hypertension

1. HYPERTENSION
Department of Cardiology
Yangon General Hospital

2. Introduction
 Prevalence of hypertension is increasing around
the world
 Under diagnosed, under treated, not achieving the
targets
 ~ 54% of all strokes & 47% of all IHD were
attributable to high BP

4.  Sitting BP routinely
 Standing BP in elderly or
DM patients
 Rest - at least 5 min in
a quiet comfortable
room
 Remove tight clothing
 Support arm at heart
level
 Ensure arm relaxed
 Avoid talking
Measuring Blood Pressure

6.  Use a properly maintained, calibrated, and validated device
 Use cuff of appropriate size ( bladder must encompass >
2/3 of the arm )
 Lower mercury column slowly (2 mm /sec)
 Read BP to the nearest 2 mm Hg
 Measure diastolic BP as disappearance of sounds
Measuring Blood Pressure

7.  If differences between initial measurements mean of
at least two readings
 Do not treat on the basis of an isolated reading
 Automated devices may not measure blood pressure
accurately if there is pulse irregularity (e.g AF).
Palpate the radial or brachial pulse before measuring
BP. Measure BP manually using direct auscultation
over the brachial artery, if pulse is irregular.
Measuring Blood Pressure

8.  Measure BP in both arms: If the difference in readings
between arms >20 mmHg, measure subsequent BP in the
arm with the higher reading.
 If the clinic BP 140/90 mmHg ,offer ambulatory BP
monitoring (ABPM) to confirm the diagnosis
 If a person is unable to tolerate ABPM, home BP
monitoring (HBPM) is a suitable alternative to confirm the
diagnosis ( optional )
Measuring Blood Pressure

9. Blood Pressure Classification
JNC 7
BP Classification Systolic BP Diastolic BP
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Stage I hypertension 140-159 or 90-99
Stage II hypertension > 160 or > 100

10. Blood Pressure Classification
Ref: 2017 ACC/ AHA Guideline for the Prevention,
Detection, Evaluation, and Management of High Blood
Pressure in Adults

11. If the clinic blood pressure is 140/90 mmHg or
higher, offer ambulatory blood pressure monitoring
(ABPM) to confirm the diagnosis of hypertension.
Diagnosis of HT (1)

12. ABPM:
 at least 2 measurements /hr during the person’s
usual waking hours, ≈14 measurements to confirm
diagnosis
HBPM:
 two consecutive seated measurements, at least 1
minute apart
 blood pressure is recorded twice a day for at least 4
days and preferably for a week
 measurements on the first day are discarded –
average value of all remaining is used.
Diagnosis of HT (2)

13. CV Mortality Risk Doubles with each 20/10 mm Hg
BP increment
*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.
Lewington S, et al. Lancet. 2002; 60:1903-1913.
JNC 7. JAMA. 2003;289:2560-2572.
CV
mortality
risk
SBP/DBP (mm Hg)
0
1
2
3
4
5
6
7
8
115/75 135/85 155/95 175/105
1
2
3
4
Prospective Collaborative Study

14. JNC VII 2003
Complications Average %reduction
Stroke incidence 35-40%
Myocardial Infarction 20-25%
Heart Failure 50%
Benefits of treating hypertension

15. Benefit of BP lowering with antihypertensive
therapy

16. Causes of Hypertension
 Drugs
 non-steroidal anti-inflammatory drugs
 oral contraceptives
 steroids
 liquorice
 sympathomimetics
 some cold cures
 Renal disease
 present, past, or family history
 proteinuria or haematuria
 palpable kidney(s)—polycystic, hydronephrosis, or
neoplasm
 Renovascular disease (abdominal or loin bruit)

17. Causes of Hypertension
 Endocrine causes
 Phaeochromocytoma
(paroxysmal symptoms)
 Conn’s syndrome
 Tetany
 Muscle weakness
 Polyuria
 Hypokalaemia
 Cushing’s syndrome
(general appearance)
 Acromegaly
 Thyrotoxicosis
Graves’ Disease
Cushing’s
Syndrome

18. Causes of Hypertension
 Alcohol
 Obesity
 Pregnancy (Pre-eclampsia)
 Coarctation of aorta (radiofemoral delay or weak
femoral pulses)

19. Contributory factors
 Overweight
 Excess alcohol
> 3 units/day for men
> 2 units/day for women
 Excess salt intake
 Lack of exercise
 Environmental stress

20. Consequences of Hypertension
 Major risk factor for stroke, myocardial infarction,
heart failure, chronic kidney disease, cognitive
decline and premature death.
 Untreated hypertension can cause vascular and
renal damage leading to a treatment-resistant
state.
 Each 2 mmHg rise in systolic BP associated with
increased risk of mortality:
 7% from heart disease
 10% from stroke.

21. Complications of Hypertension (or)
Target Organ Damage
 Stroke, transient ischaemic attack, dementia, carotid bruits
 Left ventricular hypertrophy or left ventricular strain on
electrocardiogram
 Heart failure
 Myocardial infarct , angina
 Peripheral vascular disease
 Fundal haemorrhages or exudates, papilloedema
 Proteinuria
 Renal impairment (raised serum creatinine)

22. Radiological features of Heart Failure

23. Evaluation of hypertensive patients
 Thorough history taking and physical examination.
 The purpose of the evaluation is – to assess
 the cause(s) of the hypertension
 associated cardiovascular risk factors
 evidence of target organ damage
 Co-morbid diseases

24. Assessment of Cardiovascular Risk Factors (1)
 Smoking
 Dyslipidemia
 TC >5.0 mmol/l (190 mg/dL) or
 LDL-C >3.0 mmol/l (115 mg/dL) or
 HDL-C:
 Men <1.0 mmol/l (40 mg/dL)
 Women <1.2 mmol/l (46 mg/dL)
 TG >1.7 mmol/l (150 mg/dL)

25.  Diabetes mellitus
 Microalbuminuria or estimated GFR <60 mL/min
 Age (older than 55 for men, 65 for women)
 Family history of premature cardiovascular disease
(men under age 55 or women under age 65)
 Abdominal obesity - Waist circumference
 >102cm (M)
 >88cm (W)
Assessment of Cardiovascular Risk Factors (2)

26. Risk Factors for Cardiovascular Disease

27. Routine Investigations
 Urine strip test for protein and blood
 Serum creatinine and electrolytes
 Blood glucose—ideally fasted
 Blood lipid profile (at least total and high density
lipoprotein (HDL) cholesterol)—ideally fasted for
consideration of triglycerides
 Thyroid function test
 Electrocardiogram

28. Further Investigations
 Echocardiogram
 Renal ultrasound
 To detect possible renal disease
 Renal angiography
 To detect or confirm renal artery stenosis
 Urinary catecholamines
 To detect phaeochromocytoma
 Urinary cortisol and dexamethasone suppression test
 To detect possible Cushing’s Syndrome
 Plasma renin activity and aldosterone
 To detect possible primary aldosteronism

29. Evaluation and initiation of pharmacological
treatment based on 2017 ACC/AHA guideline

30. Management algorithm
based on 2014 Hypertension Guideline

31. Management algorithm
based on 2014 Hypertension Guideline

32. Management algorithm
based on 2014 Hypertension Guideline

33. Strategies to Dose Antihypertensive drugs
 Start one drug, titrate to maximum dose and then
add a second drug
 Start one drug and then add a second drug before
achieving maximum dose of the initial drug
 Begin with two drugs at the same time, either as 2
separate pills, or as a single pill combination
(Initial combination therapy is recommended if
BP is greater than 20/10 mmHg above goal )

34. BP thresholds for and goals of pharmacological
therapy in patients with hypertension according to
clinical conditions

35. Initial Drug of Choice for Hypertension
 ACE inhibitors (ACEI)
 Angiotensin receptor blockers (ARB)
 Thiazide diuretics
 Calcium channel blockers (CCB)

36. Antihypertensive Drugs

37. Antihypertensive Drugs

38. Compelling Indications

39. Beta blockers
 Beta-1 selective beta-blockers – possibly safer in
patients with COPD, asthma, diabetes and
peripheral vascular disease
 Metoprolol
 Bisoprolol
 Betaxolol
 Acebutolol

40. Monitoring side effects of drugs
 Diuretics – hypokalaemia
 Spironolactone – gynaecomastia, hyperkalaemia
 ACEI/ARB
 Cough (ACEI only)
 Angioedema (more with ACEI)
 Hyperkalaemia
 Beta blockers
 Fatigue, decreased heart rate
 Adversely affect glucose, mask hypoglycaemia
awareness
 CCB – oedema
 Alpha blockers – orthostatic hypotension

41.  Aspirin (75 mg/day) is recommended for
 secondary prevention of ischaemic cardiovascular disease
 primary prevention, in people over the age of 50 who have
a 10 year risk of cardiovascular disease of 20%
 Statins are recommended for
 all people with high blood pressure complicated by
cardiovascular disease, irrespective of baseline
concentrations total cholesterol or LDL cholesterol
 primary prevention in people with high blood pressure
who have a 10 year risk of cardiovascular disease of 20%.
Other Drugs Recommendation

42. Life style changes
 Smoking cessation
 Control of blood glucose and lipids
 Diet
 Diet rich in fruits, vegetables, whole grain and low-fat
dairy products
 Moderate alcohol consumption
 Reduce sodium intake to no more than 2400 mg/day
 Physical activity
 Moderate to vigorous activity 3-4 days a week averaging
40 minutes per session

43. Hypertension in special situations

44. Management of Hypertension in Patients with
Stable Ischemic Heart Disease (SIHD)

45. Management of Hypertension in Patients with Chronic
Kidney Disease

46. Management of Hypertension in patients with
Acute Intracerebral Haemorrhage (ICH)

47. Management of Hypertensive patients with
Acute Ischaemic Stroke

48. Management of Hypertensive patients with
Previous history of stroke
(Secondary stroke prevention)

49. Diagnosis and Management of Hypertensive Crisis

50. Therapeutic problems
 Multiple drug intolerance
 Multiple drug contraindications
 Persistent non-adherence or non-compliance

51. Resistant Hypertension
Office SBP/DBP > 130/80 mm Hg & > 3 prescribed
antihypertensive medications at optimal doses,
including a diuretic, if possible
or
Office SBP/DBP <130/80 mm Hg but patient
requires > 4 antihypertensive medications

52. Resistant Hypertension
Exclude Pseudo-Resistance
 Ensure accurate office BP measurements
 Assess for non-adherence with prescribed regimen
 Obtain home, work, or ambulatory BP readings to exclude
white coat effect
Identify & Reverse Contributing Lifestyle Factors
 Obesity
 Physical Inactivity
 Excessive alcohol ingestion
 High salt, low-fiber diet

53. Resistant Hypertension
Discontinue or Minimize Interfering Substances
 NSAIDS
 Sympathomimetic (e.g., amphetamines,
decongestants)
 OC pills
 Licorice

54. References

55. Evidence – based dosing of antihypertensive drugs

58. Cockcroft-Gault Formula for Creatinine Clearance
Creatinine clearance (ml/min) (male)
(140 – age in years) x weight (in kg)
72 x serum creatinine (mg/dl) *
Creatinine clearance (ml/min) (female)
(140 – age in years) x weight (in kg) x 0.85
72 x serum creatinine (mg/dl) *
* 1 mg/dl = 88.4 umol/l

59. The End