Hypertension is one of the most common disease world-

wide affecting human being. It is most common

modifiable risk factor for coronary heart diseases stroke,

congestive heart failure, end stage renal disease, and

peripheral vascular disease

Definition

Based on recommendation of 7th report of JNC of

preventing, detection, evaluation, and treatment of high

blood pressure-

HYPERTENSION-AN APPROACH

BY-

DrAwadhesh Kumar Sharma,SR

Medicine,MLB Medical college,jhansi,UP,india

B.P. classification

Systolic B.P. (mmHg)*

Diastolic B.P. (mmHg)*

Normal <120 <80

Prehypertensive 120-139 80-89

Stage1 140-159 90-99

Stage2 160 100

* for adults 18 years

* Based on 2 or more reading taken at 2 or more visits

History

How to obtain blood pressure-

Recommendations-

1. BP should be measured with a well caliberated

sphygmomanometer with a bulb of proper size the

bladder width with in the cuff should encircle at least

80% of the arm circumference after the patient has

been resting comfortably, back supported in the

resting or supine position, for at least 5 minutes and at

least 30 minutes after smoking or coffee ingestion.

2. Patient should be seated quietly for minutes.

3. Smoking, exercise, caffeine ingestion should not have

occurred with in 30 min. prior to BP measurement.

4. Cuff should be wrapped snugly around arm with

bladder centred over brachial artery. Bladder should

encircle atleast 80% of arm.

5. Cuff should be inflated 20 to 30mmHg above the SBP

for auscultatory determination.

6. Position the stethoscope over brachial artery, deflate

the cuff at a rate of 2to 3 mmHg per second,

appearance of first sound (phase 1) is used to record

SBP, and disappearance of sound (phased 5) is DBP.

Evaluation

Following the documentation of HTN, we should extract the following information-

Extent of target organ damage Assessment of patient cardiovascular status. Exclusion of secondary causes of HTN.

Obtain- H/O cardio vascular disease risk factor like

hypercholesterolemia, DM, and tobacco use H/O over-the counter medication use (current and previous

antihypertensive drugs) H/O and physical findings suggesting possibility of

secondary hypertension like H/O renal disease, anemia, and urochrome pigmentation.

H/O sweating, labile HTN, and palpitation suggests diagnosis of Pheochromocytoma

H/O cold or heat intolerance, sweating, lack of energy, bradycardia or tachycardia suggests hypothyroidism/hyperthyroidism.

H/O muscular weakness suggests hyperaldosteronism.

H/O kidney stone suggests hyperparathyroidism.

Abdominal bruit suggests possibility of renal artery stenosis.

Presence of papilledema and other neurological sign raise possibility of raised intracranial tension.

H/O drug ingestion including OCPs, licorice and sympathomimmetics.

Physical Examination-

Fundoscopic evaluation for any hypertensive

retinopathy.

Palpation of all peripheral pulses should be

performed.

Look for renal artery bruit over upper abdomen,

presence of unilateral bruit with a systolic and

diastolic component suggests U/L renal artery

stenosis.

Causes

Primary or essential hypertension

Term applied to 95% of cases in which no cause for hypertension can be identified.

The pathogenesis of essential hypertension is multifactorial.

Genetic factors play a important role.

Increased salt intake and obesity have long been incriminated.

Enviromental factors also are significant.

Secondary hypertension

Approximately 5% of patients with hypertension have specific causes

When we suspect secondary hypertension

In patients who develop hypertension at an early age with or without a positive family history.

Those who first exhibit hypertension when over age 50 years.

Those previously well controlled now become refractory to treatment.

 

Causes

1. Renal (2.5-6%)- Renal parenchymal disease

Polycystic kidney disease

Urinary tract obstruction

Renin producing tumors

2. Renovascular hypertension (indicated by acute renal failure with introduction of ACEI or ARBs)

Renal vascular hypertension should be suspected in the following circumstances.

If the documented onset is below age 20 or after age 50 years.

If there are epigastric or renal artery bruits.

If there is atherosclerotic disease of the aorta or peripheral arteries (15-25% of patients with symptomatic lower limb atherosclerotic vascular disease have renal artery stenosis)

If there is abrupt deterioration in renal function after administration of angiotensin converting enzyme inhibitors.

4. Vascular- Coarctation of aorta

Vasculitis

Collagen vascular disease

5. Endocrine-Primary aldosteronism

Cushing’s syndrome

Pheochromocytoma (indicated by worsening of hypertension with introduction of beta-blocker)

Congenital adrenal hyperrplasia

Hypothyroidism and hyperthyroidism

Hyperparathyroidism (hypercalcemia)

Acromegaly

6. Neurogenic-Brain tumor

Bulbar poliomyelitis

Raised ICT

7. Pregnancy induced hypertension

8. Drugs and toxins-alcohol, cocaine, cyclosporine, erythropoietin.

Initial diagnostic laboratory testing for hypertensive patients-

Recommended tests Relevance to secondary cause CBC Polycythemia Potassium Hyperaldosteronism Sodium Hypealdosteronism Creatinine Renal Parenchyml disease Fasting glucose Diabetes mellitus Total cholesterol Electrocardogram Urinalysis Renal parenchymal disease Echocardiography HDL cholesterol Chest x-ray

Laboratory evaluation for the secondary causes-

Causes Tests Pheochromocytoma Plasma metanephrines 24hr urinary

metanephrines, MIBG scanning Cushing syndrome 24 hr urine cortisol, 1mg overnight

dexamethasone suppression tests adrenal computed tomography

Hypo/hyperthyroidism TSH, total and free thyroxine, thyroid ultrasound

Hyperparathyroidism Serum calcium, phosphorus, PTH Obstructive sleep apnea Overnight oximetery

Polysomonography with CPAP trial Coarctation Simultaneous arm and thigh BP

measurement Aortogram/MRA ultrasound

TreatmentMedical Care- JNC 7recommendation to lower BP and

decrease CVD risk include the following- Lose weight if overweight Limit alcohol intake to no more than 1 oz(30 ml) of

ethanol ie 24oz (720 ml) of beer, 10 oz of wine. Increase aerobic activity (30-45 min on most of days) Reduce sodium intake to no more than 100

mmol/day(6gm/day) Maintain adequate intake of potassium (approx. 90

mmol/day) Maintain adequate dietary intake of calcium and

magnesium Stop smoking and reduce intake of dietary saturated fat

and cholesterol for overall cardiovascular health.

Recommendation for management of hypertension- The 2000 Canadian hypertension society recommendation (similar to JNC 7 guidelines) for management of hypertension are as follows-

Risk factor/disease Preferred therapy Alternative therapy

Uncomplicated HTN (<60yrs)

Low dose thiazides,beta blockers or long cting DHP calcium channel blockers

Combination of first line drugs

Uncomplicated HTN (>60yrs)

Low dose thiazides, ACEl LADHP CCBs Do

Dyslipidemia As for uncomplicated HTN . . .

DM with nephropathy ACEI ARBs

DM without nephropathy ACEI or beta blockers ….

DM without nephropathy, with systolic hypertension

Low dose thazides or LA DHP CCBs ….

Angina Beta-blockers, ACEI ….

Systolic dysfunction ACEI (thiazide or loop diuretics, beta blockers, spironolactone as add on therapy)

ARBs, hydralazine, isosorbide di nitrate, amlodipine

Left ventricular hypertrophy Most anti hypertensives reduce LVH ….

Peripheral arterial disease As for uncomplicated HTN ….

Renal disease ACEI (diuretics as add on therapy) DHP CCBs

Prior MI Beta blocker (ACEI as add on therapy)

Resistant hypertension-

Persistant diastolic BP > 100 mmHg despite treatment. Potential causes of inadequate response to antihypertensive therapy are

1. Technical barrier-

2. White coat hypertension

3. Pseudohypertension (in old age due to arteriosclerotic walls)

4. Improper BP assessment technique

5. Patient related causes

6. Non compliance

7. Access to medical care

8. Costs of drugs

9. Side effects to drugs

10.Lack of understanding of diseases process

11.Failure to initiate / maintain life style changes

12.Ingestion of aggravating substances

13.Physician related causes-

Failure to intensify therapy (especially to elevated SBP)

14.Time/practice limitation

15.Knowledge base

Surgical Care-

Aortorenal bypass using saphenous graft or hypogastric artery is a common revascularization technique for renal artery stenosis.

Target values for hypertension control (adopted from JNC7)-

Condition Target (SBP/DBP mmHg)

Hypertension <140/90

Diabetes <140/80

Diabetes mellitus +

nephropathy

<140/80

Chronic kidney disease <140/90

Proteinurea > 1gm/day <125/75

Hypertensive Emergencies and Urgencies

Hypertensive Urgencies

Situation where blood pressure must be reduced with in a few hours.

These includes patients with symptomatic hypertension systolic blood pressure > 220 mm Hg or diastolic pressure>125 mm Hg that persists after a period of observation and those with optic disc edema, progressive target organ complications and peri operative hypertension.

Potential drug therapy is not usually required and partial reduction of blood pressure with relief of symptoms is the goal.

Hypertensive Emergencies

Substantial reduction of blood pressure with in 1 hours to avoid the risk of serious morbidity or death.

It includes hypertensive encephalopathy, hypertensive nephropathy, intravascular haemorhage, aortic dissection, preeclampsia-eclampsia, pulmonary edema, unstable angina or myocardial infarction.

Malignant hypertension

Encephalopathy or nephropathy with accompanay papilloedema.

Parenteral therapy is indicated in most hypertensive emergencies, usually if encephalopathy is present.

Assess elevated BP, Asses other risk factors and target organ damage

SBP<180 or DBP <110 mmHg SBP > 180 or DBP > 110 mmHg

Initiate lifestyle measures Begin drug treatment add lifestyle measures

Stratify absolute risk

Medium / low High

SBP 130-139 or DBP 85-89 on several occasions

Verified SBP 140- 179 or DBP 90-109 mmHg on several occasions

Begin drug treatment strongly consider therapy as

initial treatment

No treatment Monitor BP and other risk factors

Begin drug treatment

PREVENTION OF HYPERTENSIONWHO has recommended the following approaches in the

prevention of hypertension:

PRIMARY PREVENTION

Although control of hypertension can be successfully achieved by medication (secondary prevention) the ultimate goal in general is primary prevention. The earlier the prevention starts the more likely it is to be effective.

NUTRITION: these comprise:

(i) Reduction of salt intake to an average of not more than 5g per day

(ii) Moderate fat intake

(iii)The avoidance of a high alcohol intake

(iv)Restriction of energy intake appropriate to body needs.

WEIGHT REDUCTON: The prevention and correction

of obesity (Body Mass index greater than 25) is a

prudent way of reducing the risk of hypertension and

indirectly CHD.

EXERCISE PROMOTION: Regular physical activity

should be encouraged as part of the strategy for risk

factor control

BEHAVIOURAL CHANGES: Reduction of stress and

smoking , modification of personal life-style, yoga and

transcendental meditation could be profitable.

SECONDARY PREVENTION

The goal of secondary prevention is to detect and control high blood pressure in affected individuals.

TREATMENT: The aim of treatment should be to obtain a blood pressure below 140/90, and ideally a blood pressure of 120/80.

PATIENT COMPLIANCE: The treatment of high blood pressure must normally be life-long and this presents problems of patient compliance. Which is defined as “ the extent to which patient behavior (in terms of taking medicines, following diets or executing other life-style changes) coincides with clinical prescription. The compliance rates can be improved through education directed to patients, families and the community.