Study materials of HTN

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What is Blood Pressure?
• When heart beats, it pumps blood round the body
and maintains the circulation. As the blood moves,
it exerts force against the sides of the blood vessels.
The strength of this force is called the blood pressure
(figure 1).
What is hypertension?
A sustained elevation in arterial blood pressure
above the normal value of <120mm Hg of
systolic blood pressure and <80mm Hg of
diastolic blood pressure (figure 2).
Burden of Hypertension in India:
Overall prevalence for hypertension in India was 29.8%. About 33% urban and 25% rural
Indians are hypertensive. Of these, 25% rural and 42% urban Indians are aware of their
hypertensive status. Only 25% rural and 38% of urban Indians are being treated for
hypertension. One-tenth of rural and one-fifth of urban Indian hypertensive population have
their BP under control.
BP is categorized as per the American Heart Association (AHA) as in figure 3:
Figure 1 shows blood pressure force
Figure 2 shows blood vessel in high blood pressure
Figure 3 shows blood pressure category as per AHA
Basics on Hypertension

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BP Measurement Techniques (Table 1):
Types of Hypertension:
The two major types are:
Primary or essential hypertension that has no known
cause, is diagnosed in the majority of people.
Among the factors that have been intensively studied are
 Renin angiotensin aldosterone system
 Sympathetic nervous system
 Salt intake
 Obesity and Insulin resistance
Secondary hypertension is often caused by reversible
factors, like pregnancy, drug induced, kidney disease,
endocrine gland disorders and is sometimes curable.
 White-coat hypertension
 In-clinic BP is consistently elevated, though ABPM readings are normal.
 The anticipation of BP measurement alters reaction leading to increase in BP.
 Prevalence increases with age and may be a precursor of sustained hypertension.
Risk factors:
 Increasing age of people
 Smoking
 Excess salt in diet
 Lack of physical activity
 Family history of hypertension
 Excess body weight
 Diabetes Mellitus
 Chronic kidney disease
 Excess stress
Symptoms:
Figure 4 shows types of hypertension

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Hypertension is rarely accompanied by any symptoms, and its identification is usually
through screening, or when seeking healthcare for an unrelated problem. Some with high
blood pressure report headaches (particularly at the back of the head and in the morning),
as well as lightheadedness, vertigo, tinnitus (buzzing or hissing in the ears), altered vision
or fainting episodes.
ESSENTIAL HYPERTENSION:
Patho-physiology (Figure 5)
 RAAS: Renin angiotensin aldosterone system:
The renin–angiotensin–aldosterone system (RAAS) is a hormone system that
regulates blood pressure and fluid balance.
When renal blood flow is reduced, juxtaglomerular cells in the kidneys convert the prorenin
already present in the blood into renin and secrete it directly into the circulation. Plasma
renin then carries out the conversion of angiotensinogen released by the liver to angiotensin
I. Angiotensin I is subsequently converted to angiotensin II by the enzyme angiotensin-
converting enzyme found in the lungs. Angiotensin II is a potent vaso-active peptide that
causes blood vessels to constrict, resulting in increased blood pressure. Angiotensin II also
stimulates the secretion of the hormone aldosterone from the adrenal cortex. Aldosterone
causes the tubules of the kidneys to increase the reabsorption of sodium and water into the
blood, while at the same time causing the excretion of potassium (to maintain
electrochemical balance). This increases the volume of extracellular fluid in the body, which
also increases blood pressure.

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Figure 6 shows Renin- angiotensin-aldosterone system pathway
If the renin–angiotensin–aldosterone system is abnormally active, blood pressure will be too
high. There are many drugs that interrupt different steps in this system to lower blood
pressure. These drugs are one of the main ways to control high blood pressure
(hypertension), heart failure, kidney failure, and harmful effects of diabetes.
Figure 7 shows RAAS involvement in development and progression of HTN complications.
Complications:
 Heart related:

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o Left ventricular hypertrophy, coronary heart disease, heart failure
 Kidney related:
o Renal failure
 Brain related:
o Stroke
o Transient Ischemic Attacks
 Eye related:
o Retinopathy
 Blood vessels related:
o Peripheral vascular disease
o Antihypertensive Drugs: Drugs that decreases cardio output or peripheral vascular
resistance or both.
o Goals of Therapy: Blood pressure target values for treatment of hypertension
Table 2: Goal of antihypertensive therapy.
Figure 8 shows antihypertensive drugs action
Mx of Hypertension

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o Hypertension management strategies as per the JNC 8 guidelines
Figure 9 shows 2014 hypertension guideline management algorithm

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Table 3: Strategies to Dose Antihypertensive Drug:
Strategy Description Details
A Start one drug, titrate to
maximum dose, and then
add a second drug
If goal BP is not achieved with the initial drug, titrate
the dose of the initial drug up to the maximum
recommended dose to achieve goal BP
If goal BP is not achieved with the use of one drug
despite titration to the maximum recommended
dose, add a second drug from the list (thiazide-type
diuretic, CCB, ACEI, or ARB) and titrate up to the
maximum recommended dose of the second drug to
achieve goal BP
If goal BP is not achieved with 2 drugs, select a third
drug from the list (thiazide-type diuretic, CCB, ACEI,
or ARB), avoiding the combined use of ACEI and
ARB. Titrate the third drug up to the maximum
recommended dose to achieve goal BP
B Start one drug and then
add a second drug before
achieving maximum dose
of the initial drug
Start with one drug then add a second drug before
achieving the maximum recommended dose of the
initial drug, then titrate both drugs up to the
maximum recommended doses of both to achieve
goal BP
If goal BP is not achieved with 2 drugs, select a third
drug from the list (thiazide-type diuretic, CCB, ACEI,
or ARB), avoiding the combined use of ACEI and
ARB. Titrate the third drug up to the maximum
recommended dose to achieve goal BP
C Begin with 2 drugs at the
same time, either as 2
separate pills or as a
single pill combination
Initiate therapy with 2 drugs simultaneously, either
as 2 separate drugs or as a single pill combination.
Some committee members recommend starting
therapy with ≥2 drugs when SBP is >160 mm Hg
and/or DBP is >100 mm Hg, or if SBP is >20 mm Hg
above goal and/or DBP is >10 mm Hg above goal. If
goal BP is not achieved with 2 drugs, select a third
drug from the list (thiazide-type diuretic, CCB, ACEI,
or ARB), avoiding the combined use of ACEI and
ARB. Titrate the third drug up to the maximum
recommended dose.

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Figure 10: 2013 American Society of Hypertension (ASH) /ISH Hypertension Guidelines
Table 4: Drug Selection in Hypertensive Patients With or Without Other Major conditions
Patient Type First Drug
Add Second Drug If
Needed to Achieve a
BP <140/90 mm Hg
If Third Drug is
Needed to Achieve
a BP of <140/90 mm
Hg

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A. When hypertension is the only or main condition
Black patients
(African ancestry):
All ages
CCBa
or thiazide
diuretic
ARBb
or ACE inhibitor
(If unavail-able can
add alter-native first
drug choice)
Combination of CCB
+ ACE inhibitor
or ARB + thiazide
diuretic
White and other non-
black Patients:
Younger than 60
ARBb
or ACE inhibitor
CCBa
or thiazide
diuretic Combination of CCB
+ ACE inhibitor or
ARB + thiazide
diuretic
White and other non-
black
patients: 60 y and
older
CCBa
or thiazide
diuretic (Although
ACE inhibitors or
ARBs are also usually
effective)
ARBb
or ACE inhibitor
(or CCB or thiazide if
ACE inhi-bitor or ARB
used first)
Combination of CCB
+ ACE inhibitor or
ARB + thiazide
diuretic
B. When hypertension is associated with other conditions
Hypertension and
diabetes
ARB or ACE inhibitor
Note: in black
patients, it is
acceptable to start
with a CCB or thiazide
CCB or thiazide
diuretic. Note: in
black patients, if
starting with a CCB
or thiazide, add an
ARB or ACE inhibitor
The alternative
second drug
(thiazide or CCB)
Hypertension and
chronic kidney
disease
ARB or ACE inhibitor
Note: in black
patients, good
evidence for renal
protective effects of
ACE inhibitors
CCB or thiazide
diuretic
c
The alternative
second drug
(thiazide or CCB)
Hypertension and
clinical coronary
artery disease
d
-Blocker plus ARB or
ACE inhibitor
CCB or thiazide
diuretic
The alternative
second step drug
(thiazide or CCB)

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Hypertension and
stroke history
e
ACE inhibitor or ARB Thiazide diuretic or
CCB
The alternative
second drug (CCB
or thiazide)
Hypertension and
heart failure
Patients with symptomatic heart failure should usually receive an ARB
or ACE inhibitor + b-blocker + diuretic + spironolactone regardless of
blood pressure. A dihydropyridine CCB can be added if needed for BP
control.
ESC guideline 2013
 Target BP is <140/90 mmHg with few exceptions.
 Target BP is <140/85 mmHg in diabetes.
 In elderly patients the target systolic BP is 140-150 mmHg, but <140 mmHg may be
considered in fit elderly.
 In individuals older than 80 years it is recommended to reduce systolic BP to 140-
150 mmHg if they are in good physical and mental condition.
 Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors and angiotensin
receptor blockers (ARBs) are all suitable for the initiation and maintenance of
antihypertensive treatment, either as monotherapy or in combination therapy.
 Some agents should be considered as the preferential choice in specific conditions,
such as:
• Recent myocardial infarction (beta-blocker, ACE-inhibitor, ARB);
• Heart failure (diuretic, beta-blocker, ACE-inhibitor, ARB, mineralocorticoid
receptor antagonist);
• Diabetes or renal dysfunction (ACE-inhibitor, ARB);
• Pregnancy (methyldopa, labetalol, nifedipine)

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Table 5: Comparison of guidelines
JNC-8 ASH/ISH AHA/ACC
Published on 18th
Dec 2013 19th
Dec 2013 21st
Nov 2013
Target goal
For general patients
including DM/CKD
<140/90 <140/90 <140/90
Lower targets may
be appropriate for
LVD, LVH, DM, CKD
For Elderly people 150/90(≥60 yrs) 150/90(≥80 yrs) Lower targets for the
Elderly
Treatment preference
General <60 yrs Initiate Thiazide-type
Diuretic or ACEI or
ARB or CCB
For uptitration, any
possible combination
from above (avoid
ACEI+ARB)
Stage 1 HT:
ACEI or ARB
(If needed, add CCB
or Thiazide-type
Diuretic)
Stage 1 HT:
Thiazide for most
patients or
ACEI, ARB, CCB, (or
combination, if
uncontrolled)
Stage 2 HT:
ACEI or ARB
+
CCB or Thiazide-type
Diuretic
Stage 2 HT:
Thiazide with
ACEI / ARB/ CCB,
or
ACEI with CCB
General ≥60 yrs Same as above Stage 1: CCB or
Thiazide (If needed,
add ACEI or ARB)
Same as Above
Hypertension with
Diabetes
Same as above ACEI or ARB
If needed add CCB or
thiazide-type diuretic
ACEI or ARB,
thiazide, BB, calcium
channel blocker
Hypertension with
CKD
ACEI or ARB alone
Or in combination
with other
ACEI or ARB
If needed add CCB or
thiazide-type diuretic
ACEI or ARB

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drug class
Hypertension with
CAD
--- β-Blocker plus ARB
or ACE inhibitor
If needed add CCB or
thiazide-type diuretic
β-Blocker, ACEI
Hypertension with
stroke
--- ACE inhibitor or ARB
If needed add CCB or
thiazide-type diuretic
Thiazide, ACEI.
Hypertension with HF --- ARB or ACE
inhibitor+ β -
blocker+ diuretic+
spironolactone
regardless of blood
pressure
ACEI or angiotensin-
receptor blocker
(ARB), BB,
aldosterone
antagonist, thiazide;