1. Treatment of Hypertension
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)
Jai Radhakrishnan, M.D.
Division of Nephrology

2. Objectives
Define hypertension
Principles of treatment
Special groups

4. Blood Pressure Classification
BP CLASSIFICATION
SBP
DBP
Normal
<120 and
<80
Prehypertension or
80-89
Stage 1 HTN or
90-99
Stage 2 HTN
>160
>100

5. Why Treat Hypertension ?
To decrease:
Cerebrovascular Accidents %
Coronary events %
Heart failure %
Progression of renal disease
Progression to severe hypertension
All cause mortality

6. Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)

7. Factors to Consider in Treating Hypertension
Repeat readings
r/o secondary causes
Estimate CV risk status
Co-morbid conditions
Lifestyle changes
Drugs

8. “Secondary” Hypertension
Difficult to control
Sudden onset of HTN
Well controlled-> difficult to control
Severe hypertension
History/physical/labs

9. Initial Workup of Secondary HTN
Renal parenchymal disease
UA, spot urine protein/creatinine, serum creatinine, USG.
Renovascular
Captopril scan
Coarctation
Lower Extremity BP
Primary aldosteronism
Serum and urinary K
Plasma renin and aldosterone ratio
Pheochromocytoma
Spot urine for metanephrine/creatinine

10. Laboratory Tests in Uncomplicated HTN
ECG
Urine analysis
Blood glucose, hematocrit
Basic metabolic panel
Lipid profile after 9-12 hour fast
Urine microalbumin

11. Estimate Risk Status Hypertension Smoking Obesity (BMI > 30kg/m2)
Dyslipidemia
Diabetes
Microalbuminuria or GFR <60ml/min
Age > 55 (men), 65 (women)
Family history of CVD
(Men< 55, Women <65)
Metabolic Syndrome

12. Target Organ Damage Heart Disease Stroke/TIA Chronic kidney disease
CAD (Angina, myocardial infarction, coronary revascularization
Left Ventricular Hypertrophy
Heart Failure
Stroke/TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy

13. Goals of Therapy BP <140/90 mmHg
BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons >50 years of age.

14. Lifestyle 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

15. Drugs for Hypertension
Diuretics
Thiazide
Loop diuretics
Aldosterone antagonists
K-sparing
Adrenergic inhibitors
Peripheral agents
Central (α-agonists)
alpha -blockers*
beta-blockers
Alpha+beta-blockers
Direct Vasodilators *
Calcium channel blockers
Dihydropyridine
Non dihydropyridine
ACE-inhibitors
Angiotensin-II blockers
* Usually not monotherapy

17. Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
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
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
With Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

18. Classification and Management of BP for adults
BP Class
SBP
DBP
Lifestyle
Initial drug therapy
Without compelling indication
Compelling indications
Normal
<120
<80
Encourage
None
Pre-hypertension
120–139
or 80–89
Yes
No antihypertensive drug indicated.
Drug(s)
Stage 1 Hypertension
140–159
or 90–99
Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension
>160
or >100
Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB).
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

19. Heterogeneity of “Essential” Hypertension

20. Special Considerations
Compelling Indications
Special populations

21. HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled with nifedipine) is admitted with severe chest pain x24 hrs.
BP is 170/100 and she has a soft S3 gallop.
ECG shows an anterior wall MI.
She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%.
How will you manage her hypertension?

22. Compelling Indications for Certain Drug Classes

23. HTN with CAD
Beta blockers: cardioprotective (reinfarction, arrhythmias and sudden death)
ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved

24. Renal Insufficiency
A 30 year old patient with IDDM is referred with difficult-to-control HTN on diltiazem and clonidine.
Exam reveals BP=190/100 and 3+ edema.
Labs: Creatinine = 2.2 mg/dL
Serum K = 5.1 meq/L
24 hour protein = 5 g

25. Hypertension with Renal Insufficiency
Goal BP <130/80
ACE-inhibitors/angiotensin receptor blockers should be used if no contraindications
Most patients have volume overload:
Diuretics should be included in the regimen.
Thiazides ineffective if S Creat>2.5

26. A 40 year old previously healthy male is brought to the E. R
A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic. Eye exam: Papilledema Chest: Bibasilar crackles Cardiac: S1S2S4 Neuro: Bilateral upgoing plantars: Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: red cells, 2+ albumin.

27. Hypertensive Urgencies and Emergencies
HYPERTENSIVE EMERGENCIES
Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES
Require reduction of blood pressure within a few hours

28. Emergencies & Urgencies
HYPERTENSIVE EMERGENCIES
Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES
Require reduction of blood pressure within a few hours

29. Parenteral Drugs For Treatment of Hypertensive Emergencies
VASODILATORS
Nitroprusside
Fenoldopam
Nitroglycerine
Enalaprilat
Nicardipine
Hydralazine
ADRENERGIC INHIBITORS
Labetalol
Esmolol
Phentolamine

30. Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the obstetric clinic at 30 weeks gestation.
BP: 160/100, 2 + pedal edema
Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N
After 2 days of bed rest BP remains /100

31. Drug Therapy of the Hypertensive Pregnant Patient
Methyldopa: Drug of choice.
Beta blockers (not early pregnancy).
Hydralazine is the parenteral drug of choice.
Most agents if used prior to pregnancy may be continued
(except ACE-I OR A-II BLOCKERS)

32. Resistant Hypertension
Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
Inadequate doses
Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN

33. Conclusions
The initial approach to hypertension should start with ruling out secondary causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage.
Treatment should always include lifestyle changes.
Medication use should be guided by the severity of HTN and the presence of “compelling” indications.
Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
Most patients will require two or more antihypertensive drugs

34. Conclusions
HTN is a risk factor for mortality and cardiovascular and renal disease
HTN is common but not controlled.
Target BP 140/90 (130/80 in DM, CKD)
Remember Compelling Indications