HYPERTENSION
Definition
• High blood pressure is defined as BP ≥140/90
millimeters of mercury (mmHg) by JNC 8
• Hypertension (high blood pressure) is when
the pressure in your blood vessels is too high
(140/90 mmHg or higher) by WHO
• Hypertension is defined by persistent elevation
of arterial blood pressure (BP).
• Blood pressure over the range, measured as an
average of two or more seated measurements,
measured at two or more consecutive intervals.
Mean arterial pressure
• The mean arterial pressure (MAP) is a term
used in medicine to describe an average blood
pressure in an individual.
• MAP = SBP + (2 x DBP)
3
MAP is normally between 65 and 110 mmHg.
CLASSIFICATION
by JNC 8
Blood pressure goals
Population Blood pressure goal
(systolic/diastolic)
< 60 years old <140/90 mmHg
> 60 years old <150/90 mmHg
Chronic Kidney <140/90 mmHg
Disease (CKD)
Diabetes <140/90 mmHg
Causes of Hypertension
• Genetic causes
• Renal disease
• Renal vascular diseases
• Cushing syndrome (Cortisol Increase)
• Pheochromocytoma (adrenaline & noradrenaline
Increase)
• Primary hyperaldosteronism/Conns syndrome
(aldosterone)
• Coarctation of aorta
• Sleep apnea (Obstructive sleep apnea (OSA) can
cause hypertension by increasing sympathetic
nervous system activity and blood pressure
increase due to the deficiency of oxygen)
• Hypertension associated with pregnancy
• Thyroid and parathyroid disease
• Drugs (estrogen, chronic steroid therapy, alcohol,
amphetamine, ergot alkaloids, oral
contraceptives, decongestants etc )
Feature Primary Hypertension (Essential Secondary Hypertension
Hypertension)
Cause No identifiable cause, likely due to a Caused by an underlying
combination of genetic and lifestyle medical condition like
factors kidney disease, endocrine
disorders, sleep apnea, or
certain medications
Prevalence Most common form of Less common, representing
hypertension, accounting for 90% of 10% of hypertension cases
cases
Diagnosis Based on blood pressure readings Requires further
alone, as no specific identifiable investigation to identify the
cause exists underlying cause of the
hypertension
Family history Often a strong family history of Family history may not be
high blood pressure as significant as the
underlying medical
condition
BMI Very common Not common
Can be cured Not Yes
Treatment Lifestyle Treatment focuses on
modifications like addressing the
diet, exercise, weight underlying medical
management, and condition causing the
medication if hypertension
necessary
Examples of Genetics, age, Kidney disease,
potential causes ethnicity, salt intake, adrenal gland
physical inactivity disorders, sleep
apnea, certain
medications,
coarctation of the
aorta
PSEUDOHYPERTENSION
• In pseudohypertension, blood vessels become stiff and
thick because of calcification and resist compression
from the bladder of the inflatable BP cuff. Greater
pressure is then needed to occlude the artery, and this
can result in an overestimation of true SBP. Osler’s
maneuver is used to detect pseudohypertension.
WHITE-COAT HYPERTENSION
• White-coat hypertension describes patients who have
consistently elevated BP values measured in a clinical
environment in the presence of a health care professional
(e.g., physician’s office), yet when measured elsewhere
or with 24-hour ambulatory monitoring, BP is not
elevated.
• a syndrome whereby a patient's feeling of
anxiety in a medical environment results in an
abnormally high reading when their blood
pressure is measured.
• Home BP monitoring or 24-hour ABPM is
warranted in patients suspected of having
white-coat hypertension to differentiate this
from true hypertension.
• Patients with diastolic blood pressure (DBP)
values <90 mmHg and systolic blood pressure
(SBP) values ≥ 140mmHg have isolated
systolic hypertension.
HYPERTENSIVE CRISES
• Hypertensive crises are situations in which measured BP
values are markedly elevated, typically in the upper range
of stage 2 hypertension (>180/110 mm Hg).
• They are classified as either a hypertensive emergency
(with acute or progressive target organ damage) or urgency
(without acute or progressive target organ damage).
• Hypertensive emergencies require
hospitalization for immediate BP lowering
using intravenous (IV) medications and intra-
arterial BP monitoring.
1. Patients with a hypertensive emergency need
admission with continuous blood pressure
monitoring.
2. Assess for target organ injury and start parenteral
medications as needed
3. If the patient has an acute emergency like aortic
dissection, lower the blood pressure to below 140
mmHg in the first hour
4. for adults with no organ damage, lower the blood
pressure by 25% in the first hour and then to
160/100 over the next 2-6 hours, and then
gradually to normal over 2 days.
• The traditional drug of choice for therapy
of hypertensive emergencies is sodium
nitroprusside.
• Intravenous labetalol produces a prompt,
controlled reduction in blood pressure
and is a promising alternative.
• Other agents used are diazoxide,
trimethaphan camsylate, hydralazine,
nitroglycerin, and phentolamine
A first-line medical therapy in this
situation is labetalol, an adrenergic
receptor blocker with both selective
alpha 1-adrenergic and nonselective
beta-adrenergic receptor blocking
actions. This drug is available in
intravenous (I.V.) and oral forms. In a
hypertensive emergency, use the I.V.
route.
Gestational hypertension
• Gestational hypertension, also referred to
as pregnancy induced hypertension (PIH) is a
condition characterized by high blood
pressure during pregnancy. Hypertension
during pregnancy affects about 6-8% of
pregnant women.
According to the National Heart, Lung, and Blood
Institute (NHLBI), there are several possible causes of
high blood pressure during pregnancy. These include:
• being overweight or obese
• failing to stay active
• smoking
• drinking alcohol
• first time pregnancy
• a family history of kidney disease or chronic
hypertension
• age (over 40)
• assistive technology (such as IVF)
If high blood pressure continues after 20 weeks of
pregnancy, there can be complications.
• Preeclampsia can develop. This condition can cause
serious damage to maternal organs, including brain and
kidneys
Symptoms of preeclampsia include:
• protein in a urine sample
• abnormal swelling in hands and feet
• persistent headaches
• In severe disease there may be red blood cell breakdown,
a low blood platelet count, impaired liver function,
kidney dysfunction,
• swelling, shortness of breath due to fluid in the lungs, or
visual disturbances.
• If left untreated, it may result in seizures at
which point it is known as eclampsia
• Eclampsia is the onset of seizures (convulsions)
in a woman with pre-eclampsia
• The seizures are of the tonic–clonic type and
typically last about a minute.
• Following the seizure there is typically either
a period of confusion or coma.
• Complications include cerebral
hemorrhage, kidney failure, and cardiac arrest.
• Magnesium sulfate should be given to control
convulsions and is the first-line treatment for
eclamptic seizures. A loading dose of 4 to 6
grams should be given intravenously over 15
to 20 minutes. A maintenance dose of 2 g per
hour should subsequently be administered.
• Medications to treat severe preeclampsia
usually include:
• Antihypertensive drugs to lower blood
pressure.
• Anticonvulsant medication, such as
magnesium sulfate, to prevent seizures.
• Corticosteroids to promote development of
your baby's lungs before delivery.
• Although it is considered optimal to use
prednisone at less than 20mg/day in
pregnancy, it is generally accepted that
higher doses are allowable for aggressive
disease.
• Inflammation from uncontrolled
autoimmune activity is potentially more
harmful to maternal and fetal health than
high-dose steroids.
• Corticosteroids are a type of medication
that may be offered to you to help your
baby if there is a chance that you may give
birth early.
• Steroids are given by an injection into the
muscle usually of your thigh or upper arm.
• A single course can consist of two to four
injections usually over a 24-48 hour period.
Life-style changes
• Weight reduction
• Exercise
• Diet (low salt intake) DASH diet
• Smoking cessation
• Alcohol restriction
Factors influencing drug choice
• Contraindications to drug
• Presence of target organ damage, renal disease, diabetes or cardiovascular disease
• Other coexisting disorders
• Interactions with drugs used for other conditions by the patient
• Age
• Occupation
• Lifestyle
• Non pharmacological management:
• Reason for non pharmacological treatment:
• Lifestyle modification alone is appropriate therapy for patients with
prehypertension. Patients diagnosed with stage 1 or 2 hypertension should
be placed on lifestyle modifications and drug therapy concurrently as life
style modification will enhance the effect of antihypertensive drugs.
• All patients with prehypertension and hypertension should be prescribed
lifestyle modifications, including
(1) weight reduction if overweight
(2) adoption of the Dietary Approaches to Stop Hypertension eating plan
(3) dietary sodium restriction ideally to 1.5 g/day (3.8 g/day sodium
chloride),
(4) regular physical activity
(5) moderate alcohol consumption (two or fewer
drinks per day)
(6) smoking cessation.
• The dash diet
• To lower systolic BP 4-12mmHg
• Not more than 2300mg of sodium per day
• Weight loss if necessary
• Moderate activity at least 3 times per week
