Hypertension: diagnosis

and management

MUZAKKIR
DEPT. CARDIOLOGY VASCULAR HASANUDDIN UNIVERSITY
Objectives

 Review the prevalence of hypertension and

its importance as a cardiovascular risk factor
 Describe criteria for hypertension and steps
in its initial management
 Review medications used for the
management of hypertension
 Discuss treatment strategies based on case
discussions
Prevalence of Hypertension

 50 million people in the U.S.

 1 billion worldwide
 European Americans:
 15% of women > 45 years of age
 25% of men > 45
 African Americans:
 35% of women > 45
 40% of men > 45
 Classification of Blood Pressure for Adults
(JNC 7, May 2003)

Systolic Diastolic
Normal <120 And <80
Prehypertension 120 – 139 Or 80 – 89
Stage 1 140 - 159 Or 90 – 99
Stage 2 > 160 Or > 100
Cardiovascular Risk

 20 mmHg increment in SBP or

 10 mmHg increment in DBP

 Doubles risk for CVD among 40-

70 year olds across entire BP
range (115/75 – 185/115)
Morbidity and Mortality
 CHD/MI
 LVH and LV dysfunction
 Dysrrhythmias
 Stroke
 Chronic kidney disease and
failure
 PVD
 Retinopathy
Isolated Systolic
Hypertension (ii)
Normal BP SBP 140-159
All CVD 57% 89%
CHF 7% 16%
Stroke/TIA 9% 16%
CVD mortality 13% 29%

Progression to 45% 80%

HTN
Pharmacologic Therapy
Consider:
 Severity of BP
 End organ damage, including LVH
 Presence of other conditions or risk
factors: DM, CHD, smoking, LDL

 50% of patients controlled with one

drug; another 30% with two;
 The vast majority of patients with
diabetes require two or more drugs
Health Outcomes: Relative
Risk and First Line Agents (ix)

Stroke CHF CHD

ß-blocker 0.71 0.58 0.93

High dose diuretic 0.49 0.17 0.99

Low dose diuretic 0.66 0.58 0.72

Diuretics
 Only agents shown to decrease
morbidity and mortality related to
CHD in major trials
 Decrease plasma volume and CO
 Reduce peripheral vascular resistance
 Most of anti-hypertensive effect at
low doses; biochemical effects are
dose related
 Thiazides; loop; potassium sparing
Diuretics

Adverse effects:
 Electrolyte imbalance:
potassium, magnesium,
sodium, calcium, uric acid,
glucose
 Hypercholesterolemia
Diuretics
Useful in:
 All populations

 Isolated systolic hypertension

 CHF

 Renal insufficiency (loop

diuretics if CrCl < 30-50)
 Combination with second drug
Beta Adrenergic Blockers

 Decrease HR, CO, renal blood flow

 Inhibit vasoconstriction/decrease
peripheral resistance
Beta Adrenergic Blockers
Useful in:
 Patients with LVH, angina,
tachycardia, anxiety, migraine,
glaucoma

 Patients with CHD; provide

significant protection against MI
recurrence
Beta Adrenergic Blockers
Adverse effects:
 CHF exacerbation acutely; AV block
 Bronchospasm (in reversible
disease)
 CNS (lipid solubility)
 Propranolol, metoprolol >> atenolol
 ? Carbohydrate metabolism
 ? Lipid metabolism
Angiotensin Converting
Enzyme Inhibitors

 Block formation of
angiotensin II
 Promote vasodilation &
decrease aldosterone
 Increase bradykinin &
vasodilatory PG’s
Angiotensin Converting
Enzyme Inhibitors

Preferred in:
 Congestive heart failure

 Diabetes type I and II

 Known coronary heart disease

 At high risk for CHD

 Nephropathy
Angiotensin Converting
Enzyme Inhibitors
Adverse effects:
 Cough (5-15% of patients)
 Skin rash, taste alterations (esp.
Captopril)
 Hyperkalemia
 Hypotension, dizziness
 Renal dysfunction (up to 35% inc in SCr)
 Rare: angioedema (most frequent in
African Americans), neutropenia,
proteinuria
 Teratogenic
Angiotensin Receptor
Blockers
 Losartan, valsartan,
candesartan, et.al.

 No cough, rare angioedema

 Less potent antihypertensive
effect--improves if combined
with diuretic
 Teratogenic
Calcium Channel Blockers
 Peripheral vasodilators
 Non-dihydropiridines: diltiazem,
verapamil
 Dihydropiridines: amlodipine,
felodipine, isradipine, nicardipine,
nifedipine, nisoldipine
 Short-acting dihydropiridines
Short Acting Nifedipine (xx)

 Not FDA approved for treatment of

hypertension
 Poorly absorbed from oral mucosa
 Adverse effects: neurological
symptoms, hypotension,
myocardial ischemia, acute MI
 Similar concerns with other short
acting CCB like isradipine
Calcium Channel Blockers
Adverse effects:
 Dizziness, headache, peripheral
edema
 DHP’s: worse edema, flushing,
tachycardia, rash
 Non-DHP’s: CHF exacerbation, AV
block, bradycardia, constipation
Calcium Channel Blockers
 Useful in: angina
 Most effective in African
Americans as single drug
therapy
 In patients with DM, its use
assoc. with greater risk of MI
compared with ACEI
Alpha Adrenergic
Blockers

 Prazosin, terazosin, doxazosin

 Can cause postural hypotension
and syncope
 Use with caution in elderly
 Useful in men with BPH
Central Sympatholytics
 Adverse effects: sedation,
drowsiness, dry mouth,
bradycardia, heart block
 Clonidine withdrawal:
hypertension, headache,
palpitations, perspiration
 Methyldopa: hepatitis, lupus-like
syndrome, thrombocytopenia,
hemolytic anemia
Direct Vasodilators
 Tachycardia can aggravate angina
 Headache, dizziness, fluid
retention
 Hydralazine: lupus-like syndrome,
hepatitis
 Minoxidil: hirsutism, pericardial
effusion
Peripheral Adrenergic
Inhibitors
 Guanadrel and reserpine
 Orthostatic hypotension, diarrhea,
drowsiness, bradycardia
 Reserpine: depression, sedation,
nasal congestion
 Useful when other treatments fail
Goals of therapy
 Decrease morbidity and mortality
 Stroke, CHD, CHF
 Maintain function/quality of life
 Minimize side effects
 Treat co-morbidities
 Maximize therapy of other CV risk
factors
Classification of Blood Pressure for Adults
(JNC 7, May 2003)

Systolic Diastoli
c
Normal An <80
<120
d
Prehypertensio 120 – 80 – 89
Or
n 139
Stage 1 140 - Or 90 – 99
159
Stage 2 > 160 Or > 100
Stage 1, No Compelling
Indications

 Thiazide diuretic for most

patients

 Consider ACEI, ARB, BB, CCB

Compelling Indications

 IHD: BB, L.A. CCB, ACEI; lipid

management, aspirin
 CHF: ACEI, BB, ARB,
spironolactone, loop diuretics
 DM: ThD, BB, ACEI, ARB, L.A. CCB
 Renal disease: ACEI, ARB, loop
diuretics
 CVA: ACEI, ThD
Stage 2, No Compelling
Indications

 2-drug combination for most

patients

 Thiazide diuretic plus ACEI, ARB,

BB, CCB
Patient D.M.

 49 year old Latino, feels healthy, his

wife wants him to have his cholesterol
checked.
His BP is 160/85
EKG no LVH
SCreat 0.8; Lytes normal; LDL 100;
FBG 200
UA: no proteinuria;
Patient D.M., cont.
 Choices:
– Low dose thiazide
– ACE Inhibitor
– Beta Blocker
– Others?
 Treatment of concurrent RF’s
– Smoking
– Diet: DASH diet
– Exercise
– Others?
Patient C.K.
 70 year old African American woman with
history of HTN for 20 years; has been on
atenolol and losartan for three years; no
history of CHD events. Is also on
pravastatin for high cholesterol.
BP: 160/85
EKG: LVH, no dysrrhythmia or ST changes
SCreat 1.0; lytes normal; FBG 88; LDL 100
UA: trace protein
Patient C.K., cont.

 Choices
– Diuretic, diuretic, diuretic
– Maximize both beta-blocker and ACE
receptor blocker
– Consider long acting di-hydropiridine CCB
 Calculate and use GFR rather than
SCreat
“That’s just great. I discover the cure for the
common cold and all you do is criticize.”
Patient Education Tool
Assessment of the overall cardiovascular risk
Search for target organ damage

Cerebrovascular disease
- transient ischemic attacks
- ischemic or hemorrhagic stroke
- vascular dementia
Hypertensive retinopathy
Left ventricular dysfunction
Coronary artery disease
- myocardial infarction
- angina pectoris
- congestive heart failure
Chronic kidney disease
- hypertensive nephropathy (GFR < 60
ml/min/1.73 m2)
- albuminuria
Peripheral artery disease
- intermittent claudication
Some recommended electronic blood
pressure monitors for home blood
pressure measurement

Monitors A&D® or LifeSource®

Models: 767*, 767PAC*, 774AC*, 779, 787AC*
Monitor Omron® * Models with memory are preferred
Models: HEM-705 PC*, HEM-711*, HEM-741CINT*
Monitor Microlife® 2007 Canadian Hypertension Education Program Recommendations
Model: BP 3BTO-A
 PROPER BP
MEASUREMENT
•MD SHOULD CHECK
•PT SEATED /QUIET/CALM
•ARM RESTING AT HEART LEVEL
•PROPER CUFF SHOULD COVER 2/3
•AND BLADDER SHOULD CIRCLE 80 ARM
•LOWER EDGE CUFF 2,5 CM ABOVE AC FOSSA
•PALP ART RADIALIS ART TO DETERMINE SYSTOLIC
•USE BELL AUSCULTASI OVER BRACHIAL ARTERY
•INFLATE CUFF TO 20-30 mmHg above ESTIMATE SYST
Secondary hypertension
 Estrogen use
 Renal disease
 Renal vascular hypertension (~ 1%)
 Hyperaldosteronism (< 0.5%);
Cushing’s syndrome
 Pheochromocytoma
 Coarctation of aorta,
hypercalcemia, hyperthyroidism
The end…