FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5)  ​ PRIME I/ PRIME 10 CFM September 2020 | 1​  

 
 
HYPERTENSION (2018 ESC/ESH Guidelines) 
 
HOW TO DIAGNOSE HYPERTENSION   ● Age 
  ● Smoking (current or past history) 
● Hypertension is defined as o ​ ffice SBP values ≥ 140 mmHg  ● Total cholesterol and HDL-C 
and/or DBP values ≥ 90 mmHg.  ● Uric Acid 
● Masked hypertension ​is defined in people whose BP is  ● Diabetes 
normal in the office but elevated on out-of-office BP  ● Overweight/obesity 
measurements  ● Family history of premature CVD (men aged <5 years and 
  women aged <65 years) 
Abbreviations:  ● Family or prenatal history of early-onset hypertension 
HMOD: Hypertension-mediated organ damage  ● Early-onset menopause 
  ● Sedentary lifestyle 
  ● Psychosocial and socioeconomic factors 
● Heart rate (resting values >80 bpm) 

 
 
FACTORS INFLUENCING CV RISK IN PATIENTS WITH 
HYPERTENSION 
   
Demographic characteristics and laboratory parameters   
● Sex (M>F)   
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5)  ​ PRIME I/ PRIME 10 CFM September 2020 | 2
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BLOOD PRESSURE MEASUREMENT 
Conventional Office BP Measurement 
● Auscultatory or oscillometric semiautomatic or automatic 
sphygmomanometers are preferred for measuring BP in the 
doctor’s office 
● BP must be initially measured in both upper arms, using an 
appropriate cuff size for the arm circumference 
● A consistent and significant SBP difference between arms 
(ie >15mmHg) is associated with an increased CV risk 
● When there is a difference in BP between arms, the arm 
with the higher BP values should be used for all subsequent 
measurements 
● In o
​ lder people, people with DM, or people with other 
causes of orthostatic hypotension, B ​ P should be measured 
1 min and 3 min after standing. 
● Orthostatic hypotension - reduction in SBP of ≥ 20mmHg of 
in DBP of ≥ 10 mmHg within 3 min of standing 
● Heart rate must also be recorded at the time of BP 
measurements because resting HR is an independent 
predictor of CV morbid or fatal events 
 
 
 
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5)  ​ PRIME I/ PRIME 10 CFM September 2020 | 3
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● With readings in the morning and the evening 
● Taken in a quiet room after 5 min of rest 
● Patient seated with their back and arm supported 
● 2 measurements taken, performed 1-2 min apart 
 
Ambulatory BP monitoring 
● Average BP readings over a defined period, usually 24h 
● ABPM is a better predictor of HMOD than office BP 
 
SCREENING AND DIAGNOSIS OF HYPERTENSION 
 

 
 
Unattended Office BP Measurement   
● White coat effect can be substantially reduced or   
eliminated  CLINICAL EVALUATION  
● BP values are lower than those obtained by conventional  Medical History 
office BP measurement  ● Time of the first diagnosis of hypertension, including 
Out-of-office BP Measurement  records of any previous medical screening, hospitalization, 
● Uses either HBPM or ABPM, the latter usually over 24h  etc. 
Home BP Monitoring  ● Record any current and past BP values 
● Average of all BP readings performed with a  ● Record current and past antihypertensive medications 
semi-automatic, validated BP monitor for at least 3 days and  ● Record other medications 
preferably for 6-7 consecutive days before each clinic visit.  ● Family history of hypertension, CVD, stroke, or renal disease 
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● Lifestyle evaluation, including exercise levels, body weight  ● Comparison of radial with femoral pulse to detect 
changes, diet history, smoking history, alcohol use,  radio-femoral delay in aortic coarctation 
recreational drug use, sleep history, and impact of any  ● Signs of Cushing’s disease or acromegaly 
treatments on sexual function  ● Signs of thyroid disease 
● History of any concomitant CV risk factors   
● Details and symptoms of past and present comorbidities  ROUTINE WORKUP FOR EVALUATION OF HYPERTENSIVE 
● Specific history of potential secondary causes of  PATIENTS 
hypertension  Routine Laboratory Tests 
● History of past pregnancies and oral contraceptive use  ● Hgb and/or Hct 
● History of menopause and hormone replacement therapy  ● Fasting blood glucose and HbA1c 
● Use of liquorice   ● Blood lipids: total cholesterol, LDL, HDL cholesterol 
● Use of drugs that may have a pressor effect  ● Blood triglycerides 
  ● Blood potassium and sodium 
PHYSICAL EXAMINATION AND CLINICAL INVESTIGATIONS  ● Blood uric acid 
Body Habitus  ● Blood creatinine and eGFR 
● Weight and height   ● Blood liver function tests 
● Waist circumference  ● Urine analysis (microscopic, dipstick, albumin:creatinine 
  ratio) 
Signs of HMOD  ● 12-lead ecg 
● Neurological exam and cognitive status   
● Fundoscopic exam for hypertensive retinopathy   
● Palpation and auscultation of heart and carotid arteries   
● Palpation of peripheral arteries   
● Comparison of BP in both arms (at least once)   
   
Secondary Hypertension   
● Skin inspection (cafe-au-lait patches of   
neurofibromatosis//pheochromocytoma)   
● Kidney palpation for signs of renal enlargement in   
polycystic kidney disease   
● Auscultation of heart and renal arteries for murmurs or   
bruits indicative of aortic coarctation, or renovascular   
hypertension   
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ASSESSMENT OF HYPERTENSION-MEDIATED ORGAN DAMAGE  Older people with Grade 1 HTN 
(HMOD)  ● Older people: ≥ 65 years 
● Very old: ≥ 80 years 
 
INITIATION OF BP-LOWERING DRUG TREATMENT 
 

 
TREATMENT OF HYPERTENSION 
  Lifestyle Changes 
  ● Salt restriction  
TREATMENT OF HYPERTENSION  ○ <6g a day ~1 teaspoon from Doc Sam; but <5 in ESH 
2 Well-established strategies to lower BP:  ● Moderation of alcohol consumption 
● Lifestyle intervention  ○ Men: 14 units per week 
● Drug treatment  ○ Women: 8 units per week 
  ○ 1 UNIT = 125mL of wine or 250 mL of beer 
Drug Treatment: Grade 1 HTN at Low Moderate Cardiovascular  ○ Alcohol-free days and avoidance of binge drinking 
Risk  are also advised 
● Lifestyle advice with BP-lowering drug treatment  ● High consumption of vegetables and fruits 
  ○ Low-fat dairy products 
  ○ Unsaturated fatty acids (olive oil) 
  ○ Mediterranean Diet 
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○ Caffeine has an acute pressor effect 
○ Reduce consumption of sugar-sweetened soft 
drinks 
● Weight reduction 
● Maintaining ideal body weight 
● Regular physical activity 
○ 30 mins of moderate-intensity dynamic aerobic 
exercise  
○ Walking, jogging, cycling, swimming on 5-7 days per 
week 
○ Resistance exercises 2-3 days per week of moderate 
intensity 
○ 150 min a week of vigorous-intensity aerobic 
physical activity 
● Smoking cessation 
○ Nicotine replacement therapy 
○ Varenicline 
   
Pharmacological Therapy   
● ACE Inhibitors   
● Angiotensin-2 receptor blockers   
● Beta-blockers   
● Calcium channel blockers   
● Diuretics   
   
 
 
 
 
 
 
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5)  ​ PRIME I/ PRIME 10 CFM September 2020 | 7
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DRUG TREATMENT ALGORITHM FOR UNCOMPLICATED  DRUG TREATMENT ALGORITHM FOR HYPERTENSION AND 
HYPERTENSION  CHRONIC KIDNEY DISEASE 
 

 
 
  Device-based Hypertension Treatment 
  ● Carotid baroreceptor stimulation (Pacemaker and Stent) 
DRUG TREATMENT ALGORITHM FOR HYPERTENSION AND  ○ Lowers BP in patients with resistant hypertension 
CORONARY ARTERY DISEASE  ● Renal Denervation 
  ○ Lays with the importance of sympathetic nervous 
system influences on renal vascular resistance,  
● Arteriovenous Fistula 
○ Central iliac arteriovenous anastomosis 
○ Fixed conduit between external iliac artery and vein 
using a stent-like nitinol device 
○ Reversible 
○ Creates a diversion of arterial blood into the venous 
circuit with immediate, verifiable reductions in BP 
 
HYPERTENSION IN SPECIFIC CIRCUMSTANCES 
  Resistant Hypertension 
  ● When the recommended strategy fails to lower office SBP 
  and DBP values to <140 mmHg and/or <90 mmHg 
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● The inadequate control of BP is confirmed by ABPM or  Treatment of Resistant Hypertension 
HBPM in patients whose adherence therapy has been  ● Lifestyle changes 
confirmed.  ● Discontinue interfering substances 
● Appropriate lifestyle measures  ● Sequential addition of antihypertensive drugs to the initial 
● Treatment with optimal or best-tolerated doses of three or  triple therapy 
more drugs, which include a diuretic, typically an ACE   
inhibitor or an ARB and a CCB. 
 
Pseudo-resistant Hypertension 
● Causes: 
○ Poor adherence to prescribed medicines  
○ White-coat phenomenon 
○ Poor office BP measurement technique 
○ Marked brachial artery calcification 
○ Clinician inertia 
○ Lifestyle factors (obesity, high sodium intake) 
○ Obstructive sleep apnea 
○ Undetected secondary forms of hypertension 
 
Diagnostic Approach to Resistant Hypertension 
● Patient’s history 
● Lifestyle characteristics   
● Sodium and alcohol intake   
● Physical examination, focusing on determining the presence  Secondary Hypertension 
of HMOD and signs of secondary hypertension  ● Hypertension due to an identifiable cause 
● Confirmation of treatment resistance by out-of-office BP  ● Medication and other substances may cause a sufficient 
measurements  increase in BP to raise the suspicion of secondary 
● Laboratory tests to detect electrolyte abnormalities  hypertension. 
(hypokalemia), diabetes, organ damage, or secondary  ● A careful drug history is important 
hypertension  ● NSAIDs or glucocorticoids can antagonize the BP-lowering 
● Confirmation of adherence to BP-lowering therapy  effect of antihypertensive medications in patients treated 
  for hypertension 
   
FAMILY HEALTHCARE PROGRAM NOTES (SERVICE 5)  ​ PRIME I/ PRIME 10 CFM September 2020 | 9
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  HYPERTENSION IN OLDER PATIENTS (AGE ≥65 YEARS) 
● Advanced age has been a barrier to the treatment of 
hypertension because of concerns about potential poor 
tolerability and even harmful effects of BP-lowering 
interventions in people whose vital organ perfusion is 
impaired 
● Follow treatment algorithm 
● In very old patients, initiate monotherapy at the lowest 
available doses 
 
   
Reference: 
https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/e
urheartj/ehy339 
 
 
 
 
 
 
 
 
 
   
   
HYPERTENSION IN YOUNGER ADULTS (AGE <50 YEARS)   
● All younger adults with grade 1, grade 2 or more severe   
hypertension    
○ Lifestyle advice   
○ Drug treatment