Family Medicine: Hypertension Fact sheet.

May 2017.

Prevalence: Health of the Nation Study (HotN) 2015: 42% in adults 25 +

years
Also from HotN: 42% of adults on drug treatment not attaining BP targets.

Thus HTN is a very prevalent disease, and is badly managed in clinical

practice. No national programs for primary or secondary prevention are in
place. While HTN is a very prevalent condition, it is not the only condition
that increases the risk of a major cardiovascular event like a heart attack or
stroke: beware obesity, diabetes and dyslipidemias.

A few individuals are born with congenital conditions that predispose to

hypertension, and a few may develop problems early in life that are
associated with hypertension. However, the vast number of people who
develop hypertension are normotensive early in life, and over time move
through the stages: normotension, pre-hypertension, hypertension stage 1,
hypertension stage 2. Thus hypertension is a progressive disease; untreated
the blood pressure would continue to rise.

Diagnosis of HTN:
Symptoms: HTN may be asymptomatic, but symptoms associated with long-
standing pre-hypertension, higher elevations of BP include headaches; light-
headedness or dizziness; poor sleep; difficulty in concentrating; needing to
sleep on > 2 pillows (orthopnoea); getting up at night to urinate; chest pain
on exertion (later at rest); swollen ankles, esp. at the end of the day.
Whether asymptomatic or not, must measure BP accurately.
Accurate measurement required for BP. If BP > 140/90 mmhg on > 1
occasion or evidence of Target organ involvement (damage) exist, then
make diagnosis, initiate treatment.
BP diagnosis may be assisted by
o Repeated measurements in physicians office
o Self Monitoring of blood pressures SMBPs
o Ambulatory Blood Pressure Monitoring AMBP
o If repeat BP readings are > 20/10 above target, then White Coat
effect is insufficient to postpone anti-hypertensive treatment,
Once BP diagnosed, establish target BP for treatment
o Most patients BP 140/90 mmhg
o Patient with previous cardiovascular event, T2DM, target organ
involvement, CKD, or significant major cardiovascular risk factors:
130/80 mmhg.

Share target with patient, encourage SMBPs. Initiate plan to get patient
closer to target.
 Patient and family education mandatory
Diet general advice, identify high-salt foods for diet elimination, advise
on principles of DASH (Dietary Approaches to Stop Hypertension), refer
(cook) to a dietitian. Discourage frequent consumption of fast foods.
Discourage alcohol, cigarettes, marijuana, cocaine use.
Advise about general aerobic exercise: minimum 30 mins a day five
days a week. If weight loss needed, need to double that quantity.
[Remember, target weight loss first]
Drug therapy. Monotherapy drops BP ~ 20/10 mmhg, so consider fixed
dose combinations (FDC) if BP > 20/10 above target. Aim is to get BP
to target ASAP. The epidemiology of hypertension suggests that 1/3 of
patients can be controlled on monotherapy, 1/3 on dual therapy, and
1/3 need more than 2 drugs to get patients to target. Do not be afraid
to start with >1 drug if the BP mandates it.

Hypertension Classification table.

Category Diastolic BP, mmHg Systolic BP, mmHg

Normal <80 <120
Pre-hypertension 80-89 120-139
Hypertension Stage 1 90-99 140-159
Hypertension Stage 2 >100 > 160

HTN is a progressive disease: apart for a few individuals with

secondary hypertension, everyone has a normal BP. However, due to a
number of lifestyle choices, including smoking, drinking, exercise &
eating habits, the BP numbers rise from normal to pre-hypertension to
hypertension stage 1 to hypertension stage 2.
If preventive medicine is practiced (as it should be), it may be
necessary to intervene before hypertension id formally diagnosed,
Some individuals with long standing pre-hypertension may have
hypertension-related symptoms, e.g. angina, poor sleep: in these
scenarios the BP must be treated. This is also true if there is evidence
of target organ involvement. Thus the decision to treat
hypertension depends on both the numbers recorded on
measuring, as well as a evidence of target organ involvement,
both on history and/or on physical examination.
Non-drug therapy, i.e. lifestyle modification must accompany drug
therapy in all cases. While monotherapy may be the appropriate initial
treatment for patients with stage 1 hypertension, patients with stage 2
hypertension will require at least two drugs (e.g. a fixed dose
combination FDC of two anti-hypertensive drugs) as initial drug
 therapy. Most large studies suggest that about 1/3 of patients require 3
or more drugs to control blood pressures. Since HTN is progressive, a
patient whose BP was controlled with 2 drugs 2 years ago may still
require 3 drugs now if it has been difficult to achieve weight loss and/or
other lifestyle changes.

Addition considerations:
Must screen for, treat other major cardiovascular risk factors, as aim of
treatment are 1. Lower the BP numbers, and 2. Prevent target organ
damage. 3. Prevent a major cardiovascular event.

Use cardiovascular risk table, e.g. the 2013 AHA/ACC app to calculate
10 year risk of major cardiovascular event
Consider possibility of secondary hypertension: screen for same if
clinically indicated, or response to initial blood pressure lowering
efforts are inadequate. Remember, BP lowering more important than
establishing exact cause for HTN.
Evaluate renal function (urinalysis, creatinine, e-GFR app): renal
dysfunction commonly and silently accompanies hypertension, leads to
ESRD.
Review patient frequently until steady safe state achieved: BP at/below
target, patient has established healthy lifestyle routine. Check on
patient adherence: diet, exercise, medication, weight-loss (if
necessary) progress, medication side effects.
Annually review status of all major cardiovascular risk factors, renal
function; re-plot cardiovascular risk estimation.

The epidemiologists note that, in large studies, the risk for a cardiovascular
event is lowest at a BP of 115/75 mmhg, and the risk doubles with each
20/10 mmhg rise in blood pressure above this.
The SPRINT study, completed by the NIH in the USA, released results in
September 2015, In this study, two groups of non-diabetic patients were
compared, on in which it was attempted t reduce the BP to 120/80 mmhg,
and the other group to 140/90 mmhg (standard target). The SPRINT study
was stopped prematurely because the 120/80 mmhg group were doing much
better (much less cardiovascular events) than the standard group. This is
just one study, and there are some issues associated with it, but it does
suggests that, in non-diabetics, a blood pressure as close to the 115/75
mmhg if this can be achieved without side effects is desirable.