HYPERTENSION

Asst. Professor
Department of
Medicine
Bangalore Medical
College
 Commonest Non-communicable disease
next to Diabetes
Rapidly increasing incidence/prevalence
Modernization, industrialization,
urbanization increases HTN incidence
Platform for no. of complications
A life style disorder
 About 972 million patients of HTN
Incidence 3%, Prevalence 18%
About 50 million Americans have HTN
31.6% American HTN does not know
1/3 American HTN have controlled BP
50,000 deaths directly & 2 lakh deaths
indirectly every year in US
 Emerging major health problem
Increasing in epidemic proportions
Incidence & prevalence same as in US
75% patients not aware of increased BP
Most patients have inadequate treatment
50% patient change treatment/doctor
Complications are common in many
 Increased & persistent High
Blood Pressure (BP)
> 140 / 90 mm Hg
 Primary / Essential 90-95%
Secondary 5-10%
BP classification SBP mm Hg DBP mm Hg
Normal <120 and <80
Prehypertension 120 -139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 hypertension 160 100
JNC 6 category SBP/DBP JNC 7 category
Optimal < 120/80 Normal
Normal 120-129/80-84 Prehypertension
Borderline 130-139/85-89
Hypertension 140/90 Hypertension
Stage 1 140-159/90-99 Stage 1
Stage 2 160-179/100-109 Stage 2
Stage 3 180-110
 Exact cause not known
Genetic factors
Environmental Factors
- Obesity
- Increased Salt intake
- Increased Alcohol intake
- Decreased Physical
activity
- Cigarette smoking
(Tobacco)
- Chronic emotional stress
 Urbanization
Industrialization
Modernization ( Ultra )
Westernization
Life style modification
Suffocation
 Upto 60% HTN inherited
Genes influence synthesis of
Angiotensinogen, Glucocorticoid receptors &
Kallikrein
+ve family h/o 1.7 times > controls
+ve family h/o for stroke deaths
3.5 times > controls
 Back Americans highest risk
HTN occurs early
More severe
80% stroke mortality
50% heart disease mortality
32% chances of ESRD
 North India South India
HTN Incidence less more
Salt intake more less
Fat intake less more
Smoking/tobacco more less
Diet roughage more less
 Both male & female are affected equally
IncreasedAge - Increased BP ( systolic >
Diastolic)
Systolic pressure increases upto 80yrs (M)
70yrs (F)
Diastolic pressure peaks early & later declines
 BP with abdominal obesity
Risk - Abd. Obesity > 85cms(F) >98cms(M)
70% HTN (M), 61% HTN (F) have Obesity
1 mm Sys. BP increases with 2 lb weight gain
Obesity initiate / complicate HTN
2
BMI = Wt.(Kg) / Ht.(Mts )
Normal : 18-24.9
Over weight : 25 29.9
Obesity : > 30
 Heart
BMI Diabetes HTN Stroke
Disease

18.5-21.9 1.0 1.0 1.0 1.0

22.0-24.9 1.8 1.5 1.1 1.1

25.0-29.9 5.6 2.4 1.7 1.3

30.0-34.9 18.2 3.8 2.2 2.1

35 41.2 4.2 2.4 2.5

 Communities with low salt intake (<3gm/d)
have low average BP
Migration from low to high salt zone BP
Urbanization, westernization, restaurant food ,
high salt BP
Salt intake with abnormal salt(Na)
sensitivity predisposes for HTN
 Modest intake < 30ml/day does not BP
Excess alcohol BP in HTN/Non-HTN
Excess alcohol

accounts to 5-30% HTN

Alcohol has dose

related effect on BP
 Sedentary individuals 20-50% increased risk for
HTN
Physical inactivity leads

to Obesity, DM, HTN,

CVD, CVA
Physical activity
prescribed treatment for
HTN
 Mental stress Acute in BP
Chronic stress - Persistent BP
Effect of stress depends on

nature of stress, individual

perception/ reaction
Stress management

prescribed treatment
in HTN
 Powerful risk factor for HTN
Nicotine a potent

vaso-constrictor
2 cigarettes BP
by 16mm Hg
for 20min
 Sleep poor quality/ sleep
Caffeine excess
Low calcium intake
Low potassium intake
Socio-economic factors
Modern life style
 Blood pressure (BP) =
Cardiac output X Peripheral resistance
(CO) (PR)
 Autoregulation Perpetuation
Cardiac Output PR (functional Of
Vasoconstriction/ Hypertension
Structural
hypertrophy )
Cell
membrane
Excess Na intake Alterations
Fluid volume
Growth
Renal Na factors
retention Endothelium
Derived
factors
Insulin
resistance
Sympathetic
Cardiac contractility
Nervous
overactivity

Renin angiotensin
excess
Pathogenesis of Hypertension
 Asymptomatic Hematuria
Dizziness Blurring of vision
Palpitations TIAs
Easy fatiguability Angina
Impotence
Epistaxis
 Asymptomatic majority
Casual
Classical early morning occipital headache
Complicated
Causal
 Headache
Syncope
Breathlessness
Fatigue
Palpitations
 Look for Ht ,Wt ,BMI ,Gpe
BP recordings twice ( sitting ,standing ,lying
down )
Abdominal findings Bruits and palpable
kidneys
Apex beat S3 ,S4 and murmurs
Fundus examination
RS look for basal rales
 Family h/o HTN /SCD /Stroke
Occupational h/o ( including stress )
Drug intake (OCPs etc )
H/o smoking /alcohol
Systemic diseases ( DM /Renal /lipid )
h/o related to endocrinal disorders
Diet H/o
Investigations
Hemogram Special investigations
FBS Chest X Ray
PPBS ECG
Blood urea
2D echo
S .creatinine
USG abdomen
S .electrolytes

S. uric acid

Urine routine
 BP measurement by
Spygmomanometer

> 140/90 mm Hg ( 2 readings)

Cardiovascular system Atherosclerosis
Left ventricular hypertrophy
Acute MI
SCD
CCF
Central nervous system Stroke Ischemic and haemorrhagic
Encephalopathy
Infarcts
Kidney Nephrosclerosis
CRF
ESRD
Proteinuria
Retina Retinopathy
Detachment
Papilledema
Blindness
 Age < 30 years and > 60 years
Diastolic HTN
End organ damage
Resistant \ Refractory HTN
Failure of postural drop
 Derangement in the renal handling of Na and
fluids --- volume expansion
Alteration in the renal secretion of vasoactive
materials --- Systemic / local arterial tone
changes
Increased vasopressors or decreased
vasodilator production (prostaglandins ) ---
failure to inactivate vasopressors
Renal artery stenosis (atherosclerosis ) ----
decreases perfusion of renal tissue
Rarely increases renin secretion ( tumors)
 Renal artery stenosis
Glomerulonephritis ( AGN /CGN )
ARF
CRF
History
Onset of hypertension before age 30 and after age
50
Abrupt onset of hypertension
Severe or resistant hypertension
Arteriosclerotic disease
Smoker
Significant azotemia with ACE inhibition
Examination
Abdominal bruits
Other bruits
Advanced fundal changes
 Adrenal HTN primary aldosteronism
,Cushings syndrome and Pheochromocytoma
Pituitary acromegaly
Parathyroid Hyperparathyroidism
Miscellaneous OCP induced
 Commonest cause of Secondary HTN
Estrogens activate Renin Angiotensinogen
Aldosterone axis increased production HTN
Some women more prone increased vascular
sensitivity to angiotensinogen 2 ,have mild
renal disease ,familial factors ,age > 35 years
and obesity
50% patients return to normal after 6 months
after stopping OCP
 Accelerated atherosclerosis
Increased left ventricular wall stress ,tension
and stroke work
Left ventricular hypertrophy
Abnormal coronary flow reserve
Abnormal vasomotor response
Endothelial dysfunction
 Diet
Exercise
Life style modifications
Drug therapy
Treatment of complications
 To have normotension around the clock
To prevent Target organ damage /
complications
To postpone complications / Target organ
damage
To prevent acute complications
To prevent /decrease cardiovascular risk
 Stress management relaxation techniques
Diet DASH
decrease salt ( upto 10 g NaCl /day )
decrease calorie and fat intake
increase fruit and vegetables and fibre
diet
Exercise regular aerobic /Isotonic exercise
Risk factor control stop smoking ,moderate
alcohol intake and control weight and decrease
coffee intake
Modification Recommendation Approximate SBP
reduction
Weight reduction Maintain normal body 5-20 mm Hg /10 kg
weight (BMI 18.5 24.9
kg/m2)
Adopt DASH eating plan Consume a diet rich in 8-14 mm Hg
fruits ,vegetables and low-
fat dairy products with a
reduced content of
saturated and total fat
Dietary sodium restriction Reduced dietary sodium 2-8 mm Hg
intake to no more than 100
mmol/day (2.4 g sodium or
6 g NaCl )
Physical activity Engage in regular aerobic 4-9 mm Hg
physical activity such as
brisk walking ( atleast 30
minutes/day ,most days of
week )
Moderation of alcohol Limit consumption to no 2-4 mm Hg
more than two drinks (eg 24
oz beer ,10 oz wine ,or 3 oz
80-proof whiskey ) per day
 Diuretics
Adrenergic blockers ( alpha and beta )
CCBs
ACEIs
ARBs
Direct vasodilators ( venous and arterial )
 < 140/90 in all individuals
<130/90 in diabetes /renal disease
< ? 130/90 in pregnancy
 First choice in mild moderate HTN
Drug of choice in isolated systolic HTN
(elderly)
May be added to other classes of drugs
Chlorthalidone 6.25 -12.5 mg
Hydrochlorothiazide 12.5 25 mg
Side effects Hypokalemia ,abnormal GTT
,insulin resistance ,hyperuricemia and
dyslipidemia
 Established first line of treatment for HTN
Preferred in HTN with angina /MI /Post MI
Commonly used Atenolol -50 -100 mg
Metoprolol - 25 -50 mg
Nebivolol = 5 mg
Others Nadolol/Acebutolol/Pindolol/carvedilol
Side effects
Bradycardia,Bronchospasm,Impotence,
Dyslipidemia
Contraindications CHB ,severe bronchospasm
severe depression
 Important group of Cardiovascular drugs
Decrease BP and peripheral resistance and
cause reflex tachycardia
Important are Verapamil -40 -120 mg
Nifedipine 10-20 mg
Diltiazem 30 -120 mg
Amlodipine 10-20 mg
Side effects Reflex tachycardia ,gum
hypertrophy and pedal edema
 Acts via renin -angiotensin aldosterone
system
Decrease eliminate Angiotensin 2 formation
Important are Captopril 2.5 -15 mg
enalapril - 5- 40 mg
Lisinopril - 5-40 mg
Ramipril 1.25-20 mg
Benazepril 5-40 mg
Side effects Cough upto 30%,Hyperkalemia ,
Angioedema
Indications Contraindications
Hypertension [first Bilateral renal artery
time] stenosis
Unilateral renal artery Renal failure
stenosis Severe CCF
Post MI dysfunction Pregnancy
Diabetic hypertensives HTN with severe cough
Dibetic nephropathies

Nephrotic syndrome

Hypertensive heart
failure
 Selectively block Angiotensin 2 (AT ) receptors
Effects Endothelium \Heart \Kidney \ CNS
Losartan -25-100 mg
Valsartan- 80-160 mg
Irbesartan- 75-300 mg
Telmisartan 20-80 mg
Cabdesartan-4-32 mg
Indications- CHF ,LV dysfunction ,DM ,CRF
Contraindications -Pregnancy
 Acts on vascular smooth muscle
Used in moderate HTN /emergencies
Arterial vasodilators
1. Hydralazine oral 10-75 mg
2. Minoxidil oral 2.5 -40 mg
3. Fenoldopam IV 0.1 microgram /kg/min
Arterial and venodilators
1. Sodium nitroprusside IV 0.5-8 microgram
/kg/min
2. Diazoxide IV 1-3 mg/kg
 Powerful vasodilators
Cause postural hypotension
Used in HTN of pheochromocytoma
Prazosin 6-15 mg
Terazosin 5-20 mg
Doxazosin 1- 16 mg
 Methyl dopa 500-2000mg
Clonidine 0.2-2 mg
Guanabenz 4-16mg

Side effects: dry

mouth,drowsiness,depression,sexual
dysfunction,postural
hypotension,reboundHTN
 Accelerated HTN: significant increase in BP
without papilledema

Malignant HTN: significant increase in BP with

papilledema

White coat HTN: transient rise in BP in

clinics/hospitals

Pseudo HTN: false rise in BP (stiff vessels)

 HTN urgency: marked rise in BP without TOD

HTN emergency: marked rise in BP with TOD

Isolated systolic HTN: systolic BP >140

diastolic BP<90

Transient HTN: temporary rise in BP

(AMI,CVA,stress)
 Confirm HTN- assess the situation
Monotherapy in mild/ moderate HTN
Low dose thiazides (12.5/25 mg), ACE
inhibitors (ramipril 5mg), CCBs (amlodipine
5mg) beta-blockers (atenolol 50mg ) are
considered
Monitor BP and titrate for optimal dose
Treatment usually life long
Step wise approach is no longer adviced
Combination therapy is highly useful
 HTN+ pregnancy :methyl
dopa,hydralazine,CCBs

HTN+ IHD :beta blockers,CCBs

HTN+DM :ARBS+ACEi

HTN+ COPD : CCBs, ACEi

HTN+CRF :CCBs,ACEi
 HTN+anxiety :beta blockers

HTN+PAD :CCBs, alpha blockers

HTN+SAH : CCBs(nimodepine)

HTN+CCF/LVH :ACEi, ARBS

Elderly HTN :Thiazides, CCBs

 CNS: CVA- infarction/ hemorrhage
SAH,encephalopathy
Retina detachment and retinopathy

CVS LVH, LVF CAD aortic aneurysm, aortic

dissection, SCD
Kidney- proteinuria , CRF
Misc- malignant HTN, refractory HTN
 Severe HTN (>250/140) with papilledema-
exudates/hemorrhages
Seen in poorly managed HTN pt
Precipitating factors
beer/coffee/ciggarrettes/OCP
Symptoms- giddiness,headache, impaired
vision,chest pain,seizures, breathlessness
Treat this medical emergency
iv esmolol/sodium nitroprusside/glyceryl
trinitrate