Hypertension

Definition
• Hypertension ,also known as high blood pressure
(BP) ,affects millions of people. High blood
pressure is defined as BP ≥140/90 millimeters of
mercury (mmHg).

• 2018 ESC/ESH Guidelines for the Management of

Arterial Hypertension. Eur Heart J 2018;Aug
25:[Epub ahead of print].
 Etiology
• For the majority of patients with high blood
pressure, the cause is unknown. This is
classified as primary or essential
Hypertension. A small portion of patients
have a specific cause of their high blood
pressure, which is classified as secondary
Hypertension.
 Primary Hypertension
• Over 90% of patients with high blood pressure
have primary Hypertension. Primary
Hypertension cannot be cured, but it can be
controlled with appropriate therapy (including
lifestyle modifications and medications).
genetic factors may play an important role in
the development of primary Hypertension.
This form of high blood pressure tends to
develop gradually over many years.
 Secondary Hypertension
Cause of secondary hypertension.
Disease Drugs and Other Products
-Kidney Disease -NSAIDs
-Adrenal gland tumor -Birth Control Pill
-Thyroid disease -Decongestants
-Congenital blood disorder -Cocaine
-Alcohol abuse or chronic alcohol use -Amphetamines
-Obstructive sleep apnea -Corticosteroids
-Food
-Alcohol
 Classification of blood preassure for
adults (JNC VII)
BP Classification SBP mmHg DBP mmHg

Normal <120 And <80

Prehypertension 120-139 Or 80-89

Stage 1 Hypertension 140-159 Or 90-99

Stage 2 Hypertension ≥160 Or ≥100

 Pathophysiology
• Multiple factors that control blood pressure
contribute to developing primary
Hypertension. The two primary factors
include problems in either hormonal
[natriuretic hormone, reninangiotensin-
aldosterone system (rAAs)] mechanisms or
disturbances in electrolytes (sodium, chloride,
potassium).
 Risk Factor
Risk Factor for Developing Hypertension
Can be controlled Cannot be controlled
- Overweight/Obese - Age
- Sedentary lifestyle - Race
- Tobacco usage - Family history
- Unhealthy diet
- Excessive alcohol usage
- Stress
- Sleep apnea
- Diabetes
 JNC 8 Recommendation
• Recommendation 1
In the general population aged ≥60 years,
initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP)
≥150 mm Hg or diastolic blood pressure (DBP)
≥90 mm Hg and treat to a goal SBP <150 mm Hg
and goal DBP <90 mm Hg. (Strong
Recommendation – Grade A)
• Recommendation 2
In the general population <60 years, initiate
pharmacologic treatment to lower BP at DBP
≥90 mm Hg and treat to a goal DBP <90 mm Hg.
(For ages 30-59 years, Strong Recommendation
– Grade A; For ages 18-29 years, Expert Opinion
– Grade E)
• Recommendation 3
In the general population <60 years, initiate
pharmacologic treatment to lower BP at SBP
≥140 mm Hg and treat to a goal SBP <140 mm
Hg. (Expert Opinion – Grade E)
• Recommendation 4
In the population aged ≥18 years with chronic
kidney disease (CKD), initiate pharmacologic
treatment to lower BP at SBP ≥140 mm Hg or
DBP ≥90 mm Hg and treat to goal SBP <140 mm
Hg and goal DBP <90 mm Hg. (Expert Opinion –
Grade E)
• Recommendation 5
In the population aged ≥18 years with diabetes,
initiate pharmacologic treatment to lower BP at
SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat
to a goal SBP <140 mm Hg and goal DBP <90
mm Hg. (Expert Opinion – Grade E)
• Recommendation 6
In the general nonblack population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor (ACEI),
or angiotensin receptor blocker (ARB).
(Moderate Recommendation – Grade B)
• Recommendation 7
• In the general black population, including
those with diabetes, initial antihypertensive
treatment should include a thiazide-type
diuretic or CCB. (For general black population:
Moderate Recommendation – Grade B; for
black patients with diabetes: Weak
Recommendation – Grade C)
• Recommendation 8
In the population aged ≥18 years with CKD,
initial (or add-on) antihypertensive treatment
should include an ACEI or ARB to improve kidney
outcomes. This applies to all CKD patients with
hypertension regardless of race or diabetes
status. (Moderate Recommendation – Grade B)
• Recommendation 9
• The main objective of hypertension treatment
is to attain and maintain goal BP. If goal BP is
not reached within a month of treatment,
increase the dose of the initial drug or add a
second drug from one of the classes in
recommendation 6 (thiazide-type diuretic,
CCB, ACEI, or ARB).
 Cont.
• The clinician should continue to assess BP and
adjust the treatment regimen until goal BP is
reached. If goal BP cannot be reached with 2
drugs, add and titrate a third drug from the
list provided. Do not use an ACEI and an ARB
together in the same patient.
 Cont.
• If goal BP cannot be reached using only the drugs
in recommendation 6 because of a
contraindication or the need to use more than 3
drugs to reach goal BP, antihypertensive drugs
from other classes can be used. Referral to a
hypertension specialist may be indicated for
patients in whom goal BP cannot be attained
using the above strategy or for the management
of complicated patients for whom additional
clinical consultation is needed. (Expert Opinion –
Grade E)
 Best Proven Nonpharmacologic
Interventions for Prevention and
Treatment of Hypertension
 Non Pharmacologic Dose Hypertension Normotension
Weight Weight/body fat Ideal body -5 mmHg -2/-3 mmHg
loss weight is best
goal but at
least 1 kg
reduction in
body weight
for most adults
who are
overweight
Healthy DASH (Dietary Diet rich in -11 mmHg -3 mmHg
diet Approaches to Stop fruits,
Hypertension) vegetables,
diettary pattern whole grains,
and low-fat
dairy products
with reduced
content of
saturated and
trans l fat
 Non Dose Hypertension Normotension
Pharmacologic

Reduce intake Dietary Sodium <1500 mg/d is -5/6 mmHg -2/3 mmHg
dieatary optimal goal
sodium but at least
1000mg/d
reduction in
most adults

Enhaced intake Dietary 3500-5000 -4/5 mmHg -2 mmHg

of dietary pottasium mg/d,
pottasium preferably by
consumption
of a diet rich in
pottasium
Physical Aerobic 90-150 min/wk -5/8 mmHg -2/4 mmHg
activity 60%-75% heart
rate reserve

Dynamic 90-150 min/wk -4 mmHg -2 mmHg

resistance 50%-80% 1 rep
maximum
6 exercise, 3
sets/exercise,
10
repetitions/set
Isometric 4x2 min (hand -5 mmHg -4 mmHg
resistance grip) 1 min rest
between
exercise.
8-10 wk
Moderation in Alcohol In individuals -4 mmHg -3 mmHg
alcohol intake consumption who drink
alcohol, reduce
alcohol to:
Men ≤2 drinks
daily
Women: ≤1
drink daily
 Clinical trial and guideline basis for compelling
indications for individual drug classes
Compelling Diuretic BB ACEI ARB CCB Aldo Ant
indication
Heart failure + + + + +

Postmyocardial + + +
infraction
High coronary + + + +
disease risk
Diabetes + + + + +

Chronic kidney + +
disease
Recurrent + +
stroke
prevention
Oral Antihypertensive Drugs
CCB— Drug Usual dose, Daily
nondihydropyri range (mg per frequency
dines day)

Diltiazem ER 120-360 1 Avoid routine

use with beta
blockers due to
increased risk
of bradycardia
and heart block
Verapamil IR 120-360 3

Verapamil SR 120-360 1 or 2

Verapamil 100-300 1 (in the

delayed onset evening)
ER