Management of Hypetension.pptx

Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:

Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily

1. Hypertension management

2. DEFINATION Blood pressure Definition Normal SBP <120 and DBP <80 Elevated systolic 120 to 129 mm Hg and diastolic lower than 80 mm Hg   Hypertension Hypertension is defined as systolic blood pressure 130 mm Hg or higher and diastolic blood pressure 80 mm Hg or higher in adults   Stage 1 hypertension: systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg   Stage 2 hypertension: systolic 140 mm Hg or higher or diastolic 90 mm Hg or higher  

3. Ambulatory Blood Pressure

4. RISK Fewer than 1 in 5 have it under control For every 20 mmHg higher systolic and 10 mmHg higher diastolic blood pressure, the risk of death from heart disease or strokes doubles

5. Exact blood pressure 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

6. Compelling medication

7. Essential hypertension

8. Secondary HTN

9. TREATMENT

10. NON PHARMA

11. Pharma Antihypertensive therapy, as compared with placebo, produces a nearly 50 percent relative risk reduction in the incidence of heart failure, a 30 to 40 percent relative risk reduction in stroke, and a 20 to 25 percent relative risk reduction in myocardial infarction

12. Without “compelling” indication

13. Compelling indication

14. COMBINATION THERAPY a long-acting ACE inhibitor or ARB in concert with a long-acting dihydropyridine calcium channel blocker

15. Hypertensive emergency Hypertensive emergency is an acutely elevated blood pressure, usually over 120 mm Hg diastolic, accompanied by symptoms or objective signs of acute end-organ dysfunction or damage ( eg , hypertensive encephalopathy, stroke, acute coronary syndromes, pulmonary edema , aortic dissection, acute kidney injury) 4 Quickly manage hypertensive emergencies with IV administration of carefully selected antihypertensive drugs to reduce blood pressure by no more than 25% over the first hour in most cases Sodium nitroprusside, nicardipine (IV), and/or labetalol are appropriate for most hypertensive emergencies

16. CLASSIFICATION Essential hypertension: Not identifiable cause Secondary hypertension: attributed to underlying, identifiable cause (10% of patients) Other terminology Resistant hypertension: blood pressure above goal despite adherence to a combination of at least 3 optimally dosed antihypertensive medications with different mechanisms of action Hypertensive urgency: acute rise in blood pressure (diastolic higher than 120 mm Hg) without evidence of acute end-organ dysfunction Hypertensive emergency: acute rise in blood pressure (diastolic higher than 120 mm Hg) accompanied by objective findings of acute end-organ dysfunction

17. CLASSIFICATION Malignant hypertension describes a hypertensive emergency characterized by severe hypertension and systemic microcirculatory damage as evidenced by advanced hypertensive retinopathy; an alternative term for this is acute hypertensive microangiopathy White coat hypertension: blood pressure that is significantly higher when measured in the medical office than when measured at home or via ambulatory blood pressure monitor in patient’s usual environment. Risk factor for development of sustained essential hypertension. Some evidence that white coat hypertension contributes to cardiovascular mortality (to a lesser extent than essential hypertension)

18. CLASSIFICATION Masked hypertension: blood pressure is in hypertensive range out of office but not when measured in office Present in 15% to 30% of the general population who are normotensive during office blood pressure measurement .Nocturnal hypertension is a form particularly prevalent in Black patients.Associated with an increased risk for cardiovascular disease similar to that of sustained hypertension present in office environment Isolated diastolic hypertension , more common in younger individuals Not associated with increased risk of atherosclerotic cardiovascular disease or cardiovascular mortality

19. DIAGNSOIS HISTORY EXAMINATION CAUSES AND RISK FACTORS DIAGNOSTIC PROCEDURES DIFFERENTIAL DIAGNSOSIS

20. History Usually, asymptomatic Mild headache, dizziness, or epistaxis Secondary HTN Lethargy- thyroid disorders Flash pulmonary edema -renal artery stenosis Excessive perspiration-Pheochromocytoma buffalo hump- hypercortisolism) Claudication- coarctation Hypertensive emergency Dyspnoea Chest pain Severe headache Blurry vision Nausea and vomiting Confusion Seizures Somnolence Focal neurologic symptoms

21. Physical examination Examination findings may be normal except for blood pressure Measure blood pressure with patient at rest; repeat later during same encounter if elevated Increased body weight and obesity are common Examine for signs of hypertensive end-organ disease Signs of secondary HTN Hypertensive retinopathy Grade 0: normal examination findings Grade 1: minimal arterial narrowing Grade 2: obvious arterial narrowing with focal irregularities Grade 3: arterial narrowing with retinal haemorrhages ,exudate, or both Grade 4: grade 3 findings plus disk swelling Hard exudates are a common late finding

22. Risk factors and/or associations Essential hypertension increases with age Hypertension is more common in males than females up to age 64 years; after age 65 years, the percentage of females with hypertension is higher than for males Increased risk of essential hypertension with family history SMOKING ALCOHOL OBESITY SALT ANXIETY PSYCHAITRIC MEEDICATION STEROIDS CKD SEDENTARY LIFESTYLE OSA

23. Diagnostic Procedures Confirm hypertension; document elevated blood pressure on at least 2 encounters using sphygmomanometry or automated blood pressure measurement Proper technique when taking blood pressure Seat patient with feet flat on floor, legs uncrossed, and back supported; allow patient to sit for 3 to 5 minutes without talking or moving around before recording blood pressure Do not use blood pressure readings taken when patients are in pain or acutely ill as support for a diagnosis because they may be spuriously high Home blood pressure self-monitoring or ambulatory blood pressure monitoring

24. Laboratory Fasting blood glucose level and hemoglobin A1C 15 Serum sodium, potassium, and calcium levels Serum BUN and creatinine levels (with estimated or measured glomerular filtration rate) Fasting lipid profile Hematocrit level Urinalysis Measurement of urinary albumin excretion level or albumin-creatinine ratio is considered an optional baseline test unless diabetes or kidney disease is present Targeted imaging studies for suspected underlying causes are best selected with specialist consultation Obtain appropriate imaging in a hypertensive emergency based on suspected end-organ dysfunction 4 9 Head CT or MRI scan if hypertensive encephalopathy or stroke is present Chest radiography if dyspnea is present or there is concern for acute coronary syndrome Chest radiography and CT angiography if aortic dissection is suspected Renal ultrasonography to assess for postrenal obstruction and kidney size

25. Functional imaging ECG Recommended for adults at baseline; may identify, with low sensitivity, evidence of chronic cardiac end-organ dysfunction ( eg , left ventricular hypertrophy) Indicated with complaints of dyspnea or chest pain in the setting of hypertensive emergency Echocardiography Not routinely recommended May be useful in selected cases for assessment of left ventricular hypertrophy, to help define future risk of cardiovascular events Echocardiographic assessment of left ventricular mass, as well as of systolic and diastolic left ventricular function is recommended for patients with hypertension that are suspected of having left ventricular dysfunction or coronary artery disease Can be used in patients with hypertension and evidence of heart failure for assessment of left ventricular ejection fraction

26. Differential diagnosis Renal causes Endocrine causes Pheochromocytoma Hypercorticism Medication induced [OCP, psychiatric medication] Hyperaldosteronism Hypothyroid Coarctation of aorta etc

27. TREATMENT

28. TREAMENT GOAL For adults with a compelling condition ( eg , aortic dissection, severe preeclampsia or eclampsia, pheochromocytoma crisis), reduce systolic blood pressure to lower than 140 mm Hg during the first hour and to lower than 120 mm Hg in aortic dissection For adults without a compelling condition, reduce systolic blood pressure by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to within reference range during the 24 to 48 hours that follow In acute ischemic stroke, blood pressure goal depends on planned treatment (thrombolysis versus no thrombolysis) In patients with very high blood pressure (higher than 220/120 mm Hg) who are not receiving thrombolytic therapy, it is reasonable to lower blood pressure by 15% during the first 24 hours after symptom onset In patients who have high blood pressure and who are eligible for thrombolytic therapy, lower blood pressure to lower than 185/110 mm Hg before therapy and maintain at lower than 180/105 mm Hg for 24 hours after therapy No specific minimum systolic blood pressure is recommended, but systolic pressures between 141 and 150 mm Hg have been associated with optimal mortality and functional outcomes In intracerebral hemorrhage: For adults with intracerebral hemorrhage who present with systolic blood pressure higher than 220 mm Hg, it is reasonable to use continuous IV drug infusion and close blood pressure monitoring to lower systolic blood pressure Immediate lowering of systolic blood pressure to lower than 140 mm Hg in adults with spontaneous intracerebral hemorrhage who present within 6 hours of the acute event and have systolic blood pressure between 150 mm Hg and 220 mm Hg is not helpful in reducing death or severe disability and is potentially harmful

29. TREAMENT GOAL For hypertensive urgency with no evidence of acute end-organ damage, there is no specific threshold of blood pressure that must be urgently treated or specific blood pressure level that must be reached before discharge There is no indication for referral to the emergency department, immediate reduction in blood pressure in the emergency department, or hospitalization Acute reduction of blood pressure in the emergency department is not advised owing to potential adverse effects and lack of clinical benefit Goal for most patients is outpatient initiation of oral antihypertensive medication by the patient's personal physician with gradual reduction of blood pressure (over a period of days) Emergency department physician may initiate treatment with an oral antihypertensive if warranted by social or clinical situation ( eg , patient lacks transportation, other factor that limits access to outpatient follow-up) For newly diagnosed or chronic hypertension (non–hypertensive emergency) 2019 American College of Cardiology/American Heart Association guidelines on primary prevention of cardiovascular disease recommend target blood pressure of lower than 130/80 mm Hg in most cases Blood pressure targets are generally based on degree of cardiovascular risk; more stringent blood pressure goals are recommended for patients at high risk of future cardiovascular events High-risk factors include:Established atherosclerotic cardiovascular disease ( eg , coronary artery disease, ischemic stroke, peripheral vascular disease)

30. Heart failure Diabetes mellitus Chronic kidney disease Multiple risk factors and a 10-year atherosclerotic cardiovascular disease risk of 10% or more Older than 65 years Blood pressure goals for specific risk groups Patients with coronary artery disease 2017 American College of Cardiology/American Hert Association Task Force on Clinical Practice Guidelines recommend blood pressure target of lower than 130/80 mm Hg for adults with confirmed hypertension and known cardiovascular disease or 10-year atherosclerotic cardiovascular disease event risk of 10% or higher 1 UK guidelines recommend the same blood pressure targets as for people without cardiovascular disease Patients with transient ischemic attack or ischemic stroke American Heart Association/American Stroke Association guidelines An goal of office blood pressure lower than 130/80 mm Hg is recommended for most patients American College of Physicians and American Academy of Family Physicians guidelines recommend: Consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of lower than 140 mm Hg to reduce the risk for recurrent stroke Patients with diabetes 2017 American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines recommend a target of lower than 130/80 mm Hg in adults 1

31. Goals American Diabetes Association recommends individualizing blood pressure targets in all age groups A blood pressure target of lower than 140/90 mm Hg is recommended in individuals who are at lower risk of cardiovascular disease (10-year atherosclerotic cardiovascular disease risk lower than 15%) A lower blood pressure target of 130/80 mm Hg may be appropriate for individuals at high risk of cardiovascular disease (existing atherosclerotic cardiovascular disease or 10-year ASCVD risk of 15% or higher) if it can be achieved safely American Association of Clinical Endocrinologists and American College of Endocrinology recommend an individualized target, but they state that generally blood pressure should be approximately 130/80 mm Hg in all age groups Patients with chronic kidney disease (all ages) Reduce blood pressure to lower than 130/80 mm Hg Older adults 2017 American College of Cardiology/American Heart Associatin Task Force on Clinical Practice Guidelines recommend a systolic blood pressure treatment goal of lower than 130 mm Hg for noninstitutionalized ambulatory community-dwelling adults aged 65 years or older In patients aged 60 to 80 years, intensive treatment with a systolic blood pressure target of 110 to 130 mm Hg resulted in a lower risk of cardiovascular events than treatment with a target of 130 to 150 mm Hg Goals need not differ even for community-dwelling patients older than 80 years Treatment of hypertension significantly reduced cardiovascular mortality and morbidity in patients aged 80 years and older; relative risk reduction similar to that in patients aged 60 to 79 years However, blood pressure targets can be individualized in patients with significant comorbidities and a limited life expectancy; less aggressive blood pressure lowering may be considered

32. GOAL Earlier American College of Physicians and American Academy of Family Physicians joint guidelines for patients aged 60 years or older recommended higher targets, which are not consistent with those of other professional organizations; they recommended: Reducing systolic blood pressure to lower than 150 mm Hg (for patients without history of stroke or transient ischemic attack and without high individual cardiovascular risk) Considering initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk (based on individualized assessment) to achieve a target systolic blood pressure of lower than 140 mm Hg, reducing the risk for stroke or cardiac events UK guidelines recommend in-clinic blood pressure goal of lower than 150/90 mm Hg for patients aged 80 years and older; use clinical judgement for patients who are frail or who have multiple comorbidities When using ambulatory blood pressure monitoring or home blood pressure monitoring to monitor adults with hypertension, use the average blood pressure level taken during the person's usual waking hours; aim for below 145/85 mmHg for adults aged 80 years and older For patients at low risk (none of the above comorbidities) Clinical trial evidence is strongest for blood pressure target of lower than 140/90 mm Hg; however, a target of lower than 130/80 mm Hg may also be reasonable When using ambulatory blood pressure monitoring or home blood pressure monitoring to monitor adults with hypertension, use the average blood pressure level taken during the person's usual waking hours; UK guidelines recommending aiming for below 135/85 mmHg for adults younger than 80 years

33. Hypertensive emergency For adults with a compelling condition ( eg , aortic dissection, severe preeclampsia or eclampsia, or pheochromocytoma crisis), reduce systolic blood pressure to lower than 140 mm Hg during the first hour and to lower than 120 mm Hg in aortic dissection For adults without a compelling condition, reduce systolic blood pressure by no more than 25% within the first hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to within reference range during the 24 to 48 hours that follow For patients with ischemic stroke, lower blood pressure to a lesser degree, within the following parameters:n patients with very high blood pressure (higher than 220/120 mm Hg) who are not receiving thrombolytic therapy, it is reasonable to lower blood pressure by 15% during the first 24 hours after symptom onset In patients who have high blood pressure and are eligible for thrombolytic therapy, lower their blood pressure to lower than 185/110 mm Hg before therapy and maintain at lower than 180/105 mm Hg for 24 hours after therapy No specific minimum systolic blood pressure is recommended, but systolic pressures between 141 and 150 mm Hg have been associated with optimal mortality and functional outcomes 33 For adults with intracerebral hemorrhage who present with systolic blood pressure higher than 220 mm Hg, it is reasonable to use continuous IV drug infusion and close blood pressure monitoring to lower systolic blood pressure For patients with aortic dissection, rapid lowering of systolic blood pressure is required Aim for goal systolic blood pressure of 120 mm Hg or lower to be achieved within 20 minutes Otherwise, avoid rapid, extreme pressure reductions to prevent organ hypoperfusion Parenteral drugs are preferred (given as titrated IV boluses or by infusion) Sodium nitroprusside, nicardipine (IV), and/or labetalol are appropriate for most hypertensive emergencies, but initial drug of choice is based on the acute end-organ dysfunction at presentation; recommendations are consensus based Sublingual or immediate-acting nifedipine is contraindicated Initiate oral antihypertensives before discontinuing IV drugs

34. Hypertensive emergency If acute coronary syndrome is present and there is evidence of heart failure, give nitroglycerin 24 and β-blockers A fast-acting drug is preferable; 4 esmolol is suggested as an agent of choice Nitroprusside may result in coronary steal syndrome 4 If pulmonary edema is present, preferred drugs include sodium nitroprusside, nitroglycerin, and clevidipine Use loop diuretics cautiously, because patients are often normovolemic or hypovolemic β-blockers are contraindicated If acute kidney injury is present, give calcium channel blocker (nicardipine or clevidipine ) or fenoldopam Calcium channel blockers do not affect renal perfusion; fenoldopam promotes renal excretion and is as effective as nitroprusside If hypertensive encephalopathy (without stroke) is present, consider nitroprusside, labetalol, nicardipine, and/or enalapril Benzodiazepines, phenytoin, and barbiturates (given for seizure control and delirium) also result in blood pressure decrease If ischemic stroke is present, give IV nicardipine, labetalol, or clevidipine ; consider IV nitroprusside if blood pressure is not controlled or diastolic pressure is higher than 140 mm Hg

35. Hypertensive emergency If aortic dissection is present, give β-blocker to reduce shearing forces (esmolol is ideal) followed by nitroprusside or nicardipine (to provide arteriodilation ) If sympathetic crisis is caused by pheochromocytoma, give phentolamine, nicardipine, or clevidipine If sympathetic crisis is caused by cocaine, benzodiazepines are indicated and may be sufficient to decrease blood pressure Phentolamine or nitroprusside may be administered if benzodiazepines not successful Do not give β-blockers owing to reflex tachycardia risk If sympathetic crisis is caused by phencyclidine, amphetamine, tyramine reaction with use of MAOIs, or abrupt withdrawal from sympatholytic medications, give phentolamine, nitroprusside, or labetalol Avoid β-blocker use as sole treatment owing to risk of reflex tachycardia

36. HYPETENSION URGENCY No evidence for a specific threshold blood pressure that must be urgently treated or a specific blood pressure level that must be reached before discharge There is no indication for referral to the emergency department, immediate reduction in blood pressure in the emergency department, or hospitalization for such patients No evidence that acute treatment in the emergency department results in short-term cardiovascular risk reduction For most patients, outpatient follow-up with initiation of oral antihypertensive medications at that time is recommended unless medical follow-up is not ensured If medical follow-up is not ensured, emergency physicians may treat markedly elevated blood pressure in the emergency department and/or initiate therapy for long-term control

37. Outpatient treatment of essential hypertension Initiate lifestyle interventions Many patients can be started on a single agent initially, but consider starting with 2 drugs of different classes for those with stage 2 hypertension Consider patient-specific factors ( eg , age, concurrent medications, drug adherence, drug interactions, overall treatment regimen, out-of-pocket costs, comorbidities) 2 or more antihypertensive medications are recommended to achieve a blood pressure target of lower than 130/80 mm Hg in most adults with hypertension, especially in Black adults with hypertension For Black patients without heart failure or chronic kidney disease, including those with diabetes, initiate treatment with 1 of the following: Thiazide diuretic Calcium channel blocker For patients of other ethnic groups, including those with diabetes, initiate treatment with 1 of the following: Thiazide diuretic Calcium channel blocker ACE inhibitor Angiotensin receptor blocker

38. OPD TREATMENT For patients with chronic kidney disease, initial or add-on therapy should include 1 of the following: 1 ACE inhibitor Angiotensin receptor blocker, if ACE inhibitor not tolerated Use of combination pills can be useful to improve adherence to antihypertensive therapy In patients who do not respond to or do not tolerate treatment with 2 to 3 medications or medication combinations, team-based care may be effective, encouraging both nonpharmacologic and pharmacologic treatments In general, β-blockers are not recommended for initial treatment except in patients with angina pectoris, arrhythmias, heart failure, or a recent myocardial infarction; effect on cardiovascular morbidity and mortality is lower than other agents 45 Simultaneous use of an ACE inhibitor, angiotensin receptor blocker, and/or renin inhibitor is potentially harmful and is not recommended to treat adults with hypertension

39. Cochrane reviews comparing efficacy of recommended first line drugs found that all-cause mortality is similar when ACE inhibitors or angiotensin receptor blockers are compared with other first line antihypertensive agents 46 47 First line calcium channel blockers reduce risk of stroke compared to ACE inhibitors and reduce risk of myocardial infarction compared to angiotensin receptor blockers, but increase risk of congestive heart failure as compared to both ACE inhibitors and angiotensin receptor blockers 47 ACE inhibitors and angiotensin receptor blockers are associated with an increased risk of heart failure and stroke compared with thiazide diuretics Calcium channel blockers reduce major cardiovascular events, stroke, and cardiovascular mortality more than beta blockers 47 Another Cochrane review reported that first line low-dose thiazides reduced all morbidity and mortality outcomes in adult patients with moderate to severe primary hypertension 48 First line high-dose thiazides and first line β-blockers were inferior to first line low-dose thiazides

40. SECONDARY HTN TREATMENT Renal artery stenosis Initial treatment is medical control of hypertension, management of hyperlipidemia, and antiplatelet therapy 49 Drugs that block the renin-angiotensin-aldosterone system (ACE inhibitors and angiotensin receptor blockers) improve cardiovascular outcomes based on observational studies, but they must be used with caution owing to risk of worsened renal function Surgical correction may be considered for uncontrolled hypertension 49 A Cochrane review determined that "data are insufficient to conclude that revascularization in the form of balloon angioplasty, with or without stenting, is superior to medical therapy for the treatment of atherosclerotic renal artery stenosis in patients with hypertension. However, balloon angioplasty results in a small improvement in diastolic blood pressure and a small reduction in antihypertensive drug requirements" 50 Coarctation of the aorta 18 Requires surgical or interventional (transcatheter) catheter treatment in most cases Peak-to-peak gradient of 20 mm Hg or more by cardiac catheterization is an indication for intervention Endocrine conditions Hypercortisolism caused by Cushing disease (pituitary cause) or Cushing syndrome (adrenal cause) Transsphenoidal surgery is the treatment of choice for Cushing disease 51 Surgery is usually the treatment of choice for Cushing syndrome except when the tumor cannot be located 52 Medical management is necessary before surgery and when surgery is contraindicated 52

41. SECONDARY HTN TREATMENT Dopamine or somatostatin agonists to modulate corticotropin release Steroidogenesis inhibitors (metyrapone, ketoconazole, mitotane) Glucocorticoid receptor antagonist (mifepristone) Pheochromocytoma 53 Requires surgical resection of the tumor Hypertension must be medically managed preoperatively and intraoperatively, and for inoperable disease α- Blocker (phenoxybenzamine) recommended for 10 to 14 days before surgery Labetalol or nitroprusside are commonly used intraoperatively Hyperaldosteronism Kidney disease Treatment of renal parenchymal disease caused by glomerulonephritis depends on specific underlying cause 56 Manage chronic kidney disease according to published guidelines 57 58 Include an ACE inhibitor or angiotensin receptor blocker for blood pressure management 38 Requires careful monitoring of serum creatinine and potassium levels Include diuretics in the antihypertensive regimen for most patients Obstructive sleep apnea Treated with nocturnal continuous positive airway pressure mask; in milder cases, a dental appliance may be effective 59 Drug-related causes are managed with discontinuation of the offending agent

42. DIURETIC Chlorthalidone: 12.5 to 25 mg PO once daily, initially. May increase dose to 50 mg PO once daily if response is insufficient and to 100 mg PO once daily if further control is needed Hydrochlorothiazide : 25 mg PO once daily, initially. May increase dose to 50 mg/day in 1 to 2 divided doses Hydrochlorothiazide has a dose-related blood pressure–lowering effect Metolazone 2.5 to 5 mg PO once daily FRUSEMIDE TORESEMIDE

43. CALCIUM CHANNEL BLOCKER Amlodipine Besylate Oral tablet; Adults: 5 mg PO once daily, initially. May increase dose after 7 to 14 days if further control is needed. Max: 10 mg/day Amlodipine Besylate Oral tablet; Geriatric Adults: 2.5 mg PO once daily, initially. May increase dose after 7 to 14 days if further control is needed. Max: 10 mg/day. Diltiazem (extended-release forms are the only form recommended for hypertension) Once-daily dosage form Diltiazem Hydrochloride Oral tablet, extended-release; Adults: 180 to 240 mg PO once daily, initially. May increase dose after 14 days if further control is needed. Usual dose range: 120 to 360 mg/day. Max: 540 mg/ day.Twice -daily dosage form Nifedipine Oral tablet, extended-release; Adults: 30 or 60 mg PO once daily, initially. May increase dose over 7 to 14 days if further control is needed. Usual dose range: 30 to 90 mg/day. Max: 120 mg/day.

44. ACEI Benazepril Hydrochloride Oral tablet; Adults: 10 mg PO once daily, initially. May increase dose if further control is needed. Usual dose range: 10 to 40 mg/day PO in 1 to 2 divided doses. Max: 80 mg/day. Enalapril Maleate Oral tablet; Adults: 5 mg PO once daily, initially. May increase dose if further control is needed. Usual dose range: 5 to 40 mg/day PO in 1 to 2 divided doses. Lisinopril Oral tablet; Adults: 10 mg PO once daily, initially. May increase dose if further control is needed. Usual dose range: 10 to 40 mg/day. Max: 80 mg/day.

45. Angiotensin receptor blockers Losartan Potassium Oral tablet; Adults: 50 mg PO once daily, initially. May increase dose to 100 mg/day in 1 to 2 divided doses if further control is needed. Valsartan Oral tablet; Adults: 80 or 160 mg PO once daily, initially. May increase dose if further control is needed. Usual dose range: 80 to 320 mg/day. Max: 320 mg/day.

46. Aldosterone antagonists SPIRONOLACTONE EPLERONONE

47. ALPHA BLOCKER Doxazosin Mesylate Oral tablet; Adults: 1 mg PO once daily, initially. May double daily dose as needed if further control is needed. Max: 16 mg/day. Prazosin Hydrochloride Oral capsule; Adults: 1 mg PO 2 to 3 times daily, initially. May increase dose if further control is needed. Usual dose range: 2 to 20 mg/day. Max: 40 mg/day. Terazosin Hydrochloride Oral tablet; Adults: 1 mg PO once daily at bedtime, initially. Usual dose range: 1 to 20 mg/day in 1 or 2 divided doses. Max: 20 mg/day.

48. BETA BLOCKER ATENOLOL METOPROLOL CARVEDILOL

49. CENTRAL ACTING ADRENERGIC DRUGS Clonidine Hydrochloride Oral tablet; Adults: 0.1 mg PO twice daily, initially. May increase dose by 0.1 mg/day every 7 days if further control is needed. Usual dosage range: 0.1 to 0.8 mg/day. Max: 2.4 mg/day. Clonidine Transdermal patch - weekly; Adults: 0.1 mg/24 hours transdermally every 7 days. May increase dose by 0.1 mg/24 hours after 7 to 14 days if further control is needed. Usual dosage range: 0.1 to 0.3 mg/24 hours every 7 days. Max: 0.6 mg/24 hours every 7 days. Guanfacine Hydrochloride Oral tablet; Adults: 1 mg PO once daily at bedtime, initially. May increase dose by 1 mg/day after 3 to 4 weeks if further control is needed. Usual dosage range: 0.5 to 2 mg/day. Max: 3 mg/day. Methyldopa Oral tablet; Adults: 250 mg PO 2 to 3 times daily, initially. May increase dose every 2 days if further control is needed. Usual dosage: 250 to 2,000 mg/day in 2 to 4 divided doses. Max: 3,000 mg/day.

50. VASODILATORS HYDRALAZINE MINOXIDIL

51. IV DRUGS FOR HTN TREATMENT CCB BB LABETOLOL NITRATE FENOLODOPAM NITROPRUSIDE PHENOLAMINE ENALPRILAT

52. Non drug therapy for HTN Lifestyle modifications are recommended for patients with elevated blood pressure and hypertension Target weight loss based on body mass index goal of ideal body weight; aim for at least a 1- kg reduction in body weight Participate in aerobic activity at least 90 to 150 minutes per week Reduce sedentariness ( eg , by interrupting sitting time with walking or standing breaks) Follow an established healthy dietary patterns such as the Mediterranean diet or Dietary Approaches to Stop Hypertension (DASH); both emphasize fruits, vegetables, legumes, nuts, and seeds, with moderate intake of fish, seafood, poultry, and dairy and limited red meat, processed meat, and sweets 1 13 Pharmacotherapy can be considered for weight loss in patients who fail to respond to lifestyle modifications alone and have a BMI 30 kg/m² or higher (for males) or 27 kg/m² or higher (for females) Bariatric surgery can be considered for males with a BMI 40 kg/m² or higher and females with a BMI 35 kg/m² or higher who are psychologically stable and have no active substance misuse Sodium intake Optimal goal is less than 1500 mg/day; aim for at least a 1000 mg/day reduction in most adults General population-based advice is to reduce daily sodium intake to 2300 mg or less (current average daily intake in the United States is 3393 mg; ranging from approximately 2000 to 5000 mg/day) Evidence confirms significant reduction in systolic blood pressure with salt restriction

53. Non Drug therapy for HTN Modest reduction in sodium intake decreases cardiovascular and stroke risk by 20% Low potassium intake may worsen the effect of salt on blood pressure Because salt sensitivity is on an individual continuum (30%-50% of patients are considered salt sensitive), individual effect of salt reduction may vary Salt sensitivity is common in Black individuals; older adults; and people with low- renin hypertension, comorbid obesity, or metabolic syndrome Low intake of potassium and calcium increases the salt sensitivity of blood pressure Low sodium intake may increase the risk of cardiovascular events in some patients, including those with: Congestive heart failure treated with high doses of diuretics Diabetes Limit alcohol intake to 2 drinks per day or fewer for males (total 30 mL ethanol) and 1 drink per day or fewer for females (total 15 mL ethanol) 1 drink is equal to 355 mL (12 oz) of beer, 148 mL (5 oz) of wine, and 44 mL (1.5 oz) of 80-proof liquor Stop smoking to decrease overall cardiovascular risk

54. Treatment of comorbities diabetes Approximately 68% of patients with diabetes have a systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher or are taking medication for hypertension Hypertension is a modifiable risk factor for cardiovascular complications and progression of diabetic kidney disease Blood pressure targets in patients with diabetes differ according to type of diabetes and degree of impairment in kidney function ACE inhibitors are generally the first line agent for treating hypertension in patients with diabetes and chronic kidney disease; angiotensin receptor blockers are an alternative if ACE inhibitor therapy is contraindicated or not tolerated If patient is started on an ACE inhibitor or angiotensin receptor blocker, monitor for azotemia and hyperkalemia Thiazide diuretics may cause hyperglycemia; consider increased monitoring of glucose levels

55. Comorbidity :CKD Hypertension is the most common cause of chronic kidney disease; conversely, chronic kidney disease can lead to or exacerbate hypertension Target systolic blood pressure of lower than 120 mm Hg is recommended ACE inhibitor or angiotensin receptor blocker is recommended for patients with high blood pressure, chronic kidney disease, or moderate or severely increased albuminuria, with or without diabetes Treat adult kidney transplant recipients with a dihydropyridine calcium channel blocker or angiotensin receptor blocker to a target blood pressure of lower than 130 mm Hg 38 Sodium intake should be less than 2 g/day (equivalent to 5 g of sodium chloride) for most patients Progressive azotemia and hyperkalemia are possible; periodic laboratory monitoring is recommended

56. Treatment of pregnant women Chronic hypertension is Blood pressure higher than 140/90 mm Hg that predates the pregnancy or begins before the 20th week of gestation Gestational hypertension :Blood pressure higher than 140/90 mm Hg with onset after 20 weeks of gestation in a previously normotensive female: lasts less than 6 weeks postpartum not accompanied by proteinuria or severe features of preeclampsia (thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema , cerebral or visual symptoms) Preexisting hypertension with superimposed preeclampsia Preeclampsia and eclampsia Preeclampsia is defined by the presence of hypertension with proteinuria and/or new onset of signs of end-organ damage Severe features of preeclampsia include thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema , cerebral or visual symptoms Eclampsia presents as generalized, tonic- clonic seizures in patient with preeclampsia Hemolysis , elevated liver enzymes, and low platelet count (HELLP syndrome) may be accompanied by severe hypertension

57. Pregnant women Maternal risks of hypertension in pregnancy include placental abruption, stroke, multiple organ failure, and disseminated vascular coagulation Fetal risks include intrauterine growth restriction, preterm birth, intrauterine death Increased risk of congenital defects is seen in both treated and untreated hypertension, but risk is greater for babies of treated mothers Thresholds for pharmacologic treatment vary American College of Obstetricians and Gynecologists does not recommend pharmacologic therapy for mild chronic hypertension in pregnancy (higher than 140/90 mm Hg and lower than 160/110 mm Hg) and recommends considering discontinuing medication during the first trimester in females with mild hypertension who become pregnant Pharmacologic therapy is recommended for pregnant patients with severe hypertension (systolic blood pressure 160 mm Hg or higher, or diastolic blood pressure 105-110 mm Hg or higher); lower threshold for treatment (150/100 mm Hg or higher) in patients with end-organ involvement The International Society of Hypertension recommends pharmacologic treatment at blood pressure higher than 150/95 mm Hg in all pregnant patients and at blood pressure higher than 140/90 mm Hg in patients with gestational hypertension, preexisting hypertension with superimposed gestational hypertension, and hypertension with subclinical hypertension-mediated organ damage any time during pregnancy Hypertension Canada guidelines recommend initiating antihypertensive therapy at average systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher in pregnant patients with chronic hypertension, gestational hypertension, or preeclampsia Initial therapy consists of monotherapy with either oral labetalol, methyldopa, long- acting nifedipine, or other β- blockers Second line agents include clonidine, hydralazine, and thiazide diuretics

58. Pregnant women ACE inhibitors and angiotensin receptor blockers are contraindicated during pregnancy owing to teratogenicity and neonatal renal agenesis Treatment with antihypertensives decreases risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes but does not decrease risk of preeclampsia or other serious maternal complications or fetal or neonatal death or morbidity US Preventive Services Task Force and American College of Obstetricians and Gynecologists recommend the use of low-dose aspirin (81 mg/day) for prevention of preeclampsia in patients at high risk after 12 weeks of gestation Begin between 12 weeks and 28 weeks of gestation (ideally before 16 weeks) and continue daily until delivery Patients with severe hypertension (systolic at least 160-170 mm Hg and/or diastolic higher than 105-110 mm Hg) require immediate hospitalization and urgent antihypertensive therapy; considered an obstetrical emergency IV labetalol and hydralazine are first line medications for the management of acute- onset, severe hypertension in pregnant patients; immediate release oral nifedipine is an alternative if IV access is not established Magnesium sulfate is indicated for seizure prophylaxis in females with acute-onset severe hypertension during pregnancy (regardless of whether it is gestational hypertension or preeclampsia with severe features or eclampsia) Delivery, after maternal stabilization, is recommended for patients who have a diagnosis of gestational hypertension or preeclampsia with severe features at or beyond 34 weeks of gestation Delivery at or beyond 37 weeks of gestation is recommended in patients with gestational hypertension or preeclampsia without severe features

59. Monitoring Treat adults with an elevated blood pressure or stage 1 hypertension who have an estimated 10-year atherosclerotic cardiovascular disease risk lower than 10% with nonpharmacologic therapy and evaluate blood pressure again within 3 to 6 months Initially treat adults with stage 1 hypertension who have an estimated 10-year atherosclerotic cardiovascular disease risk of 10% or higher with a combination of nonpharmacologic and antihypertensive drug therapy and evaluate blood pressure again in 1 month Adults with stage 2 hypertension should be evaluated by or referred to a primary care provider within 1 month of the initial diagnosis, have a combination of nonpharmacologic and antihypertensive drug therapy (with 2 agents of different classes) initiated, and have blood pressure evaluated again in 1 month For adults with a very high average blood pressure ( eg , systolic 180 mm Hg or higher, diastolic 110 mm Hg or higher), evaluation followed by prompt antihypertensive drug treatment is recommended Adults initiating a new or adjusted drug regimen for hypertension should have a follow-up evaluation of adherence and response to treatment at monthly intervals until control is achieved

60. Monitoring For adults with blood pressure within reference range, repeating evaluation every year is reasonable Self-measured blood pressure monitoring is a validated approach for out-of-office blood pressure measurement and may be associated with improved blood pressure control Laboratory monitoring For all patients, monitor serum potassium and creatinine levels at least once or twice yearly For patients taking angiotensin receptor blockers or ACE inhibitors: Measure creatinine and potassium levels within 1 to 2 weeks of beginning therapy and 1 to 2 weeks after each dose increase; measure within 7 days if patient is at higher risk for hyperkalemia or acute kidney injury

61. Monitoring If creatinine level increases by 30% over baseline after starting, discontinue drug and recheck levels in 3 days If cause is temporary ( eg , dehydration), patient may resume drug once resolved If no cause is identified, consider renal artery stenosis or drug-induced kidney injury Potassium level higher than 5.6 mEq/L generally necessitates dose reduction or discontinuation For patients taking verapamil: In patients taking concomitant digoxin, monitor digoxin level

62. Complications Cardiovascular disease Risk lies even lowering BP to 115/75 mm Hg Coronary artery disease Diastolic blood pressure elevation is the primary predictor of risk in persons younger than 50 years Systolic blood pressure is a more important predictor in persons older than 60 years In adults aged 40 to 69 years, each 20-mm Hg increase in systolic blood pressure (or each 10-mm Hg increase in diastolic pressure) doubles the risk of a fatal coronary event Stroke ischemic and hemorrhagic stroke Similar hazard ratios for mortality for cerebral hemorrhage and ischemic stroke Left ventricular hypertrophy and heart failure

63. COMPLICATIONS In the long-term, treatment of hypertension reduces the risk of heart failure by approximately 50% and reduces heart failure mortality Increased risk of atrial fibrillation Hypertension is the most common cause of chronic kidney disease; conversely, chronic kidney disease can lead to or exacerbate hypertension Chronic hypertensive retinopathy may cause significant vision loss over time End-organ damage or dysfunction may also occur acutely (during hypertensive emergency), including: Hypertensive encephalopathy with cerebral hyperperfusion and cerebral edema Stroke, either ischemic or hemorrhagic Acute coronary syndrome Pulmonary edema caused by diastolic dysfunction or acute mitral regurgitation with left ventricular failure Aortic dissection Acute kidney injury HELLP syndrome ( ie , hemolysis, elevated liver enzymes, and low platelet count) may occur with very high blood pressure and microangiopathic hemolytic anemia associated with kidney injury Acute hypertensive retinopathy with disk edema, choroidal infarction, and retinopathy

64. PROGNOSIS Essential hypertension persists for life blood pressure tends to increase with age Nearly all patients will need to continue medication throughout life Untreated hypertension, especially with other cardiovascular risk factors, may lead to stroke, coronary artery disease, and heart failure

65. SCREENING screening for high blood pressure in all adults age 18 years and older 88 Adults age 40 years or older and persons at increased risk for high blood pressure: screen annually Adults age 18 to 39 years with no increased risk for hypertension and with prior blood pressure readings within reference range: screen every 3 to 5 years Regular BP measurement in children Office measurement of blood pressure with a manual or automated sphygmomanometer Use the mean of 2 measurements taken while the patient is seated Multiple measurements over time have better positive predictive value than measurement on a single day Ambulatory and self-measured home blood pressure monitoring can be used to confirm a diagnosis of hypertension after initial screening Other indications for self-measured blood pressure monitoring include the diagnosing of white coat hypertension and masked hypertension and detection of morning hypertension; validated blood pressure monitoring devices that use the oscillometric method are preferred

66. PREVENTION Risk of developing essential hypertension may be decreased by: Maintenance of body weight within reference range Regular exercise Low-sodium diet Calcium intake more than 1000 mg/day slightly reduces both systolic and diastolic blood pressure in normotensive people, but this finding requires confirmation

67. SUMMERY Hypertension is defined as blood pressure of 130/80 mm Hg or higher in adults Essential hypertension -90% Secondary HTN -10% Initial office evaluation is focused on identification of hypertensive end-organ damage Dose titration before addition of an additional drug or adding an additional drug without maximizing dosage of the first Frequently readdress lifestyle 2017 ACC/AHA guidelines for prevention, detection, evaluation, and management of high blood pressure in adults 2019 American College of Cardiology/American Heart Association guidelines

68. THANK YOU