HYPERTENSION

Classification of Hypertension:
Category SBP (mm Hg)
DBP (mm Hg)

Optimal <120 and/or 80

Normal 120-129 and/or 80-84

High Normal 130-139 and/or 85-89

Grade 1 Hypertension 140-159 and/or 90-99

Grade 2 Hypertension 160-179 and/or 100-109

Grade 3 Hypertension >180 and/or >110

Isolated Systolic Hypertension >140 and <90

Hypertensive urgency >180 and/or >110

Severe asymptomatic hypertension with no evidence of
acute target organ damage.
Hypertensive emergency >180 and/or >110-120
Severe hypertension associated with cardiovascular
dysfunction (e.g. Left ventricular failure), cerebral
dysfunction (e.g. Hypertensive encephalopathy, stroke),
renal dysfunction (e.g. renal failure), or Grade III-IV
hypertensive retinopathy (haemorrhage, papilledema)
 Treatment algorithm:
Patient assessed for HTN

Grade 1 or Grade 2 Grade 3

Initiate one drug therapy Initiate 2 drug therapy

+
Lifestyle modification
CHOICE OF DRUG CAN BE either one of the following:
CCBs, ACE inhibitors OR Thiazide Diuretics.
+ Choice of combination can be:
Lifestyle Modification 1. CCB + ACE inhibitor.
2. CCB + Thiazide diuretic (low dose)
3. ACE inhibitor + Thiazide diuretic
Average starting dose: (low dose)
1. Amlodipine: 5mg.
2. Enalapril: 5mg.
3. Hydrochlorthiazide: 12.5mg.
Continue
YES treatment and
Target BP achieved with monotherapy?
evaluate every
NO 2-4 weeks.
Add a second drug (preferred over maximizing the dose
of initial drug).
If initial drug is a CCB, add either an ACE inhibitor or
Thiazide diuretic.
If initial drug is ACE inhib, add a CCB or thiazide diuretic
 Grade 1 or Grade 2 Grade 3

If 2 drug combination fails to achieve

target BP

Add a 3rd drug which was not used before.

Preferred combination is CCBs + ACE
inhibitor + Thiazide diuretic.

If BP is not controlled despite of 3 drug combination in optimal dose then

HTN should be termed as RESISTANT and patient should be referred to a
specialist for further evaluation and management.

Figure: Treatment algorithm for patients with HTN.

Abbreviations used: HTN- hypertension, CCB- Calcium Channel Blocker, ACE inhibitor- Angiotensin Converting Enzyme inhibitor,
BP- Blood Pressure.
Target BP:
• For Age ≥ 80 years is <150/90
• For age <80 is <140/90
 Patients with Diabetes or
CKD present

Patient’s with compelling indications: Different strategies adopted for pharmacotherapy

of HTN:
 Drug Class Agents of Choice Comments
Diuretics HCTZ 12.5-50mg, chlorthalidone 12.5-25mg, indapamide 1.25-2.5mg Monitor for hypokalemia
triamterene 100mg Most SE are metabolic in nature
K+ sparing – spironolactone 25-50mg, amiloride 5-10mg, triamterene Most effective when combined w/ ACEI
100mg Stronger clinical evidence w/chlorthalidone
Spironolactone - gynecomastia and
furosemide 20-80mg twice daily, torsemide 10-40mg hyperkalemia
Loop diuretics may be needed when GFR
<40mL/min
ACEI/ARB ACEI: lisinopril, benazapril, fosinopril and quinapril 10-40mg, ramipril 5- SE: Cough (ACEI only), angioedema (more with ACEI),
10mg, trandolapril 2-8mg hyperkalemia
ARB: candesartan 8-32mg, valsartan 80-320mg, losartan 50-100mg, Losartan lowers uric acid levels; candesartan may
olmesartan 20-40mg, telmisartan 20-80mg prevent migraine headaches
Beta-Blockers metoprolol succinate 50-100mg and tartrate 50-100mg twice daily, Not first line agents – reserve for post-MI/CHF
nebivolol 5-10mg, propranolol 40-120mg twice daily, carvedilol 6.25-25mg Cause fatigue and decreased heart rate
twice daily, bisoprolol 5-10mg, labetalol 100-300mg twice daily, Adversely affect glucose; mask hypoglycemic
awareness
Calcium channel Dihydropyridines: amlodipine 5-10mg, nifedipine ER 30-90mg, Cause edema; dihydropyridines may be safely combined
blockers Non-dihydropyridines: diltiazem ER 180-360 mg, verapamil 80-120mg 3 w/ B-blocker
times daily or ER 240-480mg Non-dihydropyridines reduce heart rate and proteinuria
Vasodilators hydralazine 25-100mg twice daily, minoxidil 5-10mg Hydralazine and minoxidil may cause reflex tachycardia
and fluid retention – usually require diuretic + B-blocker

terazosin 1-5mg, doxazosin 1-4mg given at bedtime Alpha-blockers may cause orthostatic hypotension
Centrally-acting clonidine 0.1-0.2mg twice daily, methyldopa 250-500mg twice daily Clonidine available in weekly patch formulation for
Agents resistant hypertension
guanfacine 1-3mg

IMPORTANT POINTS:
1. ACE inhibitors should NOT be combined with Angiotensin receptor blockers.
(increased risk of renal dysfunction and other adverse effects)

2. Avoid prescribing a combination of beta-blockers and diuretics as they can

increase the risk of diabetes mellitus in those at risk, e.g. persons with
impaired glucose tolerance or obesity and metabolic syndrome.
 References
1. World Health Organization, International Society of Hypertension Writing Group. 2003 World Health
Organization (WHO)/International Society of Hypertension (ISH) statement on management of
hypertension. Journal of hypertension. 2003;21(11):1983-92.
2. Wright JT, Williamson JD, Whelton PK, Snyder JK, Sink KM, Rocco MV, et al. A randomized trial of
intensive versus standard blood-pressure control. New England Journal of Medicine.
2015;373(22):2103-16.