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Management of Hypertension
Management of Hypertension
HYPERTENSION
BY: DR SITI SYUKRIAH BINTI SHAHARUDIN
KK SELANDAR
9/9/2022
DEFINITION
Non-Communicable Diseases is already the main cause of death in Malaysia and the biggest
contributor in terms of disability life-years (DALYs), with high blood pressure the biggest
contributor for both males and females.
EPIDEMIOLOGY CONT’
• Based on National Heath and Morbidity Survey for NCD risk factors in 2015
• Prevalence 35.3% among adults 18 years and above
• An increase from 33.6% in 2011 as compared to 34.6% in 2006.
• In terms of awareness, only 37.5% were aware in 2015, a drop from 40.7% in 2011. In 2006, the awareness
rate was 35.6%.
• There is a general increasing trend in prevalence with age, from 6.7% in the 18-19 years age group,
reaching a peak of 75.4% among the 70-74 years age group
• Prevalence highest among other bumiputra (37.3%) > Malay (36.4%) > Indian (34.9%) > Chinese
(34.2%)
• HPT more prevalent at rural area 39.2% versus 34.1% (2015)
• More prevalent among males (35.9%) than females (34.8%) for year 2015
CLASSIFICATION
CLASSIFICATION
CLASSIFICATION
• Masked hypertension
• Defined as normal clinic BP but elevated daytime ambulatory/home BP level (>135/85mmHg)
DIAGNOSIS
– TO OBTAINED COMPLETE HISTORY
DIAGNOSIS
- PHYSICAL EXAMINATION
DIAGNOSIS
- INVESTIGATION
• If the patient does not show response or does not tolerate the initial drug, substituting
with a drug from another class is recommended.
• In patients presenting with stage II hypertension or beyond, combination therapy as first
line is recommended.
• Combination therapy can be considered as first line in high risk stage 1 hypertension
especially for secondary prevention.
• Single pill combination – improve adherence, however costly and not readily available at
KK.
TARGET BLOOD PRESSURE
• For high and very high risk patient – advisable to bring BP to target within 3-6 months.
• Once target BP achieved follow-up interval 3-6 months
• At least 6 monthly follow-up even BP well controlled
• Assess persistence of BP control
• Adverse reaction to treatment
• Global vascular risk – new onset and pre-existing
• Complication of HPT
STEP DOWN THERAPY
• Step down therapy is discouraged in majority of patients. However if patient insist, must
fulfill criteria:
• Patient’s BP must not be higher than stage 1 HPT (mild) with low global CV risk
• BP well-controlled for at least 1 year on the same medication at the same dosage.
• Must agree to be followed-up at least 3-6 monthly.
• Must be motivated to adopt healthy living
MANAGEMENT OF SEVERE HYPERTENSION
• Severe hypertension defined as persistent elevated SBP > 180mmHg and/or DBP
>110mmHg
• May present
• Incidental finding in asymptomatic undiagnosed patient
• Treated HPT patient who are asymptomatic
• Patient with symptoms
• Non-specific symptoms i.e headache, dizziness, lethargy
• Signs and symptoms of TOD i.e acute heart failure, ACS, acute renal failure. Etc…
• Defined as severe increase in BP which is not associated with acute end organ damage/complication.
• Initial treatment should aim 25% reduction of BP over 24 hours, but not lower than 160/100mmHg.
• Management
• Rest in quite room for at least 2 hours
• Initiate oral anti-HPT if BP remains > 180/110mmHg
• Hypertensive urgency discharge plan
HYPERTENSIVE EMERGENCY
• Definition of hypertension in the older adult (>65 years old) is the same as that of the
general adult population.
• In older adults, the risk of cardiovascular events and death is twice as that observed in
younger individuals at same levels of BP.
• SBP increases linearly with age, leading to an increase in prevalence of isolated systolic
hypertension in the older adult.
TYPES OF ANTIHYPERTENSIVE AGENTS
ANGIOTENSIN CONVERTING ENZYMES INHIBITOR -
ACEI
• ACEIs are effective antihypertensive agents, which can lower CV risk, reducing mortality
and morbidity in hypertensives and those at high CV risk.
• Works by preventing body form producing angiotensin II hormone which causes
narrowing of blood vessels. This then causes increase in BP and forces the heart to work
harder.
• Adverse effects include cough and, rarely, angioedema. In patients with renovascular
disease or renal impairment, deterioration in renal function may occur.
• Serum creatinine and potassium should be checked before initiation and within 2 weeks
after starting.
• If there is hyperkalemia (>5.6 mmol/L) or a persistent rise of serum creatinine of more than
30% from baseline within two months, the dose of the ACEI should be reduced or
discontinued.
ANGIOTENSIN RECEPTOR BLOCKER - ARB
• Works by blocking angiotensin receptor
• Recommended for those ACEI intolerant patient.
• Combination of ACEIs and ARBs is not recommended and should be avoided.
BETA-BLOCKERS
• Useful in hypertensive patients with effort angina, tachyarrhythmias or previous MI
where they have been shown to reduce cardiovascular morbidity and mortality.
• Absolutely contraindicated in patients with uncontrolled asthma and relatively
contraindicated in other forms of obstructive airways disease (including controlled
bronchial asthma).
• Also absolutely contraindicated in patients with severe peripheral vascular disease
and heart block (2nd and 3rd degree).
• Adverse effects reported include dyslipidemia, masking of hypoglycemia, and
increased incidence of new onset diabetes mellitus, erectile dysfunction, cold
extremities and nightmares (especially for lipophilic ß-blockers), increased
triglyceride levels and reduced HDL levels (especially for non-selective ß-blockers).
CALCIUM CHANNEL BLOCKERS
• ∂-Blockers
• The peripheral ∂1-adrenergic blockers lower BP by reducing peripheral
resistance.
• They also reduce prostatic and urethral smooth muscle tone and
provide symptomatic relief for patients with early benign prostatic
hyperplasia (BPH).
• ∂-blockers have favorable effects on lipid metabolism. However
postural hypotension is a known side effect, especially at initiation of
therapy. Used with care in the elderly
MISCELLANEOUS DRUGS - THE ∂-BLOCKERS AND
THE COMBINED ∂, ẞ-BLOCKERS