BP HIGHER IN MEN THAN WOMEN

High blood pressure is more common in men as compared to women before the age of 50 years
old. However, after the age of 55 years old, high blood pressure is more common among women
than men.
High blood pressure complications include heart attacks and stroke. Studies have shown that
such complications are significantly lower in women, especially in women who have not
undergone menopause. Between these two complications, the reduction in heart attacks is much
more prominent.
When comparing men and women between 40 and 70 years old with similar degrees of high
blood pressure, women have lower complication risks than men. Therefore, to have similar
damage to organs and blood vessels in women, a greater blood pressure load is required.
The reasons for gender differences in blood pressure are not known and several laboratories are
still researching. Some studies demonstrated that women tend to have higher heart pump output
and lower blood vessel resistance, thereby minimising blood vessel injury.
Younger women in their 20s to early 40s may be protected from high blood pressure and
cardiovascular disease (e.g. heart attacks, strokes) by oestrogen (a female sex hormone).
However, this is not yet proven as it is not evident that blood pressure changes are linked to
levels of endogenous sex hormones.

The womens blood pressure can escalate when oestrogen levels fall after menopause (around
the age of 50). By the age of 70, about 80 to 90 per cent of women are likely to have developed
high blood pressure.
BMI RANGE
The Body Mass Index (BMI) is a common measurement for your weight and height ratio. If your
Body Mass Index (BMI) is between 23 and 27.4, you have a moderate risk of developing high
blood pressure and heart disease. Your risk becomes very high if your BMI is 27.5 and above.
Normalise your blood pressure by keeping your BMI between 18.5 and 23.5 (the healthy weight
range for Asians).
http://www.healthxchange.com.sg/healthyliving/ManagingChronicIllnesses/Pages/high-
blood-pressure-how-do-men-and-women-differ.aspx




TYPES OF HYPERTENSION
There are two major types of hypertension and four less frequently found types.
The two major types are:
Primary or essential hypertension, that has no known cause, is diagnosed in the majority
of people.
Secondary hypertension is often caused by reversible factors, and is sometimes curable.
The other types include:
Malignant Hypertension.
Isolated Systolic Hypertension
White Coat Hypertension
Resistant Hypertension
Primary Hypertension
This type is also called essential hypertension, and it is by far the most common type of
hypertension, and is diagnosed in about 95% of cases. Essential hypertension has no obvious or
yet identifiable cause.
Secondary Hypertension:
This may be caused by:
Kidney damage or impaired function (This accounts for most secondary forms of
hypertension.)
Tumours or overactivity of the adrenal gland
Thyroid dysfunction
Coarctation of the aorta
Pregnancy-related conditions
Sleep Apnea Syndrome
Medication, recreational drugs, drinks & food
Malignant Hypertension
This, the most severe form of hypertension, is severe and progressive. It rapidly leads to organ
damage. Unless properly treated, it is fatal within five years for the majority of patients. Death
usually comes from heart failure, kidney damage or brain haemorrhage. However, aggressive
treatment can reverse the condition, and prevent its complications. Malignant hypertension is
becoming relatively rare, and is not caused by cancer or malignancy.

Isolated Systolic Hypertension
In this case the systolic blood pressure, (the top number), is consistently above 160 mm Hg, and
the diastolic below 90 mm Hg. This may occur in older people, and results from the age-related
stiffening of the arteries. The loss of elasticity in arteries, like the aorta, is mostly due to
arteriosclerosis. The Western lifestyle and diet is believed to be the root cause.
Latest studies confirm the importance of treating ISH, as it significantly reduces the incidence of
stroke and heart disease. Treatment starts with lifestyle modification, and if needed, added drugs.
White coat hypertension
Also called anxiety-induced hypertension, it means blood pressure is only high when tested by a
health professional. If confirmed, with repeat readings outside of the clinical setting, or a 24-
hour monitoring device, it does not need to be treated. However, regular follow-up is
recommended to ensure that persistent hypertension has not developed.
Lifestyle changes like more exercise, less salt and alcohol, no nicotine and weight loss, would be
wise. A low fat, high fibre diet, with increased fruit and vegetable intake, will be beneficial.
Resistant Hypertension
If blood pressure cannot be reduced to below 140/90 mmHg, despite a triple-drug regime,
resistant hypertension is considered.
STAGES OF HYPERTENSION
NORMAL, PRE-HT, STAGE 1, STAGE 2
Prehypertension
This hypertension stage is defined as a systolic blood pressure between 120 and 139 or a
diastolic pressure between 80 and 89. It is meant to identify adults who are at high risk for
developing hypertension. We dont have evidence that using medications at this range is useful
for preventing heart disease and stroke. However, because people in this group have some risk of
moving on to developing heart disease, we recommend lifestyle measures to try to prevent the
onset of hypertension. Blood pressure medication isn't usually recommended unless the patient
has diabetes or kidney disease and recommended lifestyle changes are not working.




Hypertension Stage 1
If your SBP is between 140 and 159 or your DBP is between 90 and 99, you are considered to
be in hypertension stage 1. Your doctor will recommend the same lifestyle changes mentioned
above, but you will also probably need to take medication. The JNC 7 report recommends that
the first medication to use is a thiazide-type diuretic. A diuretic is a medication that lowers blood
pressure by helping your body get rid of extra fluid and sodium. Diuretics are usually very
effective, have few side effects, and are inexpensive.
Hypertension Stage 2
If your systolic pressure is 160 or higher or your diastolic pressure is 100 or higher, you have
hypertension stage 2. People at this stage usually must modify lifestyle habits and take a diuretic
and another type of antihypertensive drug (maybe a third type if necessary). More than two-
thirds of hypertensive patients require two or more different medications.
Other factors will determine your treatment. African Americans, who have a higher risk of
developing hypertension-related complications, may require more aggressive treatment. If you
have an underlying condition, such as heart disease, diabetes, or kidney disease, your doctor will
factor that into the treatment choice.
Because none of the stages of hypertension has symptoms, everyone, even children, should get
their blood pressure checked regularly.
How to determine which stages of hypertension?
If your systolic and diastolic pressures fall into different stages, the stage with the higher number
is the one that counts. For example, if you have a systolic pressure of 150 mm Hg but your
diastolic pressure is only 85 mm Hg, you will be classified as stage 1 hypertension, not
prehypertension. And if you are over age 50, it is the diastolic number that best predicts your risk
of cardiovascular disease.
MEDICATIONS FOR STAGE 1 HT
Diuretics (water pills). Your doctor may first suggest diuretics also called water pills.
Diuretics work by flushing excess water and sodium from the body, thus lowering blood
pressure, which may be enough along with lifestyle changes to control your blood
pressure.
Although three types of diuretics are available, the first choice is usually a thiazide
diuretic. Thiazide diuretics typically have fewer side effects than do other types of
diuretics. They also offer strong protection against conditions that high blood pressure
can cause, such as stroke and heart failure. A diuretic may be the only high blood
pressure medication you need. But under some circumstances, your doctor may
recommend a different first line medication or may add another medication.
Angiotensin-converting enzyme (ACE) inhibitors. These allow blood vessels to widen
by preventing the formation of a hormone called angiotensin. Frequently prescribed ACE
inhibitors include enalapril (Vasotec), lisinopril (Prinivil, Zestril) and ramipril (Altace).
Angiotensin II receptor blockers. These help blood vessels relax by blocking the action
of angiotensin. Frequently prescribed angiotensin II receptor blockers include losartan
(Cozaar), candesartan (Atacand) and valsartan (Diovan).
Beta blockers. These work by blocking certain nerve and hormonal signals to the heart
and blood vessels, thus lowering blood pressure. Frequently prescribed beta blockers
include metoprolol (Lopressor, Toprol XL), nadolol (Corgard) and atenolol (Tenormin).
Calcium channel blockers. These prevent calcium from going into heart and blood
vessel muscle cells, thus causing the cells to relax, which lowers blood pressure.
Frequently prescribed calcium channel blockers include amlodipine (Norvasc), diltiazem
(Cardizem, Dilacor XR) and nifedipine (Adalat CC, Procardia).
Renin inhibitors. Renin is an enzyme produced by your kidneys that starts a chain of
chemical steps that increases blood pressure. Aliskiren (Tekturna) slows down the
production of renin, reducing its ability to begin this process. Due to a risk of serious
complications, including stroke, you shouldn't take aliskiren along with ACE inhibitors or
angiotensin II receptor blockers if you have diabetes or kidney disease.
Alpha Blockers (Prazosin). Prazosin is used with or without other medications to treat
high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks,
and kidney problems. Prazosin belongs to a class of medications called alpha blockers. It
works by relaxing and widening blood vessels so blood can flow more easily. Treat blood
circulation disorder and enlarge prostate to help your body pass, or get rid of kidney
stones thru urination.
Combining two medications of different classes may allow you to take a smaller dose of each,
which can reduce side effects
STAGE 2 MEDICATION
Same as Stage 1.







Drugs Common Side Effects Warning Signs
Diuretics Dizziness
Frequent urination
Headache
Feeling thirsty
Muscle cramps
Upset stomach
Severe rash
Problems breathing or
swallowing
Hyperuricemia (Gout)
ACE Inhibitors Cough
Dizziness
Feeling tired
Headache
Problems sleeping
Fast heart beat
Chest pain
Problems breathing or
swallowing
Swelling in the face,
eyes, lips, tongue, or
legs
Angiotensin II Sore throat
Sinus problems
Heartburn
Dizziness
Diarrhea
Back pain
Problems breathing
Fainting
Swelling of the face,
throat, lips, eyes,
hands, feet, ankles, or
legs
Beta Blockers
-highly metabolized, can take
with meals which the drug
amt into systemic circulation
Feeling tired
Upset stomach
Headache
Dizziness
Constipation/
Diarrhea
Feeling lightheaded
Chest pain
Problems breathing
Slow or irregular
heartbeat
Swelling in the hands,
feet, or legs

Calcium Channel Blockers Feeling drowsy
Headache
Upset stomach
Ankle swelling
Feeling flushed
(warm)
Chest pain
Serious rashes
Swelling of the face,
eyes, lips, tongue,
arms, or legs
Fainting
Irregular heartbeat
Renin Inhibitors Diarrhea Low blood pressure
Swelling of the face,
throat, lips, eyes or
tongue

Alpha blockers (prazosin) Fainting
http://www.fda.gov/forconsumers/byaudience/forwomen/ucm118594.htm

Coping with Antihypertensive Drug Side Effects
Constipation (calcium channel blockers and central alpha agonists). Eat foods high in fiber
(such as fruits, vegetables, whole grains, bran and legumes) and engage in moderate exercise.
Dehydration (loop diuretics). Drink plenty of fluids each day. If you consume beverages
containing alcohol or caffeine, do so in moderation.
Dizziness, lightheadedness or fainting (all types of antihypertensive medications but especially
alpha blockers). When standing up from a seated position, rise slowly. When getting up from a
recumbent position, sit on the edge of the bed with your feet dangling for one to two minutes and
then stand up slowly. Be especially careful about rising slowly when getting up in the middle of
the night to use the bathroom. Don't overexert yourself during exercise or in hot weather. Also,
try to avoid standing for long periods of time and consuming large amounts of alcohol.
Drowsiness (alpha blockers, beta blockers and central alpha agonists). Ask your doctor if you
can take your medication once a day 30 minutes before bedtime. If you need to take multiple
doses each day, ask if the last dose can be taken close to bedtime. Also, try to avoid other
medications that can lead to drowsiness, such as antihistamines, sleeping pills, prescription
pain relievers and muscle relaxants.
Dry mouth (central alpha agonists). Try sucking on sugarless candy, chewing sugarless gum or
melting ice cubes in your mouth. If these measures do not provide relief, ask your doctor about a
saliva substitute.
Frequent urination at night (beta blockers and diuretics). Ask your doctor whether you can
take your medication in a single dose in the morning after breakfast. If you require more than
one dose daily, ask whether you can take the last dose before 6 p.m.
Headaches (ACE inhibitors, alpha blockers, angiotensin II receptor blockers, calcium channel
blockers and direct vasodilators). Taking a hot shower or bath, pressing a cold pack to the
painful area, regular exercise and deep breathing may relieve headaches. If these measures
aren't helpful, ask your doctor to recommend a headache medication.
Increased sensitivity to cold (alpha blockers, beta blockers and direct vasodilators). Dress
warmly and be sure to keep your ears, hands and feet covered in cold weather. Take extra
precautions when you anticipate prolonged exposure to cold.
Increased sensitivity to sunlight (beta blockers, direct vasodilators and diuretics). Try to avoid
direct sunlight, particularly between the hours of 10 a.m. and 3 p.m., when the sun's rays are
strongest. Protect yourself from the sun by wearing protective clothing (including a wide-
brimmed hat and sunglasses) and using sun block and lip balm with an SPF of at least 15. Do
not use sunlamps or tanning beds or booths.
Potassium loss (loop and thiazide diuretics). Increase your intake of potassium-rich foods such
as fruits and vegetables. Alternatively, your doctor may add a potassium supplement or a
potassium-sparing diuretic to your treatment regimen.
Tender, swollen or bleeding gums (calcium channel blockers). Practice good dental hygiene
by brushing and flossing teeth and massaging gums daily. Have your teeth cleaned regularly by a
dentist.
Upset stomach (angiotensin II receptor blockers, beta blockers, direct vasodilators and diuretics).
Ask your doctor if you can take your medication with meals or with a glass of milk.

DRUG-DRUG INTERACTIONS
The new Canadian study suggests the combination can result in rare but serious kidney injuries.
The antibiotic is called clarithromycin and the high blood pressure drugs are a class of
medication called calcium channel blockers.
The authors compared rates of hospitalization for acute kidney injury, dangerously low blood
pressure and death in people taking the combination to people on calcium channel blockers
prescribed another antibiotic.
They found the risk of having one of those health outcomes within 30 days of starting the
antibiotic was doubled in people taking the clarithromycin and calcium channel blocker
combination.
Drugs in that class include amlodipine (sold under the brand name Norvasc), nifedipine (Adalat),
felodipine (Plendil), diltiazem (Cardizem) and verapamil (Isoptin). Clarithromycin is sold under
the brand name Biaxin.

Drug interactions occur when the effect of one drug is affected by the coadministration of
another.
1. Cholestyramine & thiazide diuretics
Cholestyramine resin adsorbs many substances, including drugs, and reduces the
absorption of thiazide diuretics. Best to give cholestyramine after 2-4 hours after
administration of thiazide (still there would be a reduction of 30-35% absorbed).
Cholestyramine results in lower plasma drug conc. And reduced drug effect.

2. eta blockers (propranolol) and vasodilator hydralazine
Hydralazine causes reduction in the metabolism of propranolol in its first pass
through liver before entry into the systemic circulation. This may be due to the
transient change in liver blood flow (faster rate) and hence in the rate of delivery
of drug to the liver. Increase conc. of propranolol into systemic circulation when
coadministered with hydralazine. After a meal, blood flow to the small intestine is
increased, and as a consequence, hepatic blood flow also is increased. As shown
in eqs. 8and 10the greater the blood flow, the lower will be the hepatic and
intestinal first-pass metabolism, resulting in an increased bioavailability. Clinical
studies demonstrate convincingly that the bioavailability of drugs subject to
significant first-pass metabolism during absorption is increased after a meal.


3. The reduction in propranolol conc. associated with the coadministration of
enzyme inducer rifampin (increases in propranolol clearance) will reduce its
antihypertensive effect.

4. Cimetidine (Hepatic drug metabolism inhibitor)
Increase propranolol conc. and effect.


5. Alcohol consumption and smoking (lessens effect of drug)
The effect of alcohol is not major, producing a rise in SBP of 4mmHg and smaller
changes in DBP.

6. Prazosin & beta blockers
Some of the products that may interact with this drug include: beta blockers (such
as atenolol, metoprolol, propranolol), verapamil, drugs to treat erectile
dysfunction-ED or pulmonary hypertension (such as sildenafil, tadalafil).

7. Almost all vasodilators causes fluid retention and weight gain. This increase the
intravascular volume results in loss of BP control. However, can be reversed by
diuretics.

http://hyper.ahajournals.org/content/11/3_Pt_2/II1.full.pdf
http://pharmrev.aspetjournals.org/content/51/2/135.full#title18
why does a decrease in liver blood flow will decrease the first-pass metabolism of
drug






Roles of Pharmacists:
- Determine which drug is suitable for that particular patient (based on his medical
condition)
- pharmacists should be encouraged to monitor patients' use of medications, to
provide information about potential adverse effects, and to avoid drug interactions
- Community pharmacists to work directly with specific physicians who refer
patients to them. In these collaborative relationships, pharmacists may measure
blood pressure, adjust dosages, and alter the antihypertensive regimen via
protocols. Pharmacists maintain close communication with the primary physician.
One classic older study and three more recent studies found that blood pressure
control could be improved when community pharmacists assisted with patient
education, blood pressure monitoring, drug therapy management, and compliance
assessment.
- Community pharmacists can serve as an important link between the physician and
patient.
- Clinical pharmacy specialists have multiple roles. These range from serving on
the interdisciplinary primary care team and assisting physicians with optimizing
antihypertensive drug selection and monitoring. They communicate closely and
work as true interdisciplinary teams to care for patients. In many of these settings,
clinical pharmacists do not dispense drugs but instead provide direct patient care
and interventions to physicians and nurses.
- It will be important that pharmacists be included in the team that cares for these
patients. It will require pharmacists who can use prescription and medical
databases to track drug adherence, control rates, optimal therapy, and compliance
with local standards of practice. Initiation of collaborative practice agreements,
modification of some state practice acts, and reexamination of public health
policy may be necessary to accomplish these national goals.










HYPERTENSION IN MALAYSIA~~ http://www.moh.gov.my/attachments/3885.pdf
ACEIs are drugs of choice based on extensive data attesting to their cardiovascular and renal
protective effects in diabetic patients.
If an ACEI is not tolerated, an ARB should be considered. Beta-blockers, diuretics or calcium
channel blockers may be considered if either ACEIs or ARBs cannot be used.

Table 6. Recommendations for follow-up based on initial blood
Initial BP (mmHg) Follow-up recommended to confirm
diagnosis and/or review response
to treatment

SBP DBP
<130 <85 Recheck in one year

130-139 85-89

Recheck within 3-6 months

140-159 90-99 Confirm within two months

160-179 100-109 Evaluate within one month and treat if confirmed

180-209 110-119 Evaluate within one week and treat if confirmed

210 120 Initiate drug treatment immediately


Prehypertension recheck within 3 6 months
Stage 1 confirm within two months, if positive, then follow up in 3 to 6 months provided if
target is achieved.
Stage 2 follow up within 1 month

Table 8. Effective antihypertensive combination
Effective combination Comments
-blockers + diuretics Benefits proven in the elderly, cost-effective. However may
increase risk of new onset diabetes
-blockers + CCBs Relatively cheap, appropriate for concurrent CHD
CCBs + ACEIs/ARBs Appropriate for concurrent dyslipidaemias and
diabetes mellitus
ACEIs + diuretics

Appropriate for concurrent heart failure, diabetes mellitus and
stroke

ARBs + diuretics

Appropriate for concurrent heart failure and diabetes mellitus
*Choice of first line monotherapy includes ACEIs, ARBs, CCBs and diuretics. Beta-blockers are
no longer recommended for first line monotherapy in this group of patients.