1. DR. M. Sofi MD; FRCP (London); FRCPEdin; FECSEdin

2. Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more, or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive medication. Classification of BP for adults aged 18 years or older:  Normal:  Systolic lower than 120 mm Hg, diastolic lower than 80 mm Hg  Prehypertension:  Systolic 120-139 mm Hg, diastolic 80-89 mm Hg  Stage 1:  Systolic 140-159 mm Hg, diastolic 90-99 mm Hg  Stage 2:  Systolic 160 mm Hg or greater, diastolic 100 mm Hg or greater HYPERTENSION

3. Classification: Defining normal blood pressure, prehypertension, hypertension (stages I and II), and isolated systolic hypertension. Classification Systolic pressure Diastolic pressure mmHg Normal 90–119 60–79 Prehypertension 120–139 81–89 Stage 1 140–159 90–99 Stage 2 ≥160 ≥100 Isolated systolic hypertension ≥140 <90 Stage 1 140–159 90–99 Source: American Heart Association (2003).

4.  Malignant (accelerated) hypertension: Characterized by severe hypertension (e.g. systolic >200 mm Hg, diastolic >130 mm Hg) accompanied by encephalopathy or nephropathy, or by papilloedema and/or angiopathic haemolytic anaemia.  Suspected Pheochromocytoma: Consider if there is labile or postural hypotension, headache, palpitations, pallor and profuse sweating.  Hypertensive crisis: (SBP) ≥180 mm Hg or a (DBP) ≥120 mm Hg is considered a 'hypertensive crisis'. Immediate reduction in BP is required only in patients with acute end-organ damage.  Systolic or diastolic pressure: Framingham study and the Multiple Risk Factor Intervention Trial (MRFIT) study indicates that systolic pressure is the most important determinant of cardiovascular risk. Other considerations

5. The evaluation of hypertension involves :  Accurate measuring of BP  Focused medical history  Physical examination  Routine laboratory studies.  A 12-lead electrocardiogram. Confirmation of an elevated blood pressure (at 3 separate occasions); detailed history should extract the following information: 1. Extent of end-organ damage (e.g., heart, brain, kidneys, eyes) 2. Assessment of patients’ cardiovascular risk status 3. Exclusion of secondary causes of hypertension EVALUATION: HYPERTENSION

6. Assessment end organ damage:  Heart: left ventricular hypertrophy, angina/previous myocardial infarction, previous coronary revascularization, and heart failure  Brain: stroke or transient ischemic attack dementia  Chronic kidney disease  Peripheral arterial disease  Retinopathy EVALUATION: HYPERTENSION

7.  Age – Advancing age is associated with HTN  Obesity – Obesity and weight gain are major risk factors.  Family history – HTN is about twice as common in subjects who have one or two hypertensive.  Race – HTN tends to be more common, be more severe, occur earlier in life, in blacks.  Reduced nephron number – may predispose to hypertension.  High Sodium intake (e.g., >3000 mg/day) increases the risk for hypertension  Excessive alcohol consumption  Physical inactivity – may increases the risk for hypertension  Diabetes and dyslipidemia  Personality traits and depression  Hypovitaminosis D Risk factors for primary (essential) hypertension

8.  Hypertension: component of metabolic syndrome  Tobacco use, cigarettes, including chewing tobacco  Elevated LDL cholesterol (or total cholesterol ≥240 mg/dL) or low HDL cholesterol: component of metabolic syndrome  Diabetes mellitus: component of metabolic syndrome  Obesity (BMI ≥30 kg/m 2 ): component of metabolic syndrome  Age greater than 55 years for men or greater than 65 years for women:  Estimated glomerular filtration rate less than 60 mL/min  Microalbuminuria  Family history of premature cardiovascular disease (men < 55 years; women < 65 years)  Lack of exercise Cardiovascular risk factors

9. One or more of these criteria qualifies as hypertension:  A 24-hour average of 130/80 mmHg or above  Daytime (awake) average of 135/85 mmHg or above  Nighttime (asleep) average of 120/70 mmHg or above PRIMARY (ESSENTIAL) HYPERTENSION:  The pathogenesis of primary hypertension (formerly called "essential" hypertension) is poorly understood but is most likely the result of  Genetic and environmental factors that have multiple compounding effects on cardiovascular and renal structure and function. Diagnosis of HTN is made using ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring.

10. Prescription or over-the- counter medications:  Oral contraceptives, particularly those containing higher doses of estrogen,  NSAIDs, particularly chronic use  Antidepressants, including tricyclic antidepressants and SSRI’s  Glucocorticoids  Decongestants pseudoephedrine Weight loss medications  Erythropoietin  Cyclosporin  Stimulants: methylphenidate and amphetamines  Illicit drug: Drugs such as methamphetamines and cocaine can raise blood pressure SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION

11.  Secondary hypertension is commonly caused by renal disease or pregnancy.  Renal disease - approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys.  Approximately 25% are due to renovascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION

12. Endocrine disease:  Cushing's syndrome  Conn's syndrome  Pheochromocytoma  Acromegaly  Hyperparathyroidism  Coarctation  Pre-eclampsia and hypertension in pregnancy.  Drugs and toxins, e.g. alcohol, cocaine, ciclosporin, tacrolimus, erythropoietin, adrenergic medications, decongestants containing ephedrine and herbal remedies containing licorice. SECONDARY OR CONTRIBUTING CAUSES OF HYPERTENSION

13. Medical history Duration and classification of hypertension Patient history of CVD Family history Symptoms suggesting causes of hypertension Lifestyle factors Current and previous medications Duration and classification of hypertension Physical examination BP readings (2 or more), including the standing position Verification in contralateral arm Height, weight, and waist circumference Funduscopic examination for hypertensive retinopathy Exam. neck, heart, lungs, A/S for target organ damage BP readings (2 or more), including the standing position Medical history and physical examination

14.  LVH: is a common and early finding in patients with hypertension.  LVH is associated with a higher incidence of subsequent heart failure, myocardial infarction, sudden death, and stroke  Heart failure: both systolic (reduced ejection fraction) and diastolic (preserved ejection fraction), increases with the degree of blood pressure elevation.  Ischemic stroke: HTN is the most common and most important risk factor for ischemic stroke, the incidence of which can be markedly reduced by effective antihypertensive therapy COMPLICATIONS OF HYPERTENSION

15.  Hypertension is the most important risk factor for the development of intracerebral hemorrhage.  Hypertension is a leading risk factor for IHD, including myocardial infarction and coronary interventions.  Chronic kidney disease and end-stage renal disease.  It can both directly cause kidney disease, which is called hypertensive nephrosclerosis, and accelerate the progression of a variety of other renal diseases COMPLICATIONS OF HYPERTENSION

16.  Electrolytes and serum creatinine (to calculate the estimated glomerular filtration rate)  Fasting glucose  Urinalysis  Lipid profile (total and HDL- cholesterol, triglycerides)  Electrocardiogram (ECG)  Additional tests may be indicated in certain settings:  Increased albuminuria is increasingly recognized as an independent risk factor for cardiovascular disease.  Echocardiography is a more sensitive means of identifying the presence of left ventricular hypertrophy (LVH) than an ECG Laboratory testing

17. GENERAL CLINICAL CLUES:  Severe or resistant hypertension  Acute rise in BP in a patient with previously stable HT.  Age < 30 years in non-obese, patients with a negative F/H and no other risk factors.  Malignant or accelerated HT (e.g., patients with severe hypertension and signs of end-organ damage such as retinal hemorrhages or papilledema, heart failure, neurologic disturbance, or acute kidney injury).  Proven age of onset before puberty Evaluation of secondary hypertension:  Not cost effective for a complete evaluation for secondary HT in every pt.  Important to be aware of the clinical clues that suggest secondary HTN

18.  CLINICAL CLUES FOR RENOVASCULAR HYPERTENSION  Onset of severe HTN(blood pressure ≥180 mmHg systolic and/or 120 mmHg diastolic) after the age of 55 years  Unexplained deterioration of kidney function during antihypertensive therapy  Severe hypertension in patients with diffuse atherosclerosis  Severe hypertension in a patient with an unexplained atrophic kidney  A systolic-diastolic abdominal bruit that lateralizes to one side. Evaluation of secondary hypertension:

19. Identifiable Hypertension and Screening Tests ConditionScreening Test Chronic kidney diseaseEstimated glomerular filtration rate Coarctation of the aortaComputed tomography angiography Cushing syndrome; other states of glucocorticoid excess Dexamethasone suppression test Drug-induced/drug-related HTN Drug screening Pheochromocytoma24-hour urinary metanephrine and normetanephrine Primary aldosteronism, other states of mineralocorticoid excess 24-hour urinary aldosterone level, specific mineralocorticoid tests Renovascular hypertensionDoppler flow U/S, MR Angiography, computed tomography angiography Sleep apneaSleep study with oxygen saturation (ESS) Thyroid/parathyroid diseaseThyroid stimulating hormone level, serum parathyroid hormone level

20.  Less aggressive targeting of blood pressures and treatment-initiation thresholds for elderly patients and for those younger than age 60 years with diabetes and kidney disease  Initial therapy in most patients (ACE) inhibitors, angiotensin receptor blockers [ARBs], calcium channel blockers, or diuretics are recommended).  Initiate therapy in 60 years with BP levels at 150/90 mm Hg or greater  In younger than 60 years as well as those older than 18 years with either chronic kidney disease (CKD) or diabetes, the BP treatment initiation and goals should be 140/90 mm Hg.  In nonblack hypertensive patients, begin treatment with either a thiazide-type diuretic, CCB, ACE inhibitor, or ARB Treatment Guidelines:

21.  In hypertensive black patients, initiate therapy with a thiazide-type diuretic or CCB  Regardless of race or DM, in 18 years or older with CKD, therapy should consist of an ACE inhibitor or ARB  Do not use an ACE inhibitor together with an ARB in the same patient  If goal is not achieved within 1/12, increase the dose or add an agent from another of the recommended drug  If 2-drug therapy is unsuccessful, add a third agent from the recommended drug classes.  If goal BP cannot be reached with 3/12 use agents from other drug classes and/or refer the patients to a hypertension specialist Treatment Guidelines:

22. Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way Initial Drug Choices If the patient is young (≤55 years) and non- black, start with: (A) angiotensin-converting enzyme (ACE) inhibitor or low-cost angiotensin-II receptor antagonist (AIIRA). A beta-blocker may be appropriate in younger adults if an ACE is not tolerated, in women who may become pregnant or if there is evidence of increased sympathetic drive. If the patient is aged >55 years or a black person of African or Caribbean family origin, use: (C) calcium-channel blocker (CCB). Stage 2 Drug Choices (A+C) ACE inhibitor or AIIRA with CCB. Use an ACE/AIIRA and a thiazide-like diuretic (D) if CCB is not tolerated (or if there is any evidence of heart failure). If initially started on a beta-blocker, add a CCB rather than a thiazide-like diuretic second-line (reduce diabetic risk). Consider an AIIRA rather than an ACE with a CCB in black (African or Caribbean) patients

23. Treatment should be started in all patients (any age) with stage 2 hypertension. Treat isolated systolic hypertension in the same way Stage 3 Drug Choices (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic (chlortalidone or indapamide). Stage 4 Drug Choices (A+C+D) ACE inhibitor or AIIRA and a CCB and a thiazide-like diuretic plus a further diuretic (higher-dose thiazide-like diuretic or spironolactone, depending on potassium). If the higher-dose diuretic is not tolerated, consider an alpha- or beta-blocker, or seek expert advice. The combination of an ACE inhibitor with an AIIRA is not recommended for the treatment of hypertension Treatment targets People aged <80 years: clinic <140/90 mm Hg, ABPM/HBPM <135/85 mm Hg. People aged ≥80 years: clinic <150/90 mm Hg, ABPM/HBPM <145/85 mm Hg.

24. Urgent treatment needed:  Accelerated hypertension, severe hypertension (>220/>120 mm Hg) or impending complications (e.g. (TIA), (LV) failure).  Possible underlying cause: low K+, Na+ elevated (possible Conn's syndrome); elevated creatinine, proteinuria or haematuria; rapidly worsening or resistant hypertension (i.e. needs >3 drugs); young age: patient aged <20 years, or <30 years needing treatment. Therapeutic problems:  Multiple drug intolerance or contra-indications, persistent noncompliance or treatment refusal (the reluctant hypertensive).  Special situations: hypertension in pregnancy, unusual BP variability. Indications for specialist referral