Guideline for hypertension

Blood Pressure Classification(JNC7) Normal<120and<80 Prehypertension 120 – 139 or 80 – 89 Stage 1 Hypertension 140 – 159 or 90 – 99 Stage 2 Hypertension >160 or >100 BP Classification SBP mmHg DBP mmHg

Etiology Essential (90%) Renal : renal artery stenosis ; parenchymal disease Endocrine : Pheochromocytoma ; Hyperaldosteronism ; Cushing syndrome ; hyperthyroidism Exogenous agent Coarctation of aorta : Toxemia of pregnancy

Standard work-up Conformation of real hypertension Identify Etiology of H/T Access of End-organ damage Identify cardiovascular risk

How to record BP Measure BP several times on several occasions with the patient in sitting position. including Self Measurement Use a mercury sphygmomanometer or other non-invasive device.including Ambulatory BP monitorings non-invasive device.including Ambulatory BP monitorings

BP Measurement Techniques Method Brief Description In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm. Ambulatory BP monitoring Indicated for evaluation of “ white-coat ” HTN. Absence of 10 – 20% BP decrease during sleep may indicate increased CVD risk. Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “ white-coat ” HTN.

History Onset of hypertension; Drug history; Family History; Other major cardiovascular risk factors; major target organ complications; Exogenous agents (e.g. oral pills, Licorice)

History Hisory of flank pain, hematuria, history of renal trauma -> Hisory of flank pain, hematuria, history of renal trauma -> Renovascular hyprertension; Renovascular hyprertension; Histoy of proteinuria, pyelitis of pregnancy, renal stones, dysuria, fever, or chill -> Parenchymal renal disease as a cause of hypertension; Histoy of proteinuria, pyelitis of pregnancy, renal stones, dysuria, fever, or chill -> Parenchymal renal disease as a cause of hypertension; History of headache, sweating, palpitations, tachycardia, thoracic and epigastric distress, and weight loss …. Pheochromocytoma; Heat intolence and loss of weight …… Hyperthyroidism, History of weakness, paralysis, tetany, paresthesia, polyuria… primary aldosteronism.

Physical Examination General apperance : eg.Cushing syndrome Serial blood pressure determinations Blood pressure in both arms Funduscopic examination :arteriovenous nicking, hemorrhage, Exudates Palpation of thyroid Auscultation Lungs for wheezing and rales Cardiac: heart beat; S3,S4 murmur, PMI, thrill …. Abdominal and cervical ( check bruit ) Palpation of pulses, especially femoral artery :delayed pulse and decrease pressure -> coarctation

Laboratory test Routine screen,including CBC/DC,biochemistry and admission panel Urinalysis : including specific gravity, albumin, microanalysis Serum potassium, Calcium,Creatinine Thyroid function, Cortisol level Chlesterol, TG EKG Chest X-Ray Catecholamines only in presence of diastolic pressure >110 mmHg in patient younger than 30 Echocardiography

Risk factor for Cardiovascular disease Levels of systolic and diastolic blood pressure (Grades 1-3) Men > 55 years Women > 65 years Smoking Total cholesterol > 6.5 mmol / L ( 250 mg / dl) Diabetes Family history of premature cardiovascular disease Homocystine

End –Organ damage Left ventricular hypertrophy ( electrocardiogram, echocardiogram or radiogram ) ( electrocardiogram, echocardiogram or radiogram ) Proteinuria and/or slight elevation of Left ventricular hypertrophy plasma creatinine concentration ( mg/dl) Ultrasound or radiological evidence of atherosclerotic plaque (carotid, iliac and femoral arteries, aorta) Generalized or focal narrowing of the retinal arteries

Associated clinical conditions Cerebrovascular disease Renal disease Ischaemic stroke * Diabetic nephropathy Cerebral haemorrhage * Renal failure (plasma creatinine Transient ischaemic attack concentration > 2.0 mg/dl) Heart disease Vascular disease Myocardial infarction * Dissecting aneurysm Angina * Symptomatic arterial disease Coronary revascularization Congestive heart failure Advanced hypertensive retinopathy * Haemorrhages or exudates * Papilloedema

Goals of Therapy  Reduce CVD and renal morbidity and mortality.  Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.  Achieve SBP goal especially in persons >50 years of age.

Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

Classification and Management of BP for adults BP classification SBP* mmHg DBP* mmHg Lifestyle modificati on Initial drug therapy Without compelling indication With compelling indications Normal<120 and <80 Encourage Prehypertensi on 120 – 139 or 80 – 89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140 – 159 or 90 – 99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension >160 or >100 Yes Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). *

Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5 – 20 mmHg/10 kg weight loss Adopt DASH eating plan 8 – 14 mmHg Dietary sodium reduction 2 – 8 mmHg Physical activity 4 – 9 mmHg Moderation of alcohol consumption 2 – 4 mmHg

Considerations For Individualizing Antihypertensive Drug Theraphy Indication Drug Therapy Compelling Indications Unless Contraindicated Diabetes mellitus (type 1) with ACE I proteinuria Heart failure ACE I, diuretics Isolated systolic hypertension Diuretics (preferred), (older patients) CA (long-acting DHP) Myocardial infarction Beta-blockers (non-ISA), ACE I (with systolic dysfunction) May Have Favorable Effects on Comorbid Conditions + Angina Beta-blockers, CA Atrial tachycardia and fibrillation Beta-blockers, CA (non DHP) Cyclosporine-induced hypertension CA (caution with the dose of cyclosporine) Diabetes mellitus (types 1 and 2) ACE I (preferred), CA with proteinuria Diabetes mellitus (type 2) Low – dose diuretics

Considerations For Individualizing Antihypertensive Drug Therapy* Indication Drug Therapy DyslipidemiaAlpha-blockers Essential tremorBeta-blockers (non-CS) Heart failureCarvedilol, losartan potassium HyperthyoidismBeta-blockers MigraineBeta-blockers (non-CS, CA (non-DHP) Myocardial infarctionDiltiazem hydrochloride, verapamil hydrochloride OsteoporosisThiazides Preoperative hypertensionBeta-blockers, clonidine Prostatism (BPH)Alpha-blockers Renal Insufficiency ACE I (caution in renovascular) Hypertension and creatinine  mmol/L (3mg/dL)

Considerations For Individualizing Antihypertensive Drug Therapy Indication Drug Therapy May Have Unfavorable Effects on Comorbid Conditions ++ Bronchospastic disease Beta-blockers Depression Beta-blockers, central alpha-agonists, reserpine Diabetes mellitus Beta-blockers, high-dose diuretics (types 1 and 2) Dyslipidemia Beta-blockers (non-ISA), diuretics (high-dose) Gout Diruretics 2  or 3  heart block Beta-blockers CA (non-DHP) Heart failure Beta-blockers (except carvedilol), CA (except amlodipine besylate, felodipine) Liver disease Labetalol hydrochloride, methyldopa Peripheral vascular disease Beta-blockers Pregnancy ACE I, angiotension II receptor blockers Renal insufficiency Potassium-sparing agents Renovascular disease ACE I, angiotension II receptor blockers