Hypertension

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Hypertension
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Definition

• Systolic Blood Pressure 140 mmHg and/or
• Diastolic Blood Pressure 90 mm Hg

ECS/ESH Guidelines 2018
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Types of Hypertension

• Primary Hypertension
• Also known as essential hypertension
• Idiopathic
• Includes 90-95

• Secondary Hypertension
• Hypertension with underlying causes

ECS/ESH Guidelines 2018 Marwah Deepak Medicine
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Risk Factors

• Modifiable
• Obesity or Overweight
• Diabetes Mellitus
• Sedentary Lifestyle
• Alcohol consumption
• Tobacco Use
• Stress
• Increased Salt Intake
• Socioeconomic State

• Non- Modifiable
• Age
• Gender Male gt Female
• Genetic Predisposition
• Early Menopause

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Secondary Hypertension

• Renal parenchymal disease CKD, PCKD,
  Obstructive Uropathy
• Renovascular disease Atherosclerotic renal
  artery stenosis, Fibromuscular dysplasia
• Hemodynamic Causes Coarctation of Aorta,
  Takayasu Disease, Aortic Regurgitation
• Obstructive Sleep Apnoea (Metabolic Syndrome)
• Endocrine Causes Primary Aldosteronism,
  Pheochromocytoma, Cushing Syndrome, Thyroid
  Disease( Hyper and Hypo ) and Thyrotoxicosis,
  Hyperparathyroidism , Acromegaly
• Drug Induces NSAIDs, OCPs, Corticosteroids
• Neurogenic Spinal cord transaction, Raised ICP
• Mendelian Cause Gordon Syndrome , Liddle
  Syndrome

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Pathophysiology of Hypertension
DUCTIN Heart Foundation
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Researchgate.net
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Grades of Hypertension
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Stage and risk
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Clinical Features of Hypertension

• Mostly asymptomatic
• Some symptoms may show up
• Headache
• Asphyxia
• Nausea
• Epistaxis
• Fatigue
• Chest pain
• Palpitation
• Vison Problems

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Hypertension Mediated Organ Damage
Biomedforms.org
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ECS/ESH Guidelines 2018
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Diagnosis

• Medical History
• BP (Previous Current)
• History of current or past anti-hypertensive
  medications
• History other medications, menopause history
• History of other r diseases( CVD, Renal, CNS)
• Evaluation of Risk Factors and Lifestyle
• Family history of HTN, CVD, Stroke or Renal
  Diseases
• Assessment of overall CV risk
• Physical Examination
• BP measurement, (equal and symmetric BP
  bilaterally)
• Pulse rate, rhythm and JVP
• Edema
• BMI
• Auscultation of heart and carotid artery- apex
  beat, extra heart sound, basal crackles
• Other organs/system- enlarged kidneys, enlarged
  thyroid, fatty deposits and coloured striae
  abdominal masses and bruits
• Skin examination
• Any signs of Cushing disease, acromegaly
• Neurolgical examination (seizures, papilledema,
  hemorrhage)

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• ROUTINE LAB TESTS
• CBC cardiac markers, infection, anemia
• Urine Analysis microscopic examination, urinary
  protein by dip stick testor,AER, albumin
  creatinine ratio
• Fasting blood glucose increase
• Lipid profile total cholesterol increase, LDL
  increase , HDL
• Blood triglycerides increase
• Blood uric acid increase
• Blood creatinine and GFR
• Blood potassium and sodium
• KFT Uric acid, BUN, Creatinine
• TSH endocrine diseases
• Instrumental
• ECG Afib, signs of LVH, ischemic heart disease,
  arrhythmia, HR, cardiac rhythm
• Echo coarctation of aorta, LVH, aortic root
  dimensions
• USD Renal size and structure,
• Fundoscopy retinal changes
• CT , MRI Hemorrhagic brain injury

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TREATMENT AND MANAGEMENT

• LIFE STYLE MODIFICATION
• Waist circumference (Flt 80cm , Mlt94cm)
• Smoking Cessation
• Alcohol cessation
• D.A.S.H
• Na (decrease) , K (increase,)
• Salt restriction lt5gm/day
• Stop saturated fats
• Deacrese carbohydrates
• Vegetables
• Nuts
• Fruits
• Low red meat
• Physical activity- (weight loss, BMI (20-25kg/m²)
  
• 30mins for 4-5 days a week

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ECS/ESH Guidelines 2018
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UNCOMPLICATED

• If patient lt55 yr
• Begin with ACEI (Ramipril 2.5-20mg)If not
  effective add ACEICCB(Amilodipine 2.5-10mg)If
  not effective add ACEICCBTHIAZIDE DIURETICS(
  spirinolactone 20-50mg)
• If patient gt55 yr
• Begin with CCB(Amilodipine 2.5-10mg)If not
  effective add CCBACEI(Ramipril 2.5-20mg)If not
  effective add CCBACEITHIAZIDE
  DIURETICS(spirinolactone 20-50mg)
• Resistant HTN
• Uncontrolled BP inspite of 3 classes of anti
  hypertensive drugs including thiazide diuretics
  (beta blocker or alpha blocker)

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COMPLICATED

• ACEI
• acs post mi diabetic nephropathy HF with ??
  EF
• Ischemic neuropathy
• Beta blockers
• CHF due to systolic dysfunction
  
• chronic stable angina
• Alpha blockers
• Htn BPH
• Htn pheochromocytoma
• Aldosterone antagonist
• pt with HFpEF

ECS/ESH Guidelines 2018 Marwah Deepak Medicine
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Antihypertensive Drugs

• ACE INHIBITOR
• ENALAPRIL (10-20mg/B.I.D) RAMIPRIL
  (2.5-20mg ) , S/E Hyperkalemia,dry cough CI
  Pregnancy
• THIAZIDE DIURETICS
• HYDROCHLOROTHIAZIDE 12.5- 50mg PO once daily
  INDAPAMIDE 1.25mg P.O CHLORTHALIDONE 12.5
  25mg S/E Hypercalcemia, Hypokalemia, Gout
  hyperglycemia, CI Hypotension
• CCB
• DIHYDROPYRIDINE AMLODIPINE (2.5-10 mg once a
  day) NONDIHYDROPYRIDINE VERAPAMIL (80mg) S/E
  Edema and flushing, constipation
• ARB
• LOSARTAN (25-100mg / day) , S/E Hyperkalemia
• B-BLOCKER
• LABETALOL (50mg/ once a day)
• METOPROLOL (100-200mg)

EC/SESH Guidelines 2018 Marwah Deepak Medicine
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• HTN in pregnancy Methyldopa- 250mg
• HTN emergency in pregnancy- Hydralazine
• HTN emergency Nitroprusside
• RESISTANT HTN gt3CLASSES of antihypertensive
  medication use, Uncontrolled HTN MUST INCLUDE
  THIAZIDE, If Still not control Add Alpha
  Blocker (phenoxybenzamine 10mg)
• lt 55yr ACE INH. / ARB
• gt55yr CCB
• 30yr ACEI-gtCCB-gtTHIAZIDES

ECS/ESH Guidelines 2018 Marwah Deepak Medicine
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Hypertensive crisis

• HYPERTENSIVE URGENCY
• BP gt220/125mmHg without Target Organ
  Damage
• HYPERTENSIVE EMERGENCY / CRISIS
• gt220/125mmHg with Tareget Organ Damage
• Eg Malignant htn fibrinoid necrosis of blood
  vessels of retina, brain, heart, kidney, blood
  vesselsMalignant htn mortality ? 50 ( 6-12
  months )Rx Several hours, MAP 20-25
  Lebetalol . Nicardioine SNP
  ACEI ( intravenously) Sodium
  Nitroprusside Hypertensive encepalopathy
  Labetalol, Nicardipine , Sodium Nitroprusside.

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Target BP goal

• lt65 yrs old lt130/80 mmHg
• gt65 yrs old lt130-139 / lt80 mmHg
• Both SBP DBP Should be corrected
• Malignant htn on admission 160/110 mmHg
  MAP ? 25
  over 2 hours

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PREVENTION

• Healthy lifestyle
• Regular exercise ( weight loss)
• Healthy diet
• Limit alcohol
• Stop smoking
• Managee stress
• Goal lt140/90 mmHg in all patients regular
  health care visits

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Thank You