Treatment of Hypertension

Based on the Seventh Report of the

Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)

Jai Radhakrishnan, M.D.

Division of Nephrology
Objectives
 Define hypertension
 Principles of treatment
 Special groups
 P r e v a le n c e o f H y p e r t e n s io n in t h e U S

80 72 %
66 %
Percent hypertensive

60 51 %

38 %
40
18 %
20 9 %
3 %

0
1 8 -2 9 3 0 -3 9 4 0 -4 9 5 0 -5 9 6 0 -6 9 7 0 -7 9 80+

B ased on N H A N ES III (p h ase 1 an d 2 ) Age S lid e S o u r c e

H y p e rt e n s io n O n lin e
H y p e r t e n s io n d e f in e d a s b lo o d p r e s s u r e  1 4 0 / 9 0 m m H g o r t r e a t m e n t w w w .h y p e r te n s io n o n lin e .o r g

J N C - V I . A r c h I n t e r n M e d . 1 9 9 7 ;1 5 7 : 2 4 1 3 - 2 4 4 6 . w w w .h y p e r t e n s io n o n lin e .o r g
Blood Pressure Classification
BP
SBP DBP
CLASSIFICATION
Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 HTN 140-159 or 90-99

Stage 2 HTN >160 >100

 Why Treat Hypertension ?
 To decrease:
 Cerebrovascular Accidents 35-40%
 Coronary events 20-25%
 Heart failure 50%
 Progression of renal disease
 Progression to severe hypertension
 All cause mortality
Awareness, Treatment and Control of
Blood Pressure 1976-2000 (NHANES)

80
70
60
50
Awareness
40
Treatment
30 Control
20
10
0
1976-1980 1988-1991 1991-1994 1999-2000
Factors to Consider in Treating
Hypertension

 Repeat readings
 r/o secondary causes
 Estimate CV risk status
 Co-morbid conditions
 Lifestyle changes
 Drugs
“Secondary” Hypertension
 Difficult to control
 Sudden onset of HTN
 Well controlled-> difficult to
control
 Severe hypertension
 History/physical/labs
Initial Workup of
Secondary HTN
 Renal parenchymal disease
 UA, spot urine protein/creatinine, serum creatinine, USG.
 Renovascular
 Captopril scan
 Coarctation
 Lower Extremity BP
 Primary aldosteronism
 Serum and urinary K
 Plasma renin and aldosterone ratio
 Pheochromocytoma
 Spot urine for metanephrine/creatinine
Laboratory Tests in
Uncomplicated HTN
 ECG
 Urine analysis
 Blood glucose, hematocrit
 Basic metabolic panel
 Lipid profile after 9-12 hour fast
 Urine microalbumin
 Estimate Risk Status
 Hypertension
 Smoking
 Obesity (BMI > 30kg/m2)
 Dyslipidemia
 Diabetes
 Microalbuminuria or GFR <60ml/min
 Age > 55 (men), 65 (women)
 Family history of CVD
(Men< 55, Women <65)

Metabolic Syndrome
Target Organ Damage
 Heart Disease
 CAD (Angina, myocardial infarction, coronary
revascularization
 Left Ventricular Hypertrophy
 Heart Failure
 Stroke/TIA
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
 Goals of Therapy
 BP <140/90 mmHg

 BP <130/80 mmHg in patients

with diabetes or chronic kidney disease.

 Achieve SBP goal especially in persons

>50 years of age.
 Lifestyle Modification
Modification Approximate SBP reduction
(range)
Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol 2–4 mmHg

consumption
 Drugs for Hypertension
 Diuretics  Direct Vasodilators *
 Thiazide
 Loop diuretics
 Aldosterone antagonists  Calcium channel
 K-sparing blockers
 Dihydropyridine
 Adrenergic inhibitors  Non dihydropyridine
 Peripheral agents

 Central (α-agonists)

 alpha -blockers*
 beta-blockers
 Alpha+beta-blockers
 ACE-inhibitors
 Angiotensin-II blockers
* Usually not monotherapy
 Algorithm for Treatment of Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 (SBP >160 or DBP >100 mmHg) indications
mmHg) 2-drug combination for most Other antihypertensive drugs
Thiazide-type diuretics for most. (usually thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
May consider ACEI, ARB, BB, CCB, ACEI, or ARB, or BB, or CCB) as needed.

or combination.
Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.
 Classification and Management
of BP for adults
Initial drug therapy
BP Class SBP DBP Lifestyle Without compelling Compelling
indication indications
Normal <120 <80 Encourage None None
Pre- 120– or 80– Yes No antihypertensive drug Drug(s)
hypertension 139 89 indicated.
Stage 1 140– or 90– Yes Thiazide-type diuretics
Hypertension 159 99 for most. May consider
ACEI, ARB, BB, CCB, or Other
combination. antihypertensive
drugs (diuretics,
Stage 2 >160 or Yes Two-drug combination ACEI, ARB, BB,
Hypertension >100 (usually thiazide and CCB) as needed.
ACEI or ARB or BB or
*Treatment determined by highest BP category. CCB).
†
Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡
Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
Special Considerations

Compelling Indications
Special populations
HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled with
nifedipine) is admitted with severe chest pain x24 hrs.
BP is 170/100 and she has a soft S3 gallop.

ECG shows an anterior wall MI.

She is not a candidate for thrombolysis. ECHO shows an

ejection fraction of 35%.

How will you manage her hypertension?

Compelling Indications for
Certain Drug Classes
HTN with CAD
 Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden
death)
 ACE inhibitors: MI with systolic
dysfunction- heart failure and mortality
improved
Renal Insufficiency
 A 30 year old patient with IDDM is referred with
difficult-to-control HTN on diltiazem and clonidine.

 Exam reveals BP=190/100 and 3+ edema.

 Labs: Creatinine = 2.2 mg/dL

Serum K = 5.1 meq/L
24 hour protein = 5 g
Hypertension with Renal Insufficiency
 Goal BP <130/80
 ACE-inhibitors/angiotensin receptor blockers
should be used if no contraindications
 Most patients have volume overload:
 Diuretics should be included in the regimen.
 Thiazides ineffective if S Creat>2.5
A 40 year old previously healthy male is brought to the E.R. with 3
days of progressive shortness of breath and has experienced
blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic.
Eye exam: Papilledema
Chest: Bibasilar crackles
Cardiac: S1S2S4
Neuro: Bilateral upgoing plantars:
Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.
Hypertensive Urgencies and
Emergencies
 HYPERTENSIVE EMERGENCIES
 Require immediate blood pressure reduction (not necessarily
to normal range) to prevent or limit target organ damage.

 HYPERTENSIVE URGENCIES
 Require reduction of blood pressure within a few hours
Emergencies
& Urgencies
 HYPERTENSIVE
EMERGENCIES
 Require immediate
blood pressure reduction
(not necessarily to
normal range) to
prevent or limit target
organ damage.

 HYPERTENSIVE
URGENCIES
 Require reduction of
blood pressure within a
few hours
 Parenteral Drugs For Treatment of
Hypertensive Emergencies

VASODILATORS ADRENERGIC
 Nitroprusside INHIBITORS
 Fenoldopam  Labetalol

 Nitroglycerine  Esmolol

 Enalaprilat  Phentolamine

 Nicardipine

 Hydralazine
Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the
obstetric clinic at 30 weeks gestation.

BP: 160/100, 2 + pedal edema

Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N

After 2 days of bed rest BP remains 160-170/100

 Drug Therapy of the Hypertensive
Pregnant Patient

 Methyldopa: Drug of choice.

 Beta blockers (not early pregnancy).
 Hydralazine is the parenteral drug of
choice.

 Most agents if used prior to pregnancy

may be continued
 (except ACE-I OR A-II BLOCKERS)
 Resistant Hypertension
 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral
contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN
 Conclusions
 The initial approach to hypertension should start with ruling out secondary
causes, detecting and treating other cardiovascular risk factors, and
looking for target organ damage.
 Treatment should always include lifestyle changes.
 Medication use should be guided by the severity of HTN and the
presence of “compelling” indications.
 Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
 Most patients will require two or more antihypertensive drugs
Conclusions
 HTN is a risk factor for mortality and
cardiovascular and renal disease
 HTN is common but not controlled.
 Target BP 140/90 (130/80 in DM, CKD)
 Remember Compelling Indications
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