1. What Is Blood Pressure?
Blood pressure measures the pressure of the blood in arteries.
Arteries are groups of tubes which carry blood from your heart to the rest of your body.
The arteries can automatically contract (get smaller) or expand (get bigger).
When arteries contract, the pressure inside becomes higher. When arteries expand, the pressure inside becomes lower.
If arteries remain contracted or become clogged, the condition called hypertension or high blood pressure results.

2. How Is Blood Pressure Measured?
A blood pressure reading consists of two numbers: systolic and diastolic.
Systolic refers to systole, the phase when the heart pumps blood out into the aorta.
Diastolic refers to diastole, the resting period when the heart refills with blood.
At each heartbeat, blood pressure is raised to the systolic level, and, between beats, it drops to the diastolic level.

3. Hypertension is defined as systolic blood pressure (SBP) of 140 mmHg or greater, diastolic blood pressure (DBP) of 90 mmHg or greater, or taking antihypertensive medication.
VI JNC, 1997

4. Types of hypertension Essential hypertension Secondary hypertension
90%
No underlying cause
Secondary hypertension
Underlying cause

5. Causes of Secondary Hypertension
Renal Congenital anomalies, pyelonephritis, renal artery obstruction, acute and chronic glomerulonephritis Reduced blood flow to kidney causes release of renin. Renin reacts with serum protein in liver Coarctation of aorta
EndocrinePheochromocytoma Adrenal cortex tumors Cushing’s syndrome Hyperthyroidism
Medications such as estrogens, sympathomimetics, antidepressants, NSAIDs, steroids, Amphetamines
Neurogenic
Miscellaneous

6. Identifiable Causes of Hypertension
Sleep apnea Drug-induced
Chronic kidney disease
Primary aldosteronism Renovascular disease
Chronic steroid therapy and Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

7. Hypertension: Predisposing factors
Age > 60 years
Sex (men and postmenopausal women)
Family history of cardiovascular disease
Smoking
High cholesterol diet
High intake of alcohol
Sedentary life style
Too much salt in the diet
Stress
Chronic kidney disease
Co-existing disorders such as diabetes, obesity and hyperlipidaemia Adrenal and thyroid disorders

8. Causes Hypertension
The exact causes of hypertension are not known. Several factors and conditions may play a role in its development, including:

9. The old renin-angiotensin-aldosterone system...

11. 1999 WHO-ISH Guidelines : Definitions and Classifications of BP Levels
SBP DBP
Category* (mm Hg) (mm Hg)
Optimal < 120 < 80
Normal < 130 < 85
High-normal
Grade 1 hypertension (mild)
Borderline subgroup
Grade 2 hypertension (moderate)
Grade 3 hypertension (severe) > 180 > 110
ISH > 140 < 90
Borderline subgroup < 90
WHO-ISH Guidelines Subcommittee J Hypertens 1999; 17:151

12. JNC-VI, 1997 Optimal: <120 / and <80
Normal: <130 / and <85
High-Normal: / or 85-89
Stage I: / or 90-99
Stage II: / or
Stage III: ≥180 / or ≥110

13. Definitions thankfully simplified
JNC-VII, 2003
NORMAL: <120/ and <80
Pre-Hypertension: / or 80-89
Stage I: / or
Stage II: >160 / or ≥

14. 1999 WHO-ISH Guidelines: Stratification of risk to Quantify Prognosis
Degree of hypertension (mm Hg)
Risk factors and Grade 1-mild Grade 2-moderate Grade3-severe
disease history (SBP (SBP (SBP > 180
or DBP 90-99) or DBP ) or DBP > 110)
I No other risk Low risk Med risk High risk
factors
II 1-2 risk factors Med risk Med risk Very high risk
III > 3 risk factors or High risk high risk Very high risk
target organ disease
or diabetes
IV Associated Very high risk Very high risk Very high risk
Clinical conditions
WHO-ISH Guidelines Subcommittee J Hypertens 1999;17:151

15. CLINICAL MANIFESTATIONS
There are usually no symptoms or signs of hypertension.
In fact, nearly one-third of those who have it don't know it.
The only way to know if you have hypertension definitely is to have your blood pressure checked
May cause headache, dizziness, blurred vision when greatly elevated BP readings more than 140/90 mm of Hg

16. DIAGNOSTIC EVALUATION
ECG
Chest X-ray
Proteinuria,
elevated serum blood urea nitrogen (BUN), and creatinine
levels Serum potassium Urine (24-hour) for catecholamines
Renal scan Renal duplex imaging
Outpatient ambulatory BP measurements

17. Diseases Attributable to Hypertension
Left Ventricular Hypertrophy
Heart Failure
Gangrene of the Lower Extremities
Myocardial Infarction
Hypertensive Encephalopathy
Aortic Aneurym
HYPERTENSION
Coronary Heart Disease
Blindness
Cerebral Hemorrhage
Chronic Kidney Failure
Stroke
Preeclampsia/Eclampsia
Adapted from Dustan HP et al. Arch Intern Med. 1996; 156:

18. Health Problems Are Associated With Hypertension
Atherosclerosis: Blood vessel damage occurs through arteriosclerosis in which smooth muscle cell proliferation, lipid infiltration, and calcium accumulation occur in the vascular epithelium Damage to heart, brain, eyes, and kidneys is termed target organ disease
Heart Disease: heart failure (the heart can't adequately pump blood),
ischemic heart disease (the heart tissue doesn't get enough blood),
and hypertensive hypertrophic cardiomyopathy (enlarged heart) are all associated with high blood pressure.

19. Kidney Disease: Hypertension can damage the blood vessels and filters in the kidneys, so that the kidneys cannot excrete waste properly
Stroke: Hypertension can lead to stroke, either by contributing to the process of atherosclerosis (which can lead to blockages and/or clots), or by weakening the blood vessel wall and causing it to rupture.
Eye Disease: Hypertension can damage the very small blood vessels in the retina.

20. 1999 WHO-ISH Guidelines: Desirable BP Treatment Goals
Optimal or normal BP (< 130/85 mm Hg) for
Young patients
Middle-age patients
Diabetic patients
High-normal BP (< 140/90 mm Hg) desirable for elderly patients
Aggressive BP lowering may be necessary in patients with nephropathy, chronic renal failure, particularly if proteinuria is
< 1 g/d - 130/80 mm Hg
> 1 g/d - 125/75 mm Hg

21. Significant benefits from intensive BP reduction in diabetic patients
Major CV events / 100 patient-yr
Lancet 1998, 351, 1755

22. Relative risks of specific types of clinical complications related to tight and less tight BP Control
Patients with Absolute risk
aggregate (events/1000
and points patients-yr)
Tight Less tight Less RR for
control control Tight tight tight control
Clinical end point (n=758) (n=390) control control p (95% Cl)
Any diabetes-related ( )
end point
Deaths related to ( )
diabetes
All cause mortality ( )
Myocardial infarction ( )
Stroke ( )
Peripheral vascular ( )
disease
Microvascular disease ( )
Ref : UK Prospective Diabetes Study Group BMJ 1998; 317:703

23. Life style modifications
Lose weight, if overweight
Limit alcohol intake
Increase physical activity
Reduce salt intake
Stop smoking
Limit intake of foods rich in fats and cholesterol
Discourage excessive consumption of coffee and other caffeine-rich products.

25. Diet
A healthy diet, such as the DASH (Dietary Approaches to Stop Hypertension) diet, is very effective at lowering high blood pressure. The DASH diet calls for a certain number of daily servings from various food groups, including fruits, vegetables, and whole grains. The following steps can also help: Eating more fruits, vegetables, and low-fat dairy foods
Eating less of foods that are high in saturated fat and cholesterol, such as fried foods Eating more whole grain products, fish, poultry, and nuts Eating less red meat and sweets Eating foods that are high in magnesium, potassium, and calcium

26. Factors affecting choice of antihypertensive drug
The cardiovascular risk profile of the patient
Coexisting disorders
Target organ damage
Interactions with other drugs used for concomitant conditions
Tolerability of the drug
Cost of the drug

27. Drug therapy for hypertension
Class of drug Example Initiating dose Usual maintenance dose
Diuretics Hydrochlorothiazide mg o.d mg o.d.
-blockers Atenolol mg o.d mg o.d.
Calcium Amlodipine mg o.d mg o.d.
channel
blockers
-blockers Doxazosin 1 mg o.d. 1-8 mg o.d.
ACE- inhibitors Lisinopril mg o.d mg o.d.
Angiotensin-II Losartan mg o.d mg o.d.
receptor blockers

28. Diuretics Example: Hydrochlorothiazide
Act by decreasing blood volume and cardiac output
Decrease peripheral resistance during chronic therapy
Drugs of choice in elderly hypertensives
Drawbacks
Hypokalaemia
Hyponatraemia
Hyperlipidaemia
Hyperuricaemia (hence contraindicated in gout)
Hyperglycaemia (hence not safe in diabetes)
Not safe in renal and hepatic insufficiency

29. Beta blockers Example: Atenolol Block b1 receptors on the heart
Block b2 receptors on kidney and inhibit release of renin
Decrease rate and force of contraction and thus reduce cardiac output
Drugs of choice in patients with co-existent coronary heart disease
Drawbacks
Adverse effects: lethargy, impotency, bradycardia
Not safe in patients with co-existing asthma and diabetes
Have an adverse effect on the lipid profile

30. Calcium channel blockers
Example: Amlodipine
Block entry of calcium through calcium channels
Cause vasodilation and reduce peripheral resistance
Drugs of choice in elderly hypertensives and those with co-existing asthma
Neutral effect on glucose and lipid levels
Drawbacks
Adverse effects: Flushing, headache, Pedal edema

31. ACE inhibitors
Example: Lisinopril, Enalapril
Inhibit ACE and formation of angiotensin II and block its effects
Drugs of choice in co-existent diabetes mellitus
Drawbacks
Adverse effect: dry cough, hypotension, angioedema

32. Angiotensin II receptor blockers
Example: Losartan
Block the angiotensin II receptor and inhibit effects of angiotensin II
Drugs of choice in patients with co-existing diabetes mellitus
Drawbacks
Adverse effect: dry cough, hypotension, angioedema

33. Alpha blockers Example: Doxazosin
Block a-1 receptors and cause vasodilation
Reduce peripheral resistance and venous return
Exert beneficial effects on lipids and insulin sensitivity
Drugs of choice in patients with co-existing hyperlipidaemia, diabetes mellitus and BPH
Drawbacks
Adverse effects: Postural hypotension

34. Antihypertensive therapy: Side-effects and Contraindications
Class of drugs Main side-effects Contraindications/ Special Precautions
Diuretics Electrolyte imbalance, Hypersensitivity, Anuria (e.g. Hydrochloro- ­ total and LDL cholesterol thiazide) levels, ¯ HDL cholesterol
levels, ­ glucose levels, ­ uric acid levels
b-blockers Impotence, Bradycardia, Hypersensitivity, (e.g. Atenolol) Fatigue Bradycardia, Conduction disturbances, Diabetes, Asthma, Severe cardiac failure

35. Antihypertensive therapy: Side-effects and Contraindications (Contd.)
Class of drug Main side-effects Contraindications/ Special
Precautions
Calcium channel blockers Pedal edema, Headache Non-dihydropyridine (e.g. Amlodipine, CCBs (e.g diltiazem)– Diltiazem) Hypersensitivity, Bradycardia, Conduction disturbances, Congestive heart failure, Left ventricular dysfunction.
Dihydropyridine CCBs– Hypersensitivity
a-blockers Postural hypotension Hypersensitivity (e.g. Doxazosin)
ACE-inhibitors Cough, Hypertension, Hypersensitivity, Pregnancy, (e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis
Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy, blockers (e.g. Losartan) Bilateral renal artery stenosis

36. Choosing the right antihypertensive
Condition Preferred drugs Other drugs Drugs to be that can be used avoided
Asthma Calcium channel a-blockers/Angiotensin-II b-blockers blockers receptor blockers/Diuretics/ ACE-inhibitors
Diabetes a-blockers/ACE Calcium channel blockers Diuretics/ mellitus inhibitors/ b-blockers Angiotensin-II receptor blockers
High cholesterol a-blockers ACE inhibitors/ Angiotensin-II b-blockers/ levels receptor blockers/ Calcium Diuretics channel blockers
Elderly patients Calcium channel -blockers/ACE- (above 60 years) blockers/Diuretics inhibitors/Angiotensin-II
receptor blockers/- blockers
BPH a-blockers b-blockers/ ACE inhibitors/
Angiotensin-II receptor
blockers/ Diuretics/
Calcium channel blockers

37. Limitations on use of antihypertensives in patients with coexisting disorders
Coexisting Diuretic b-blocker ACE All CCB a1-blocker Disorder inhibitor antagonist
Diabetes Caution/x Caution/x    
Dyslipidaemia x x    
CHD      
Heart failure  3/Caution   Caution 
Asthma/COPD  x  /Caution   
Peripheral  Caution Caution Caution   vascular disease
Renal artery   x x   stenosis

38. Effect of various antihypertensives on coexisting disorders
Total LDL- HDL- Serum Glucose Insulin cholesterol cholesterol cholesterol triglycerides tolerance sensitivity
Diuretic ­ ­ ¯ ­­ ¯ ¯
b-blockers - ­ ¯¯ ­­­ - -
ACE inhibitors ­ ­
All antagonists ­ ­
CCBs
a-blockers ¯ ¯ ­ ¯ ­ ­

39. (Combination therapy)
Combination therapy for hypertension – Recommended by JNC-VI guidelines and 1999 WHO-ISH guidelines
With any single drug, not more than 25–50% of hypertensives achieve adequate blood pressure control
J Hum. Hypertens 1995; 9:S33–S36
For patients not responding adequately
to low doses of monotherapy
Increase the dose of drug. This, however, may lead to increased side effects
Substitute with another drug from a different class
Add a second drug from a different class
(Combination therapy)
If inadequate response obtained
Add second drug from different class (Combination therapy)

40. Advantages of fixed-dose combination therapy
Better blood pressure control
Lesser incidence of individual drug’s side-effects
Neutralisation of side-effects
Increased patient compliance
Lesser cost of therapy

41. Fixed-dose combinations as recommended by JNC-VI (1997) guidelines and 1999 WHO-ISH guidelines
Calcium channel blocker and b-blocker (e.g. Amlodipine and Atenolol)
Calcium channel blocker and ACE-inhibitor (e.g. Amlodipine and Lisinopril)
ACE-inhibitor and Diuretic (e.g. Lisinopril and Hydrochlorothiazide)
b-blocker and Diuretic (e.g. Atenolol and Hydrochlorothiazide)

42. Reduces BP effectively
Efficacy and Tolerability of a fixed-dose combination of amlodipine and atenolol (Amlopres-AT) in Indian Hypertensives (n=369)
Reduces BP effectively
80.5%
Blood Pressure (mm Hg)
% responders
Safe and well tolerated
Adverse events were reported in 7.9% of patients
Common side effects included edema, fatigue and headache
Indian Practitioner 1997; 50:

43. Reduces BP effectively
Efficacy and Tolerability of combined amlodipine and lisinopril (Amlopres-L) in Indian hypertensives (n=330)
Reduces BP effectively
77.65
Blood Pressure (mm Hg)
% responders
Safe and well tolerated
Adverse events were reported in 9.7% of patients
Side effects commonly reported included cough and edema
Only 1.76% of patients withdrew from the study.
Indian Practitioner 1998; 51:

44. Drugs in special conditions
Pregnancy
Coronary heart disease
Congestive heart failure
Preferred Drugs
Nifedipine, labetalol, hydralazine, beta-blockers, methyldopa, prazosin
Beta-blockers, ACE inhibitors, Calcium channel blockers
ACE inhibitors, beta-blockers
1999 WHO-ISH guidelines

45. BEST MANAGEMENT OF HYPERTENSION
To use the fewest drugs at the lowest doses while encouraging the patient to maintain lifestyle changes.
After BP has been under control for at least 1 year, a slow, progressive decline in drug therapy can be attempted.
However, most patients need to resume medication within 1 year.

46. Summary
Hypertension is a major cause of morbidity and mortality, and needs to be treated
It is an extremely common condition; however it is still underdiagnosed and undertreated
Hypertension is not controlled with monotherapy in at least 50% of patients; in these patients combination therapy is required

47. ISOLATED SYSTOLIC HYPERTENSION
Systolic BP elevation in the absence of elevated diastolic BP is termed isolated systolic hypertension

48. Definitions Hypertensive Crisis Urgency or Emergency
MALIGNANT: papilledema
ACCELERATED: retinal hemorrhages and exudates
No clinical difference so all “Accelerated-Malignant”

49. “Severe elevation of blood pressure”
Hypertensive Urgency
“Severe elevation of blood pressure”
Generally DBP >
No progressive end organ damage
RISK OF IMMINENT TARGET ORGAN DAMAGE ALTHOUGH INJURY HAS NOT YET OCCURRED
NO EVIDENCE BASED DATA EXISTS TO GUIDE PRACTITIONER
IN MANY CASES CLINICIANS MAY BE FORCED TO INITIATE ANTI-HTN TREATMENT WITHOUT BEING CERTAIN OF DIAGNOSTIC CLASSIFICATION

50. Hypertensive Emergency
“Severe elevation of blood pressure”
Generally occurs with DBP >130
WITH significant or progressive end organ damage
Hypertensive Encephalopathy
CVA – Ischemic versus hemorrhagic
Acute Aortic Dissection
Acute LVF with Pulmonary Edema
Acute MI / Unstable Angina
Acute Renal Failure
Eclampsia
Occurs in 1% of HTNsives
Rare unless DBP > 130
NOT DEFINED BY ABSOLUTE PRESSURE MEASUREMENTS BUT INSTEAD CONTINGENT ON PRESENCE OF RELATIVE BP INCREASES COMBINED WITH EVIDENCE OF END ORGAN DAMAGE.
Evidence suggests it is the rate of rise, not how high BP gets…
Like temp spikes in febrile seizures.

51. Urgency vs. Emergency Urgency Emergency
No need to acutely lower blood pressure
May be harmful to rapidly lower blood pressure
Death not imminent
Emergency
Immediate control of BP essential
Irreversible end organ damage or death within hours
MAIN CAUSE IS OF HYPERTENSIVE URGENCY IS MEDICATION NON-COMPLIANCE SO GENERALLY FIND OUT WHY NOT TAKING AND RESTART OR CHOOSE NEW AGENTS.