1. HYPERTENSION
:Presented by
Reda A Goweda
Family medicine department

2. :Objectives
• Definition • BP measurement
• Classification techniques
• Epidemiology • Evaluation
• Benefits of lowering • Prevention
BP • Treatment

3. Definition
• Persistent elevation of arterial BP at
or more than 140/90.
• An initial elevated reading should be
confirmed on at least 2 subsequent
visits over 1 to several weeks.

4. the real threshold for defining
”“hypertension
must be considered as flexible, being
high or low based on the total CV
.risk of each individual

5. Classification
• 1ry & 2ry.
• Controlled & Uncontrolled.
• Complicated &Uncomplicated.
• Systolic & Diastolic.
• JNC-7 classification.
• European society of hypertension

7. European society of hypertension

8. Epidemiology:
• HTN prevalence ~ 50 million people in the United
States.
• 1 billion individuals worldwide.
• Egypt has one of the highest prevalence rates in the
world (26.3%).
• There is age related increase in the prevalence of HTN
in Egypt, reaching its peak in the age group 55-64
yrs(59.4%)
• The rates of HTN awareness, ttt & control in USA are
70%, 59% &34%.but these rates in Egypt are 37.5% ,
23.9% & 8% respectively.

15. RECOMMENDED BLOOD PRESSURE
MEASUREMENT TECHNIQUE
2.
2.
••The cuff must be level with heart.
The cuff must be level with heart.
••If arm circumference exceeds 33 cm,
If arm circumference exceeds 33 cm,
aalarge cuff must be used.
large cuff must be used.
••Place stethoscope diaphragm over
Place stethoscope diaphragm over
brachial artery.
brachial artery.
1.
1. 3.
3.
••The patient should
The patient should Stethoscope
••The column of
The column of
be relaxed and the
be relaxed and the mercury must be
mercury must be
arm must be
arm must be vertical .
vertical.
supported.
supported. Mercury ••Inflate to occlude the
••Ensure no tight Inflate to occlude the
Ensure no tight machine pulse. Deflate at 2 to
clothing constricts pulse. Deflate at 2 to
clothing constricts 3 mm/s. Measure
the arm. 3 mm/s. Measure
the arm. systolic (first sound)
systolic (first sound)
and diastolic
and diastolic
(disappearance) to
(disappearance) to
nearest 2 mm Hg.
nearest 2 mm Hg.
Continuing Medical©
3
Implementation

18. :When measuring BP, care should be taken to
;Allow the patients to sit quietly for several minutes ■
;Take at least two measurements spaced by 1–2 minutes ■
(Use a standard bladder (12–13 cm long and 35 cm wide ■
but have a larger bladder available for fat arms and a
;smaller one for thin arms and children
Have the cuff at the level of the heart, whatever the■
;position of the patient
;Deflate the cuff at a speed of 2 mmHg/s■
Use phase I and V (disappearance( Korotkoff sounds to ■
;identify SBP and DBP, respectively
Measure BP in both arms at first visit to detect possible■
differences due to peripheral vascular disease. In this
;instance, take the higher value as the reference one
Measure BP 1 and 5 min after assumption of the standing ■
position in elderly subjects, diabetic patients, and when
;postural hypotension may be frequent or suspected
(.Measure heart rate by pulse palpation (at least 30 sec ■

19. Optimum conditions for measurement
Relaxed patient
Comfortable temperature
Quiet room—no telephones or noises

20. Posture and position:
Measure blood pressure routinely with patient
.in sitting position
Back should be supported.
Legs should be uncrossed.
Patient should be relaxed.
Measure after ten minutes of rest.

21. Arm support
If the arm in which blood pressure is being measured is
unsupported—as tends to happen when the patient is sitting or
standing—the patient is performing isometric exercise, which
increases blood pressure by as much as 10%. The arm
therefore must be supported during measurement of blood
pressure, especially when the patient is in the standing
position. This is achieved best in practice by the observer
holding the patient’s arm at the elbow

22. Arm position
The forearm should be at the level of the heart—that is, the
mid-sternum. Measurement in an arm lower than the level of
the heart leads to an overestimation of systolic and diastolic
pressures, while measurement in an arm above the level of the
heart leads to underestimation. Such inaccuracy can be as
much as 10 mm Hg, especially when the patient is in the sitting
or standing position, when the arm is likely to be below heart
.level by the side

24. Cuff hypertension
However sophisticated a blood pressure measuring device, if it
is dependent on cuff occlusion of the arm (as most devices
are(, it will be prone to the inaccuracy of miscuffing. This
occurs when a cuff contains a bladder that is too long or too
.short relative to the circumference of the patient’s arm
Miscuffing is a serious source of error that leads inevitably to
incorrect diagnosis in clinical practice and erroneous
conclusions in research into hypertension. A further problem is
that inflation of the cuff itself may result in a transient but
substantial increase (up to 40 mm Hg( in the patient’s blood
.pressure

25. ?Which arm

26. ?Which arm
Arterial disease can cause differences in blood pressure
between arms, but because blood pressure varies from beat to
beat, any differences may simply reflect blood pressure
variability or measurement errors, or both. Bilateral
measurement should be made at the first consultation; if
differences 20 mm Hg for systolic or 10 mm Hg for diastolic
blood pressure are present on consecutive readings, the
patient should be referred to a cardiovascular centre for
further evaluation with simultaneous bilateral
measurement and for the
exclusion of arterial disease

28. AMBULATORY BP
,Although office BP should be used as the reference■
ambulatory BP may improve prediction of CV risk in
.untreated and treated patients
,h ambulatory BP monitoring should be considered-24■
in particular, when
considerable variability of office BP is found■
high office BP is measured in subjects otherwise at low■
total CV risk
there is a marked discrepancy between BP values■
measured in the office and at home
resistance to drug treatment is suspected■
hypotensive episodes are suspected, particularly in■
elderly and diabetic patie

29. sleep apnoea is suspected■
office BP is elevated in pregnant women and■
pre-eclampsia is suspected
Normal values for 24 hour average BP are lower
than for
office BP, i.e. 125–130mmHg systolic and 80mmHg
diastolic. Normal values of daytime BP are 130–
135mmHg
.systolic and 85 mmHg diastolic

30. HOME BP
Self-measurement of BP at home is of clinical value. Home ■
:BP measurements should be encouraged in order to
provide more information on the BP lowering effect of ■
treatment at trough, and thus on therapeutic coverage
throughout the dose-to-dose time interval
improve patient’s adherence to treatment regimens ■
understand technical reliability/environmental■
conditions of ambulatory BP data
Self-measurement of BP at home should be discouraged ■
:whenever
it causes anxiety to the patient■
it induces self-modification of the treatment regimen■
,Normal values for home BP are lower than for office BP ■
i.e. 130–135mmHg systolic and 85 mmHg diastolic

31. 03
20 Home (Self) Measurement of BP:
Specific Role in Selected Patients
Which patients?
Non adherence
Hypertension and
diabetes Further assess
Normal using
Office-induced blood ambulatory
pressure elevation Home BP? blood pressure
monitoring
BP over 135/85 mm Hg should be considered elevated
Continuing Medical©
Implementation
Canadian Hypertension Education Program Recommendations 47

32. 03
20 Home (Self) Measurement of BP:
Patient Education
How to?
Use devices:
- appropriate for the individual (cuff size)
- have met the standards of the AAMI Adequate patient training in:
and or the BHS and or IP - measuring their BP
- interpreting these readings
Values over
135 / 85 mm Hg
should be Regular verifications
considered elevated - accuracy of the device
- measuring techniques
Self measurement can help to
improve patient adherence
AAMI=Association for the Advancement of Medical Instrumentation;
BHS=British Hypertension Society; IP: International Protocol.
Continuing Medical©
Implementation
Canadian Hypertension Education Program Recommendations 48

34. )HYPERTENSION
Office BP persistently 140/90mmHg
Normal daytime ambulatory (130–135/85mmHg( or home
135/85mmHg( BP–130(
In these subjects CV risk is less than in individuals with
raised office and ambulatory or home BP but may be
slightly greater than that of individuals with in and out-
ofoffice normotension

35. )MASKED HYPERTENSION(
ISOLATED AMBULATORY HYPERTENSION
(Office BP persistently normal (140/90mHg
Elevated ambulatory (125–130/80 mmHg( or home
135/85mmHg( BP–130(
In these subjects CV risk is close to that of individuals
with in and out-of-office hypertension

39. DIAGNOSTIC EVALUATION
AIMS
Establishing BP values■
Identifying secondary causes of■
hypertension
Searching for■
;other risk factors■
;subclinical organ damage■
;concomitant diseases■
accompanying CV and renal complications■

40. DIAGNOSTIC EVALUATION: MEDICAL
HISTORY AND PHYSICAL EXAMINATION
FAMILY AND CLINICAL HISTORY
Duration and previous level of high BP . 1
Indications of secondary hypertension . 2
Risk factors. 3
Symptoms of organ damage. 4
Previous antihypertensive therapy . 5
((efficacy, adverse events
Personal, family, environmental factors. 6

41. PHYSICAL EXAMINATIONS
Signs suggesting secondary hypertension . 1
Signs of organ damage. 2
.Evidence of visceral obesity . 3

43. :Framingham Heart Study
.Calculation of the 10-Year CHD Risk in Men and Women

45. STRATIFICATION OF TOTAL CV RISK

52. A 72-year-old white female, previously well
controlled on a once-daily
combination pill containing atenolol 50 mg and
hydrochlorothiazide 25 mg, presents
with a rise in her blood pressure to 170/110. You add
5 mg of lisinopril, and her
creatinine rises from 1.1 to 1.9. What do you
?suspect
A. Nonadherence
B. Hypertensive nephrosclerosis
C. Hyperaldosteronism
D. Atherosclerotic renal artery stenosis
E. Pheochromocytoma

53. Answer: D. The recurrence of hypertension
in a previously well-controlled patient
should prompt the clinician to consider
nonadherence to the medication, as well as
a
secondary cause of hypertension. The decline
in renal function after addition of an
angiotensin-converting enzyme inhibitor,
however, is most suggestive of bilateral
renal artery stenosis

54. A 42-year-old obese male returns for follow-up. His last visit with you
was threevyears ago, and since that time his weight has increased by
15 kg, such that his BMI
is now 32. He reports feeling tired during the day, and has increased his
coffeevconsumption to four cups per day and his tobacco use to one
pack of cigarettes pervday. His blood pressure has increased from
136/86 at last visit to 152/90 today. Hevstates that he has not drunk
coffee or smoked in the last six hours. Which of thevfollowing is most
?likely to be contributing to his elevated blood pressure at this visit
A. Type 2 diabetes
B. Excessive licorice consumption
C. Obstructive sleep apnea
D. Increased coffee intake
E. Tobacco use

55. Answer: C. Type 2 diabetes is an important comorbidity
in patients with
hypertension, but not a cause of hypertension. Excessive
licorice intake is a very rare
cause of hypertension. Obstructive sleep apnea is a common
identifiable cause of
hypertension. Coffee and tobacco use can raise blood
pressure acutely, but do not
.increase the risk of development of hypertension

56. You are treating a 61-year-old man for hypertension. He is
not responding
well to combination therapy with a thiazide diuretic and a
.beta-blocker
On physical examination, you note an abdominal bruit.
Which of the following
?tests is most likely to help you evaluate him further
a. Chest x-ray
b. Captopril renal scan
c. Urinary metanephrines and vanillymandelic acid levels
d. Aortic CT scan
e. Echocardiogram

57. The answer is b. (Mengel, pp 499–507.) The patient
described in the
question has physical examination findings consistent with
renal artery
stenosis. A captopril renal scan or renal magnetic resonance
angiography
would evaluate this. Urinary metanephrines and
vanillymandelic acid levels
would help rule out pheochromocytoma. A chest x-ray would
be helpful
if coarctation of the aorta were suspected. An aortic CT
would help to
or quantify an aortic aneurysm, and an echocardiogram would
help to
.identify left ventricular hypertrophy or systolic dysfunction

58. You are treating a 40-year-old man for hypertension. He is
not responding
well to a thiazide diuretic, and on further evaluation reports
intermittent
tachycardia, diaphoresis, and dizziness upon standing. Which
of the following
?tests is most likely to help you evaluate these symptoms
a. Chest x-ray
b. Captopril renal scan
c. Urinary metanephrines and vanillymandelic acid levels
d. Plasma renin activity levels
e. Echocardiogram

59. The answer is c. (Mengel, pp 499–507.) The patient described in
the question has symptoms consistent with pheochromocytoma. The best
test to rule this out is urinary metanephrines and vanillymandelic acid
.levels
.A chest x-ray would be helpful if coarctation of the aorta were suspected
A captopril renal scan or renal magnetic resonance angiography
would evaluate renal artery stenosis. Plasma renin activity levels would
identify primary aldosteronism, and an echocardiogram would help to
identify left ventricular hypertrophy or systolic dysfunction

60. You are examining a 40-year-old patient for
the first time, and find her
blood pressure to be 155/92 mm Hg. Which
of the following physical examination
findings, if present, would indicate a
?secondary cause of hypertension
a. A left-sided carotid bruit
b. Distended jugular veins
c. A precordial heave
d. Absence of a femoral pulse
e. Papilledema

61. When examining a hypertensive
patient, the physician should be alert for signs of end-organ damage and
possible causes of secondary hypertension. Signs of end-organ damage
include arteriolar narrowing, hemorrhages, exudates or papilledema,
carotid
bruits or jugular venous distension, a loud second heart sound or
precordial
heave, arrhythmias, absent peripheral pulses, and peripheral edema, just
to
name a few. Signs suggestive of secondary hypertension include
abdominal or
flank masses (polycystic kidneys(, absence of femoral pulses (coarctation
of
the aorta(, tachycardia/flushing/diaphoresis (pheochromocytoma(,
abdominal
bruits (renal artery stenosis(, pigmented striae (Cushing’s syndrome(, or
an
(.enlarged thyroid gland (hyperthyroidism

64. Patient evaluation:
:History
• Risk factors
• Symptoms of 2ry HTN
• Symptoms of TOD.
• Drug history

65. Examination:
• BP
• BMI
• Fundus Ex
• LL
• Cardiac ex.
• Chest ex.
• Abd. Ex.
• Thyroid gland ex.

66. You have just diagnosed a 35-year-old man with
hypertension. He is
otherwise healthy and has no complaints. Which of
the following laboratory
?tests is not indicated in the initial workup
a. Hemoglobin and hematocrit
b. Potassium
c. A thyroid stimulating hormone level
d. Fasting glucose
e. A resting electrocardiogram

67. The answer is c. (Mengel, pp 499–507.) Baseline laboratory
screening
is important to assess for end-organ damage and identify
patients at
high risk for cardiovascular complications. The routine tests
for a newly
diagnosed hypertensive patient include: hemoglobin and
,hematocrit
potassium, creatinine, fasting glucose, calcium, a fasting lipid
,profile, urinalysis
and a resting electrocardiogram. Other tests are not indicated
unless physical examination or history makes them likely to
be positive

69. RECOMMENDED TESTS
Echocardiogram■
Carotid ultrasound■
Quantitative proteinuria (if dipstick test ■
(positive
Ankle-brachial BP Index■
Fundoscopy■
Glucose tolerance test (if fasting plasma ■
glucose
(mmol/L (100 mg/dL 5.6
Home and 24 h ambulatory BP monitoring ■

74. GOALS OF TREATMENT
In hypertensive patients, the primary goal of treatment■
is to achieve maximum reduction in the long-term total
.risk of CV disease
This requires treatment of the raised BP per se as well as■
.of all associated reversible risk factors
BP should be reduced to at least below 140/90mmHg■
systolic/diastolic(, and to lower values, if tolerated, in(
.all hypertensive patients
Target BP should be at least 130/80 mmHg in patients■
with diabetes and in high or very high risk patients, such
,as those with associated clinical conditions (stroke
(.myocardial infarction, renal dysfunction, proteinuria
.

75. Despite use of combination treatment, reducing systolic■
BP to 140mmHg may be difficult and more so if the
target is a reduction to 130mmHg. Additional
difficulties should be expected in the elderly, in patients
with diabetes, and in general, in patients with CV
.damage
,In order to more easily achieve goal BP■
antihypertensive treatment should be initiated before
significant CV damage develops

76. You are counseling a 33-year-old obese woman with
hypertension. Which
of the following interventions would lower her systolic blood
?pressure the most
a. Weight loss amounting to 10% of her total body weight
b. Adopting a diet high in fruits, vegetables, and low fat dairy
products
c. Restricting dietary sodium
d. Increasing physical activity at least 30 minutes a day, most
days of the week
e. Limit alcohol consumption to no more than 1 drink per day

77. The answer is b. (Mengel, pp 499–507.) While all of the interventions
,listed in this question have the potential to lower systolic blood pressure
the DASH diet (described in the landmark study, Dietary Approaches
.to Stop Hypertension( has been shown to lower blood pressure the most
The diet is high in potassium, calcium, and magnesium. The study found
that diets high in fruits and vegetables, with a reduced content of
saturated
and total fat can lower systolic blood pressure by 8–14 mm Hg. A 10%
weight loss will lower blood pressure by 5–10 mm Hg. Sodium
restriction
will lower blood pressure 2–8 mm Hg. Regular aerobic activity is also
,beneficial
lowering blood pressure by 4–9 mm Hg, and limiting alcohol can
.lower systolic blood pressure by 2–4 mm Hg

79. Pharmacologic treatment

80. You have seen a 36-year-old man with elevated blood pressure. On
one occasion, his blood pressure was 163/90 mm Hg, and on a second
occasion, his blood pressure was 158/102 mm Hg. You have encouraged
lifestyle modifications including weight loss using exercise and dietary
changes. Despite some modest weight loss, at his current visit, his blood
pressure is 166/92 mm Hg. Which of the following is the best treatment
?strategy at this point
a. Use a thiazide diuretic
b. Use an ACE inhibitor
c. Use an angiotensin receptor blocker
d. Use a beta-blocker
e. Use a two drug combination of medications

81. The answer is e. (Mengel, pp 499–507.) The patient described above has
stage 2 hypertension (systolic blood pressure greater or equal to 160 mm
,Hg
or diastolic blood pressure greater or equal to 90 mm Hg(. Since lifestyle
modifications
have not helped, the next step is to institute drug therapy. JNC
guidelines state that in patients with stage 2 hypertension, two-drug 7
combination
therapy is indicated. The most common regimen would be a thiazide
diuretic along with either an ACE inhibitor, ARB, beta-blocker, or
calciumchannel
blocker

84. INITIATION OF BP LOWERING
THERAPY
Initiation of BP lowering therapy should be decided on■
:two criteria
The level of SBP and DBP■
The level of total CV risk■
This is detailed in the Figure 47.2 which considers■
treatment based on lifestyle changes and
,anti-hypertensive drugs with, in addition
recommendations on the time delay to be used for
.assessing the BP lowering effects

86. :The following points should be emphasized
Drug treatment should be initiated promptly in grade 3■
hypertension as well as in grade 1 and 2 when total CV
.risk is high or very high
In grade 1 or 2 hypertensives with moderate total CV■
risk drug treatment may be delayed for several weeks
and in grade 1 hypertensives without any other risk
factor for several months. However, even in these
patients lack of BP control after a suitable period
.should lead to initiation of drug treatment
.

87. When initial BP is in the high normal range the decision■
.on drug intervention heavily depends on the level of risk
In the case of diabetes, history of cerebrovascular, coronary
or peripheral artery disease, the recommendation to start
BP lowering drugs is justified by the results of controlled
trials. Subjects with BP in the high normal range in whom
total CV risk is high because of a subclinical organ damage
should be advised to implement intense lifestyle
measures. In these subjects BP should be closely
monitored and drug treatment considered in the presence
of a worsening of the clinical condition

88. CHOICE OF ANTIHYPERTENSIVE
DRUGS

89. The main benefits of antihypertensive therapy are due■
to lowering of BP per se
Five major classes of antihypertensive agents–thiazide■
,diuretics, calcium antagonists, ACE-inhibitors
blockers–are‫ -ك‬angiotensin receptor blockers and
suitable for the initiation and maintenance of
.antihypertensive treatment, alone or in combination
blockers, especially in combination with a thiazide-‫ك‬
diuretic, should not be used in patients with the
metabolic syndrome or at high risk of incident
diabetes

90. In many patients more than one drug is■
needed, so
emphasis on identification of the first class of
drugs to
be used is often futile. Nevertheless, there are
conditions
for which there is evidence in favour of some
drugs
versus others either as initial treatment or as
part of a
.combination

91. ,The choice of a specific drug or a drug combination■
and the avoidance of others should take into account
:the following
The previous favourable or unfavourable experience of■
the individual patient with a given class of
.compounds
The effect of drugs on CV risk factors in relation to the■
.CV risk profile of the individual patient
,The presence of subclinical organ damage■
clinical CV disease, renal disease or diabetes, which
may be more favourably treated by some drugs than
.others

92. The presence of other disorders that may limit the
use
.of particular classes of antihypertensive drugs
The possibilities of interactions with drugs used■
for
.other conditions
The cost of drugs, either to the individual■
patient or to the health provider. However, cost
considerations should never predominate over
efficacy, tolerability, and protection of the individual
patient

93. Continuing attention should be given to side-effects■
of drugs, because they are the most important
cause of non-compliance. Drugs are not equal in
terms of adverse effects, particularly in individual
.patients
The BP lowering effect should last 24 hours. This can be■
checked by office or home BP measurements at trough
.or by ambulatory BP monitoring
Drugs which exert their antihypertensive effect over■
hours with a once-a-day administration should be 24
preferred because a simple treatment schedule favours
.compliance

94. CONTRA-INDICATIONS TO USE
CERTAIN ANTIHYPERTENSIVE DRUGS

95. MONOTHERAPY VERSUS
COMBINATION THERAPY
Regardless of the drug employed, monotherapy allows■
to achieve BP target in only a limited number of
.hypertensive patients
Use of more than one agent is necessary to achieve■
target BP in the majority of patients. A vast array
of effective and well tolerated combinations is
.available
Initial treatment can make use of monotherapy or■
combination of two drugs at low doses with a
subsequent increase in drug doses or number, if
.needed

96. Monotherapy could be the initial treatment■
for mild BP elevation with low or moderate total CV
risk. A combination of two drugs at low doses
should be preferred as the first step in
treatment when the initial BP is in the grade 2 or 3
or total CV risk is high or very high with mild BP
.elevation
Fixed combinations of two drugs can simplify the ■
.treatment schedule and favour compliance
In several patients BP control is not achieved by two ■
drugs, and a combination of three of more drugs is
.required
,In uncomplicated hypertensives and in the elderly■
antihypertensive therapy should normally be initiated
gradually. In higher risk hypertensives, goal BP
should be achieved more promptly, which favours
initial combination therapy and quicker adjustment of
.doses

100. Classes&generic Trade Dail Time/ Side effects Compellin Possible Possible Compelling
names names y day g indication contraindication contraindication
dose indication s s s
s
I-Diuretics •Isolated
systolic
----------
•Dyslipid •Gout
HTN e-mia
1-Thiazides Hypokalemia (elderly)
Hyponatremia •Systolic
Hypovolemia HF
hydrochlorothiazid Hydrex 12.5 1 Hypochloremic
e t. -50 alkalosis
Hyperglycemia
2-Loop Hyperureicemia
Hyperlipidemia
hypercalcemia
furosemide Lasix 20- 1-2
tab,amp 320
3-K-sparing
spironolactone aldacton 25- 2-3 Gynacomastia
e 100 hyperkalemia

101. Classes&gener Trade Dail Time/d Side effects Compelling Possible Possible Compelling
ic names names y ay indications indicatio contraindicatio contraindicatio
dose ns ns ns
II_Adrenergic
blockers
1-Beta Bronchospas MI HF HF BA
blockers m angina Dyslipidemia COPD
Sexual P.V.D. Heart block
Atenolol Ateno 25- 1 dysfunction
Tenormi 100 Mask s. of
n hypoglycemia
blokium Enhance s. of
P.V.D.
propranolol inderal 30- 3-4 Enhance HF
240 Depression
dyslipidemia
bisoprolol Concor 2.5- 1 (no sexual
10 dysfunction(
2-Alpha-beta
blockers
labetalol 200- 2-3 As beta pheochromocytom As beta blockers
120 blockers a
0
3-Alpha
blockers

102. Classes&generic Trade Daily Time/da Side effects Compellin Possible Possible Compelling
names names dose y g indication contraindicatio contraindication
indication s ns s
s
III_ACE_I
captopril Capoten 12.5- 2-3 Dry cough HF CRF Renal Pregnancy
150 Hyperkalemi LV DM impairment Renovascular
a dysfunctio PVD disease
Increase n
S.creat.
IV-ARBs
valsartan tareg 80- 1 Same as Cough HF PVD Pregnancy
320 ACE-I(no induced by Renovascular
dry cough( ACE-I disease
V-CCB
Diltiazem Altiazem 90- 3 Bradycardia Isolated MI migraine HB
360 Dizziness systolic Systolic HF
HF HTN
Nifedipine Epilat 30- 1 Headache
120 Gum
huperplasia
Ankle edema
flushing

103. You have diagnosed a 39-year-old woman with
hypertension. Lifestyle
modifications helped reduce her blood pressure, but she
was still above goalYou chose to start
hydrochlorothiazide, 25 mg daily. This helped her blood
pressure, but her blood pressure is still 142/94. Which of
the following is the
best approach to take in this situation?
a. Increase her hydrochlorothiazide to 50 mg per day
b. Change to a loop diuretic
c. Change to an ACE inhibitor
d. Change to a beta-blocker
e. Add an ACE inhibitor

104. The answer is e. (Mengel, pp 499–507.) According to JNC 7
guidelines,
if the initial agent does not control blood pressure sufficiently, a
second
agent of a different class should be added. Keeping both agents at
lower doses will decrease side effects. ACE inhibitors and
diuretics work
well together with a relatively low incidence of side effects.

106. Combination therapy
Spironolactone
BB
Diuretics
CCB
ACE-I
verapamil

112. PATIENTS’ FOLLOW-UP
Effective and timely titration to BP control requires■
frequent visits in order to timely modify the treatment
regimen in relation to BP changes and the appearance
.of side-effects
Once the target BP has been reached, the frequency of ■
visits can be considerably reduced. However, excessively
wide intervals between visits are not advisable because
,they interfere with a good doctor-patient relationship
.which is crucial for patient’s compliance
Patients at low risk or with grade 1 hypertension may be ■
seen every 6 months and regular home BP measurements
may further extend this interval. Visits should be more
frequent in high or very high risk patients. This is the case
also in patients under non-pharmacological treatment
alone due to the variable antihypertensive response and
.the low compliance to this intervention

113. Follow-up visits should aim at maintaining control of
all reversible risk factors as well as at checking the status
of organ damage. Because treatment-induced changes in
left ventricular mass and carotid artery wall thickness
are slow, there is no reason to perform these
.examinations at less than 1 year intervals
Treatment of hypertension should be continued for life■
because in correctly diagnosed patients cessation of
treatment is usually followed by return to the hypertensive
state. Cautious downward titration of the existing
treatment may be attempted in low risk patients after
long-term BP control, particularly if non-pharmacological
treatment can be successfully implemented

115. 3
0Recommendations for Follow-up
2 0
Diagnosis of hypertension
Non Pharmacological treatment
With or without Pharmacological treatment
Are BP readings below target during 2 consecutive visits?
Yes No
Follow-up at 3-6 Symptoms, Severe
month intervals hypertension, Intolerance to
anti-hypertensive treatment
or Target Organ Damage
Yes No
More frequent Monthly visits
visits
Continuing Medical©
Implementation
Canadian Hypertension Education Program Recommendations 52

116. :Referral points
• BP .=180/120
• S&S of TOD
• HTN refractory to outpatient ttt.
• 2ry HTN
• HTN in pregnancy.

117. A 42-year-old male patient of yours presented to the
emergency department
with a stroke. After full recovery, he presents to your office
.for follow up
Assuming he has no other medical concerns, which of the
following medications
is best to lower his blood pressure and prevent recurrent
?stroke
a. An aldosterone antagonist
b. An ACE inhibitor
c. An angiotensin receptor blocker
d. A calcium-channel blocker
e. A beta-blocker

118. The answer is b. (Mengel, pp 499–507.) The
PROGRESS study
Perindopril Protection against Recurrent (
Stroke Study( found that an ACE
inhibitor and diuretic in combination are
effective in preventing recurrent
.stroke

127. ELDERLY PATIENTS
,Drug treatment can be initiated with thiazide diuretics ■
,calcium antagonists, angiotensin receptor antagonists
blockers, in line with general‫ -ك‬ACE-inhibitors, and
guidelines. Trials specifically addressing treatment of
isolated systolic hypertension have shown the benefit of
thiazides and calcium antagonists but subanalysis of
other trials also show efficacy of angiotensin receptor
.blockers
Initial doses and subsequent dose titration should be ■
more gradual because of a greater chance of undesirable
.effects, especially in very old and frail subjects
/BP goal is the same as in younger patients, i.e. 140 ■
mmHg or below, if tolerated. Many elderly patients 90
need two or more drugs to control blood pressure and
reductions to 140mmHg systolic may be difficult to
.obtain
.

128. ,Drug treatment should be tailored to the risk factors■
target organ damage and associated cardiovascular and
non-cardiovascular conditions that are frequent in the
elderly. Because of the increased risk of postural
hypotension, BP should always be measured also in the
.erect posture
In subjects aged 80 years and over, evidence for benefits■
.of antihypertensive treatment is as yet inconclusive
However, there is no reason for interrupting a successful
and well tolerated therapy when a patient reaches
years of age 80

129. DIABETIC PATIENTS
Where applicable, intense non-pharmacological■
measures should be encouraged in all patients with
diabetes, with particular attention to weight loss and
.reduction of salt intake in type 2 diabetes
Goal BP should be 130/80mmHg and■
antihypertensive drug treatment may be started already
.when BP is in the high normal range
To lower BP, all effective and well tolerated drugs can be■
used. A combination of two or more drugs is frequently
.■needed

130. Available evidence indicates that lowering BP also
exerts
a protective effect on appearance and progression of
renal damage. Some additional protection can be
obtained by the use of a blocker of the
reninangiotensin
system (either an angiotensin receptor
(.antagonist or an ACE-inhibitor
A blocker of the renin-angiotensin system should■
be a
regular component of combination treatment and the
one preferred when monotherapy is sufficient

131. Microalbuminuria should prompt the use of■
antihypertensive drug treatment also when initial BP is
in the high normal range. Blockers of the reninangiotensin
system have a pronounced antiproteinuric
.effect and their use should be preferred
Treatment strategies should consider an intervention■
.against all CV risk factors, including a statin
,Because of the greater chance of postural hypotension■
.BP should also be measured in the erect posture

132. PATIENTS WITH RENAL DYSFUNCTION
Renal dysfunction and failure are associated with a very ■
.high risk of CV events
Protection against progression of renal dysfunction has■
two main requirements: a( strict blood pressure control
/mmHg and even lower if proteinuria islg 130/80(
day(; b( lowering proteinuria to values as near to
.normal as possible
To achieve the BP goal, combination therapy of several■
antihypertensive agents (including loop diuretics( is
.usually required
To reduce proteinuria, an angiotensin receptor■
antagonist, an ACE-inhibitor or a combination of both
.are required
.

133. There is controversial evidence as to whether blockade■
of the renin-angiotensin system has a specific beneficial
role in preventing or retarding nephro-sclerosis in
non-diabetic non-proteinuric hypertensives, except
,perhaps in Afro-American individuals. However
inclusion of one of these agents in the combination
therapy required by these patients appears well
.founded
,An integrated therapeutic intervention (antihypertensive■
statin and antiplatelet therapy( has to be frequently
considered in patients with renal damage because, under
these circumstances, CV risk is extremely high

134. PATIENTS WITH CEREBROVASCULAR
DISEASE
In patients with a history of stroke or transient■
ischaemic attacks, antihypertensive treatment
markedly reduces the incidence of stroke recurrence
and also lowers the associated high risk of cardiac
.events
Antihypertensive treatment is beneficial in hypertensive■
patients as well as in subjects with BP in the high
.normal range. BP goal should be 130/80mmHg
Because evidence from trials suggests that the benefit■
largely depends on BP lowering per se, all available
drugs and rational combinations can be used. Trial
data have been mostly obtained with ACE-inhibitors
and angiotensin receptor antagonists, in association
with or on the top of diuretic and conventional
treatment, but more evidence is needed before their
specific cerebrovascular protective properties are
.established
There is at present no evidence that BP lowering has a■
beneficial effect in acute stroke but more research is
under way. Until more evidence is obtained
antihypertensive treatment should start when

135. post-stroke clinical conditions are stable, usually
several days after the event. Additional research in
this is necessary because cognitive dysfunction is
present in about 15% and dementia in 5% of subjects
.aged 65 years
In observational studies, cognitive decline and■
incidence of dementia have a positive relationship with
BP values. There is some evidence that both can be
.somewhat delayed by antihypertensive treatment

136. PATIENTS WITH CORONARY HEART DISEASE
AND HEART FAILURE
In patients surviving a myocardial infarction, early■
blockers, ACE-inhibitors or‫ -ك‬administration of
angiotensin receptor blockers reduces the incidence of
recurrent myocardial infarction and death. These
beneficial effects can be ascribed to the specific
protective properties of these drugs but possibly also to
.the associated small BP reduction
Antihypertensive treatment is also beneficial in ■
hypertensive patients with chronic coronary heart
disease. The benefit can be obtained with different
drugs and drug combinations (including calcium
antagonists( and appears to be related to the
degree of BP reduction. A beneficial effect has been
demonstrated also when initial BP is 140/90mmHg
and for achieved BP around 130/80mmHg
.or less
.

137. A history of hypertension is common while a raised BP■
.is relatively rare in patients with congestive heart failure
In these patients, treatment can make use of thiazide
,and loop diuretics, as well as of -blockers
ACE-inhibitors, angiotensin receptor antagonist and
antialdosterone drugs on top of diuretics. Calcium
antagonists should be avoided unless needed to control
.BP or anginal symptoms
Diastolic heart failure is common in patients with a■
.history of hypertension and has an adverse prognosis
There is at present no evidence on the superiority of
specific antihypertensive drugs

141. ORAL CONTRACEPTIVES
Even oral contraceptives with low oestrogen
content are
associated with an increased risk of
hypertension, stroke and
myocardial infarction. The progestogen-only
pill is a
contraceptive option for women with high BP,
but their
influence on cardiovascular outcomes has
been insufficiently
.investigated

142. HYPERTENSION IN PREGNANCY
,Hypertensive disorders in pregnancy, particularly preeclampsia ■
may adversely affect neonatal and maternal
.outcomes
Non-pharmacological management (including close■
supervision and restriction of activities( should be
considered for pregnant women with SBP 140–149mmHg
or DBP 90–95 mmHg. In the presence of gestational
hypertension (with or without proteinuria( drug
.treatment is indicated at BP levels 140/ 90mmHg
SBP levels 170 or DBP 110 mmHg should be
.considered an emergency requiring hospitalization
,In non-severe hypertension, oral methyldopa, labetalol■
blockers are‫ (-ك‬calcium antagonists and (less frequently
.drugs of choice
■

143. ,In pre-eclampsia with pulmonary oedema
nitroglycerine is the drug of choice. Diuretic therapy is
.inappropriate because plasma volume is reduced
As emergency, intravenous labetalol, oral methyldopa■
and oral nifedipine are indicated. Intravenous
hydralazine is no longer the drug of choice because of
an excess of perinatal adverse effects. Intravenous
infusion of sodium nitroprusside is useful in
hypertensive crises, but prolonged administration
.should be avoided
Calcium supplementation, fish oil and low dose aspirin■
are not recommended. However, low dose aspirin may
be used prophylactically in women with a history of
early onset pre-eclampsia

150. Hypertensive urgencies
Severe uncomplicated essential hypertension
Severe uncomplicated secondary hypertension
Postoperative hypertensiona
Hypertension associated with severe epistaxis
Drug-induced hypertension
(Rebound hypertension (i.e., sudden withdrawal of clonidine
Cessation of prior antihypertensive therapy
Severe hypertensive crises related to anxiety, panic attacks or
pain

158. HOW TO IMPROVE COMPLIANCE
WITH BLOOD PRESSURE LOWERING
THERAPY
Inform the patient of the risk of hypertension and the■
.benefit of effective treatment
Provide clear written and oral instructions about■
.treatment
Tailor the treatment regimen to patient’s lifestyle and ■
.needs
Simplify treatment by reducing, if possible, the number ■
.of daily medicaments
Involve the patient’s partner or family in information■
.on disease and treatment plans
Make use of self measurement of BP at home and of■
.behavioural strategies such as reminder systems
Pay great attention to side-effects (even if subtle( and be ■
.prepared to timely change drug doses or types, if needed
Dialogue with patient regarding adherence and be■
informed of his/her problems

159. Provide reliable support system and ■
.affordable prices
.Arrange a schedule of follow-up visits■

160. RESISTANT HYPERTENSION
DEFINITION
BP140/90 mmHg despite treatment with at least three
drugs (including a diuretic( in adequate doses and
after
exclusion of spurious hypertension such as isolated
office
hypertension and failure to use large cuffs on large
.arms

162. TREATMENT OF ASSOCIATED RISK
FACTORS
LIPID LOWERING AGENTS
All hypertensive patients with established CV disease or■
with type 2 diabetes should be considered for statin
therapy aiming at serum total and LDL cholesterol levels
of, respectively, 4.5 mmol/L (175 mg/dL( and
.mmol/L (100 mg/dL(, and lower, if possible 2.5
Hypertensive patients without overt CV disease but with■
high CV risk (20% risk of events in 10 years( should
also be considered for statin treatment even if their
baseline total and LDL serum cholesterol levels are not
elevated

163. ANTIPLATELET THERAPY
,Antiplatelet therapy, in particular low-dose aspirin■
should be prescribed to hypertensive patients with
previous CV events, provided that there is no excessive
.risk of bleeding
Low-dose aspirin should also be considered in■
hypertensive patients without a history of CV disease if
older than 50 years and with a moderate increase in
serum creatinine or with a high CV risk. In all these
conditions, the benefit-to-risk ratio of this intervention
reduction in myocardial infarction greater than the risk(
.of bleeding( has been proven favourable
,To minimize the risk of haemorrhagic stroke■
antiplatelet treatment should