Treatment of Hypertension

Part 2Jeevan Jacob

JR, Pharmacology

Pre-treatment evaluation

• Multiple BP readings in supine & standing positions after sufficient rest

• Assessment of target organ damage

a) Detailed history & physical examination: dyspnoea, polyuria, nocturia, edema

b) Kidney: urine examination, serum creatinine, serum electrolytes

c) Heart: ECG, X ray chest

d) fundoscopy

Assessment of other CV risk factors• Salt intake, Alcohol consumption, smoking, obesity,

diabetes, hyperlipidaemia, premature CV death in close relatives

Special investigations to identify cause of HTN• USG urinary tract/renal blood vessels, renal

angiography, test for pheochromocytoma (These are done if indications exist & HTN is drug resistant)

• Reassurance by physicians & lifestyle modifications are necessary in all hypertensive patients include normotensives with risk factors

Non pharmacological treatment Recommendations to reduce BP and/or CV risk factors

Salt intake Restrict 5-6 g/day

Moderate alcohol intake Limit to 20-30 g/day men,10-20 g/day women

Increase vegetable, fruit, low-fat dairy intakeDASH diet

BMI goal 25 kg/m2

Waist circumference goal Men: <102 cm (40 in.)*Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7 days/week(moderate, dynamic exercise)

Quit smoking

Hypertensive urgency & emergency

• Hypertensive urgencies – sudden or severe elevation of BP usually with DBP>120mmHg or higher with an impending complication

• Include: severe epistaxis, severe perioperative HTN, unstable angina, diabetic retinopathy, pre eclampsia etc.

• Need immediate treatment in ICU, DBP needs to be reduced to 100-110mmHg within 24-48hrs without use of loading dose

• Hypertensive emergencies defined as severe elevation of BP to 210/120-130mmHg with evidence of target organ damage or dysfunction

• These include: hypertensive encephalopathy, ICH, acute MI,

acute LVF with pulmonary edema, eclampsia

• Also require admission to ICU & rapid lowering of BP to 150-

160/100-110 within 1 hr.

• Most HTNsive emergencies are characterised by

vasoconstriction and normal or reduced plasma volume

• Therefore drugs which donot cause reduction in renal blood flow

CCBs, fenoldopam, sodium nitroprusside are preferred

Clinical scenario Recommendations

Drug treatment of severe hypertension in pregnangy(SBP >160 mmHg or DBP >110 mmHg)

• Recommended

Pregnant women with persistent BP elevations ≥150/95 mmHg

BP ≥140/90 mmHg in presence of gestational hypertension, subclinical OD, or symptoms

• Consider drug treatment

Hypertension treatment in pregnant women

High risk of pre-eclampsia • Consider treating with low-dose aspirin from 12 weeks until delivery

• Providing low risk of GI hemorrhage

Women with child-bearing potential

• RAS blockers not recommended

Methyldopa (1-2g)Labetolol (100mg BD)Nifedipine (30-60mg)

• Consider as preferential drugs in pregnancy

• For pre-eclampsia: intravenous labetolol or infusion of nitroprusside

General Principles

• In younger pt avoid B.Blockers alone ( impotence, dyslipidemia)

• In elders : 1st diuretics, then B.Blockers, ACE inhibitors.

• In CCF: ACE inh, Nitrate• Ischemic HD: B.Blockers, Ca blockers• DM: ACE inh• CRF: Diureics

Refractory HTN (Treatment failure)

• 1- Noncompliance • 2- Inadequate treatment• 3- 2° HTN ( RA stenosis, Pheochromocytoma )• 4- Using of anagonists ( eg: steroids, NSAID)

• In patients 60 years of age or older who do not have diabetes or chronic kidney disease, the goal blood pressure level is now <150/90 mmHg

• In patients 18 to 59 years of age without major comorbidities, and in patients 60 years of age or older who have diabetes, chronic kidney disease, or both conditions, the new goal blood pressure level is <140/90 mmHg

Highlights of JNC8 Guidelines

• First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACEIs, and ARBs

• Second- and third-line alternatives included higher doses or combinations of ACEIs, ARBs, thiazide-type diuretics, and CCBs

• Several medications are now designated as later-line alternatives

• When initiating therapy, patients of African descent without chronic kidney disease should use CCBs and thiazides instead of ACEIs

• Use of ACEIs and ARBs is recommended in all patients with chronic kidney disease regardless of ethnic background, either as first-line therapy or in addition to first-line therapy

• ACEIs and ARBs should not be used in the same patient simultaneously

• CCBs and thiazide-type diuretics should be used instead of ACEIs and ARBs in patients over the age of 75 with impaired kidney function due to the risk of hyperkalemia, increased creatinine, and further renal impairment

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