Prof.Dr.

Medhat Ashmawy
Professor of Cardiology,
Tanta University
 Blood Pressure Classification
JNC7
BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

Diabetes/Kidney Dz > 130 or >80

2
HTN is a real burden !!!

50 million hypertensive patients in

the U.S.A.

30% of the population (> 25 years)

are hypertensives in Egypt

So the challenge is big

4
Why Hyp. Is a Risk Factor ?
1- Hyp. Increases workload over the heart.
2- LVH.
3- Increase shear and tear forces over the
arterial wall increase the chance for
deposition of lipids & Ca in aterial wall
leading to atherosclerosis.
 Patient Evaluation
Evaluation of patients with documented HTN has three
objectives:

1. Assess lifestyle and identify other CV risk factors or

concomitant disorders that affects prognosis and guides
treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and

CVD.

19
 CVD Risk Factors
 Hypertension*
 Cigarette smoking
 Obesity* (BMI >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 CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.

20
 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

21
 Physical Exam
BP in both arms
Funduscopic
Thyroid
Cardiovascular - Auscultation, Carotids, Pulses
Pulmonary
Abdomen - Bruits, AAA, masses
Extremities
Neurological

22
 Laboratory Tests
Routine
– ECG
– Urinalysis
– Blood Glucose
– Hematocrit, potassium, calcium, creatinine (or eGFR)
– Lipid profile (9-12 hour fast)
Optional
– Urine albumin excretion or albumin/creatinine ratio
More extensive testing not generally indicated
unless BP control not obtained or secondary HTN
suspected
23
European guidelines 2007

Journal of Hypertension 2007, Vol 25 No 6

Stratification of CV Risk in four
categories

Journal of Hypertension 2007, Vol 25 No 6

 Factors influencing prognosis

1- Risk factors

Electrocardiographic LVH (Sokolow-Lyon )

Levels of pulse pressure (in the elderly)
LVMI by echo

Age (M>55 years; W>65 years) .

Carotid wall thickening (IMT>0.9 mm) or plaque

Carotid-femoral pulse wave velocity >12 m/s

Dyslipidaemia
Journal of Hypertension 2007, Vol 25 No 6
Low estimated glomerular filtration ratey (<60
ml/min/1.73m2) or creatinine clearance^ (<- TG>1.7
mmol/l (150 mg/dl) 60 ml/min)

Fasting plasma glucose 5.6–6.9 mmol/L (102–125 mg/dl)

Microalbuminuria 30–300 mg/24 h or albumin-creatinine
ratio:

Abnormal glucose tolerance test 22 (M); or 31(W) mg/g

creatinine

Abdominal obesity (Waist circumference>102cm (M),

>88cm (W))

Family history of premature CV disease (M at age <55

years; W at age<65 years)
Journal of Hypertension 2007, Vol 25 No 6
Established CV or renal disease

Cerebrovascular disease: ischaemic stroke;

cerebral haemorrhage;
transient ischaemic attack.
Heart disease: myocardial infarction; angina;
coronary
Revascularization.
Heart failure
Renal disease “proteinuria” > 300 mg/24 h.
Peripheral artery disease
Advanced retinopathy.

Journal of Hypertension 2007, Vol 25 No 6

 Physical examination for secondary
hypertension, organ damage and visceral
obesity
Signs suggesting secondary
hypertension and organ damage

Features of Cushing syndrome

Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidney)
Auscultation of abdominal murmurs (renovascular
hypertension)
Auscultation of precordial or chest murmurs (aortic
coarctation or aortic disease)
Diminished and delayed femoral pulses and
reduced femoral BP (aortic coarctation, aortic
disease)

Journal of Hypertension 2007, Vol 25 No 6

Signs of organ damage
Brain: murmurs over neck arteries, motor or
sensory defects
Retina: fundoscopic abnormalities
Heart: location and characteristics of apical
impulse, abnormal cardiac rhythms, ventricular
gallop, pulmonary rales, peripheral oedema
Peripheral arteries: absence, reduction, or asymmetry
of pulses, cold extremities, ischaemic skin
lesions
Carotid arteries: systolic murmurs

Journal of Hypertension 2007, Vol 25 No 6

Evidence of visceral obesity
Body weight
Increased waist circumference (standing
position)
M: > 102 cm; F: > 88 cm
Increased body mass index [body weight (kg)/
height (m)2]
Overweight 25 kg/m2; Obesity 30 kg/m2

Journal of Hypertension 2007, Vol 25 No 6

 Laboratory investigations

Routine tests
Fasting plasma glucose
Serum total cholesterol, Serum LDL-
cholesterol, Serum HDL-cholesterol,
Fasting serum triglycerides.
Serum potassium, Serum uric acid.
Haemoglobin and haematocrit

Journal of Hypertension 2007, Vol 25 No 6

Initiation of antihypertensive
treatment

Journal of Hypertension 2007, Vol 25 No 6

Despite use of combination treatment, reducing
systolic BP to < 140mmHg may be difficult and
more so if the target is a reduction to <
130mmHg.

Additional difficulties should be expected in

elderly and diabetic patients, and, in general, in
patients with cardiovascular damage.

Journal of Hypertension 2007, Vol 25 No 6

Causes of resistant hypertension

Poor adherence to therapeutic plan

Failure to modify lifestyle.

Continued intake of drugs that raise blood pressure(liquorice,

cocaine, glucocorticoids, non-steroid anti-inflammatory drugs, etc.)

Obstructive sleep apnea

Unsuspected secondary cause

Irreversible or scarcely reversible organ damage

Volume overload due to: inadequate diuretic therapy, progressive

renal insufficiency ,high sodium intake, hyperaldosteronism

Journal of Hypertension 2007, Vol 25 No 6

 Patients’ follow-up

Titration to BP control requires frequent visits in

order to timely modify the treatment regimen in
relation to BP changes and appearance of side
effects.

Once target BP has been obtained, the

frequency of visits can be considerably reduced.
However, excessively wide intervals between
visits are not advisable because they interfere
with a good doctor-patient relationship, which is
crucial for patient’s compliance.

Journal of Hypertension 2007, Vol 25 No 6

 Patients’ follow-up
Patients at low risk or with grade 1
hypertension may be seen every 6 months .

Follow-up visits should aim at maintaining

control of all reversible risk factors as well as
at checking the status of organ damage.

Journal of Hypertension 2007, Vol 25 No 6

 Goal of Hypertension
Prevention and Management
To reduce morbidity and mortality by the
least intrusive means possible. This may be
accomplished by achieving and maintaining:

– SBP < 140 mm Hg

– DBP < 90 mm Hg

– controlling other cardiovascular risk

factors
 Algorithm forTreatment
of Hypertension
Begin or Continue
Lifestyle Modifications

Not at Goal Blood Pressure

Initial Drug Choices

Not at Goal Blood Pressure

No response or Inadequate response
troublesome side effects but well tolerated

Substitute drug Add agent from

from different class different class
Not at Goal Blood Pressure

Continue adding agents from other

classes. Consider referral to a
hypertension specialist.
 Algorithm for Treatment of
Hypertension (continued)

Begin or Continue Lifestyle

• Lose weight Modifications
• Maintain potassium
• Limit alcohol • Maintain calcium and
• Increase physical magnesium
activity • Stop smoking
• Reduce Sodium • Reduce saturated
fat, cholesterol

Not at Goal Blood Pressure

 Algorithm for Treatment of
Hypertension (continued)
Begin or Continue Lifestyle Modifications

Not at Goal Blood Pressure (< 140/90 mm Hg)

lower goals for patients with diabetes or renal

disease

Initial Drug Choices

 Algorithm for Treatment of
Hypertension (continued)
Not at Goal Blood Pressure

Initial Drug Choices

Uncomplicate Specific
d Indications
Compelling
Indications
– Start at low dose and titrate upward.
– Low-dose combinations may be
appropriate.

Not at Goal Blood Pressure

 Algorithm for Treatment of
Hypertension (continued)

Initial Drug Choices*

Uncomplicate
d
• Diuretics
• -blockers

*Based on randomized controlle‫۽‬

 Algorithm for Treatment of
Hypertension (continued)

Initial Drug Choices*

Compelling Indications
• Heart failure
– ACE inhibitors
– Diuretics
• Myocardial infarction
 -blockers (non-ISA)
– ACE inhibitors (with systolic dysfunction)
• Diabetes mellitus (type 1) with proteinuria
– ACE inhibitors
• Isolated systolic hypertension (older
persons)
– Diuretics preferred
– Long-acting dihydropyridine calcium
*Based on randomized controlled trials.
antagonists
 Algorithm for Treatment of
Hypertension (continued)

Initial Drug Choices

Specific indications for the following

drugs:
• ACE inhibitors • --blockers
• Angiotensin II receptor • -blockers
blockers • Calcium
• -blockers antagonists
• Diuretics
 Specific Drug Indications

Some antihypertensive drugs may have

favorable effects on comorbid conditions:
Angina Heart failure
– -blockers – Carvedilol
– Calcium antagonists – Losartan
Atrial tachycardia and
Myocardial infarction
fibrillation
– Diltiazem
– -blockers
– Nondihydropyridine – Verapamil
– calcium antagonists
 Specific Indications (continued)

Some antihypertensive drugs may have

favorable effects on comorbid conditions:
Cyclosporine-induced
hypertension
– Calcium antagonists
Diabetes mellitus (1 and 2)
with proteinuria
– ACE inhibitors
(preferred)
– Calcium antagonists
Diabetes mellitus (type 2)
– Low-dose diuretics
Dyslipidemia
 -blockers
Prostatism (benign prostatic
hyperplasia)
 -blockers
Renal insufficiency (caution
in renovascular
hypertension and creatinine
 3 mg/dL
[ 265.2 mol/L])
– ACE inhibitors
 Specific Indications (continued)

Some antihypertensive drugs may have

favorable effects on comorbid conditions:
Essential tremor Osteoporosis
– Noncardioselective -blockers
– Thiazides
Hyperthyroidism
– -blockers
Perioperative
hypertension
Migraine
– Noncardioselective -blockers – -blockers
– Nondihydropyridine calcium
– antagonists
 Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices

Not at Goal Blood Pressure (< 140/90 mm Hg)

No response or Inadequate response but
troublesome side effects well tolerated

Substitute another Add second agent

drug from different from different class
class (diuretic if not already
used)
Not at Goal Blood Pressure (<140/90
mmHg)
 Algorithm for Treatment of
Hypertension (continued)
Substitute drug from Add second agent from
different class different class

Not at Goal Blood Pressure (< 140/90 mm

Hg)
Continue adding agents from other
classes.

Consider referral to a hypertension

specialist.
 Algorithm for Treatment
of Hypertension
Begin or Continue
Lifestyle Modifications

Not at Goal Blood Pressure

Initial Drug Choices

Not at Goal Blood Pressure

No response or Inadequate response
troublesome side effects but well tolerated

Substitute drug Add agent from

from different class different class
Not at Goal Blood Pressure

Continue adding agents from other

classes. Consider referral to a
hypertension specialist.
 Lifestyle Modifications
For Prevention and
Management
Lose weight if overweight.
Limit alcohol intake.
Increase aerobic physical
activity.
Reduce sodium intake.
Maintain adequate intake of
potassium.
For Overall and
Cardiovascular Health
Maintain adequate intake of
calcium and magnesium.
Stop smoking.
Reduce dietary saturated fat
and cholesterol.
 Pharmacologic Treatment

Decreases cardiovascular morbidity

and mortality based on randomized
controlled trials.

Protects against stroke, coronary

events, heart failure, progression of
renal disease, progression to more
severe hypertension, and all-cause
mortality.
 Special Considerations
in Selecting Drug Therapy
Demographics
Coexisting diseases and therapies
Quality of life
Physiological and biochemical
measurements
Drug interactions
Economic considerations
 Drug Therapy

A low dose of initial drug should be used,

slowly titrating upward.

Optimal formulation should provide 24-hour

efficacy with once-daily dose with at least
50% of peak effect remaining at end of 24
hours.

Combination therapies may provide

additional efficacy with fewer adverse effects.
 Classes of
Antihypertensive Drugs
ACE inhibitors
Adrenergic inhibitors
Angiotensin II receptor
blockers
Calcium antagonists
Direct vasodilators
Diuretics
 Combination Therapies
• -adrenergic blockers and diuretics

• ACE inhibitors and diuretics

• Angiotensin II receptor antagonists and

diuretics
• Calcium antagonists and ACE
inhibitors
• Other combinations
 Followup
Follow up within 1-2 months after initiating therapy.

Recognize that high-risk patients often require high

dose or combination therapies and shorter intervals
between changes in medications.

Consider reasons for lack of responsiveness if blood

pressure is uncontrolled after reaching full dose.

Consider reducing dose and number of agents after

1 year at or below goal.
 Causes for Inadequate
Response to Drug Therapy
Pseudoresistance
Nonadherence to therapy
Volume overload
Drug-related causes
Associated conditions
Identifiable causes of
hypertension
 Guidelines for Improving
Adherence to Therapy
Be aware of signs of nonadherence.
Establish goal of therapy.
Encourage a positive attitude about achieving
goals.
Educate patients about the disease and therapy.
Maintain contact with patients.
Encourage lifestyle modifications.
Keep care inexpensive and simple.
 Guidelines for Improving
Adherence to Therapy
(continued)
Integrate therapy into daily routine.
Prescribe long-acting drugs.
Adjust therapy to minimize adverse affects.
Continue to add drugs systematically to meet goal.
Consider using nurse case management.
Utilize other health professionals.
Try a new approach if current regime is
inadequate.
 Hypertensive Emergencies
and Urgencies
Emergencies require immediate blood
pressure reduction to prevent or limit target
organ damage.
Urgencies benefit from reducing blood
pressure within a few hours.
Elevated blood pressure alone rarely requires
emergency therapy.
Fast-acting drugs are available.
 Drugs Available for
Hypertensive Emergencies
Vasodilators Adrenergic
Nitroprusside Inhibitors

Nicardipine Labetalol

Fenoldopam Esmolol

Nitroglycerin Phentolamine

Enalaprilat
Hydralazine
 Summary of Chapter 3
Modifying lifestyles in populations can have a major
protective effect against high blood pressure and
cardiovascular disease.
Lowering blood pressure decreases death from stroke,
coronary events, and heart failure; slows progression
of renal failure; prevents progression to more severe
hypertension; and reduces all-cause mortality.
A diuretic and/or a -blocker should be chosen as
initial therapy unless there are compelling or specific
indications for another drug.
 Summary of Chapter 3
(continued)
Management strategies can improve adherence
through the use of multidisciplinary teams.
The reductions in cardiovascular events
demonstrated in randomized controlled trials have
important implications for managed care
organizations.
Management of hypertensive emergencies requires
immediate action whereas urgencies benefit from
reducing blood pressure within a few hours.
 Special Populations

Racial and ethnic groups

Children and adolescents

Women

Older persons
 Children and Adolescents

Blood pressure at 95th or higher percentile is

considered elevated.
Lifestyle modifications should be recommended.
Drug therapy should be prescribed for higher levels
of blood pressure.
Attempts should be made to determine other causes
of high blood pressure and other cardiovascular risk
factors.
 95th Percentile of Blood Pressure
by Selected Ages and Height in
Girls
SBP/DBP (mm Hg)
Age 50th Percentile for 75th Percentile for
Height Height
1 104/58 105/59
6 111/73 112/73
12 123/80 124/81
17 129/84 130/85
 95th Percentile of Blood Pressure
by Selected Ages and Height in
Boys
SBP/DBP (mm Hg)
Age 50th Percentile for 75th Percentile for
Height Height
1 102/57 104/58
6 114/74 115/75
12 123/81 125/82
17 136/87 138/88
 Women
Clinical trials have not demonstrated significant
differences between men and women in
treatment response and outcomes.

Some women using oral contraceptives may

have significant increases in blood pressure.

High blood pressure in not a contraindication to

hormone replacement therapy.
 Pregnant Women
Chronic hypertension is high blood pressure present
before pregnancy or diagnosed before 20th week of
gestation.
Preeclampsia is increased blood pressure that occurs
in pregnancy (generally after the 20th week) and is
accompanied by edema, proteinuria, or both.
ACE inhibitors and angiotensin II receptor blockers
are contraindicated for pregnant women.
Methyldopa is recommended for women diagnosed
during pregnancy.
 Antihypertensive Drugs
Used in Pregnancy
These agents* may be used with chronic hypertension
(DBP > 100 mm Hg) or acute hypertension (DBP > 105 mm Hg).

Central -agonists Methyldopa is the drug of choice.

-blockers and Atenolol, metoprolol, and labetalol appear safe

--blockers and effective in late pregnancy.

Calcium antagonists Potential synergism with magnesium sulfate may

lead to precipitous hypotension.

*Limited or no controlled trials in pregnant women.

 Antihypertensive Drugs
Used in Pregnancy (continued)
These agents* may be used with chronic hypertension (DBP > 100 mm Hg) or acute
hypertension (DBP > 105).

Diuretics Diuretics are recommended for chronic hypertension if

prescribed before gestation, but they are not recommended
for preeclampsia.

Direct Hydralazine is the parenteral drug of choice based on its long

vasodilators history of safety and efficacy.

*Limited or no controlled trials in pregnant women.

ACE inhibitors and angiotensin II receptor blockers are contraindicated.

 Older Persons
Hypertension is common.
SBP is better predictor of events than DBP.
Pseudohypertension and “white-coat hypertension”
may indicate need for readings outside office.
Primary hypertension is most common cause, but
common identifiable causes (e.g., renovascular
hypertension) should be considered.
 Older Persons (continued)
Therapy should begin with lifestyle
modifications.

Starting doses for drug therapy should be

lower than those used in younger adults.

Goal of therapy is the same (< 140/90 mm

Hg) although an interim goal of SBP < 160
mm Hg may be necessary.
 Special Situations

Cardiovascular • Sleep apnea

diseases
• Bronchial asthma
Renal disease
• Gout
Diabetes mellitus
• Surgery
Dyslipidemia
• Various chemical
agents
 Cardiovascular Diseases
Cerebrovascular disease
– Indication for treatment, except immediately
after ischemic cerebral infarction
Coronary artery disease
– Benefits of therapy well established
Left ventricular hypertrophy
– Antihypertensive agents (except direct
vasodilators) indicated
– Reduced weight and decreased sodium
intake beneficial
 Cardiovascular Diseases
(continued)

Cardiac failure
– ACE inhibitors, especially with digoxin
or diuretics, shown to prevent
subsequent heart failure
Peripheral arterial disease
– Limited or no data available
 Renal Disease
Hypertension may result from renal disease that
reduces functioning nephrons.
Evidence shows a clear relationship between high
blood pressure and end-stage renal disease.
Blood pressure should be controlled to < 130/85
mm Hg or lower (< 125/75 mm Hg) in patients
with proteinuria in excess of 1 gram per 24 hours.
ACE inhibitors work well to control blood pressure
and slow progression of renal failure.
 Diabetes Mellitus
Drug therapy should begin along with lifestyle
modifications to reduce blood pressure to
< 130/85 mm Hg.

ACE inhibitors, -blockers, calcium antagonists, and

low dose-diuretics are preferred.

Insulin resistance or high peripheral insulin levels may

cause hypertension, which can be treated with lifestyle
changes, insulin-sensitizing agents, vasodilating
antihypertensive drugs, and lipid-lowering agents.
 Dyslipidemia

Coexistence of hypertension and dyslipidemia

requires aggressive management.
Emphasis should be on weight loss; reduced
intake of saturated fat, cholesterol, sodium,
and alcohol; and increased physical activity.
Lifestyle changes and hypolipidemic agents
should be used to reach appropriate goals.
 Sleep Apnea

Obstructive sleep apnea is more

common in patients with hypertension
and is associated with several adverse
clinical consequences.

Improved hypertension control has

been reported following treatment of
sleep apnea.
 Bronchial Asthma or Chronic
Airway Disease
Elevated blood pressure is common in acute
asthma and is possibly related to treatment with
systemic corticosteroids or -agonists.
 -blockers and--blockers may exacerbate
asthma.

ACE inhibitors only rarely induce bronchospasm.

Over-the-counter medications are generally safe

in limited doses for patients on drug therapy.
 Gout
Diuretics can increase serum uric
acid levels.

Diuretics should be avoided in

patients with gout.

Diuretic-induced hyperuricemia
does not require treatment in the
absence of gout or urate stones.
 Patients Undergoing Surgery
When possible, surgery should be delayed
until blood pressure is < 180/110 mm Hg.
Those not on prior drug therapy may be
best treated with cardioselective-blockers
before and after surgery.
Those with controlled blood pressure should
continue medication until surgery and begin
as soon after surgery as possible.
 Cocaine and Amphetamines
Cocaine abuse must be considered in patients
presenting to the emergency department with
hypertension-related problems.
Nitroglycerin is indicated to reverse cocaine-
related coronary vasoconstriction.
Acute amphetamine toxicity is similar to that of
cocaine but longer in duration.
Ongoing cocaine abuse does not appear to
cause chronic hypertension.
 Immunosuppressive Agents

Immunosuppressive regimens produce

widespread vasoconstriction in both
transplant and nontransplant situations.

Treatment is based on vasodilation

including dihydropyridine calcium
antagonists.
 Erythropoietin
Erythropoietin often increases blood
pressure in treatment of patients with end-
stage renal disease.

Management includes optimal volume

control, antihypertensive agents, and
reducing erythopoietin dose or changing
method of administration.
 Other Chemical Agents
That May Induce
Hypertension
Mineralocorticoids and derivatives
Anabolic steroids
Monoamine oxidase inhibitors
Lead
Cadmium
Bromocriptine