1. Approach to hypertension
Dr.shamsaee

2. Who to treat
How to treat
When suspect secondary HTN
HTN crisis

3. Definition Pre HTN: 120-129/<80 Stage 1:130_139/80_89
Treat stage 1 if ASCVD presents or 10 y CVR is >10%

4. Key points in Hx Duration of HTN
Previous therapies: response and side effects
Dietary and psychosocial hx
Other RF: weight change, dyslipidemia, smoking, diabetes, physical inactivity
Target organ damage: hx of TIA, stroke, transient blindness, angina, MI, CHF, sexual function

5. Key points in PH Ex Weight and height
Lower extremity BP in patients under 30
Pulse examination for AF
Signs of LV hypertrophy and CHF
Examination of bruits over the carotid and femoral and renal arteries
Thyroid exam
Funduscopic examination

6. Who to think?: Secondary HTN
Drug resistant
Abrupt onset
Exacerbation of previously controlled HTN
Accelerated or malignant HTN
Onset before age 30
Diastolic HTN in older than 65
hypokalemia

7. Causes of Secondary HTN
Renal
Reno vascular
Adrenal
Aortic dissection
Obstructive sleep apnea
Medication

8. Secondary HTN: what to do?
Hx of renal disease
Change in appearance, muscle weakness
Spells of sweating, tremor, palpitation
Erratic sleep, snoring, daytime somnolence
Symptoms of hypo or hyperthyroidism
Use of agents that may increase blood pressure (alcohol, antidepressants, antipsychotics, caffeine, NSAIDs, OCP,…)

9. Lab tests U/A, alb excretion BUN and creatinine, Na, K, Ca, TSH?
FBS, lipid profile
CBC
ECG

10. Does patient have EOD?

11. How to treat? Lifestyle modification: -weight reduction ( BMI=25)
dietary salt less than 6g/d
DASH dietary plan
physical activity
Reassess in 3-6 months if no pharmacologic treatment is indicated or BP goal met
If pharmacologic treatment is indicated reassess in 1 month

12. How to treat? Pharmacologic therapy
first choice : thiazide type diuretic, ACEI or ARB, CCB
2nd choice: other diuretics, BB, DRI, alpha B, direct vasodilators
More than 55: CCB or thiazide
Less than 55 : ACEI or ARB

13. In stable heart disease
Goal : 130/80
Beta blockers( carvedilol, methoral, nadolol,bisoprolol, propranolol, timolol>3y after MI), ACEI or ARB
DHP CCBs (amlodipine) or thiazid type diuretic, MRA(spironolacton)

14. CHF Goal: 130/80 Diuretics to control volume control
ACEI or ARB and BB
No NDHP CCB

15. DM/CKD Goal : 130/80(AHA) 140/90(ADA)
Usual first choice : (thiazide type diuretic, ACEI or ARB, CCB)
Albuminuria more than 300mg/d in stage 1 & 2 CKD or stage>=3 CKD: ACEI, ARB if ACEI is not tolerated
DM+Albuminuria more than 30mg/d : ACEI, ARB

16. Hx of stroke GOAL: 140/90 thiazide diuretic, ACEI, ARB
ACEI plus thiazide diuretic reduce the rate of recurrence
CCB has stroke protection effect

17. Pregnancy Labetalol Nifedipine ER
Methyldopa ( mg/d q8-12h ( max: 3g/d)
increase every 2 days if needed)

18. In BP more than 160/100 start with two antihypertensive drugs.

19. Thiazide type diuretic
Tab hydrochlorothiazide 50 mg: 12.5_50 mg/d
Tab clorthalidone ( prolonged half life and reduce CVD) 100 mg : 12.5_100 mdg/d
Contraindication: Hx of acute gout, severe dyslipidemia
Adverse events: hypokalemia, hyperglycemia, hyperuricemia, decrease libido

20. ACEI Tab captopril 25 & 50 mg: 12.5-100mg/d (q8-12h) max: 450 mg/d
Tab enalapril 2.5 & 5 & 10 & 20 mg: mg/d ( q12h)
Contraindication: pregnancy, bilateral RAS
Adverse events: cough, hyperkalemia, angioedema

21. ARB Tab losartan 25 & 50 & 100 mg : 20-100mg/d (QD or BD)
Tab valsartan 40 & 80 & 160 mg : 80 _ 320 mg/d (QD or BD)
Contraindication: pregnancy, bilateral RAS
Adverse events: hyperkalemia, angioedema

22. DHP CCB
Tab amlodipine 2.5 & 5 & 10 mg : 2.5_10 mg/d ( increase 2.5 mg every 7-10 days if needed)
Tab nifedipine 10 & 20 mg & SR 30 mg : 30 _ 90 mg/d QD ( increase every 7-10 days if needed)
Contraindication: noun
Adverse events: flushing, ankle edema

23. NDHP CCB Tab diltiazem 60 & SR 120 mg : 120_540 mg/d
Tab verapamil 40 & SR 140 mg: 120 _ 480 mg/d (BD to QID)
Contraindication: heart block degree 2 or 3
Adverse events: negative inotrope , exacerbate HF symptoms

24. Beta Blockers Tab atenolol 50 & 100 mg : 25_100 mg/d
Tab propranolol 10 & 20 & 40 & ER 80 & 160 mg : 40_160 mg/d (BD) max: 640 mg/d
Tab metoprolol 50 & 100 mg : 50_100 mg/d (QD or BD) max: 450mg/d
Contraindication: heart block , active asthma or COPD, sexually active patients, PVD
Adverse events: Depression, bronchospasm, hyper TG & cholesterol, impotence, rebound angina

25. Alpha blochers Tab trazocin 2 & 5 & 10 mg : 10_20 mg/d (BID)
Tab prazocin 1 & 5 mg : 2_ 20 mg/d (BID)
Adverse events: syncope, headache, tachycardia, anticholinergic effect

26. Loop diuretics Tab furosemide 40 mg : 20_80 mg/d (BD or TID)
Contraindication: AKI
Adverse effects: hypokalemia, volume depletion

27. hypertension emergencies
Malignant HTN: abrupt increase in BP in previously normo or hypertensive patient.(>180/120)
The absolute level of BP is not as important as the rate of rise.
Pathologically fibrotic necrosis
Clinically retinopathy( hemorrhage or exudate or papilledema) proteinuria, MHA , encephalopathy

29. If there is end organ damage admit the patient
R/O aortic dissection, pheochromocytoma, preeclampsia
Initiate IV treatment

30. Hypertensive encephalopathy
Nitroprusside
Nicardipine: 5 _ 15 mg/h
Labetalol : 2mg/min or 20 mg in 2 minutes and then 40 _ 80 mg every 10 minutes up to 300 mg total

31. stroke Nicardipine Labetalol Nitroprusside
Ischemic in BP > 220/130 ( if thrombolytic > 185/110)
Hemorrhagic in BP> 180/130

32. MI/USA Nitroglycerine ( 5 _ 20 microgram/min) Nicardipine Labetalol
esmolol

33. LV HF
Nitroglycerine
Enalaprilat
Loop diuretics

34. Pregnancy
Hydralazine ( 10 _ 50 mg every 30 min)
Nicardipine
Labetalol

35. 25% decrease in MAP within 2 hours in the range of 160/100_110 within 6 hours and then to normal range within 24_48 hours
In patients without EOD can use frequent oral doses of captopril, clonidine and labetalol or maybe furosemide