HYPERTENSION

OMAID HAYAT KHAN

Pharm. D (PU, PAK), MS in Clinical pharmacy (USM, MY)
Assistant Professor in Clinical Pharmacy
The University of Lahore, (Main Campus)
Content Framework
▪ General consideration
▪ Definition
▪ Classification (JNC7-8)
▪ The relationship b/w elevated BP and CV diseases
▪ Epidemiology
▪ Physiology
▪ Complications

▪ Secondary Hypertension
▪ Clinical evaluation
▪ Cause
▪ Treatment

▪ Essential (Primary) Hypertension

▪ Clinical evaluation
▪ Treatment

▪ Hypertensive Emergencies
▪ Definition
▪ Treatment

▪ Principles of HTN treatment in Elderly

▪ General principles
▪ Selection of special drug classes in elderly
GENERAL
CONSIDERATIONS
 DEFINITION

▪ HTN is defined as persistently elevated arterial blood pressure.

▪ A patient is said to be hypertensive when;

▪ Systolic blood pressure  140 mm Hg

▪ Diastolic blood pressure  90 mm Hg

Classification of Blood Pressure (JNC-7)
The relationship b/w elevated BP and CV diseases

▪ Greater the blood pressure, greater will be the risk of Myocardial

Infarction (MI), Stroke, Heart failure (HF), or Kidney disease.
 Epidemiology

▪ Approximately 43 million American have blood pressure > 140/90 mmHg.

▪ Incidence increases with age. E.g., 60-71% of people with HTN were >60 years old.
▪ (3rd National Health and Nutrition Examination Survey)

▪ >90% cases of systemic HTN are of Primary (essential) HTN

▪ Average age of onset is 35 years
▪ 2-5% of cases constitute Secondary HTN.
▪ Usually develops between ages 30 and 50.
▪ Facts regarding HTN in PAKISTAN
▪ 33% of Pakistani population above the age of 45 has hypertension
▪ Prevalence of hypertension is 19% in people of age 15 or above
▪ The estimated annual incidences of stroke in Pakistan are 250/100,000, translating to 350,000 new
cases every year
▪ Source: Journal of Pakistan Medical Association& National Health Survey (2011)
PHYSIOLOGY
 PHYSIOLOGY

▪ Sympathetic Nervous system ▪ Renin-angiotensin-aldosterone

system
Baroreceptors in the carotid and aortic arch

Arteriolar dilation Arteriolar constriction

Sympathetic
stimulation
Renal artery
hypotension
If stimulated to constrict

Increased HR Increased TPR

↓ Na
delivery to
Distal
tubules

Increased Cardiac Output

If pressure remains elevated ↑ RENIN

Baroreceptors sustain the HTN by resetting (from juxtamedullary apparatus of kidney)
 COMPLICATIONS

▪ CARDIAC EFFECTS ▪ RENAL EFFECTS

▪ CEREBRAL EFFECTS ▪ RETINAL EFFECTS

Secondary Hypertension
(CLINICAL EVALUATION, CAUSE, AND TREATMENT)
 Clinical Evaluation

• Most of the patients present with primary HTN, thus extensive screening is
unwarranted.
• Thorough history and lab. Investigations should rule out most of the
secondary causes of secondary HTN.
• Findings:
• Patient age
• Sudden onset of worsening of HTN
• BP not responding to treatment.

• If secondary cause is not found => Primary (Essential) HTN

 Clinical Evaluation
(History and physical findings)

• Drug-induced hypertension
• Renovascular disease (Renal artery stenosis) • Steroids
• Estrogen
• Oral
Sleep apnea contraceptives

Chronic Kidney Disease •

•
NSAIDs
Nasal
decongestants
• Primary aldosteronism • TCAs

• Pheochromocytoma • Appetite
suppressants
• Cyclosporine
parathyroid disease • Erythropoietin
coarctation of aorta • MAO inhibitors
Thyroid disease
• Cushing’s Syndrome
 Clinical Evaluation
(Laboratory findings)

• Blood Urea Nitrogen (BUN)

• Renal disease
• Creatinine elevation

• Increased Urinary levels • Pheochromocytoma

of catecholamines and metabolites

• Serum potassium (Hypokalemia) • Primary aldosteronism

or Cushing’s syndrome
 Clinical Evaluation
(Diagnostic tests)

• Renal arteriography
• Ultrasound • Renal Artery stenosis
• Renal Venography

Electrocardiography (ECG) • LVH or ischemia

Cause
 Treatment

• Treat Underlying disease (as mentioned in cause)

• Supplementary control of hypertensive effects

Primary (Essential)
Hypertension
(CLINICAL EVALUATION, CAUSE, AND TREATMENT)
 Clinical Evaluation

Rule out uncommon cause of secondary HTN

Determine presence and extent of target-organ damage

• Objectives
Determine other CV risk problems

Reduce morbidity and mortality and QOL by both pharma- and non-
pharmacological strategies.
 Clinical Evaluation

Family History

Patient History

Racial predisposition
• Pre-disposing
factors
Lifestyle risks
•Obesity, Smoking, Stress, Dietary intake of saturated fats and Na., Sedentary lifestyle

Diabetes mellitus

Hyperlipidemia

Target-organ damage
 Clinical Evaluation

• Physical findings
•Serial BP reading ≥ 140/90 mmHg should be obtained on at least
two difference occasions.

•If BP is already above 210/120 mmHg or is associated with target-

organ damage, diagnosis is confirm.

•A single reading is insufficient to confirm diagnosis.

•Essential HTN usually stays clinically not evident, therefore serial

BP elevation or signs of end-organ damage remain the only
indicators.
 Treatment

• Treat Underlying disease (as mentioned in cause)

• Supplementary control of hypertensive effects

7 Joint National
th
Committee Report
(JNC 7 HYPERTENSION GUIDELINES)
8 Joint National
th
Committee Report
(JNC 8 HYPERTENSION GUIDELINES)
Updates on Joint 8th
National Committee
Report 2017
(2017 GUIDELINES FOR THE PREVENTION, DETECTION, EVALUATION,
AND MANAGEMENT OF HIGH BLOOD PRESSURE IN ADULTS)
Important updates
Important updates
Hypertensive crises
(2017 GUIDELINES FOR THE PREVENTION, DETECTION, EVALUATION,
AND MANAGEMENT OF HIGH BLOOD PRESSURE IN ADULTS)
Hypertensive Emergency Hypertensive Urgency
• Develops over hours to days. • Develops over days to weeks.
• BP > 180/120 mm Hg & have • BP severely increased but no
evidence of acute target organ evidence of target organ damage.
damage.
like; • Usually treated with oral medicines
stroke, coma, blurred vision, as out-patient.
transient blindness, myocardial
infarction etc.
 REFERENCES

• Comprehensive Pharmacy Review NAPLEX Eighth Edition by Shargel

• 7th Joint National Committee Report on Hypertension

• 8th Joint National Committee Report on Hypertension

• 2017 Guidelines on for the Prevention, Detection, Evaluation, and management of high
blood pressure in adults