➢ Definition

• Persistent elevation of arterial BP greater than 140/90 mmHg& above

130/80 mmHg in patients with diabetes or renal disease.

➢ Classification of hypertension
• Prehypertension
o Systolic BP 120 – 140
o Diastolic BP 80 – 90
• Primary Hypertension I
o Systolic BP 140 – 160
o Diastolic BP 90 – 100
• Secondary Hypertension II
o Systolic BP > 160
o Diastolic BP > 100

➢ Urgency VS Emergency hypertension

Hypertensive urgency: Rapid rise of BP > 220/120mmHg and not
associated with organ damage (Ex. Renal failure, Heart failure)
Hypertensive emergency: Rapid rise of BP > 220/120mmHg and
associated with organ damage.
❖ Malignant HTN: Hypertensive emergency with development of
papilledema.
❖ Accelerated HTN: like Malignant HTN without papilledema.

➢ Types
1) Isolated systolic hypertension
• ↑ in systolic BP only.
❖ Etiology
o Atherosclerosis
o Stroke volume
2) Systolic & diastolic hypertension
• ↑ in systolic & diastolic BP (true hypertension).
❖ Types
o Primary (essential) hypertension
o Secondary hypertension
➢ Primary hypertension
• Has no know cause.
• Age of onset 35-55
• +ve family history
• Predisposing factors (Genetic, Obesity, Stress, Salt sensitivity, smoking)

Theories
• Sympathetic over activity
• Activation of renin system
• Increased adrenal gland activity (↑ aldosterone secretion)
• Hyperinsulinemia (due to insulin resistance)
• Multifactorial theory

➢ Secondary hypertension
• Has a known underlying cause.
• Age of onset <25 or >55 years
• -ve family history
• Rapidly progressive with early complications

Causes
❖ Renal
• Parenchymal (volume dependent hypertension)
▪ Clinical Picture
i. Diabetic nephropathy
ii. Pyelonephritis
iii. Polycystic kidney
▪ Mechanism
i. Ineffective in disposing Na.
ii. Failed to produce necessary VD substances.
• Renovascular
▪ Clinical Picture
i. Generalized atherosclerosis.
ii. Flank bruits.
▪ Mechanism
i. Renal artery stenosis which activates the renin
system.
❖ Endocranial
• Pituitary
▪ Acromegaly
• Thyroid
▪ Hypothyroidism
▪ Hyperthyroidism → Isolated systolic hypertension
• Parathyroid
▪ Hyperparathyroidism
• DM
• SRG
▪ Conn’s syndrome
▪ Cushing syndrome
▪ Pheochromocytoma
❖ CNS
• ↑ICT
• Lesions of the medulla
❖ Vascular
• Polyarteritis
• Polycythemia
• Coarctation of the aorta
❖ Iatrogenic
• Contraceptive pills
• Cortisone
• Catecholamine
• Calcium
➢ Symptoms
❖ Asymptomatic (in most cases)
❖ Complications may be the first presentation.

• Headache after information (usually occipital)

• Blurring of vision, Epistaxis, nausea, and vomiting

➢ Complications
❖ Cardiac
o LSHF (due to pressure overload)
o Ischemic heart disease (due to atherosclerosis & hypertrophy)

❖ Cerebral
o Cerebral atherosclerosis
o Cerebral Ischemia & thrombosis
o Cerebral hemorrhage (stroke)
▪ Have signs of lateralization (unilateral)
o Hypertensive encephalopathy
▪ Have no signs of lateralization (bilateral)
▪ As a result of acute rise of BP, the cerebral blood vessels
are no longer able to maintain necessary degree of
constriction (failure of auto regulation) and they begin to
dilate

❖ Renal
o Renal Failure
o Hematuria & proteinuria

❖ Retinal (4 grades)
i. Thickening of retinal arterioles (silver wire appearance)
ii. Kinking of retinal veins
iii. Hemorrhage and exudate
iv. Papilledema

❖ Vascular
o Atherosclerosis
o Aortic dissection
➢ Investigations
For complications
❖ Cardiac
o Xray
o ECG
o Echo
❖ Cerebral
o CT
o MRI brain
❖ Renal
o Urine analysis
o Renal function
o Renal imaging

For the cause

o When secondary HTN is suspected
o In a case of refractory hypertension

➢ Treatment
• The target BP is lower than 140/90mmHg, unless the patient has diabetes
or renal disease, in that case target BP will be 130/80mmHg

a) Lines of treatment
1) Pharmacological
▪ Treatment of associated risk factor (Ex. hyperlipidemia)
▪ Treatment of the cause (in case of secondary HTN)
▪ Antihypertensive drugs
2) Non-Pharmacological (lifestyle modifications)
b) Choice of treatment
➢ Lines of treatment
Pharmacological
1) Diuretics
• Thiazide
• Lasix
• Indapamide
• K sparing diuretic

2) Sympathetic blockers
a) Centrally acting
❖ Medicine
o Clonidine
❖ Side effect
o Rebound hypertension with sudden withdrawal
o Postural hypotension
o Dry mouse
b) Nerve ending blockers
❖ Medicine
o α methyl dopa
❖ Action
o ↓ synthesis of catecholamine
❖ Side effect (3H)
o Hepatitis
o Hemolysis
o Postural hypotension
c) α blockers
❖ Medicine
o Prazosin
❖ Action
o Vasodilatation
❖ Side effect
o First dose syncope
o Tachycardia
 d) β blockers
❖ Medicine
o lol family
❖ Side effect
o Bronchospasm
o Bradycardia
o Heart block
❖ Usage
o Hypertension
o Heart failure
o Angina
o Arrhythmia

3) Vasodilators
❖ Medicine
▪ Arteriolar (used in emergencies)(rapid acting)
o Hydralazine
o Diazoxide
▪ Venous
o Nitrates
▪ Both (venous & arteriolar)
o ACEIs
o Na nitroprusside
❖ Usage
o Hypertensive encephalopathy

4) Calcium channel blockers

5) Angiotensin converting enzyme (ACE) inhibitors
❖ Medicine
o pril family
❖ Side effect
o Dry cough
6) Angiotensin II receptor blockers (ARBs)
❖ Medicine
o tan family
 Non-Pharmacological (life style)
• Lose weight if overweight.
• Reduce salt and dietary fat intake
• Stop smoking
• Regular exercise

➢ Choice of treatment
1) Uncomplicated hypertension
❖ ACE inhibitors | β blockers | Ca channel blockers | Diuretics
o Step 1 → use one of the above drugs
o Step 2 →use combination of 2 drugs
o Step 3 →use combination of 3 drugs
o Step 3 →use combination of 4 drugs
❖ The use of lower doses of 2 or more drugs may lower BP with
fewer adverse effects than the use of higher dose of a single drug

2) Hypertensive crisis (emergency)

❖ Rapid acting antihypertensive drugs
o Hydralazine
o Diazoxide
o Na nitroprusside
o Nitroglycerine
o Labetalol
o Lasix

❖ Specific treatment
o Hypertensive encephalopathy → use mannitol
o Treatment of target organ damage
3) Treatment of hypertension with certain concomitant disease
❖ Heart failure
▪ ACE inhibitors | Diuretics
▪ Ca channel blockers

❖ Ischemic heart disease

▪ β blockers | Ca channel blockers
▪ Hydralazine

❖ DM
▪ ACE inhibitors | Ca channel blockers
▪ β blockers

❖ Renal Impairment
▪ β blockers | Ca channel blockers | Diuretics | ACE inhibitors
▪ ACE inhibitors in bilateral renal stenosis

❖ Asthma or COPD
▪ β blockers

❖ Pregnancy
▪ α methyl dopa | Ca channel blockers | Hydralazine | labetalol
▪ ACE inhibitors | β blockers | Diuretics

❖ Hyperthyroidism
▪ β blockers

❖ peripheral vascular disease

▪ Ca channel blockers | α blockers
▪ β blockers