzamine

57. Hypertension with Pregancy
Drugs Comments
Methyldopa Preferred based on long-term followup
studies
supporting safety
BBs Reports of intrauterine growth
retardation (atenolol)
Generally safe
Labetalol Increasingly preferred to methyldopa
due to reduced
side effects

58. Hypertension with Pregancy
Drugs Comments
Clonidine Limited data
Calcium antagonists Limited data
No increase in major teratogenicity
with exposure
Diuretics Not first-line agents
Probably safe
ACEIs, angiotensin II receptor
antagonists
Contraindicated
Reported fetal toxicity and death

59. Pre-eclampsia
• If delivery is not immediately needed oral methydopa,
oral labetalol, BBs & CCBs
• If delivery is immediately needed I/V drugs are indicated
eg. I/V Hydralazine
I/V labetalol
Oral nifedipine (contoversial)
• I/V nitroprusside is rarely used when others failed as risk
of fetal cyanide poisoning.

60. Hypertension in lactating women
• Stage 1 preferably avoid drugs, continue F/U
• Avoid ACEIs & ARBs( Causes adverse neonatal renal
effects)
• Avoid Diuretics ( reduces milk volume)

61. Hypertension in Dyslipidemia
• Preferable drugs:
~ ACEIs, ARBs & CCBs
• High doses of Thiazides, Loop diuretics & BBs may
transiently increase total cholesterol

62. Hypertension with Asthma & COPD
• CCBs most preferable
• ACEIs safe in most pts
• ARBs can be used if cough is troublesome after using
ACEIs
• Contraindicated:
~BBs ( except in special circumstances)

63. Hypertension with liver diseases
• All are safe except methydopa

64. Hypertension with GOUT
• All the drugs can be used
• All diuretics increase serum uric acid level but rarely
induce acute gout, so diuretics should be avoided if
possible

65. Hypertension with BHP
• α-blockers helpful

66. Hypertension with Psoriasis
• BBs & ACEIs aggravate psoriasis so better to avoid them

67. Hypertension with raynaud’s phenomenon
• Nifidipine & prostacycline infusions may occasionally be
helpful
• Avoid BBs

68. Hypertension with PVD
• Drug of choice:
~ CCBs
~ Vasodilators
• BBs should be avoided

69. Resistant hypertension
Resistant hypertension is defined as the failure to
achieve goal BP in patients who are adhering to full
doses of an appropriate three-drug regimen that includes
a diuretic.
Causes:
Improper BP measurement
Volume overload
Drug-related
Drug-induced
Associated conditions
Potential identifiable cause.

70. Hypertensive crisis
• Hypertensive emergency
• Hypertensive urgency
• Malignant hypertension

71. Hypertensive emergencies
• Marked BP elevation with acute target organ damage eg.
~Encephalopathy ~MI
~Unstable angina ~LVF
~Stroke ~Eclampsia
~Aortic dissection ~ARF
~Retinopathy ~SAH

72. Treatment of Hypertensive emergency
• Hospitalization
• Parenteral drug therapy but can be controlled with oral
drug therapy
• Controlled reduction to a level of 150/90 mm Hg over a
period of 24-48 hrs
• Rapid uncontrolled reduction of BP may cause coma,
stroke, MI, ARF or death

73. Drug of choice
• Nitroprusside
• Nicardipine
• Labetalol
• Nitroglycerine
• hydralazine

74. Hypertensive urgency
• Markedly elevated BP but without acute target organ
damage.
• Don’t require hospitalization.
• Combination oral drug therapy
• Search for identifiable causes of HTN.
• Control over several days to weeks.

75. Potential favorable effects of anti-HTN
• Thiazide diuretics → ↓ Osteoporosis
• BBs → Tachyarrhythmia, AF, Migraine, Thyrotoxicosis,
Essential Tremor, Peri-operative HTN
• CCBs → Raynaud's syndrome, Arrhythmias
• Alpha-Blockers → Prostatism

76. Potential unfavorable effects
• Thiazide diuretics → Gout, Hyponatremia
• BBs → Asthma, COPD, second & third degree heart
block
• ACEIs & ARBs → Pregnancy
• ACEIs → Angioedema
• Aldosterone antagonist & K+sparing diuretics →
Hyperkalaemia

77. • Take home messages
• Recommendations of JNC-8
• Choice of drugs in different secondary hypertensions

78. Thanks