HYPERTENSION • Peripheral vascular

o Absence of 1 or more pulses in the
• A sustained diastolic blood pressure of >90 extremities except in the dorsalis
mmHg accompanied by an elevated blood pedis with or without intermittent
pressure of >140 mmHg resulting from an claudication
increased arteriolar resistance and o Arterial aneurysms
decreased capacitance of the vessels. • Renal
• WHO: BP >160/95 mmHg o Serum creatinine >/= 130
• AHA: BP >140/90 mmHg
MALIGNANT HYPERTENSION
CLASSIFICATION OF HYPERTENSION ACCORDING TO
ETIOLOGY
• An accelerated phase of severe HPN with a
• Primary or essential H P N rapidly progressing damage to end-organs
o 90-95% of cases. and rising BP which may be signaled by
o Cause: Unknown. deteriorating renal function,
o Predisposing factors: encephalopathy, retinal hemorrhages,
 Family history, stressful angina, stroke, or MI.
lifestyle, increased dietary
intake of sodium, obesity. MECHANISMS OF CONTROLLING BLOOD
PRESSURE
• Secondary H P N
o 5-10% of cases. • Baroreceptor and sympathetic nervous
o Causes: system
 Renal artery stenosis, • Renin-angiotensin-aldosterone system
Cushing’s syndrome,
pheochromocytoma.

CLASSIFICATION OF BP FOR ADULTS 18 YRS AND
OLDER (PHIL. SOCIETY OF HPN)

• Optimal
o <120 mmHg / <80 mmHg
Recheck in 2 years.
• Normal
o 120-129 mmHg / 80-84 mmHg
Recheck in 2 years.
• High normal
o 130-139 mmHg / 85-89 mmHg
Recheck in 1 year.
• Stage 1 (mild) HPN
o 140-159 mmHg / 90-99 mmHg
Confirm in 2 months.
• Stage 2 (moderate) HPN
o 160-179 mmHg / 100-109 mmHg
Evaluate within a month.
• Stage 3 (severe) HPN
o 180-209 mmHg / 110-119mmHg TREATMENT STRATEGIES
Evaluate within a
week. Non-pharmacologic therapy
• Stage 4 (very severe) HPN • Low salt diet.
o >/=210 mmHg / >/=120 mmHg • Weight reduction.
Evaluate • Exercise.
immediately. • Cessation of smoking.
MANIFESTATIONS OF TARGET-ORGAN DAMAGE • Decreased alcohol consumption.
• Psychological methods: Relaxation /
• Cardiac
meditation.
o Evidence of CAD
• Dietary decrease in saturated fat.
o Clinical, ECG, radiologic à evidence
Drug therapy
of LVH or cardiac failure
• Stepped Care
• Cerebrovascular
o Progressive addition of drugs to a
o TIA or stroke
regimen, starting with one, usually a

Nadolol  Bisoprolol .Propranolol fashion.  Fenoldopam • Calcium channel blockers STEPPED CARE  Amlodipine .Losartan ANTI-HYPERTENSIVE DRUGS  Telmisartan .  Reserpine • Labetalol • a-blockers o 20-80 mg IV at 10-minute  Doxazosin intervals (max.Gallopamil AGENTS THAT BLOCK THE PRODUCTION OR ACTION OF ANGIOTENSIN • ACE inhibitors  Benazepril .  Prazosin immediate onset  Terazosin • b-blockers MECHANISMS OF DRUG ACTION  Acebutolol .Metoprolol  Betaxolol . Drugs that alter sympathetic nervous system instantaneous onset function à Sympatholytic drugs. • Sodium nitroprusside • Centrally-acting sympatholytics o 5-10 mg/L IV infusion.  Guanethidine onset within 5-30 min.Trandolapril • AT1-receptor blockers CATEGORIES OF  Irbesartan .Hydralazine and relatively low incidence of  Minoxidil .Pindolol .Valsartan  Candesartan . • Loop diuretics DRUGS FOR HYPERTENSIVE EMERGENCIES OR • Thiazides CRISES • Spironolactone and Triamterene • Trimethaphan o 1 mg/ml IV infusion.Timolol and sometimes an ACE inhibitor.Labetalol  Atenolol . and adding.Nimodipine  Felodipine .  Diazoxide .  Esmolol .Nitroprusside toxicity.Verapamil  Lercanidipine .Quinapril  Enalapril .Eprosartan Drugs that alter sodium and water balance à  Olmesartan Diuretics.Nifedipine  Diltiazem .Nicardipine  Lacidipine . • Monotherapy VASODILATORS o Advantageous because of its • Direct vasodilators simplicity. in a stepwise  Carvedilol .Ramipril  Lisinopril .  Clonidine instantaneous onset  Guanabenz • Diazoxide  Guanfacine o 300-600 mg Rapid IV push.Perindopril  Fosinopril . a sympatholytic.Nitrendipine  Manidipine .  Methyldopa instantaneous onset • Peripherally-acting sympatholytics • Nifedipine  Guanadrel o 10-20 mg Sublingual or chewed.Penbutolol  Carteolol .Moexipril  Captopril . titrate.dose: 300mg).Nisoldipine  Isradipine . diuretic. vasodilator. better patient compliance. titrate.

Renal damage in fetus à CI on the 2nd and 3rd tri of pregnancy. Proteinuria. nightmares. Sedation. severe depression. o CAPTOPRIL: Cough. • GUANADREL o Orthostatic hypotension and syncope. Taste changes. Used with caution in patients with peptic ulcers (inc. GI hyperactivity. Accumulates in patients with impaired renal function.DRUG ADVERSE EFFECTS • RESERPINE o Interacts with MAO inhibitors. hypOtension. Angioedema. Pregnancy problems . Edema. Interacts with TCAs. Hypotension and syncope. • ACE Inhibitors: Captopril o Dry cough. Hyperkalemia. Nasal stuffiness. GI act.).

adverse effects of combined regimen. • CLONIDINE o Xerostomia. sedation. . Hirsutism. drowsiness. in slow acetylators. it has gained popularity o Hypotension. constipation. Reversible lupus-like syndrome esp. Hyperglycemia. Peripheral edema. dizziness. Worsens myocardial ischemia and angina (reflex sympathetic stimulation). • DIAZOXIDE o Severe hypotension. Drug fever: Chills and fever with alteration in liver function. • b-BLOCKERS o Precipitates heart failure (abrupt cessation) in patients with left ventricular dysfunction. Increase in cholesterol concentration. • SODIUM NITROPRUSSIDE o Hypotension. Increased renin. palpitations. Abrupt withdrawal à cardiac arrhythmias. edema. Arrhythmias. and sweating. Hemolytic anemia. nausea. Sudden withdrawal à dysrhythmias. headache. • VERAPAMIL o Cardiodepression. • MINOXIDIL o Pericardial effusion and tamponade in patients with inadequate renal function. Rebound HPN (abrupt cessation). Orthostatic hypotension. Vertigo. Psoriasis. (teratogenic). anorexia. drowsiness. • METHYLDOPA o Sedation at onset of treatment. headache. • THIAZIDE DIURETICS o Potassium and magnesium loss. • Monotherapy is generally reserved for mild • NIFEDIPINE to moderate HPN. and improved patient compliance. Hypotension. Rash. palpitation (rapid vasodilation). Worsen Coronary Artery Disease (myocardial stimulation). fluid retention. nausea. Fluid retention. dizziness. headache. Use with caution in patients with Bronchial asthma. peripheral edema. fewer side effects. Headache. • DILTIAZEM • More severe HPN may require treatment with o Hypotension. Rebound HPN PRINCIPLES OF DRUG THERAPY (abrupt cessation). several drugs that are selected to minimize Cardiodepression. • HYDRALAZINE o Headache. Decreased HDL. Hyperglycemia (inhibits insulin release). Edema (salt and water retention). Edema (salt and water retention). Cyanide toxicity. • PRAZOSIN o Sudden syncope. Lower angiotensin II. weakness. Peripheral because of its simplicity.

a 2nd-drug is then added. ACEI.• Treatment is initiated with any of 4 drugs depending on individual patient: Diuretic. and a Ca-channel blocker. rather than in relieving present discomfort of the patient. • Therapy is directed at preventing disease that may occur in the future. if BP is inadequately controlled. b- blocker. it is important to enhance compliance by carefully selecting a drug regimen that minimizes adverse effects. . • Lack of patient compliance is the most common reason for failure of anti-HPN therapy. • HPN may co-exist with other disease that may be aggravated by some of the anti-HPN agents.