Hypertension: by Krikor Jabourian Nakhleh Nehmeh Yara Younes

Hypertension
By Krikor Jabourian
Nakhleh Nehmeh
Yara Younes
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
High blood pressure occurs when the
body’s small blood vessel narrow causing
the blood to exert excessive pressure
against the vessel walls. This forces the
heart to work harder to maintain the
pressure eventually leading to damage to
the vessels.
Types of hypertension
• Essential or Primary hypertension

– 90-95%
– No underlying medical condition
– This form of high blood pressure is often due to
obesity, family history or an unhealthy diet. The
condition is reversible with medications and
lifestyle changes
Secondary hypertension 2-10%

– Due to a medical condition or use of certain medicines
– Resolved by treating the condition or stopping the
medication
Causes of
Secondary Hypertension
• Renal Parenchymal Disease

• Renal failure
• Renal artery stenosis
• Coarctation of the aorta (narrowing)
• Atherosclerosis of blood vessels
• Endocrine causes like Cushing syndrome(hyperactivity of
adrenal glands)
• Pregnancy induced HTN
• Others: sleep apnea, medications(NSAIDs,
corticosteroids…)
Classification
Blood Pressure
Classification
BP SBP DBP
Classification mmHg mmHg
Normal <120 and <80
Prehypertension 120–139 and 80–89
Stage 1 140–159 and 90–99

Hypertension
Stage 2 >160 and >100
Hypertension
Who are at risk ?
Hypertension:
Predisposing factors
• Advancing Age
• Sex (men and postmenopausal women)
• Family history
• Sedentary life style & psycho-social stress
• Smoking ,High cholesterol diet, Low fruit
consumption
• Obesity & wt. gain
• Co-existing disorders such as diabetes, and
hyperlipidemia
• High intake of alcohol
Why to treat ?
Complications of
Hypertension
Heart Left Ventricular
Gangrene of the
Failure Hypertrophy Myocardial
Lower Extremities
Infarction
Aortic Coronary Heart
Aneurysm Disease
HYPERTENSION
Hypertensive
Blindness encephalopathy
Chronic Cerebral
Stroke Preeclampsia/ Hemorrhage
Kidney
Eclampsia
Failure
Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935
Target Organ Damage
 Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
Diagnosis
Clinical manifestations
• No specific complains or manifestations other than

elevated systolic and/or diastolic BP (Silent Killer )
• Morning occipital headache
• Difficulty breathing and chest pain
• Lightheadedness/Fainting
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision
Self-Measurement of BP
 Provides information on:

1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN
 Home measurement of >135/85 mmHg is generally

considered to be hypertensive.
 Home measurement devices should be checked regularly.

Measuring
Blood Pressure
• Patient seated quietly for at least

5minutes in a chair, with feet on the
floor and arm supported at heart
level
• An appropriate-sized cuff (cuff bladder encircling at least

80% of the arm)
• At least 2 measurements
Continue…
Measuring
Blood Pressure
• Systolic Blood Pressure is the point at which

the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of

disappearance of the sounds (Korotkoff 5th)
Continue…
How to treat ?
Treatment Overview
 Goals of therapy
 Lifestyle modification
 Pharmacologic treatment
 Algorithm for treatment of hypertension
 Follow up and monitoring
Goals of Therapy
 Reduce HTN-associated morbidity and mortality.

 Prevent cardiovascular damage
 Achieve desired BP
 Avoid unhealthy lifestyle options
 Treat BP <140/90 mmHg or BP <130/80 mmHg in
patients with diabetes or chronic kidney disease.
Non pharmacological
Treatment of hypertension
DASH
diet
Regular exercise
Loose weight , if obese
Reduce salt and high fat diets
Avoid harmful habits ,smoking ,alcohol

Life style modifications
• Lose weight, if overweight

• Relief of stress
• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and
cholesterol
• increase consumption of fruits and vegetables(
potassium, magnesium ,calcium and vitamin C)
• Limit alcohol intake
Lifestyle Modification
Modification Approximate SBP reduction

(range)
Weight reduction 1 mmHg for 1 kilo lost approx.
Adopt DASH eating 8–14 mmHg

plan
Dietary sodium 2–8 mmHg
reduction
Physical activity 4–9 mmHg
Moderation of alcohol 2–4 mmHg

consumption
Drug therapy for hypertension
Class of drug Example Initiating dose Usual maintenance

dose
DiureticsHydrochlorothiazIDE 12.5 mg o.d. 12.5-25 mg o.d.
-blockers AtenoLOL 25-50 mg o.d. 50-100 mg o.d.

Calcium AmloDIPINE 2.5-5 mg o.d.5-10 mg o.d.
channel
blockers
-blockers prazOSIN 2.5 mg o.d 2.5-10mg o.d.
ACE- inhibitors ramiPRIL 1.25-5 mg o.d. 5-20 mg o.d.
Angiotensin-II LoSARTAN 25-50 mg o.d. 50-100 mg o.d.

receptor blockers
Diuretics
Example: Hydrochlorothiazide
• Act by decreasing blood volume and cardiac output
• Help the body decrease salt and water by helping the kidneys
release more sodium into the unrine
• Decrease peripheral resistance during chronic therapy
• Drugs of choice in elderly hypertensive patients
Side effects-
• Hypokalemia
• Hyponatremia
• Hyperlipidemia
• Hyperuricemia (hence contraindicated in gout)
• Hyperglycemia (hence not safe in diabetes)
• Dizziness, Headaches, dehydration, muscle cramps
• Not safe in renal and hepatic insufficiency
Beta blockers
Example: Atenolol, Metoprolol, nebivolol,

• 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
Side effects-
• Lethargy, impotency, bradycardia
• Cold hands or feet
• Weight gain
• Not safe in patients with co-existing asthma and
diabetes
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
Side effects
• Flushing/Fatigue
• Headache/Dizziness
• Constipation/Nausea
ACE inhibitors
Example: Ramipril, Lisinopril, Enalapril

• Inhibit ACE and formation of angiotensin II and
block its effects( block vasoconstriction)
• Drugs of choice in co-existent diabetes mellitus,
Heart failure
Side effects-
• Dry cough
• Hypotension
• Headaches
• Dizziness
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 and safer than ACEI
• Avoid during pregnancy
Side effects-
• Hypotension
• Dizziness
• Hyperkalemia
Alpha blockers
Example: prazosin
• Block a-1 receptors and cause vasodilation
• Reduce peripheral resistance and venous
return
• In combination with other hypertension drugs
Side effects
• Postural hypotension
• Dizziness
• Impotence
• Headache
Causes of
Resistant Hypertension
 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs)
• Over-the-counter drugs and some herbal supplements
 Excess alcohol intake
take home message --------------
• Hypertension is a major cause of morbidity and mortality, and

needs to be treated
• It is an extremely common condition; however it is still under-
diagnosed and undertreated
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from the
deleterious effect
• Besides pharmacology we have other choices and one has to be
acquainted with that choice
• Life style modification should always be encouraged in all
Hypertensive patients
Thank You!

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Hypertension

• Essential or Primary hypertension

Secondary hypertension 2-10%

• Renal Parenchymal Disease

Stage 1 140–159 and 90–99

• No specific complains or manifestations other than

 Provides information on:

 Home measurement of >135/85 mmHg is generally

 Home measurement devices should be checked regularly.

• Patient seated quietly for at least

• An appropriate-sized cuff (cuff bladder encircling at least

• Systolic Blood Pressure is the point at which

• Diastolic Blood Pressure is the point of

 Reduce HTN-associated morbidity and mortality.

Loose weight , if obese

Reduce salt and high fat diets

Avoid harmful habits ,smoking ,alcohol

• Lose weight, if overweight

Modification Approximate SBP reduction

Weight reduction 1 mmHg for 1 kilo lost approx.

Adopt DASH eating 8–14 mmHg

Moderation of alcohol 2–4 mmHg

Class of drug Example Initiating dose Usual maintenance

DiureticsHydrochlorothiazIDE 12.5 mg o.d. 12.5-25 mg o.d.

-blockers AtenoLOL 25-50 mg o.d. 50-100 mg o.d.

-blockers prazOSIN 2.5 mg o.d 2.5-10mg o.d.

ACE- inhibitors ramiPRIL 1.25-5 mg o.d. 5-20 mg o.d.

Angiotensin-II LoSARTAN 25-50 mg o.d. 50-100 mg o.d.

Example: Atenolol, Metoprolol, nebivolol,

Example: Ramipril, Lisinopril, Enalapril

• Hypertension is a major cause of morbidity and mortality, and

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