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Hypertension
Dr. Satheesh S, Pharm.D., Rph.,
Associate Professor
Department of Pharmacy Practice
Contents
Contents
● Definition
● Introduction
● Classification
● Etiology
● Signs and Symptoms
● Pathophysiology
● Complications
● Diagnosis
● Treatment Goal
● Non-Pharmacologic Therapy
● Pharmacologic Therapy
Definition
Definition
Blood pressure is the result of the exertion of force by the circulating
blood upon the inner walls of blood vessels, and its intensity is
determined by both cardiac output and the resistance encountered
within the vasculature.
Introduction
Introduction
● Hypertension, commonly known as high blood pressure, is a chronic medical condition
characterized by elevated levels of blood pressure within the arteries.
● The normal range for blood pressure is typically defined as systolic blood pressure (the
pressure when the heart beats) below 120 mm Hg and diastolic blood pressure (the
pressure when the heart is at rest) below 80 mm Hg.
● Globally, hypertension is a significant health concern, impacting populations around the
world and serving as a leading risk factor for various cardiovascular diseases.
● In India, hypertension has reached epidemic proportions, affecting a substantial portion of
the population. This increase is attributed to changing lifestyles, dietary habits, and
urbanization.
Introduction
● Often referred to as the "silent killer," hypertension is asymptomatic in its early stages,
necessitating regular blood pressure monitoring for early detection and prevention, which
is especially critical in the context of the growing issue in India.
● Hypertension development is influenced by various factors. In the Indian context, genetic
predisposition, high salt consumption, stress, and physical inactivity play significant roles.
● Uncontrolled hypertension can lead to severe health consequences, including heart disease,
stroke, kidney problems, and damage to other vital organs. Managing and preventing these
complications on a large scale is a significant challenge for the Indian healthcare system
due to the high prevalence of hypertension.
Classification
Classification
● According to JNC (Joint National Committee) - 7 guidelines for hypertension which is update in
September 2021, the classification is as follows
Category
Systolic BP Range
(mm Hg)
Diastolic BP Range
(mm Hg)
Normal < 120 < 80
Prehypertension 120-139 80-89
Stage 1 140-159 90-99
Stage 2 ≥ 160 ≥ 100
Etiology
Etiology
Hypertension, or high blood pressure, is a complex condition influenced by a combination of genetic,
environmental, and lifestyle factors. The exact causes of hypertension can vary from person to person,
and it is often the result of a combination of factors. Some of the key etiological (causal) factors for
hypertension include:
● Genetics: Family history plays a significant role in the development of hypertension. If you have a
family history of high blood pressure, you may be at a higher risk of developing it yourself.
Certain genetic factors can make individuals more susceptible to hypertension.
● Age: Blood pressure tends to increase with age. This is partly due to the stiffening of arteries and
changes in the cardiovascular system that occur over time.
● Gender: Men and women can both develop hypertension, but the risk can vary by age. Men are
more likely to develop high blood pressure before the age of 55, while women have an increased
risk after menopause.
Etiology
● Race and Ethnicity: Some racial and ethnic groups, such as African Americans, have a higher
predisposition to hypertension. They are also more likely to develop it at an earlier age and often
experience more severe forms of the condition.
● Obesity: Excess body weight, especially around the abdomen, is a significant risk factor for
hypertension. Obesity can lead to increased resistance in blood vessels and overall higher blood
pressure.
● Diet: A diet high in salt (sodium), saturated and trans fats, and low in potassium and other
essential nutrients can contribute to hypertension. Excessive salt intake, in particular, can lead to
water retention and increased blood pressure.
● Physical Inactivity: A sedentary lifestyle can lead to obesity and a decrease in overall
cardiovascular health, increasing the risk of hypertension.
Etiology
● Alcohol Consumption: Excessive alcohol consumption can raise blood pressure. While moderate
alcohol consumption may have some cardiovascular benefits, excessive drinking is detrimental.
● Smoking: Smoking or exposure to secondhand smoke can damage blood vessels and raise blood
pressure. Nicotine, a component of tobacco, can constrict blood vessels.
● Stress: Chronic stress and high levels of stress hormones can contribute to hypertension. Stress
can lead to unhealthy coping behaviors, such as overeating or excessive alcohol consumption.
● Sleep Apnea: Sleep apnea, a condition in which a person's breathing is interrupted during sleep,
is associated with hypertension. Treating sleep apnea can help manage blood pressure.
● Chronic Kidney Disease: Kidneys play a crucial role in regulating blood pressure. Damage to the
kidneys, such as that caused by kidney disease, can lead to high blood pressure.
Etiology
● Hormonal Factors: Conditions like Cushing's syndrome and primary aldosteronism, which affect
hormone levels in the body, can lead to hypertension.
● Medications and Other Medical Conditions: Some medications, such as non-steroidal
anti-inflammatory drugs (NSAIDs), decongestants, and birth control pills, can raise blood
pressure. Additionally, certain medical conditions, like diabetes, can increase the risk of
hypertension.
Signs and Symptoms
Signs and Symptoms
● Headaches: Frequent headaches, especially in the morning, can be a symptom of hypertension
due to increased pressure in the blood vessels of the brain.
● Fatigue: Persistent fatigue and a lack of energy are common in individuals with uncontrolled
high blood pressure.
● Shortness of Breath: Difficulty in breathing or shortness of breath may occur, particularly
during physical activity or exertion.
● Chest Pain: Hypertension can strain the heart, leading to chest pain or discomfort, especially
during physical activity or emotional stress.
● Vision Changes: Blurred vision or visual disturbances can result from hypertension-induced
damage to blood vessels in the eyes.
● Dizziness: Feeling lightheaded or dizzy may be a sign of fluctuating blood pressure.
Signs and Symptoms
● Irregular Heartbeat (Arrhythmia): Hypertension can contribute to irregular heart rhythms,
leading to palpitations or sensations of a racing heart.
● Nosebleeds: Frequent nosebleeds may be linked to high blood pressure, although other factors
can also cause them.
● Tinnitus (Ringing in Ears): Ringing or buzzing sounds in the ears can occur in individuals with
hypertension.
● Nausea and Vomiting: Hypertension can cause nausea and, in some cases, vomiting.
● Confusion or Cognitive Impairment: Cognitive changes, including confusion or memory
problems, can be related to untreated hypertension.
● Chest Congestion: Fluid buildup in the lungs due to hypertension can cause chest congestion
and a persistent cough.
Signs and Symptoms
● Swelling (Edema): Hypertension can lead to fluid retention and swelling in the ankles, legs, or
other parts of the body.
● Frequent Urination: Excessive urination, especially at night, may be a symptom of uncontrolled
high blood pressure.
● Facial Flushing: Redness or flushing of the face, particularly when accompanied by a feeling of
warmth, can sometimes occur in individuals with hypertension.
Pathophysiology
Pathophysiology
● Blood Pressure is directly Proportional to Cardiac output and Peripheral Vascular Resistance
● Cardiac Output and Peripheral Vascular Resistance is controlled by Baroreceptor Reflex and
Renin Angiotensin Aldosterone System
● Anti hypertensive agents lowers the blood pressure by reducing cardiac output and decreasing
peripheral resistance
Arterial Pressure
Cardiac Output Peripheral Resistance
Vascular Function
Vascular Structure
Heart Rate
Stroke Volume
Baroreceptors and Sympathetic Nervous System
● Baroreceptors act by changing the activity of sympathetic and parasympathetic nervous system
Example: If Low BP - Activate Sympathetic and If High BP - Activate Parasympathetic
● Baro reflux is also known as baroreceptor reflex. Main work is to regulate blood pressure
● Baro receptor is located in Aortic Arch and Carotid Sinus (A widening in the carotid artery in the
neck)
● A fall in Blood Pressure Causes a pressure sensitive neurons to send fewer impulses to
cardiovascular centers in spinal cord. It causes the increase in sympathetic activity and decrease
in parasympathetic activity.
Baroreceptors and Sympathetic Nervous System
Baroreceptor Reflex
Increased
Blood
Pressure
Decreased
Blood
Pressure
Increased
Baroreceptor
Activity
Decreased
Baroreceptor
Activity
Contd…
Increase in
number of afferent
impulses towards
the cardiovascular
centre
Decrease in
number of afferent
impulses towards
the cardiovascular
centre
Increased PSNS activity
Decreased SNS activity
Increased SNS activity
Decreased PSNS activity
Decrease in Cardiac
Output and Vasodilation to
reduce blood pressure
Increase in Cardiac Output
and Vasoconstriction to
increase blood pressure
Renin Angiotensin Aldosterone System (RAAS)
Renin Angiotensin Aldosterone System (RAAS) is a complex system in body that plays a crucial role in
regulating Blood Pressure, Fluid Balance, and electrolyte homeostasis
● Renin: Renin is an enzyme produced by kidney cells called juxtaglomerular cells. It is released in
response to decrease in blood pressure, decrease in blood volume, decreased sodium levels in
blood.
● Angiotensinogen: Renin acts on Angiotensinogen to produce Angiotensin I
● Angiotensin I: Angiotensin I is an inactive precursor peptide
● Angiotensin II: Stimulate the release of Aldosterone
● Aldosterone: Promotes reabsorption of Na+ and excretion of K+
● AntiDiuretic Hormone: Increases thirst and reduces urine output to help regulate fluid balance
in the body.
● Vasopressin: Regulates water reabsorption in the kidneys and plays a role in osmotic balance.
Renin Angiotensin Aldosterone System (RAAS)
(Reduced Blood
Flow to Kidneys)
Angiotensinogen
Renin
Angiotensin I
Angiotensin
Converting
Enzyme
Angiotensin II
Aldosterone
(Secreted by Adrenal
gland)
Mineralocorticoid
Receptor
Sodium and Water
Reabsorption
HYPERTENSION
Vasculature
Vasoconstriction
Low Blood
Pressure
Complications
Complications
Hypertension, if left uncontrolled or untreated, can lead to a range of serious complications, including:
● Cardiovascular Disease: High blood pressure is a major risk factor for heart disease, including
coronary artery disease, heart attacks, and heart failure.
● Stroke: Hypertension increases the risk of stroke, both ischemic (caused by a blood clot) and
hemorrhagic (caused by bleeding in the brain).
● Kidney Damage: Prolonged hypertension can harm the blood vessels in the kidneys, potentially
leading to chronic kidney disease or kidney failure.
● Eye Problems: Hypertension can damage the blood vessels in the eyes, causing retinopathy and
increasing the risk of vision loss.
● Peripheral Artery Disease: Narrowing of the arteries due to hypertension can lead to reduced
blood flow to the limbs, increasing the risk of peripheral artery disease.
Complications
● Aneurysms: High blood pressure can weaken the walls of arteries and lead to the development
of aneurysms, which can rupture and be life-threatening.
● Cognitive Impairment: Hypertension is associated with an increased risk of cognitive decline,
vascular dementia, and Alzheimer's disease.
● Metabolic Syndrome: Hypertension is often part of a cluster of metabolic abnormalities that
include obesity, high blood sugar, and high cholesterol, increasing the risk of diabetes and
cardiovascular disease.
● Sexual Dysfunction: Hypertension can contribute to erectile dysfunction in men and reduced
sexual desire in both men and women.
● Preeclampsia: In pregnant women, hypertension can lead to a condition called preeclampsia,
which can be dangerous for both the mother and the baby.
Complications
● Arrhythmias: High blood pressure can disrupt the normal rhythm of the heart, leading to
arrhythmias.
● Heart Valve Problems: Hypertension can cause the heart to work harder, potentially leading to
valve problems over time.
● Thickening of the Heart Muscle (Hypertrophy): The heart may enlarge and thicken in
response to high blood pressure, which can impair its function.
● Obstructive Sleep Apnea: Hypertension and sleep apnea often coexist, and untreated sleep
apnea can exacerbate high blood pressure.
● Increased Risk of Atherosclerosis: Hypertension is a major contributor to the development of
atherosclerosis (hardening and narrowing of the arteries), which can affect various organs.
Diagnosis
Diagnosis
● Patient history collection
● History of Diabetes mellitus
● Blood Pressure Monitoring
● Ambulatory BP Monitoring
● Lifestyle and Risk Factor Evaluation
● Uric acid
● Lipid profile
● C-reactive Protein (CRP)
● Cardiac Biomarkers
● Electrocardiogram
Treatment Goal
Treatment Goal
● Blood Pressure Control: The main goal is to lower and maintain blood pressure at a
level that reduces the risk of cardiovascular events. This often involves achieving a
blood pressure below 130/80 mm Hg.
● Lifestyle Modifications: Encourage lifestyle changes that can help control blood
pressure, such as maintaining a healthy diet low in salt, saturated fats, and processed
foods, engaging in regular physical activity, losing weight if necessary, and limiting
alcohol and caffeine intake.
● Medication Management: If lifestyle modifications are insufficient to control blood
pressure, healthcare providers may prescribe antihypertensive medications. The goal is
to find the right combination and dosage of medications to effectively lower blood
pressure while minimizing side effects.
Treatment Goal
● Regular Monitoring: Patients should have their blood pressure regularly monitored
by a healthcare professional to track progress and adjust treatment plans as needed.
● Risk Factor Management: In addition to controlling blood pressure, it's important to
manage other risk factors for heart disease, such as diabetes, high cholesterol, and
obesity, as these are often comorbid conditions with hypertension.
● Patient Education: Provide education to patients about the importance of medication
adherence, lifestyle modifications, and the potential consequences of uncontrolled
hypertension. Ensure that patients understand their condition and treatment plan.
● Cultural Sensitivity: Be culturally sensitive when providing care to Indian patients.
Take into account cultural practices, dietary preferences, and beliefs that may influence
their ability to manage their hypertension.
Treatment Goal
● Stress Management: Help patients manage stress, as stress can contribute to elevated
blood pressure. Techniques such as relaxation exercises, mindfulness, or meditation
may be beneficial.
● Dietary Guidelines: Provide guidance on dietary changes specific to the Indian
context. Encourage consumption of foods that are part of a traditional, heart-healthy
Indian diet, such as fruits, vegetables, legumes, and whole grains.
● Regular Follow-Up: Schedule regular follow-up appointments to assess progress and
adjust the treatment plan as necessary.
Non-Pharmacological Therapy
Non-Pharmacological Therapy
● Dietary Modifications:
○ Reduce Sodium Intake: Indian diets often contain high levels of salt, which can
contribute to hypertension. Encourage patients to reduce their salt intake by
avoiding or minimizing the use of high-sodium condiments, pickles, and
processed foods.
○ Increase Potassium: Encourage the consumption of potassium-rich foods like
bananas, oranges, and leafy greens, which can help counteract the effects of
sodium on blood pressure.
○ Adopt the DASH Diet: The Dietary Approaches to Stop Hypertension (DASH)
diet, which emphasizes fruits, vegetables, whole grains, and lean proteins, can be
effective in reducing blood pressure.
Non-Pharmacological Therapy
● Physical Activity:
○ Regular Exercise: Promote regular physical activity, such as brisk walking, yoga,
or swimming. Encourage at least 150 minutes of moderate-intensity exercise per
week.
○ Yoga and Meditation: These practices are culturally relevant in India and can
help manage stress, which is often associated with hypertension.
● Weight Management:
○ Obesity Prevention: Indian patients should aim for a healthy weight, as excess
body weight can contribute to hypertension. Encourage weight loss through a
combination of dietary changes and exercise.
Non-Pharmacological Therapy
● Tobacco and Alcohol Cessation:
○ Smoking Cessation: Provide support and resources to help patients quit smoking,
as tobacco use is a significant risk factor for hypertension and cardiovascular
disease.
○ Alcohol Moderation: If patients consume alcohol, advise moderation and, if
necessary, reducing or eliminating alcohol intake.
● Stress Reduction:
○ Stress Management Techniques: Teach stress-reduction techniques, such as deep
breathing exercises, mindfulness, and meditation, which are culturally accepted
practices in India.
Non-Pharmacological Therapy
● Herbal and Ayurvedic Approaches:
○ Some patients may be interested in or currently use herbal remedies or
Ayurvedic treatments. While these can be complementary, it's essential to ensure
that they do not interfere with prescribed medications and that patients discuss
their use with a healthcare provider.
● Regular Monitoring:
○ Encourage patients to measure their blood pressure at home regularly. This can
help individuals track their progress and adjust their lifestyle modifications
accordingly.
Non-Pharmacological Therapy
● Cultural Considerations:
○ Be aware of cultural dietary preferences and traditions. Help patients make
healthier choices within the context of their cultural norms.
● Education and Support:
○ Provide education on the risks of hypertension, its complications, and the
importance of adhering to lifestyle changes. Offer ongoing support and
reinforcement of positive behaviors.
Pharmacological Therapy
1. Diuretics:
Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure.
Subclassifications:
a. Thiazide Diuretics:
Hydrochlorothiazide:
Min Dose: 12.5 mg; Max Dose: 50 mg
T-half: 5.6-14.8 hours; Dosage Form: Tablet (Tab)
Common ADRs: Electrolyte imbalances, increased urination, dehydration
Chlorthalidone:
Min Dose: 12.5 mg; Max Dose: 50 mg
T-half: 40-60 hours; Dosage Form: Tab
Common ADRs: Electrolyte imbalances, increased urination, dehydration
Pharmacological Therapy
1. Diuretics:
Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure.
Subclassifications:
b. Loop Diuretics:
Furosemide:
Min Dose: 20 mg; Max Dose: 160 mg
T-half: 2 hours; Dosage Form: Tab
Common ADRs: Electrolyte imbalances, increased urination, dehydration
Pharmacological Therapy
1. Diuretics:
Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure.
Subclassifications:
c. Potassium-Sparing Diuretics:
Spironolactone:
Min Dose: 25 mg; Max Dose: 100 mg
T-half: 1.3-1.6 hours; Dosage Form: Tab
Common ADRs: Hyperkalemia, gynecomastia, menstrual irregularities
Amiloride:
Min Dose: 5 mg; Max Dose: 10 mg
T-half: 6-9 hours; Dosage Form: Tab
Common ADRs: Hyperkalemia, metabolic acidosis, muscle cramps
Pharmacological Therapy
2. Beta Blockers:
Mechanism of Action: Reduce heart rate and contractility, lowering blood pressure.
Metoprolol:
Min Dose: 25 mg; Max Dose: 200 mg
T-half: 3-7 hours; Dosage Form: Tab
Common ADRs: Bradycardia, fatigue, cold extremities
Propranolol:
Min Dose: 10 mg; Max Dose: 80 mg
T-half: 3-6 hours; Dosage Form: Tab
Common ADRs: Bradycardia, fatigue, cold extremities
Pharmacological Therapy
2. Beta Blockers:
Mechanism of Action: Reduce heart rate and contractility, lowering blood pressure.
Atenolol:
Min Dose: 25 mg; Max Dose: 100 mg
T-half: 6-7 hours; Dosage Form: Tab
Common ADRs: Bradycardia, fatigue, cold extremities
Pharmacological Therapy
3. Alpha Blockers:
Mechanism of Action: Block alpha-adrenergic receptors, causing vasodilation and reduced
blood pressure.
Doxazosin:
Min Dose: 1 mg; Max Dose: 16 mg
T-half: 22 hours; Dosage Form: Tab
Common ADRs: Dizziness, headache, nasal congestion
Prazosin:
Min Dose: 1 mg; Max Dose: 20 mg
T-half: 2-3 hours; Dosage Form: Tab
Common ADRs: Dizziness, headache, nasal congestion
Pharmacological Therapy
4. Combined Alpha and Beta Blockers:
Mechanism of Action: Block both alpha and beta receptors to lower blood pressure.
Carvedilol:
Min Dose: 3.125 mg; Max Dose: 25 mg
T-half: 7-10 hours; Dosage Form: Tab
Common ADRs: Fatigue, dizziness, orthostatic hypotension
Labetalol:
Min Dose: 100 mg; Max Dose: 400 mg
T-half: 5.5-8 hours; Dosage Form: Tab
Common ADRs: Fatigue, dizziness, orthostatic hypotension
Pharmacological Therapy
5. ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors):
Mechanism of Action: Block the conversion of angiotensin I to angiotensin II, leading to
vasodilation and reduced blood pressure.
Enalapril:
Min Dose: 2.5 mg; Max Dose: 20 mg
T-half: 2 hours; Dosage Form: Tab
Common ADRs: Cough, hyperkalemia, kidney dysfunction
Lisinopril:
Min Dose: 2.5 mg; Max Dose: 40 mg
T-half: 12 hours; Dosage Form: Tab
Common ADRs: Cough, hyperkalemia, kidney dysfunction
Pharmacological Therapy
5. ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors):
Mechanism of Action: Block the conversion of angiotensin I to angiotensin II, leading to
vasodilation and reduced blood pressure.
Ramipril:
Min Dose: 2.5 mg; Max Dose: 10 mg
T-half: 13-17 hours; Dosage Form: Tab
Common ADRs: Cough, hyperkalemia, kidney dysfunction
Pharmacological Therapy
Pharmacological Therapy
6. Angiotensin Receptor Blockers (ARBs):
Mechanism of Action: Block the effects of angiotensin II, resulting in vasodilation and
lowered blood pressure.
Losartan:
Min Dose: 25 mg; Max Dose: 100 mg
T-half: 1.5-2 hours; Dosage Form: Tab
Common ADRs: Dizziness, hyperkalemia, fatigue
Valsartan:
Min Dose: 40 mg; Max Dose: 320 mg
T-half: 6 hours; Dosage Form: Tab
Common ADRs: Dizziness, hyperkalemia, fatigue
Pharmacological Therapy
6. Angiotensin Receptor Blockers (ARBs):
Mechanism of Action: Block the effects of angiotensin II, resulting in vasodilation and
lowered blood pressure.
Olmesartan:
Min Dose: 10 mg; Max Dose: 40 mg
T-half: 12 hours; Dosage Form: Tab
Common ADRs: Dizziness, hyperkalemia, fatigue
7. Calcium Channel Blockers:
Mechanism of Action: Inhibit calcium entry into cells, causing vasodilation and reduced
blood pressure.
Amlodipine:
Min Dose: 2.5 mg; Max Dose: 10 mg
T-half: 30-50 hours; Dosage Form: Tab
Common ADRs: Peripheral edema, headache, dizziness
Nifedipine:
Min Dose: 10 mg; Max Dose: 90 mg
T-half: 2-5 hours; Dosage Form: Tab
Common ADRs: Peripheral edema, headache, dizziness
Pharmacological Therapy
Pharmacological Therapy
8. Vasodilators:
Mechanism of Action: Directly relax and dilate blood vessels, reducing blood pressure.
Subclassifications:
a. Direct-Acting Vasodilators:
Hydralazine:
Min Dose: 10 mg; Max Dose: 100 mg
T-half: 2-4 hours; Dosage Form: Tab
Common ADRs: Headache, flushing, rapid heart rate
Minoxidil:
Min Dose: 2.5 mg; Max Dose: 100 mg
T-half: 4 hours; Dosage Form: Tab
Common ADRs: Headache, flushing, rapid heart rate
Pharmacological Therapy
8. Vasodilators:
Mechanism of Action: Directly relax and dilate blood vessels, reducing blood pressure.
Subclassifications:
b. Nitrate Vasodilators:
Nitroglycerin (sublingual):
Min Dose: 0.4 mg; Max Dose: 2.4 mg
T-half: 1-4 minutes; Dosage Form: Sublingual Tablet (Subl Tab)
Common ADRs: Headache, flushing, rapid heart rate
Pharmacological Therapy
9. Central Sympatholytics:
Mechanism of Action: Act on the central nervous system to reduce sympathetic nerve
signals and lower blood pressure.
Clonidine:
Min Dose: 0.1 mg; Max Dose: 0.8 mg
T-half: 9-12 hours; Dosage Form: Tab
Common ADRs: Drowsiness, dry mouth, bradycardia
Methyldopa:
Min Dose: 125 mg; Max Dose: 500 mg
T-half: 1.5-2 hours; Dosage Form: Tab
Common ADRs: Drowsiness, dry mouth, bradycardia
Pharmacological Therapy
10. Direct Renin Inhibitors:
Mechanism of Action: Inhibit the enzyme renin, which is involved in the
renin-angiotensin-aldosterone system, leading to blood pressure reduction.
Aliskiren:
Min Dose: 150 mg; Max Dose: 300 mg
T-half: 24 hours; Dosage Form: Tab
Common ADRs: Diarrhea, cough, hyperkalemia
Thank You

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Hypertension.pdf

  • 1. Hypertension Dr. Satheesh S, Pharm.D., Rph., Associate Professor Department of Pharmacy Practice
  • 3. Contents ● Definition ● Introduction ● Classification ● Etiology ● Signs and Symptoms ● Pathophysiology ● Complications ● Diagnosis ● Treatment Goal ● Non-Pharmacologic Therapy ● Pharmacologic Therapy
  • 5. Definition Blood pressure is the result of the exertion of force by the circulating blood upon the inner walls of blood vessels, and its intensity is determined by both cardiac output and the resistance encountered within the vasculature.
  • 7. Introduction ● Hypertension, commonly known as high blood pressure, is a chronic medical condition characterized by elevated levels of blood pressure within the arteries. ● The normal range for blood pressure is typically defined as systolic blood pressure (the pressure when the heart beats) below 120 mm Hg and diastolic blood pressure (the pressure when the heart is at rest) below 80 mm Hg. ● Globally, hypertension is a significant health concern, impacting populations around the world and serving as a leading risk factor for various cardiovascular diseases. ● In India, hypertension has reached epidemic proportions, affecting a substantial portion of the population. This increase is attributed to changing lifestyles, dietary habits, and urbanization.
  • 8. Introduction ● Often referred to as the "silent killer," hypertension is asymptomatic in its early stages, necessitating regular blood pressure monitoring for early detection and prevention, which is especially critical in the context of the growing issue in India. ● Hypertension development is influenced by various factors. In the Indian context, genetic predisposition, high salt consumption, stress, and physical inactivity play significant roles. ● Uncontrolled hypertension can lead to severe health consequences, including heart disease, stroke, kidney problems, and damage to other vital organs. Managing and preventing these complications on a large scale is a significant challenge for the Indian healthcare system due to the high prevalence of hypertension.
  • 10. Classification ● According to JNC (Joint National Committee) - 7 guidelines for hypertension which is update in September 2021, the classification is as follows Category Systolic BP Range (mm Hg) Diastolic BP Range (mm Hg) Normal < 120 < 80 Prehypertension 120-139 80-89 Stage 1 140-159 90-99 Stage 2 ≥ 160 ≥ 100
  • 12. Etiology Hypertension, or high blood pressure, is a complex condition influenced by a combination of genetic, environmental, and lifestyle factors. The exact causes of hypertension can vary from person to person, and it is often the result of a combination of factors. Some of the key etiological (causal) factors for hypertension include: ● Genetics: Family history plays a significant role in the development of hypertension. If you have a family history of high blood pressure, you may be at a higher risk of developing it yourself. Certain genetic factors can make individuals more susceptible to hypertension. ● Age: Blood pressure tends to increase with age. This is partly due to the stiffening of arteries and changes in the cardiovascular system that occur over time. ● Gender: Men and women can both develop hypertension, but the risk can vary by age. Men are more likely to develop high blood pressure before the age of 55, while women have an increased risk after menopause.
  • 13. Etiology ● Race and Ethnicity: Some racial and ethnic groups, such as African Americans, have a higher predisposition to hypertension. They are also more likely to develop it at an earlier age and often experience more severe forms of the condition. ● Obesity: Excess body weight, especially around the abdomen, is a significant risk factor for hypertension. Obesity can lead to increased resistance in blood vessels and overall higher blood pressure. ● Diet: A diet high in salt (sodium), saturated and trans fats, and low in potassium and other essential nutrients can contribute to hypertension. Excessive salt intake, in particular, can lead to water retention and increased blood pressure. ● Physical Inactivity: A sedentary lifestyle can lead to obesity and a decrease in overall cardiovascular health, increasing the risk of hypertension.
  • 14. Etiology ● Alcohol Consumption: Excessive alcohol consumption can raise blood pressure. While moderate alcohol consumption may have some cardiovascular benefits, excessive drinking is detrimental. ● Smoking: Smoking or exposure to secondhand smoke can damage blood vessels and raise blood pressure. Nicotine, a component of tobacco, can constrict blood vessels. ● Stress: Chronic stress and high levels of stress hormones can contribute to hypertension. Stress can lead to unhealthy coping behaviors, such as overeating or excessive alcohol consumption. ● Sleep Apnea: Sleep apnea, a condition in which a person's breathing is interrupted during sleep, is associated with hypertension. Treating sleep apnea can help manage blood pressure. ● Chronic Kidney Disease: Kidneys play a crucial role in regulating blood pressure. Damage to the kidneys, such as that caused by kidney disease, can lead to high blood pressure.
  • 15. Etiology ● Hormonal Factors: Conditions like Cushing's syndrome and primary aldosteronism, which affect hormone levels in the body, can lead to hypertension. ● Medications and Other Medical Conditions: Some medications, such as non-steroidal anti-inflammatory drugs (NSAIDs), decongestants, and birth control pills, can raise blood pressure. Additionally, certain medical conditions, like diabetes, can increase the risk of hypertension.
  • 17. Signs and Symptoms ● Headaches: Frequent headaches, especially in the morning, can be a symptom of hypertension due to increased pressure in the blood vessels of the brain. ● Fatigue: Persistent fatigue and a lack of energy are common in individuals with uncontrolled high blood pressure. ● Shortness of Breath: Difficulty in breathing or shortness of breath may occur, particularly during physical activity or exertion. ● Chest Pain: Hypertension can strain the heart, leading to chest pain or discomfort, especially during physical activity or emotional stress. ● Vision Changes: Blurred vision or visual disturbances can result from hypertension-induced damage to blood vessels in the eyes. ● Dizziness: Feeling lightheaded or dizzy may be a sign of fluctuating blood pressure.
  • 18. Signs and Symptoms ● Irregular Heartbeat (Arrhythmia): Hypertension can contribute to irregular heart rhythms, leading to palpitations or sensations of a racing heart. ● Nosebleeds: Frequent nosebleeds may be linked to high blood pressure, although other factors can also cause them. ● Tinnitus (Ringing in Ears): Ringing or buzzing sounds in the ears can occur in individuals with hypertension. ● Nausea and Vomiting: Hypertension can cause nausea and, in some cases, vomiting. ● Confusion or Cognitive Impairment: Cognitive changes, including confusion or memory problems, can be related to untreated hypertension. ● Chest Congestion: Fluid buildup in the lungs due to hypertension can cause chest congestion and a persistent cough.
  • 19. Signs and Symptoms ● Swelling (Edema): Hypertension can lead to fluid retention and swelling in the ankles, legs, or other parts of the body. ● Frequent Urination: Excessive urination, especially at night, may be a symptom of uncontrolled high blood pressure. ● Facial Flushing: Redness or flushing of the face, particularly when accompanied by a feeling of warmth, can sometimes occur in individuals with hypertension.
  • 21. Pathophysiology ● Blood Pressure is directly Proportional to Cardiac output and Peripheral Vascular Resistance ● Cardiac Output and Peripheral Vascular Resistance is controlled by Baroreceptor Reflex and Renin Angiotensin Aldosterone System ● Anti hypertensive agents lowers the blood pressure by reducing cardiac output and decreasing peripheral resistance Arterial Pressure Cardiac Output Peripheral Resistance Vascular Function Vascular Structure Heart Rate Stroke Volume
  • 22. Baroreceptors and Sympathetic Nervous System ● Baroreceptors act by changing the activity of sympathetic and parasympathetic nervous system Example: If Low BP - Activate Sympathetic and If High BP - Activate Parasympathetic ● Baro reflux is also known as baroreceptor reflex. Main work is to regulate blood pressure ● Baro receptor is located in Aortic Arch and Carotid Sinus (A widening in the carotid artery in the neck) ● A fall in Blood Pressure Causes a pressure sensitive neurons to send fewer impulses to cardiovascular centers in spinal cord. It causes the increase in sympathetic activity and decrease in parasympathetic activity.
  • 23. Baroreceptors and Sympathetic Nervous System Baroreceptor Reflex Increased Blood Pressure Decreased Blood Pressure Increased Baroreceptor Activity Decreased Baroreceptor Activity
  • 24. Contd… Increase in number of afferent impulses towards the cardiovascular centre Decrease in number of afferent impulses towards the cardiovascular centre Increased PSNS activity Decreased SNS activity Increased SNS activity Decreased PSNS activity Decrease in Cardiac Output and Vasodilation to reduce blood pressure Increase in Cardiac Output and Vasoconstriction to increase blood pressure
  • 25. Renin Angiotensin Aldosterone System (RAAS) Renin Angiotensin Aldosterone System (RAAS) is a complex system in body that plays a crucial role in regulating Blood Pressure, Fluid Balance, and electrolyte homeostasis ● Renin: Renin is an enzyme produced by kidney cells called juxtaglomerular cells. It is released in response to decrease in blood pressure, decrease in blood volume, decreased sodium levels in blood. ● Angiotensinogen: Renin acts on Angiotensinogen to produce Angiotensin I ● Angiotensin I: Angiotensin I is an inactive precursor peptide ● Angiotensin II: Stimulate the release of Aldosterone ● Aldosterone: Promotes reabsorption of Na+ and excretion of K+ ● AntiDiuretic Hormone: Increases thirst and reduces urine output to help regulate fluid balance in the body. ● Vasopressin: Regulates water reabsorption in the kidneys and plays a role in osmotic balance.
  • 26. Renin Angiotensin Aldosterone System (RAAS) (Reduced Blood Flow to Kidneys) Angiotensinogen Renin Angiotensin I Angiotensin Converting Enzyme Angiotensin II Aldosterone (Secreted by Adrenal gland) Mineralocorticoid Receptor Sodium and Water Reabsorption HYPERTENSION Vasculature Vasoconstriction Low Blood Pressure
  • 28. Complications Hypertension, if left uncontrolled or untreated, can lead to a range of serious complications, including: ● Cardiovascular Disease: High blood pressure is a major risk factor for heart disease, including coronary artery disease, heart attacks, and heart failure. ● Stroke: Hypertension increases the risk of stroke, both ischemic (caused by a blood clot) and hemorrhagic (caused by bleeding in the brain). ● Kidney Damage: Prolonged hypertension can harm the blood vessels in the kidneys, potentially leading to chronic kidney disease or kidney failure. ● Eye Problems: Hypertension can damage the blood vessels in the eyes, causing retinopathy and increasing the risk of vision loss. ● Peripheral Artery Disease: Narrowing of the arteries due to hypertension can lead to reduced blood flow to the limbs, increasing the risk of peripheral artery disease.
  • 29. Complications ● Aneurysms: High blood pressure can weaken the walls of arteries and lead to the development of aneurysms, which can rupture and be life-threatening. ● Cognitive Impairment: Hypertension is associated with an increased risk of cognitive decline, vascular dementia, and Alzheimer's disease. ● Metabolic Syndrome: Hypertension is often part of a cluster of metabolic abnormalities that include obesity, high blood sugar, and high cholesterol, increasing the risk of diabetes and cardiovascular disease. ● Sexual Dysfunction: Hypertension can contribute to erectile dysfunction in men and reduced sexual desire in both men and women. ● Preeclampsia: In pregnant women, hypertension can lead to a condition called preeclampsia, which can be dangerous for both the mother and the baby.
  • 30. Complications ● Arrhythmias: High blood pressure can disrupt the normal rhythm of the heart, leading to arrhythmias. ● Heart Valve Problems: Hypertension can cause the heart to work harder, potentially leading to valve problems over time. ● Thickening of the Heart Muscle (Hypertrophy): The heart may enlarge and thicken in response to high blood pressure, which can impair its function. ● Obstructive Sleep Apnea: Hypertension and sleep apnea often coexist, and untreated sleep apnea can exacerbate high blood pressure. ● Increased Risk of Atherosclerosis: Hypertension is a major contributor to the development of atherosclerosis (hardening and narrowing of the arteries), which can affect various organs.
  • 32. Diagnosis ● Patient history collection ● History of Diabetes mellitus ● Blood Pressure Monitoring ● Ambulatory BP Monitoring ● Lifestyle and Risk Factor Evaluation ● Uric acid ● Lipid profile ● C-reactive Protein (CRP) ● Cardiac Biomarkers ● Electrocardiogram
  • 34. Treatment Goal ● Blood Pressure Control: The main goal is to lower and maintain blood pressure at a level that reduces the risk of cardiovascular events. This often involves achieving a blood pressure below 130/80 mm Hg. ● Lifestyle Modifications: Encourage lifestyle changes that can help control blood pressure, such as maintaining a healthy diet low in salt, saturated fats, and processed foods, engaging in regular physical activity, losing weight if necessary, and limiting alcohol and caffeine intake. ● Medication Management: If lifestyle modifications are insufficient to control blood pressure, healthcare providers may prescribe antihypertensive medications. The goal is to find the right combination and dosage of medications to effectively lower blood pressure while minimizing side effects.
  • 35. Treatment Goal ● Regular Monitoring: Patients should have their blood pressure regularly monitored by a healthcare professional to track progress and adjust treatment plans as needed. ● Risk Factor Management: In addition to controlling blood pressure, it's important to manage other risk factors for heart disease, such as diabetes, high cholesterol, and obesity, as these are often comorbid conditions with hypertension. ● Patient Education: Provide education to patients about the importance of medication adherence, lifestyle modifications, and the potential consequences of uncontrolled hypertension. Ensure that patients understand their condition and treatment plan. ● Cultural Sensitivity: Be culturally sensitive when providing care to Indian patients. Take into account cultural practices, dietary preferences, and beliefs that may influence their ability to manage their hypertension.
  • 36. Treatment Goal ● Stress Management: Help patients manage stress, as stress can contribute to elevated blood pressure. Techniques such as relaxation exercises, mindfulness, or meditation may be beneficial. ● Dietary Guidelines: Provide guidance on dietary changes specific to the Indian context. Encourage consumption of foods that are part of a traditional, heart-healthy Indian diet, such as fruits, vegetables, legumes, and whole grains. ● Regular Follow-Up: Schedule regular follow-up appointments to assess progress and adjust the treatment plan as necessary.
  • 38. Non-Pharmacological Therapy ● Dietary Modifications: ○ Reduce Sodium Intake: Indian diets often contain high levels of salt, which can contribute to hypertension. Encourage patients to reduce their salt intake by avoiding or minimizing the use of high-sodium condiments, pickles, and processed foods. ○ Increase Potassium: Encourage the consumption of potassium-rich foods like bananas, oranges, and leafy greens, which can help counteract the effects of sodium on blood pressure. ○ Adopt the DASH Diet: The Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains, and lean proteins, can be effective in reducing blood pressure.
  • 39. Non-Pharmacological Therapy ● Physical Activity: ○ Regular Exercise: Promote regular physical activity, such as brisk walking, yoga, or swimming. Encourage at least 150 minutes of moderate-intensity exercise per week. ○ Yoga and Meditation: These practices are culturally relevant in India and can help manage stress, which is often associated with hypertension. ● Weight Management: ○ Obesity Prevention: Indian patients should aim for a healthy weight, as excess body weight can contribute to hypertension. Encourage weight loss through a combination of dietary changes and exercise.
  • 40. Non-Pharmacological Therapy ● Tobacco and Alcohol Cessation: ○ Smoking Cessation: Provide support and resources to help patients quit smoking, as tobacco use is a significant risk factor for hypertension and cardiovascular disease. ○ Alcohol Moderation: If patients consume alcohol, advise moderation and, if necessary, reducing or eliminating alcohol intake. ● Stress Reduction: ○ Stress Management Techniques: Teach stress-reduction techniques, such as deep breathing exercises, mindfulness, and meditation, which are culturally accepted practices in India.
  • 41. Non-Pharmacological Therapy ● Herbal and Ayurvedic Approaches: ○ Some patients may be interested in or currently use herbal remedies or Ayurvedic treatments. While these can be complementary, it's essential to ensure that they do not interfere with prescribed medications and that patients discuss their use with a healthcare provider. ● Regular Monitoring: ○ Encourage patients to measure their blood pressure at home regularly. This can help individuals track their progress and adjust their lifestyle modifications accordingly.
  • 42. Non-Pharmacological Therapy ● Cultural Considerations: ○ Be aware of cultural dietary preferences and traditions. Help patients make healthier choices within the context of their cultural norms. ● Education and Support: ○ Provide education on the risks of hypertension, its complications, and the importance of adhering to lifestyle changes. Offer ongoing support and reinforcement of positive behaviors.
  • 44. 1. Diuretics: Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure. Subclassifications: a. Thiazide Diuretics: Hydrochlorothiazide: Min Dose: 12.5 mg; Max Dose: 50 mg T-half: 5.6-14.8 hours; Dosage Form: Tablet (Tab) Common ADRs: Electrolyte imbalances, increased urination, dehydration Chlorthalidone: Min Dose: 12.5 mg; Max Dose: 50 mg T-half: 40-60 hours; Dosage Form: Tab Common ADRs: Electrolyte imbalances, increased urination, dehydration Pharmacological Therapy
  • 45. 1. Diuretics: Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure. Subclassifications: b. Loop Diuretics: Furosemide: Min Dose: 20 mg; Max Dose: 160 mg T-half: 2 hours; Dosage Form: Tab Common ADRs: Electrolyte imbalances, increased urination, dehydration Pharmacological Therapy
  • 46. 1. Diuretics: Mechanism of Action: Promote diuresis, reducing fluid volume and blood pressure. Subclassifications: c. Potassium-Sparing Diuretics: Spironolactone: Min Dose: 25 mg; Max Dose: 100 mg T-half: 1.3-1.6 hours; Dosage Form: Tab Common ADRs: Hyperkalemia, gynecomastia, menstrual irregularities Amiloride: Min Dose: 5 mg; Max Dose: 10 mg T-half: 6-9 hours; Dosage Form: Tab Common ADRs: Hyperkalemia, metabolic acidosis, muscle cramps Pharmacological Therapy
  • 47. 2. Beta Blockers: Mechanism of Action: Reduce heart rate and contractility, lowering blood pressure. Metoprolol: Min Dose: 25 mg; Max Dose: 200 mg T-half: 3-7 hours; Dosage Form: Tab Common ADRs: Bradycardia, fatigue, cold extremities Propranolol: Min Dose: 10 mg; Max Dose: 80 mg T-half: 3-6 hours; Dosage Form: Tab Common ADRs: Bradycardia, fatigue, cold extremities Pharmacological Therapy
  • 48. 2. Beta Blockers: Mechanism of Action: Reduce heart rate and contractility, lowering blood pressure. Atenolol: Min Dose: 25 mg; Max Dose: 100 mg T-half: 6-7 hours; Dosage Form: Tab Common ADRs: Bradycardia, fatigue, cold extremities Pharmacological Therapy
  • 49. 3. Alpha Blockers: Mechanism of Action: Block alpha-adrenergic receptors, causing vasodilation and reduced blood pressure. Doxazosin: Min Dose: 1 mg; Max Dose: 16 mg T-half: 22 hours; Dosage Form: Tab Common ADRs: Dizziness, headache, nasal congestion Prazosin: Min Dose: 1 mg; Max Dose: 20 mg T-half: 2-3 hours; Dosage Form: Tab Common ADRs: Dizziness, headache, nasal congestion Pharmacological Therapy
  • 50. 4. Combined Alpha and Beta Blockers: Mechanism of Action: Block both alpha and beta receptors to lower blood pressure. Carvedilol: Min Dose: 3.125 mg; Max Dose: 25 mg T-half: 7-10 hours; Dosage Form: Tab Common ADRs: Fatigue, dizziness, orthostatic hypotension Labetalol: Min Dose: 100 mg; Max Dose: 400 mg T-half: 5.5-8 hours; Dosage Form: Tab Common ADRs: Fatigue, dizziness, orthostatic hypotension Pharmacological Therapy
  • 51. 5. ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors): Mechanism of Action: Block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced blood pressure. Enalapril: Min Dose: 2.5 mg; Max Dose: 20 mg T-half: 2 hours; Dosage Form: Tab Common ADRs: Cough, hyperkalemia, kidney dysfunction Lisinopril: Min Dose: 2.5 mg; Max Dose: 40 mg T-half: 12 hours; Dosage Form: Tab Common ADRs: Cough, hyperkalemia, kidney dysfunction Pharmacological Therapy
  • 52. 5. ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors): Mechanism of Action: Block the conversion of angiotensin I to angiotensin II, leading to vasodilation and reduced blood pressure. Ramipril: Min Dose: 2.5 mg; Max Dose: 10 mg T-half: 13-17 hours; Dosage Form: Tab Common ADRs: Cough, hyperkalemia, kidney dysfunction Pharmacological Therapy
  • 53. Pharmacological Therapy 6. Angiotensin Receptor Blockers (ARBs): Mechanism of Action: Block the effects of angiotensin II, resulting in vasodilation and lowered blood pressure. Losartan: Min Dose: 25 mg; Max Dose: 100 mg T-half: 1.5-2 hours; Dosage Form: Tab Common ADRs: Dizziness, hyperkalemia, fatigue Valsartan: Min Dose: 40 mg; Max Dose: 320 mg T-half: 6 hours; Dosage Form: Tab Common ADRs: Dizziness, hyperkalemia, fatigue
  • 54. Pharmacological Therapy 6. Angiotensin Receptor Blockers (ARBs): Mechanism of Action: Block the effects of angiotensin II, resulting in vasodilation and lowered blood pressure. Olmesartan: Min Dose: 10 mg; Max Dose: 40 mg T-half: 12 hours; Dosage Form: Tab Common ADRs: Dizziness, hyperkalemia, fatigue
  • 55. 7. Calcium Channel Blockers: Mechanism of Action: Inhibit calcium entry into cells, causing vasodilation and reduced blood pressure. Amlodipine: Min Dose: 2.5 mg; Max Dose: 10 mg T-half: 30-50 hours; Dosage Form: Tab Common ADRs: Peripheral edema, headache, dizziness Nifedipine: Min Dose: 10 mg; Max Dose: 90 mg T-half: 2-5 hours; Dosage Form: Tab Common ADRs: Peripheral edema, headache, dizziness Pharmacological Therapy
  • 56. Pharmacological Therapy 8. Vasodilators: Mechanism of Action: Directly relax and dilate blood vessels, reducing blood pressure. Subclassifications: a. Direct-Acting Vasodilators: Hydralazine: Min Dose: 10 mg; Max Dose: 100 mg T-half: 2-4 hours; Dosage Form: Tab Common ADRs: Headache, flushing, rapid heart rate Minoxidil: Min Dose: 2.5 mg; Max Dose: 100 mg T-half: 4 hours; Dosage Form: Tab Common ADRs: Headache, flushing, rapid heart rate
  • 57. Pharmacological Therapy 8. Vasodilators: Mechanism of Action: Directly relax and dilate blood vessels, reducing blood pressure. Subclassifications: b. Nitrate Vasodilators: Nitroglycerin (sublingual): Min Dose: 0.4 mg; Max Dose: 2.4 mg T-half: 1-4 minutes; Dosage Form: Sublingual Tablet (Subl Tab) Common ADRs: Headache, flushing, rapid heart rate
  • 58. Pharmacological Therapy 9. Central Sympatholytics: Mechanism of Action: Act on the central nervous system to reduce sympathetic nerve signals and lower blood pressure. Clonidine: Min Dose: 0.1 mg; Max Dose: 0.8 mg T-half: 9-12 hours; Dosage Form: Tab Common ADRs: Drowsiness, dry mouth, bradycardia Methyldopa: Min Dose: 125 mg; Max Dose: 500 mg T-half: 1.5-2 hours; Dosage Form: Tab Common ADRs: Drowsiness, dry mouth, bradycardia
  • 59. Pharmacological Therapy 10. Direct Renin Inhibitors: Mechanism of Action: Inhibit the enzyme renin, which is involved in the renin-angiotensin-aldosterone system, leading to blood pressure reduction. Aliskiren: Min Dose: 150 mg; Max Dose: 300 mg T-half: 24 hours; Dosage Form: Tab Common ADRs: Diarrhea, cough, hyperkalemia