DR.Hesham Mohammed updated management of Hypertension.pdf
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Sep 24, 2024
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About This Presentation
This Pdf Help you to management of patients with Hypertension according to the newest Guidelines OF AMERICAN HEART ASSOCIATION,CANADIAN HEART ASSOCIATION AND AEUROBIAN HEART ASSOCIATION.
Slide Content
Presented By:
Hesham Mohammed Ali Saeed .
UPDATED MANAGEMENT OF HYPERTENSION
Supervisor By :
Assist. Prof. Dr. Mohammed Kassim Salah .
Hesham Mohammed Ali Saeed .
UPDATED MANAGEMENT OF HYPERTENSION
Supervisor By :
Assist. Prof. Dr. Mohammed Kassim Salah .
High blood pressure (BP), or hypertension : is
defined by two levels by 2017 American College of
Cardiology/American Health Association (ACC/AHA)
guidelines :
(1) elevated BP: with a systolic pressure (SBP)
between 120 and 129 mmHg and diastolic
pressure (DBP ) less than 80 mmHg, and
(2) stage 1 hypertension: with an SBP of 130 to 139
mm Hg or a DBP of 80 to 89 mm Hg.
Hypertension divided into:
•Primary Hypertension (essential HTN): MC 95%
unknown cause may be environmental or genetic causes.
•Secondary Hypertension : less common ~5%
has multiple etiologies, including renal, vascular, and
endocrine causes.
Classification or category of HTN :
1.Sustained HTN .
2.White coat HTN : (untreated white coat HTN or
isolated office HTN).
3.Masked HTN : ( untreated masked HTN or
Masked uncontrolled HTN ).
4.Nocturnal HTN.
5.Others…
DEFINATION
defined by two levels by 2017 American College of
Cardiology/American Health Association (ACC/AHA)
guidelines :
(1) elevated BP: with a systolic pressure (SBP)
between 120 and 129 mmHg and diastolic
pressure (DBP ) less than 80 mmHg, and
(2) stage 1 hypertension: with an SBP of 130 to 139
mm Hg or a DBP of 80 to 89 mm Hg.
Hypertension divided into:
•Primary Hypertension (essential HTN): MC 95%
unknown cause may be environmental or genetic causes.
•Secondary Hypertension : less common ~5%
has multiple etiologies, including renal, vascular, and
endocrine causes.
Classification or category of HTN :
1.Sustained HTN .
2.White coat HTN : (untreated white coat HTN or
isolated office HTN).
3.Masked HTN : ( untreated masked HTN or
Masked uncontrolled HTN ).
4.Nocturnal HTN.
5.Others…
DEFINATION
Classification or category of HTN
White-coat hypertension is suspected when BP readings in the
office exceed those outside of the clinical setting .
Masked hypertension is suspected when out-of-office BP
measurements exceed those taken in the clinical setting .
ABPM or HBPM can be used to identify these patients .
White-coat hypertension is suspected when BP readings in the
office exceed those outside of the clinical setting .
Masked hypertension is suspected when out-of-office BP
measurements exceed those taken in the clinical setting .
ABPM or HBPM can be used to identify these patients .
White coat hypertension is defined as office BP is ≥130/80 mm Hg but out of
office (home or daytime ambulatory BP) <130/80 mm Hg after 3 months of diet
and lifestyle modification.
In drug naïve hypertensive, this hypertension phenotype should be considered in
individuals with office BP 130–159/80–99 mm Hg .
Masked hypertension also represents non-concordance between office and out
of office BP readings and is defined as office BP < 130/80 mm Hg but home or
daytime ambulatory BP ≥ 130/80 mm Hg.
This hypertension phenotype should be considered in individuals with office BP
120–129/ < 80 mm Hg after a three month trial of diet and lifestyle intervention .
patients with masked hypertension, prescription of drug therapy is
recommended to come from one of four drug classes (usual first line therapy) –
thiazide diuretics, calcium antagonists, angiotensin converting enzyme (ACE)
inhibitors, or angiotensin receptor blockers (ARBs) – unless there is a
comorbidity consideration favoring the use of a different drug class .
Classification or category of HTN
office (home or daytime ambulatory BP) <130/80 mm Hg after 3 months of diet
and lifestyle modification.
In drug naïve hypertensive, this hypertension phenotype should be considered in
individuals with office BP 130–159/80–99 mm Hg .
Masked hypertension also represents non-concordance between office and out
of office BP readings and is defined as office BP < 130/80 mm Hg but home or
daytime ambulatory BP ≥ 130/80 mm Hg.
This hypertension phenotype should be considered in individuals with office BP
120–129/ < 80 mm Hg after a three month trial of diet and lifestyle intervention .
patients with masked hypertension, prescription of drug therapy is
recommended to come from one of four drug classes (usual first line therapy) –
thiazide diuretics, calcium antagonists, angiotensin converting enzyme (ACE)
inhibitors, or angiotensin receptor blockers (ARBs) – unless there is a
comorbidity consideration favoring the use of a different drug class .
Classification or category of HTN
NOCTURNAL HTN
In general BP level at morning is higher than evening Why ?
Because sympathytic over activity due to high catecholamines level at morning .
BP level at evening (sleep ) < BP level at morning by (10 - 20% ) this called normal dipper .
Some patients have abnormal dipper :
Extreme dipper : BP level at evening (sleep ) < BP level at morning by > 20% .
Non dipper : evening BP< morning BP by less than 10% or non.
Rister : the evevning BP level is > morning BP level.
Risk factors that increase the possibility of (non dipper, Rister):
1.Salt sensitivity .
2.DM .
3.CKD .
4.CHF .
5.Structural vascular disease .
6.Insomnia .
7.Obstructive sleep apnea .
When called Nocturnal HTN : According of AHA / ACC guidelines :
the cut off value for normal night BP is 110 / 65 mmhg but if it more it called Nocturnal HTN .
In general BP level at morning is higher than evening Why ?
Because sympathytic over activity due to high catecholamines level at morning .
BP level at evening (sleep ) < BP level at morning by (10 - 20% ) this called normal dipper .
Some patients have abnormal dipper :
Extreme dipper : BP level at evening (sleep ) < BP level at morning by > 20% .
Non dipper : evening BP< morning BP by less than 10% or non.
Rister : the evevning BP level is > morning BP level.
Risk factors that increase the possibility of (non dipper, Rister):
1.Salt sensitivity .
2.DM .
3.CKD .
4.CHF .
5.Structural vascular disease .
6.Insomnia .
7.Obstructive sleep apnea .
When called Nocturnal HTN : According of AHA / ACC guidelines :
the cut off value for normal night BP is 110 / 65 mmhg but if it more it called Nocturnal HTN .
NOCTURNAL HTN
Modifiable and fixed risk factors.
Risk Factors of Hypertension
Risk Factors of Hypertension
Management of Hypertensive patient :
Diagnosis:
•Clinical(Hx& Physical Examination) .
•laboratory Evaluation (Routinely and according to presentation).
Treatment :
•Non pharmacological treatment (patient education & lifestyle modification).
•Pharmacological Treatment by (antihypertensive drugs).
•Follow up and monitoring .
: Management of Hypertensive patient
Diagnosis:
•Clinical(Hx& Physical Examination) .
•laboratory Evaluation (Routinely and according to presentation).
Treatment :
•Non pharmacological treatment (patient education & lifestyle modification).
•Pharmacological Treatment by (antihypertensive drugs).
•Follow up and monitoring .
: Management of Hypertensive patient
•Accurately measuring the patient’s blood pressure.
•Performing a focused medical history and physical examination.
•Results of routine laboratory studies.
•A 12 lead electrocardiogram should also be obtained.
These steps can help determine the following :
•Presence of end-organ disease .
•Possible causes of hypertension.
•Cardiovascular risk factors.
•Baseline values for judging biochemical effects of therapy.
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (Routinely and according to presentation).
In general, the evaluation of hypertension primarily involves :
•Performing a focused medical history and physical examination.
•Results of routine laboratory studies.
•A 12 lead electrocardiogram should also be obtained.
These steps can help determine the following :
•Presence of end-organ disease .
•Possible causes of hypertension.
•Cardiovascular risk factors.
•Baseline values for judging biochemical effects of therapy.
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (Routinely and according to presentation).
In general, the evaluation of hypertension primarily involves :
History may elicit :
•family history of hypertension or coronary artery disease risk factors. It is
important to assess overall cardiac risk burden .
•The age of onset may be of value when considering aetiology, as the
proportion of secondary causes diminishes with increasing age .
•Patients at increased risk for essential hypertension include those over 60
years of age, or with diabetes, or of black race .
•Excess alcohol intake or lack of exercise should be documented .
•Medication history should be taken including :screening for use of oral
contraceptive pills, non-steroidal anti-inflammatory drugs , Corticosteroids
,ciclosporin , atypical antipsychotics , SNRIs , Erythropoietin , tacrolimus
,sympathomimetics, or herbal medications
•Most patients are asymptomatic, but clinical indications of :
ohyperthyroidism, hypothyroidism, or catecholamine excess : ( e.g.
tachycardia, weight loss, sweating, or palpitations )
oEnd-organ damage (e.g., shortness of breath, chest pain, or
sensory/motor deficits ) .
oHeadache or visual changes are unusual .
Diagnosis:
& Physical Examination) . History(Clinical
•family history of hypertension or coronary artery disease risk factors. It is
important to assess overall cardiac risk burden .
•The age of onset may be of value when considering aetiology, as the
proportion of secondary causes diminishes with increasing age .
•Patients at increased risk for essential hypertension include those over 60
years of age, or with diabetes, or of black race .
•Excess alcohol intake or lack of exercise should be documented .
•Medication history should be taken including :screening for use of oral
contraceptive pills, non-steroidal anti-inflammatory drugs , Corticosteroids
,ciclosporin , atypical antipsychotics , SNRIs , Erythropoietin , tacrolimus
,sympathomimetics, or herbal medications
•Most patients are asymptomatic, but clinical indications of :
ohyperthyroidism, hypothyroidism, or catecholamine excess : ( e.g.
tachycardia, weight loss, sweating, or palpitations )
oEnd-organ damage (e.g., shortness of breath, chest pain, or
sensory/motor deficits ) .
oHeadache or visual changes are unusual .
Diagnosis:
& Physical Examination) . History(Clinical
The physical examination should include :
•Office blood pressure (BP) measurement : see below..
•Palpation of all peripheral pulses should be performed : Absent, weak, or
delayed femoral pulses suggests coarctation of the aorta or severe peripheral
vascular disease.
•Examination of optic fundi : For Hypertensive retinopathy .
Grade 1 : Arteriolar thickening, tortuosity and increased reflectiveness (silver wiring )
Grade 2 : Grade 1 plus constriction of veins at arterial crossings (arteriovenous nipping ) .
Grade 3 :Grade 2 plus evidence of retinal ischaemia (flame-shaped or blot haemorrhages and
"cotton wool" exudates ) .
Grade 4 :Grade 3 plus papilloedema.
presence of new retinal hemorrhages, exudates, or papilledema : suggests a hypertensive
emergency.
•Calculation of BMI from height and weight .
•Auscultation for possible carotid, abdominal, or femoral bruits .
•Palpation of the thyroid gland .
•Examination of the heart and lungs .
•Examination of the abdomen for enlarged kidneys, masses, distended urinary bladder,
or abnormal aortic pulsation .
•Palpation of the lower extremities for oedema and pulses .
•Neurological assessment.
Diagnosis:
) .Physical Examination(Hx& Clinical
•Office blood pressure (BP) measurement : see below..
•Palpation of all peripheral pulses should be performed : Absent, weak, or
delayed femoral pulses suggests coarctation of the aorta or severe peripheral
vascular disease.
•Examination of optic fundi : For Hypertensive retinopathy .
Grade 1 : Arteriolar thickening, tortuosity and increased reflectiveness (silver wiring )
Grade 2 : Grade 1 plus constriction of veins at arterial crossings (arteriovenous nipping ) .
Grade 3 :Grade 2 plus evidence of retinal ischaemia (flame-shaped or blot haemorrhages and
"cotton wool" exudates ) .
Grade 4 :Grade 3 plus papilloedema.
presence of new retinal hemorrhages, exudates, or papilledema : suggests a hypertensive
emergency.
•Calculation of BMI from height and weight .
•Auscultation for possible carotid, abdominal, or femoral bruits .
•Palpation of the thyroid gland .
•Examination of the heart and lungs .
•Examination of the abdomen for enlarged kidneys, masses, distended urinary bladder,
or abnormal aortic pulsation .
•Palpation of the lower extremities for oedema and pulses .
•Neurological assessment.
Diagnosis:
) .Physical Examination(Hx& Clinical
Physical examination may reveal end-organ damage associated with untreated
hypertension: for example
•Retinopathy, vascular bruits, signs of congestive heart failure, evidence of aortic
aneurysm (pulsatile mass/bruit), left ventricular hypertrophy (displaced point of
maximal impact), or neurological deficit(s).
•Absence of femoral pulses suggests coarctation of the aorta.
•An abdominal bruit may suggest aortic aneurysm or renal artery stenosis
(both Systolic and Diastolic Abdominal bruit).
•patients may have stigmata of endocrinopathy such as :
oCushing's disease (moon face, centripetal obesity, striae) .
oAcromegaly (acral enlargement) .
oGraves' disease (goitre, exophthalmos, pretibial myxoedema)
oHypothyroidism (dry skin, delayed return of deep tendon reflexes) .
oOthers…..
Diagnosis:
) .Physical ExaminationClinical(Hx&
hypertension: for example
•Retinopathy, vascular bruits, signs of congestive heart failure, evidence of aortic
aneurysm (pulsatile mass/bruit), left ventricular hypertrophy (displaced point of
maximal impact), or neurological deficit(s).
•Absence of femoral pulses suggests coarctation of the aorta.
•An abdominal bruit may suggest aortic aneurysm or renal artery stenosis
(both Systolic and Diastolic Abdominal bruit).
•patients may have stigmata of endocrinopathy such as :
oCushing's disease (moon face, centripetal obesity, striae) .
oAcromegaly (acral enlargement) .
oGraves' disease (goitre, exophthalmos, pretibial myxoedema)
oHypothyroidism (dry skin, delayed return of deep tendon reflexes) .
oOthers…..
Diagnosis:
) .Physical ExaminationClinical(Hx&
Clinical clues that should raise suspicion for a secondary
cause of hypertension include:
1.snoring/daytime sleepiness .
2.abrupt onset of hypertension .
3.hypertension onset < 30 years of age .
4.accelerated/malignant hypertension.
5.abrupt loss of BP control in a patient with prior BP control .
6.BP raising substances such as : use of
NSAIDs/amphetamines/immunosuppressive agents .
7.Resistant (taking 3 or 4 antihypertensive drugs, including a
diuretic and BP above goal or taking >4 drugs, including a
diuretic and BP below goal ).
8.Refractory hypertension (taking 5 drugs or more ,including a
diuretic, and BP above goal) .
9.Unprovoked (not taking a diuretic) or excessive hypokalemia.
10.The onset of diastolic hypertension in older patients (65 years
or more).
Diagnosis:
& Physical Examination) . History(Clinical
cause of hypertension include:
1.snoring/daytime sleepiness .
2.abrupt onset of hypertension .
3.hypertension onset < 30 years of age .
4.accelerated/malignant hypertension.
5.abrupt loss of BP control in a patient with prior BP control .
6.BP raising substances such as : use of
NSAIDs/amphetamines/immunosuppressive agents .
7.Resistant (taking 3 or 4 antihypertensive drugs, including a
diuretic and BP above goal or taking >4 drugs, including a
diuretic and BP below goal ).
8.Refractory hypertension (taking 5 drugs or more ,including a
diuretic, and BP above goal) .
9.Unprovoked (not taking a diuretic) or excessive hypokalemia.
10.The onset of diastolic hypertension in older patients (65 years
or more).
Diagnosis:
& Physical Examination) . History(Clinical
MEASUREMENT OF BLOOD PRESSURE
Measurement of Blood pressure:
•Either in Office (Medical settings) or out-off office (Home).
•By using of ABPM or HBPM .
•Method to do accurate measurements: descripe in this photo . For accurate BP results
Measurement of Blood pressure:
•Either in Office (Medical settings) or out-off office (Home).
•By using of ABPM or HBPM .
•Method to do accurate measurements: descripe in this photo . For accurate BP results
When patient diagnosed as HTN from the first reading ?
We can diagnose HTN from the first reading and start treatment in these
conditions :
If initial BP reading is more than or equal to 180 /120 mmhg + Acute End organ
damage (HTN urgency or Emergency) .
If initial BP reading is more than or equal to 160/100mmhg with Target End organ
damage (TEOD) as (LVH ,CHF , IHD ,CVA ,CKD ,HTN retinopathy ).
But if BP ≥130/80mmhg : advice pt to measure their BP by ABM over 24 hours
if available , if not available by HBPM over separated days if home
measurement not available so that measurements in office at least 2- 3 times
with interval between them weeks to months : in both if means BP level is
>130/80mmhg diagnosed as HTN .
IF BP IS 120-129 /70 - 79mmhg in Office and patients have any of : ASCVD risk
>10% ,CKD , HF or DM : advice the patients to do BP out office measurements .
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
We can diagnose HTN from the first reading and start treatment in these
conditions :
If initial BP reading is more than or equal to 180 /120 mmhg + Acute End organ
damage (HTN urgency or Emergency) .
If initial BP reading is more than or equal to 160/100mmhg with Target End organ
damage (TEOD) as (LVH ,CHF , IHD ,CVA ,CKD ,HTN retinopathy ).
But if BP ≥130/80mmhg : advice pt to measure their BP by ABM over 24 hours
if available , if not available by HBPM over separated days if home
measurement not available so that measurements in office at least 2- 3 times
with interval between them weeks to months : in both if means BP level is
>130/80mmhg diagnosed as HTN .
IF BP IS 120-129 /70 - 79mmhg in Office and patients have any of : ASCVD risk
>10% ,CKD , HF or DM : advice the patients to do BP out office measurements .
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
Any patient diagnosed as hypertension should be
do some laboratory tests as :
•Routinely and according to presentation.
•Calculate the ASCVD 10 years Score , according to its
value do Risk assessment and depending on Risk make
the treatment plan .
To calculate the ASCVD 10 years Score enter to
this Link: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to
presentation).
do some laboratory tests as :
•Routinely and according to presentation.
•Calculate the ASCVD 10 years Score , according to its
value do Risk assessment and depending on Risk make
the treatment plan .
To calculate the ASCVD 10 years Score enter to
this Link: https://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to
presentation).
following tests should be performed
in all patients with newly diagnosed
hypertension :
•Electrolytes including calcium,
others
• serum creatinine (to estimated
glomerular filtration rate)
•Fasting glucose
•Urinalysis
•Complete blood count (CBC)
•Thyroid-stimulating hormone
•Lipid profile
•Electrocardiogram
Calculate 10 year atherosclerotic
cardiovascular disease risk .
If hypertensive patients have DM or
CKD : order to do this test
Urinary albumin to creatinine
ratio.
Evaluation for secondary causes is not
recommended For all patients with primary
hypertension .
Instead, a targeted approach is indicated whereby
evaluation for secondary causes should be
performed only in patients with one or more of the
following features :
An unusual presentation of hypertension (eg, new
onset at an especially young or especially old age,
presentation with stage 2 hypertension, abrupt onset
of hypertension in a patient with previously normal
blood pressure, or significant recent elevation in
blood pressure in a patient with previously well-
controlled hypertension despite adherence to their
antihypertensive regimen)
Drug-resistant hypertension .
The presence of a clinical clue for a specific cause of
hypertension, such as an abdominal bruit (suggestive
of renovascular hypertension) or low serum
potassium (suggestive of primary aldosteronism ) .
Laboratory Evaluation of Hypertensive patient
in all patients with newly diagnosed
hypertension :
•Electrolytes including calcium,
others
• serum creatinine (to estimated
glomerular filtration rate)
•Fasting glucose
•Urinalysis
•Complete blood count (CBC)
•Thyroid-stimulating hormone
•Lipid profile
•Electrocardiogram
Calculate 10 year atherosclerotic
cardiovascular disease risk .
If hypertensive patients have DM or
CKD : order to do this test
Urinary albumin to creatinine
ratio.
Evaluation for secondary causes is not
recommended For all patients with primary
hypertension .
Instead, a targeted approach is indicated whereby
evaluation for secondary causes should be
performed only in patients with one or more of the
following features :
An unusual presentation of hypertension (eg, new
onset at an especially young or especially old age,
presentation with stage 2 hypertension, abrupt onset
of hypertension in a patient with previously normal
blood pressure, or significant recent elevation in
blood pressure in a patient with previously well-
controlled hypertension despite adherence to their
antihypertensive regimen)
Drug-resistant hypertension .
The presence of a clinical clue for a specific cause of
hypertension, such as an abdominal bruit (suggestive
of renovascular hypertension) or low serum
potassium (suggestive of primary aldosteronism ) .
Laboratory Evaluation of Hypertensive patient
New-onset or uncontrolled hypertension in adults
Conditions
Drug-resistant/induced hypertension
Abrupt onset of hypertension
Onset of hypertension before age 30 years
Exacerbation of previously controlled hypertension
Disproportionate target organ damage for
degree of hypertension
Accelerated/malignant hypertension
Onset of diastolic hypertension in older adults
( age 65years or older) .
Unprovoked or excessive hypokalemia
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
Figure show
screening for
secondary
hypertension .
Conditions
Drug-resistant/induced hypertension
Abrupt onset of hypertension
Onset of hypertension before age 30 years
Exacerbation of previously controlled hypertension
Disproportionate target organ damage for
degree of hypertension
Accelerated/malignant hypertension
Onset of diastolic hypertension in older adults
( age 65years or older) .
Unprovoked or excessive hypokalemia
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
Figure show
screening for
secondary
hypertension .
in individuals with suspected secondary hypertension and/or evidence of
target-organ disease, such as complete blood count (CBC), chest radiograph,
uric acid, and urine microalbumin.
•Chronic kidney disease :Estimated glomerular filtration rate
•Coarctation of the aorta : CTA
•Cushing syndrome; other states of glucocorticoid excess (eg, chronic
steroid therapy) : Dexamethasone suppression test
•Drug-induced/drug-related hypertension: Drug screening
•Pheochromocytoma : 24-hour urinary metanephrine and normetanephrine
•Primary aldosteronism, other states of mineralocorticoid excess : Plasma
aldosterone to renin activity ratio (ARR) ratio of more than 20-30 is
suggestive. If abnormal, refer for further evaluation such as saline infusion
to determine if aldosterone levels can be suppressed, 24-hour urinary
aldosterone level, and specific mineralocorticoid tests.
•Renovascular hypertension : Doppler flow ultrasonography, MRA ,CTA
•Sleep apnea : Sleep study with oxygen saturation (screening would also
include the Epworth Sleepiness Scale [ESS]).
•Thyroid/parathyroid disease : Thyroid stimulating hormone level, serum
parathyroid hormone level.
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
target-organ disease, such as complete blood count (CBC), chest radiograph,
uric acid, and urine microalbumin.
•Chronic kidney disease :Estimated glomerular filtration rate
•Coarctation of the aorta : CTA
•Cushing syndrome; other states of glucocorticoid excess (eg, chronic
steroid therapy) : Dexamethasone suppression test
•Drug-induced/drug-related hypertension: Drug screening
•Pheochromocytoma : 24-hour urinary metanephrine and normetanephrine
•Primary aldosteronism, other states of mineralocorticoid excess : Plasma
aldosterone to renin activity ratio (ARR) ratio of more than 20-30 is
suggestive. If abnormal, refer for further evaluation such as saline infusion
to determine if aldosterone levels can be suppressed, 24-hour urinary
aldosterone level, and specific mineralocorticoid tests.
•Renovascular hypertension : Doppler flow ultrasonography, MRA ,CTA
•Sleep apnea : Sleep study with oxygen saturation (screening would also
include the Epworth Sleepiness Scale [ESS]).
•Thyroid/parathyroid disease : Thyroid stimulating hormone level, serum
parathyroid hormone level.
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
SCREENING
The American College of Cardiology (ACC)/American Heart Association (AHA)
guideline :
Recommends : annual screening in all patients with normal BP .
Measurements should be obtained outside of the clinical setting
( ambulatory blood pressure monitoring [ABPM] or home blood pressure
monitoring [ HBPM] ) : to Confirm the diagnosis .
If a patient has an untreated systolic BP > 160 mmHg but < 130 mmHg or
diastolic BP >100 mmHg but < 80 mmHg : it is reasonable to screen for
the presence of white-coat hypertension by using either daytime ABPM or
HBPM before diagnosis of hypertension .
In adults with elevated clinic BP (120 -129 /<80 mmHg) but not meeting the
criteria for hypertension : screening for masked hypertension with daytime
ABPM or HBPM is reasonable .
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
The American College of Cardiology (ACC)/American Heart Association (AHA)
guideline :
Recommends : annual screening in all patients with normal BP .
Measurements should be obtained outside of the clinical setting
( ambulatory blood pressure monitoring [ABPM] or home blood pressure
monitoring [ HBPM] ) : to Confirm the diagnosis .
If a patient has an untreated systolic BP > 160 mmHg but < 130 mmHg or
diastolic BP >100 mmHg but < 80 mmHg : it is reasonable to screen for
the presence of white-coat hypertension by using either daytime ABPM or
HBPM before diagnosis of hypertension .
In adults with elevated clinic BP (120 -129 /<80 mmHg) but not meeting the
criteria for hypertension : screening for masked hypertension with daytime
ABPM or HBPM is reasonable .
Diagnosis:
Clinical(Hx& Physical Examination) .
laboratory Evaluation (routinely and according to presentation).
Aims of management :
•To prevent the progression of the Hypertension and its complications if present.
•To decrease the risk of mortality and of cardiovascular and renal morbidity.
The general roles for management including of:
•Treatment depending on : Type of hypertension and patients, level of
Blood pressure, comorbidities and presentation.
•Treatment consist of :
Non pharmacological : Patients education and lifestyle modification:
should be indicated in all individual or patients.
pharmacological Treatment in selected patients depending on stage of HTN
and ASCVD risk as :-
1.stage 1 HTN + plus any of : ( high risk ASCVD as >10% ,
established CVD { chronic coronary syndrome, HF, carotid
disease, previous stroke , PAD} , CKD, T2DM,age 65 years old or
more ) start by Monotherapy
2.Stage 2 HTN regardless of ASCVD risk : start by Dual therapy.
3.Hypertensive crisis.
AHA GUIDELINES recommendation to Start treatment by:
•Monotherapy for Stage 1 HTN as above
•Dual therapy for : stage 2 HTN or Stage 1 HTN not respond with maximum tolerated dose
of monotherapy .
Treatment of Hypertension :
•To prevent the progression of the Hypertension and its complications if present.
•To decrease the risk of mortality and of cardiovascular and renal morbidity.
The general roles for management including of:
•Treatment depending on : Type of hypertension and patients, level of
Blood pressure, comorbidities and presentation.
•Treatment consist of :
Non pharmacological : Patients education and lifestyle modification:
should be indicated in all individual or patients.
pharmacological Treatment in selected patients depending on stage of HTN
and ASCVD risk as :-
1.stage 1 HTN + plus any of : ( high risk ASCVD as >10% ,
established CVD { chronic coronary syndrome, HF, carotid
disease, previous stroke , PAD} , CKD, T2DM,age 65 years old or
more ) start by Monotherapy
2.Stage 2 HTN regardless of ASCVD risk : start by Dual therapy.
3.Hypertensive crisis.
AHA GUIDELINES recommendation to Start treatment by:
•Monotherapy for Stage 1 HTN as above
•Dual therapy for : stage 2 HTN or Stage 1 HTN not respond with maximum tolerated dose
of monotherapy .
Treatment of Hypertension :
Stage 1 HTN + Plus Any Of: ( high risk ASCVD as >10% , established CVD { chronic
coronary syndrome, HF, carotid disease, previous stroke , PAD} , CKD, T2DM, age 65 years
old or more ) start by Monotherapy
depending on patients colour:
In black patient as African American start by one of the following:
Thiazide or Thiazide like diuretics : long acting chlorthalidone is prefer than
hydrochlorothiazide.
Dihydropyridine Calcium channels blockers : long acting Amlodipine is preferred .
But if not black skin as Non African American, others start by one of the
following :
1.ACE Inhibitors . Or
2.ARBs If ACE Is not tolerated . Or
3.Dihydropyridine Calcium channels blockers : long acting Amlodipine is
preferred than other Dihydropyridine CCBs. Or
4.Thiazide or Thiazide like diuretics : long acting chlorthalidone is prefer than
hydrochlorothiazide.
Then Reassessment the patient within 1 month as if BP reached to target,
continue Treatmen with similar drug and does also regular follow up ..
Treatment of Hypertension :
coronary syndrome, HF, carotid disease, previous stroke , PAD} , CKD, T2DM, age 65 years
old or more ) start by Monotherapy
depending on patients colour:
In black patient as African American start by one of the following:
Thiazide or Thiazide like diuretics : long acting chlorthalidone is prefer than
hydrochlorothiazide.
Dihydropyridine Calcium channels blockers : long acting Amlodipine is preferred .
But if not black skin as Non African American, others start by one of the
following :
1.ACE Inhibitors . Or
2.ARBs If ACE Is not tolerated . Or
3.Dihydropyridine Calcium channels blockers : long acting Amlodipine is
preferred than other Dihydropyridine CCBs. Or
4.Thiazide or Thiazide like diuretics : long acting chlorthalidone is prefer than
hydrochlorothiazide.
Then Reassessment the patient within 1 month as if BP reached to target,
continue Treatmen with similar drug and does also regular follow up ..
Treatment of Hypertension :
Then Reassessment the patient within 1 month as if BP reached to target,
continue Treatmen with similar drug and does also regular follow up ..
But if not reached to target :
•Either titrate the dose upto maximum tolerated dose or standard dose.
•Or added other drugs from the first line drugs ( avoid combination ACEIs
with ARBs ) this Strategy is prefer .
Then Reassessment the patient within1 month as if BP reached to target,
continue Treatmen with similar drug and does also regular follow up .....
But if not reached to target with maximum tolerated dose or combination drugs:
check the patient adherence to drugs and lifestyle modification and added
other drug from first line drugs ( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 4 weeks :
1)If BP reached to target, continue Treatmen with similar drugs and
doses , Also regular follow up ..
2)But if not reached to target with maximum tolerated dose or
combination drugs : check the patient adherence to drugs and
lifestyle modification ;
If not reached to target ?? It called resistant hypertension .
Treatment of Hypertension :
continue Treatmen with similar drug and does also regular follow up ..
But if not reached to target :
•Either titrate the dose upto maximum tolerated dose or standard dose.
•Or added other drugs from the first line drugs ( avoid combination ACEIs
with ARBs ) this Strategy is prefer .
Then Reassessment the patient within1 month as if BP reached to target,
continue Treatmen with similar drug and does also regular follow up .....
But if not reached to target with maximum tolerated dose or combination drugs:
check the patient adherence to drugs and lifestyle modification and added
other drug from first line drugs ( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 4 weeks :
1)If BP reached to target, continue Treatmen with similar drugs and
doses , Also regular follow up ..
2)But if not reached to target with maximum tolerated dose or
combination drugs : check the patient adherence to drugs and
lifestyle modification ;
If not reached to target ?? It called resistant hypertension .
Treatment of Hypertension :
oBut if not reached to target with maximum tolerated dose or
combination drugs : check the patient adherence to drugs and
lifestyle modification ;
If not reached to target ?? It called resistant hypertension .
•Which need consultation with specialist .
•Added one of the Fourth drugs as :
1)BB .
2)Miniralocorticoid antagonist .
3)Alpha blockers .
4)Vasodilators .
5)Central acting drugs.
Beta blockers not used as first line drugs for Stage 1 HTN except in the following
conditions :
•Hypertensive patient with coronary artery Syndrome (Angina , MI ).
•HFrEF .
as use ACEIs or ARBs plus Beta blockers as part of GDMT( ACEIs or ARBs + BB +
antiplatelets + Statin + SGLT 2 Inhibitors) .
If not reached to target : added either diuretics ( Thiazide or Thiazide like
diuretics) or Dihydropyridine CCBs . Avoid combination BB and ND CCB.
Treatment of Hypertension :
combination drugs : check the patient adherence to drugs and
lifestyle modification ;
If not reached to target ?? It called resistant hypertension .
•Which need consultation with specialist .
•Added one of the Fourth drugs as :
1)BB .
2)Miniralocorticoid antagonist .
3)Alpha blockers .
4)Vasodilators .
5)Central acting drugs.
Beta blockers not used as first line drugs for Stage 1 HTN except in the following
conditions :
•Hypertensive patient with coronary artery Syndrome (Angina , MI ).
•HFrEF .
as use ACEIs or ARBs plus Beta blockers as part of GDMT( ACEIs or ARBs + BB +
antiplatelets + Statin + SGLT 2 Inhibitors) .
If not reached to target : added either diuretics ( Thiazide or Thiazide like
diuretics) or Dihydropyridine CCBs . Avoid combination BB and ND CCB.
Treatment of Hypertension :
Stage 2 HTN regardless of ASCVD risk :
Start by tow drugs from the first line as use long acting of ( ACEI or ARBs plus CCB or
diuretics thiazide or thiazide like diuretics ),( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 1 month as
•If BP Reached To Target, Continue Treatment With Similar Drug And Does Also Regular
Follow Up ..
•But if not reached to target : check the patient adherence to drugs and lifestyle
modification and added other drug from first line drugs ( ACEI or ARBs plus CCB plus
diuretics thiazide or thiazide like diuretics ).
( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 1 month as
•IF BP reached to target, continue Treatmen with similar drugs and doses , Also regular
follow up ....
•But if not reached to target with maximum tolerated dose or combination drugs :
check the patient adherence to drugs and lifestyle modification ;
oif not reached to target ?? It called resistant hypertension .
•Which need consultation with specialist .
•Added one of the Fourth drugs as :
1)BB .
2)Mineralocorticoid antagonist .
3)Alpha blockers .
4)Vasodilators .
5)Central acting drugs.
Treatment of Hypertension :
Start by tow drugs from the first line as use long acting of ( ACEI or ARBs plus CCB or
diuretics thiazide or thiazide like diuretics ),( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 1 month as
•If BP Reached To Target, Continue Treatment With Similar Drug And Does Also Regular
Follow Up ..
•But if not reached to target : check the patient adherence to drugs and lifestyle
modification and added other drug from first line drugs ( ACEI or ARBs plus CCB plus
diuretics thiazide or thiazide like diuretics ).
( avoid combination ACEIs with ARBs ).
Then Reassessment the patient within 1 month as
•IF BP reached to target, continue Treatmen with similar drugs and doses , Also regular
follow up ....
•But if not reached to target with maximum tolerated dose or combination drugs :
check the patient adherence to drugs and lifestyle modification ;
oif not reached to target ?? It called resistant hypertension .
•Which need consultation with specialist .
•Added one of the Fourth drugs as :
1)BB .
2)Mineralocorticoid antagonist .
3)Alpha blockers .
4)Vasodilators .
5)Central acting drugs.
Treatment of Hypertension :
Treatment of Hypertension :
Hypertensive crisis : see later for more details
Hypertensive urgency : treat in out patient and home with oral antihypertensive drugs .
Hypertensive Emergency : need consultation with a specialist , admission to ICU and
treatment by parenteral antihypertensive drugs with caution .
If Secondary Hypertension : need consultation with a specialist and Treat
the cause .
Monitoring
While adjusting medication dosage, blood pressure (BP) should be monitored
every 2-4 weeks .
Once stabilised, BP should be checked and medications reviewed every 6 - 12
months .
Serum potassium and creatinine should be checked annually .
Patients taking thiazide and thiazide-type diuretics should also have serum
sodium checked annually.
Hypertensive crisis : see later for more details
Hypertensive urgency : treat in out patient and home with oral antihypertensive drugs .
Hypertensive Emergency : need consultation with a specialist , admission to ICU and
treatment by parenteral antihypertensive drugs with caution .
If Secondary Hypertension : need consultation with a specialist and Treat
the cause .
Monitoring
While adjusting medication dosage, blood pressure (BP) should be monitored
every 2-4 weeks .
Once stabilised, BP should be checked and medications reviewed every 6 - 12
months .
Serum potassium and creatinine should be checked annually .
Patients taking thiazide and thiazide-type diuretics should also have serum
sodium checked annually.
Indications for consultation with a specialist including of:
Treatment of Hypertension :
Indications for Consultation :
Hypertensive emergency – DBP > 130 mm hg or BP > 180/110 mm hg
with signs/symptoms.
Sudden onset in the elderly.
Abnormal nocturnal BP; as the differences : (>20% an extreme
nocturnal BP dip ), or (<10% non/small nocturnal BP dip) , or an
increase in nocturnal BP are at risk for CVD.
Signs or symptoms suggesting of secondary causes of the HTN .
Resistant HTN :Not achieving desired BP despite considerable
treatment effort.
More than 15 mm Hg difference between the arms.
Treatment of Hypertension :
Indications for Consultation :
Hypertensive emergency – DBP > 130 mm hg or BP > 180/110 mm hg
with signs/symptoms.
Sudden onset in the elderly.
Abnormal nocturnal BP; as the differences : (>20% an extreme
nocturnal BP dip ), or (<10% non/small nocturnal BP dip) , or an
increase in nocturnal BP are at risk for CVD.
Signs or symptoms suggesting of secondary causes of the HTN .
Resistant HTN :Not achieving desired BP despite considerable
treatment effort.
More than 15 mm Hg difference between the arms.
The ACC/AHA guidelines dissociated the BP threshold for the diagnosis of hypertension
from the BP threshold for initiation of pharmacological therapy and, in most patients the
latter is distinct from the on-target blood pressure .
High-risk patients, those with diabetes, CKD (eGFR < 60 ml/min/1.73 m2 and/or urine
albumin: creatinine ratio Equal to 300mg/g or more ), post-renal transplantation, heart
failure with reduced or preserved ejection fraction, known CVD, peripheral arterial disease,
and/orEqual to 10% or more ,ten years ASCVD risk qualify for antihypertensive drug
therapy when BP is persistently systolic Equal to 130 mm hg or more and/or Equal to 80 mm
Hg or more diastolic .
the on-treatment target BP is <130/80 mm Hg .
The 10 years ASCVD risk calculator can be accessed at www.cvriskcalculator.com .
Secondary (non-lacunar) stroke prevention in antihypertensive drug naïve patients is the
only high-risk co-morbidity for which the 140/90 mm Hg treatment initiation threshold is
recommended. The on-treatment BP target is, howeve <130/80 mm Hg.
Lower-risk patients (under 65 years of age), defined as those without the before
mentioned high-risk co-morbidities and 10-years ASCVD risk <10%, are recommended for
antihypertensive drug therapy when BP is ≥140/90 mm Hg.
Similar to most high-risk hypertensives, their target BP is <130/80 mm Hg.
Blood pressure treatment initiation thresholds and on-treatment targets
Treatment of Hypertension :
from the BP threshold for initiation of pharmacological therapy and, in most patients the
latter is distinct from the on-target blood pressure .
High-risk patients, those with diabetes, CKD (eGFR < 60 ml/min/1.73 m2 and/or urine
albumin: creatinine ratio Equal to 300mg/g or more ), post-renal transplantation, heart
failure with reduced or preserved ejection fraction, known CVD, peripheral arterial disease,
and/orEqual to 10% or more ,ten years ASCVD risk qualify for antihypertensive drug
therapy when BP is persistently systolic Equal to 130 mm hg or more and/or Equal to 80 mm
Hg or more diastolic .
the on-treatment target BP is <130/80 mm Hg .
The 10 years ASCVD risk calculator can be accessed at www.cvriskcalculator.com .
Secondary (non-lacunar) stroke prevention in antihypertensive drug naïve patients is the
only high-risk co-morbidity for which the 140/90 mm Hg treatment initiation threshold is
recommended. The on-treatment BP target is, howeve <130/80 mm Hg.
Lower-risk patients (under 65 years of age), defined as those without the before
mentioned high-risk co-morbidities and 10-years ASCVD risk <10%, are recommended for
antihypertensive drug therapy when BP is ≥140/90 mm Hg.
Similar to most high-risk hypertensives, their target BP is <130/80 mm Hg.
Blood pressure treatment initiation thresholds and on-treatment targets
Treatment of Hypertension :
Goal/target for lowering of BLOOD PRESSURE
New-onset or uncontrolled hypertension in adults
Conditions
•Drug-resistant/induced hypertension
•Abrupt onset of hypertension
•Onset of hypertension before age 30years
•Exacerbation of previously controlled
hypertension
•Disproportionate target organ damage for
•degree of hypertension
•Accelerated/malignant hypertension
•Onset of diastolic hypertension in older
adults(age 65years or older).
•Unprovoked or excessive hypokalemia.
Figure show
screening for
secondary
hypertension .
Conditions
•Drug-resistant/induced hypertension
•Abrupt onset of hypertension
•Onset of hypertension before age 30years
•Exacerbation of previously controlled
hypertension
•Disproportionate target organ damage for
•degree of hypertension
•Accelerated/malignant hypertension
•Onset of diastolic hypertension in older
adults(age 65years or older).
•Unprovoked or excessive hypokalemia.
Figure show
screening for
secondary
hypertension .
Blood Pressure Goal for Patients
withHypertension
Recommendation: For adults with confirmed
hypertension and known CVD, or a 10-year ASCVD
risk of 10 % or more, a BP target of less than
130 /80mm Hg is recommended.
Recommendation : For adults with confirmed
hypertension without additional markers of
increased CVD risk, a BP target of less than
130/80 mm Hg may be reasonable.
The updated guideline indicates that this
target BP may be reasonable for those without
additional markers of increased CVD risk.
The available evidence indicates that a lower BP
target is generally better than a higher one, and
some patients will benefit from a systolic BP
treatment goal below 120 mmHg, especially
those at high risk for CVD .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65 years
But , If ASCVD less than 10% and
no Cardiovascular disease; Start
to treat HTN when :
•BP equal or more than
140/90mmhg.
withHypertension
Recommendation: For adults with confirmed
hypertension and known CVD, or a 10-year ASCVD
risk of 10 % or more, a BP target of less than
130 /80mm Hg is recommended.
Recommendation : For adults with confirmed
hypertension without additional markers of
increased CVD risk, a BP target of less than
130/80 mm Hg may be reasonable.
The updated guideline indicates that this
target BP may be reasonable for those without
additional markers of increased CVD risk.
The available evidence indicates that a lower BP
target is generally better than a higher one, and
some patients will benefit from a systolic BP
treatment goal below 120 mmHg, especially
those at high risk for CVD .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65 years
But , If ASCVD less than 10% and
no Cardiovascular disease; Start
to treat HTN when :
•BP equal or more than
140/90mmhg.
BP thresholds and recommendations for treatment and follow-up .
2017 AHA/ACC guideline on high BP
2017 AHA/ACC guideline on high BP
When initiating
antihypertensive drug
therapy, use first-line ages
that include
Thiazide or Thiazide like
diuretics
Calcium channel
blockers
Angiotensin-converting
enzyme inhibitor
angiotensin-receptor
blockers (ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics
(30 %lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
antihypertensive drug
therapy, use first-line ages
that include
Thiazide or Thiazide like
diuretics
Calcium channel
blockers
Angiotensin-converting
enzyme inhibitor
angiotensin-receptor
blockers (ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics
(30 %lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
Treatment strategy for Hypertension
According to the level of BP (Stage)
and patients comorbidities
oTreatment including:
Either non pharmacological therapy
(lifestyle modification) and/or
pharmacological therapy with
(antihypertensive drugs) and regular
follow-up for (Reassessment and
Monitoring) .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65
years
But , If ASCVD less than 10%
and no Cardiovascular disease;
Start to treat HTN when :
•BP equal or more than
140/90mmhg.
According to the level of BP (Stage)
and patients comorbidities
oTreatment including:
Either non pharmacological therapy
(lifestyle modification) and/or
pharmacological therapy with
(antihypertensive drugs) and regular
follow-up for (Reassessment and
Monitoring) .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65
years
But , If ASCVD less than 10%
and no Cardiovascular disease;
Start to treat HTN when :
•BP equal or more than
140/90mmhg.
When initiating
antihypertensive drug
therapy, use first-line ages
that include
Thiazide or Thiazide like
diuretics
Calcium channel
blockers
Angiotensin-converting
enzyme inhibitor
angiotensin-receptor
blockers (ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics
(30 %lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
antihypertensive drug
therapy, use first-line ages
that include
Thiazide or Thiazide like
diuretics
Calcium channel
blockers
Angiotensin-converting
enzyme inhibitor
angiotensin-receptor
blockers (ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics
(30 %lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
Lifestyle Therapy :
Lifestyle Changes
Recommendation: Use effective behavioral and
motivational strategies to help adults with hypertension
achieve a healthy lifestyle.
The updated guideline emphasizes the benefits of lifestyle
changes to prevent and treat hypertension (Table below).
Nonpharmacologic therapy alone is especially useful for
preventing hypertension, including in adults with elevated
BP and in the management of milder forms of
hypertension.
Nonpharmacologic Interventions:
Lifestyle Changes
Recommendation: Use effective behavioral and
motivational strategies to help adults with hypertension
achieve a healthy lifestyle.
The updated guideline emphasizes the benefits of lifestyle
changes to prevent and treat hypertension (Table below).
Nonpharmacologic therapy alone is especially useful for
preventing hypertension, including in adults with elevated
BP and in the management of milder forms of
hypertension.
Nonpharmacologic Interventions:
Nonpharmacologic
Intervention
Dose Effects on BP (reduce BP
about...Mmhg)
Healthy diet: Use the
Dietary Approaches to
Stop Hypertension (DASH)
dietary pattern
Diet rich in fruits,
vegetables, whole grains,
and low-fat dairy products
with reduced content of
saturated and total fat
In HTN -11
In normotensive -3
Weight loss: Focus on losing
excess
weight/body fat
Ideal body weight is best
goal, but aim for at least 1
kg body weight reduction
for most overweight adults.
•Expect about 1 mm Hg for
every 1 kg reduction in
body weight..
In HTN -5
In normotensive -3
Sodium: Reduce intake of
dietary sodium
•<1500 mg/day is optimal
goal, but aim for at least
1000 mg/day reduction
in most adults
In HTN -5/6
In normotensive -2/3
Nonpharmacologic Interventions:
Cont...
Intervention
Dose Effects on BP (reduce BP
about...Mmhg)
Healthy diet: Use the
Dietary Approaches to
Stop Hypertension (DASH)
dietary pattern
Diet rich in fruits,
vegetables, whole grains,
and low-fat dairy products
with reduced content of
saturated and total fat
In HTN -11
In normotensive -3
Weight loss: Focus on losing
excess
weight/body fat
Ideal body weight is best
goal, but aim for at least 1
kg body weight reduction
for most overweight adults.
•Expect about 1 mm Hg for
every 1 kg reduction in
body weight..
In HTN -5
In normotensive -3
Sodium: Reduce intake of
dietary sodium
•<1500 mg/day is optimal
goal, but aim for at least
1000 mg/day reduction
in most adults
In HTN -5/6
In normotensive -2/3
Nonpharmacologic Interventions:
Cont...
Nonpharmacologic
Intervention
Dose Effects on BP (reduce BP
about...Mm hg)
Potassium: Increase intake
of dietary
potassium
3500 - 5000 mg/day, preferably
by consumption of a diet rich in
potassium
In HTN -4/5
In normotensive -2 /4
Physical activity: Add
aerobic exercises to weakly
routine
•90-150 min/week
• 65%-75% heart rate
reserve
In HTN -5/8
In normotensive -2/4
Physical activity: Add
dynamic resistance
training to weekly routine
•90 – 150 min / week
•50% -80% 1 rep maximum
6 exercises ,3 sets/exercise
, 10repetitions/set
In HTN -4
In normotensive -2
Physical activity: Add
isometric resistance
training to weekly routine
•4 x 2min (hand grip) , 1
minute of rest between
exercises ,30% -
40%maximum voluntary
contraction , 3
sessions/week .
•8-10 weeks .
In HTN -5
In normotensive -4
Alcohol: Reduce
consumption of alcohol
For those who drink alcohol, the
recommended daily consumption is no
more than 2 drinks for men and 1
drink for women.
In HTN -4mmhg
In normotensive -3
Nonpharmacologic Interventions:
Intervention
Dose Effects on BP (reduce BP
about...Mm hg)
Potassium: Increase intake
of dietary
potassium
3500 - 5000 mg/day, preferably
by consumption of a diet rich in
potassium
In HTN -4/5
In normotensive -2 /4
Physical activity: Add
aerobic exercises to weakly
routine
•90-150 min/week
• 65%-75% heart rate
reserve
In HTN -5/8
In normotensive -2/4
Physical activity: Add
dynamic resistance
training to weekly routine
•90 – 150 min / week
•50% -80% 1 rep maximum
6 exercises ,3 sets/exercise
, 10repetitions/set
In HTN -4
In normotensive -2
Physical activity: Add
isometric resistance
training to weekly routine
•4 x 2min (hand grip) , 1
minute of rest between
exercises ,30% -
40%maximum voluntary
contraction , 3
sessions/week .
•8-10 weeks .
In HTN -5
In normotensive -4
Alcohol: Reduce
consumption of alcohol
For those who drink alcohol, the
recommended daily consumption is no
more than 2 drinks for men and 1
drink for women.
In HTN -4mmhg
In normotensive -3
Nonpharmacologic Interventions:
Modifiable and fixed risk factors.
Modifiable and fixed risk factors of HTN
Modifiable and fixed risk factors of HTN
Drug Therapy
Choice of Single vs Combination
Drug Therapy
Recommendation : initiate antihypertensive drug therapy with tow drugs
from first-line agents of different classes for adults with stage 2 hypertension
and BP more than 20/10 mm hg higher than their target. antihypertensive
therapy with 2 agents for stage 2 hypertension
Recommendation :it is reasonable to initiating therapy with a single agent for
adults with stage 1 hypertension and a goal of less than 130/80 mm hg.
•This approach is resonable in the very elderly, those with high CVD risk, or
patients with a history of hypotension or drug associated side effects.
o Be cautious when initiating antihypertensive pharmacotherapy with 2 drugs
in older patients because hypotension or orthostatic hypotension may
develop .
Treatment of Hypertension :
Choice of Single vs Combination
Drug Therapy
Recommendation : initiate antihypertensive drug therapy with tow drugs
from first-line agents of different classes for adults with stage 2 hypertension
and BP more than 20/10 mm hg higher than their target. antihypertensive
therapy with 2 agents for stage 2 hypertension
Recommendation :it is reasonable to initiating therapy with a single agent for
adults with stage 1 hypertension and a goal of less than 130/80 mm hg.
•This approach is resonable in the very elderly, those with high CVD risk, or
patients with a history of hypotension or drug associated side effects.
o Be cautious when initiating antihypertensive pharmacotherapy with 2 drugs
in older patients because hypotension or orthostatic hypotension may
develop .
Treatment of Hypertension :
When initiating
antihypertensive drug
therapy, use first-line ages
that include
•Thiazide or Thiazide like
diuretics
•Calcium channel blockers
•Angiotensin-converting
enzyme inhibitor
angiotensin-receptor blockers
(ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics 30%
lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
antihypertensive drug
therapy, use first-line ages
that include
•Thiazide or Thiazide like
diuretics
•Calcium channel blockers
•Angiotensin-converting
enzyme inhibitor
angiotensin-receptor blockers
(ARBs)
Five drug classes have been shown to prevent
CVDcompared with placebo :
•Diuretics
•ACE inhibitors
•ARBs
•Calcium channel blockers
•β-Blockers.
– β-Blockers were less effective than
calcium channel blockers (36 %
lower risk) and thiazide diuretics 30%
lower risk) in preventing
stroke in the general population
There is updated drug that used to treat HTN is Zilebesiran.
Administer as 300mg subcutaneous Injection /6months
Zilebesiran which is siRNA inhibition of Angiotensinogen in liver .
Treatment of Hypertension :
Blood Pressure Goal for Patients with
Hypertension
Recommendation: For adults with confirmed
hypertension and known CVD, or a 10-year ASCVD
risk of 10 % or more, a BP target of less than
130 /80mm Hg is recommended.
Recommendation : For adults with confirmed
hypertension without additional markers of
increased CVD risk, a BP target of less than
130/80 mm Hg may be reasonable.
The updated guideline indicates that this
target BP may be reasonable for those without
additional markers of increased CVD risk.
The available evidence indicates that a lower BP
target is generally better than a higher one, and
some patients will benefit from a systolic BP
treatment goal below 120 mmHg, especially
those at high risk for CVD .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65 years
But , If ASCVD less than 10% and
no Cardiovascular disease; Start
to treat HTN when :
•BP equal or more than
140/90mmhg.
Hypertension
Recommendation: For adults with confirmed
hypertension and known CVD, or a 10-year ASCVD
risk of 10 % or more, a BP target of less than
130 /80mm Hg is recommended.
Recommendation : For adults with confirmed
hypertension without additional markers of
increased CVD risk, a BP target of less than
130/80 mm Hg may be reasonable.
The updated guideline indicates that this
target BP may be reasonable for those without
additional markers of increased CVD risk.
The available evidence indicates that a lower BP
target is generally better than a higher one, and
some patients will benefit from a systolic BP
treatment goal below 120 mmHg, especially
those at high risk for CVD .
Start to treatment of HTN: if
BP 130/80mmhg PLUS any one
or more of:
•ASCVD equal or more than 10%
•Heart dx(IHD ,HF)
•DM
•CKD
•PAD
•Previous Stroke
•Carotid artery disease
•Age equal or more than 65 years
But , If ASCVD less than 10% and
no Cardiovascular disease; Start
to treat HTN when :
•BP equal or more than
140/90mmhg.
2017American Diabetes Association (ADM).
Adults with diabetes target to decrease BP to < 140/90 mm Hg; or to
< 130/80 mm Hg target may be appropriate for those at high risk of
cardiovascular disease.
2017American College of Cardiology/American Heart Association (ACC/AHA)
All adults target to decrease BP to < 130/80 mm Hg
2015 American Heart Association/American College of Cardiology/American
Society of Hypertension (AHA/ACC/ASH)
•Adults with CAD, except as noted below target to decrease BP to<
140/90 mm Hg.
•Adults with MI, stroke, TIA, carotid artery disease, peripheral
artery disease or abdominal aortic aneurysm target to decrease BP
to < 130/80 mm Hg.
•Adults ages >80 years target to decrease BP to< 150/90 mm Hg.
Target of BP
Adults with diabetes target to decrease BP to < 140/90 mm Hg; or to
< 130/80 mm Hg target may be appropriate for those at high risk of
cardiovascular disease.
2017American College of Cardiology/American Heart Association (ACC/AHA)
All adults target to decrease BP to < 130/80 mm Hg
2015 American Heart Association/American College of Cardiology/American
Society of Hypertension (AHA/ACC/ASH)
•Adults with CAD, except as noted below target to decrease BP to<
140/90 mm Hg.
•Adults with MI, stroke, TIA, carotid artery disease, peripheral
artery disease or abdominal aortic aneurysm target to decrease BP
to < 130/80 mm Hg.
•Adults ages >80 years target to decrease BP to< 150/90 mm Hg.
Target of BP
ACE inhibitors were notably less effective
in preventing heart failure and stroke
compared with calcium channel blockers in
black patients.
ARBs may be better tolerated than ACE
inhibitors in black patients, with less cough
and angioedema, but they offer no proven
advantage over ACE inhibitors in preventing stroke or CVD
in this population, making thiazide diuretics(especially
chlorthalidone)or calcium channel blockers the best initial
choice for single-drug therapy .
Pharmacological therapy
in preventing heart failure and stroke
compared with calcium channel blockers in
black patients.
ARBs may be better tolerated than ACE
inhibitors in black patients, with less cough
and angioedema, but they offer no proven
advantage over ACE inhibitors in preventing stroke or CVD
in this population, making thiazide diuretics(especially
chlorthalidone)or calcium channel blockers the best initial
choice for single-drug therapy .
Pharmacological therapy
If BP <120/80mmhg ( Normal BP ) :
lifestyle modification and reassessment of BP annually (every year ).
If SBP 120 -129mmhg /DBP<80mmhg ( Elevated BP ) :
lifestyle modification and reassessment of BP every 3 - 6 months.
Pharmacological therapy
For patients with systolic blood pressure >120 mm Hg or diastolic
blood pressure >80 mm Hg, lifestyle intervention consists of weight
loss if overweight or obese; a Dietary Approaches to Stop
Hypertension (DASH)-style dietary pattern, including reduced
sodium and increased potassium intake; increased fruit and
vegetable consumption; moderation of alcohol intake; and
increased physical activity .
lifestyle modification and reassessment of BP annually (every year ).
If SBP 120 -129mmhg /DBP<80mmhg ( Elevated BP ) :
lifestyle modification and reassessment of BP every 3 - 6 months.
Pharmacological therapy
For patients with systolic blood pressure >120 mm Hg or diastolic
blood pressure >80 mm Hg, lifestyle intervention consists of weight
loss if overweight or obese; a Dietary Approaches to Stop
Hypertension (DASH)-style dietary pattern, including reduced
sodium and increased potassium intake; increased fruit and
vegetable consumption; moderation of alcohol intake; and
increased physical activity .
If BP ≥130/80mmhg ( stage 1 HTN ) :
management depending on ASCVD Risk as the following :
If ASCVD < 10 %
Non pharmacological TTT(lifestyle modification) and reassessment every 3-6
months .
If ASCVD > 10 %
management by :
Non pharmacological TTT (lifestyle modification) as before
plus pharmacological treatment : as we start by :
either monotherapy from first line drugs or by combination of 2 drugs of
first line ( avoid combination ACEI +ARB together) ,then reassessment of
BP within 4-6 weeks depending on response (if reached to target or not) :
• If result reach to target BP : continue same ttt if no SE. and
monitoring PT.
but
•If BP not reach to target with maximum tolerated dose: see below..
Pharmacological therapy
management depending on ASCVD Risk as the following :
If ASCVD < 10 %
Non pharmacological TTT(lifestyle modification) and reassessment every 3-6
months .
If ASCVD > 10 %
management by :
Non pharmacological TTT (lifestyle modification) as before
plus pharmacological treatment : as we start by :
either monotherapy from first line drugs or by combination of 2 drugs of
first line ( avoid combination ACEI +ARB together) ,then reassessment of
BP within 4-6 weeks depending on response (if reached to target or not) :
• If result reach to target BP : continue same ttt if no SE. and
monitoring PT.
but
•If BP not reach to target with maximum tolerated dose: see below..
Pharmacological therapy
•But if BP not reach to target with maximum tolerated dose :
Reinforce lifestyle and adherence and add other drugs from
first line as CCB.
Then reassessment of BP within 4-6weeks :
oif reach to target BP : continue TTT and monitoring.
oBut if BP not reach to target with maximum tolerated dose :
•Reinforce lifestyle and adherence and add other drugs from
first line as Thiazide then reassessment of BP if reached to
target : continue TTT and monitoring .
oBut if BP not reach to target with maximum tolerated dose :
it called resistant HTN. which need other drugs beside
previous drugs : as (mineralocorticoid antagonist or Alpha
Blockers or vasodilator or central acting drugs) see later....
Pharmacological therapy
Reinforce lifestyle and adherence and add other drugs from
first line as CCB.
Then reassessment of BP within 4-6weeks :
oif reach to target BP : continue TTT and monitoring.
oBut if BP not reach to target with maximum tolerated dose :
•Reinforce lifestyle and adherence and add other drugs from
first line as Thiazide then reassessment of BP if reached to
target : continue TTT and monitoring .
oBut if BP not reach to target with maximum tolerated dose :
it called resistant HTN. which need other drugs beside
previous drugs : as (mineralocorticoid antagonist or Alpha
Blockers or vasodilator or central acting drugs) see later....
Pharmacological therapy
IF SBP > = 140mmhg or DBP > = 90mmhg ( Stage 2 HTN ) :
Need combination of two drugs from First Line .
IF SBP>180mmhg and/or DBP>120mmhg ( hypertensive
crisis ) :have special strategy for treatment see later....
Pharmacological therapy
Note: the good responder ;
generally respond to low dose
with few side effects.
Need combination of two drugs from First Line .
IF SBP>180mmhg and/or DBP>120mmhg ( hypertensive
crisis ) :have special strategy for treatment see later....
Pharmacological therapy
Note: the good responder ;
generally respond to low dose
with few side effects.
•HTN +CKD : ACEI or ARB both have same efficacy to decrease BP
•HTN+ CKD stage 3 or more or CKD stage 1 or 2 plus Albuminuria >300mg/dl or
> 300mg/g Albumin: creatinine ratio : best drug is ACEI
•HTN +renal transplantation : DH CCB (Amlodipine)
• HTN +DM :Start by one of the following : ACEI/ARB or CCB or Thiazide or
Thiazide like diuretics.
•HTN +DM with Albuminuria (DNP) : ACEI is the best
•HTN+ DM : Start to treat HTN by ACEI or ARB iF BP not reached to target added
Thiazide diuretics IF eGFR >30ml/min but if eGFR<30 ml/min add loop diuretics .
Monitor RFT , serum electrolytes.
• HTN+AF :NDH CCB or ARB.
• HTN + HFrEF : ACEI /ARB + BB (DH CCB or thiazide add if target if not reach)
•HTN + HFpEF: after management of volume overload ,give ACEI or ARB + BB
• HTN +PAD : DH CCB or any of first line drugs.
•HTN + hx of IHD (MI ,Angina) : ACEI/ARB or BB
• HTN + Stable IHD : BB and /or NDHCCB.
First line of Antihypertensive Drugs for stage I according to comorbidity
Pharmacological therapy
•HTN+ CKD stage 3 or more or CKD stage 1 or 2 plus Albuminuria >300mg/dl or
> 300mg/g Albumin: creatinine ratio : best drug is ACEI
•HTN +renal transplantation : DH CCB (Amlodipine)
• HTN +DM :Start by one of the following : ACEI/ARB or CCB or Thiazide or
Thiazide like diuretics.
•HTN +DM with Albuminuria (DNP) : ACEI is the best
•HTN+ DM : Start to treat HTN by ACEI or ARB iF BP not reached to target added
Thiazide diuretics IF eGFR >30ml/min but if eGFR<30 ml/min add loop diuretics .
Monitor RFT , serum electrolytes.
• HTN+AF :NDH CCB or ARB.
• HTN + HFrEF : ACEI /ARB + BB (DH CCB or thiazide add if target if not reach)
•HTN + HFpEF: after management of volume overload ,give ACEI or ARB + BB
• HTN +PAD : DH CCB or any of first line drugs.
•HTN + hx of IHD (MI ,Angina) : ACEI/ARB or BB
• HTN + Stable IHD : BB and /or NDHCCB.
First line of Antihypertensive Drugs for stage I according to comorbidity
Pharmacological therapy
•HTN + hx of CVA or TIA : Thiazide and /or ACEI/ARB
•HTN +pregnancy : labetolol (first line), nifedipine,
methyldopa ,hydralazine
•HTN +COPD or B.Asthma : CCB
•HTN +black :CCB or Thiazide
•HTN +non black: any of (ACEI/ARB /CCB /Thiazide)
First line of Antihypertensive Drugs for stage I according to comorbidity
Pharmacological therapy
•HTN +pregnancy : labetolol (first line), nifedipine,
methyldopa ,hydralazine
•HTN +COPD or B.Asthma : CCB
•HTN +black :CCB or Thiazide
•HTN +non black: any of (ACEI/ARB /CCB /Thiazide)
First line of Antihypertensive Drugs for stage I according to comorbidity
Pharmacological therapy
HTN in pt with acute CVA (either ischemic or haemorrhagic) :
•HTN +Acute ICVA (Present within 6 hours of event) When to give
antihypertensivedrugs toreduce BP : HTN emergency BP 180/110mmhg plus one or
more of the following Hypertensive (Encephalopathy , Nephropathy , MI or HF ,
Preeclampsia or Eclampsia ,Aortic dissection
Consider to reduce BP if ICVA patient who candidate for Emergency reperfusion
Treatment as IV thrombolysis therapy or Thrombectomy .
•Reduce BP to < 185/110mmhg before administration of IV Thrombolysis therapy ,
to <185/110mmhg before EVT and maintain BP to <180/105mmhg during and
after ERT , monitoring of BP /15Min for 2hrs , then /30mins for 6hrs after that/hr
for 16hrs.
If ICVA patient not candidate for IV thrombolysis therapy or EVT(Thrombectomy)
reduce BP aboute 15%-25% of SBP within 24hrs if BP>220/120 mmhg
•Labetolol iv 10-20mg over 1-2min
•Nicardipin iv 5mg/hr titrate by2.5mg /hr every 5-15min max.dose 15mg/hr.
•Clevidipine iv 1-2mg/hr titrate by doubling dose /2-5min until desire effect.
Max.21mg/hr
If BP Not control by previous options or if DBP>140mmhg use Sodium Nitroprusside .
TARGET BP control in HTN adult patient with HCVA who present within 6 hrs of acute
event and SBP Between 150-220mmhg targeted to<140mmhg.
Pharmacological therapy
•HTN +Acute ICVA (Present within 6 hours of event) When to give
antihypertensivedrugs toreduce BP : HTN emergency BP 180/110mmhg plus one or
more of the following Hypertensive (Encephalopathy , Nephropathy , MI or HF ,
Preeclampsia or Eclampsia ,Aortic dissection
Consider to reduce BP if ICVA patient who candidate for Emergency reperfusion
Treatment as IV thrombolysis therapy or Thrombectomy .
•Reduce BP to < 185/110mmhg before administration of IV Thrombolysis therapy ,
to <185/110mmhg before EVT and maintain BP to <180/105mmhg during and
after ERT , monitoring of BP /15Min for 2hrs , then /30mins for 6hrs after that/hr
for 16hrs.
If ICVA patient not candidate for IV thrombolysis therapy or EVT(Thrombectomy)
reduce BP aboute 15%-25% of SBP within 24hrs if BP>220/120 mmhg
•Labetolol iv 10-20mg over 1-2min
•Nicardipin iv 5mg/hr titrate by2.5mg /hr every 5-15min max.dose 15mg/hr.
•Clevidipine iv 1-2mg/hr titrate by doubling dose /2-5min until desire effect.
Max.21mg/hr
If BP Not control by previous options or if DBP>140mmhg use Sodium Nitroprusside .
TARGET BP control in HTN adult patient with HCVA who present within 6 hrs of acute
event and SBP Between 150-220mmhg targeted to<140mmhg.
Pharmacological therapy
Nondihydropyridine calcium channel blockers (CCBs)
are not recommended in the treatment of
hypertension in adults with HFrEF.
Adults with HTN and HFrEF should be reduce BP to be
BP less than 130/80 mm Hg.
Adults with hypertension and chronic kidney disease
(CKD) should be treated to a BP goal of less than
130/80 mm Hg.
After kidney transplantation, it is reasonable to treat
patients with hypertension to a BP goal of less than
130/80 mm Hg. After kidney transplantation, it is
reasonable to treat patients with hypertension with a
calcium antagonist on the basis of improved
glomerular filtration rate (GFR) and kidney survival.
Pharmacological therapy
are not recommended in the treatment of
hypertension in adults with HFrEF.
Adults with HTN and HFrEF should be reduce BP to be
BP less than 130/80 mm Hg.
Adults with hypertension and chronic kidney disease
(CKD) should be treated to a BP goal of less than
130/80 mm Hg.
After kidney transplantation, it is reasonable to treat
patients with hypertension to a BP goal of less than
130/80 mm Hg. After kidney transplantation, it is
reasonable to treat patients with hypertension with a
calcium antagonist on the basis of improved
glomerular filtration rate (GFR) and kidney survival.
Pharmacological therapy
•Immediate lowering of SBP to lower than 140 mm Hg in
adults with spontaneous intracerebral hemorrhage (ICH)
who present within 6 hours of the acute event and have
an SBP between 150 mm Hg and 220 mm Hg is not of
benefit to reduce death or severe disability and can be
potentially harmful.
•Adults with acute ischemic stroke and elevated BP who
are eligible for treatment with intravenous (IV) tissue
plasminogen activator (tPA) should have their BP slowly
lowered to below 185/110 mm Hg before thrombolytic
therapy is initiated.
Pharmacological therapy
adults with spontaneous intracerebral hemorrhage (ICH)
who present within 6 hours of the acute event and have
an SBP between 150 mm Hg and 220 mm Hg is not of
benefit to reduce death or severe disability and can be
potentially harmful.
•Adults with acute ischemic stroke and elevated BP who
are eligible for treatment with intravenous (IV) tissue
plasminogen activator (tPA) should have their BP slowly
lowered to below 185/110 mm Hg before thrombolytic
therapy is initiated.
Pharmacological therapy
•In adults with an acute ischemic stroke, BP should be less than
185/110 mm Hg before administration of IV tPA and should be
maintained below 180/105 mm Hg for at least the first 24 hours
after initiating drug therapy.
•For adults who experience a stroke or transient ischemic attack
(TIA), treatment with a thiazide diuretic, ACEI, or angiotensin
receptor blocker (ARB), or combination treatment consisting of a
thiazide diuretic plus ACEI, is useful.
An ACEI or ARB, at the maximum tolerated dose indicated for
blood pressure treatment, is the recommended first-line
treatment for hypertension in patients with diabetes and urine
albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g
creatinine. If one class is not tolerated, the other should be
substituted.
Pharmacological therapy
185/110 mm Hg before administration of IV tPA and should be
maintained below 180/105 mm Hg for at least the first 24 hours
after initiating drug therapy.
•For adults who experience a stroke or transient ischemic attack
(TIA), treatment with a thiazide diuretic, ACEI, or angiotensin
receptor blocker (ARB), or combination treatment consisting of a
thiazide diuretic plus ACEI, is useful.
An ACEI or ARB, at the maximum tolerated dose indicated for
blood pressure treatment, is the recommended first-line
treatment for hypertension in patients with diabetes and urine
albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g
creatinine. If one class is not tolerated, the other should be
substituted.
Pharmacological therapy
Pregnancy and Hypertension
JNC 7 Classification of Hypertensive Disorders in Pregnancy :
Chronic hypertension : SBP ≥140 mm Hg or DBP ≥90 mm Hg, present pre-pregnancy
or before 20 weeks’ gestation and persisting >12 weeks postpartum .
Preeclampsia : SBP ≥140 mm Hg or DBP ≥90 mm Hg with proteinuria (>300 mg/24 h)
that develops >20 weeks’ gestation; Can progress to eclampsia.
Chronic hypertension with superimposed preeclampsia : New-onset proteinuria after
20 weeks’ gestation in a hypertensive woman or
In a woman with hypertension and proteinuria before 20 weeks’ gestation:
• Sudden 2- to 3-fold increase in proteinuria
• Sudden increase in BP
• Thrombocytopenia
• Elevated AST or ALT levels
Gestational hypertension : Temporary diagnosis
•Hypertension without proteinuria after 20 weeks’ gestation
•May be a preproteinuric phase of preeclampsia or a recurrence of chronic
hypertension that abated in mid-pregnancy
•May lead to preeclampsia , Severe cases may cause higher rates of premature
delivery and growth retardation relative to mild preeclampsia
Transient hypertension : Diagnosis made retrospectively
•BP returns to normal by 12 weeks postpartum
•May recur in subsequent pregnancies
•Predictive of future primary hypertension
7 Joint National Committe: 7 JNC
Pregnancy and Hypertension
Chronic hypertension : SBP ≥140 mm Hg or DBP ≥90 mm Hg, present pre-pregnancy
or before 20 weeks’ gestation and persisting >12 weeks postpartum .
Preeclampsia : SBP ≥140 mm Hg or DBP ≥90 mm Hg with proteinuria (>300 mg/24 h)
that develops >20 weeks’ gestation; Can progress to eclampsia.
Chronic hypertension with superimposed preeclampsia : New-onset proteinuria after
20 weeks’ gestation in a hypertensive woman or
In a woman with hypertension and proteinuria before 20 weeks’ gestation:
• Sudden 2- to 3-fold increase in proteinuria
• Sudden increase in BP
• Thrombocytopenia
• Elevated AST or ALT levels
Gestational hypertension : Temporary diagnosis
•Hypertension without proteinuria after 20 weeks’ gestation
•May be a preproteinuric phase of preeclampsia or a recurrence of chronic
hypertension that abated in mid-pregnancy
•May lead to preeclampsia , Severe cases may cause higher rates of premature
delivery and growth retardation relative to mild preeclampsia
Transient hypertension : Diagnosis made retrospectively
•BP returns to normal by 12 weeks postpartum
•May recur in subsequent pregnancies
•Predictive of future primary hypertension
7 Joint National Committe: 7 JNC
Pregnancy and Hypertension
In severe hypertension: systolic BP ≥160 mm Hg or diastolic BP ≥110 mm Hg or both.
Women who have preexisting end-organ damage from chronic hypertension or who have previously
required multidrug therapy for BP control should have a lower threshold for starting antihypertensive
medication (ie, >139/89 mm Hg) and a lower target BP (< 140/90 mm Hg).
In women with eclampsia or preeclampsia, the SBP should lowered to below 140 mm Hg during the first
hour.
If the platelet count is less than 100,000 cells mm3, the BP should be maintained below 150/100 mm Hg.
Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic
blood pressure <160 mm Hg, diastolic blood pressure <105 mm Hg, and no evidence of end-organ damage:
do not need to be treated with pharmacological antihypertensive therapy.
In pregnant patients with diabetes and preexisting hypertension who are treated with
antihypertensive therapy, systolic or diastolic blood pressure targets of 120 -160/80-105 mm Hg are
suggested in the interest of optimizing long-term maternal health and fetal growth.
Methyldopa is generally the preferred first-line agent because of its safety profile.
Other drugs that may be considered include labetalol, beta-blockers, and diuretics.
ACOG does not recommend the use of any of the following :
ACEIs
ARBs
Renin inhibitors
Mineralocorticoid receptor antagonists
Pharmacological therapy
Pregnancy and Hypertension
treatment targets-Blood pressure treatment initiation thresholds and on
Women who have preexisting end-organ damage from chronic hypertension or who have previously
required multidrug therapy for BP control should have a lower threshold for starting antihypertensive
medication (ie, >139/89 mm Hg) and a lower target BP (< 140/90 mm Hg).
In women with eclampsia or preeclampsia, the SBP should lowered to below 140 mm Hg during the first
hour.
If the platelet count is less than 100,000 cells mm3, the BP should be maintained below 150/100 mm Hg.
Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic
blood pressure <160 mm Hg, diastolic blood pressure <105 mm Hg, and no evidence of end-organ damage:
do not need to be treated with pharmacological antihypertensive therapy.
In pregnant patients with diabetes and preexisting hypertension who are treated with
antihypertensive therapy, systolic or diastolic blood pressure targets of 120 -160/80-105 mm Hg are
suggested in the interest of optimizing long-term maternal health and fetal growth.
Methyldopa is generally the preferred first-line agent because of its safety profile.
Other drugs that may be considered include labetalol, beta-blockers, and diuretics.
ACOG does not recommend the use of any of the following :
ACEIs
ARBs
Renin inhibitors
Mineralocorticoid receptor antagonists
Pharmacological therapy
Pregnancy and Hypertension
treatment targets-Blood pressure treatment initiation thresholds and on
Severe hypertension:
There is consensus across guidelines (JNC 7, ESH/ESC, ACOG, SOGC) for the need
to acutely manage severe hypertension, defined as systolic BP ≥160 mm Hg or
diastolic BP ≥110 mm Hg or both, with the goal of preventing maternal stroke and
avoiding intrauterine growth restriction (IUGR).
In 2015, the American College of Obstetricians and Gynecologists Committee on
Obstetric Practice issued updated guidelines regarding the emergency treatment
of acute-onset severe hypertension during pregnancy, including the following :
Acute-onset, severe hypertension that is accurately measured using standard
techniques and is persistent for 15 minutes or longer is considered a hypertensive
emergency.
Intravenous (IV) labetalol and hydralazine have long been considered first-line
medications for the management of acute-onset, severe hypertension in pregnant
and post-partum women, oral nifedipine also may be considered as a first-line
therapy .
Parenteral labetalol should be avoided in women with asthma, heart disease, or
congestive heart failure.
When urgent treatment is needed before the establishment of IV access, the oral
nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of
labetalol can be administered orally; the latter can be repeated in 30 minutes if
appropriate improvement is not observed .
Pregnancy and Hypertension
There is consensus across guidelines (JNC 7, ESH/ESC, ACOG, SOGC) for the need
to acutely manage severe hypertension, defined as systolic BP ≥160 mm Hg or
diastolic BP ≥110 mm Hg or both, with the goal of preventing maternal stroke and
avoiding intrauterine growth restriction (IUGR).
In 2015, the American College of Obstetricians and Gynecologists Committee on
Obstetric Practice issued updated guidelines regarding the emergency treatment
of acute-onset severe hypertension during pregnancy, including the following :
Acute-onset, severe hypertension that is accurately measured using standard
techniques and is persistent for 15 minutes or longer is considered a hypertensive
emergency.
Intravenous (IV) labetalol and hydralazine have long been considered first-line
medications for the management of acute-onset, severe hypertension in pregnant
and post-partum women, oral nifedipine also may be considered as a first-line
therapy .
Parenteral labetalol should be avoided in women with asthma, heart disease, or
congestive heart failure.
When urgent treatment is needed before the establishment of IV access, the oral
nifedipine algorithm can be initiated as IV access is being obtained, or a 200-mg dose of
labetalol can be administered orally; the latter can be repeated in 30 minutes if
appropriate improvement is not observed .
Pregnancy and Hypertension
In pregnant patients with diabetes and chronic hypertension, the ADA 2016
Standards of Medical Care in Diabetes recommends blood pressure targets of
110-129 /65-79 mm Hg in the interest of optimizing long-term maternal health
and minimizing impairment of fetal growth .
ACEIs and ARBs are contraindicated during pregnancy .
But
The 2017 ADA position statement on diabetes and hypertension indicates no
antihypertensive pharmacotherapy is necessary for pregnant women with
diabetes and preexisting hypertension or mild gestational hypertension with
an SBP below 160 mm Hg and a DBP below 105 mm Hg, and no evidence of
end organ damage.
For pregnant women with diabetes and preexisting hypertension on
antihypertensive therapy, suggested BP targets are an SBP of 120-160 mm Hg
and a DBP target of 80-105 mm Hg.
Pregnancy and Hypertension
Hypertension and diabetes in pregnancy
Standards of Medical Care in Diabetes recommends blood pressure targets of
110-129 /65-79 mm Hg in the interest of optimizing long-term maternal health
and minimizing impairment of fetal growth .
ACEIs and ARBs are contraindicated during pregnancy .
But
The 2017 ADA position statement on diabetes and hypertension indicates no
antihypertensive pharmacotherapy is necessary for pregnant women with
diabetes and preexisting hypertension or mild gestational hypertension with
an SBP below 160 mm Hg and a DBP below 105 mm Hg, and no evidence of
end organ damage.
For pregnant women with diabetes and preexisting hypertension on
antihypertensive therapy, suggested BP targets are an SBP of 120-160 mm Hg
and a DBP target of 80-105 mm Hg.
Pregnancy and Hypertension
Hypertension and diabetes in pregnancy
In the hypertensive pregnant women without preeclampsia
•blood pressure should be closely monitored every other day, or more
frequently in an admitted patient .
•Monitor full blood count, liver and renal function tests twice a week .
Women with preeclampsia when first diagnosed,
•should be initially treated in hospital and managed until they are
stable .
•If with features of preeclampsia, the blood pressure should be
monitored at least 6 hourly.
• Monitor full blood count, liver function, coagulation and renal
function tests three times a week.
if the pregnant women has severe hypertension )BP≥160/110
mmhg with or without features of preeclampsia:
• should be admitted and blood pressure checked more frequently .
then should be monitored at least 6 hourly .
•Monitor full blood count, liver function, coagulation and renal function
tests three times a week .
•Testing for urine protein should be repeated as clinically indicated.
Pregnancy and Hypertension
•blood pressure should be closely monitored every other day, or more
frequently in an admitted patient .
•Monitor full blood count, liver and renal function tests twice a week .
Women with preeclampsia when first diagnosed,
•should be initially treated in hospital and managed until they are
stable .
•If with features of preeclampsia, the blood pressure should be
monitored at least 6 hourly.
• Monitor full blood count, liver function, coagulation and renal
function tests three times a week.
if the pregnant women has severe hypertension )BP≥160/110
mmhg with or without features of preeclampsia:
• should be admitted and blood pressure checked more frequently .
then should be monitored at least 6 hourly .
•Monitor full blood count, liver function, coagulation and renal function
tests three times a week .
•Testing for urine protein should be repeated as clinically indicated.
Pregnancy and Hypertension
ANTIHYPERTENSIVE DRUGS
Class Drug Usual Dose,
Range(mg per
day)*Daily Frequency
Comments
Thiazide diuretic
Thiazide like diuretics
Hydrochlorothiazide
Chlorthalidone
Indapamide
Metolazone
25-50 mg . od
12.5- 25 mg . od
1.25-2.5 mg . od
2.5-10 mg . od
Chlorthalidone
preference based
on prolonged half-
life and proven trial
reduction of CVD
• Monitor for
hyponatremia and
hypokalemia, uric
acid and calcium
levels
• Use with caution
in patients with
history of acute
gout unless patient
is on uric acid-
lowering therapy
Pharmacological therapy
Range(mg per
day)*Daily Frequency
Comments
Thiazide diuretic
Thiazide like diuretics
Hydrochlorothiazide
Chlorthalidone
Indapamide
Metolazone
25-50 mg . od
12.5- 25 mg . od
1.25-2.5 mg . od
2.5-10 mg . od
Chlorthalidone
preference based
on prolonged half-
life and proven trial
reduction of CVD
• Monitor for
hyponatremia and
hypokalemia, uric
acid and calcium
levels
• Use with caution
in patients with
history of acute
gout unless patient
is on uric acid-
lowering therapy
Pharmacological therapy
Class Drug Usual Dose, Range
(mg per day)*Daily
Frequenc
Comments
CCB—
dihydropyridines
Amlodipine
Felodipine
Isradipine
Nicardipine SR
Nifedipine LA
Nisoldipine
2.5-10mg. Od
5-10mg. Od
5-10mg. Bid
5-20 mg . Od
60-120mg.Od
30-90mg. Od
Avoid use in
patients with heart
failure with reduced
ejection fraction;
amlodipine or
felodipine may be
used if required.
• Associated with
dose-related pedal
edema, which is
more common in
women than in men.
Pharmacological therapy
(mg per day)*Daily
Frequenc
Comments
CCB—
dihydropyridines
Amlodipine
Felodipine
Isradipine
Nicardipine SR
Nifedipine LA
Nisoldipine
2.5-10mg. Od
5-10mg. Od
5-10mg. Bid
5-20 mg . Od
60-120mg.Od
30-90mg. Od
Avoid use in
patients with heart
failure with reduced
ejection fraction;
amlodipine or
felodipine may be
used if required.
• Associated with
dose-related pedal
edema, which is
more common in
women than in men.
Pharmacological therapy
Class Drug Usual Dose,
Range(mg per
day)*Daily Frequency
Comments
ACEI Captopril
Benazepril
Enalapril
Fosinopril
Lisinopril
Quinapril
Perindopril
Ramipril
Trandolapril
Moexipril
12.5-150 mg 2 or 3
10-40 mg od/Bid
5-40mg od /bid
10-40 mg.Od
10-40 mg.Od
10-80mg . Od/ bid
4-16mg.Od
2.5-10mg . od /Bid
1-4mg . od
7.5-30mg.od /Bid
Do not use in
combination with
ARBs or direct renin
inhibitor
• Increased risk of
hyperkalemia,
especially in patients
with chronic kidney
disease or in those on
K+ supplements, or
K+-sparing drugs
• May cause acute
renal failure in
patients with severe
bilateral renal artery
stenosis
• Do not use if history
of angioedema with
ACE inhibitors
• Avoid in pregnancy
Pharmacological therapy
Range(mg per
day)*Daily Frequency
Comments
ACEI Captopril
Benazepril
Enalapril
Fosinopril
Lisinopril
Quinapril
Perindopril
Ramipril
Trandolapril
Moexipril
12.5-150 mg 2 or 3
10-40 mg od/Bid
5-40mg od /bid
10-40 mg.Od
10-40 mg.Od
10-80mg . Od/ bid
4-16mg.Od
2.5-10mg . od /Bid
1-4mg . od
7.5-30mg.od /Bid
Do not use in
combination with
ARBs or direct renin
inhibitor
• Increased risk of
hyperkalemia,
especially in patients
with chronic kidney
disease or in those on
K+ supplements, or
K+-sparing drugs
• May cause acute
renal failure in
patients with severe
bilateral renal artery
stenosis
• Do not use if history
of angioedema with
ACE inhibitors
• Avoid in pregnancy
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
ARBs Valsartan
Candesartan
Losartan
Telmisartan
Eprosartan
Irbesartan
Azilsartan
Olmesartan
80-320mg. Od
8-32 mg.
50-100 mg.Od/Bid
20-80mg .Od
600-800mg.Od/Bd
150-300mg. Od
40-80mg .Od
20-40mg. Od
•Do not use in
combination with
ACE/direct renin inhibitors
•Increased risk of
hyperkalemia in chronic
kidney disease or in those
on K+ supplements or K+-
sparing drugs.
•May cause acute renal
failure in patients with
severe bilateral renal
artery stenosis
•Do not use if history of
angioedema with ARBs;
patients with a history of
angioedema with an ACE
inhibitor can receive an
ARB beginning 6 weeks
after ACE inhibitor
discontinued
•Avoid in pregnancy
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
ARBs Valsartan
Candesartan
Losartan
Telmisartan
Eprosartan
Irbesartan
Azilsartan
Olmesartan
80-320mg. Od
8-32 mg.
50-100 mg.Od/Bid
20-80mg .Od
600-800mg.Od/Bd
150-300mg. Od
40-80mg .Od
20-40mg. Od
•Do not use in
combination with
ACE/direct renin inhibitors
•Increased risk of
hyperkalemia in chronic
kidney disease or in those
on K+ supplements or K+-
sparing drugs.
•May cause acute renal
failure in patients with
severe bilateral renal
artery stenosis
•Do not use if history of
angioedema with ARBs;
patients with a history of
angioedema with an ACE
inhibitor can receive an
ARB beginning 6 weeks
after ACE inhibitor
discontinued
•Avoid in pregnancy
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequenc
Comments
CCB—
nondihydropyridines
Diltiazim SR
Diltiazim ER
Verapamil IR
Verapamil SR
Verapamil-delayed
onset ER (various
forms)
180-360mg. Bid
120 - 480 mg . Od
40-80 mg. Od
120-480 mg.Od/Bid
120-480mg .Od (in
the evening)
Avoid routine use
with -blockers due
to increased risk of
bradycardia and
heart block
• Do not use in
patients with heart
failure with reduced
ejection fraction
• Drug interactions
with diltiazim and
verapamil (CYP3A4
major substrate and
moderate inhibitor).
Pharmacological therapy
(mg per day)*Daily
Frequenc
Comments
CCB—
nondihydropyridines
Diltiazim SR
Diltiazim ER
Verapamil IR
Verapamil SR
Verapamil-delayed
onset ER (various
forms)
180-360mg. Bid
120 - 480 mg . Od
40-80 mg. Od
120-480 mg.Od/Bid
120-480mg .Od (in
the evening)
Avoid routine use
with -blockers due
to increased risk of
bradycardia and
heart block
• Do not use in
patients with heart
failure with reduced
ejection fraction
• Drug interactions
with diltiazim and
verapamil (CYP3A4
major substrate and
moderate inhibitor).
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
Diuretics—
loop
Bumetanide
Furosemide
Torsemide
0.5-4mg .Bid
20-80mg .Bid
5-10mg. Od
Preferred diuretics in patients with
symptomatic heart failure.
•Preferred over thiazides in patients
with moderate-to-severe chronic
kidney disease
(eg, GFR <30 mL/min)
Diuretics—
potassium
sparing
Amiloride
Triamterene
5-10mg .Od/Bid
50-100mg.Od/Bid
•Monotherapy ages minimally
effective antihypertensives•
Combination therapy
of potassium-sparing diuretic with a
thiazide can be considered in
patients with hypokalemia on
thiazide monotherapy
•Avoid in patients with significant
chronic kidney disease (eg, GFR
<45mL/min)
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
Diuretics—
loop
Bumetanide
Furosemide
Torsemide
0.5-4mg .Bid
20-80mg .Bid
5-10mg. Od
Preferred diuretics in patients with
symptomatic heart failure.
•Preferred over thiazides in patients
with moderate-to-severe chronic
kidney disease
(eg, GFR <30 mL/min)
Diuretics—
potassium
sparing
Amiloride
Triamterene
5-10mg .Od/Bid
50-100mg.Od/Bid
•Monotherapy ages minimally
effective antihypertensives•
Combination therapy
of potassium-sparing diuretic with a
thiazide can be considered in
patients with hypokalemia on
thiazide monotherapy
•Avoid in patients with significant
chronic kidney disease (eg, GFR
<45mL/min)
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
Diuretics—
aldosterone
antagonists
Eplerenone
Spironolactone
50-100mg. Bid
25-100mg. Od
Preferred agents in primary
aldosteronism and resistant
hypertension
• Spironolactone associated
with greater risk of
gynecomastia and impotence
compared to eplerenone
• Common add-on therapy in
resistant hypertension
• Avoid use with K+
supplements, other K+-
sparing diuretics or significant
renal dysfunction
• Eplerenone often requires
twice daily dosing for
adequate BP lowering
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
Diuretics—
aldosterone
antagonists
Eplerenone
Spironolactone
50-100mg. Bid
25-100mg. Od
Preferred agents in primary
aldosteronism and resistant
hypertension
• Spironolactone associated
with greater risk of
gynecomastia and impotence
compared to eplerenone
• Common add-on therapy in
resistant hypertension
• Avoid use with K+
supplements, other K+-
sparing diuretics or significant
renal dysfunction
• Eplerenone often requires
twice daily dosing for
adequate BP lowering
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
B Blockers—
cardioselective
Atenolol
Betaxolol
Bisoprolol
Metoprolol tartrate
Metoprolol succinate
25-100mg. Bid
5-20mg . Od
2.5-10mg.Od
100-400mg.Bid
50-200mg.Od
- B Blockers are not
recommended as first-line
agents unless the patient has
ischemic heart disease or
heart failure.
• Preferred in patients with
bronchospastic airway
disease requiring a –blocker.
• Bisoprolol and metoprolol
succinate preferred in
patients with heart failure
with reduced ejection
fraction.
• Avoid abrupt cessation.
B Blockers—
cardioselective
and vasodilatory
Nebivolol 5-40mg.Od •Induces nitric
oxide-induced
vasodilation.
• Avoid abrupt
cessation
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
B Blockers—
cardioselective
Atenolol
Betaxolol
Bisoprolol
Metoprolol tartrate
Metoprolol succinate
25-100mg. Bid
5-20mg . Od
2.5-10mg.Od
100-400mg.Bid
50-200mg.Od
- B Blockers are not
recommended as first-line
agents unless the patient has
ischemic heart disease or
heart failure.
• Preferred in patients with
bronchospastic airway
disease requiring a –blocker.
• Bisoprolol and metoprolol
succinate preferred in
patients with heart failure
with reduced ejection
fraction.
• Avoid abrupt cessation.
B Blockers—
cardioselective
and vasodilatory
Nebivolol 5-40mg.Od •Induces nitric
oxide-induced
vasodilation.
• Avoid abrupt
cessation
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
B Blockers
Non selective
Nadolol
Propranolol IR
Propranolol LA
40-120mg.Od
160-480mg.Bid
80-320mg. Od
Avoid in patients with
reactive airways disease
• Avoid abrupt
cessation
B Blockers—
Intrinsic
sympathomimetic
activity
Acebutolol
Carteolol
Penbutolol
Pindolol
200-800mg
2.5-10mg.Od
10-40mg.Od
10-60mg.Od
•Generally avoid,
especially in patients
with ischemic heart
disease or heart failure
•Avoid abrupt
cessation
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
B Blockers
Non selective
Nadolol
Propranolol IR
Propranolol LA
40-120mg.Od
160-480mg.Bid
80-320mg. Od
Avoid in patients with
reactive airways disease
• Avoid abrupt
cessation
B Blockers—
Intrinsic
sympathomimetic
activity
Acebutolol
Carteolol
Penbutolol
Pindolol
200-800mg
2.5-10mg.Od
10-40mg.Od
10-60mg.Od
•Generally avoid,
especially in patients
with ischemic heart
disease or heart failure
•Avoid abrupt
cessation
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
B Blockers—
combined alpha
and B receptor
Carvedilol
Carvedilol
phosphate
Labetalol
12.5-50mg.Bid
20-80mg.Od
200-800mg.Bid
Carvedilol
preferred in
patients with heart
failure with
reduced ejection
fraction
• Avoid abrupt
cessation
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
B Blockers—
combined alpha
and B receptor
Carvedilol
Carvedilol
phosphate
Labetalol
12.5-50mg.Bid
20-80mg.Od
200-800mg.Bid
Carvedilol
preferred in
patients with heart
failure with
reduced ejection
fraction
• Avoid abrupt
cessation
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
Direct renin inhibitor Aliskiren 150-300mg. Od •Do not use in combination
with ACE inhibitors or ARBs
•Aliskiren is very long acting
•Increased risk of
hyperkalemia in chronic kidney
disease or in those on K+
supplements or K+-sparing
drugs
•May cause acute renal failure
in patients with severe bilateral
renal artery stenosis
•Avoid in pregnancy
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
Direct renin inhibitor Aliskiren 150-300mg. Od •Do not use in combination
with ACE inhibitors or ARBs
•Aliskiren is very long acting
•Increased risk of
hyperkalemia in chronic kidney
disease or in those on K+
supplements or K+-sparing
drugs
•May cause acute renal failure
in patients with severe bilateral
renal artery stenosis
•Avoid in pregnancy
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily
Frequency
Comments
Alpha 1-blocker Doxazosin
Prazosin
Terazosin
1-8mg .Od
2-20mg.Bid/Tid
1-20mg.Od/Bid
Associated with orthostatic
hypotension, especially in
older adults
• May consider as second-line
agent in patients with
concomitant benign prostatic
hyperplasia
Central Alpha1-
agonist and other
centrally acting
drugs
Clonidine oral
Clonidine patch
Methyldopa
Guanfacine
0.1-0.8mg .Bid
0.1-0.3mg .
1/weekly
250-1000mg.Bid
0.5-2mg.Od
•Generally reserved as last-
line due to significant central
nervous system adverse
effects, especially in older
adults
•Avoid abrupt
discontinuation of clonidine,
which may induce
hypertensive crisis; clonidine
must be tapered to avoid
rebound hypertension
Pharmacological therapy
(mg per day)*Daily
Frequency
Comments
Alpha 1-blocker Doxazosin
Prazosin
Terazosin
1-8mg .Od
2-20mg.Bid/Tid
1-20mg.Od/Bid
Associated with orthostatic
hypotension, especially in
older adults
• May consider as second-line
agent in patients with
concomitant benign prostatic
hyperplasia
Central Alpha1-
agonist and other
centrally acting
drugs
Clonidine oral
Clonidine patch
Methyldopa
Guanfacine
0.1-0.8mg .Bid
0.1-0.3mg .
1/weekly
250-1000mg.Bid
0.5-2mg.Od
•Generally reserved as last-
line due to significant central
nervous system adverse
effects, especially in older
adults
•Avoid abrupt
discontinuation of clonidine,
which may induce
hypertensive crisis; clonidine
must be tapered to avoid
rebound hypertension
Pharmacological therapy
Class Drugs Usual Dose, Range
(mg per day)*Daily Frequency
Comments
Direct vasodilators Hydralazine
Minoxidil
50-200mg.Bid/Tid
5-100mg. Od/Bid/Tid
•Associated with
sodium and
water retention
and reflex
tachycardia; use
with a diuretic
and B blocker.
• Hydralazine
associated with
drug-induced
lupus-like
syndrome at
higher doses.
•Minoxidil
associated with
hirsutism and
requires a loop
diuretic; can
induce
pericardial
effusion
Pharmacological therapy
(mg per day)*Daily Frequency
Comments
Direct vasodilators Hydralazine
Minoxidil
50-200mg.Bid/Tid
5-100mg. Od/Bid/Tid
•Associated with
sodium and
water retention
and reflex
tachycardia; use
with a diuretic
and B blocker.
• Hydralazine
associated with
drug-induced
lupus-like
syndrome at
higher doses.
•Minoxidil
associated with
hirsutism and
requires a loop
diuretic; can
induce
pericardial
effusion
Pharmacological therapy
ACE inhibitors were notably less effective
in preventing heart failure and stroke
compared with calcium channel blockers in
black patients.
ARBs may be better tolerated than ACE
inhibitors in black patients, with less cough
and angioedema, but they offer no proven
advantage over ACE inhibitors in preventing stroke or CVD
in this population, making thiazide diuretics
(especially chlorthalidone)or calcium channel blockers
the best initial choice for single-drug therapy .
Pharmacological therapy
in preventing heart failure and stroke
compared with calcium channel blockers in
black patients.
ARBs may be better tolerated than ACE
inhibitors in black patients, with less cough
and angioedema, but they offer no proven
advantage over ACE inhibitors in preventing stroke or CVD
in this population, making thiazide diuretics
(especially chlorthalidone)or calcium channel blockers
the best initial choice for single-drug therapy .
Pharmacological therapy
There is updated drug that used to treat HTN is Zilebesiran
months .6subcutaneous Injection / singlemg 600 -mg300Administer as
which is siRNA inhibition of Angiotensinogen in liver . Zilebesiran
Pharmacological therapy
months .6subcutaneous Injection / singlemg 600 -mg300Administer as
which is siRNA inhibition of Angiotensinogen in liver . Zilebesiran
Pharmacological therapy
Zilebesiran
Zilebesiran is an investigational RNA interference
therapeutic agent that inhibits synthesis of hepatic
angiotensinogen (the precursor of all angiotensin
peptides ).
It has been investigated in a phase 1 study, which
found that patients receiving zilebesiran had decreases
in serum angiotensinogen and BP that were sustained
for up to 24 weeks.
Pharmacological therapy
Zilebesiran is an investigational RNA interference
therapeutic agent that inhibits synthesis of hepatic
angiotensinogen (the precursor of all angiotensin
peptides ).
It has been investigated in a phase 1 study, which
found that patients receiving zilebesiran had decreases
in serum angiotensinogen and BP that were sustained
for up to 24 weeks.
Pharmacological therapy
Antihypertensive drugs that act on RAAS
Goal/target for lowering of BLOOD PRESSURE
BP thresholds and recommendations for treatment and follow-up .
2017 AHA/ACC guideline on high BP
2017 AHA/ACC guideline on high BP
Follow-up and Patient Adherence to Treatment
Recommendations for Follow-up Haffner Initial BP
Evaluation recommendation :
After initial BP evaluation ,treat adults who have
elevated BP or stage 1 hypertension with
nonpharmacological therapy and
follow-up in 3 to 6 months .
For adults with stage 1 hypertension and a 10 year
CVD risk of 10 %or higher, or adults with stage 2
Hypertension treated with a combination of
nonpharmacological and drug therapy and
follow-up in 1 month .
Adults with a very high average BP should be Promptly
evaluated and started on drug therapy.
up and Patient Adherence to -Follow
Treatment
Recommendations for Follow-up Haffner Initial BP
Evaluation recommendation :
After initial BP evaluation ,treat adults who have
elevated BP or stage 1 hypertension with
nonpharmacological therapy and
follow-up in 3 to 6 months .
For adults with stage 1 hypertension and a 10 year
CVD risk of 10 %or higher, or adults with stage 2
Hypertension treated with a combination of
nonpharmacological and drug therapy and
follow-up in 1 month .
Adults with a very high average BP should be Promptly
evaluated and started on drug therapy.
up and Patient Adherence to -Follow
Treatment
Schedule follow-up evaluations at monthly intervals for
adults initiating or adjusting a drug regimen for
hypertension until control is should include assessing
and evaluating of :
•BP control
•Orthostatic hypotension
•Adherence to pharmacological and non
pharmacological treatments
•Need for adjustment of medication dosage
•Other assessments of target organ damage
Simplyfing medication regimens,either by less
frequent dosingor by using combination drug
therapy, improves the chance that patients identify
and address areas for improvement .
Follow-up and Patient Adherence to Treatment
adults initiating or adjusting a drug regimen for
hypertension until control is should include assessing
and evaluating of :
•BP control
•Orthostatic hypotension
•Adherence to pharmacological and non
pharmacological treatments
•Need for adjustment of medication dosage
•Other assessments of target organ damage
Simplyfing medication regimens,either by less
frequent dosingor by using combination drug
therapy, improves the chance that patients identify
and address areas for improvement .
Follow-up and Patient Adherence to Treatment
Monitoring
While adjusting medication dosage, blood pressure (BP)
should be monitored every 2-4 weeks .
Once stabilised, BP should be checked and medications
reviewed every 6 - 12 months .
Serum potassium and creatinine should be checked annually .
Patients taking thiazide and thiazide-type diuretics should also
have serum sodium checked annually.
Monitoring
While adjusting medication dosage, blood pressure (BP)
should be monitored every 2-4 weeks .
Once stabilised, BP should be checked and medications
reviewed every 6 - 12 months .
Serum potassium and creatinine should be checked annually .
Patients taking thiazide and thiazide-type diuretics should also
have serum sodium checked annually.
Monitoring
Resistant hypertension
Resistant hypertension is defined as hypertension not controlled
(SBP >140 mmHg and/or DBP >90 )by appropriate lifestyle
measures and treatment with optimal or best-tolerated doses of
three or more drugs, which should include a diuretic, typically an
ACE inhibitor or an ARB, and a CCB .
Diagnosis : In order to make the diagnosis of resistant
hypertension, pseudo resistance, and secondary hypertension
need to be excluded.
Causes of pseudo resistance :
•Poor BP measurement technique
•White-coat hypertension
•Non-adherence
•Inadequate medication dose
•Clinical inertia
•Inappropriate drug combination
•Co-administration of drugs causing hypertension
•Substance abuse
•Excess alcohol
•Excess salt intake
Resistant hypertension
(SBP >140 mmHg and/or DBP >90 )by appropriate lifestyle
measures and treatment with optimal or best-tolerated doses of
three or more drugs, which should include a diuretic, typically an
ACE inhibitor or an ARB, and a CCB .
Diagnosis : In order to make the diagnosis of resistant
hypertension, pseudo resistance, and secondary hypertension
need to be excluded.
Causes of pseudo resistance :
•Poor BP measurement technique
•White-coat hypertension
•Non-adherence
•Inadequate medication dose
•Clinical inertia
•Inappropriate drug combination
•Co-administration of drugs causing hypertension
•Substance abuse
•Excess alcohol
•Excess salt intake
Resistant hypertension
Three important points emphasized in the 2018 updated AHA guidelines on
resistant hypertension include
(1) routine queries about patients' sleep patterns, as poor sleep duration and
quality can interfere with blood control .
(2) lifestyle modifications (eg, low-sodium diet, weight loss, exercise, ≥6 hours
of uninterrupted sleep each night; and
(3) considering a change in antihypertensive agents from hydrochlorothiazide
to chlorthalidone or indapamide if an above-goal BP persists despite
adherence to a three-drug regimen and an optimal lifestyle (if the BP remains
elevated despite the drug change, consider adding spironolactone as a fourth
agent.
Be extra vigilant if the estimated glomerular filtrate rate [eGFR] is < 30
mL/min/1.73 m2)
Clinicians should also assess and ensure optimal medication adherence in
patients with resistant hypertension.
Resistant hypertension
resistant hypertension include
(1) routine queries about patients' sleep patterns, as poor sleep duration and
quality can interfere with blood control .
(2) lifestyle modifications (eg, low-sodium diet, weight loss, exercise, ≥6 hours
of uninterrupted sleep each night; and
(3) considering a change in antihypertensive agents from hydrochlorothiazide
to chlorthalidone or indapamide if an above-goal BP persists despite
adherence to a three-drug regimen and an optimal lifestyle (if the BP remains
elevated despite the drug change, consider adding spironolactone as a fourth
agent.
Be extra vigilant if the estimated glomerular filtrate rate [eGFR] is < 30
mL/min/1.73 m2)
Clinicians should also assess and ensure optimal medication adherence in
patients with resistant hypertension.
Resistant hypertension
Resistant hypertension
DIAGNOSIS
DIAGNOSIS
Resistant hypertension
TREATMENT
TREATMENT
New-onset or uncontrolled hypertension in adults
Figure show
screening for
secondary
hypertension .
Conditions
•Drug-resistant/induced hypertension
•Abrupt onset of hypertension
•Onset of hypertension before age 30years
•Exacerbation of previously controlled
hypertension
•Disproportionate target organ damage for
•degree of hypertension
•Accelerated/malignant hypertension
•Onset of diastolic hypertension in older
adults(age 65years or older).
•Unprovoked or excessive hypokalemia.
Figure show
screening for
secondary
hypertension .
Conditions
•Drug-resistant/induced hypertension
•Abrupt onset of hypertension
•Onset of hypertension before age 30years
•Exacerbation of previously controlled
hypertension
•Disproportionate target organ damage for
•degree of hypertension
•Accelerated/malignant hypertension
•Onset of diastolic hypertension in older
adults(age 65years or older).
•Unprovoked or excessive hypokalemia.
Malignant hypertension
Malignant hypertension and accelerated hypertension
are both hypertensive emergencies (ie, systolic BP
[SBP ] >180 mm Hg or diastolic BP [DBP] >120 mm
Hg, and acute target organ damage, with similar
outcomes and therapies.
patient with malignant hypertension always has
retinal papilledema , as well as flame-shaped
hemorrhages and exudates.
Other clinical features of malignant hypertension may
include encephalopathy, confusion, left ventricular
failure, intravascular coagulation, and impaired renal
function, with hematuria and weight loss.
Malignant hypertension and accelerated hypertension
are both hypertensive emergencies (ie, systolic BP
[SBP ] >180 mm Hg or diastolic BP [DBP] >120 mm
Hg, and acute target organ damage, with similar
outcomes and therapies.
patient with malignant hypertension always has
retinal papilledema , as well as flame-shaped
hemorrhages and exudates.
Other clinical features of malignant hypertension may
include encephalopathy, confusion, left ventricular
failure, intravascular coagulation, and impaired renal
function, with hematuria and weight loss.
severe cases of hypertension, or hypertensive crises, are defined as a BP of
more than 180/120 mm Hg and may be further categorized as hypertensive
emergencies or urgencies. Hypertensive emergencies are characterized by
evidence of impending or progressive target organ dysfunction, whereas
hypertensive urgencies are those situations without progressive target organ
dysfunction.
Hypertensive emergencies
more than 180/120 mm Hg and may be further categorized as hypertensive
emergencies or urgencies. Hypertensive emergencies are characterized by
evidence of impending or progressive target organ dysfunction, whereas
hypertensive urgencies are those situations without progressive target organ
dysfunction.
Hypertensive emergencies
Hypertensive emergencies are characterized by severe elevations in
blood pressure (>180/120 mm Hg) associated with acute end-organ
damage.
oExamples include hypertensive encephalopathy, intracerebral hemorrhage,
acute myocardial infarction, acute left ventricular failure with pulmonary
edema, aortic dissection, unstable angina pectoris, eclampsia,[5]or
posterior reversible encephalopathy syndrome (PRES) (a condition
characterized by headache, altered mental status, visual disturbances, and
seizures.
•Patients with hypertensive emergencies should be monitored and
managed in an intensive care unit.
•The long-term prognosis for patients with hypertensive emergencies or
urgencies is not good.
Hypertensive emergencies
blood pressure (>180/120 mm Hg) associated with acute end-organ
damage.
oExamples include hypertensive encephalopathy, intracerebral hemorrhage,
acute myocardial infarction, acute left ventricular failure with pulmonary
edema, aortic dissection, unstable angina pectoris, eclampsia,[5]or
posterior reversible encephalopathy syndrome (PRES) (a condition
characterized by headache, altered mental status, visual disturbances, and
seizures.
•Patients with hypertensive emergencies should be monitored and
managed in an intensive care unit.
•The long-term prognosis for patients with hypertensive emergencies or
urgencies is not good.
Hypertensive emergencies
Hypertensive emergencies
*“ Headache, visual
disturbances, chest
pain, dyspnea, focal or
general neurological
symptoms, dizziness,
gastrointestinal
complaints (abdominal
pain, nausea, anorexia)
Cont...
disturbances, chest
pain, dyspnea, focal or
general neurological
symptoms, dizziness,
gastrointestinal
complaints (abdominal
pain, nausea, anorexia)
Cont...
The primary goal of the emergency physician is to determine
which patients with acute hypertension are exhibiting symptoms
of end-organ damage and require immediate intravenous (IV)
parenteral therapy.
In contrast, patients presenting with acutely elevated BP (systolic
BP [SBP] >200 mm Hg or diastolic BP [DBP] >120 mm Hg) without
symptoms and whose BP stays significantly elevated to this level
on discharge should have initiation of medical therapy and close
follow-up in the outpatient setting, with BP reduction over hours
or days.
Initial treatment goals are to reduce the mean arterial BP by no
more than 25% within minutes to 1 hour. If the patient is stable,
reduce the BP to 160/100-110 mm Hg within the next 2-6 hours.
Management of Hypertensive Emergencies
which patients with acute hypertension are exhibiting symptoms
of end-organ damage and require immediate intravenous (IV)
parenteral therapy.
In contrast, patients presenting with acutely elevated BP (systolic
BP [SBP] >200 mm Hg or diastolic BP [DBP] >120 mm Hg) without
symptoms and whose BP stays significantly elevated to this level
on discharge should have initiation of medical therapy and close
follow-up in the outpatient setting, with BP reduction over hours
or days.
Initial treatment goals are to reduce the mean arterial BP by no
more than 25% within minutes to 1 hour. If the patient is stable,
reduce the BP to 160/100-110 mm Hg within the next 2-6 hours.
Management of Hypertensive Emergencies
The history and physical examination determine the
nature, severity, and management of the hypertensive
event .
The history should focus on the presence of end-organ
dysfunction, the circumstances surrounding the
hypertension, and any identifiable etiology .
The physical examination should assess whether end-
organ dysfunction is present (eg, neurologic,
cardiovascular ).
BP should be measured in both the supine position
and the standing position (assess volume depletion).
BP should also be measured in both arms (a significant
difference may suggest aortic dissection ).
Management of Hypertensive Emergencies
nature, severity, and management of the hypertensive
event .
The history should focus on the presence of end-organ
dysfunction, the circumstances surrounding the
hypertension, and any identifiable etiology .
The physical examination should assess whether end-
organ dysfunction is present (eg, neurologic,
cardiovascular ).
BP should be measured in both the supine position
and the standing position (assess volume depletion).
BP should also be measured in both arms (a significant
difference may suggest aortic dissection ).
Management of Hypertensive Emergencies
Pharmacotherapy:
Dependent Upon The Specific Organ At Risk see below..
oSodium nitroprusside is a commonly used medication. It is a short-
acting agent, and the BP response can be titrated from minute to
minute .
oLabetalol, an alpha- and beta-blocking agent, has proven to be
quite beneficial in the treatment of patients with hypertensive
emergencies.
• Labetalol is particularly preferred in patients with acute dissection
and those with end-stage renal disease. Boluses of 10-20 mg may
be administered, or the drug may be infused at 1 mg/min until the
desired BP is obtained. Once an adequate BP level is obtained, oral
Antihypertensive therapy should be initiated, and patients are
gradually weaned from parenteral ages.
•Clevidipine, a dihydropyridine CCB, is administered IV for rapid and precise BP
reduction . It is rapidly metabolized in the blood and tissues and does not
accumulate in the body. Initiate IV infusion of clevidipine at 1-2 mg/hour; titrate
the dose at short intervals (ie, 90 seconds) initially by doubling the dose.
Management of Hypertensive Emergencies
Dependent Upon The Specific Organ At Risk see below..
oSodium nitroprusside is a commonly used medication. It is a short-
acting agent, and the BP response can be titrated from minute to
minute .
oLabetalol, an alpha- and beta-blocking agent, has proven to be
quite beneficial in the treatment of patients with hypertensive
emergencies.
• Labetalol is particularly preferred in patients with acute dissection
and those with end-stage renal disease. Boluses of 10-20 mg may
be administered, or the drug may be infused at 1 mg/min until the
desired BP is obtained. Once an adequate BP level is obtained, oral
Antihypertensive therapy should be initiated, and patients are
gradually weaned from parenteral ages.
•Clevidipine, a dihydropyridine CCB, is administered IV for rapid and precise BP
reduction . It is rapidly metabolized in the blood and tissues and does not
accumulate in the body. Initiate IV infusion of clevidipine at 1-2 mg/hour; titrate
the dose at short intervals (ie, 90 seconds) initially by doubling the dose.
Management of Hypertensive Emergencies
Admit adults with a hypertensive emergency to an ICU for continuous
monitoring of BP and target organ damage, as well as for parenteral
administration of an appropriate medication.
For adults with a compelling condition (ie, aortic dissection, severe
preeclampsia or eclampsia, or pheochromocytoma crisis), lower SBP to below
140 mm Hg during the first hour and to below 120 mm Hg in aortic
dissection.
For adults without a compelling condition, reduce the SBP to a maximum of
25% within the first hour; then, if the patient is clinically stable, lower the BP to
160/100 -110 mm Hg over the next 2-6 hours, and then cautiously to normal
over the following 24-48 hours.
The 2017 American College of Cardiology/American Health
Association (ACC/AHA) guidelines recommendations for
hypertensive crises and emergencies include the following:
Management of Hypertensive Emergencies
monitoring of BP and target organ damage, as well as for parenteral
administration of an appropriate medication.
For adults with a compelling condition (ie, aortic dissection, severe
preeclampsia or eclampsia, or pheochromocytoma crisis), lower SBP to below
140 mm Hg during the first hour and to below 120 mm Hg in aortic
dissection.
For adults without a compelling condition, reduce the SBP to a maximum of
25% within the first hour; then, if the patient is clinically stable, lower the BP to
160/100 -110 mm Hg over the next 2-6 hours, and then cautiously to normal
over the following 24-48 hours.
The 2017 American College of Cardiology/American Health
Association (ACC/AHA) guidelines recommendations for
hypertensive crises and emergencies include the following:
Management of Hypertensive Emergencies
Hypertensive encephalopathy:
•In hypertensive encephalopathy, the treatment guidelines are to reduce the MAP
25% over 8 hours.
•Labetalol, nicardipine, esmolol are the preferred medications;
•nitroprusside and hydralazine should be avoided.
Acute intracerebral hemorrhage:
the preferred medications are labetalol, nicardipine, and esmolol; avoid nitroprusside and
hydralazine.
The treatment is based on clinical/radiographic evidence of increased intracranial
pressure (ICP) :-
•If there are signs of increased ICP, maintain the MAP just below 130 mm Hg (or SBP
< 180 mm Hg) for the first 24 hours after onset.
• If patients without increased ICP, maintain the MAP below 110 mm Hg (or SBP <
160 mm Hg) for the first 24 hours after symptom onset.
In adults with acute intracerebral hemorrhage who present with an SBP above 220 mm Hg, continuous IV drug and
close BP monitoring is reasonable to lower SBP.
Note that it may be harmful to immediately lower SBP to below 140 mm Hg in adults with
spontaneous intracerebral hemorrhage who present within 6 hours of the acute event and have an SBP
between 150 and 220 mm Hg.
Neurological Emergencies
BP reduction is indicated in neurological emergencies, such as hypertensive
encephalopathy, acute ischemic stroke, acute intracerebral hemorrhage, and
subarachnoid hemorrhage.
•In hypertensive encephalopathy, the treatment guidelines are to reduce the MAP
25% over 8 hours.
•Labetalol, nicardipine, esmolol are the preferred medications;
•nitroprusside and hydralazine should be avoided.
Acute intracerebral hemorrhage:
the preferred medications are labetalol, nicardipine, and esmolol; avoid nitroprusside and
hydralazine.
The treatment is based on clinical/radiographic evidence of increased intracranial
pressure (ICP) :-
•If there are signs of increased ICP, maintain the MAP just below 130 mm Hg (or SBP
< 180 mm Hg) for the first 24 hours after onset.
• If patients without increased ICP, maintain the MAP below 110 mm Hg (or SBP <
160 mm Hg) for the first 24 hours after symptom onset.
In adults with acute intracerebral hemorrhage who present with an SBP above 220 mm Hg, continuous IV drug and
close BP monitoring is reasonable to lower SBP.
Note that it may be harmful to immediately lower SBP to below 140 mm Hg in adults with
spontaneous intracerebral hemorrhage who present within 6 hours of the acute event and have an SBP
between 150 and 220 mm Hg.
Neurological Emergencies
BP reduction is indicated in neurological emergencies, such as hypertensive
encephalopathy, acute ischemic stroke, acute intracerebral hemorrhage, and
subarachnoid hemorrhage.
Subarachnoid hemorrhage:
In subarachnoid hemorrhage, nicardipine, labetalol, and esmolol are also the
preferred agents; again, nitroprusside and hydralazine should be avoided.
Maintain the SBP below 160 mm Hg until the aneurysm is treated or cerebral
vasospasm occurs.
Although oral nimodipine is used to prevent delayed ischemic neurologic
deficits, it is NOT indicated for treating acute hypertension.
Acute ischemic stroke:
For acute ischemic stroke, the preferred medications are
labetalol and nicardipine.
oWithhold antihypertensive medications unless the SBP is above
220 mm Hg or the DBP is over 120 mm Hg, UNLESS the patient is
eligible for IV tissue plasminogen activator (tPA); then, the goal is a gradual
reduction of BP with a goal SBP of less than 185 mm Hg and a DBP below 110
mm Hg before initiating thrombolitic therapy.
•After initiating drug therapy but before administering tPA, the SBP
should be maintained at less than 180 mm Hg and the DBP below 105 mm
Hg for 24 hours.
In subarachnoid hemorrhage, nicardipine, labetalol, and esmolol are also the
preferred agents; again, nitroprusside and hydralazine should be avoided.
Maintain the SBP below 160 mm Hg until the aneurysm is treated or cerebral
vasospasm occurs.
Although oral nimodipine is used to prevent delayed ischemic neurologic
deficits, it is NOT indicated for treating acute hypertension.
Acute ischemic stroke:
For acute ischemic stroke, the preferred medications are
labetalol and nicardipine.
oWithhold antihypertensive medications unless the SBP is above
220 mm Hg or the DBP is over 120 mm Hg, UNLESS the patient is
eligible for IV tissue plasminogen activator (tPA); then, the goal is a gradual
reduction of BP with a goal SBP of less than 185 mm Hg and a DBP below 110
mm Hg before initiating thrombolitic therapy.
•After initiating drug therapy but before administering tPA, the SBP
should be maintained at less than 180 mm Hg and the DBP below 105 mm
Hg for 24 hours.
Cardiovascular emergencies
Rapid BP reduction is also indicated in cardiovascular emergencies, such as aortic
dissection, acute coronary syndrome, and acute heart failure.
Aortic dissection :
Beta blockers are the recommended antihypertensive agents in patients with
hypertension and thoracic aortic disease.
•In aortic dissection, the preferred medications are labetalol, nicardipine,
nitroprusside (with beta-blocker), esmolol, and morphine sulfate.
• However, avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac
tamponed.
For adults with aortic dissection, rapidly lower the SBP to below 120 mm Hg;
the preferred agents are esmolol and labetalol.
Beta blockers: should precede vasodilator administration, if needed for BP control
or to prevent reflex tachycardia or inotropic effect.
achieve SBP up to 120 mm Hg within 20 minutes.
Maintain the SBP below 110 mm Hg, unless signs of end-organ hypo perfusion are
present.
The preferred treatment includes
a combination of narcotic analgesics (morphine sulfate), beta blockers (labetalol,
esmolol), and vasodilators (nicardipine, nitroprusside).
CCBs (verapamil, diltiazem) are an alternative to beta blockers.
Rapid BP reduction is also indicated in cardiovascular emergencies, such as aortic
dissection, acute coronary syndrome, and acute heart failure.
Aortic dissection :
Beta blockers are the recommended antihypertensive agents in patients with
hypertension and thoracic aortic disease.
•In aortic dissection, the preferred medications are labetalol, nicardipine,
nitroprusside (with beta-blocker), esmolol, and morphine sulfate.
• However, avoid beta-blockers if there is aortic valvular regurgitation or suspected cardiac
tamponed.
For adults with aortic dissection, rapidly lower the SBP to below 120 mm Hg;
the preferred agents are esmolol and labetalol.
Beta blockers: should precede vasodilator administration, if needed for BP control
or to prevent reflex tachycardia or inotropic effect.
achieve SBP up to 120 mm Hg within 20 minutes.
Maintain the SBP below 110 mm Hg, unless signs of end-organ hypo perfusion are
present.
The preferred treatment includes
a combination of narcotic analgesics (morphine sulfate), beta blockers (labetalol,
esmolol), and vasodilators (nicardipine, nitroprusside).
CCBs (verapamil, diltiazem) are an alternative to beta blockers.
Acute coronary syndrome:
beta blockers and nitroglycerin are the preferred drugs.
•Treatment is indicated if the SBP is above 160 mm Hg and/or the DBP is over 100 mm
Hg.
• Reduce the BP by 20%-30% of baseline.
•Note : that thrombolytics are contraindicated if the BP is above 185/100 mm Hg.
•Note : that nitrates administered in the presence of phosphodiesterase type 5 (PDE-5)
inhibitors may induce profound hypotension.
Acute heart failure
In acute heart failure, the preferred medications are IV nitroglycerin or sublingual
nitroglycerin and IV enalaprilat.
Treat with vasodilators (in addition to diuretics) for a SBP of 140 mm Hg.
•In adults with hypertension at an increased risk of heart failure, the optimal BP should be
below 130/80 mm Hg.
•In hypertensive adults with reduced ejection fraction (HFrEF), prescribe guideline-
directed medical therapy (GDMT) to achieve a BP below 130/80 mm Hg.
•Note : that nondihydropyridine CCBs are not recommended for treatment in this patient
population.
•In hypertensive adults with preserved ejection fraction (HFpEF) and symptoms of volume
overload, prescribe diuretics to control BP.
•For those with persistent hypertension after management of volume overload, prescribe
ACEIs or ARBs and beta blockers titrated to achieve an SBP below 130 mm Hg.
beta blockers and nitroglycerin are the preferred drugs.
•Treatment is indicated if the SBP is above 160 mm Hg and/or the DBP is over 100 mm
Hg.
• Reduce the BP by 20%-30% of baseline.
•Note : that thrombolytics are contraindicated if the BP is above 185/100 mm Hg.
•Note : that nitrates administered in the presence of phosphodiesterase type 5 (PDE-5)
inhibitors may induce profound hypotension.
Acute heart failure
In acute heart failure, the preferred medications are IV nitroglycerin or sublingual
nitroglycerin and IV enalaprilat.
Treat with vasodilators (in addition to diuretics) for a SBP of 140 mm Hg.
•In adults with hypertension at an increased risk of heart failure, the optimal BP should be
below 130/80 mm Hg.
•In hypertensive adults with reduced ejection fraction (HFrEF), prescribe guideline-
directed medical therapy (GDMT) to achieve a BP below 130/80 mm Hg.
•Note : that nondihydropyridine CCBs are not recommended for treatment in this patient
population.
•In hypertensive adults with preserved ejection fraction (HFpEF) and symptoms of volume
overload, prescribe diuretics to control BP.
•For those with persistent hypertension after management of volume overload, prescribe
ACEIs or ARBs and beta blockers titrated to achieve an SBP below 130 mm Hg.
Preeclampsia/eclampsia:
The preferred medications are hydralazine, labetalol, and nicardipine.
Avoid nitroprusside, ACEIs, ARBs, and renin inhibitors.
•In women with eclampsia or preeclampsia, the SBP should lowered to below 140
mm Hg during the first hour.
•If the platelet count is less than 100,000 cells mm3, the BP should be maintained
below 150/100 mm Hg.
• Patients with eclampsia or preeclampsia should also be treated with IV
magnesium sulfate to avoid seizures.
•Antihypertensive therapy should be started in pregnant women if the systolic BP
is greater than 160 mm Hg or the diastolic BP is greater than 100-105 mm Hg.
•The goal of pharmacologic treatment should be a diastolic BP of less than 100-
105 mm Hg and a systolic BP of less than 160 mm Hg.
•Women who have preexisting end-organ damage from chronic hypertension or
who have previously required multidrug therapy for BP control should have a
lower threshold for starting antihypertensive medication (ie, >139/89 mm Hg)
and a lower target BP (< 140/90 mm Hg).
•The JNC 7 recommendations are to continue antihypertensive medication as
needed to control BP and to reinstate antihypertensive therapy when the SBP is
150-160 mm Hg or the DBP is 100-110 mm Hg.
Methyldopa is generally the preferred first-line agent because of its safety profile.
Other drugs that may be considered include : labetalol, beta-blockers, and diuretics.
The preferred medications are hydralazine, labetalol, and nicardipine.
Avoid nitroprusside, ACEIs, ARBs, and renin inhibitors.
•In women with eclampsia or preeclampsia, the SBP should lowered to below 140
mm Hg during the first hour.
•If the platelet count is less than 100,000 cells mm3, the BP should be maintained
below 150/100 mm Hg.
• Patients with eclampsia or preeclampsia should also be treated with IV
magnesium sulfate to avoid seizures.
•Antihypertensive therapy should be started in pregnant women if the systolic BP
is greater than 160 mm Hg or the diastolic BP is greater than 100-105 mm Hg.
•The goal of pharmacologic treatment should be a diastolic BP of less than 100-
105 mm Hg and a systolic BP of less than 160 mm Hg.
•Women who have preexisting end-organ damage from chronic hypertension or
who have previously required multidrug therapy for BP control should have a
lower threshold for starting antihypertensive medication (ie, >139/89 mm Hg)
and a lower target BP (< 140/90 mm Hg).
•The JNC 7 recommendations are to continue antihypertensive medication as
needed to control BP and to reinstate antihypertensive therapy when the SBP is
150-160 mm Hg or the DBP is 100-110 mm Hg.
Methyldopa is generally the preferred first-line agent because of its safety profile.
Other drugs that may be considered include : labetalol, beta-blockers, and diuretics.
In the hypertensive pregnant women with out preeclampsia,
• blood pressure should be closely monitored every other day, or
more frequently in an admitted patient .
•Monitor full blood count, liver and renal function tests twice a week .
Women with preeclampsia when first diagnosed ,
•should be initially treated in hospital and managed until they are
stable .
•If with features of preeclampsia, the blood pressure should be
monitored at least 6 hourly.
• Monitor full blood count, liver function, coagulation and renal
function tests three times a week.
if the pregnant women has severe hypertension )BP≥160/110
mmhg with or without features of preeclampsia:
• should be admitted and blood pressure checked every 00000
•Then it should be monitored at least 6 hourly .
•Monitor full blood count, liver function, coagulation and renal function
tests three times a week .
•Testing for urine protein should be repeated as clinically indicated.
Pregnancy and Hypertension
• blood pressure should be closely monitored every other day, or
more frequently in an admitted patient .
•Monitor full blood count, liver and renal function tests twice a week .
Women with preeclampsia when first diagnosed ,
•should be initially treated in hospital and managed until they are
stable .
•If with features of preeclampsia, the blood pressure should be
monitored at least 6 hourly.
• Monitor full blood count, liver function, coagulation and renal
function tests three times a week.
if the pregnant women has severe hypertension )BP≥160/110
mmhg with or without features of preeclampsia:
• should be admitted and blood pressure checked every 00000
•Then it should be monitored at least 6 hourly .
•Monitor full blood count, liver function, coagulation and renal function
tests three times a week .
•Testing for urine protein should be repeated as clinically indicated.
Pregnancy and Hypertension
Cocaine toxicity/pheochromocytoma :
Diazepam, phentolamine, and nitroglycerin/nitroprusside are the
preferred drugs. However, avoid beta-adrenergic antagonists
before administering phentolamine.
Hypertension and tachycardia from cocaine toxicity rarely require
specific treatment.
Alpha-adrenergic antagonists (phentolamine) are the preferred
agents for cocaine-associated acute coronary syndromes.
Pheochromocytoma : treatment guidelines are similar to that
of cocaine toxicity.
The ACC/AHA recommends : lowering the SBP to below 140 mm
Hg during the first hour, with phentolamine IV bolus dose of 5 mg.
Additional bolus doses may be given every 10 minutes as needed to
achieve target BP.
Only after alpha blockade can beta blockers be added for BP
control.
Diazepam, phentolamine, and nitroglycerin/nitroprusside are the
preferred drugs. However, avoid beta-adrenergic antagonists
before administering phentolamine.
Hypertension and tachycardia from cocaine toxicity rarely require
specific treatment.
Alpha-adrenergic antagonists (phentolamine) are the preferred
agents for cocaine-associated acute coronary syndromes.
Pheochromocytoma : treatment guidelines are similar to that
of cocaine toxicity.
The ACC/AHA recommends : lowering the SBP to below 140 mm
Hg during the first hour, with phentolamine IV bolus dose of 5 mg.
Additional bolus doses may be given every 10 minutes as needed to
achieve target BP.
Only after alpha blockade can beta blockers be added for BP
control.
Perioperative hypertension :
The ACC/AHA defines perioperative hypertension as a BP of 160/90 mm Hg or higher or
an SBP elevation of at least 20 %of the preoperative value that persists for longer than
15 minutes.
Nitroprusside, nitroglycerin, clevidipine, nicardipine, and esmolol are preferred.
Target the perioperative BP to within 20% of the patient's baseline pressure, except if
there is the potential for life-threatening arterial bleeding.
Perioperative beta blockers are the first choice in patients undergoing vascular procedures
or in patients with an intermediate or high risk of cardiac complications.
Perioperative :
In patients with preoperative hypertension undergoing major surgery who have been
taking chronic beta blockers, continue the beta blockers.
In those with preoperative hypertension undergoing major surgery, consider
perioperative discontinuation of ACEIs or ARBs.
Note : that abrupt preoperative discontinuation of beta blockers or clonidine in patients
undergoing surgery may be harmful .
Note : avoid the initiation of beta blockers on the day of surgery in beta blocker-naïve
patients.
Intraoperative :
Manage patients with intraoperative hypertension with IV agents until oral medications
can be resumed.
Whelton PK, Carey RM, Aronow WS, et al .2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of
Cardiology/American Health Association Task Force on Clinical Practice Guidelines. Hypertension .2017 Nov 13
The ACC/AHA defines perioperative hypertension as a BP of 160/90 mm Hg or higher or
an SBP elevation of at least 20 %of the preoperative value that persists for longer than
15 minutes.
Nitroprusside, nitroglycerin, clevidipine, nicardipine, and esmolol are preferred.
Target the perioperative BP to within 20% of the patient's baseline pressure, except if
there is the potential for life-threatening arterial bleeding.
Perioperative beta blockers are the first choice in patients undergoing vascular procedures
or in patients with an intermediate or high risk of cardiac complications.
Perioperative :
In patients with preoperative hypertension undergoing major surgery who have been
taking chronic beta blockers, continue the beta blockers.
In those with preoperative hypertension undergoing major surgery, consider
perioperative discontinuation of ACEIs or ARBs.
Note : that abrupt preoperative discontinuation of beta blockers or clonidine in patients
undergoing surgery may be harmful .
Note : avoid the initiation of beta blockers on the day of surgery in beta blocker-naïve
patients.
Intraoperative :
Manage patients with intraoperative hypertension with IV agents until oral medications
can be resumed.
Whelton PK, Carey RM, Aronow WS, et al .2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of
Cardiology/American Health Association Task Force on Clinical Practice Guidelines. Hypertension .2017 Nov 13
Postoperative :
Blood pressure goal in patients treated for postoperative
hypertension is similar to the general population .
Recommendation :
Any patient who experiences a marked and sustained rise
in blood pressure following surgery ( sustained increase in
systolic pressure greater than 180 mmHg not due to severe
pain ) : Should be treated immediately with intravenous
antihypertensive therapy .
•In patients treated for postoperative hypertension who did
not have preexisting hypertension, discontinue
antihypertensive therapy once the patient is surgically
stable and the blood pressure is at goal for at least 24
hours, and observe them over a period of 48 to 72 hours .
•Antihypertensive therapy should be resumed if the blood
pressure remains consistently elevated.
Blood pressure goal in patients treated for postoperative
hypertension is similar to the general population .
Recommendation :
Any patient who experiences a marked and sustained rise
in blood pressure following surgery ( sustained increase in
systolic pressure greater than 180 mmHg not due to severe
pain ) : Should be treated immediately with intravenous
antihypertensive therapy .
•In patients treated for postoperative hypertension who did
not have preexisting hypertension, discontinue
antihypertensive therapy once the patient is surgically
stable and the blood pressure is at goal for at least 24
hours, and observe them over a period of 48 to 72 hours .
•Antihypertensive therapy should be resumed if the blood
pressure remains consistently elevated.
• Emergency: major and often sudden elevation in BP,
associated with progressive, acute target organ damage .
•Urgency: major elevations in BP without acute,
progressive target organ damage.
o Severe HTN: SBP >180 mm Hg or DBP >115 to 120 mm
Hg.
o Severe headache, shortness of breath, epistaxis, or
severe anxiety .
o ATOD : absent or stable .
Hypertensive Emergencies and Urgencies
associated with progressive, acute target organ damage .
•Urgency: major elevations in BP without acute,
progressive target organ damage.
o Severe HTN: SBP >180 mm Hg or DBP >115 to 120 mm
Hg.
o Severe headache, shortness of breath, epistaxis, or
severe anxiety .
o ATOD : absent or stable .
Hypertensive Emergencies and Urgencies
•Treating the patient rather than their numbers .
•It is not the degree of BP elevation, but instead the TOD
and clinical status of the patient that defines the
emergency.
•Female with 220/120 mmHg : HTN urgency → oral
medications at home .
•160/110 mmHg + pregnancy : HTN emergency :ICU
admission .
Hypertensive Emergencies and Urgencies
•It is not the degree of BP elevation, but instead the TOD
and clinical status of the patient that defines the
emergency.
•Female with 220/120 mmHg : HTN urgency → oral
medications at home .
•160/110 mmHg + pregnancy : HTN emergency :ICU
admission .
Hypertensive Emergencies and Urgencies
Hypertensive Emergencies: Clinical Situations
CNS
-Ischemic Stroke
- IC Hge
- HTN encephalopathy
EYE
- Papilledema or acute retinal Hge / exudates (malignant hypertension)
CVS
- Acute LV failure (APO)
- ACS
- Acute Aortic dissection
RENAL
-Rapidly progressive renal failure
-- Scleroderma crisis
PREGNANCY - Severe preclampsia - Eclampsia - HELLP syndrome
DRUGS
- Overdose: cocaine
- Withdrawal: clonidine - BB
- Food interactions with MAOI
SURGERY
- Preoperative severe HTN in pts requiring immediate surgery
- Postoperative HTN
- Postop bleeding from vascular suture line
OTHERS
- Pheochromocytoma crisis
- Severe body burns
Hypertensive Emergencies
CNS
-Ischemic Stroke
- IC Hge
- HTN encephalopathy
EYE
- Papilledema or acute retinal Hge / exudates (malignant hypertension)
CVS
- Acute LV failure (APO)
- ACS
- Acute Aortic dissection
RENAL
-Rapidly progressive renal failure
-- Scleroderma crisis
PREGNANCY - Severe preclampsia - Eclampsia - HELLP syndrome
DRUGS
- Overdose: cocaine
- Withdrawal: clonidine - BB
- Food interactions with MAOI
SURGERY
- Preoperative severe HTN in pts requiring immediate surgery
- Postoperative HTN
- Postop bleeding from vascular suture line
OTHERS
- Pheochromocytoma crisis
- Severe body burns
Hypertensive Emergencies
EvaluationHypertensive Emergencies:
Focused History:
o Headaches, seizures, mental status changes, chest pain,
shortness of breath, change in urination, LL edema
o Drug intake / withdrawal
o Pregnancy
Clinical Examination
o Fundus examination
o Thorough neurological
o Congestion, Pulsations
Laboratory
o Routine : CBC,RFT,….
o Blood film
o Urinalysis: RBCs cast
Imaging
o Chest pain / SOB: ECG, CXR, Echo
o Acute neurology symptoms: CT - MRI
Focused History:
o Headaches, seizures, mental status changes, chest pain,
shortness of breath, change in urination, LL edema
o Drug intake / withdrawal
o Pregnancy
Clinical Examination
o Fundus examination
o Thorough neurological
o Congestion, Pulsations
Laboratory
o Routine : CBC,RFT,….
o Blood film
o Urinalysis: RBCs cast
Imaging
o Chest pain / SOB: ECG, CXR, Echo
o Acute neurology symptoms: CT - MRI
Management of HTN Emergency: General Rules
Rule #1 .Admit to ICU
Rule #2 .Immediate reduction (not normalization) of BP
Rule #3 .IV medications (not oral or IM)
Rule #4 .Target BP:
First 2 hours: mean BP 25 %below pretreatment level
Next 2-6 hours :160/100 mmHg
24-48 hours: further gradual reductions
Rule # 5. exceptions to rule # 4
a. Acute Aortic dissection (< 120 mmHg over 20 minutes)
b. Acute heart failure
c. Acute stroke-in-evolution: generally no BP reduction
Rule # 6. Assess volume status, give IV crystalloids
Rule # 7. After Stabilization
1. Oral medications after 6-24 hours
2. Screen for 2ry hypertension (as appropriate)
Rule #1 .Admit to ICU
Rule #2 .Immediate reduction (not normalization) of BP
Rule #3 .IV medications (not oral or IM)
Rule #4 .Target BP:
First 2 hours: mean BP 25 %below pretreatment level
Next 2-6 hours :160/100 mmHg
24-48 hours: further gradual reductions
Rule # 5. exceptions to rule # 4
a. Acute Aortic dissection (< 120 mmHg over 20 minutes)
b. Acute heart failure
c. Acute stroke-in-evolution: generally no BP reduction
Rule # 6. Assess volume status, give IV crystalloids
Rule # 7. After Stabilization
1. Oral medications after 6-24 hours
2. Screen for 2ry hypertension (as appropriate)
Choice of Agents
•Rapidity of onset / offset
action
•Propensity of side effects
•Propensity of
hypotension (overshoot)
•Type of TOD
•Ease of administration
I. Vasodilators
•Nicardipine,Fenoldopam
•Sodium nitroprusside
•NTG, Hydralazine
II. BB
•Labetalol , Esmolol
III. Loop Diuretics
•Avoided in acute phase
•Unless: volume overload
(CHF)
•Introduced after 12hours
after VD use
•Rapidity of onset / offset
action
•Propensity of side effects
•Propensity of
hypotension (overshoot)
•Type of TOD
•Ease of administration
I. Vasodilators
•Nicardipine,Fenoldopam
•Sodium nitroprusside
•NTG, Hydralazine
II. BB
•Labetalol , Esmolol
III. Loop Diuretics
•Avoided in acute phase
•Unless: volume overload
(CHF)
•Introduced after 12hours
after VD use
Management of HTN Urgency
I. ER / Clinic
•Rest , repeat BP measurement in 30 minutes
•Reassurance , explanation
•Prescribe oral medication:
short onset of action
Combination
Never SL nifedipine, captopril
Target: reduce (not normalize) BP in 24-48 hours
II. Discharge home
III. FU visit after 3 days
32 %of Pts had BP dropped
<180/110mmhg
after 30 minutes of rest without
any anti HTN medications .
J Clin Hypertens (Greenwich) 2008;
Management of HTN Urgency
I. ER / Clinic
•Rest , repeat BP measurement in 30 minutes
•Reassurance , explanation
•Prescribe oral medication:
short onset of action
Combination
Never SL nifedipine, captopril
Target: reduce (not normalize) BP in 24-48 hours
II. Discharge home
III. FU visit after 3 days
32 %of Pts had BP dropped
<180/110mmhg
after 30 minutes of rest without
any anti HTN medications .
J Clin Hypertens (Greenwich) 2008;
Management of HTN Urgency
Furosemide
Onset 0.5-1hr
Duration 6-8hr
Dose 20-40 mg
Captopril
Onset 15 min
Duration 4-6 hr
Dose 6.5-50mg
Clonidine
Onset 0.5-2hr
Duration 6-8hr
Dose
0.1-0.2 mg /h (up to 0.8mg
total)
Management of HTN Urgency
Labetalol
Onset 0.5-2hr
Duration 8-12hr
Dose 100-200 mg
Propranolol
Onset -15-30 min
Duration 3-6 hr
Dose 20-40-mg
J Clin Hypertens (Greenwich) 2008;
Onset 0.5-1hr
Duration 6-8hr
Dose 20-40 mg
Captopril
Onset 15 min
Duration 4-6 hr
Dose 6.5-50mg
Clonidine
Onset 0.5-2hr
Duration 6-8hr
Dose
0.1-0.2 mg /h (up to 0.8mg
total)
Management of HTN Urgency
Labetalol
Onset 0.5-2hr
Duration 8-12hr
Dose 100-200 mg
Propranolol
Onset -15-30 min
Duration 3-6 hr
Dose 20-40-mg
J Clin Hypertens (Greenwich) 2008;
Baxdrostat
In one phase 2 trial, baxdrostat, an aldosterone
synthase inhibitor, was shown to reduce BP in
patients with resistant hypertension over 12 weeks
compared with placebo. Reductions were dose-
related.
In one phase 2 trial, baxdrostat, an aldosterone
synthase inhibitor, was shown to reduce BP in
patients with resistant hypertension over 12 weeks
compared with placebo. Reductions were dose-
related.
Amiloride
In the PATHWAY-2 study of resistant hypertension,
the potassium-sparing diuretic amiloride was shown
to be as effective at reducing BP as spironolactone,
suggesting it may be an alternative option for
resistant hypertension.
In the PATHWAY-2 study of resistant hypertension,
the potassium-sparing diuretic amiloride was shown
to be as effective at reducing BP as spironolactone,
suggesting it may be an alternative option for
resistant hypertension.
THE END…
ANY QUESTION❓❓
THANK YOU F0R YOUR LISTENING.
ANY QUESTION❓❓
THANK YOU F0R YOUR LISTENING.
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