Hypertension

Hypertension is another name for high blood pressure. It can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Blood pressure is the force that a person's blood exerts against the walls of their blood vessels.

1. Management of Hypertension

2. Definition of hypertension SBP/DBP Clinic HBPM Daytime ABPM Nighttime ABPM 24-hour ABPM ACC/AHA Guidelines 2017 ≥130/80 ≥130/80 ≥130/80 ≥110/65 ≥125/75 ESC/ESH Guidelines 2018 ≥140/90 ≥135/85 ≥135/85 ≥120/70 ≥130/80

3. TREATMENT GOAL/TARGET Routine/conventional office blood pressure Unattended AOBPM, daytime ABPM, or home blood pressure Higher-risk population ASCVD Heart failure Diabetes mellitus Chronic kidney disease Age ≥65 years Calculated 10-year risk of ASCVD event ≥10% 125 to 130/<80 120 to 125/<80 Lower-risk None of the above risk factors 130 to 139/<90 125 to 135/<90

4. WHY HTN IS IMPORTANT LVH HF STROKE MI RENAL FAILURE

5. Severe hypertension:>180/120 Emergency Hypertensive encephalopathy Retinal hemorrhages Papilledema Acute and subacute kidney injury Urgency No end organ damage

6. Resistant Hypertension Blood pressure GOAL is not achieved despite concurrent use of three antihypertensive agents of different classes taken at maximally tolerated doses, one of which should be a diuretic Blood pressures achived at goal while taking four or more antihypertensive medications are considered to have "CONTROLLED RESISTANT HYPERTENSION”

7. HTN CAUSES LVH

8. HTN CAUSES RENAL FAILURE

9. HTN CAUSES ISCHEMIC HEART DISEASE

10. HTN CAUSES STROKE

11. HTN INCREASES CVD MORTALITY

12. BP MEASUREMENT Patient conditions Posture Initially, check for postural changes by taking readings after five minutes supine, then immediately and two minutes after standing; this is particularly important in patients over age 65 years, diabetics, or those taking antihypertensive drugs Sitting pressures are recommended for routine follow-up; the patient should sit quietly with the back supported for five minutes and the arm supported at the level of the heart Circumstances No caffeine during the hour preceding the reading, and no smoking during the preceding 30 minutes No exogenous adrenergic stimulants, such as phenylephrine in decongestants or eye drops for pupillary dilatation A quiet, warm setting Home readings should be taken upon varying circumstances Equipment Cuff size The length of the bladder should be 80%, and the width of the bladder should be at least 40% of the circumference of the upper arm Manometer Aneroid gauges should be calibrated every six months against a mercury manometer

13. Cont. Technique Number of readings Take at least two readings on each visit, separated by as much time as possible; if readings vary by more than 5 mmHg, take additional readings until two consecutive readings are close For the diagnosis of hypertension, take three readings at least one week apart Initially, take blood pressure in both arms; if pressures differ, use the higher arm If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 years Performance Inflate the bladder quickly to 20 mmHg above the systolic pressure as estimated from loss of radial pulse Deflate the bladder by 3 mmHg per second Record the Korotkoff phase V (disappearance) as the diastolic pressure except in children in whom use of phase IV (muffling) may be preferable If the Korotkoff sounds are weak, have the patient raise the arm, open and close the hand 5 to 10 times, and then inflate the bladder quickly Recordings Note the pressure, patient position, arm, and cuff size: eg , 140/90, seated, right arm, large adult cuff

14. IDEAL CUFF SIZE Arm circumference Usual cuff size 22 to 26 cm Small adult 27 to 34 cm adult 35 to 44 cm Large adult 45 to 52 cm Adult thigh

15. HISTORY TAKING Duration of hypertension Last known normal blood pressure Course of the blood pressure Prior treatment of hypertension Drugs: types, doses, side effects Intake of agents that may cause hypertension Nonsteroidal antiinflammatory drugs Estrogens Adrenal steroids Cocaine Sympathomimetics Excessive sodium Family history Hypertension Premature cardiovascular disease or death Familial diseases: pheochromocytoma, renal disease, diabetes, gout Symptoms of secondary causes Muscle weakness Spells of tachycardia, sweating, tremor Thinning of the skin Flank pain

16. Cont. Symptoms of target-organ damage Headaches Transient weakness or blindness Loss of visual acuity Chest pain Dyspnea Claudication Presence of other risk factors Smoking Diabetes Dyslipidemia Physical inactivity Dietary history Sodium Processed foods Alcohol Saturated fats Psychosocial factors Family structure Work status Educational leve Sexual function Features of sleep apnea Early morning headaches Daytime somnolence Loud snoring Erratic sleep

17. EAMINATION Accurate measurement of blood pressure General appearance Distribution of body fat Skin lesions Muscle strength Alertness Fundoscopy Haemorrhage Papilledema Cotton wool spots Arteriolar narrowing and arteriovenous nicking Neck Palpation and auscultation of carotids Thyroid Heart Size Rhythm Sounds Lungs Rhonchi Rales Abdomen Renal masses Bruits over aorta or renal arteries Femoral pulses Extremities Peripheral pulses Edema Neurologic assessment Visual disturbance Focal weakness Confusion

18. TREATMENT GOAL/TARGET Routine/conventional office blood pressure Unattended AOBPM, daytime ABPM, or home blood pressure Higher-risk population ASCVD Heart failure Diabetes mellitus Chronic kidney disease Age ≥65 years Calculated 10-year risk of ASCVD event ≥10% 125 to 130/<80 120 to 125/<80 Lower-risk None of the above risk factors 130 to 139/<90 125 to 135/<90

19. SBP:J-curve

20. DBP:J-Curve

21. Lifestyle modification Modification Recommendation Approximate systolic BP reduction, range Weight reduction Maintain normal body weight (BMI, 18.5 to 24.9 kg/m 2 ) 5 to 20 mmHg per 10 kg weight loss Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat 8 to 14 mmHg Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mEq/day (2.4 g sodium or 6 g sodium chloride) 2 to 8 mmHg Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week) 4 to 9 mmHg Moderation of alcohol consumption Limit consumption to no more than two drinks per day in most men and no more than one drink per day in women and lighter-weight persons 2 to 4 mmHg

22. Essential HTN Thiazide-type diuretics Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs) Calcium channel blockers Beta blocker in compelling indication like CAD

23. ALLHAT trial Compared to chlorthalidone, there was no significant difference with amlodipine (relative risk 0.98) or lisinopril (relative risk 0.99 percent) at a mean of 4.9 years.

24. Individual medication in higher doses cause significant side effect :

25. Individual medication in higher doses cause significant side effect

26. Compelling indications Indication or contraindication Antihypertensive drugs Compelling indications (major improvement in outcome independent of blood pressure Heart failure with reduced ejection fraction ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist* Postmyocardial infarction ACE inhibitor or ARB, beta blocker, aldosterone antagonist Proteinuric chronic kidney disease ACE inhibitor or ARB Angina pectoris Beta blocker, calcium channel blocker Atrial fibrillation rate control Beta blocker, nondihydropyridine calcium channel blocker Atrial flutter rate control Beta blocker, nondihydropyridine calcium channel blocker Likely to have a favorable effect on symptoms in comorbid conditions Benign prostatic hyperplasia Alpha blocker Essential tremor Beta blocker (noncardioselective) Hyperthyroidism Beta blocker Migraine Beta blocker, calcium channel blocker Osteoporosis Thiazide diuretic Raynaud phenomenon Dihydropyridine calcium channel blocker

27. Cont. Contraindications Angioedema Do not use an ACE inhibitor Bronchospastic disease Do not use a non-selective beta blocker Liver disease Do not use methyldopa Pregnancy (or at risk for) Do not use an ACE inhibitor, ARB, or renin inhibitor (eg, aliskiren) Second- or third-degree heart block Do not use a beta blocker, nondihydropyridine calcium channel blocker unless a functioning ventricular pacemaker Drug classes that may have adverse effects on comorbid condition Depression Generally avoid beta blocker, central alpha-2 agonist Gout Generally avoid loop or thiazide diuretic Hyperkalemia Generally avoid aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor Hyponatremia Generally avoid thiazide diuretic Renovascular disease Generally avoid ACE inhibitor, ARB, or renin inhibitor Depression Generally avoid beta blocker, central alpha-2 agonist

28. PREGRNCY HTN Gestational hypertension New onset of systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least 2 occasions 4 hours apart after 20 weeks of gestation in a previously normotensive woman And: No proteinuria No severe features of preeclampsia (thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema , cerebral or visual symptoms) Preeclampsia New onset of systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least 2 occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive woman  or  systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy And: Proteinuria (≥300 mg per 24-hour urine collection [or this amount extrapolated from a timed collection], or protein:creatinine ratio ≥0.3, or urine dipstick reading ≥1+ [if other quantitative methods are not available]) Or, in the absence of proteinuria, new-onset hypertension with the new onset of any of the following: Thrombocytopenia (platelet count <100,000/ microL ) Renal insufficiency (serum creatinine of >1.1 mg/dL [97 micromol /L] or a doubling of the serum creatinine concentration in the absence of other renal disease) Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration Pulmonary edema Persistent cerebral or visual symptoms Preeclampsia with severe features Any of these findings in a patient with preeclampsia: Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg on 2 occasions at least 4 hours apart while a patient is on bed rest (unless antihypertensive therapy is initiated before this time) Thrombocytopenia (platelet count <100,000/ microL ) Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration or severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL [97 micromol /L] or a doubling of the serum creatinine concentration in the absence of other renal disease) Pulmonary edema Persistent cerebral or visual disturbances Eclampsia In a patient with preeclampsia, generalized seizures that cannot be attributed to other causes

29. Cont. HELLP syndrome Presence of HELLP syndrome in a pregnant woman; hypertension may be present (HELLP in such cases is often considered a variant of preeclampsia) Chronic (preexisting) hypertension Hypertension diagnosed or present before pregnancy or before 20 weeks of gestation. Hypertension that is first diagnosed during pregnancy and persists at least 12 weeks post-delivery is also considered chronic hypertension. The blood pressure criteria are systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or both. Ideally, this diagnosis is based on at least 2 elevated blood pressure measurements taken at least 4 hours apart. In the setting of severe hypertension, the diagnosis can be confirmed in a shorter interval to facilitate timely treatment. Chronic hypertension with superimposed preeclampsia * Any of these findings in a patient with chronic hypertension: A sudden increase in blood pressure that was previously well-controlled or an escalation of antihypertensive therapy to control blood pressure New onset of proteinuria or sudden increase in proteinuria in a patient with known proteinuria before or early in pregnancy Chronic hypertension with superimposed preeclampsia with severe features Any of these findings in a patient with chronic hypertension and superimposed preeclampsia: Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg despite escalation of antihypertensive therapy Thrombocytopenia (platelet count <100,000/ microL ) Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration or severe persistent right upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both New-onset or worsening renal insufficiency Pulmonary edema Persistent cerebral or visual disturbances

30. Antihypertensive agents used for urgent blood pressure control in pregnancy: Labetalol 20 mg IV gradually over 2 minutes. Repeat BP measurement at 10-minute intervals:If BP remains above target level at 10 minutes, give 40 mg IV over 2 minutes. If BP remains above target level at 20 minutes, give 80 mg IV over 2 minutes. If BP remains above target level at 30 minutes, give 80 mg IV over 2 minutes. If BP remains above target level at 40 minutes, give 80 mg IV over 2 minutes. Cumulative maximum dose is 300 mg. If target BP is not achieved, switch to another class of agent. A continuous IV infusion of 1 to 2 mg/minute can be used instead of intermittent therapy or started after 20 mg IV dose. Requires use of programmable infusion pump and continuous noninvasive monitoring of blood pressure and heart rate. Adjust dose within this range to achieve target blood pressure. Cumulative maximum dose is 300 mg. If target BP is not achieved, switch to another class of agent. Hydralazine 5 mg IV gradually over 1 to 2 minutes.* Adequate reduction of blood pressure is less predictable than with IV labetalol. Repeat BP measurement at 20-minute intervals:If BP remains above target level at 20 minutes, give 5 or 10 mg IV over 2 minutes, depending on the initial response. If BP remains above target level at 40 minutes, give 10 mg IV over 2 minutes, depending on the previous response. Cumulative maximum dose is 30 mg. If target BP is not achieved, switch to another class of agent.

31. Cont. Nifedipine extended release 30 mg orally. If target BP is not achieved in 1 to 2 hours, another dose can be administered. If target BP is not achieved, switch to another class of agent. Nicardipine (parenteral) The initial dose is 5 mg/hour IV by infusion pump and can be increased to a maximum of 15 mg/hour. Onset of action is delayed by 5 to 15 minutes; in general, rapid titration is avoided to minimize risk of overshooting dose. Requires use of a programmable infusion pump and continuous noninvasive monitoring of blood pressure and heart rate. Adjust dose within this range to achieve target BP. Nifedipine immediate release* 10 mg orally. May be associated with precipitous drops in BP in some women, with associated FHR decelerations for which emergency cesarean delivery may be indicated. As such, this regimen is not typically used as a first-line option and is usually reserved only for women without IV access. If used, FHR should be monitored while administering short-acting nifedipine. Repeat BP measurement at 20-minute intervals:If BP remains above target at 20 minutes, give 10 or 20 mg orally, depending on the initial response. If BP remains above target at 40 minutes, give 10 or 20 mg orally, depending on the previous response. If target BP is not achieved, switch to another class of agent.

32. Drug doses for oral treatment of hypertension in pregnancy Drug Class Initial dose Usual effective dose range Maximum suggested total daily dose Comments Labetalol Combined alpha and beta blocker 100 mg 2 times daily, increase by 100 mg twice daily every 2 to 3 days as needed 200 to 800 mg in 2 divided doses 2400 mg Can cause bronchoconstriction. Avoid in women with asthma, chronic obstructive lung disease, heart failure, bradycardia, or greater than first-degree heart block. Hydralazine NOTE:  Due to reflex tachycardia, monotherapy with oral hydralazine is not recommended; hydralazine may be combined with methyldopa or labetalol if needed as add-on therapy Peripheral vasodilator Begin with 10 mg 4 times per day, increase by 10 to 25 mg/dose every 2 to 5 days 50 to 100 mg in 2 to 4 divided doses 200 mg   Nifedipine extended release ¶ Calcium channel blocker 30 to 60 mg once daily as an extended release tablet, increase at 7 to 14 day intervals 30 to 90 mg once daily 120 mg Do not administer sublingually.

33. THANK YOU