Hipertensi - Kul - Sept 2021

HYPERTENSION
A CLINICAL APPROACH
Management of Hypertension
1 www.drsarma.in Dr.Sarma@works
Blood Pressure Classification JNC VII
BP Classification SBP mmHg DBP mmHg
Normal < 120 and < 80
Pre-hypertension* 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension > 160 or > 100
*newly recognized, requiring

lifestyle modifications
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Definitions
Are the values same for Diabetics , CKD?
No, for DM, IHD and CKD the criteria

are more stringent
The cut off values are 10 mm lower
Stage 1 SBP 130 to 149
DBP 80 to 89
Stage 2 SBP 150 and more
DBP 90 and more
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Diseases Attributable to Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy Hypertension Chronic kidney failure
Hypertensive
Aortic aneurysm encephalopathy
Retinopathy
Peripheral vascular disease All
Vascular
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Adapted from: Arch Intern Med 1996; 156:1926-1935.
Target Organ Damage
What is single most imp. predictor of CHD, HF, Death ?

LVH – LV mass index
What is the time course of HT to LVH to LVF to death ?
The chart is explained
Can LVH be regressed at all ?
Very much Yes. Diuretics and ACEi are the best
Will drugs help to regress ↓TOD ?
Yes. All TOD regresses; LVF and CVA most
How important is Micro-albuminuria ?
The most important prognostic indicator of TOD
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TARGET ORGAN DAMAGE
o Apa yang paling penting sebagai. prediktor PJK, HF,
Kematian ?
LVH – indeks massa LV
o Berapa lama perjalanan HT ke LVH ke LVF sampai
mati?
Bagan dijelaskan Bisakah
o LVH diregresi sama sekali?
Bisa  Diuretik dan ACEi adalah yang terbaik
o apakahObat akan membantu untuk menurunkan TOD ?
Ya. Semua TOD mengalami regresi; LVF dan CVA
o Seberapa penting peran mikroalbuminuria?
Indikator prognostik paling penting dari TOD
LVF:Left ventricular….;
www.drsarma.in 6
Transverse Section of HEART - LVH
10 mm 25 mm
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Dr.Sarma@works
Progression of HT to LVH to HF
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Target Organ Damage - Assessment
Routine Tests
• Electrocardiogram, Echocardiography
• Urinalysis for proteinuria, Microalbuminuria
• Blood glucose (F and PP), and Hematocrit
• Serum Na and K, Creatinine or GFR, Calcium
• Lipid Profile complete, Eye examination, ABI
Optional tests
• X-Ray Chest PA
• 24 hr. urine albumin excretion
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Hypertension – Why Combinations ?
 If goal BP is not achieved by a single drug in full dose
 Then adding another agent will help achieve the goal BP
 Two agents sometimes nullify each others side effects
 Fixed dose combinations will reduce the no. of tablets
 Once daily formulations are good for compliance
 Sustained release or LA formulations for 24 h BP control
 If three drugs can’t achieve goal BP – Resistant HT
www.drsarma.in
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o Jika tujuan BP tidak tercapai dengan obat tunggal

dalam dosis maksimal
o Kemudian menambahkan antiHT lain akan membantu
mencapai tujuan BP
o Dua antiHT terkadang meniadakan efek samping satu
sama lain
o Kombinasi dosis tetap akan mengurangi jumlah dari
tablet
o Formulasi sekali sehari bagus untuk kepatuhan
o Sediaan lepas lambat untuk kontrol BP 24 jam
o Jika tiga obat tidak dapat mencapai tujuan BP –
Resistan HT
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Which drug should we prescribe ?
 Choice must be tailored to individual

patient
 Should be rational and as per approved
guidelines
 Only class1 evidence based medications
to be used
 Suitable to patients’ purse
 Can never be arbitrary
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Which drug should we prescribe ?
 Pilihan harus disesuaikan dengan pasien individu

 Harus rasional dan sesuai pedoman yang disetujui
 Hanya obat berbasis bukti kelas 1(first line) yang
digunakan
 Sesuai kemampuan pasien
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AB/CD Rule – HT Treatment
(AB/CD = ACEi, Beta-blocker Ca++-blocker, Diuretic)

AGE
Younger (< 55) Renin Older (> 55)

High Renin HT Low Renin HT
I ACEi BB III III CCB Diuretic I
II A+B A+B+D D+C+A D + C II

Resistant HT / IV: Add / substitute alpha blocker
Intolerance V: Re-consider 20 causes  trial of spironolactone
www.drsarma.in Dickerson et al. Lancet 353:2008-11;1999 14

Drug Combinations
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Dr.Sarma@works 15
Recommended combinations of antihypertensive drugs. Panel A. Antihypertensive drug combinations recommended as

preferred (thick lines) or possible (dash lines) in the 2007 ESH/ESC Guidelines. Panel B. The five combinations retained for
priority use in the 2009 reappraisal of the 2007 ESH/ESC Guidelines.Abbreviations: ACE, angiotensin converting enzyme;
ARB, angiotensin receptor blockers; CCB, calcium channel blockers, ESC, European Society of Cardiology; ESH, European
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Society of Hypertension.
Hypertension – Rational Drug Combinations
ACEI and ARB = A Diuretics = D – Rank 1

Beta Blockers = B ACEI and ARB = A – Rank 2
Calcium Channel (CCB) = C Beta Blockers = B – Rank 3
Diuretics Drugs= D CCB = C – Rank 4
D and A combination is excellent - Ramace H, Losar H, Enace D

D and B combination next - Betaloc H, Atecard D, Tenoric
D and C combination sixth - Amlogaurd H, Stamlo D
A and B combination Third - Losar A, Cardif Beta
A and C combination fourth - Amlopres L, Hipril A, Amlo LS
B and C combination fifth - Amlo AT, Amlobet, Beta Nicardia
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Some Irrational Combinations
Beta blockers + Beta1 stimulants - Rebound HT, Paradoxical BP ↑

Beta blockers + Vepapamil - Extreme bradycardia, HB, CHF
Thiazide + Furesemide - Potential volume ↓ and K ↓
CCB + Thiazide - No RCTs to support the additive
Prazocin + Beta blocker - They nullify the effects of each other
Verapamil / Dilzem + Nefidepine - No rationale (cardiac actions contridic)
Beta blocker + ACEI Not for HT alone, Good for CHF, MI, IHD
Sub clinical doses of two drugs Try one drug in good dosage, then add
Two drugs of same class - No rationale (like Enalapril + Ramipril)
(Atenelol + Metoprolol, Nefidepine + Amlo)
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DIURETIC KNOW ME WELL
I am ‘D’ for DIURETIC
 My Good aspects
Fluid depletion, Na washout, Low cost
Improve CHF, Systolic function, Ca saving
Reduce LVH, Morbidity & Mortality
 My Bad aspects
Potassium washout, ↑ in Uric acid, ↑ Ca
Adverse on Lipids, Glucose control
 Don’t use me in
Gout, Hypokalaemia
Dyslipedemia, Uncontrolled DM
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ACEI, ARB KNOW ME WELL
I am ‘A’ for ACEI and ARB
 My Good aspects
Improve Diastolic function, Systolic function
Control Proteinuria, Very favourable in DM
Improve Coronary Ischemia, Good on Lipids
Reduce LVH, Morbidity & Mortality
 My Bad aspects
Bradykinin accumulation, Angio-edema
↑ Serum K , ↓ GFR
Pregnancy, Creatinine is > 3 mg%, ↑ K 5.0 meq
Bilateral Renal Artery Stenosis, Angio-edema
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β Blocker I am ‘B’ for βBlocker
KNOW ME WELL
 My Good aspects
↓Heart rate, ↓Forceof contraction, ↓Conduction
↓Myocardial O2 demand, Improve Ischemia
Improve QUALY in CHD, Useful in CHF, Migraine
 My Bad aspects
Constrict peripheral vessels, Bradycardia
Unfavourable on Lipids, Glucose
Bradycardia, Conduction defects, Caution in CHF
Prinzmetal Angina, MSD, PVD, BA, COPD, Dys lipid
Pheochromocytoma, Chronic smokers
www.drsarma.in 21
Ca+ Blockers KNOW ME WELL
I am ‘C’ for Ca channel Blocker
 My Good aspects
Vasodilatory, Suitable in elderly, Low cost
Anti arrhythmic (Verapamil), ↑Coronary BF (Diltz)
Neutral on lipidemia, Vasospastic Angina
 My Bad aspects
Fluid retention, Impair failing heart
Adverse on Glucose control , Pedal edema ? Rx.
Tachycardia, arrhythmias, CHF,
Uncontrolled DM, Volume overload
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ABCD Compare & Contrast
Parameter Diuretic ACEi, ARB βblocker Ca+ Blocker

Ischemia No effect Improves Improves Negative
LVH, LVF Improves Improves Improves* Negative
CV Mortality Improves Improves Improves Increases
Heart rate No effect No effect Bradycardia Tachycardia
Use in DM Negative Excellent Negative Negative
Lipid effects Negative Excellent Negative Neutral
Fluid & Na Enhances No effect Vasoconstr. Vasodilatory
K ex / bronchi Enhances No effect Bronchospa No effect
UA / Conduct. ↑ Uric acid No effect ↓conduction No effect
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Which drug in each class
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Hypertension
Case specific approach
some selected case scenarios
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Case 1 Pre Hypertension TLC, No Drug Yearly F/u
Case 2 Stage 1 HT Single Drug D or D + A
Case 3 Stage 2 HT Two Drugs D + A, D + B
Case 4 HT + Tachycardia Beta blockers Not CCB
HT + Bradycardia
Case 5 CCB, ACEi Not BB
Heart Blocks BBB
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HT + Bradycardia
Heart Blocks BBB
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HT + Bradycardia
Heart Blocks BBB
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HT + Bradycardia
Heart Blocks BBB
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HT + Bradycardia
Heart Blocks BBB
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HT + Bradycardia
Heart Blocks BBB
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Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto)
Case 7 HT + IHD (No MI) BB + ACEi B+A+D
BB (Car) + Aldactone
Case 8 HT + MI or (RVP)
ACEi, ARB Diltiazem
Case 9 HT + PZM Angina CCB, α bloc Not BB
ARB Losartan
Case 10 HT + Diast. Dys BB - Meto
ACE Ramipril
Case 11 HT + Sys Dys ACEi + D A+D+B

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ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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Case 6 HT + CHD Risk f ACEi (Perindo) BB (Meto)
ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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ACEi, ARB Diltiazem
ARB Losartan
ACE Ramipril

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Diu - Fru. Sp. Not CCB,

Case 12 HT + CHF
+ ARB / ACEi α bloc
Case 13 HT + DM (No DK) ARB, ACEi Not D, C
Not CCB,
Case 14 HT + DM+ DKD MD, HYZ, D
ACEi, ARB
Case 15 HT + Dys lipidem. ACEi, CCB Not BB, D
Case 16 HT + BA / COPD ACEi / ARB Not BB
Case 17 HT + PVD / smoker CCB, ACEi, HZ Not BB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 12 HT + CHF
Not CCB,
ACEi, ARB

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Case 18 HT + BPH α bloc, Tamsu Not BB
α bloc, HZ,
Case 19 HT + ED Not BB
ACEi /CCB
Not ACEi,
Case 20 HT + Pregnancy MD, HYZ, CCB
or ARB
Case 21 HT + Gout, ￪ UA ACEi, CCB Not D
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
Case 23 HT + Cough ACEi cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH - SBP > 140 Not BB
Enalapril
Cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
remedy
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α bloc, HZ,
ACEi /CCB
Not ACEi,
or ARB
Indap, Amlo,
Case 22 ISH Not BB
Enalapril
Cough
remedy
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Case 24 Hypertension and cough
 Hypertensives may present with cough  carefuly

1. Consider LVF as the cause of cough
2. Consider ACEI induced dry cough
3. Stop ACEI and give ARB or other agents
4. Check the composition of the cough remedy you give
5. Ephedrine, Pseudephedrine, should be avoided
6. Oral Beta agonists like Orciprenaline, Salbutamol,
Terbutaline the less used, the better.
7. Inhaled beta agonists, ICS are safe
8. Decongestants like phenyl propanolamine to be avoided
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Case 25 Secondary Hypertension – various causes
 Secondary HT Usually Stage 2 - HT

Secondary causes will be present
May present in young individuals
 Treatment Look for secondary cause and treat
Life style interventions must
Vigorous efforts required to control HT
Often two or even 3 drugs may be required
Resistant HT may be encountered
Anti HT drugs as per secondary cause
 Absolute contra ACEI or ARB in bilateral renal artery stenosis
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Case 26 Secondary Hypertension in Pheochromocytoma
 Pheochromocytoma Usually Stage 2 HT, Episodic or Labile

Secondary adrenal medullay tumor
 Treatment Surgical Ablation of the chromaffin tissue
HT needs to be controlled before surgery
Alpha blockers are the drugs of choice
Phentolamine, Phenoxybenzamine, Prazocin
Vigorous efforts required to control HT
Often two or even 3 drugs may be required
Resistant HT may be encountered
 Surgery First reduce HT, then surgery
 Do not use Beta blockers

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Case 27 Resistant Hypertension
 Resistant HT Usually Stage 2 HT

May have secondary causes
 Reasons Not taking medication (liers)
Improper BP measurement
Excessive Na intake, Inadequate diuretic Rx.
Full doses of drugs not employed
Drug interactions – NSAIDs, SMA, OCP, OTC
Herbal remedies, Excessive alcohol use
 Rationale Identify the above and correct
Secondary causes to be searched for
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Case 29 Hypertensive emergencies
 HT emergency Marked DBP elevation

Acute TOD present
 TOD Presentation Encephalopathy, MI, ACS, Pul Edema,
Eclampsia, stroke, head trauma, life-
threatening arterial bleeding, or aortic
dissection
 Treatment With TOD immediate admission to ICU
IV Nitroprusside, Diazoxide, Labetolol
Without TOD Combination of 2 or 3 drugs
Close monitoring
Life style modification not now – no time
 Do not use No sublingual nefedipine,
www.drsarma.in 57
Case 30 Hypertensive with Acute CVA (Stoke)
 HT + CVA (Stroke) Marked DBP elevation

May be SAH, ICH, Acute Brain Infarction
 Rationale In acute setting, no consensus on
treatment of elevated BP
HT at time of an acute stroke associated
with increased risk of cerebral hemorrhage
and edema, increased mortality
After acute ischemic stroke, cerebral
auto regulation affected
Active treatment of BP in the first 7 days
could worsen symptoms
 Treatment Recommendation not to start HT Rx.
before 7 to 10 days after ischemic stroke
www.drsarma.in
58
Current Indications for Alpha Blockers
1. Hypertension with BPH

2. In Pheochromoytoma before surgery
3. In the treatment of Ergot over dose
4. Raynaud’s syndrome and PVD, TAO
5. Vasospastic (prinzemetal Angina)
6. Diabetic neuropathy
7. Hypertensive smokers
8. Hypertension with Dyslipidemia
First dose syncope and Postural Hypotension

How to avoid ?
www.drsarma.in 59
Learning is a cyclical process
Each of these presentations

is a valuable learning
experience for me
Thank You all
www.drsarma.in 60

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HYPERTENSION

Normal < 120 and < 80

Pre-hypertension* 120-139 or 80-89

Stage 1 Hypertension 140-159 or 90-99

Stage 2 Hypertension > 160 or > 100

*newly recognized, requiring

Are the values same for Diabetics , CKD?

No, for DM, IHD and CKD the criteria

What is single most imp. predictor of CHD, HF, Death ?

 If goal BP is not achieved by a single drug in full dose

 Then adding another agent will help achieve the goal BP

 Two agents sometimes nullify each others side effects

 Fixed dose combinations will reduce the no. of tablets

 Once daily formulations are good for compliance

 Sustained release or LA formulations for 24 h BP control

 If three drugs can’t achieve goal BP – Resistant HT

o Jika tujuan BP tidak tercapai dengan obat tunggal

 Choice must be tailored to individual

 Pilihan harus disesuaikan dengan pasien individu

(AB/CD = ACEi, Beta-blocker Ca++-blocker, Diuretic)

Younger (< 55) Renin Older (> 55)

I ACEi BB III III CCB Diuretic I

II A+B A+B+D D+C+A D + C II

www.drsarma.in Dickerson et al. Lancet 353:2008-11;1999 14

Recommended combinations of antihypertensive drugs. Panel A. Antihypertensive drug combinations recommended as

ACEI and ARB = A Diuretics = D – Rank 1

D and A combination is excellent - Ramace H, Losar H, Enace D

Beta blockers + Beta1 stimulants - Rebound HT, Paradoxical BP ↑

Parameter Diuretic ACEi, ARB βblocker Ca+ Blocker

some selected case scenarios

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 1 Pre Hypertension TLC, No Drug Yearly F/u

Case 2 Stage 1 HT Single Drug D or D + A

Case 3 Stage 2 HT Two Drugs D + A, D + B

Case 4 HT + Tachycardia Beta blockers Not CCB

Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto)

Case 7 HT + IHD (No MI) BB + ACEi B+A+D

Case 9 HT + PZM Angina CCB, α bloc Not BB

Case 11 HT + Sys Dys ACEi + D A+D+B

Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto)

Case 7 HT + IHD (No MI) BB + ACEi B+A+D

Case 9 HT + PZM Angina CCB, α bloc Not BB

Case 11 HT + Sys Dys ACEi + D A+D+B

Case 6 HT + CHD Risk F ACEi (Perindo) BB (Meto)