Hypertension

CME, Nakasongola Health Center IV on prevention, types, diagnosis, Management of Hypertension

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

26. GUIDELINE
•If labetalol is unsuitable, methyldopa or modified-release
nifedipinemay be considered.
•Women with gest hypor pre-eclampwho have been
managed with methyldopa during pregshuddiscontinue tx
within 2 days of the birth
•Women with a BP Hof160/110 mmHg who require critical
care during pregor after birth shudreceive immediate tx with
either PO or IV labetalol, IV hydralazine, or oral modified-
release nifedipineto achieve a target BP of<150 mmHg syst,
and diast80–100 mmHg.

27. HYPERTENSIVE CRISES
•If BP is reduced too quickly in the mg’tof hypertensive crises, there is a
risk of reduced organ perfusion.
•Ahypertensiveemergency is defined as severe hypertension with acute
damage to the target organs
•Prompt tx with IV antihypertensive therapy is generally required.
•Over the first few minutes or within 2 hours, BP should be reduced by
20–25%. When IV therapy is indicated, tx options include sodium
nitroprusside, labetalol, glyceryltrinitrate, phentolamine, hydralazine, or
esmolol
•Choice of drug is dependent on concomitant conditions and clinical status
of the patient.

28. HYPERTENSIVE CRISES
•Severe hypH(BP180/110 mmhg) without acute TOD is
defined as a hypertensive urgency; BP should be reduced
gradually over 24–48hrs.
•Oral antihypertensive therapy, such as labetalol, or the
calcium-channel blockers amlodipine, felodipine, or
isradipine.
NB: Use of sublingual nifedipineis not recommended

29. THE END
QUESTIONS AND DISCUSSIONS