1) The document defines hypertension and provides its classification and diagnostic criteria. It discusses non-pharmacological and pharmacological treatment options. 2) Specific treatment recommendations are provided for different hypertensive patient groups including those with diabetes, chronic kidney disease, heart disease and the elderly. 3) Treatment of hypertensive emergencies and crises is covered, along with definitions of resistant and refractory hypertension. Device-based renal denervation therapy is mentioned briefly.

1. By: Nur Amalina Aminuddin
Baki

2. Content
 Definition
 Classification
 Diagnosis
 Non pharmalogical
treatment
 Pharmalogical
treatment
 Hypertensive crisis
 Hypertension in
special groups

4. Hypertension
 Persistent elevation of SBP of 140mmHg or
greater and/or DBP 90mmHg or greater

6.  SBP ≥140 mmHg
with DBP <90
mmHg
 Common after 50
years old
 non-pharmacological and aim for adoption of
healthy living.
Isolated Systolic Hypertension
Isolated Office
(White Coat)
Hypertension
Masked
Hypertensio
n
Elevated Clinic BP Normal
Normal Home
BP
Elevated

7. Etiologic Classication
 Primary
 Secondary

8. History
 Duration and level of elevated BP
if known
 Symptoms of
 Secondary causes of hypertension
 Target organ complications
 Risk factor
 Dietary history
 Drug history (OTC / traditional
/complementary medicine
 Lifestyle factors

9. Physical examination
 General examination including
height, weight and waist
circumference
 Measure BP appropriately
 Fundus examination
 Examination for carotid bruit,
abdominal bruit, presence of
peripheral pulses and radio-
femoral delay
 CVS:cardiomegaly, signs of
heart failure and aortic
regurgitation
 P/A: renal masses/bruit and
aortic aneurysm
 CNS: stroke
 Signs of endocrine disorders
(e.g. Cushing syndrome,
acromegaly and thyroid
disease)

10. Investigation
 Full blood count
 Blood glucose
 Renal function tests
(creatinine, eGFR, serum
electrolytes)
 Lipid profile (total
cholesterol, HDL
cholesterol, LDL cholesterol
and triglycerides)
 Urinalysis (dip stick:
albuminuria/microalbuminuri
a & microscopic
haematuria)
 Electrocardiogram (ECG)
 Chest x ray

11. Risk stratification

14. Non-
pharmalogical
management
 Weight reduction
 Reduce salt
intake
 Reduction of
stress
 Reduce
excessive alcohol
intake and
smoking
 Regular physical
exercise
 DASH diet

16. Pharmacological therapy
 At risk hypertension
that failed non-
pharmalogical
method
 Medium/high CV
risk
 SBP >160 and/or
DBP >100 mmHg
 Start monotheraphy for
stage1
 Combination therapy
for stage 2 and above /
Stage 1 with medium
risk
 If ineffective, consider
increasing dose /add
another /substitute
drug
 Measure the BP at the
same time each day.
WHEN TO TREAT : GUIDELINES

17. 1) A or C or D
2) If target not reached,
A+C or A +D
3) If target not reached,
A+C+D
 ACE inhibitor or ARB
 Calcium-channel
blocker
 thiazide Diuretic
STARTING
REGIMENS
Group Target BP
<80 y/o <140/90
>80 y/o <150/90
High risk <130/80

18.  3-6 monthly  stage I (mild)
hypertension with low
global CV risk
 BP well-controlled for
>1 year on the same
medication at the same
dosage
 Agree to be followed-up
at least 3-6 monthly
 motivated to adopt
healthy living
Follow up Step down therapy

20. Thiazide diuretic Beta-blocker Calcium-channel
blocker
Renin Angiotensin
Blocker
Typical
examples
Hydrochlorothiazide
12.5 mg daily
Indapamide (SR)
1.5 mg daily
Atenolol
50 mg daily
Metoprolol
50 mg daily
Propranolol
40 mg daily
Amlodipine
5 mg daily
Nifedipine
5mg TDS
Diltiazem
90mg BD
Verapamil
80 mg TDS
ACE inhibitor
Captopril
25 mg bd
Peridopril
4mg OD
ARB
Irbesartan
150 mg daily
Losartan
50 mg daily
Recomme
nded
in
•Heart failure (mild)
•Older patients
•Angina
•Postmyocardial
infarction
•Tachyarrythmia
•Asthma
•Angina
•PVD
•Heart failure
•PVD
•Diabetes
•Stroke
Contraind
ication
•Type 2 diabetics
•Hyperuricaemia
•Kidney failure
•Asthma
•COPD
•Heart failure
•Heart block
•Heart block
•Heart failure
(verapamil,
diltiazem)
•Bilateral kidney
artery stenosis
•Pregnancy
•Hyperkalaemia
Important
side
effects
•Rashes
•Hypokalaemia
•Hyponatraemia
•Hyperuricaemia
•Bronchospasm
•Cold extremities
•Dyslipidemia
•Headache
•Flushing
•Ankle oedema
•Palpitations
• Cough
• Dysgeusia
• Hyperkalaemia
• Angioedema

21. Miscellaneous Drugs
Groups Recommend
ed
Alpha blocker Prazosin
0.5mg bd/tds
BPH
Alpha, beta
blocker
Labetolol
100mg bd
Hypertension
in pregnancy
Centrally
acting
Methyldopa
250mg bd/tds
Clonidine
50mcg tds
Hypertension
in pregnancy
Resistant
hypertension
Direct
vasodilator
Hydralazine
Minoxidil 5mg
od

22. Hypertensive Crises
 Persistent elevated SBP >180 mmHg and/or
DBP >110 mmHg
 Non compliance/ acute pain/ emotional stress

23. Target Organ
Damage/Complication

25. Hypertensive
Urgency
 Severe increase in
BP which is not
associated with
acute end organ
damage/complicatio
n
damage/complicatio
n
 Aka accelerated
/malignant
hypertension

27. Hypertensive Emergency
 Severe elevation of blood pressure associated
with new or progressive end organ
damage/complication
 Eg. acute heart failure, dissecting aneurysm,
acute coronary syndromes, hypertensive
encephalopathy, acute renal failure,
subarachnoid haemorrhage and/or intracranial
haemorrhage

29. Pg 1.26 sarawak
Drug
s
Dose Remarks
Labetolol
20 mg injected slowly for at least 2 min; followed by 40-80 mg every
10 min.
Max: 200 mg
Caution in heart
failure.
Nitroglycerin
e
Initial: 5-25 mcg/min.
Usual range: 10-200 mcg/ min; up to 400 mcg/min
in some cases.
Preferred in ACS and
acute pulmonary oedema.
Isoke
t
IV infusion 2-20 mg/hr, titrate based on target BP. Preferred in ACS
Hydralazin
e
Initial: 5-10 mg via slow inj, may repeat after 20-30 min.
Alternatively, as a continuous infusion, initial
dose of 0.2-0.3 mg/min.
Maintenance: 0.05-0.15 mg/min.
Caution in ACS, CVA and dissecting
aneurysm.
Unpredictable BP-lowering effects.
Nicardipin
e
Slow IVI at an initial rate of 5 mg/hr. Increase infusion rate as
necessary, up to max 15 mg/hr.
Consider reducing to 3 mg/hr
after response is achieved.
Caution in acute heart failure and
coronary ischaemia.
Esmolol
Loading dose of 80 mg over 15-30 sec, followed by an infusion of
150 mcg/kg/min, may increase to 300 mcg/kg/min if necessary.
Used in perioperative situations and
tachyarrhythmias.
Sodium
Nitroprusside
Initial: 0.3-1.5 mcg/kg/min, adjust gradually
as needed. Usual: 0.5-6 mcg/kg/min. Max rate: 8 mcg/kg/min,
discontinue if there is no response after 10 mins. May continue for a
few hr if there is response.
Caution in heart failure.
Require intraarterial blood pressure
monitoring. Lower dosing adjustmen
required for elderly and those alread
receiving antihypertensives.

30. Hypertension
in
Special Group

31. Stroke

33. Target BP Drug
preferred
Caution
Diabetes <140/90 ACEI
ARB
Diuretic decrease
insulin response
Beta blocker mask
hypoglycemia
Chronic Kidney
Disease
<140/90
<130/80 (proteinuria
≥1g/24hour)
ACEI
ARB
Monitor creatinine
after start
ACEI/ARB
CHD/ Heart
Failure/Atrial
Fibrillation
<140/90
<130/80 (CHD)
Beta blocker
ACEI
ARB
Peripheral Arterial
Disease
<140/90 Beta blocker
worsen intermittent
claudication
Left Ventricular
Hyperthrophy
<130/80 ARB

34. Hypertension in Elderly
Respond to non-
pharmacological treatment
Drug dosage—Monotherapy
‘start low and go slow’
Treat when SBP>160
Age Target SBP
>80 <150
65- 80 <140

35.  BP > 140/90mmHg
despite good medication
adherence while on
three or four anti-
hypertensive agents in
adequate doses.
 Exclude secondary
causes
 Spirinolactone is the
preferred 4th drug
 BP are not
controlled after ≥5
antihypertensives
 Beta blocker/ alpha
blocker or centrally
acting
Resistant Hypertension Refractory Hypertension

36. Device /Procedure based therapy
Renal Denervation Therapy

39. Reference
 Clinical Practical Guideline, Management of
Hypertension, 5th edition, 2018
 Eighth Joint National Committee Guidelines for
Management of Hypertension , 2014