APPROACH TO HYPERTENSION

DEFINITION
• Persistent elevation of
– Systolic BP of 140 mmHg or greater

And/ or
– Diastolic BP of 90 mmHg or greater
BP (mmHg) Normal Pre hypertension HPT Stage 1 HPT Stage 2 systolic <120 120-139 140-159 ≥160 diastolic <80 80-89 90-99 ≥100

Based on average of two or more properly measured, seated BP readings on 2 or more office readings

Patient Evaluation
• Objectives:
– To assess lifestyle and identify cardiovascular risk factors or concomittant disorder that may affect prognosis and treatment – To reveal identifiable cause of HPT – To assess the presence of target organ damage.

TARGET ORGAN DAMAGE (TOD) • Heart – Left ventricular hypertrophy – Angina or prior myocardial infarction – Prior coronary revascularization – Heart failure • Brain – Stroke or transient ischaemic attack • Chronic kidney disease • Peripheral artery disease • Retinopathy .

SECONDARY CAUSES • • • • • Sleep apnoea Drug-induced or drug-related Chronic kidney disease Renovascular disease Endocrinopathies – – – – – Primary aldosteronism Phaeochromocytoma Cushing syndrome Acromegaly Thyroid and parathyroid disease • Coarctation of the aorta • Takayasu arteritis .

HISTORY • • • • • • • • Duration and level of elevated BP if known Symptoms of secondary causes of HPT Symptoms of target organ damage Symptoms of concomitant disease Family history Dietary history Drug history Lifestyle and social history .

weight. grade 4: papillloedema • Bruit and peripheral pulses • Systems examination (cardiovascular.PHYSICAL EXAMINATION • General (height. waist circumference) • Appropriate BP measurements • Fundoscopy-hypertensive retinopathy: – – – – grade 1: tortous artery grade 2: A-V nipping. grade 3: flame hemorrhage and cotton woolspots. neurological examinations) • Lower limb edema . respiratory. abdomen.

serum electrolytes. and uric acid) • Urinalysis • ECG • Chest x-ray . creatinine.INVESTIGATIONS • Full blood count • Renal function tests ( urea.

ARB. consider consultation with HPT specialist . CCB or combinations Stage II -2-drugs combination -Usually thiazide diuretics with ACE-i/ARB/BB/CCB Drugs for the compelling indication Not at Goal BP Optimize dosage. BB.JNC 7 Lifestyle modification Not at Goal BP Initial drug choices Without compelling indication With compelling indication Stage I -Thiazide diuretics -May consider ACE-I. add additional drugs.

Diuretics . ARB. BB. CCB.TREATMENT • LIFESTYLE MODIFICATION – Reduction of weight – Adopt DASH eating plan – Dietary sodium reduction – Physical activity – Reduction of alcohol consumption • PHARMACOLOGIC – ACE-I.

5 kg/m2 – Reduction of 5-10% in 6-12 months – As little as 4.Lifestyle Modification • Weight reduction – As far as possible.5 kg significantly reduce BP • Sodium intake restriction – Intake of <100 mmol of sodium or 6g of sodium chloride a day (<1¼ tsp of salt) .5 – 23. aim ideal BMI – Asians – 18.

g. . • Regular physical exercise – Aerobic type of exercise e.Lifestyle Modification • Avoidance of alcohol – Intake ≤21 units (men) and ≤14 units (women) per week. brisk walking for 3060 minutes at least 3 times a week.

vegetables and dairy products with reduced saturated and total fat can lower BP – BP 11/6 mmHg in hypertensive patients .Lifestyle Modification • Healthy eating – Diet rich in fruits.

http://www.JNC 7 Treatment Recommendations Initial Drug Therapy JNC 7 Express. 2003. May. .pdf.gov/guidelines/hypertension/express. NIH publication No 03-5233.nih.nhlbi.

289:2560-72.Algorithm for Treatment of HTN Compelling Indications Heart Failure Diuretic B-Blocker X X ACE Inhibitor X ARB X CCB Aldosterone antagonisst X Post-MI High CAD risk Diabetes Chronic renal disease 2° Stroke prevention X X X X X X X X X X X X X X Non-DHP X X Non-DHP NHBPEP Coordinating Committee. . JAMA 2003. The JNC 7 Report.

serum creatinine should be checked before initiation and repeated after one or two weeks after initiation. . ACE-I to reduce morbidity and mortality . .in patient with increased cardiovascular risk.side effect: cough and angioedema.Types of Antihypertensive Drugs 1) ACE-i .prevent onset of microalbuminuria. reduce protenuria. and progression of renal disease .

5mg od 10mg od 5mg od Maximum daily dose 50 mg tds 20 mg bd 40 mg od 80 mg od .Inhibitor ACEi captopril enalapril fosinopril lisinopril Starting daily dose 25mg bd 2.ACE.

Preventing progression of diabetic retinopathy.Recommended in ACEi intolerance patient .Less side effect of dry cough . and reduce major cardiac events.• 2) Angiotensin Receptor Blocker . .

ARB ARBs Candesartan Irbesartan losartan Valsartan telmisartan Starting dose 8 mg od 150mg od 50 mg od 80 mg od 20 mg od Maximum daily dose 16 mg od 300 mg od 100 mg od 100 mg od 160 mg od .

. severe peripheral vascular disease and heart block. . tachyarrhytmia. hypoglycemia. erectile dysfunction and cold extremities.Side effect: dyslipidemia. increase incidence of new onset of DM.Useful in hypertensive patient with angina.3) Beta blocker . or previous myocardial infarction .Contraindicated in obstructive airway disease.

• Beta blockers B Blockers acebutolol atenolol betaxolol bisoprolol metoprolol propanolol Starting dose 200mg bd 50 mg od 10 mg od 5mg od 50 mg bd 40 mg bd Maximum daily dose 400mg bd 100mg od 40mg od 200mg bd 200 mg bd 320 mg bd .

headache.Adverse effect: initial tachycardia.4) Calcium channel blocker . flushing. constipation and ankle edema .Use as first line treatment and other combination with other drug .No undesirable adverse metabolic effect .

• CCB CCBs Amilodipine Starting dose 5mg od Maximum daily dose 10 mg od Diltiazem felodipine 30mg tds 2.5mg od 60 mg tds 10 mg od nifedipine verapamil Verapamil CR 10 mg tds 80 mg bd 200mg od 30mg tds 240mg tds 200 mg bd .

Patient with essential hypertension and normal renal function. and loop diuretics are to be used instead. thiazide are more potent than loop diuretics .most widely used antihypertensive agents . thiazide are less effective.Potassium sparing diuretics may cause hyperkalemia if given together with ACEi or ARBs . . sodium and magnesium level .Side effets: increased serum cholesterol. Decreased potassium.• 5) Diuretics .Patient with renal insufficiency. glucose and uric acid.

5 mg od 1 tablet bd 2.5 mg od 2 tablet bd .DIURETICS diuretics Starting dose Maximum dose daily chlorothiazide hydrocholorothiazide Amiloride 5g/ 50 mg 250 mg od 25mg od 1 table t od 500mg od 200mg od 4 tablet od indaparamide Triamterene 50 mg/ 25 mg 2.

In ED • HPT Emergency • HPT Urgency .

Acute renal failure VII. Hypertensive Lt ventricular failure(acute pulmonary edema) III. Eclampsia JNC 7 .HYPERTENSIVE EMERGENCY • Severe elevation in BP (usually >180/120) complicated by evidence of progressive target organ dysfunction • Target organ dysfunction includes: I. Haemorrhagic / Ischaemic Stroke / SAH VI. Hypertensive encephalopathy II. Acute aortic dissection IV. ACS / Acute MI V.

HYPERTENSIVE URGENCY • Situations associated with severe elevation in BP without progressive target organ dysfunction JNC 7 .

BUSE/CREAT. CE accordingly • Radiology – CXR – CT brain .Is it HPT emergency or urgency? • • • • History Is the BP measurement correct? Any evidence of end organ damage? Physical examination: – Fundoscopy – Neurological examinations – Cardiovascular examinations • Bedside ix – ECG – Urine dipstick-proteinuria – UPT in woman of child bearing age • Lab ix : FBC.

Management • Hypertensive emergency – BP to be reduced by 25% over 3 to 12 hours but not lower than 160/90 mmHg – best achieved with parenteral drugs .

IV bolus 50mg <5min (over at least 1 minute) at 5 min intervals to max of 200mg then 2mg/min IVI 5-100μ/min 2-5min 1-5min 3-6hrs Caution in renal failure Caution in heart failure Nitrates 3-5min Prefferred in ACS and acute pulmonary edema .25-10 μg/kg/min Sec.HYPERTENSIVE EMERGENCIES DRUGS DOSE ONSET OF ACTION DURATION REMARKS Sodium nitroprusside Labetalol 0.

Mainte nance 50150μg/min IV bolus 1030μg/kg over 1min IVI 210μg/kg/min IV bolus 1-2min. May repeat sequence 5-10min 1-4 hrs Caution in ACS.DRUGS DOSE ONSET OF ACTION DURATION REMARKS Hydralazine IV 5-10mg maybe 10-20min 3-8hrs repeated after 2030min of IVI 200300μg/min. 250-500 μg/kg over I min. IVI 50200μg/kg/min for 4 min. CVA and dissecting aneurysm Nicardipine Caution in heart failure and coronary ischaemia Used in perioperative situations and tachyarrythmia Esmolol 3-10min .

Management • Hypertensive urgency – aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg – Oral drugs proven to be effective .

HYPERTENSIVE URGENCY DRUG DOSE ONSET OF ACTION DURATION FREQUENCY Captopril Nifedipine 25mg 10-20mg ½ hour ½ hour 6 hour 3-5 hour 1-2 hours 1-2 hours Labetalol 200-400mg 2 hours 6 hour 4 hours .

Disposition • HPT emergency – Admit to ICU in consultation with general medicine and respective subspecialities • HPT urgency – Can be discharge if response is prompt and BP acceptable after 4hours monitoring. but must arrange for follow up within 48 hours – Newly diagnosed HPT with uncertain cause. admit for further evaluation and exclusion of 2ry causes .

REFERRENCE • JNC 7 • CPG on HPT • Guide to essentials in emergency medicineShirley Ooi .