1

HYPERTENSION
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Learning Objectives
 To describe the epidemiology of hypertension.
 To define “Hypertension”.
 To diagnose hypertension.
 To manage patients diagnosed with hypertension.
 To monitor compliance and adherence of hypertensive patients
to treatment.
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EPIDEMIOLOGY
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Epidemiology
 Around 26% of the world adult population had hypertension in
the year 2000.
 By 2025, around 29% of the world adult population are
expected to suffer from hypertension.
 Most of this increase is expected to happen in the developing
countries.
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DEFINITION
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Definition of Hypertension
 Hypertension is defined as systolic blood pressure of 140
mmHg or higher OR a diastolic blood pressure of 90 mmHg or
higher.
 Average of two or more different readings are needed to make
the diagnosis.
 Patients who are actively taking antihypertensive medications
are defined as having hypertension.
 Isolated systolic hypertension is present when the blood
pressure is ≥140/<90 mmHg.
 Isolated diastolic hypertension is considered to be present
when the blood pressure is <140/≥90 mmHg.
 Patients with blood pressure ≥140/≥90 mmHg are considered
to have mixed systolic/diastolic hypertension.
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Additional Definitions
 White coat hypertension is defined as blood pressure that is
consistently elevated in the clinic but does not meet diagnostic
criteria for hypertension based upon out-of-clinic readings.
 Masked hypertension is defined as blood pressure that is
consistently elevated by out-of-clinic measurements but does
not meet the criteria for hypertension based upon clinic
readings.
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Risk Factors
 Age
 Obesity
 Family history
 High sodium diet (>3000mg/day)
 Excessive alcohol consumption
 Physical inactivity
 Diabetes mellitus
 Dyslipidemia
 Personality traits and depression
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Complications
 Left ventricular hypertrophy
 Coronary artery disease
 Heart failure
 Myocardial infarction
 Retinopathy
 Chronic kidney diseases
 Cerebro-vascular accidents
 Death
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SCREENING
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Screening
 Screen for Hypertension all adults aged 18 years and older.
 Frequency of screening:
o Every 2 years if systolic and diastolic blood pressures are
below 120 mmHg and 80 mmHg respectively.
o Yearly for persons with a systolic blood pressure of 120 to
139 mmHg or a diastolic blood pressure of 80 to 89 mmHg.
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DIAGNOSIS
 Diagnosing Hypertension
Category Systolic Blood Diatolic Blood
Pressure (mmHg) Pressure (mmHg)

Normal < 120 And <80

Pre-hypertension 120-139 80-89

Or
Stage 1 140-159 90-99
hypertension
Stage 2 ≥160 ≥100
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EVALUATION
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Objectives of the Evaluation

 To determine the level of target-organ damage.
 To assess other cardiovascular risk factors.
 To identify lifestyle factors that could contribute to
hypertension.
 To identify interfering substances and potentially curable
causes of secondary hypertension.
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History (1)
 Duration of high blood pressure.
 Previous attempts of treatment for high blood pressure.
 Presence of aggravating factors.
 Symptoms of secondary causes.
 Symptoms of target organ damage.
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History (2)
 Presence of cardiovascular risk factors.
 Dietary history: sodium, alcohol, saturated fats.
 Family history of: hypertension, premature cardiovascular
disease or death, familial diseases.
 Psychosocial factors.
 Sexual function.
 Features of sleep apnea.
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When to Suspect Secondary Hypertension?

 Severe or resistant hypertension.
 Acute increase in blood pressure compared to previous stable
values.
 Proven age of onset before puberty.
 Age < 30 years with no family history of hypertension and no
obesity.
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Causes of Secondary Hypertension

 Over the counter medications
 Renal diseases
 Illicit drug use
 Primary aldosteronism
 Renovascular hypertension
 Obstructive sleep apnea
 Pheochromocytoma
 Cushing’s syndrome
 Other endocrine disorders: hypothyroidism, hyperthyroidism,
and hyperparathyroidism.
 Coarctation of the aorta
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Physical Examination
 Accurate measurement of blood pressure
 General appearance
 Fundoscopy is important to check for hypertensive retinopathy.
 Neck: palpation and auscultation of carotids, thyroid
 Heart: size, rhythm, sounds
 Lungs: rhonchi, rales
 Abdomen: renal masses, bruits over the aorta or renal arteries,
femoral pulses
 Extremities: peripheral pulses, edema
 Neurologic assessment: visual disturbance, focal weakness,
confusion
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Laboratory Tests
 Blood Glucose level
 Fasting lipid profile
 Serum Creatinine (and estimated glomerular filtration rate)
 Serum Calcium
 Serum Potassium level
 Hematocrit (CBC)
 Urinalysis
 Spot urine for microalbumin (albumin/creatinine ratio) is
indicated in specific conditions.
 Other tests might be indicated in case secondary hypertension
is suspected.
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Other Tests
 Electrocardiography (EKG): should be done for every patient.
 Echocardiography: it can identify the presence of left
ventricular hypertrophy better than an EKG. It is indicated if left
ventricular dysfunction or coronary artery disease is suspected
and in patients with clinically evident heart failure.
 Ambulatory blood pressure monitoring: It is indicated in
specific situations.
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Indications for Ambulatory Blood Pressure monitoring

 To confirm the diagnosis of suspected white coat hypertension

 To confirm a poor response to antihypertensive medications
 To confirm normal blood pressure readings obtained by self-
monitoring at home
 It can identify masked hypertension
 Suspected episodic hypertension
 To determine blood pressure control in patients known to have
substantial white coat effect
 Presence of hypotensive symptoms while taking
antihypertensive medications
 Resistant hypertension
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MANAGEMENT
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Non-Pharmacological Management (1)

 Weight reduction: maintain body mass index (BMI) within
normal ranges.
 Dietary approaches to stop hypertension (DASH).
o a diet rich in fruits, vegetables, fiber, low fat dairy products,
lean meat, calcium, magnesium and potassium with a
reduced content of saturated and total fat.
 Reduction in dietary sodium
o reduce dietary sodium intake to no more than 2.4 gram
sodium or 6 gram sodium chloride.
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Non-Pharmacological Management (2)

 Physical activity
o aerobic physical activity such as brisk walking for at least 30
minutes per day on most days of the week.
 Moderate alcohol consumption
o Limit consumption to no more than 2 alcoholic drinks per day
for men and one alcoholic drink for women.
 Smoking Cessation
 Decrease Caffeine Intake
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Pharmacologic Treatment (1)

 Antihypertensive medications should be started
o if systolic blood pressure is persistently ≥140 mmHg in
patients younger than 60 years or ≥150mmHg in patients 60
years and above
o and/or diastolic blood pressure is persistently ≥90mmHg
despite attempted non-pharmacologic treatment.
 Starting with 2 drugs should be considered in patients with a
baseline blood pressure above 160/100 mmHg.
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Pharmacological Treatment (2)

 Initial monotherapy: any of the following classes
o Thiazide diuretics
o long acting calcium channel blockers
o Angiotensin-converting enzyme inhibitors (ACE inhibitors)
o Angiotension II Receptor blockers (ARB)
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Factors to Consider When Starting

Antihypertensive Medications
 Potential side effects on co-morbid conditions
 Contraindications
 Potential favorable effects
 Compelling indications
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Potential Side Effects on Co-Morbid Conditions

 Depression: Beta Blockers, central alpha-2 agonist
 Gout: Diuretic
 Hyperkalemia: Aldosterone antagonist, ACE inhibitor, ARB,
Renin inhibitor
 Hyponatremia: Thiazide diuretic
 Renovascular disease: ACE inhibitor, ARB, rennin inhibitor
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Contraindications
 Angioedema: ACE inhibitor
 Bronchospastic disease: Beta blocker
 Liver disease: Methyldopa
 Pregnancy (or at risk of pregnancy): ACE inhibitor, ARB, rennin
inhibitor
 Second or third degree heart block: Beta blocker,
nondihydropyridine calcium channel blocker
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Potential Favorable Effects

 Benign Prostatic Hypertrophy: Alpha Blocker
 Essential tremor: Beta blocker (non-cardio-selective)
 Hyperthyroidism: Beta Blocker
 Migraine: Beta Blocker, Calcium Channel Blocker
 Osteoporosis: Thiazide diuretic
 Raynaud’s syndrome: Dihydropyridine calcium channel blocker
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Compelling Indications
 Systolic heart failure: ACE inhibitor, ARB, beta blocker, diuretic,
aldosterone antagonist
 Post myocardial infarction: ACE inhibitor, beta blocker, ARB,
aldosterone antagonist
 Proteinuric chronic kidney disease: ACE inhibitor, 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
Strategies to Dose Antihypertensive
Medications
 Strategy A- Start with one medication, then titrate to
maximum dose; and then add a second medication.
 Strategy B- Start with one medication and then add a
second one before reaching the maximal dose of the initial
medication OR
 Strategy C- Begin with two medications at the same time
either as two separate pills or as a single pill combination.
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Protocol for Home Blood Pressure Measurement

 Use a validated electronic device.
 Choose a cuff with an appropriate bladder size matched to the
size of the arm.
 Measure BP after resting comfortably for 5 minutes in the
seated position with back support.
 The arm should be bare.
 The BP cuff should be at heart level.
 Avoid caffeine or tobacco in the hour and exercise 30 minutes
preceding the measurement.
 Take measurements in the morning and evening for around 7
days.
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FOLLOW UP AND
MONITORING
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Target Blood Pressure

 BP < 140/90 mmHg in patients younger than 60 years of age.
 BP< 150/90 mmHg in patients 60 years and older is
recommended by the eight joint national committee; however
a target <140/90 is still aimed in those who are fit.
 BP<140/90 mm Hg in patients with diabetes mellitus and
chronic kidney disease is recommended by the eight joint
national committee.
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Follow Up
 Follow up visits twice per year if blood pressure is controlled.
 Annual follow up laboratory tests: spot urine for microalbumin
(albumin/creatinine ratio), fasting lipid profile, serum
potassium and serum creatinine.
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During Each Visit

 Measure blood pressure
 Measure weight and calculate BMI
 Assess end organ damage
 Address other cardiovascular risks
 Remind patient about lifestyle modifications
 Monitor compliance with drugs
 Monitor presence of side effects.
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Referral to Specialists
 Uncontrolled hypertension
 Suspicion of secondary hypertension
 Malignant hypertension
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ADHERENCE OF
PATIENTS TO TREATMENT
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Non - Adherence
 Around 50-80% of patients with Hypertension may not take
all the prescribed medications.
 Reasons for non-adherence include:
o Misunderstanding of Condition
o Denial of illness
o Being asymptomatic
o Non-involvement of patients in care plan
o Side effects of the medication
o Too many follow up visits, lab requests
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Recommendations to improve adherence

 Assess adherence to treatment every visit.
 Advise patients to schedule the intake of their medications in
relation to a routine daily activity.
 Use long-acting once-daily dosing.
 Replace multiple pill antihypertensive combinations with single
pill combinations, if feasible.
 Encourage greater patients engagement in regular monitoring
of their blood pressure.
 Educate patients and patients' families about their
disease/treatment regimens verbally and in writing.
 Coordinate the care of your patients with other healthcare
members and pharmacists if available.
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References
 Basile J, Block MJ. Overview of Hypertension in Adults. In: UpToDate, Bakris
G (Ed), UpToDate, Waltham MA, 2014. www.uptodate.com.
 Chobanian AV, et al. The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pres-sure
[published correction appears in JAMA. 2003; 290 (2):197]. JAMA. 2003;
289(19):2560-2572.
 Daskalopoulou SS, Rabi DM, Zarnke KB, Dasgupta K, et al for the Canadian
Hypertension Education Program. The 2015 Canadian Hypertension
Education Program Recommendations for Blood Pressure Measurement,
Diagnosis, Assessment of Risk, Prevention, and Treatment of
Hypertension. Can J Cardiol. (2015); 31(5): 549-568.
 James PA, Oparil S, Carter BL, et al. 2014 evidence-based guidelines for the
management of high blood pressure in adults: report from the panel
members appointed to the Eighth Joint National Committee (JNC8). JAMA
2014; 311 (5): 507-520.
 Wexler R, Aukerman G. Nonpharmacologic Strategies for Managing
Hypertension. Am Fam Physician 2006; 73: 1953-6, 1957-8.