- Dr.Mohammed Sadiq Azam M.D.

Assistant Professor,

Department of Medicine,

Prof Siraj’s Unit (M – 1)

Deccan College of Medical Sciences

HYPERTENSIONApproach & Management

PROBLEM MAGNITUDE

Hypertension( HTN) is the most common primary

diagnosis.

35 million office visits are as the primary

diagnosis of HTN.

50 million or more Americans have high BP.

Worldwide prevalence estimates for HTN may be

as much as 1 billion.

7.1 million deaths per year may be attributable

to hypertension.

Definition

A systolic blood pressure (SBP)

≥140mmHg and/or

A diastolic (DBP) ≥90 mmHg.

Based on the average of two or more

properly measured, seated BP readings.

On each of two or more office visits.

Accurate Blood Pressure Measurement

The equipment should be regularly inspected and

validated.

The operator should be trained and regularly

retrained.

The patient must be properly prepared and positioned

and seated quietly for at least 5 minutes in a chair.

The auscultatory method should be used.

Caffeine, exercise, and smoking should be avoided for

at least 30 minutes before BP measurement.

An appropriately sized cuff should be used.

BP Measurement

At least two measurements should be

made and the average recorded.

Clinicians should provide to

patients their specific BP numbers

and the BP goal of their treatment.

JNC 7 Classification of HTN

Follow-up based on initial BP measurements for adults*

*Without acute end-organ damage

Prehypertension SBP >120 mmHg and <139mmHg and/or

DBP >80 mmHg and <89 mmHg.

Prehypertension is not a disease

category rather a designation for

individuals at high risk of developing

HTN.

Pre-HTN

Individuals who are prehypertensive are not

candidates for drug therapy, BUT,

Should be firmly and unambiguously advised

to practice lifestyle modification

Those with pre-HTN, who also have diabetes

or kidney disease, drug therapy is indicated

IF a trial of lifestyle modification fails

to reduce their BP to 130/80 mmHg or less.

Isolated Systolic Hypertension

Not distinguished as a separate entity as

far as management is concerned.

SBP should be primarily considered during

treatment and not just diastolic BP.

Systolic BP is more important cardiovascular

risk factor after age 50.

Diastolic BP is more important before age

50.

Hypertensive Crises

Hypertensive Urgencies: No progressive target-

organ dysfunction. (Accelerated Hypertension)

Hypertensive Emergencies: Progressive end-organ

dysfunction. (Malignant Hypertension)

Hypertensive Urgencies

Severe elevated BP in the upper range of

stage II hypertension.

Without progressive end-organ dysfunction.

Examples: Highly elevated BP without

severe headache, shortness of breath or

chest pain.

Usually due to under-controlled HTN.

Hypertensive Emergencies

Severely elevated BP (>180/120mmHg).

With progressive target organ dysfunction.

Require emergent lowering of BP.

Examples: Severely elevated BP with:

Hypertensive encephalopathy

Acute left ventricular failure with pulmonary edema

Acute MI or unstable angina pectoris

Dissecting aortic aneurysm

Types of Hypertension

Primary HTN:

Also known as

essential HTN.

Accounts for 95%

cases of HTN.

No universally

established cause

known.

Secondary HTN:

Less common cause

of HTN ( 5%).

Secondary to other

potentially

rectifiable causes.

Causes of Secondary HTN

Common

Intrinsic renal

disease

Renovascular disease

Mineralocorticoid

excess

Sleep Breathing

disorder

Uncommon

Pheochromocytoma

Glucocorticoid

excess

Coarctation of

Aorta

Hyper/

hypothyroidism

Secondary HTN - Clues in Medical History

Onset: at age < 30 yrs ( Fibromuscular

dysplasia) or > 55 (athelosclerotic renal

artery stenosis), sudden onset (thrombus or

cholesterol embolism).

Severity: Grade II, unresponsive to treatment.

Episodic, headache and chest pain/palpitation

(pheochromocytoma, thyroid dysfunction).

Morbid obesity with history of snoring and

daytime sleepiness (sleep disorders)

Secondary HTN - clues on Exam

Pallor, edema, other signs of renal

disease.

Abdominal bruit especially with a

diastolic component (renovascular)

Truncal obesity, purple striae,

buffalo hump (hypercortisolism)

Secondary HTN - Clues on Routine Labs

Increased creatinine, abnormal urinalysis

(renovascular and renal parenchymal

disease)

Unexplained hypokalemia (hyperaldosteronism)

Impaired blood glucose

(hypercortisolism)

Impaired TFT (Hypo/hyperthyroidism)

Secondary HTN - Screening Tests

Renal Parenchymal Disease

Common cause of secondary HTN (2-5%)

HTN is both cause and consequence of

renal disease

Multifactorial cause for HTN including

disturbances in Na/water balance,

vasodepressors/ prostaglandins imbalance

Renal disease from multiple etiologies.

Renovascular HTN Atherosclerosis 75-90% ( more common in older patients)

Fibromuscular dysplasia 10-25% (more common in young patients, especially females)

Other• Aortic/renal dissection• Takayasu’s arteritis• Thrombotic/cholesterol emboli• CVD• Post transplantation stenosis• Post radiation

Complications of Prolonged Uncontrolled HTN

Changes in the vessel wall leading to

vessel trauma and arteriosclerosis

throughout the vasculature

Complications arise due to the “target

organ” dysfunction and ultimately

failure.

Damage to the blood vessels can be seen

on fundoscopy.

Target Organs CVS (Heart and Blood Vessels) The kidneys Nervous system The Eyes

Effects On CVS Ventricular hypertrophy, dysfunction and failure.

Arrhithymias Coronary artery disease, Acute MI

Arterial aneurysm, dissection, and rupture.

Effects on The Kidneys

Glomerular sclerosis leading to

impaired kidney function and

finally end stage kidney disease.

Ischemic kidney disease especially

when renal artery stenosis is the

cause of HTN

Nervous System Stroke, intracerebral and subaracnoid hemorrhage.

Cerebral atrophy and dementia

The Eyes Retinopathy, retinal hemorrhages and impaired vision.

Vitreous hemorrhage, retinal detachment

Neuropathy of the nerves leading to extraoccular muscle paralysis and dysfunction

Retina Normal and Hypertensive Retinopathy

Normal Retina Hypertensive Retinopathy

A: HemorrhagesB: Exudates (Fatty Deposits)C: Cotton Wool Spots (Micro Strokes)

A B

C

Stage I- Arteriolar Narrowing

Arteriolar Narrowing

Stage II- AV Nicking

AV Nicking

AV Nicking

AV Nicking

AV Nicking

Stage III- Hemorrhages (H), Cotton Wool Spots and Exudates (E)

H

E

Stage IV- Stage III+Papilledema

Patient Evaluation Objectives

(1) To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment

(2) To reveal identifiable causes of high BP

(3) To assess the presence or absence of target organ damage and CVD

(1) Cardiovascular Risk factors Hypertension Cigarette smoking Obesity (body mass index ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR <60 mL/min

Age (older than 55 for men, 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65)

(2) Identifiable Causes of HTN

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome

Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

(3) Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction

Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

History Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers

Asthma, COPD: Preclude the use of b-blockers

Heart failure: ACE inhibitors indication

DM: ACE preferred Polyuria and nocturia: Suggest renal impairment

History-contd. Claudication: May be aggravated by b-blockers, atheromatous RAS may be present

Gout: May be aggravated by diuretics Use of NSAIDs: May cause or aggravate HTN

Family history of HTN: Important risk factor

Family history of premature death: May have been due to HTN

History-contd. Family history of DM : Patient may also be Diabetic

Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and stroke

High alcohol: A cause of HTN High salt intake: Advice low salt intake

Examination Appropriate measurement of BP in both arms

Optic fundi Calculation of BMI ( waist circumference also may be useful)

Auscultation for carotid, abdominal, and femoral bruits

Palpation of the thyroid gland.

Examination-contd. Thorough examination of the heart and lungs

Abdomen for enlarged kidneys, masses, and abnormal aortic pulsation

Lower extremities for edema and pulses

Neurological assessment

Routine Labs ECG.

Urinalysis.

Blood glucose (FPG/PPG) and hematocrit;

serum potassium, creatinine ( or estimated

GFR), and calcium.

HDL cholesterol, LDL cholesterol, and

triglycerides.

Urinary albumin excretion or Spot

Albumin/creatinine ratio.

Goals of Treatment Treating SBP and DBP to targets that are

<140/90 mmHg

Patients with diabetes or renal disease,

the BP goal is <130/80 mmHg

The primary focus should be on attaining

the SBP goal.

To reduce cardiovascular and renal

morbidity and mortality

Benefits of Treatment

Reductions in stroke incidence,

averaging 35–40 percent

Reductions in MI, averaging 20–25

percent

Reductions in HF, averaging >50

percent.

Lifestyle modifications

Lifestyle Changes Beneficial in Reducing Weight

Decrease time in sedentary behaviors such as

watching television, playing video games, or

spending time online.

Increase physical activity such as walking,

biking, aerobic dancing, tennis, soccer,

basketball, etc.

Decrease portion sizes for meals and snacks.

Reduce portion sizes or frequency of

consumption of calorie containing beverages.

DASH Diet

Dietary Approach to Stop

Hypertension

As effective as one

medication

Management of HTN

THANK YOU