Lebanese University

Faculty of Medicine

Hypertension

Dr. Majdi S. Hamadeh

Chief of Department of Internal Medicine
& Nephrology at ZUH
 History of Hypertension
 In 1896, hypertension as a medical entity really came into being
with the invention of the cuff based sphygmomanometer by
Scipione Riva-Rocci which allowed BP to be measured in the clinic
 In 1905, Nikolai Korotkoff improved the technique by describing
the Korotkoff sounds that are heard when the artery is ausculated
with a stethoscope while the sphygmomanometer cuff is deflated.
 In 1981, invention of an accurate fully automated oscillometric
sphygmomanometer device by Donal Nunn
 Prevalence of hypertension

 Prevalence of hypertension is 30.4% of

population for a developing country
 Prevalence among elderly subjects was
highest reaching 60-80% above age 65 years
Prevalence of HTN according to age and gender

18 to 34
 Cost of High Blood Pressure

 Estimation of $131 billion in higher annual healthcare

costs nationwide for those with HTN compared to those
without it (based on the U.S. prevalence of HTN)
 The total cost of HTN, using direct and indirect costs, is
estimated at a staggering $4 trillion globally
Definition and Classification Of HTN
 Factors Influencing Blood Pressure

Systemic Vascular
Blood Pressure = Cardiac Output x
Resistance
Hemodynamic Pattern in Hypertension

Young :  BP = CO X TPR

Elderly :  BP =  CO X   TPR
2017 Guideline for the Prevention, Detection, Evaluation
and Management of High Blood Pressure in Adults
Classification of Office Blood Pressurea and
Definitions of Hypertension Gradeb (ESC/ESH 2018)
Definitions of hypertension according to office,
ambulatory, and home blood pressure level
 Definition of high blood pressure

 A rise In systolic and/or diastolic blood pressure

≥ 140/90 European guidelines + JNC8
≥ 130/80 AHA/ACC guidelines
 Based on the average of two or more properly
measured, seated BP readings.
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 is preferably used
 Caffeine, exercise, and smoking should be avoided for at
least 30 minutes before BP measurement
 An appropriately sized cuff should be used
Selection Criteria for BP Cuff Size for Measurement
of BP in Adults

Arm Circumference Usual Cuff Size

22–26 cm Small adult

27–34 cm Adult

35–44 cm Large adult

45–52 cm Adult thigh

 Classification of Hypertension
 Primary (Essential) Hypertension
Elevated BP with unknown cause
90% to 95% of all cases
 Secondary Hypertension
Elevated BP with a specific cause
5% to 10% in adults
 Isolated systolic hypertension (elderly)
 White coat hypertension
 Masked hypertension
 Pulse pressure (PP) = SBP – DBP/ normal: 40-60 mmHg
 Central pressure

Mean pressure = 1/3 SBP + 2/3 DBP

BP patterns based on office
an out-of-office measurements

Office/Clinic/Healthcare Home/Nonhealthcare/ABP
Setting M Setting
Normotensive No hypertension No hypertension
Sustained
Hypertension Hypertension
hypertension
Masked
No hypertension Hypertension
hypertension
White coat
Hypertension No hypertension
hypertension

ABPM indicates ambulatory blood pressure monitoring; and BP, blood pressure.
 Hypertensive Urgencies

 Severe elevated BP in the upper range of

stage II hypertension (European Guidelines).
 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

 Mostly 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
Primary Hypertension
Risk Factors for Primary Hypertension

 Age (> 55 for men;  Family history

> 65 for women)  Obesity (BMI > 30)
 Alcohol  Ethnicity (African
 Cigarette smoking Americans)
 Diabetes mellitus  Sedentary lifestyle
 Elevated serum lipids
 Socioeconomic status
 Excess dietary sodium
 Stress
 Gender
Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 35–40%

Myocardial infarction 20–25%

Heart failure 50%

Common examples of target organ damage

Brain Heart
Stroke CAD
TIA LV hypertrophy
Dementia LV systolic dysfunction

Target organ damage

Kidneys Vacsular system/Eye

Hypertensive Hypertensive retinopathy
Nephropathy Aortic aneurysm
PVD
(Microalbuminuria
Overt atherosclerosis
Proteinuria
Renal failure)
Retina Normal and Hypertensive Retinopathy

Normal Retina Hypertensive

Retinopathy
Stage I- Arteriolar Narrowing Stage II- AV Nicking
 H

Stage III- Hemorrhages (H) and Exudates (E)

Stage IV: Stage III + Papilledema
The basics in the vessels

Vascular Flexibility
PWV

Vascular Rigidity
PWV
Mediators of peripheral vascular resistance

Increase Resistance Decrease Resistance

Angiotensine ‫ ׀׀‬Noradrenalin Bradykinin Nitric Oxide
Adrenalin ADH Atrial Natriuretic Peptide
Endothelin Prostaglandins
Prostacyclins
 Mediators of cardiac output

Decrease Output Increase output

Hemorrhage Aldosterone ADH
Loss of salt and water intravascular volume
intravascular volume sympathetic
activity
Relation between high BP and the Kidney

 HTN follows the kidney (Guyton theory)

 Pressure Natriuresis
 Genetic
 Environment factors (habits)
 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
 Micro Albuminuria

 The current explanation is the urinary albumin leakage,

in fact, reflects a generalized vascular dysfunction
particular endothelial dysfunction
 Endothilial dysfunction is the cause of accelerated
atherosclerosis and thus cardiovascular and renal risk
 Alternatively, albumin leakage itself may cause
inflammation, thus further damaging the microvessels
Profil des pressions hydrostatiques vasculaires renales
Renin - Angiotension System
Daily Salt Intake
 Dietary Salt and Hypertension

1 mmole sodium = 23 mg sodium

1 g sodium = 43.5 mmoles sodium
1 g salt (NaCl) = 400 mg sodium

1 tsp salt = 6 g salt = 2400 mg Na = 104 mmoles or meq Na

Effects On the CVS

Ventricular hypertrophy, dysfunction and failure

 Arrhythmias
 Coronary artery disease, Acute MI
 Arterial aneurysm, dissection, and rupture.
Left Ventricular Hypertrophy
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.
 Hypertension
 For persons over age 50, SBP is more important
than DBP as a CVD risk factor

 Starting at 115/75 mmHg, CVD risk doubles

with each increment of 20/10 mmHg throughout
the BP range
Hypertension
Clinical Manifestations

 Frequently asymptomatic until severe and

target organ disease has occurred
• Fatigue, reduced activity tolerance
• Dizziness
Hypertension Diagnosis

 Diagnosis requires several elevated readings over

several weeks
 BP measurement in both arms
Use arm with higher reading for subsequent measurements
 Ambulatory BP Monitoring
for “white coat” phenomenon, masked HTN, hypotensive or
hypertensive
episodes, apparent drug resistance
 Examination

 Appropriate measurement of BP in both arms

 Optic fundi (Stage 2 HTN)
 Calculation of BMI (waist circumference may be useful)
 Auscultation for carotid, abdominal, and femoral bruits
 Palpation of the thyroid gland.
Basic and Optional Laboratory Tests
for Primary Hypertension

Basic testing Fasting blood glucose*

Complete blood count
Lipid profile
Serum creatinine with eGFR*
Serum sodium, potassium, calcium*
Thyroid-stimulating hormone
Urinalysis
Electrocardiogram

Optional testing Echocardiogram

Uric acid
Urinary albumin to creatinine ratio

* May be included in a comprehensive metabolic panel.

eGFR indicates estimated glomerular filtration rate.
Secondary Forms of Hypertension
Secondary Forms of Hypertension

Recommendations for Secondary Forms of Hypertension

Screening for specific form(s) of secondary hypertension is recommended

when the clinical indications and physical examination findings are
present or in adults with resistant hypertension.

If an adult with sustained hypertension screens positive for a form of

secondary hypertension, referral to a physician with expertise in that
form of hypertension may be reasonable for diagnostic confirmation and
treatment.
Screening for Secondary
New-onset Hypertension
or uncontrolled hypertension in adults

Conditions
• Drug-resistant/induced hypertension
• Abrupt onset of hypertension
• Onset of hypertension at <30 y
• Exacerbation of previously controlled hypertension
• Disproportionate TOD for degree of hypertension
• Accelerated/malignant hypertension
•• Onset
Difference between
of diastolic the sizes of two
hypertension kidneys
in older of ≥2
adults (agecm≥65 y)
• Unprovoked or excessive hypokalemia
Colors correspond to Class of Recommendation in Table 1 .
TOD indicates target organ damage (e.g., cerebrovascular disease,
hypertensive retinopathy, left ventricular hypertrophy, left ventricular
dysfunction, heart failure, coronary artery disease, chronic kidney disease,
Yes No
albuminuria, peripheral artery disease).
Causes of Secondary Hypertension
With Clinical Indications

Common causes
Renal parenchymal disease
Renovascular disease
Primary aldosteronism
Obstructive sleep apnea
Drug or alcohol induced
Uncommon causes
Pheochromocytoma/paraganglioma
Cushing’s syndrome
Hypothyroidism
Hyperthyroidism
Aortic coarctation (undiagnosed or repaired)
Primary hyperparathyroidism
Congenital adrenal hyperplasia
Mineralocorticoid excess syndromes other than primary aldosteronism
Acromegaly
Primary Aldosteronism

Recommendations for Primary Aldosteronism

In adults with hypertension, screening for primary aldosteronism is
recommended in the presence of any of the following concurrent
conditions: resistant hypertension, hypokalemia (spontaneous or
substantial, if diuretic induced), incidentally discovered adrenal mass,
family history of early-onset hypertension, or stroke at a young age (<40
years).

Use of the plasma aldosterone: renin activity ratio is recommended when

adults are screened for primary aldosteronism.

In adults with hypertension and a positive screening test for primary

aldosteronism, referral to a hypertension specialist or endocrinologist is
recommended for further evaluation and treatment.
Renal Artery Stenosis

Recommendations for Renal Artery Stenosis

Medical therapy is recommended for adults with atherosclerotic renal
artery stenosis.

In adults with renal artery stenosis for whom medical management

has failed (refractory hypertension, worsening renal function) and
those with nonatherosclerotic disease, including fibromuscular
dysplasia, it may be reasonable to refer the patient for consideration
of revascularization (percutaneous renal artery angioplasty and/or
stent placement).
Obstructive Sleep Apnea

Recommendation for Obstructive Sleep Apnea

In adults with hypertension and obstructive sleep apnea, the

effectiveness of continuous positive airway pressure (CPAP) to
reduce BP is not well established.
Hypertension in Pregnancy
Hypertension in Pregnancy

Etiology & Definition

 Complicates 10-20% of pregnancies
 Elevation of BP ≥140 mmHg systolic
and/or ≥90 mmHg diastolic, on two
occasions at least 6 hours apart.
Categories

 Chronic Hypertension
 Gestational Hypertension
 Preeclampsia
 Preeclampsia superimposed on Chronic
Hypertension
 Chronic Hypertension
 Preexisting Hypertension
 Definition
- Systolic pressure ≥ 140 mmHg, DBP≥90 mmHg,
or both.
- Presents before 20th week of pregnancy
 Causes
- Primary = Essential Hypertension
- Secondary = Result of other medical condition (ie:
renal disease)
 Treatment for Chronic Hypertension

 Avoid treatment in women with uncomplicated mild

essential HTN as blood pressure may decrease as
pregnancy progresses.
 May taper or discontinue meds for women with blood
pressures less than 120/80 in 1st trimester.
 Reinstitute or initiate therapy for persistent diastolic
pressures >95 mmHg, systolic pressures >150 mmHg,
or signs of hypertensive end-organ damage.
 Medication choices = Oral methyldopa and labetalol.
 Preeclampsia
 Definition
New onset of hypertension and proteinuria after 20
weeks gestation.
- SBP ≥140 mmHg OR DBP ≥90 mmHg
- Proteinuria of 0.3 g or greater in a 24-hour urine specimen
- Preeclampsia before 20 weeks, think MOLAR PREGNANCY!
 Categories
- Mild Preeclampsia
- Severe Preeclampsia
 Eclampsia
Occurrence of generalized convulsion and/or coma in the setting
of preeclampsia, with no other neurological condition.
Preeclampsia superimposed on Chronic HTN
 Affects 10-25% of patients with chronic HTN
 Preexisting Hypertension with the following
additional signs/symptoms:
• New onset proteinuria
• Hypertension and proteinuria during pregnancy
• A sudden increase in blood pressure.
• Thrombocytopenia.
• Elevated aminotransferases
• Hemolysis exists

HELLP Syndrome
Treatment of Preeclampsia

 Definitive Treatment = Delivery

 Major indication for antihypertensive
therapy is prevention of stroke.
• DBP≥ 110 mmHg or SDB≥160 mmHg
 Choice of drug therapy:
• Acute – IV labetalol, IV hydralazine, Nifedipine
• Long-term – Oral methyldopa or labetalol
Gestational Hypertension

 Mild HTN without proteinuria or other signs of

preeclampsia.
 Develops in late pregnancy, after 20 weeks gestation.
 Resolves by 12 weeks postpartum.
 Can progress onto preeclampsia.
• Often when hypertension develops <30 weeks gestation.

 Indications for and choice of antihypertensive therapy

are the same as for women with preeclampsia.
Evaluation of Hypertension in Pregnancy

• Laboratory Tests
• CBC (Hgb, Plts)
• Renal Function (Cr, UA, Albumin)
• Liver Function (AST, ALT, ALP, LD)
• Coagulation (PT, PTT, INR, Fibrinogen)
• Urine Protein (Dipstick, 24 hour)
Management of Hypertension in Pregnancy

• Depends on severity of hypertension and gestational age!!!!

• Observational Management
• Restricted activity
• Close Maternal and Fetal Monitoring
• BP Monitoring
• Management of preeclampsia
• Fetal growth and well being (NST, and U/S)
• Routine weekly or biweekly blood work
Management of Hypertension in Pregnancy

• Medical Management
• Acute Therapy = IV Labetalol, IV Hydralazine, SR Nifedipine
• Expectant Therapy = Oral Labetalol, Methyldopa, Nifedipine
• Eclampsia prevention = MgSO4

• Contraindicated antihypertensive drugs

• ACE inhibitors
• Angiotensin receptor antagonists
• Diuretics
Management of Hypertension in Pregnancy

• Proceed with Delivery

• Vaginal Delivery VS Cesarean Section
• Depends on severity of hypertension!
• May need to administer antenatal corticosteroids depending on gestation!

Only cure is DELIVERY!!!

 Nonpharmacological
Treatment Of Essential HTN
Nonpharmacological Interventions

Recommendations for Nonpharmacological Interventions

Weight loss is recommended to reduce BP in adults with elevated BP or

hypertension who are overweight or obese.
A heart-healthy diet, such as the DASH (Dietary Approaches to Stop
Hypertension) diet, that facilitates achieving a desirable weight is
recommended for adults with elevated BP or hypertension.

Sodium reduction is recommended for adults with elevated BP or

hypertension.
Potassium supplementation, preferably in dietary modification, is
recommended for adults with elevated BP or hypertension, unless
contraindicated by the presence of CKD or use of drugs that reduce
potassium excretion.
Nonpharmacological Interventions

Recommendations for Nonpharmacological Interventions

Increased physical activity with a structured exercise program is

recommended for adults with elevated BP or hypertension.

Adult men and women with elevated BP or hypertension who currently

consume alcohol should be advised to drink no more than 2 and 1 standard
drinks* per day, respectively.

*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is
typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about
12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension*

Approximate
Nonpharmacologi- Impact
cal Intervention
Dose
on SBP

Best goal is ideal body weight, but aim for ≥

1kg reduction in body weight for most adults .
Weight loss Weight/body fat Expect about 1 mm Hg decrease for 1kg -5 mm Hg
reduction in body weight.
Consume a diet rich in fruits, vegetables,
Healthy diet DASH dietary whole grains, and low-fat dairy products, with -11 mm Hg
pattern reduced content of saturated and total fat.
Reduced Optimal goal is <1500 mg/d, but aim for at
intake of Dietary least a 1000 mg/d reduction in most adults. -5/6 mm Hg
dietary Na sodium
Enhanced Aim for 3500–5000 mg/d, preferably by
intake of Dietary consumption of a diet rich in potassium. -4/5 mm Hg
dietary potassium
potassium
*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.
Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?
Available at:
Best Proven Nonpharmacological Interventions for Prevention and
Treatment of Hypertension*
Nonpharmacologica Dose Approximate Impact on SBP
l Intervention Hypertension Normotension
Physical Aerobic ● 90–150 min/wk -5/8 mm Hg -2/4 mm Hg
activity ● 65%–75% heart rate reserve
Dynamic resistance ● 90–150 min/wk -4 mm Hg -2 mm Hg
● 50%–80% 1 rep maximum
● 6 exercises, 3 sets/exercise, 10
repetitions/set
Isometric resistance ● 4 × 2 min (hand grip), 1 min rest -5 mm Hg -4 mm Hg
between exercises, 30%–40%
maximum voluntary contraction, 3
sessions/wk
● 8–10 wk
Moderation Alcohol In individuals who drink alcohol, -4 mm Hg -3 mm
in alcohol consumption reduce alcohol† to:
intake ● Men: ≤2 drinks daily
● Women: ≤1 drink daily

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.
†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular
beer (usually about 5% alcohol), 5 oz of wine (usually about 12%
alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).
Non pharmacological Treatment of HTN

DASH diet

Regular exercise

Loose weight , if obese

Reduce salt and high fat diets

Avoid harmful habits ,smoking ,alcohol

Algorithm of treatment 2018
 Pharmacological
Treatment Of Essential HTN
Treatment of essential HTN 2018

Be cautious with these medications:

 Oral contraceptive pills
 Steroids
 Nasal decongestants
Hypertension: Drugs Therapy

1. Diuretics
2. Beta Blockers
3. calcium channel blockers
4. ACEIs
5. ARBs
6. Central acting drugs
- Alpha methyl dopa
- Clonidine
7. Alpha blocker
- Doxazosin (Cardular)
Diuretics
 Thiazide-type Diuretics
Inhibit NaCl reabsorption
 Side effects:
- Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K
(advise K rich foods)
- Fluid volume depletion (monitor for orthostatic
hypotension)
- Urgency
- Hyperuricemia
Beta Blockers

 β-adrenergic blockers (suffix “olol”)

- metoprolol, propranolol
- Block β-adrenergic receptors
- ↓ HR, ↓ inotrope, vasoconstriction
 Side effects
Bradycardia, orthostatic hypotension,
impotence
Calcium Channel Blockers
 In patients with arrhythmia, IHD or
peripheral vascular disorders
 Side effects:
- Headache
- Flushing
- Ankle edema
- Constipation
- Slow heart rate (verapamil)
 ACEIs
 ACE Inhibitors (suffix “pril)
- Enalapril, captopril
- Improve proteinuria, improve heart failure, improve
renal failure,
- Prevents conversion of angiotensin I to angiotensin II,
thereby preventing the vasoconstriction associate with A.II.
 Side effects
Hypotension, cough, Hyperkaliemia, renal failure,
quincke edema
ARBs
 Improve microalbuminuria
 Improve renal functions

Ongoing studies are comparing the effect of ARBs with ACEI and are
investigating the use in patients with heart failure

SE : Sometimes renal failure

 Goals of treatment
 < 140/90 in all patients
 ≤ 130/80 , if tolerated
 For patients ≤ 65 yrs , it is recommended that
SBP be reduced to 120-129 mmHg in most
patients
 For patients ≥ 65 yrs , it’s recommended that the
target PAS be between 130-139 mmHg
 DBP <80 mmHg for all patients, regardless
of the level of cardiovascular risk and
comorbidities
 Close monitoring of adverse effects is
recommended, including the presence of
orthostatic hypotension
N.B:
 For patients ≥80 yrs, start treatment at 160/90 mmHg
 Remember that over treatment of Hypertension can
be
dangerous
 Renal Denervation
 The sympathetic nervous system plays a central role in
the regulation of BP and the pathogenesis of HTN
 In the first half of the 20th century, surgical
sympathectomy was shown to reduce SBP by more than
40 mm Hg in approximately one half of treated patients
with severe symptomatic HTN
 This approach was abandoned because of intraoperative
and long-term morbidity and the increased availability
of effective antihypertensive medications
Take home message
 Reduce levels of BP
 Reduce LVH
 Reduce levels of CABP
 Reduce Microalbuminuria
 Prevent and/or Reduce all CV risks
 Reduce proteinuria
 Prevent and/or Reduce CRF
 Block the Renin Angiot. Ald. System