Hypertension

Definition
- Essential hypertension: idiopathic or primary hypertension:
• The sustained elevation of systemic arterial blood pressure, most commonly defined as
systolic blood pressure (SBP) ≥ 140 mm hg or diastolic blood pressure (DBP) ≥ 90 mm hg,
without an identified cause.

- Resistant hypertension:
• Elevated blood pressure despite concurrent use of 3 antihypertensive drugs of different
classes, including a diuretic

- Secondary hypertension: hypertension due to an identifiable, potentially curable cause .

- Masked hypertension: elevated blood pressure at home but normal office blood pressure.

- White coat hypertension: normal blood pressure at home but elevated office blood pressure.

- labile hypertension: characterized by sudden increases in blood pressure usually attributed to

emotional stress.

- paroxysmal hypertension:
• characterized by sudden and considerable elevations in blood pressure accompanied by
marked symptoms; differs from labile hypertension due to general absence of emotional
stress as a cause .

Classification
- Varies per different guidelines.
- Seventh report of Joint National Committee (JNC 7 and 8) Classification: (Adopted at our
Institution)
• Normal if SBP < 120 mm Hg and DBP < 80 mm Hg
• Prehypertension if SBP 120-139 mm Hg or DBP 80-89 mm Hg
• Stage 1 hypertension if SBP 140-159 mm Hg or DBP 90-99 mm Hg
• Stage 2 hypertension if SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg
• Based on≤ 2 readings on ≤ 2 occasions.

- European Society of Cardiology/European Society of Hypertension (ESC/ESH)

• Grade 1 hypertension if SBP 140-159 mm hg and/or DBP 90-99 mm hg
• Grade 2 hypertension if SBP 160-179 mm hg and/or DBP 100-109 mm hg
• Grade 3 hypertension if SBP ≥ 180 mm hg and/or DBP ≥ 110 mm hg
- American College of Cardiology/American Heart Association:
• Stage 1 hypertension if SBP 130-139 mm hg or DBP 80-89 mm hg
• Stage 2 hypertension if SBP ≥ 140 mm hg or DBP ≥ 90 mm hg.
 ⇨ Confirm within two months if readings are within 140-159/90-99.
⇨Within one month if readings are within 160-179/100-109.
⇨Within one week if readings within 180-199/110-119.
⇨One reading if more than 200/120.
Or:
⇨BP>= 140/90 with the Presence of end- organ damage.
⇨ambulatory blood pressure values consistent with hypertension
o 135/85 mm Hg when awake
o > 120/75 mm Hg when asleep

Investigations: Recommended by all guidelines

• Fasting blood sugar.
• Serum Creatinine
• Serum NA and potassium
• Urine Analysis.
• Lipid profile.
• ECG. echo if abnormal ECG.

Test recommended by some (but not all) expert panel.

• S. Ca
• S. Na
• S.Uric acid
• Urine microalbumine
• Hb or P
Other tests may be ordered based on clinical findings
- If coarctation of aorta suspected
• computed tomography (CT) angiography, echocardiography, or magnetic resonance
imaging (MRI)
- If cushing syndrome suspected
• dexamethasone suppression test or 24-hour urinary free cortisol
- If parathyroid disease suspected
• serum parathyroid hormone
- If pheochromocytoma suspected
• plasma or urinary metanephrines
- If primary aldosteronism suspected
• plasma aldosterone and plasma renin activity
- If renovascular hypertension (renal artery stenosis) suspected
• duplex ultrasonography, CT angiography, or magnetic resonance angiography (MRA)
- If sleep apnea suspected
• sleep study or nocturnal pulse oximetry
- If thyroid disease suspected
• thyroid-stimulating hormone (TSH)
Hypertension is a risk factor for
• Coronary artery disease (CAD) • Transient ischemic attack (TIA)
• Heart failure • Peripheral arterial disease (PAD)
• Chronic kidney disease • Aortic regurgitation
• Stroke • Cardiac arrhythmias
• Intracerebral hemorrhage
Risk Factors for HTN
• Male gender
• Age ≥ 55 years in men or ≥ 65 years in women
• Smoking
• Dyslipidemia
• Diabetes or prediabetes)
• Obesity and abdominal obesity (waist circumference ≥ 102 cm in white men or ≥ 88 cm in white
women)
• Family history of premature cardiovascular disease (men < 55 years old, women < 65 years old.

Who is most affected:

- Onset generally at age 20-50 years, but prevalence increases with increasing age.
• Incidence/Prevalence: (varies according to definition)
• Prevalence of hypertension in general population > 25%. ( 32% in USA).
• > 50% of people aged 60-69 years and about 75% of people ≥ 70 years old are affected.
- More in males.

Clinical Presentation
- History:
• Generally asymptomatic.
• Usually diagnosed incidentally during routine visits.
• 30% of pop unaware of their hypertension.
• Clinical manifestation include symptoms of ischemic heart disease, stroke, peripheral
vascular disease, renal insufficiency and retinopathy.

Symptoms of sever HTN

- Most cases of HTN cases asymptomatic , as BP increase HTN became more symptomatic
• Severe headaches. • Nausea
• Chest pain. • Vomiting.
• Dizziness. • Blurred vision or other vision changes.
• Difficulty breathing. • Anxiety
How to measure BP
- Patient seated and relaxed for > 5 minutes with arm rested on support at level of heart, with back
supported, and with feet flat on the floor.
- Patient should avoid caffeine, exercise, and smoking for ≥ 30 minutes before measurement
- Ensure patient has emptied their bladder, and neither patient nor observer should talk during rest
period or during measurement
- Inflatable bladder of cuff should encircle 80% of patients' arm circumference; clothing should be
removed from location of cuff placement
- Use validated blood pressure measurement device and ensure device is calibrated periodically
- Separate repeated measurements by 1-2 minutes
- Use average of ≥ 2 readings obtained on ≥ 2 occasions to estimate blood pressure. (each occasions
we need 2 readings)

Management
- Goals of the therapy :
• The ultimate goal of antihypertensive therapy is to reduce morbidity and mortality.
• Treating the SBP and DBP to targets that are below 140/90 mmHg is associated with a
decrease in the risk of cardiovascular complications .
• Target blood pressure (BP) < 140/90 mm Hg recommended for most patients.
• In patients with HTN and DM or renal disease the BP goal is still <140/90 mmHg .(JNC 8).
- BENEFITS OF LOWERING THE BP
• In clinical trials , antihypertensive therapy has been associated with reductions in the risks
of:
a) stroke by 35 – 40%
b) MI by 20 – 25%
c) HF by 50%
- Management
1) The first step in treatment is lifestyle modification.
- Lifestyle modification alone effectively controls about 10% of patients.
- Adoption of a healthy lifestyle is critical for the prevention of high blood pressure, and is an
important part in the management of hypertension patients.
- Weight loss:can reduce blood pressure (BP) by about 1 mm Hg per kg lost
- Adoption of the DASH (dietary approach to stop hypertension ) eating plan.
- Emerging in regular aerobic physical activity , such as brisk walking at least 30 minutes a day most
days of the week.
- Salt restriction to< 5 g per day OR sodium < 2.4 g/day
- Recommended restricting salt intake to <2.4 g/day reduces BP by mean 5-10/2-3 mm hg.
- Limiting alcohol intake.
- Counselling to quit smoking.
- DASH Eating plan
• Dietary approach to stop hypertension eating plan (can reduce BP by 8-14 mm Hg )
• Limiting the intake of saturated fat, cholesterol and total fat.
• Include fruits, vegetables and low fat dairy products in the diet.
• Avoiding red meat, sweets and sugar-containing beverages.
• Increasing k , Ca , Mg , protein and fiber content of diet.

2) Pharmacological treatment
- Start medications from the beginning, one med for stage 1, 2 for stage 2.

- Initial antihypertensive therapy typically starts with 1 of 5 drug classes:

• Thiazide-type diuretic
o Thiazide-type diuretic - recommended option for all patients in most
guidelines.
• Angiotensin-converting enzyme (ACE) inhibitor
o Initial treatment with ACE inhibitor or ARB often recommended for patients
with diabetes, chronic kidney disease, or coronary artery disease
o ACE inhibitor and beta blocker recommended in patients with heart failure.
o Many patients will require > 1 drug to reach goal
a) Add drugs (from other classes than initial therapy) if target blood
pressure levels not achieved with monotherapy.
b) ACE inhibitor and ARBs combination not recommended.

• Angiotensin receptor blocker (ARB)

• Calcium channel blocke
o Calcium channel blocker - recommended option for all patients in most
guidelines.

• Beta blocker “ second line not first”

o Beta blockers - recommended option in some guidelines for patients < 60
years old, but not recommended as initial option in American or British
guidelines
o And may increase risk of adverse cardiovascular events compared to other
antihypertensive drugs.
o beta-blockers (especially atenolol) appear less effective for reducing stroke
incidence than other antihypertensives as first-line therapy.

- For non black patients

• Angiotensin-converting enzyme (ACE) inhibitor - recommended option to start
with for nonblack patients .
• Angiotensin receptor blocker (ARB) - recommended option to start with for
nonblack patient
Recommendations per NICE Guidelines
- In hypertensive patients aged 55or over , the first choice for initial therapy should be either a
calcium channel blocker or a thiazide diuretic.
- In hypertensive patients younger than 55 , the first choice for initial therapy should be an ACE
inhibitor or ARB.
- If treatment with 3 drugs is required , the combination of a calcium channel blocker , ACE inhibitor
and a thiazide diuretic should be used.
- If BP remains uncontrolled on adequate doses of 3 drugs consider adding a fourth and/or seek an
expert advise

Follow up and Monitoring

- Follow-up every month until readings on 2 consecutive visits are below target.
- Bp at goal and stable, follow-up visits at 3to 6-month intervals
- More frequent visits for stage 2 HTN or with complicating co-morbid conditions.
- Serum potassium and creatinine monitored 1–2 times per year.
- Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for
laboratory tests influence the frequency of visits.
- Every year we must do: ECG , FBS, Lipid profile, urinalysis.
• On ECG look LV of there is LVH do echo.
- Note: ACEI and ARBS if used in renal artery stenosis may increase creatinine

HYPERTENSION TREATMENT: SPECIAL POPULATIONS

- African Americans and Elderly
• Thiazide diuretics,or CCB Note:
- Diabetes Mellitus
• ACEI OR ANY antihypertensive med. • ACEI and ARBs not used with
each other
• Note: kidney disease or DM: ARBS or ACEI
• Out of control patients the
- Congestive Heart Failure
next step: Increase dose, add
• ACEIs, ARBs, Beta blockers, or Aldosterone antagonists other medication, change the
- Coronary Artery Disease medication
• Beta blockers, CCBs, or ACEIs
- Cerebrovascular Accident
• ACEIs and indapamide
- Pregnancy
• Methyldopa, nifedipine, or labetalol
• Note: ACEI, ARBs Contraindicated

Aspirin and HTN

- Aspirin not recommended for cardiovascular prevention in low-moderate risk patients with
hypertension because absolute benefit and harm are equivalen
- Aspirin for primary prevention may decrease risk of cardiovascular event but may increase risk
of major bleeding in adults with hypertension
 Primary or Essential HTN
- Accounts for 95% of cases.
- Cause unknown, but it’s a complex process that results from a variety of physiological and
environmental factors.
a) Heredity: interaction of genetic, and environmental factors .
b) High salt diet.
c) Altered renin-angiotensin mechanism.
d) Stress which activate the sympathetic system.
e) Insulin resistence and Hyperinsulinemia.

Type 1 Type 2 :

- Manifested by vasoconstriction and high - Is sodium retention and low rennin

rennin levels. - Excessive sodium reabsorption.
- Common in young white people - Common in young black people.
- Responds better to ACEIs, ARBs and beta - Responds better to diuretics and calcium
blockers. channel blockers.

Secondary HTN
- Accounts for 5% of cases.
- Specific cause of HTN can be identified.
- Causes:
• Renal: any cause of chronic kidney disease
• Renovascular hypertension and renal parenchymal disease.
• Endocrine: Cushing syndrome, primary
hyperaldosteronism,hyperthyroidism,hyperparathyroidism
,pheochromocytoma,obstructive sleep apnea (OSA),coarctation of aorta.

• Medication
o Alcohol o Systemic corticosteroids
o Caffeine o Immunosuppressants
o Nonsteroidal anti- o Oral contraceptives
inflammatory drugs o Antidepressants
o Decongestants (for example, o Second-generation
phenylephrine and antipsychotics
pseudoephedrine) o Amphetamines

Medications that elevate blood pressure temporarily

Note: Medications that elevate blood pressure temporarily

Note: Medications that elevate blood pressure temporarily

Secondary Hypertension-Causes by age
- In children and adolescents,:
• Renal parenchymal disease, such as
o glomerulonephritis, including
o acute postinfectious glomerulonephritis
o Alport syndrome
o IgA nephropathy
o minimal change disease
o lupus nephritis
o membranoproliferative glomerulonephritis
o membranous nephropathy.
o Reflux nephropathy
• Coarctation of aorta
- In adults 19-39 years old
• Thyroid disease
• Renal artery stenosis: fibromuscular dysplasia
• Renal parenchymal diseases
- In adults 40-64 years old
• Primary hyperaldosteronism
• Thyroid disease
• Obstructive sleep apnea (OSA)
• Cushing disease
• Pheochromocytoma
- In adults ≥ 65 years old
• Atherosclerotic renal artery stenosis
• Renal failure
• Hypothyroidism

Features of secondary HTN

a. Early or late onset of HTN (<20, >50).
b. History of tachycardia, sweating and headache.
c. Past or family history of renal disease.
d. Resistant HTN in a compliant patient.(pheochromocytoma, or hyperthyroidism)
e. Symptoms of sleep apnea.
f. History of amphetamine, cocaine, or alcohol abuse.
g. Use of OCP, NSAID, coticosteroids.
h. History of hirstuism or easy bruising