Hypertension

Management
OMAR M AL NOZHA, MD

Endocrinologist
Assistant Professor - Taibah University
 Outline
Diagnostic points Therapeutic points

•Defining HTN •Target BP !

•Importance of Rx ?
•How to diagnose HTN •complications ?

•Secondary HTN •Ambulatory care :

•Approach to HTN Rx !!
High lights on the last Joint National •Which anti HTN agent ?
Committee on Prevention, Detection,
Evaluation, and Treatment of High
Blood Pressure consensus (JNC-7)
 Definitions
• Normal BP
• Pre-HTN
• HTN stages ” importance of knowing the stages ?”

• Hypertensive emergency
• Hypertensive urgency
JNC-7 classification
 Establishing Dx of HTN

In-office:

Two readings, 5 minutes apart.

sitting in chair.
Confirm elevated reading in contra-lateral arm.
 Definitions Contd.
Hypertensive emergency
• Acute, life-threatening, usually associated with marked
increases in (BP), generally ≥ 180/120 mmHg with evidence
of end-organ damage
( Heart, Brain, Kidney & Eye …Etc.)

• Target of Rx is to of alleviate damage and not causing

another !

• Lower DBP to about 100 mmHg; should be 2-6 Hrs, maximum

initial fall in BP not >25% of presenting value
 Definitions Contd.
Hypertensive urgency

Equivalent degree of hypertension

but

relatively asymptomatic
&
no acute signs of end-organ damage !

Optimal management is still controversial

 Secondary HTN
•When to suspect a secondary cause ?
• Young age
• Associations, Eg. : HTN & hypokaleamia /HTN & weakness
• Clinical syndromes

•What's the importance of knowing that ?

•How/when to role out secondary causes ?

 Complications
• The BP is an independent risk factor of CVD. (the major compl.)
(Stroke / MI / CHF)

• Each increment of 20/10 mmHg doubles the risk of CVD across the
entire BP range (starting from 115/75 mmHg.)

• Renal impairment esp. in DM Pts

• Eye : retinal , vitreous hemorrhage >>> blindness

• Peripheral Vascular Disease (PVD)

 Benefits of Therapy
• In stage 1 HTN and additional CVD risk factors, achieving
a sustained 12 mmHg reduction in SBP over 10 years will
prevent 1 death for every 11 Pts treated .

Average Percent Reduction if Rxed:

Stroke 35–40%

Myocardial infarction 20–25%

Heart failure 50%

 Targets of Therapy
•Prevent complications

•Target BP in different pt groups

(renal failure / DM patients )

•Hypertensive urgency / emergency approach

a general rule >> not too fast not too slow !!
Reminder of important
complications
 Ambulatory care
•First steps in the clinic after diagnosis !

•Role of diet & life style changes !

•Educating pt about symptoms !

•The importance of Rx ?

•Preventable complications ?

•JNC 7 and some facts about choosing agents !

 Initial Management !
• Diet :

• low salt Diet

• eg. DASH (Dietary Approaches to Stop Hypertension) trial
• low salt DASH group had a mean fall in systolic BP of
11.5 mmHg.

•Life style:
exercise 30 min x 4-5 / week couple of studies
Mean fall 5-15 mmHg
quit smoking, Risk modification in general!
 Why we need to know all those
CVD risk factors?
 Hypertension  Microalbuminuria or
 Diabetes mellitus estimated GFR <60 ml/min
 Cigarette smoking  Age (older than 55 for men,
65 for women)
 Obesity (BMI >30 kg/m2)
 Family history of premature
 Physical inactivity
CVD
 Dyslipidemia
(men under age 55 or
women under age 65)
In summery
After Clinical assessment is done !!!

WHAT’S NEXT ???

 Investigations
 Routine Testing:
• Serum K+, Renal function “Cr,”
• ECG
• Urinalysis
• Blood glucose, ( concurrent risks)
• Lipid profile
 Extra tests :
• Measurement of urinary albumin or albumin/creatinine ratio

• Other Tests for secondary HTN if indicated !!!

 When to screen for
2ndry HTN ?
• HTN & hypokalemia

• Severe or resistant HTN

• HTN & an adrenal incidentaloma

• HTN & a Family Hx of early-onset HTN or cerebrovascular accident

at a young age (<40 years).

• HTN & first-degree relatives with documented primary

aldosteronism /pheo/MEN
Drugs and therapeutic
Agents!
 DRUG CLASSES
Office Emergency
 Thiazide diuretics
•Using IV medication
 ACE-I
•Nitroprusside
 ARBs
•IV labetalol
 Ca-channel Blockers
•Other IV meds.
 Beta Blockers
 Loop diuretics / K+ sparing
diuretics
 Alfa blockers
 Methyldopa
 IV medications !!
 Which to start?
Preferences/Restrictions None Available
•General Guidance : •The 1st line is always thiazides :

•DM •Why ? Evidence, coast, A/E

•Renal failure
•CHF
•How it works ?
•ACEI / ARBs to be part of the therapy
•In CHF diuretics play more role •any class can be chosen afterwards!

•Pregnancy Methyldopa, BBs, and vasodilators, •If gout or prediabetes avoid HCTZ
preferred for the safety of the fetus. ACEI and
ARBs are contraindicated in pregnancy. •If PH of electrolyte imbalance avoid HCTZ
 If BP uncontrolled despite Rx!
• None proper measurement of BP

• None compliance to life style and diet

Especially salt intake !!! If Rx is diuretics ( thiazide)
• Not compliant with medications
• Physician Fault :
• Improper dosing or choice of Anti HTN agent
• Drug interactions
• Un identified etiology of HTN ( secondary HTN)
ESSENTIAL HTN
MOST COMMON
CAUSE IS
 SOME IMPORTANT
POINTS
FROM JNC-7 CONSENSUSS
 Summery of objectives
in ambulatory care Rx of HTN

1. Assess lifestyle and identify other CV risk factors or

co-morbid conditions that affects prognosis and guides
treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and

CVD.
 JNC has provided allot of help to
physicians in HTN management

Management guidelines
Educational material
Website : http://www.nhlbi.nih.gov/guidelines/hypertension/

Power point presentations

&
Pocket cards
Time for discussion and
questions ….