Hypertension

HYPERTENSION
CME, NAKASONGOLA HEALTH CENTRE IV
BY ORIBA DAN LANGOYA, MBCHB

HYPERTENSION
• Is defined as sustained
abnormal elevation in
arterial BP.
• Sustained arterial
hypertension damages blood
vessels in:
• Kidney, heart, and brain and
leads to an increased
incidence of
• Renal failure, coronary
disease, heart failure, stroke,
and dementia.
• CASE STUDY
• A 35-year-old man presents with a blood
pressure of 150/95 mm hg. He has been
generally healthy, is sedentary, drinks
several cocktails per day, and does not
smoke cigarettes. He has a family history
of hypertension, and his father died of a
myocardial infarction at age 55. Physical
examination is remarkable only for
moderate obesity. Total cholesterol is
220, and high-density lipoprotein (HDL)
cholesterol level is 40 mg/dl. Fasting
glucose is 105 mg/dl. Chest x-ray is
normal. Electrocardiogram shows left
ventricular enlargement. How would you
treat this patient?

HYPERTENSION & REGULATION OF
BLOOD PRESSURE
• DIAGNOSIS
• Based on repeated, reproducible
measurements of elevated blood
pressure.
• The risks of damage to
Kidney, heart, and brain
are directly related to the
extent of BP elev.
• Both syst hyper and dias
hypertension are associated
with end-organ damage.

NORMAL REGULATION OF BP
• 4 sites of Reg
• BP = co x TPR

CLASSIFICATION OF HYPERTENTION
 PRIMARY (ESSENTIAL) HTN: Is
hypertension that that has no
identifiable cause; it acs for 80 –
95 % of HTN
 SECONDARY HTN: Is
attributable to a diagnosable
d’se, a/cs for the remainder of
HTN cases
 ETIOLOGY
• Hyperlipidemia
• Diabetes
• Genetic
• Diet (high salt)
• Stress

ETIOLOGY
• Renal artery constriction
• Coarctation of the aorta (narrowing of
aorta)
• Phaeochromocytoma (tumor of adrenal
glands)
• Cushing’s disease (hypercortisolism)
• Primary aldosteronism (elevated aldosterone)
• Hyperthyroidism

SUMMARY OF CONTROL TARGETS
Intervention Targets
Reduce foods with
added sodium
< 100 mmol/day
Weight loss BMI <25 kg/m2
Alcohol restriction Less or equal to 2 drinks/day
Exercise at least 4 times/week
Dietary patterns DASH diet
Smoking cessation Smoke free environment
Waist Circumference
< 102 cm for men
< 88 cm for women

ADVICE TO PATIENTS
Advice on lifestyle changes to reduce blood pressure
or cardiovascular risk; these include
• Smoking cessation, weight reduction, reduction of
excessive intake of alcohol and caffeine,
• Reduction of dietary salt.
• Reduction of total and saturated fat,
• Increasing exercise, and increasing fruit and
vegetable intake.

MANAGEMENT: PHARMACOLOGICAL
• Diuretics- thiazides (HCTZ), loop (furosemide),
potassium-sparing (spironolactone)
• Beta-blockers- carvedilol, atenolol, nadolol,
propranolol
• ACE inhibitors- enalpril, captopril, cilizapril
• Ca+ channel blockers- nifedipine, verapamil
• Alpha blockers- prazosin, terazosin
• ARBs- losartan, valsartan, losartan
• Vasodilators- apresoline

THRESHOLDS AND TARGETS FOR TX
• Patients presenting with a BP of 140/90mmhg or higher
when measured in a clinic setting, should be offered ambul
BP monitoring.
• Stage 1 hypertension:
• Clinic blood pressure 140/90 mmHg or higher
• Tx pts under 80 years who have stage 1 hypertension and
target-organ damage
• In the absence of TOD, advise lifestyle changes and review
annually.

THRESHOLDS AND TARGETS FOR TX
• STAGE 2 HYPERTENSION:
Clinic blood pressure 160/100 mmHg or
higher,
And ambulatory daytime average or home
blood
pressure average 150/95 mmHg or higher
Severe hypertension:
. Clinic systolic blood pressure180 mmHg or
clinic
diastolic blood pressure 110 mmHg; treat
promptly
A target clinic blood pressure below 140/90 mmHg is
suggested for patients under 80 years
A target clinic blood
pressure below 130/80
mmHg should be considered
for those with established
atherosclerotic CVD, or
diabetes in the presence of
kidney, eye, or
cerebrovascular disease.

THRESHOLDS AND TARGETS FOR TREATMENT
• Severe hypertension:
• Clinic systolic blood pressure180 mmhg or clinic Diastolic blood pressure
110 mmhg, treat Promptly
• A target clinic blood pressure below 140/90 mmhg is suggested for
patients under 80 years;
• A target clinic BP below 130/80 mmhg should be considered For those
with established atherosclerotic CVD, or diabetes in the presence of
kidney, eye, or cerebrovascular disease.

DRUG TREATMENT OF HYPERTENSION
• A single antihypertensive drug is often inadequate in the
management of hypertension
• Additional antihypertensive drugs are usually added in a
step-wise manner until control is achieved.
• An interval of at least 4 weeks should be allowed to
determine response.
• Response to drug treatment may be affected by age and
ethnicity.

PATIENTS UNDER 55 YEARS:
STEP 1
• CCB; If not tolerated or if there is evidence of, or a high risk of, heart
failure, give a thiazide-related diuretic (e.g. Chlortalidone or
indapamide)
Step 2
• CB or thiazide-related diuretic in combination with an ACE inhibitor or
angiotensin-II receptor antagonist (an angiotensin-II receptor antagonist
in combination with a CCB is preferred.

• STEP 3
• ACE inhibitor or angiotensin-ii receptor antagonist in comb with a CCB
and a thiazide-related diuretic
• Step 4 (resistant hypertension)
• Consider seeking specialist advice
• Add low-dose spironolactone, or use high-dose thiazide related diuretic
if plasma-potassium concentration above 4.5 mmol/litre
• Monitor renal function and electrolytes

HYPERTENSION IN THE ELDERLY
• Patients who reach 80 years of age while taking
antihypertensive drugs should continue tx
• Patients with stage 2 hypertension should be treated as for
patients over 55 years.
• A target clinic BP below 150/90 mmhg is suggested for
patients over 80 years.

ISOLATED SYSTOLIC HYPERTENSION
• Isolated systolic hypertension (systolic pressure160 mmhg,
diastolic pressure<90 mmhg)
• Is common in patients over 60yrs, and is associated with an
increased CVD risk; it should be treated as for patients with
both a raised systolic and diastolic BP.
• Patients with severe postural hypotension should be referred
to a specialist.

HYPERTENSION IN DIABETES
• For patients with diabetes, a target clinic blood pressure below
140/80mmhg is suggested (below 130/80mmhg is advised if kidney,
eye, or CVD are also present)
• Hypertension is common in type 2 diabetes, and antihypertensive tx
prevents macro and microvascular complications.
• An ACE inhibitor (or an ARB ) may have a specific role in the
management of diabetic nephropathy.
• In patients with type 2 diabetes, an ACE inhibitor (or an ARB) can delay
progression of microalbuminuria to nephropathy.

HYPERTENSION IN RENAL DISEASE
• A target clinic BP below 140/90mmhg is suggested (below
130/80mmhg is advised in patients with chronic kidney
disease and diabetes, or if proteinuria exceeds 1 g in 24
hours).
• An ACE inhibitor (or an ARB) should be considered for
patients with proteinuria; however, ACE inhibitors should be
used with caution in renal impairment.
• Thiazide diuretics may be ineffective and high doses of loop
diuretics may be required

HYPERTENSION IN PREGNANCY
• Hypertensive comps in pregnancy can be hazardous for
both the mother and the fetus.
• Labetalol is widely used for treating hypertension in
pregnancy.
• Methyldopa considered safe for use in pregnancy.
• Modified-release preps of nifedipine are also used

NICE CLINICAL GUIDELINE
• Preg women with chronic
hypertension who are already
receiving antihypertensive
treatment should have their drug
therapy reviewed
• In uncomplicated chronic
hypertension, a target BP of
<150/100 mmHg is
recommended;
• Women with TOD as a result of
chronic hypertension, and in
women with chronic hypertension
who have given birth, a target BP
of <140/90 mmhg is advised.
• Long-term antihypertensive tx
should be reviewed 2 weeks
following the birth.

NICE CLINICAL GUIDELINE
• Women managed with
methyldopa during preg shud
discontinue tx
• Restart their orig
antihypertensive meds within
2days of the birth.

GUIDELINE
• Pregnant women are at high risk of developing
preeclampsia if they have chronic kidney disease,
• Diabetes mellitus, autoimmune disease, chronic hypertension,
or
• If they have had hypertension during a previous pregnancy;
these women are advised to take aspirin in a dose of 75 mg
once daily from week 12 of pregnancy until the baby is
born.

GUIDELINE
• Women with more than one moderate risk factor (first
pregnancy, aged 40 years, pregnancy interval >10 years,
BMI 35 kg/m2 At first visit,
• Multiple preg, or FH of pre-eclampsia) for developing pre-
eclampsia are also advised to take aspirin 75 mg once daily
from week 12 of preg until the baby is born.
• Women with pre-eclam or gest hyp who present with a BP
over 150/100 mmhg, should receive initial tx with oral
labetalol to achieve a target blood pressure of 150 mmHg
syst, and dias 80–100 mmHg.

GUIDELINE
• If labetalol is unsuitable, methyldopa or modified-release
nifedipine may be considered.
• Women with gest hyp or pre-eclamp who have been
managed with methyldopa during preg shud discontinue tx
within 2 days of the birth
• Women with a BP of 160/110 mmHg who require critical
care during preg or after birth shud receive immediate tx with
either PO or IV labetalol, IV hydralazine, or oral modified-
release nifedipine to achieve a target BP of150 mmHg syst,
and diast 80–100 mmHg.

HYPERTENSIVE CRISES
• If BP is reduced too quickly in the mg’t of hypertensive crises, there is a
risk of reduced organ perfusion.
• Ahypertensive emergency is defined as severe hypertension with acute
damage to the target organs
• Prompt tx with IV antihypertensive therapy is generally required.
• Over the first few minutes or within 2 hours, BP should be reduced by
20–25%. When IV therapy is indicated, tx options include sodium
nitroprusside, labetalol, glyceryl trinitrate, phentolamine, hydralazine, or
esmolol
• Choice of drug is dependent on concomitant conditions and clinical status
of the patient.

HYPERTENSIVE CRISES
• Severe hyp (BP 180/110 mmhg) without acute TOD is
defined as a hypertensive urgency; BP should be reduced
gradually over 24–48hrs.
• Oral antihypertensive therapy, such as labetalol, or the
calcium-channel blockers amlodipine, felodipine, or
isradipine.
NB: Use of sublingual nifedipine is not recommended

THE END
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