Diagnosis

Diagnosis and
and management
management
of
of Hypertension
Hypertension

DR BEDARBAKHAT KHAN
MBBS,FCPS
ASSISTANT PROFESSOR OF
MEDICINE
LUMHS
Objective

• Definition of HTN
• Types of HTN
• Causes of 2ndry HTN
• Classification of HTN on basis of level
• Predisposing factor of HTN
• Disease attributed to HTN
• Diagnosis
• Treatment
Hypertension is defined as systolic blood
pressure (SBP) of 140 mmHg or greater,
diastolic blood pressure (DBP) of
90 mmHg or greater,
Types of hypertension

• Essential hypertension
– 95%
– No underlying cause

• Secondary hypertension
– Underlying cause
Causes of
Secondary Hypertension

• Renal
– Parenchymal
– Vascular
– Others
• Endocrine
• Miscellaneous
• Unknown
 Aetiology of Systemic
Hypertension

Secondary HTN (05%)

A. Renal (80%) • AGN • Renal Artery stenosis
• CGN,
• CPN,
• Polycyst. K.D

B. Endocrine • Adrenal • Primary aldosteronism

• Cushing’s syndrome
• Pheochromocytoma
• Acromegaly

• Exogenous hormone • Oral contraceptive

• Glucocorticoids
• Hypothyroidism &
• Hyperparathyroidism

Continue…
 Aetiology of
Systemic Hypertension

Others
– Coarctation of the aorta
– Pregnancy Induced HTN (Pre-eclampsia)
– Sleep Apnea Syndrome.
Classification
Who are at risk ?
 Hypertension:
Predisposing factors
• Advancing Age
• Sex (men and postmenopausal women)
• Family history of cardiovascular disease
• Sedentary life style & psycho-social stress
• Smoking ,High cholesterol diet, Low fruit
consumption
• Obesity & wt. gain
• Co-existing disorders such as diabetes, and
hyperlipidaemia
• High intake of alcohol
 Why to
treat ?
 Diseases Attributable to
Hypertension
Heart Left Ventricular
Gangrene of the
Failure Hypertrophy Myocardial
Lower Extremities
Infarction
Aortic Coronary Heart
Aneurym Disease
HYPERTENSION
Hypertensive
Blindness encephalopathy

Chronic Cerebral
Stroke Preeclampsia/ Hemorrhage
Kidney
Eclampsia
Failure
Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935
 Target Organ Damage

 Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
Diagnosis
 Clinical manifestations

• No specific complains or manifestations other than

elevated systolic and/or diastolic BP (Silent
Killer )
• Morning occipital headache
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision
 Self-Measurement of BP

 Provides information on:

1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN

 Home measurement of >135/85 mmHg is generally

considered to be hypertensive.

 Home measurement devices should be checked

regularly.
 Measuring
Blood Pressure

• Patient seated quietly for at least

5minutes in a chair, with feet on
the floor and arm supported at
heart level

•An appropriate-sized cuff (cuff bladder encircling at least

80% of the arm)

•At least 2 measurements

Continue…
 Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose,
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine
ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
How to treat ?
 Treatment Overview

 Goals of therapy
 Lifestyle modification
 Pharmacologic treatment
 Follow up and monitoring
 Goals of Therapy

 Reduce Cardiac and renal morbidity and mortality.

 Treat to BP <140/90 mmHg or BP <130/80 mmHg in

patients with diabetes or chronic kidney disease.
Non pharmacological
Treatment of hypertension

DASH
diet

Regular exercise

Loose weight , if obese

Reduce salt and high fat diets

Avoid harmful habits ,smoking ,alcohal

Life style modifications

• Lose weight, if overweight

• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and
cholesterol
• increase consumption of fruits and
vegetables
• Limit alcohol intake
 Lifestyle Modification

Modification Approximate SBP reduction

(range)

Weight reduction 5–20 mmHg / 10 kg weight loss

Adopt DASH eating 8–14 mmHg

plan
Dietary sodium 2–8 mmHg
reduction
Physical activity 4–9 mmHg
 Drug therapy for hypertension

Class of drug Example Initiating dose Usual maintenance

dose

Diuretics Hydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.

-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.

Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.
channel
blockers

-blockers prazosin 2.5 mg o.d 2.5-10mg o.d.

ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.

Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.

receptor blockers
 Diuretics

Example: Hydrochlorothiazide
• Act by decreasing blood volume and cardiac output
• Decrease peripheral resistance during chronic therapy
• Drugs of choice in elderly hypertensives
Side effects-
• Hypokalaemia
• Hyponatraemia
• Hyperlipidaemia
• Hyperuricaemia (hence contraindicated in gout)
• Hyperglycaemia (hence not safe in diabetes)
• Not safe in renal and hepatic insufficiency
 Beta blockers

Example: Atenolol, Metoprolol, nebivolol,

• Block 1 receptors on the heart
• Block 2 receptors on kidney and inhibit release of renin
• Decrease rate and force of contraction and thus reduce
cardiac output
• Drugs of choice in patients with co-existent coronary
heart disease
Side effects-
• lethargy, impotency, bradycardia
• Not safe in patients with co-existing asthma and
diabetes
• Have an adverse effect on the lipid profile
 Calcium channel blockers

Example: Amlodipine
• Block entry of calcium through calcium channels
• Cause vasodilation and reduce peripheral
resistance
• Drugs of choice in elderly hypertensives and
those with co-existing asthma
• Neutral effect on glucose and lipid levels

Side effects
Flushing, headache, Pedal edema
 ACE inhibitors

Example: Ramipril, Lisinopril, Enalapril

• Inhibit ACE and formation of angiotensin II
and block its effects
• Drugs of choice in co-existent diabetes
mellitus, Heart failure
Side effects-
dry cough, hypotension, angioedema
Angiotensin II receptor
blockers
Example: Losartan
• Block the angiotensin II receptor and
inhibit effects of angiotensin II
• Drugs of choice in patients with co-
existing diabetes mellitus

Side effects-
safer than ACEI, hypotension,
 Alpha blockers

Example: prazosin
• Block -1 receptors and cause vasodilation
• Reduce peripheral resistance and venous
return
• Exert beneficial effects on lipids and insulin
sensitivity
• Drugs of choice in patients with co-existing
BPH
Side effects-
Postural hypotension,
 Antihypertensive therapy:
Side-effects and Contraindications

Class of drugs Main side-effects Contraindications/

Special Precautions
Diuretics Electrolyte imbalance, Hypersensitivity,
Anuria
(e.g. Hydrochloro- total and LDL cholesterol
thiazide) levels, HDL cholesterol
levels,  glucose levels,
 uric acid levels
-blockers Impotence, Bradycardia,
(e.g. Atenolol) Fatigue Bradycardia,
Conduction
disturbances,
Diabetes,
Asthma, Severe
cardiac
failure
 Antihypertensive therapy: Side-
effects and Contraindications (Contd.)

Class of drug Main side-effects Contraindications/ Special

Precautions
Calcium channel blockers Pedal edema, Headache Non-dihydropyridine
(e.g. Amlodipine, CCBs (e.g diltiazem)–
Diltiazem) Hypersensitivity,
Bradycardia, Conduction
disturbances, CHF, LV
dysfunction.

-blockers Postural hypotension Hypersensitivity

(e.g. prazosin)
ACE-inhibitors Cough, Hypotension, Hypersensitivity, Pregnancy,
(e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis
Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy,
blockers (e.g. Losartan) Bilateral renal artery stenosis
 Choice of Drug

Condition Preferred drugs Other drugs Drugs to be

that can be used avoided
Asthma Calcium channel -blockers/Angiotensin-II -blockers
blockers receptor blockers/Diuretics/
ACE-inhibitors
Diabetes /ACE Calcium channel blockers Diuretics/
mellitùs/ -blockers
Angiotensin-II
receptor blockers
Elderly patients Calcium channel -blockers/ACE-
(above 60 years) blockers/Diuretics inhibitors/Angiotensin-II
receptor blockers/- blockers
BPH -blockers -blockers/ ACE inhibitors/
Angiotensin-II receptor
blockers/ Diuretics/
Calcium channel blockers
 Condition Preferred Drugs

• Pregnancy • Nifedipine, labetalol,

hydralazine, beta-blockers,
methyldopa, prazosin

• Coronary heart disease • Beta-blockers, ACE

inhibitors, Calcium channel
blockers

• Congestive heart failure • ACE inhibitors,

beta-blockers

1999 WHO-ISH guidelines

 Causes of
Resistant Hypertension

 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs,
sympathomimetics, OCP)
• Over-the-counter drugs and some herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN
 take home message --------------

• Hypertension is a major cause of morbidity and mortality,

and needs to be treated
• It is an extremely common condition; however it is still
under-diagnosed and undertreated
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from
the deleterious effect
• Besides pharmacology we have other choices and one
has to be acquainted with that choice
• Life style modification should always be encouraged in all
Hypertensive patients
 Life style intervention for management of
hypertension includes all except:
a) Regular aerobic activity 30 min /day
b) Salt intake to <6 gm./day
c) Attain and maintaining BMI >25k/m2
d) Diets rich in fruits and vegetables and restricted
content of saturated fats
 Hypertension management is helpful in the
prevention of all except:
a) Coronary heart disease
b) Heart failure
c) Chronic kidney disease
d) Deep venous thrombosis
e) Cerebrovascular disease
 which of the following is the side effect of
ACE inhibitors:
a) Hyperkalaemia
b) Hypercalcemia
c) Hyperglycaemia
d) Hypertension
e) Hypermagnesemia
 : Safest drug for hypertension in pregnancy
is:
a) ACE inhibitors
b) Angiotensin receptor blockers
c) Diuretic
d) Methyldopa
 the first line antihypertensive in diabetic
patients is:
a) Diuretics
b) Angiotensin converting enzyme inhibitors
c) Beta blockers
d) Calcium channel blockers
• A 48-year-old woman has been diagnosed with essential
hypertension and was commenced on treatment three
months ago. She presents to you with a dry cough which has
not been getting better despite taking cough linctus and
antibiotics. You assess the patient’s medication history. Which
of the following antihypertensive medications is responsible
for the patient’s symptoms?
• A. Amlodipine
• B. Lisinopril
• C. Bendroflumethiazide
• D. Frusemide
• E. Atenolol
• B. Lisinopril
• THANKS