This is an overview of the medical management of high blood pressure (hypertension) in adults.

1. Overview of the Medical
Management of High
Blood Pressure in Adults
Luis Daniel Lugo, MD
Medical Resident
Roger Williams Medical Center
Boston University School of Medicine
Providence, Rhode Island

2. Hypertension
• Hypertension affects approximately 75 million
adults in the United States and is a major risk
factor for stroke, myocardial infarction, vascular
disease, and chronic kidney disease.

3. Introduction to HTN
• Hypertension (HTN)
• Stage 1
• 140 – 159 systolic
• 90 – 99 diastolic
• Stage 2
• Greater or equal to 160 systolic
• Greater or equal to 100 diastolic
• Can be seen as isolated systolic or isolated
diastolic

4. Introduction
• Malignant Hypertension
• It refers to evident hypertension with retinal
hemorrhage, exudates or papilledema.
• Hypertensive Urgency
• It refers to severe hypertension (diastolic > 120) in
asymptomatic patients.
• There is no proven benefit in the rapid reduction of
blood pressure in asymptomatic patients.

5. Primary Hypertension
• Essential Hypertension
• Idiopathic
• Increased sympathetic neural activity
• Multiple risk factors: ethnicity, hereditary, lifestyle…
• Vitamin D deficiency is associated with increased
risk

6. Secondary Hypertension
• Secondary (Identifiable) Hypertension
• It is associated with an identifiable process.
• Renal disease
• Drug related
• Obstructive Sleep Apnea
• Endocrine disorders
• Mineralocorticoid imbalance (aldosteronism, Cushing’s)
• Thyroid disease
• Primary or essential hypertension accounts for 90-
95% of adult cases, and secondary hypertension
accounts for 2-10% of cases.

7. Complications related to HTN
• Premature cardiovascular disease
• Intracerebral hemorrhage
• Organ disease (particularly renal)
• Clinical trials have demonstrated the following
benefits with antihypertensive therapy:
• Average 35-40% reduction in stroke incidence
• Average 20-25% reduction in myocardial infarction
• Average >50% reduction in heart failure

8. Diagnosis
• Annual screening – recommended
• In the absence of end-organ damage, diagnosis of
hypertension should not be made until the blood
pressure has been measured on at least three to
six visits spaced over a period of weeks to
months.
• Postural hypotension
• It is a 20 mmHg fall or greater fall in systolic pressure
upon rising from supine to an upright position.

9. White Coat Hypertension
• It is more common in the elderly. One way to
minimize the white coat effect is to have the
blood pressure measured while seated after
five minutes in a quiet, unobserved setting by an
automated device.
• Ambulatory blood pressure monitoring
(ABPM):
• Suspected episodic hypertension
(pheochromocytoma)
• HTN resistant to medication
• Hypotensive symptoms while taking anti-HTN meds
• Autonomic dysfunction

10. Evaluation
• History – assessment of precipitating factors,
extend of organ damage, presence of risk factors
• PE – assessment of organ damage
• Laboratory:
• Renal function tests, UA, electrolytes
• Lipid profile
• EKG
• Microalbumin, ECHO, abdominal CT

11. Hypertensive
Emergencies
• The most common clinical presentations of
hypertensive emergencies are cerebral
infarction (24.5%), pulmonary edema (22.5%),
hypertensive encephalopathy (16.3%), and
congestive heart failure (12%).
• Other clinical presentations associated with
hypertensive emergencies include intracranial
hemorrhage, aortic dissection, and eclampsia, as
well as acute myocardial infarction.

12. Treatment
• Lifestyle modification
• Dietary salt restriction
• Weight loss
• DASH diet
• Exercise
• Limited alcohol intake

13. Medical Therapy
• Main drugs:
• Thiazide diuretics
• Long-acting calcium channel blockers
• ACE inhibitors / ARBs
• Single therapy may not adequately control the
blood pressure, particularly in those whose blood
pressure is 20/10 mmHg above goal. When more
than one agent is needed, it is recommended
to use an ACE inhibitor or ARB with a long-
acting CCB.

14. Efficacy of Medical Therapy
• Each of the anti-hypertensive agents is roughly
equally effective in lowering the blood pressure.
There is, however, wide inter-patient variability as
many patients will respond to one drug but not to
another.
• Thiazide Diuretics
• Chlorthalidone is superior than hydrochlorothiazide
• Both require K monitoring

15. Indications for Specific Drugs
• Young patients
• Respond better to ACE inhibitors and ARBs
• Elderly patients and Black patients
• Respond best to thiazide diuretics and long-acting
calcium blockers
• Consider sequential monotherapy (try drug 2 or
drug 3 alone) when first choice therapy fails
instead of trying combined therapy

16. Indications for Specific Drugs
• ACE inhibitors and ARBs
• First line in all patients with HF or LV dysfunction, systolic
dysfunction, ST or non ST-segment elevation MI, diabetes
and in patients with proteinuric chronic kidney disease.
• Both have cardioprotective effects
• Calcium Channel Blockers
• Used in rate control for AF and for the control of angina.
• Beta Blockers
• Not routine for HTN but are used in stable HF and post-
MI.

17. Sequential Monotherapy
• This regimen may minimize the side effects,
maximize patient compliance and is as effective
as some forms of combination therapy. However,
over time, more than one drug will be needed.

18. Drug Dosing
• Good responders generally respond to lower
doses with few side effects, while higher doses
produce more side effects often with little further
reduction in blood pressure.

19. Resistant Hypertension
• Resistant hypertension is commonly defined as a
blood pressure (BP) level higher than 140/90 mm
Hg despite treatment with antihypertensive
agents of 3 or more different classes, of which
1 is a thiazide diuretic.
• A study demonstrated that the addition of low-
dose spironolactone provides significant additive
BP reduction in both black patients and white
patients who have resistant hypertension, with or
without primary hyperaldosteronism.

20. Dual therapy
• Starting with two drugs should be considered in
patients with a baseline blood pressure above
160/100 mmHg. This increases the likelihood that
the blood pressure will reach target at a
reasonable time period.

21. The Goal
• The goal blood pressure is to reach below 140/90
mmHg or below 150/90 in patients 60 years or
older.
• Clinical trials have shown benefit from lower blood
pressures in patients with atherosclerotic disease
and chronic kidney disease.
• It is recommended that, at least, one medication is
given at bedtime, rather than taking all
medications in the morning.

22. Medications

23. Diuretics
• Thiazide diuretics inhibit reabsorption of sodium and
chloride mostly in the distal tubules –thereby
increasing urine output. Long-term use of these drugs
may result in hyponatremia.
• Chlorthalidone is indicated for the management of
hypertension either alone or in combination with other
antihypertensives.
• The initial dosage is 25 mg as a single daily dose.
Dosage can be titrated to 50 mg if the clinical response
is not adequate. If additional control is required,
increase the dosage to 100 mg once daily, or a second
antihypertensive drug may be added.

24. ACE inhibitors
• Angiotensin converting enzyme (ACE) inhibitors are the
treatment of choice in patients with hypertension, chronic
kidney disease, and proteinuria. ACE inhibitors reduce
morbidity and mortality rates in patients with heart failure,
patients with recent myocardial infarctions, and patients with
proteinuric renal disease. ACE inhibitors appear to act primarily
through suppression of the renin-angiotensin-aldosterone
system.
• Lisinopril may be used as monotherapy or concomitantly with
other classes of antihypertensive agents.
• The initial dose of lisinopril is 10 mg daily. The dosage can
range from 20-40 mg/day as a single daily dose. Doses up to
80 mg/day have been used; however, they do not show a
greater effect.

25. ARBs
• Generally, ACE inhibitors should remain the initial treatment
of choice for hypertension. Angiotensin II receptor
antagonists or angiotensin receptor blockers (ARBs) are
used for patients who are unable to tolerate ACE inhibitors.
ARBs competitively block binding of angiotensin-II to
angiotensin type I (AT1) receptors, thereby reducing effects
of angiotensin II–induced vasoconstriction.
• Losartan may be used alone or in combination with other
antihypertensive agents, including diuretics.
• The initial dose is 50 mg daily; however, in patients on
diuretic therapy, the initial dose is 25 mg daily. A low-dose
diuretic (eg, hydrochlorothiazide) may be added if blood
pressure is not controlled. Losartan can be titrated up to 100
mg daily.

26. Calcium Channel Blockers
• Calcium channel blockers (CCBs) can be divided into
dihydropyridines and nondihydropyridines. Dihydropyridines
bind to L-type calcium channels in the vascular smooth muscle,
which results in vasodilatation and a decrease in blood
pressure. They are effective as monotherapy in black patients
and elderly patients.
• Amlodipine is a dihydropyridine CCB that has antianginal and
antihypertensive effects. Amlodipine is a peripheral arterial
vasodilator that acts directly on vascular smooth muscle to
cause a reduction in peripheral vascular resistance and
reduction in blood pressure.
• 5 mg/day PO initially; may be increased by 2.5 mg/day every 7-
14 days; not to exceed 10 mg/day PO; maintenance: 5-10
mg/day PO.

27. Central-acting (alpha2
agonist)
• Centrally acting alpha2-agonists stimulate presynaptic
alpha2-adrenergic receptors in the brain stem, which
reduces sympathetic nervous activity. These effects
result in a decrease in peripheral resistance, renal
vascular resistance, blood pressure, and heart rate.
• Clonidine can be used alone or in combination with
other antihypertensives. Clonidine is associated with a
rebound effect, especially at higher doses or with more
severe hypertension.
• Immediate-release tablets: 0.1 mg PO q12hr. Range:
0.1-0.8 mg/day divided q12hr; not to exceed 2.4
mg/day.

28. Vasodilators
• Vasodilators relax blood vessels to improve blood flow,
thus decreasing blood pressure. Hydralazine may
lower blood pressure by exerting a peripheral,
vasodilating effect through a direct relaxation of
vascular smooth muscle.
• Hydralazine is indicated for essential hypertension,
alone or as an adjunct.
• Initial dose is 10 mg given 4 times daily for the first 2 to
4 days, then 25 mg 4 times a day for 1 week.
Hydralazine IV or IM is indicated for severe essential
hypertension when the drug cannot be given orally or
when there is an urgent need to lower BP.

29. Prognosis
• Most individuals diagnosed with hypertension will
have increasing blood pressure (BP) as they age.
Untreated hypertension is notorious for
increasing the risk of mortality and is often
described as a silent killer. Mild to moderate
hypertension, if left untreated, may be associated
with a risk of atherosclerotic disease in 30% of
people and organ damage in 50% of people within
8-10 years after onset.

30. Death Prevention
• It is estimated that 1 death is prevented per 11
patients treated for stage 1 hypertension and
other cardiovascular risk factors when a sustained
reduction of 12 mm Hg in systolic BP over 10
years is achieved. However, for the same
reduction is systolic BP reduction, it is estimated
that 1 death is prevented per 9 patients treated
when cardiovascular disease or end-organ
damage is present.

31. References
• UpToDate. (2014). Overview of hypertension in adults.
Retrieved from
http://www.uptodate.com/contents/overview-of-
hypertension-in-adults/.
• UpToDate. (2014). Choice of therapy in primary
(essential) hypertension: Recommendations. Retrieved
from http://www.uptodate.com/contents/choice-of-
therapy-in-primary-essential-hypertension-
recommendations/.
• Medscape. (2014). Hypertension. Retrieved from
http://emedicine.medscape.com/article/241381-
overview/.