HYPERTENSION

HYPERTENSION (HIGH BLOOD PRESSURE)

Is a disease of vascular regulation in which the mechanisms that control arterial pressure within the
normal range are altered?
One of the most important preventable causes of premature morbidity and mortality (WHO).
PATHOPHYSIOLOGY AND ETIOLOGY
Primary or Essential Hypertension
(Approximately 95% of patients with hypertension)
*
*

Cause of essential hypertension is unknown; however, there are several areas of investigation:
Systolic BP elevation in the absence of elevated diastolic BP is termed isolated systolic
hypertension and is treated in the same manner.
Classification of Blood Pressure for Adults
BP Classification

SBP*
(MM HG)

DBP*
(MM HG)

Normal

<120

<80

Pre hypertension

120-139

80-89

Stage 1 Hypertension

140-159

90-99

Stage 2 Hypertension

160

100

DBP: diastolic blood pressure; SBP: systolic blood pressure.

*Treatment determined by highest BP category.
Joint National Committee on Prevention, detection, Evaluation, and
Treatment og High Blood Pressure (2003). Available:
www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
Secondary Hypertension
1. Occurs in approximately 5% of patients with hypertension secondary to other pathology.
2. Renal pathology:
a. Congenital anomalies, pyelonephritis, renal artery obstruction, acute and chronic glomerulonephritis.
b. Reduced blood flow to kidney causes release of renin. Renin reacts with serum protein in liver (2-globulin)
angiotensin I; this plus angiotensin-converting enzyme (ACE) angiotensin II leads to increased BP.
3. Coarctation of aorta (stenosis of aorta) blood flow to upper extremities is greater than flow to lower
extremities hypertension of upper part of body.
4. Endocrine disturbances:
a. Pheochromocytoma a tumor of the adrenal gland that causes release of epinephrine and
norepinephrine and a rise in BP (extremely rare).
b. Adrenal cortex tumors lead to an increase in aldosterone secretion (hyperaldosteronism) and an elevated
BP (rare).
c. Cushing's syndrome leads to an increase in adrenocortical steroids (causing sodium and fluid retention) and
hypertension.
d. Hyperthyroidism causes increased cardiac output.
5. Medications, such as estrogens, sympathomimetics, antidepressants, NSAIDs, steroids.
Consequences of Hypertension
1. Prolonged hypertension damages blood vessels in the brain, eyes, heart, and kidneys and increases the risk
of stroke, angina, MI, blindness, and heart and kidney failure.

2. Blood vessel damage occurs through arteriosclerosis in which smooth muscle cell proliferation, lipid
infiltration, and calcium accumulation occur in the vascular epithelium.
3. Damage to heart, brain, eyes, and kidneys is termed target organ disease; this is the major object of
prevention in patients with high BP.
Prevalence and Risk Factors
1. Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most
patients with hypertension are untreated.
2. There are no symptoms; thus, it is termed the silent killer.
3. Increase in incidence is associated with the following risk factors:
a. Age between 30 and 70
b. Race Black
c. Overweight, sleep apnea
d. Family history
e. Smoking
f. Sedentary lifestyle
g. Diabetes mellitus
h. Metabolic syndrome
4. Prevalence in Blacks is 30%; in non-Hispanic Whites, 25%; and in Mexican-Americans, 22%.
Clinical Presentation
Usually asymptomatic
May cause headache, dizziness, blurred vision when greatly elevated.
Diagnostic Evaluation
1. ECG to determine effects of hypertension on the heart (left ventricular hypertrophy, ischemia) or
presence of underlying heart disease.
2. Chest X-ray may show cardiomegaly
3. Proteinuria, elevated serum blood urea nitrogen (BUN), and creatinine levels indicate kidney
disease as a cause or effect of hypertension; first voided urine microalbumin or spot urine for albumincreatinine ratio are earlier indicators.
4. Serum potassium decreased in primary hyperaldosteronism; elevated in Cushing's syndrome, both
causes of secondary hypertension.
5. Urine (24-hour) for catecholamines increased in pheochromocytoma.
Management
Lifestyle Modifications
1.
2.
3.
4.
5.
6.
7.
8.
9.

Lose weight if body mass index is greater than or equal to 25.

Limit alcohol
Get regular aerobic exercise equivalent to 30 to 45 minutes of brisk walking most days.
Cut sodium intake to 2.4 g or less per day.
Include recommended daily allowances of potassium, calcium, and magnesium in diet.
Smoking cessation.
Reduce dietary saturated fat and cholesterol.
Consider reducing coffee intake (5 cups per day has been shown to increase BP in hypertensive men).
If, despite lifestyle changes, the BP remains at or above 140/90 mm Hg (or is not at optimal level in the
presence of other cardiovascular risk factors) over 3 to 6 months, drug therapy should be initiated.
10. If BP extremely elevated or in presence of cardiovascular risk factors, single drug therapy may be given.
Drug Therapy
DIURETICS
Lower BP by promoting urinary excretion of water and sodium to lower blood volume.

Diuretics are divided into several subgroups:

Thiazide and thiazide-related diuretics inhibit reabsorption of sodium and chloride in the distal renal
tubule, increasing the excretion of sodium, chloride, and water by the kidney.
Loop diuretics inhibit the reabsorption of sodium and chloride in the loop of Henle and in the distal renal
tubule; because of this added effect, loop diuretics are more potent.
Potassium sparing diuretics block the effect of aldosterone on the renal tubule, leading to a loss of
sodium and water and the retention of potassium; their overall effect is much weaker.
Osmotic diuretics pull fluid out of the tissues with a hypertonic effect.
Contraindications and cautions

Contraindicated with fluid and electrolyte imbalances, renal or hepatic disease, gout , SLE, glucose
tolerance abnormalities, hyperparathyroidism, manic-depressive disorders , or lactation.

Selected adverse effects

Decreased potassium, sodium, magnesium; increased uric acid, calcium. Short duration of action,
hyperkalemia.
Interactions:
Drug-drug
Increased thiazide effects and possible acute hyperglycemia with diazoxide
Drug-lab test
Monitor for decreased PBI levels without clinical signs of thyroid disturbances.
Representative drugs

*
*
*
*
*
*
*

Thiazide and related diuretics

chlorothiazide
chlorthalidone
hydrochlorothiazide
hydroflumethiazide
indapamide
methyclothiazide
metolazone

*
*
*
*

Loop diuretics
bumetanide
ethacrynic acid
furosemide
torsemide

*
*
*

Potassium-sparing diuretics
amiloride
spironolactone
triamterene

Osmotic diuretics
* glycerin
* isosorbide
* mannitol
* urea

BETA ADRENERGIC BLOCKERS (-BLOCKERS)

Beta-adrenergic inhibitors that lower BP by slowing the heart and reducing cardiac output as well as release of
renin from the kidneys.
Contraindications and cautions
Contraindicated with allergy to beta-adrenergic blockers, sinus bradycardia, second- or third-degree heart
block, cardiogenic shock, heart failure, bronchial asthma, bronchospasm, COPD, pregnancy (neonatal
bradycardia, hypoglycemia, and apnea have occurred in infants whose mothers received propranolol; low
birth weight occurs with chronic maternal use during pregnancy), or lactation.
Use cautiously with hypoglycemia and diabetes, thyrotoxicosis, hepatic impairment.
Selected adverse effects
Bronchospasm, bradycardia, heart failure, fatigue, hypertriglyceridemia; may mask hypoglycemia.
Interactions
Drug-drug
Increased effects with verapamil and diltiazem
Drug-lab test
Interference with glucose or insulin tolerance tests, glaucoma screening tests
Representative drug
Atenolol
nadolol
Bisoprolol
pindolol
Carvedilol
propranolol
metoprolol
timolol
ALPHA-RECEPTOR BLOCKERS
Alpha-adrenergic inhibitors that lower BP by dilating peripheral blood vessels and lowering peripheral vascular
resistance Research has indicated these medications provide little protection against heart failure.
Contraindications and cautions

Contraindicated with hypersensitivity to any alpha1-adrenergic blocker, lactation.

Use cautiously with heart failure, renal failure, pregnancy.

Selected adverse effects
Orthostatic hypotension
Interactions
Drug-drug
Risk of severe hypotension if combined with sildenafil, tadalafil, vardenafil
Representative drugs
Alfuzosin
silodosin
Doxazosin
tamsulosin
Prazosin
terazosin
ACE INHIBITORS
Lower BP by blocking the enzyme that converts angiotensin I to the potent vasoconstrictor angiotensin II.
These drugs also raise the level of bradykinin, a potent vasodilator, and lower aldosterone levels.
Contraindications and cautions
Contraindicated with allergy to the drug, impaired renal function, heart failure, salt or volume depletion,
lactation, pregnancy, history of angioedema, bilateral renal artery stenosis.
Selected adverse effects
Cough, hyperkalemia, rash, angioedema
Interactions
Drug-drug
Increased risk of hypersensitivity reactions with allopurinol
Drug-lab test

 False-positive test for urine acetone

Representative
benazepril
captopril
enalapril

drugs
fosinopril
lisinopril
perindopril

quinapril
ramipril

ANGIOTENSIN II RECEPTOR BLOCKERS

Selectively block the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle
and adrenal gland. This action blocks the vasoconstriction effect of the renin-angiotensin system as well as the
release of aldosterone leading to decrease BP.
Contraindications and cautions

Contraindicated with hypersensitivity to any ARB, pregnancy (use during the second or third trimester can
cause injury or even death to the fetus), lactation
Use cautiously with renal impairment, hypovolemia.

Selected adverse effects

Hyperkalemia, angioedema
Interactions
Drug-drug

Decreased effectiveness if combined with phenobarbital

Risk of increased lithium levels
Representative drugs
candesartan
eprosartan
losartan

olmesartan
telmisartan
valsartan

CALCIUM ANTAGONISTS (CALCIUM CHANNEL BLOCKERS)

Stop the movement of calcium into the cells; relax smooth muscle, which causes vasodilation; and inhibit
reabsorption of sodium in the renal tubules.
Contraindications and cautions
Contraindicated with heart block, allergy to calcium channel blockers, sick sinus syndrome, ventricular
dysfunction, pregnancy
Use cautiously during lactation.
Selected adverse effects

Conduction defects, worsening diastole, dysfunction, gingival hyperplasia

Interactions
Drug-drug
Increased effects with cimetidine, ranitidine
Representative drugs
amlodipine
nifedipine
Diltiazem
nimodipine
felodipine
verapamil
nicardipine
OTHER ANTIHYPERTENSIVE DRUGS

CENTRAL ALPHA AGONISTS lower BP by diminishing sympathetic outflow from the brain, thereby
lowering peripheral resistance

Adverse effects: sedation, dry mouth, bradycardia

Representative drugs:

clonidine
methyldopa

guanfacine
reserpine

DIRECT VASODILATORS direct smooth muscle relaxants that primarily dilate arteries and arterioles.
Adverse effects: headache, fluid retention, tachycardia
Representative drugs:
hydralazine
minoxidil
COMPLICATIONS
Angina pectoris or MI due to decreased coronary perfusion
Left ventricular hypertrophy and heart failure due to consistently elevated aortic pressure
Renal failure due to thickening of renal vessels and diminished perfusion to the glomerulus
TIAs, stroke, or cerebral hemorrhage due to cerebral ischemia and arteriosclerosis
Retinopathy
Accelerated hypertension also called malignant hypertension, occurs when the BP elevates extremely rapidly,
threatening one or more of the target organs: brain, kidney, heart.
CONDITIONS FAVOURING USE OF PARTICULAR ANTIHYPERTENSIVE AGENTS
Thiazide diuretics
* systolic hypertension in the elderly
* heart failure
* black patients
ACE inhibitors
* heart failure
* left ventricular dysfunction
* post-myocardial infarction
* diabetic nephropathy
* left ventricular hypertrophy
* proteinuria
-blockers
* angina
* post-myocardial infarction
* heart failure (stable)
* atrial fibrillation
* pregnancy
Calcium channel blockers (dihydropyridines)
* systolic hypertension in the elderly
* angina
* pregnancy
* black patients
Calcium channel blockers (verapamil/diltiazem)
* angina
* atrial fibrillation
Loop diuretics
* renal impairment
* heart failure
Aldosterone antagonists
* heart failure
* post-myocardial infarction
* Conns syndrome

ALGORITHM

A= ace inhibitor
C= calcium channel blocker
D= diuretic

I can do all things through Christ who gives me

strength. Phil. 4:13 ]