Common Misconceptions About Hypertension

HYPERTENSION
Dr Kirath – ASP Medical

DEFINITION
• Blood pressure is the force exerted by our

blood against the walls of our blood vessels
• Systolic pressure: the pressure as the heart
pumps blood around the body
• Diastolic pressure: the pressure as the
heart relaxes and refills with blood
• Hypertension is universally defined as:
• Systolic pressure more than 140mmHg or a
diastolic pressure more than 90mmHg,
taken twice on 2 separate occasions
FACTORS THAT AFFECT BP
• Heart rate – the higher the rate, the higher the

pressure
• Stroke volume – the amount of blood pumped
per beat. A greater volume results in higher
pressure
• Systemic vascular resistance – the resistance
from our blood vessels that our heart needs to
overcome in order for blood to reach our
organs.
• The greater the resistance (atherosclerosis), the
higher the pressure.
CAUSES
There are 2 types of Hypertension:
1. Essential Hypertension – 95% of all hypertensive

cases, no direct cause
1. Secondary Hypertension – has an identifiable direct

cause such as kidney disease, pheochromocytoma,
sleep apnea, arterial defects
RISK FACTORS
• Advancing age
• Sedentary lifestyle
• Psycho-social stress – overworked, lack of sleep
• Smoking
• Obesity
• Co-existing disorders – Diabetes Mellitus, hyperlipidemia
• Hereditary
SYMPTOMS
• Hypertension is known as a silent killer

– very rarely exhibiting symptoms until
it is severe or an emergency
• Known symptoms include – headache,

dizziness, fatigue
• Symptoms that occur in late,

undiagnosed cases – loss of vision,
blood in urine, confusion, chest pain
COMPLICATIONS
CLASSIFICATION
RISK STRATIFICATION
• In addition to target organ damage, it is also

important to identify co-existing cardiovascular risk
factors.
• There are 5 main risk factors:
1. Diabetes Mellitus
2. Dyslipidemia
3. Cigarette smoking
4. Proteinuria
5. eGFR < 60ml/min/m2
RISK STRATIFICATION
TREATMENT
• Divided into:
1. non-pharmacological
2. pharmacological management
• Low to intermediate risk patients can be advised on

healthy living first for the first three to six months.
NON-PHARMACOLOGICAL
• Weight reduction – studies show reduction of 1kg leads to drop by 1mmgHg

• Sodium intake – average Malaysian salt intake 9g/day, reduction to 4g/day
leads to drop of 8mmgHg SBP
• Physical activity – low/moderate intensity aerobic exercise at least 150
minutes/week
• Diet – DASH diet – rich in fruits and vege, low fat, low sodium
• Smoking and alcohol – dose-dependent reduction
• Relaxation therapy – limited evidence
DIETARY APPROACHES TO STOP
HYPERTENSION
• When following DASH, it is important to choose

foods that are:
Rich in potassium, calcium, magnesium, fiber and
protein
Low in saturated fat
Low in sodium
• Studies have shown that the DASH diet can lower
blood pressure in as little as two weeks. The diet
can also lower low-density lipoprotein (LDL or
"bad") cholesterol levels in the blood.
• The standard DASH diet limits sodium to 2,300mg
a day.
SAMPLE MENU
• Grains: 6 to 8 servings a day. One serving is one slice bread, 1 ounce dry cereal, or 1/2 cup cooked cereal, rice or
pasta.
• Vegetables: 4 to 5 servings a day. One serving is 1 cup raw leafy green vegetable, 1/2 cup cut-up raw or cooked
vegetables, or 1/2 cup vegetable juice.
• Fruits: 4 to 5 servings a day. One serving is one medium fruit, 1/2 cup fresh, frozen or canned fruit, or 1/2 cup fruit
juice.
• Fat-free or low-fat dairy products: 2 to 3 servings a day. One serving is 1 cup milk or yogurt, or 1 1/2 ounces
cheese.
• Lean meats, poultry and fish: six 1-ounce servings or fewer a day. One serving is 1 ounce cooked meat, poultry
or fish, or 1 egg.
• Nuts, seeds and legumes: 4 to 5 servings a week. One serving is 1/3 cup nuts, 2 tablespoons peanut butter, 2
tablespoons seeds, or 1/2 cup cooked legumes (dried beans or peas).
• Fats and oils: 2 to 3 servings a day. One serving is 1 teaspoon soft margarine, 1 teaspoon vegetable oil, 1
tablespoon mayonnaise or 2 tablespoons salad dressing.
• Sweets and added sugars: 5 servings or fewer a week. One serving is 1 tablespoon sugar, jelly or jam, 1/2 cup
sorbet, or 1 cup lemonade.
Physical Activity
• At least 150 minutes a week
• Aerobic exercise releases

Nitric Oxide
• NO acts as a vasodilator -
relaxes blood vessels and
reduces peripheral vascular
resistance
PHARMACOLOGICAL
TREATMENT
• In newly diagnosed, uncomplicated cases - first line

monotherapy
• First line medication consists of 5 classes:
1. Angiotensin Converting Enzyme Inhibitor - ACEI

2. Angiotensin Receptor Blocker - ARB
3. Calcium Channel Blocker - CCB
4. Diuretics
5. Beta Blockers
ACE INHIBITORS
• Works by dilating your blood vessels - reducing peripheral vascular

resistance
• Perindopril. Captopril, Enalapril
• Preferred for Diabetic patients - helps to slow down kidney damage
• Specific side effects: dry cough, metallic taste (goes away with use)
ANGIOTENSIN RECEPTOR
BLOCKERS
• Another vasodilator
• Valsartan, Telmisartan, Losartan
• Can be used for patients who develop ACEI-induced cough
• Specific side effects: Dizziness, Cramps (need to check

potassium level)
CALCIUM CHANNEL BLOCKERS
• Calcium moves into cells to create a stronger muscle contraction
• CCBs slow the movement of calcium particularly for the muscles of

the heart and blood vessel walls
• This allows the heart and blood vessels to have a more significant
relaxation, allowing for better diastole and peripheral blood flow
• Amlodipine, Felodipine, Nifedipine
• Specific side effects: Dry mouth, Reflux

DIURETICS
• Diuretics increase the excretion of water and sodium from the

body
• The lower volume of fluid results in lower pressure circulating

in the blood vessels and reduces the burden on the heart
• Hydrochlorothiazide, Spironolactone, Furosemide
• Specific side effects: dehydration, muscle cramps

BETA BLOCKERS
• Beta adrenergic blockers suppress the action of

adrenaline, subsequently reducing the heart rate
and force of heart contractions
• Bisoprolol, Metoprolol, Nebivolol
• Specific side effects: fatigue, shortness of breath,

contra-indicated in patients with Asthma
COMBINATION THERAPY
FOLLOW UP
• For high and very high risk patients, it is advisable to bring the
BP to target within 3 to 6 months.
• Once target BP is achieved, follow-up at three to six-month
intervals is appropriate.
• As a rule, once the BP is controlled, most patients will require
life-long treatment.
• Patients must be counseled to have at least six monthly
follow ups even though the BP is well controlled and not to
resort to merely going for repeat prescription without seeing
a doctor
STEP DOWN
• Step-down therapy is discouraged in the vast

majority of patients. However in patients who insist
on it, the following criteria must be considered first:
1. Patients’ BP must not be higher than stage I (mild)
hypertension with low global CV risk
2. BP well-controlled for at least 1 year on the same
medication at the same dosage
3. Must agree to be followed-up at least 3-6 monthly
4. Must be motivated to adopt healthy living
Common
Misconceptions
Only affects older people
1. While it's true that the risk of hypertension increases with

age, it can affect people of all ages, including children and
young adults
2. The prevalence of hypertension among individuals aged
20-29 is 7-8%.
3. hypertension in younger individuals is often associated with
certain risk factors such as obesity, sedentary lifestyle, poor
dietary choices (high sodium intake), family history of
hypertension, and certain medical conditions.
Hypertension can be cured
completely
1. Hypertension is a chronic condition that can be

managed and controlled, but it typically requires
ongoing monitoring and lifestyle modifications.
2. While blood pressure can be reduced and
maintained within a healthy range through
medication and lifestyle changes, there is currently
no known cure for hypertension.
I feel fine, I don’t need to worry
about hypertension
1. Hypertension is often referred to as the "silent killer"

because it typically doesn't cause noticeable symptoms
until it reaches an advanced stage.
2. Many people with high blood pressure are unaware of
their condition until it's detected during a routine
check-up.
3. Uncontrolled high blood pressure can lead to serious
complications, including heart disease, stroke, kidney
damage, and other health issues.
I will always need
hypertension
1. While medication is commonly prescribed to manage
hypertension, lifestyle modifications can also play a
significant role in its control.
2. Adopting a healthy lifestyle, including a balanced diet, regular
exercise, weight management, limiting alcohol consumption,
reducing sodium intake, and managing stress, can help lower
blood pressure.
3. In some cases, lifestyle changes alone may be sufficient to
control hypertension, but this should be determined by a
healthcare professional.
Medication can cause organ
damage
1. It it the opposite that is true, uncontrolled

hypertension can lead to kidney failure, stroke and
heart disease.
2. In advanced cases individuals neglect screening for
hypertension to the point where when it is finally
diagnosed, there is already target organ damage.
SUMMARY
• 95% of hypertension cases have no direct secondary cause,

but is a result of modifiable risk factors
• Hypertension is a silent killer, rarely exhibiting symptoms but

insidiously causing organ damage
• Lifestyle and Diet modifications are easy to accomplish
• Medication is usually life-long

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HYPERTENSION

Dr Kirath – ASP Medical

• Blood pressure is the force exerted by our

• Heart rate – the higher the rate, the higher the

There are 2 types of Hypertension:

1. Essential Hypertension – 95% of all hypertensive

1. Secondary Hypertension – has an identiﬁable direct

• Hypertension is known as a silent killer

• Known symptoms include – headache,

• Symptoms that occur in late,

• In addition to target organ damage, it is also

• Low to intermediate risk patients can be advised on

• Weight reduction – studies show reduction of 1kg leads to drop by 1mmgHg

• When following DASH, it is important to choose

• At least 150 minutes a week

• Aerobic exercise releases

• In newly diagnosed, uncomplicated cases - ﬁrst line

1. Angiotensin Converting Enzyme Inhibitor - ACEI

• Works by dilating your blood vessels - reducing peripheral vascular

• Perindopril. Captopril, Enalapril

• Preferred for Diabetic patients - helps to slow down kidney damage

• Valsartan, Telmisartan, Losartan

• Can be used for patients who develop ACEI-induced cough

• Speciﬁc side effects: Dizziness, Cramps (need to check

• Calcium moves into cells to create a stronger muscle contraction

• CCBs slow the movement of calcium particularly for the muscles of

• Amlodipine, Felodipine, Nifedipine

• Speciﬁc side effects: Dry mouth, Reﬂux

• Diuretics increase the excretion of water and sodium from the

• The lower volume of ﬂuid results in lower pressure circulating

• Hydrochlorothiazide, Spironolactone, Furosemide

• Speciﬁc side effects: dehydration, muscle cramps

• Beta adrenergic blockers suppress the action of

• Bisoprolol, Metoprolol, Nebivolol

• Speciﬁc side effects: fatigue, shortness of breath,

• Step-down therapy is discouraged in the vast

1. While it's true that the risk of hypertension increases with

1. Hypertension is a chronic condition that can be

1. Hypertension is often referred to as the "silent killer"

1. It it the opposite that is true, uncontrolled

• 95% of hypertension cases have no direct secondary cause,

• Hypertension is a silent killer, rarely exhibiting symptoms but

• Lifestyle and Diet modiﬁcations are easy to accomplish

• Medication is usually life-long

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