HYPERTENSION

DR SEIF JUMA ABAS

MD
 Learning
objectives
At the end of this session each participant should
be able to:
• Introduction
• Explain epidemiology of Hypertension
• Describe pathogenesis of Hypertension
• Explain clinical features of Hypertension
• Explain functional classification
• Describe management of Hypertension
• Provide measures to prevent and control of
Hypertension
 Introduction
• Hypertension is simply defined as a
persistently abnormal elevation in blood
pressure greater than 140/90mmHg
• HTN is not diagnosed unless BP is elevated
on multiple occasions (at least 2‐3) or if the
patient has complications of HTN (i.e.
hypertensive emergency)
• Hypertension is a major risk factor for
stroke, MI, CCF, CKD, retinopathy and
peripheral vascular disease
• Hypertension is one of the main risk factors
for CVD
 Introduction...
• Hypertension is attributed by a combination of
cardiac output, peripheral vascular resistance and
sodium retention
• The factors affecting cardiac output include; sodium
intake, renal function, and mineralocorticoids; the
inotropic effects occur via extracellular fluid volume
expansion and an increase in heart rate and
contractility
• Peripheral vascular resistance is dependent upon the
sympathetic nervous system, humoral factors and
local autoregulation
• The sympathetic nervous system produces its
effects via the vasoconstriction or the vasodilatation
effect
 Types of Hypertension

1. Essential (Primary) HTN – most common

(95%) and due to a combination of genetic,
aging and environmental factors (excessive
salt intake, excess weight, lack of
exercise)
• Its also known as idiopathic hypertension
due to the fact that it has no identifiable
causes
• Usually develops after the age of 30 but
can develop earlier
 Types of Hypertension...
2. Secondary HTN – due to other causes
• All patients <30years of age with HTN and those with
HTN no sufficiently controlled on three drugs should
be assessed for the causes of 2º HTN that include:
 Renal – most common; can be related to CKD or renal artery
stenosis
 Cushing’s syndrome – hypercortisolemia
 Conn’s syndrome ‐ hyperaldosteronemia
 Coarctation of the Aorta
 Pheochromocytoma – catecholamine producing tumor
 Hyperthyroidism or hypothyroidism
 Pregnancy (pre- eclampsia)
 Drugs e.g. Oral contraceptives containing oestrogens, anabolic
steroids, corticosteroids, non-steroidal anti-inflammatory drugs,
carbenoxolone, sympathomimetic agents
 Risk factors for Hypertension
The most common risk factors for
Hypertension are as follows:
• Age: both systolic and diastolic BP
increase with age
• Gender: more common in men (gap
narrows over age of 60years); men have
higher complication rates
• Race: it is twice as common in African-
American patients as in Caucasian
patients; African-American patients have
higher complication rates (stroke, renal
failure, heart disease)
Risk factors for
Hypertension...
• Obesity, sedentary lifestyle, dyslipidemia
• Family history of hypertension
• Increased sodium intake: this correlates
with increased prevalence in large
populations, although not in individuals;
individual susceptibility to the effects of
high salt intake varies
• Alcohol: intake of more than one unit per
day is associated with HTN
 Grades of Hypertension
Category Systolic blood Diastolic blood
pressure (mmHg) pressure (mmHg)
Blood pressure
Optimal < 120 < 80

Normal < 130 < 85

High 130-139 85-89

Hypertension
Grade 1 (mild) 140-159 90-99

Grade 2 (moderate) 160-179 100-109

Grade 3 (severe) ≥180 ≥110

Isolated systolic hypertension

Grade 1 140-159 < 90

Grade 2 ≥160 < 90

Stratification of risk
 Clinical Features - History

• Most patients with HTN are asymptomatic!

Symptoms and signs develop only with
complications of HTN where the patient may
presents with headache, blurred vision and mouth
deviation or in cases of secondary HTN where
patient may present with features of disease that
cause 2º HTN
• History of risk factors for cardiovascular includes
hypercholesterolemia, diabetes mellitus, and
tobacco use
• Possibility of secondary hypertension are a history
of known renal disease, abdominal masses,
anemia
Clinical Features –
History...
• History of sweating, labile
hypertension, and palpitations
suggests the diagnosis of
pheochromocytoma
• History of cold or heat tolerance,
sweating, lack of energy, and
bradycardia or tachycardia may
indicate hypothyroidism or
hyperthyroidism
• The presence of papilledema and
other neurologic signs raises the
possibility of increased intracranial
 On examination
• In Most patients with HTN physical examinations
are normal! Mostly signs develop only with
complications or underlying cause of secondary
HTN. An accurate measurement of blood pressure
is the key to diagnosis (measurement of Blood
pressure in both the supine and sitting positions)
• On physical examination the patient may have;
Edema, finger clubbing, anxiety, Tachycardia,
Hepatomegaly, Signs of left ventricular
hypertrophy, displacement of apex, a sustained
and enlarged apical impulse, presence of a 4th
heart sound etc.
 On examination...
• Asses for enlarged thyroid gland, and
signs of
hypothyroidism/hyperthyroidism,
palpable kidneys as in polycystic
kidneys
• Palpation of peripheral arterial pulses
for radiofemoral delay found in
Coarctation of aorta
Complications of HTN
Common complications of HTN
 Investigations
Diagnosis is based on medical history and
symptoms but imaging and blood tests are also
done, they are as follows:
• Electrocardiogram - for ischemic disease and
arrhythmias
• Echocardiogram – for CCF and Cardiomyopathy
• Full blood picture – to evaluate anemia
• Liver functions tests – ALT, AST, Bilirubin and
Albumin
• Renal Ultrasound (Polycystic kidney disease)
• Lipid panel/profile – to assess hyperlipidemia
• CXR - usually in the acute inpatient setting to
evaluate for pulmonary edema, cardiomegaly,
pleural effusion etc.
• Brain CT scan – to evaluate ischemia (hypodense
lesion) or hemorrhage (hyperdense lesion) in the
brain
 Management
Non-pharmacological treatment:

 Lifestyle modifications – critically important to

maximize cardiac function and exercise tolerance,
these include:
• Low salt diet → to decrease fluid retention
• Reduce intake of dietary saturated fat and
cholesterol → for overall cardiovascular health
• Fluid restriction → usually 1-2 L of total fluid intake
daily for those patients with congestion
• Regular weights monitoring→ monitor for signs of
fluid overload and allows self-adjustment of
medications
• Avoid alcohol consumptions
• Increase aerobic activity (30-45 min most days of
the week)
 Management…
Pharmacological treatment:
• In general, any patient with severe (Grade 3) HTN
and/or signs of complications (stroke, CKD, CAD,
CCF, retinopathy etc.) should be started on
antihypertensive treatment immediately

• Patients with mild to moderate (Grade 1‐2) HTN

should be under close follow up for 3 months to
see if they respond to behavioral modification
first. but If BP remains >140/90 they should then
be started on antihypertensive(s)

• Goal for lowering BP

• In most patients (Low risk pt), the goal BP is <
140/90
 Which drug to start with?

• For most patient, Bendrofluazide 5mg PO OD is

the best first drug as it is cheap, easy to take and
very effective in Africans, use with caution in
patients with DM and gout as Bendrofluazide can
cause hyperglycemia and hyperuricemia

• CCBs (like Nifedipine or amlodipine) are all very

effective in black people (Africans) and is a good
first antihypertensive if you want to lower the BP
rapidly (as in hypertensive urgency)
Which drug to start
with?...
• For patients with DM or CCF and a normal or
stable creatinine, ACE inhibitors (like Captopril
and Lisinopril) are the best first
antihypertensive

• In patient with CAD, beta blockers (such as

Metoprolol and Carvedilol) are the best first
antihypertensive as they reduce the risk of
death from CAD

• NOTE: Most antihypertensive take 2‐4 weeks

to reach maximal effect so it is good to wait 1
month before increasing the dose of a
medicine or adding another one
 What to do if the first
drug doesn’t work?
• 2/3 of patient with hypertension will require at
least 2 drugs to control their hypertension and 1/3
will require 3 drugs
• Always titrate your first drug to its maximum dose
first before adding another drug
• Monitor for side effects
 ACE inhibitors – monitor createnine
 Thiazide diuretics – monitor electrolytes
 Beta blockers – monitor heart rate

• If the BP remains elevated despite maximum dose

of a first drug, add another drug and then titrate
this to its maximal dose

• Whatever you start with, either thiazides or CCB

 Hypertensive Urgency

• Hypertensive Urgency is a hypertensive crisis without end-

organ damage

• It is a complicated hypertension characterized by

extremely high blood pressure, diastolic pressure
usually exceeding 120 mm Hg, but there is no sign
or evidence target organ dysfunction
 Hypertensive Urgency…
• Treatment:
• BP can be lowered gradually over 24-48 hours, usually with oral
medications

• Admit in the ward

• The main Goal is MAP by 25% over 2 – 3 days using
oral antihypertensive medication
• Through history and quick assessment
• Ask; Does the patient take antihypertensive
medicines at home?
• If yes: restart them
• If no: start Nifedipine 20mg PO BD
• If still > 160/100 next morning, Start
Bendrofluazide 5mg PO OD or Add other
medications as necessary
• Before discharge, optimize antihypertensive regimen
based on patient co‐morbidities. With the aim to lower
BP slowly over 4 weeks to <140/90
 Hypertensive
Emergency
• Hypertensive Emergency – Elevated BP with
evidence of end-organ damage
• It is a hypertensive crisis characterized by
extremely high blood pressure (Severe
hypertension), diastolic pressure usually
exceeding 120 mmHg, and evidence of potentially
life-threatening end organ dysfunction that
include:
• Hypertensive Encephalopathy (confusion,
headache)
• Acute retinal hemorrhage (sudden onset of
blurry vision, massive hemorrhage on
ophthalmoscopy)
• Myocardial infarction (chest pain, ECG
changes)
• Pulmonary Edema (shortness of breath, CXR
 Hypertensive
Emergency…
Treatment:
• Use IV Hydralazine 20mg in 250mls of N/S drips
titrated, aiming to lower MAP (Mean arterial
pressure) by 25% over 1‐2 hours

• Also Labetalol 10-20mg IV over 2 minutes, repeat

every 10 min may be used instead
• Other meds like Nitroglycerin sublingual spray 2
sprays or Nitroglycerin sublingual tablets 0.4mg
stat can be used if available

• Once the BP improves, switch to usual oral

medications

• NB. MAP = [SBP + (DBP × 2)]/3

 Hypertensive
Emergency…
• For CARDIAC ISCHAEMIA / MYOCARDIO
INFRACTION, start beta blocker (IV first then PO) +
Aspirin + Nitroglycerin.
• For AORTIC DISECTION, start beta blocker (IV start
then PO)
• For PULMONARY OEDEMA, start Nitroglycerin +
Lasix IV
• NOTE: If there is one of the above complication and/
or BP is still not lowered by 25% immediately give
Hydralazine 10mg IV every 30 minutes prn
• RECHECK BP 30 minutes LATER:
• If BP not lowered by 25%, start hydralazine drip per
ICU protocol and write goal MAP in orders

• After 24 hours, start PO medications and titrate off

IV medication
 Compelling Indications for
antihypertensive medications
Compelling Indication Antihypertensive
medications of Choice
Heart Failure ACEI/ARB + BB + diuretic +
potassium sparing diuretic
Post –MI/Clinical CAD ACEI/ARB and BB
CAD (Coronary artery ACEI, BB, diuretic, CCB
disease)
Diabetes mellitus ACEI/ARB, CCB, diuretic
CKD (chronic kidney ACEI/ARB if CKD is not ≥
injury) stage 4
Prevention of ACEI, diuretic
recurrent stroke
Drug Adverse Effects Special Contraindicati
Indications ons
Labetalol Vomiting, Most HTN Heart failure,
bronchoconstricti emergencies: asthma,
on, dizziness, especially second degree
heart block acute heart block
coronary
syndrome,
aortic
dissection,
eclampsia
Nitroprussi Vomiting, Most HTN Contraindicate
de sweating, emergencies d with high
thiocynate and intracranial
cyanide pressure
intoxication
Nitroglyceri Headache, Acute
ne vomiting, coronary
 Side effects of common
antihypertensive medications
Medication Side effects
Thiazide Hypokalemia, hyperuricemia,
diuretics hyperglycemia, elevation of
cholesterol and triglyceride levels,
metabolic alkalosis, hyperuricemia,
hypomagnesemia
β-Blockers Bradycardia, bronchospasm, sleep
disturbances (insomnia), fatigue, may
increase TGs and decrease HDL,
depression, sedation, may mask
hypoglycemic symptoms in diabetic
patients on insulin
ACE Acute renal failure, hyperkalemia, dry
inhibitors cough, angioedema, skin rash, altered
Class of Antihypertensives Drug Dose
Thiazide Diuretics Bendroflumethia 5mg once daily
zide
Hydrochlothiazid 12.5mg daily
e
Loop Diuretics Furosemide 40mg- 80mg daily
Torasemide 2.5mg – 5mg daily
Potassium Sparing Diuretics Spironolactone 25mg once daily
Eplerenone 25mg once daily
Central Adrenergic Inhibitor Methyldopa 250mg 12hrly
Clonidine 50μg 8hrly
Angiotensin converting enzyme Captopril 12.5mg- 25mg
Inhibitors 12hrly
Enalapril 5- 20mg daily
Angiotensin receptor blockers Losartan 50 -100mg daily
Direct Vasodilators Hydralazine 25mg twice daily
Calcium channel blockers Nifedipine 10- 20mg 12hrly
Amlodipine 5 – 10mg once
daily
 References
• Davidson, S, (2014) - Principles and Practice
of Medicine, 22nd Edition, Churchill
Livingstone.
• Longmore, M, et al, (1999), Oxford Handbook
of Clinical Medicine, 6th Edition, Oxford
• Swash, M., & Glynn, M. (2007). Hutchinson’s
Clinical Methods: An Integrated Approach to
Clinical Practice: 22nd Edition. Philadelphia,
PA: Saunders Elsevier
• Trouse, (2000) Short textbook of Medicine
University Press
• MoHCDGEC Standard treatment guidelines
& national essential medicines list Tanzania
mainland 2021