: BY

Rawabi Saleh Bakrman

Fatima Mohammed Dawood
Supervision: Dr. Hassan Bayashoot
: Hypertension
Is diefined as persistently elevated in arterial blood
. pressure
Hypertension

Primary (or essential) Secondary

hypertension hypertension

Unknown etology :Specific cause

.cause Chronic kidney disease ,
Age, Genetic , stress or some drugs e.g:
,smooking , high .Corticosteroids , NSAIDs
sodium intake
 Diastolic Systolic Classification

mm Hg 80< mm Hg 120< NORAML

mm Hg 89 – 80 mm Hg 139 -120 Prehypertension

mm Hg 99- 90 mm Hg 159 – 140 Stage 1

Or = 100 mm Hg > or = 160 mm Hg> Stage 2

  : Treatment 
Goals of Treatment 

,BP less than 140/90 mm Hg for most patients #

,less than 140/80 mm Hg for patients with diabetes mellitus #
less than 130/80 mm Hg for patients with CKD who have#
persistent albuminuria
Stop smoking and reduce intake of dietary saturated fat and
cholesterol for overall cardiovascular health
 

 
  
 
NONPHARMACOLOGIC THERAPY:
 : Life style
-Weight loss
Limit alcohol intake-
Reduce sodium intake-
Maintain adequate intake of dietary-
potassium
 exercise-
: Pharmacological therapy # 
Initial drug selection depends on ¥
 .the degree of BP elevation-1

the presence of compelling indications-2

 Notes Examples Grops to
Treatment HTN

Long-term treatment with ACEI Captopril , Angiotensin-Converting

usually combined with diuretics Enzyme Inhibitor
reduce BP and albuminuria
Lisinopril ,Enalapril
(ACEI)
. and protect kidney function

Losartan , azilsartan , Angiotensin II

valsartan Receptor Blocker
Dihydropyridine : Calcium Channel
Amlodipine , Bloker
. Nifedipine
Nondihydropyridin
e: verapamil
Treatment of HTN in Aliskiren Renin inhibitors
Adult and children >6
years
 Examples Groups
Cardioselective : Beta Blocker
Atenolol , metoprlol,
bisoprolol
Non selective:
propranolol, Timolol

Thazide diuretics Diuretics

Loop diuretics :
furosemide
Potassium sparing:
Amiloride
:COMPELLING INDICATIONS 
compelling indications represent specific comorbid # 
conditions for which clinical trial data support using
specific antihypertensive drug classes to treat both
:hypertension and the compelling indication
  
Left Ventricular Dysfunction (Systolic Heart Failure) 
:Standard pharmacotherapy consists of three to four drugs 
  
ACE inhibitor or ARB plus diuretic therapy, # 
followed by addition of an appropriate β-blocker
  .and possibly an aldosterone receptor antagonist
.are often needed   

  
Postmyocardial Infarction
  
β-Blockers and ACE inhibitor or ARB therapy are• 
recommended.. ARBs are alternatives to ACE inhibitors
.in post-MI patients with LV dysfunction
  

Chronic Kidney Disease 

Either an ACE inhibitor or an ARB is first-line therapy to • 
.control BP and preserve kidney function in CKD
Diuretics and a third antihypertensive drug class (eg, β- - 
blocker or CCB) are often needed
  
Diabetes Mellitus
Treat all patients with diabetes and hypertension with an ACE inhibitor or •
.ARB
CCBs are the most appropriate add-on -
A thiazide diuretic is recommended as an add-on to the previous agents - 
to lower BP and
B.Blocker should be avoided as they can mask the signs and symptoms - 
of hypoglycemia .However pt have concomitant ischemic heart disease
.then B.B are usually prescribed
Coronary Artery Disease 
β-Blockers are first-line therapy in chronic stable angina and reduce BP,. • 
.CCBs are either alternatives) or add-on therapy
For acute coronary syndromes, first-line therapy includes a β-blocker and 
ACE inhibitor (or ARB); the combination lowers BP, controls acute
.ischemia, and reduces CV risk
  
  
 : SPECIAL POPULATIONS
: older people -1
the ultimate goal : less than 140 mm Hg, less than 130 mm Hg,
.or less than 120 mm Hg

Diuretics, ACE inhibitors, and ARBs ===> significant benefits✔️

.and safe, but smaller doses for initial therapy
:ACE inhibitors-1 
: captopril (alone or with thiazide )✔️
.Initial: 25 mg PO q8-12hr • 
.Maintenance: 25-150 mg PO q8-12hr ,max: 450 mg/day •

 
lisinopril : ( not taking diuretic )
.lower initial dose of 2.5-5 mg
.Usual range is 20-40 mg/day as single daily dose

diuretics -2
.furosemide: 10 mg/day PO #
: chlorthalidone and hydrochlorothiazide #
.usual range, 12.5-25 md /day
notes : monitor serum electrolytes , increased #
.hypotension
:children and adolescents - 2
 
.Secondary hypertension is more common than in adults
.the most common cause : Kidney disease e.g, pyelonephritis
Medical or surgical management of the underlying disorder
.usually normalizes BP
Non pharmacological treatment : weight loss in obese 
.children with primary hypertension
: medications #
ACE inhibitors, ARBs, β-blockers, CCBs, and thiazide diuretics
.===> drugs of choices
 
: pregnancy -3
Preeclampsia, defined as BP of 140/90 mm Hg or more that
appears after 20 weeks’ gestation accompanied by new-
onset proteinuria (≥300 mg/24 h), can lead to life-
threatening complications for both mother and fetus.
Eclampsia, the onset of convulsions in preeclampsia, is a
.medical emergency
.Definitive treatment of preeclampsia is delivery
the management : restricting activity, bedrest, close 
.monitoringand Salt restriction
 
Antihypertensives are used prior to induction of labor if the DBP is
greater than 105 mm Hg, with a target DBP of 95 to 105 mm Hg.
IV hydralazine is most commonly used; IV labetalol is also
.effective

drug doses and frequencies

Hydralazine mg IV/IM initially, THEN 5-10 mg q20-30min 5-10

,PRN
or
.mg/hr IV infusion 0.5-10

labetalol mg PO q12hr initially; increased by 100 mg 100

.q12hr every 2-3 days
Usual dosage range: 200-400 mg PO q12hr; not to
exceed 2400 mg/day
:African Americans -4 
HTN is more common and severe in them than in other 
.races
may be related to differences in electrolyte homeostasis, 
... GFR, sodium excretion and transport mechanisms
.increased need for combination therapy ==>goals 
Start with two drugs in patients with SBP values ≥15 mm 
.Hg from goal
.Thiazide diuretics and CCBs particularly effective 
When either of these two classes (especially thiazides) is 
used in combination with a β- blocker, ACE inhibitor, or
.ARB, antihypertensive response is significantly increased
a β-blocker is first-line therapy for BP control in an 
.)African American patient who is post-MI

 
Pulmonary Disease and Peripheral Arterial -5
:Disease
.cardio selective β-blockers ==> used safely 
cardio selective β-blockers ==> should be used to treat a 
compelling indication (ie, post-MI, coronary disease, or HF)
.in patients with reactive airway disease
PAD : ==> β-blocker with α-blocking properties (eg, 
.carvedilol)
: hypertension crisis💥 
.is a severe elevation in BP , BP> 180/110 mmHg - 
:two types of this condition 
: Hypertensive urgencies -1 
.without acute or progressive target- organ 
managed by adding a new antihypertensive and/or 
.increasing the dose of a present medication
: The management
drug doses and frequencies

captopril mg PO at 1-2 intervals 25-50

clonidine mg PO initially, then 0.1 mg/hr up to 0.8 mg total 0.2–0.1

 

labetalol mg PO repeated 400–200

Q 2–3 hr
: Hypertensive emergencies - 2
require immediate BP reduction to limit new or progress- ing 
.target-organ damage
: the management

drug doses and frequencies

sodium nitroprusaide .mcg/kg/min intravenous infusion 10–0.25 •
Not to exceed 10 mcg/kg/min •
Nicardipine HCl mg/h IV 15–5
Fenoldopam .Initial : 0.1–0.3 mcg/kg/min intravenous infusion •
Nitroglycerin .mcg/min intravenous infusion 100–5
Hydralazine hydrochloride mg intravenous 20–12
mg intramuscular 50–10
Labetalol hydro- chloride mg intravenous bolus every 10 min; 0.5–2.0 mg/min intrave- 80–20
nous infusion
Esmolol hydrochloride mcg/kg/min intravenous bolus, then 50–100 mcg/kg/min 500–250
intravenous infusion; may repeat
bolus after 5 minutes or increase infusion to 300 mcg/min
Enalaprilat mg IV every 6 h 5–1.25
Clevidipine mg/h (32 mg/h max) 2–1