APPROACH TO HYPERTENSION

DEFINITION
Persistent elevation of
Systolic BP of 140 mmHg or greater

And/ or
Diastolic BP of 90 mmHg or greater
BP (mmHg) Normal Pre hypertension HPT Stage 1 HPT Stage 2 systolic <120 120-139 140-159 160 diastolic <80 80-89 90-99 100

Based on average of two or more properly measured, seated BP readings on 2 or more office readings

Patient Evaluation
Objectives:
To assess lifestyle and identify cardiovascular risk factors or concomittant disorder that may affect prognosis and treatment To reveal identifiable cause of HPT To assess the presence of target organ damage.

TARGET ORGAN DAMAGE (TOD)

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischaemic attack Chronic kidney disease Peripheral artery disease Retinopathy

SECONDARY CAUSES
Sleep apnoea Drug-induced or drug-related Chronic kidney disease Renovascular disease Endocrinopathies
Primary aldosteronism Phaeochromocytoma Cushing syndrome Acromegaly Thyroid and parathyroid disease

Coarctation of the aorta Takayasu arteritis

HISTORY
Duration and level of elevated BP if known Symptoms of secondary causes of HPT Symptoms of target organ damage Symptoms of concomitant disease Family history Dietary history Drug history Lifestyle and social history

PHYSICAL EXAMINATION
General (height, weight, waist circumference) Appropriate BP measurements Fundoscopy-hypertensive retinopathy:
grade 1: tortous artery grade 2: A-V nipping, grade 3: flame hemorrhage and cotton woolspots, grade 4: papillloedema

Bruit and peripheral pulses Systems examination (cardiovascular, respiratory, abdomen, neurological examinations) Lower limb edema

INVESTIGATIONS
Full blood count Renal function tests ( urea, creatinine, serum electrolytes, and uric acid) Urinalysis ECG Chest x-ray

JNC 7
Lifestyle modification

Not at Goal BP Initial drug choices

Without compelling indication

With compelling indication

Stage I -Thiazide diuretics -May consider ACE-I, ARB, BB, CCB or combinations

Stage II -2-drugs combination -Usually thiazide diuretics with ACE-i/ARB/BB/CCB

Drugs for the compelling indication

Not at Goal BP Optimize dosage, add additional drugs, consider consultation with HPT specialist

TREATMENT
LIFESTYLE MODIFICATION
Reduction of weight Adopt DASH eating plan Dietary sodium reduction Physical activity Reduction of alcohol consumption

PHARMACOLOGIC ACE-I, ARB, BB, CCB, Diuretics

Lifestyle Modification
Weight reduction
As far as possible, aim ideal BMI Asians 18.5 23.5 kg/m2 Reduction of 5-10% in 6-12 months As little as 4.5 kg significantly reduce BP

Sodium intake restriction

Intake of <100 mmol of sodium or 6g of sodium chloride a day (<1 tsp of salt)

Lifestyle Modification
Avoidance of alcohol
Intake 21 units (men) and 14 units (women) per week.

Regular physical exercise

Aerobic type of exercise e.g. brisk walking for 3060 minutes at least 3 times a week.

Lifestyle Modification
Healthy eating
Diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can lower BP BP 11/6 mmHg in hypertensive patients

JNC 7 Treatment Recommendations

Initial Drug Therapy

JNC 7 Express. NIH publication No 03-5233. http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf. May, 2003.

Algorithm for Treatment of HTN

Compelling Indications Heart Failure Diuretic B-Blocker X X ACE Inhibitor X ARB X CCB Aldosterone antagonisst X

Post-MI
High CAD risk Diabetes Chronic renal disease 2 Stroke prevention X X X

X
X X

X
X X X X X X X
Non-DHP

X
Non-DHP

NHBPEP Coordinating Committee. The JNC 7 Report. JAMA 2003;289:2560-72.

Types of Antihypertensive Drugs

1) ACE-i
- in patient with increased cardiovascular risk, ACE-I to reduce morbidity and mortality - prevent onset of microalbuminuria, reduce protenuria, and progression of renal disease - side effect: cough and angioedema. - serum creatinine should be checked before initiation and repeated after one or two weeks after initiation.

ACE- Inhibitor
ACEi captopril enalapril fosinopril lisinopril Starting daily dose 25mg bd 2.5mg od 10mg od 5mg od Maximum daily dose 50 mg tds 20 mg bd 40 mg od 80 mg od

 2) Angiotensin Receptor Blocker - Recommended in ACEi intolerance patient - Preventing progression of diabetic retinopathy, and reduce major cardiac events. - Less side effect of dry cough

ARB
ARBs Candesartan Irbesartan losartan Valsartan telmisartan Starting dose 8 mg od 150mg od 50 mg od 80 mg od 20 mg od Maximum daily dose 16 mg od 300 mg od 100 mg od 100 mg od 160 mg od

3) Beta blocker - Useful in hypertensive patient with angina, tachyarrhytmia, or previous myocardial infarction - Contraindicated in obstructive airway disease, severe peripheral vascular disease and heart block. - Side effect: dyslipidemia, hypoglycemia, increase incidence of new onset of DM, erectile dysfunction and cold extremities.

 Beta blockers
B Blockers acebutolol atenolol betaxolol bisoprolol metoprolol propanolol Starting dose 200mg bd 50 mg od 10 mg od 5mg od 50 mg bd 40 mg bd Maximum daily dose 400mg bd 100mg od 40mg od 200mg bd 200 mg bd 320 mg bd

4) Calcium channel blocker - Use as first line treatment and other combination with other drug - No undesirable adverse metabolic effect - Adverse effect: initial tachycardia, headache, flushing, constipation and ankle edema

 CCB
CCBs Amilodipine Starting dose 5mg od Maximum daily dose 10 mg od

Diltiazem
felodipine

30mg tds
2.5mg od

60 mg tds
10 mg od

nifedipine
verapamil Verapamil CR

10 mg tds
80 mg bd 200mg od

30mg tds
240mg tds 200 mg bd

 5) Diuretics
- most widely used antihypertensive agents - Patient with essential hypertension and normal renal function, thiazide are more potent than loop diuretics - Patient with renal insufficiency, thiazide are less effective, and loop diuretics are to be used instead. - Potassium sparing diuretics may cause hyperkalemia if given together with ACEi or ARBs - Side effets: increased serum cholesterol, glucose and uric acid. Decreased potassium, sodium and magnesium level

DIURETICS
diuretics Starting dose Maximum dose daily

chlorothiazide
hydrocholorothiazide Amiloride 5g/ 50 mg

250 mg od
25mg od 1 table t od

500mg od
200mg od 4 tablet od

indaparamide
Triamterene 50 mg/ 25 mg

2.5 mg od
1 tablet bd

2.5 mg od
2 tablet bd

In ED
HPT Emergency HPT Urgency

HYPERTENSIVE EMERGENCY
Severe elevation in BP (usually >180/120) complicated by evidence of progressive target organ dysfunction Target organ dysfunction includes:
I. Hypertensive encephalopathy II. Hypertensive Lt ventricular failure(acute pulmonary edema) III. Acute aortic dissection IV. ACS / Acute MI V. Haemorrhagic / Ischaemic Stroke / SAH VI. Acute renal failure VII. Eclampsia
JNC 7

HYPERTENSIVE URGENCY
Situations associated with severe elevation in BP without progressive target organ dysfunction

JNC 7

Is it HPT emergency or urgency?

History Is the BP measurement correct? Any evidence of end organ damage? Physical examination:
Fundoscopy Neurological examinations Cardiovascular examinations

Bedside ix
ECG Urine dipstick-proteinuria UPT in woman of child bearing age

Lab ix : FBC, BUSE/CREAT, CE accordingly Radiology

CXR CT brain

Management
Hypertensive emergency
BP to be reduced by 25% over 3 to 12 hours but not lower than 160/90 mmHg best achieved with parenteral drugs

HYPERTENSIVE EMERGENCIES
DRUGS DOSE
ONSET OF ACTION
DURATION

REMARKS

Sodium nitroprusside Labetalol

0.25-10 g/kg/min Sec. IV bolus 50mg <5min (over at least 1 minute) at 5 min intervals to max of 200mg then 2mg/min IVI 5-100/min 2-5min

1-5min 3-6hrs

Caution in renal failure Caution in heart failure

Nitrates

3-5min

Prefferred in ACS and acute pulmonary edema

DRUGS

DOSE

ONSET OF ACTION

DURATION

REMARKS

Hydralazine

IV 5-10mg maybe 10-20min 3-8hrs repeated after 2030min of IVI 200300g/min.Mainte nance 50150g/min IV bolus 1030g/kg over 1min IVI 210g/kg/min IV bolus 1-2min, 250-500 g/kg over I min. IVI 50200g/kg/min for 4 min. May repeat sequence 5-10min 1-4 hrs

Caution in ACS, CVA and dissecting aneurysm

Nicardipine

Caution in heart failure and coronary ischaemia Used in perioperative situations and tachyarrythmia

Esmolol

3-10min

Management
Hypertensive urgency
aim for about 25% reduction in BP over 24 hours but not lower than 160/90 mmHg Oral drugs proven to be effective

HYPERTENSIVE URGENCY
DRUG DOSE ONSET OF ACTION DURATION
FREQUENCY

Captopril Nifedipine

25mg 10-20mg

hour hour

6 hour 3-5 hour

1-2 hours 1-2 hours

Labetalol

200-400mg

2 hours

6 hour

4 hours

Disposition
HPT emergency
Admit to ICU in consultation with general medicine and respective subspecialities

HPT urgency
Can be discharge if response is prompt and BP acceptable after 4hours monitoring, but must arrange for follow up within 48 hours Newly diagnosed HPT with uncertain cause, admit for further evaluation and exclusion of 2ry causes

REFERRENCE
JNC 7 CPG on HPT Guide to essentials in emergency medicineShirley Ooi