Hypertension

Dr. Dhiman Banik

Professor of Cardiology
Department of Cardiology
National Heart Foundation Hospital & Research Institute
History of Hypertension
• Historical records as far back as 2600 B.C. hold mention of “hard
pulse disease”
• First treatments: Leeching/phlebotomy, acupuncture
• Hippocrates recommended phlebotomy
• 120 AD –cupping of the spine to draw animal spirits down and out
was recommended
Lithograph showing the
leeching of a patient,
date unknown.
National Library of Medicine,
Bethesda, Maryland
Hypertensive Guidelines
• NICE – BHS guideline, 2011
• JNC-8 guideline, 2014
• ACC/AHA guideline, 2017
• ESH/ESC guideline, 2018
• 2020 ISH Global Hypertension Practice Guidelines
 Classification of Hypertension Based on Office Blood
Pressure (BP) Measurement

• Isolated systolic hypertension defined as elevated SBP (≥140 mm Hg) and low
DBP (<90 mm Hg) is common in young and in elderly people.
 Definition of Hypertension

• In accordance with most major guidelines it is recommended that

hypertension be diagnosed when a person’s systolic blood pressure
(SBP) in the office or clinic is ≥140 mm Hg and/or their diastolic blood
pressure (DBP) is ≥90 mm Hg following repeated examination.
• The diagnosis should not be made on a single office visit. Usually 2–3
office visits at 1–4-week intervals (depending on the BP level) are
required to confirm the diagnosis of hypertension. The diagnosis
might be made on a single visit, if BP is ≥180/110 mm Hg and there is
evidence of cardiovascular disease (CVD).
 Controversy??
Classification of BP

ACC/AHA Hypertension Guideline, 2017.

Controversy??

2018 ESC/ESH Guidelines for the Management of Arterial Hypertension

 Epidemiology
 Latest survey on Cardiovascular diseases carried out in
Bangladesh showed prevalence of Hypertension in adult
population about 20-25%. (NHF Bangladesh)
 In Bangladesh, approximately 20% of adult and 40–65% of
elderly people suffer from HTN
(A.K.M. Monwarul Islam and Abdullah A.S. Majumder Hypertension in Bangladesh: a review Indian Heart J. 2012
May; 64(3): 319–323)

 About 70 million American adults (29%) have high blood

pressure—that’s 1 of every 3 adults. (CDC)
 Globally, the overall prevalence of raised blood pressure in
adults aged 25 and over was around 40% in 2008. (WHO)
 Worldwide, raised blood pressure is estimated to cause 7.5
million deaths, about 12.8% of the total of all deaths. (WHO)
Fig: Modifiable and fixed risk factors.
ACC/AHA Hypertension Guideline, 2017.
 Risk Associated with HTN
• Each 2mm rise in systolic blood pressure is associated with a 7%
increased risk of IHD and 10% increased risk of stroke
• 20 mm Hg higher SBP and 10 mm Hg higher DBP were each
associated with a doubling in the risk of death from stroke, heart
disease, or other vascular disease.
• higher levels of both SBP and DBP have been associated with
increased CVD risk (1).
• Pulse pressure and mid-BP have been associated with increased
CVD risk independent of SBP and DBP in some studies (2).

1. Lewington S, Clarke R, Qizilbash N, et al. 2002;360:1903-13.

2. Zhao L, Song Y, Dong P, et al. 2014;16:678-85.

BP Measurement Definitions

ACC/AHA Hypertension Guideline, 2017.

 Measurement of Blood Pressure

• No way to measure prior to

1700.
• 1733 –Reverend Stephen Hales
measured the intra-arterial BP
of a horse.
• 1905 –N.C. Korotkoff
reported on the method of
auscultation of brachial
artery, the method which
is widely used today
 Blood pressure measurement
• Clinic / office BP
• ABPM
• HBPM

Machine
• Mercury sphygmomanometer
• Auscultatory or oscillometric semiautomatic sphygmomanometers
(should be validated according to standardized protocols and their accuracy should be
checked periodically through calibration)
Checklist for Accurate Measurement of office/clinic
BP

ACC/AHA Hypertension Guideline, 2017.

Selection Criteria for BP Cuff Size for Measurement of BP in Adults

ACC/AHA Hypertension Guideline, 2017.

Office/Clinic BP, ABPM, HBPM…….
• The precise relationships between office readings, ABPM, and HBPM
are unsettled, but there is general agreement that office BPs are often
higher than ABPM or HBPM BPs, especially at higher BPs.
• A systematic review conducted by the U.S. Preventive Services Task
Force reported that ABPM provided a better method to predict long-
term CVD outcomes than did office BPs.
• Meta-analyses of RCTs have identified clinically useful reductions in
SBP and DBP and achievement of BP goals at 6 months and 1 year
when self-monitoring of BP has been used in conjunction with other
interventions, compared with usual care.

ACC/AHA Hypertension Guideline, 2017.

Corresponding Values of SBP/DBP for Clinic, HBPM, Daytime,
Nighttime, and 24-Hour ABPM Measurements

ACC/AHA Hypertension Guideline, 2017.

Procedures for Use of HBPM

ACC/AHA Hypertension Guideline, 2017.

BP Patterns Based on Office and
Out-of-Office Measurements

ACC/AHA Hypertension Guideline, 2017.

• Between-arms difference ≥10 mmHg is significant.

• Orthostatic hypotension—defined as a reduction in SBP

of 20 mmHg or in DBP of ≥10 mmHg within 3 min of
standing.
White-coat hypertension, Masked hypertension

• Prevalence of white coat hypertension averaged 13%

(range 9–16%) and it amounted to about 32% (range 25–
46%) among hypertensive subjects on treatment in
different RCTs. (1)
• The prevalence of masked hypertension varies from 10%
to 26% (mean 13%) in population-based surveys and from
14% to 30% in normotensive clinic populations. (2)

1. National Clinical Guideline Centre (UK). London, UK: Royal College of Physicians (UK); 2011.
2. Asayama K, Thijs L, Li Y, et al. Hypertension 2014;64:935- 42.
Detection of White Coat Hypertension or Masked
Hypertension in Patients Not on Drug Therapy
Detection of White Coat Effect or Masked Uncontrolled
Hypertension in Patients on Drug Therapy
Types of HTN
PRIMARY HYPERTENSION
Primary hypertension or essential hypertension is defined
when underlying cause of hypertension is not known. It
accounts 90% of adult patients with hypertension. (1).

Calhoun DA, Jones D, Textor S, et al. 2008;51:1403-19.

SECONDARY HYPERTENSION
 When high blood pressure is as a result of other medical problems or medication.
 Secondary hypertension should be suspected in younger patients (<30 years of age) with elevated BP
 Commonest causes are:
• Renal parenchymal disease
• Renovascular disease
• Primary aldosteronism
• Obstructive sleep apnea
• Drug or alcohol induced
• Pheochromocytoma/paraganglioma
• Cushing’s syndrome
• Hypothyroidism
• Hyperthyroidism
• Aortic coarctation (undiagnosed or repaired)
• Primary hyperparathyroidism
• Congenital adrenal hyperplasia
• Mineralocorticoid excess syndromes other than primary aldosteronism
• Acromegaly
Calhoun DA, Jones D, Textor S, et al. 2008;51:1403-19.
 Drugs and Other Substances With Potential to Impair BP Control
• Alcohol
• Amphetamines (e.g., amphetamine, methylphenidate dexmethylphenidate, dextroamphetamine)
• Antidepressants (e.g., MAOIs, SNRIs, TCAs)
• Atypical antipsychotics (e.g., clozapine, olanzapine)
• Caffeine
• Decongestants (e.g., phenylephrine, pseudoephedrine)
• Herbal supplements (e.g., Ma Huang [ephedra], St. John’s wort [with MAO inhibitors, yohimbine])
• Immunosuppressants (e.g., cyclosporine)
• Oral contraceptives
• NSAIDs
• Recreational drugs (e.g., “bath salts” [MDPV], cocaine, methamphetamine, etc.)
• Systemic corticosteroids (e.g., dexamethasone, fludrocortisone, methylprednisolone, prednisone, prednisolone)
• Angiogenesis inhibitor (e.g., bevacizumab) and tyrosine kinase inhibitors (e.g., sunitinib, sorafenif)

1. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). 1993;153:154-
83.
Screening for Secondary Hypertension

ACC/AHA Hypertension Guideline, 2017.

 Symptom
• Severe headache
• Fatigue or confusion
• Vision problems
• Chest pain
• Difficulty breathing
• Irregular heartbeat
• Blood in the urine
• Pounding in your chest, neck, or ears.
Patient Evaluation
• The patient evaluation is designed to identify target organ damage and possible secondary causes
of hypertension and to assist in planning an effective treatment regimen.

Historical Features Favoring Hypertension Cause

Basic and Optional Laboratory Tests for Primary Hypertension
Basic testing Fasting blood glucose
Complete blood count
Lipid profile
Serum creatinine with eGFR
Serum sodium, potassium, calcium
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram

Optional testing Echocardiogram

Uric acid
Urinary albumin to creatinine ratio
Cardiovascular Target Organ Damage
• Pulse-wave velocity, carotid intima-media thickness, and coronary
artery calcium score provide noninvasive estimates of vascular target
organ injury and atherosclerosis (1).
• LVH is a secondary manifestation of hypertension and independently
predicts future CVD events. LVH is commonly measured by
electrocardiography, echocardiography, or MRI. Left ventricular (LV)
mass is associated with body size (particularly lean body mass),
tobacco use, heart rate (inverse), and long-standing DM. BP lowering
leads to a reduction in LV mass. (2-3)

1. Persu A, De Plaen J-F. 2004;59:369-81.

2. Santos M, Shah AM. 2014;16:428.
3. Devereux RB, Roman MJ. Hypertens Res. 1999;22:1-9.
Physical examination
• To establish or verify the diagnosis of hypertension, establish
current BP, screen for secondary causes of hypertension and
refine global CV risk estimation

• Differences between the two arms in SBP >20 mmHg and/or

in DBP >10 mmHg—if confirmed—should trigger further
investigations of vascular abnormalities

• Auscultation of the carotid arteries, heart and renal arteries.

murmurs should suggest further investigation (carotid
ultrasound, echocardiography, renal vascular ultrasound,
depending on the location of the murmur).
 Physical examination
• Height, weight, and waist circumference should be
measured with the patient standing, and BMI calculated.
• Pulse palpation and cardiac auscultation may reveal
arrhythmias.
• In all patients, heart rate should be measured while the
patient is at rest. An increased heart rate indicates an
increased risk of heart disease.
• An irregular pulse should raise the suspicion of atrial
fibrillation, including silent atrial fibrillation.
 Treating Hypertension
• Integrating a comprehensive set of nonpharmacological and
pharmacological strategies.
• Intensify BP management.

1. Nonpharmacological Intervention
2. Pharmacological treatment
Use effective behavioral and motivational strategies to help adults with hypertension achieve a healthy
lifestyle
Best Nonpharmacologic Interventions for Prevention and Treatment of Hypertension
ACC/AHA Hypertension Guideline, 2017.
ASCVD score:
 Blood Pressure Goal for Patients With Hypertension

• 1. For adults with confirmed hypertension and known CVD, or a 10-year ASCVD
risk of 10% or more, a BP target of less than 130/80 mm Hg is recommended.
• 2. For adults with confirmed hypertension without additional markers of
increased CVD risk, a BP target of less than 130/80 mm Hg may be reasonable.

ACC/AHA Hypertension Guideline, 2017.

Oral Antihypertensive Drugs
Cont.….
Cont.….
Cont.….
Choice of Single vs Combination Drug
Therapy
• 1. Initiate antihypertensive drug therapy with 2 first-line agents of
different classes for adults with stage 2 hypertension and BP more
than 20/10 mm Hg higher than their target (The updated guideline
recommends initiating antihypertensive therapy with 2 agents for
stage 2 hypertension).
• 2. It is reasonable to initiate therapy with a single agent for adults
with stage 1 hypertension and a goal of less than 130/80 mm Hg.

ACC/AHA Hypertension Guideline, 2017.

• The advantage of initiating with combination therapy is
• a prompter response in a larger number of patients
(potentially beneficial in high-risk patients)
• a greater probability of achieving the target BP in patients
with higher BP values
• a lower probability of discouraging patient adherence with
many treatment changes.
• pharmacological synergies between different classes of
agents, that may not only justify a greater BP reduction but
also cause fewer side effects
• Possible combinations of classes of antihypertensive drugs.
• Green continuous lines: preferred combinations; green dashed
line: useful combination
• black dashed lines: possible but less well-tested combinations;
• red continuous line: not recommended combination.

• Although verapamil and diltiazem are sometimes used with a beta-blocker to improve
ventricular rate control in permanent atrial fibrillation, only dihydropyridine calcium
antagonists should normally be combined with beta-blockers.
 HYPERTENSIVE CRISIS
• HYPERTENSIVE EMERGENCIS:
• Hypertensive emergencies are defined as severe elevations in BP (>180/120 mm Hg)
associated with evidence of new or worsening target organ damage.
• The 1-year death rate associated with hypertensive emergencies is >79%, and the
median survival is 10.4 months if the emergency is left untreated.
• Examples of target organ damage include hypertensive encephalopathy, ICH, acute
ischemic stroke, acute MI, acute LV failure with pulmonary edema, unstable angina
pectoris, dissecting aortic aneurysm, acute renal failure, and eclampsia.

• HYPERTENSIVE URGENCY:
• Hypertensive urgencies are situations associated with severe BP elevation in
otherwise stable patients without acute or impending change in target organ
damage or dysfunction.
• Do not have clinical or laboratory evidence of acute target organ damage.
• There is no indication for referral to the emergency department, immediate
reduction in BP in the emergency department, or hospitalization for such patients.
ACC/AHA Hypertension Guideline, 2017.
Hypertensive Crises: Emergencies and
Urgencies

ACC/AHA Hypertension Guideline, 2017.

Diagnosis and Management of a Hypertensive Crisis
Intravenous Antihypertensive Drugs for Treatment of Hypertensive
Emergencies
Intravenous Antihypertensive Drugs for Treatment of Hypertensive
Emergencies in Patients With Selected Comorbidities
• ACCELERATED HYPERTENSION:
• recent significant increase over baseline blood pressure (usually
SBP >180 mmHg, DBP >120 mmHg) with vascular damage on
fundoscopic examination, such as flame- shaped hemorrhages
or soft exudates, but without papilledema.
• Presence of papilledema indicates MALIGNANT HYPERTENSION
Target Organ Damage
• Hypertensive encephalopathy
• Renal insufficiency
• Aortic dissection
• Heart failure
• Pulmonary edema
• CVD
Intracerebral hemorrhage:
Spontaneous, nontraumatic ICH is a significant global cause of morbidity and mortality (3).
Elevated BP is highly prevalent in the setting of acute ICH and is linked to greater hematoma
expansion, neurological worsening, and death and dependency after ICH.
 Acute ischemic stroke:

• Elevated BP is common during acute ischemic stroke (occurring in up to 80% of patients), especially among
patients with a history of hypertension.
• However, BP often decreases spontaneously during the acute phase of ischemic stroke, as soon as 90
minutes after the onset of symptoms.
• Countervailing theoretical concerns about arterial hypertension during acute ischemic stroke include aiming
to enhance cerebral perfusion of the ischemic tissue while minimizing the exacerbation of brain edema and
hemorrhagic transformation of the ischemic tissue.
 Resistant Hypertension
• The diagnosis of resistant hypertension is made when a patient takes
3 antihypertensive medications with complementary mechanisms of
action (a diuretic should be 1 component) but does not achieve
control or when BP control is achieved but requires ≥4 medications.

• On the basis of the previous cutoff of 140/90 mm Hg, the prevalence

of resistant hypertension is approximately 13% in the adult
population.
Resistant Hypertension: Diagnosis, Evaluation, and Treatment
Hypertension in Pregnancy

Gestational Hypertension

Preeclamsia-Eclampsia
Hypertension in
Pregnancy
Chronic Hypertension

Preeclamsia superimposed
on Chronic Hypertension
 Hydralazine
inj.: now
available

Acute Labetalol
Injection

Nifedipine
capsule/Tablet
What are the
options??? Methyl Dopa
250 mg Tab.

Long Labetalol Tablet

term 100 mg

Nifedipine
5,10,20 mg
• HYPERTENSION WITH PSORIASIS:
• β-Blocker and ACEI aggravate psoriasis. So better to avoid
them.

• HYPERTENSION WITH SCLERODERMA WITH REYNAUD'S

PHENOMENON
• Nifedipine and prostacycline infusion may occasionally helpful
in patient with severe Reynaud's phenomenon.
• HYPERTENSION WITH LIVER DISEASE:
• All Antihypertensive drugs can be used except methyldopa.

• HYPERTENSION WITH GOUT :

• All hypertensive drugs can be used But all Diuretics can
increase serum uric acid level. So diuretics should be avoided if
possible. Contraindications: diuretics
 Sexual dysfunction
• Erectile dysfunction is considered to be an independent CV
risk factor and an early diagnostic indicator for
asymptomatic.
• Lifestyle modification may ameliorate erectile function.
• Compared with older antihypertensive drugs, newer agents
(ARBs, ACE inhibitors, calcium antagonists and vasodilating
beta-blockers) have neutral or even beneficial effects on
erectile function.

• Phospho-diesterase-5 inhibitors may be safely administered

to hypertensives, even those on multiple drug regimens
(with the possible exception of alpha-blockers and in
absence of nitrate administration)
Follow up
• Follow-up of hypertensive patients
• Initially 2- to 4-week intervals to evaluate the effects on BP and
to assess possible side-effects.
• Once the target is reached 3- 6-monthly

• Follow-up of subjects with high normal blood pressure

and white-coat hypertension
• at least annually
Can antihypertensive medications be reduced or
stopped?
• an effective BP control for an extended period, it may be
possible to reduce the number and dosage of drugs.
• This may be particularly possible if BP control is accompanied
by healthy lifestyle changes, such as weight loss, exercise habits
and a low-fat and low-salt diet
The follow-up evaluation should include
assessing and evaluating the following points:
BP control ,
Orthostatic hypotension,
Side effects from medication therapy ,
Adherence to pharmacological and
nonpharmacological treatments,
Need for adjustment of medication dosage,
Laboratory testing (including electrolyte and renal
function status),
Other assessments of target organ damage.

ACC/AHA Hypertension Guideline, 2017.

 Take Home Message:
• The prevalence of hypertension rises dramatically with increasing age.
• 20 mm Hg higher SBP and 10 mm Hg higher DBP were each
associated with a doubling in the risk of death from stroke, heart
disease, or other vascular disease.
• Uncontrolled hypertension causes dreadful target organ involvement
which are really fatal.
• So, early detection and proper management of this dreadful disease
can decrease the morbidity and mortality of the patients.