hypertension and its management

Hypertension and Its Management

Hypertension and Its ManagementDr. Suman ChowdhuryCMCHExaminee of FCPSHypertension:Hypertension is a condition in which arterial BP is chronically [email protected], What is the upper [email protected]> 140/90 [email protected] Diabetic Patients:> 130/[email protected] it a Sign or Disease?It is more than a signIt will not be an exaggeration if we consider it as a disease!

[email protected][email protected] of HypertensionCategoryBHS JNC 7SBP (mmHg)

DBP (mmHg)

Optimal Normal< 120 < 80NormalPre hypertension< 130< 85High Normal130-13985-89HypertensionHypertension Grade 1 (Mild)Stage 1 140-15990-99 Grade 2 (Moderate)Stage 2160-179100-109 Grade 3 (Severe) 180 110Isolated Systolic Hypertension Grade 1 140-159< 90 Grade 2 160< 90 BHS = British Hypertension SocietyJNC 7= Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood [email protected] Primary/Essential Hypertension is said to be due to these following mechanisms: [email protected] nervous system hyperactivityThis is most apparent in younger persons with hypertension, who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pressure are poor. Insensitivity of the baro-reflexes may play a role in the genesis of adrenergic hyperactivity.Abnormal cardiovascular or renal developmentThe normal cardiovascular system develops so that elasticity of the great arteries is matched to the resistance in the periphery to optimize large vessel pressure waves. In this way, myocardial oxygen consumption is minimized and coronary flow maximized. Elevated blood pressure later in life could arise from abnormal development of aortic elasticity or reduced development of the microvascular network. This has been postulated as the sequence of events in low birth weight infants who have an increased risk of hypertension developing in adulthood. Another hypothesis proposes that the association between low birth weight and hypertension arises from reduced nephron [email protected] system activityRenin, a proteolytic enzyme, is secreted by cells surrounding glomerular afferent arterioles in response to a number of stimuli, including reduced renal perfusion pressure, diminished intravascular volume, circulating catecholamines, increased sympathetic nervous system activity, increased arteriolar stretch, and hypokalemia. Renin acts on angiotensinogen to cleave off the ten-amino-acid peptide angiotensin I. This peptide is then acted upon by angiotensin-converting enzyme (ACE) to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and stimulant of aldosterone release from the adrenal glands. Despite the role of renin in the regulation of blood pressure, it probably does not play a central role in the pathogenesis of most primary (essential) hypertension; only 10% of patients have high renin activity, whereas 60% have normal levels, and 30% have low levels. Black persons with hypertension and older patients tend to have lower plasma renin activity, which may be associated with expanded intravascular volume.

[email protected] in natriuresisNormal individuals increase their renal sodium excretion in response to elevations in arterial pressure. In hypertensive patients, this pressure-natriuresis relationship is reset so that maintenance of sodium homeostasis requires increased extracellular fluid volume and higher arterial pressure.Intracellular sodium and calciumIntracellular Na+ is elevated in primary (essential) hypertension. An increase in intracellular Na+ may lead to increased intracellular Ca2+ concentration as a result of facilitated exchange and might explain the increase in vascular smooth muscle tone that is characteristic of established [email protected] secondary causes are only 5%, the list is not too [email protected] causes of HypertensionSleep apneaDrug-induced or drug-relatedChronic kidney diseasePrimary aldosteronismRenovascular diseaseLong-term corticosteroid therapy and Cushing syndromePheochromocytomaCoarctation of the aortaThyroid or parathyroid [email protected] [email protected] EmergencyHypertensive Crisis These include patients with asymptomatic severe hypertension, very high blood pressure diastolic > 120 to 130 mm HgThere is no target organ damage BP at these levels often worries the physician; however, acute complications are unlikely, so immediate BP reduction is not required. Patients should be started on a 2-drug oral combination, and close evaluation (with evaluation of treatment efficacy) should be continued on an outpatient basis.

Hypertensive Urgency May be defined as acute and rapidly developing end organ damage with significant hypertension. Here blood Pressure is usually > 220 mm of Hg.Hypertensive emergencies require substantial reduction of blood pressure within 1 hour to avoid the risk of serious morbidity or deathThere is target organ damage.Hypertensive emergencies are treated in an ICU BP is progressively (although not abruptly) reduced using a short-acting, titratable IV drug. Choice of drug and speed and degree of reduction vary somewhat with the target organ involved, but generally a 20 to 25% reduction in MAP over an hour or so is appropriate, with further titration based on symptoms. Then if stable, to 160/100110 mmHg within the next 26 [email protected] Target Organ damageSigns and SymptomsHypertensive Retinopathy Grade 4RenalRetinalTransient disturbances of speech or vision, paraesthesiae, fits, disorientation, and loss of consciousness, Papilloedema is common A CT scan of the brain often shows haemorrhage in and around the basalganglia. CardiacCNSOrgans'Cotton wool' exudates are associated with retinal ischaemia or infarction, central retinal vein thrombosis Hypertensive nephropathyHematuria,proteinuria,and progressive kidneyAcute MI, acute left ventricularfailure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysmHypertensive EncephalopathyDisordersChest pain, Dyspnoes, sudden severe pain in back with [email protected] also, Preeclampsia + ConvulsionSigns and SymptomsEclampsiaPreeclampsiaDisordersIn PregnancyProteinuria, [email protected]!!!Interesting to note that, in case of Hypertensive encephalopathy, we have to very cautious to exclude stroke of any kind. For which, even an early MRI (T2 weighted) should be done if we are not confident enough after history, and physical (neurological) examination!! Because, the target and the management plan will be totally changed in case of [email protected] anti Hypertensive in strokeSAHIn Haemorrhagic stroke*In ischaemic strokeIntracerebral Who are not candidates for thrombolytic therapyIf thrombolytic therapy is to be usedTarget is MAP > 130mmHgTarget is SBP> 180mmHg and DBP > 130mmHg Target is SBP> 185mm Hg and DBP > 110mm HgTarget is SBP> 220mmHg and DBP> [email protected] Recommended Guidelines for TreatingElevated Blood Pressure in Spontaneous ICHIf SBP is 200 mm Hg or MAP is 150 mm Hg, then consider aggressive reduction of blood pressure with continuous intravenous infusion, with frequent blood pressure monitoring every 5 minutesIf SBP is 180 mm Hg or MAP is 130 mm Hg and there is evidence of or suspicion of elevated ICP, then consider monitoring ICP and reducing blood pressure using intermittent or continuous intravenous medications to keep cerebral perfusion pressure 60 to 80 mm [email protected] HypertensionMalignant Hypertension1. Complication with high blood pressure, target organ damageMalignant hypertension is by historical definition characterized by encephalopathy or nephropathy with accompanying papilledemaComplication of high blood pressure characterized by very elevated high blood pressure2. There is no fibrinoid necrosis of arterioles and small arteries2. There is fibrinoid necrosis of arterioles and small arteries.3. Target organ(eyes, heart, lungs, kidney)damage is present3. Target organ(eyes, heart, lungs, kidney)damage is present4. Fundoscopy shows flame shapedhemorrhages, or soft exudates, but nopapilledema.4. Fundoscopy shows papilledema5. There is no microangiopathic hemolyticanemia.5. There is microangiopathic hemolytic anemia6. There is no such demarcation6. Systolic and diastolic blood pressures are usually greater than 240 and 120, [email protected][email protected] person with Increased BP If not available, manage in WardLook for compelling indicationsSelect drugs after excluding compelling ContraindicationsIV GTN, Hydralazine, LabeteololIV drugs with titratable dosesCall for ICU/HDUYesNoLook for Hypertensive Crisise.g. CaptoprilStart Oral drugsEmergencyUrgencyEstablish HTN*Look for co-morbid conditionsWhen the blood pressure has been brought under control, combinations of oral antihypertensive agents can be added as parenteral drugs are tapered offover a period of 23 days. Most subsequent regimens should include a diuretic.If not controlledAdd other drugs later if necessaryLife style ModificationDrug Rx Consider special [email protected]* Persistent Raised BP:Measured at past two visits and Systolic BP or DBP or Both are > 140/90mmHg

Threshold for offering Drug treatment:BP > 160/100mmHg, orIsolated Systolic HTN (Systolic BP> 160 mmHg), orBP > 140/90mmHg, and10 yr CVD risk at list 20 % or Existing CVD or Target organ damage

[email protected] of Hypertensive [email protected] strategies:All patients should be provided a quiet room to rest; this can lead to a fall in BP of 10 to 20 mmHg or more. The approach varies depending on whether the patient has already been treated for hypertension or is untreated.Previously treated hypertensionPreviously Untreated hypertensionIncrease the dose of existing antihypertensive medications, or add another agent.Reinstitution of medications in non-adherent patients.Addition of a diuretic, and reinforcement of dietary sodium restriction, in patients who have worsening hypertension due to high sodium intake.In the previously untreated patient, several options are available. The approach should take into consideration:The individual patient's risk with persistence of severe hypertensionThe likely duration of severe hypertension,Of cerebrovascular or myocardial ischemia with rapid reduction in blood pressureRelatively rapid initial blood pressure reduction (over several hours). We use Oral [email protected] administration of drugs, the patient is observed for a few hours, to ascertain a reduction in blood pressure of 20 to 30 mmHg. Thereafter, a longer acting agent is prescribed and the patient is sent home to follow up within a few days. The drop in blood pressure may take relatively longer with captopril, and may be too large among patients with hemodynamically significant unilateral renal artery stenosis.Blood pressure reduction over one to two days. There are no data supporting the use of a particular agent in this setting although we generally do not begin therapy with extended release preparations or with a diuretic alone. Depending on the patient, a calcium channel blocker (but not sublingual nifedipine), beta blocker or angiotensin converting enzyme (ACE) inhibitor or receptor blocker can be started, like ramipril 10 mg once [email protected] choice of agent should take into consideration the type of antihypertensive agent that is most appropriate in the long term (eg, calcium channel blockers and thiazide-like diuretics are preferred over ACE inhibitors and beta blockers as monotherapy in blacks), and underlying conditions that may be favorably or adversely affected by the antihypertensive agent .Some experts initiate therapy with two agents or a combination agent, one of which is a thiazide diuretic. The rationale is that most patients with blood pressure 20/10 mmHg above goal will require two or more antihypertensive agents in order to achieve the goal blood pressure . It is unlikely that a diuretic in combination with a modest dose of another agent will cause a dangerous reduction in the blood pressure; however, initiation of two agents simultaneously must be done with close blood pressure follow-up, since the full effects of both agents may not occur for a few days, and adverse consequences may ensue if the blood pressure is lowered too quickly. This is particularly true among patients with cerebrovascular disease in whom more cautious blood pressure reduction is warranted.

[email protected] and follow-up [email protected] patient with severe asymptomatic hypertension is usually managed in the emergency room, since exclusion of acute end-organ damage requires laboratory testing, and the patient may require administration of medications and several hours of observation. However, the patient can often be safely managed in the physician's office if the evaluation and management can be carried out. The management of a patient who does not have established HTN, follow-up is difficult. Rarely, such patients may require admission. In addition, patients at high risk for cardiovascular events (e.g, long-standing diabetes, known coronary artery disease or prior stroke), should probably be admitted. [email protected], the patient should be observed for a few hours to ascertain that the blood pressure is stable or improving, and that indeed they are asymptomatic. If so, the patient can be sent home with close follow-up over the subsequent days directed towards evaluation for symptoms related to hypertension or hypotension, and adjustment of medications to achieve the initial blood pressure goal of 160/100 mmHg. In reliable patients who can monitor their blood pressure at home, close phone follow-up may substitute for direct physician visits. If the patient does not have a physician, follow-up may need to be in the emergency room or other acute care setting.Over the subsequent weeks and months, the dose and selection of medications should be adjusted as needed to achieve the desired blood pressure goals. These issues are discussed elsewhere. [email protected] for the Hypertensive [email protected]. Drugs for Hypertensive Emergency:DrugsDosageSodium NitroprusideInitially 0.3 g/kg/min, then 0.2510 g/kg/minIV infusion (maximum dose for 10 min only)Labetelol20-80 mg IV bolus over 2 min, followed q 10 min by 40 mg, then up to 3 doses of 80 mg; or 0.52 mg/min IV infusionNicardipineInitial 5mg/hr , Max. 15 mg/hrNitroglycerineInitial 5 g/min , then titrate 5 g/min at 3-5 mins intervalRange is: 5100 g/min IV infusionHydralazine10-50mg at 30 mins interval , (1040 mg IV, 1020 mg IM)Esmolol250500 g/kg/min for 1 min, then 50100 g/kg/min for 4 min; may repeat sequenceEnalapril0.625-1.25 mg over 5mins. Every 6-8 hrs, max. 5mg/[email protected] I.V drugs in Selected conditions:SituationsDrugsHypertensive encephalopathyNitropruside, Nicardipine, LabetelolAcute LVFNitroglycerine, Enalapril, Loop diureticsMI, Unstable anginaNitroglycerine, Nicardipine, Labetelol, EsmololEclampsiaLabetelol, HydralazineAortic dissectionNitropruside, Esmolol, [email protected]:Non pharmacologic therapy: Lifestyle modification may have an impact on morbidity and mortality. A diet rich in fruits, vegetables, and low-fat dairy foods and low in saturated and total fats (DASH diet) has been shown to lower blood [email protected] modifications to manage hypertensionModification RecommendationApproximate Systolic BP Reduction, RangeWeight reductionMaintain Norma l Body weight (BMI 18.5-24.9)5-20mmHg, 10 kg weight lossAdopt DASH eating planConsume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated fat and total fat814 mm HgDietary Sodium restrictionReduce dietary sodium intake to no more than 100 mEq/d (2.4 g sodium or 6 g sodium chloride)28 mm HgPhysical activityEngage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)49 mm HgModeration of alcoholconsumptionLimit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and no more than one drink per day in women and lighter-weight persons24 mm [email protected] approach:Depends mainly on:Compelling indicationsContraindicationsPresence of co-morbid conditionsSome special [email protected] Indications:CVD risk+ IHD+ (Previous H/O CVD= ACEi, ARBCardiac:Post MI=ACEi, Aldosterone antagonistsLVF = ARB, Aldosterone antagonistsDM Type 1= ACEiDM Type = ARBOlder patients+ Isolated Systolic HTN= Thiazide or Thiazide like diureticsCKD= ARB, ACEi

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Old ConceptNew [email protected] means, Beta blocker is less favored as an Antihypertensive [email protected]:Pregnancy: No ACEi, ARBAsthma+ COPD= No BlockerYoung male patient = No Blocker (Relative)Significant Renal artery stenosis = ARB, ACEiHyperkalaemia = ARB, ACEi

[email protected]:For all patients:Urinalysis for blood, protein and glucoseBlood urea, electrolytes and creatinineN.B. Hypokalaemic alkalosis may indicate primary hyperaldosteronism but is usually due to diuretic therapyBlood glucoseSerum total and HDL cholesterol12-lead ECG (left ventricular hypertrophy, coronary artery disease)[email protected] Selected Patients:Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aortaAmbulatory BP recording: to assess borderline or 'white coat' hypertensionEchocardiogram: to detect or quantify left ventricular hypertrophyRenal ultrasound: to detect possible renal diseaseRenal angiography: to detect or confirm presence of renal artery stenosisUrinary catecholamines: to detect possible phaeochromocytomaUrinary cortisol and dexamethasone suppression test: to detect possible Cushing's syndromePlasma renin activity and aldosterone: to detect possible primary [email protected]

RESISTANT HYPERTENSIONResistant hypertension is defined in JNC 7 as the failure to reach blood pressure control in patients who are adherent to full doses of an appropriate three drug regimen (including a diuretic). In this situation, the clinician should first exclude identifiable causes of hypertension, and then carefully explore reasons why the patient might not be at goal blood pressure. The clinician should pay particular attention to the type of diuretic being used in relation to the patient's kidney function. Aldosterone may play an important role in resistant hypertension and aldosterone receptor blockers can be very useful. If goal blood pressure cannot be achieved following completion of these steps, consultation with a hypertension specialist should be [email protected]

Causes of resistant hypertensionImproper blood pressure measurementVolume overload and pseudotoleranceExcess sodium intakeVolume retention from kidney diseaseInadequate diuretic therapyDrug-induced or other causes:NonadherenceInadequate dosesInappropriate combinationsNonsteroidal anti-inflammatory drugs; cyclooxygenase-2 inhibitorsCocaine, amphetamines, other illicit drugsSympathomimetics (decongestants, anorectics)[email protected] contraceptivesAdrenal steroidsCyclosporine and tacrolimusErythropoietinLicorice (including some chewing tobacco)Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma huang, bitter orange)Associated conditionsObesityExcess alcohol [email protected] antihypertensive drug therapy is initiated, most patients should return for follow up and adjustment of medications at monthly intervals or until the BP goal is reached and laboratory testing limited to tests appropriate for the patient and the medications used. More frequent visits will be necessary for patients with stage 2 hypertension or with complicating co morbid conditions. Serum potassium and creatinine should be monitored at least one to two times per year. Yearly monitoring of blood lipids is recommended, and an electrocardiogram should be repeated at 2- to 4-year intervals depending on whether initial abnormalities are present, the presence of coronary risk factors, and age.

Follow-Up of Patients Receiving Hypertension [email protected] target blood pressures during antihypertensive treatment:

No diabetesDiabetesClinic measurements< 140/85 mmHg< 130/80 mmHgMean day-time ambulatory or home measurement< 130/80 mmHg< 130/75 [email protected] BP is at goal and stable, follow up visits can usually be at 3- to 6-month intervals. Co morbidities such as HF, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. Other cardiovascular risk factors should be monitored and treated to their respective goals, and tobacco avoidance must be promoted vigorously. Low-dose aspirin therapy should be considered only when BP is controlled because of the increased risk of hemorrhagic stroke when the hypertension is not controlled. Pharmacy care programs have been shown to improve compliance with medications. Patients who have had excellent blood pressure control for several years, especially if they have lost weight and initiated favorable lifestyle modifications, should be considered for "step-down" of therapy to determine whether lower doses or discontinuation of medications are feasible.

[email protected] to note:Target BP is similar to that for younger patients.Antihypertensives are tolerated in elder patients as well as in younger patients.Not only the SBP, but DBP is also equally important regarding treatmentSometimes, antihypertensives are used not only to reach the target BP, but also for some other beneficial effects.We should be cautious about the combination antihypertensive drugs, as they causes Electrolytes Imbalance, Bradycardia, Exacerbation of Br. Asthma etc.

[email protected] is helpful if we consider the contraindications rather than the indicationsEffectiveness of some antihypertensive drugs may only be seen after a long period, so we should not hurry

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hypertension and its management

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