DIAGNOSIS:

Periodic screening for all people older than 21 years .

Patients should seated quietly in chair for at least 5 minutes
Use appropriate cuff size
Take BP at least twice
Etiology:

1. Essential HTN: 90% (no identifiable cause)

2. Secondary HTN: triggered by specific underlying cause (Primary aldosteronism,

Renal artery stenosis, Obstructive sleep apnea.)

Drugs with the potential to impair blood pressure control:

Alcohol
Amphetamines
Antidepressants (serotonin-norepinephrine reuptake inhibitors, tricyclic
antidepressants)
Caffeine
Decongestants
Systemic corticosteroids
Immunosuppressants (e.g., cyclosporine, tacrolimus)
Oral contraceptives
Blood Pressure Treatment:
Principles of drug therapy : titrate dose first then add another agents
First-line agents:
ACEIs:(( lisinopril,captopril,ramipril..) USES :
Non–African American patients
• Albuminuria
Contraindications
• Pregnancy
• Angioedema
ARBs: ( candesartan, losartan )
Important ADRs – Similar to those with ACEIs except for cough
(C) Monitor SCr and K values 7–10 days after initiation or titration.
(D) Monitor K closely,
Thiazide and thiazide-type diuretics( thiazide and chlorthalidone:
Mechanism of action – Act on the kidneys to reduce sodium reabsorption in the
distal convulted tubule.
ADRs:
Electrolyte abnormalities
Hyperuricemia,hyperglycemia

CCBs:( (amlodipine,felodipine…)
Mechanism of action – Act by relaxing the smooth muscle in the arterial
wall,decreasing total peripheral resistance.
Important ADRs
• Peripheral edema

• Reflex tachycardia
 Secondary antihypertensive agents

α1-Blockers (doxazosin, prazosin, terazosin) In

general, reserved for hypertensive male patients
with concomitant benign
prostatic hyperplasia.
Important ADRs – Dizziness and orthostatic
hypotension (OH)
β-Blockers:Mechanism of action – Selective (β1
only) or nonselective (β1
and β2) receptor blocker results in negative
inotropic and chronotropic actions.
Clinical uses :
HF or left ventricular systolic dysfunction with left
ventricular ejection fraction of 40% or less –( First
line)
• Post-MI (within first 3 years) – First line
• Important ADRs
• (A) Bradycardia
• (B) Heart block
• (C) Bronchospastic disease
Loops (bumetanide, furosemide, torsemide)
Clinical use: HTN management for patients with HF and CKD, using scheduled twice-
daily dosing

Important ADRs
• Electrolyte abnormalities (hypokalemia,
hyponatremia, hypomagnesemia)
• Dehydration/hypovolemia
K-sparing (amiloride, triamterene):
Important ADR Hyperkalemia
Aldosterone antagonists (eplerenone,
spironolactone)
Clinical use:
Resistant HTN
Contraindications
(A) Anuria
(B) Acute renal insufficiency – Avoid if CrCl is 30 mL/minute/1.73
m2
or less.
(C) Hyperkalemia
Central α2-androgenic agonist and other centrally
acting drug (clonidine, methyldopa)
(A) May be useful for resistant HTN
Direct vasodilators (hydralazine, minoxidil)
(1) Mechanism of action – Direct-acting smooth muscle
relaxants that act as a vasodilator
• Important ADRs
Tachycardia (consider use with β-blocker)
Resistant HTN
• Office SBP/DBP of 130/80 mm Hg or greater
and patient taking three or more
antihypertensive medications, including a
long-acting CCB, an ACE inhibitor or ARB, and
a diuretic, at maxi-mal or maximally tolerated
doses. OR
• Office SBP/DBP less than 130/80 mm Hg but
patient requires four or more antihypertensive
• STEP 1 Exclude causes of HTN: secondary causes,
white-coat effect, medication nonadherence
• Step 2: Substitute optimally dose thiazide diuretic
(chlorthalidone or indapamide) for previous diuretic
• c. Step 3: Add mineralocorticoid (aldosterone) receptor
antagonist: spironolactone or eplerenone
• d. Step 4
• i. If heart rate ≥70 beats/min, add β-blocker
• ii. If β-blocker is contraindicated, add central α1-agonist
(clonidine or guanfacine)
• Step 5: Add hydralazine and titrate to maximal
dose (use concomitantly with a β-blocker and
diuretic)
• f. Step 6: Substitute minoxidil for hydralazine
and titrate
• g. Step 7: Refer to HTN specialist or ongoing
clinical trial