DIAGNOSTIC MEDICIE-2

CHOs in training-Year 3

Diagnosis and management of

Hypertension.

Dr. Brima Bobson Sesay

Medicine Department
Njala University-Bo Campus
 DEFINITION-HTN
Hypertension was defined according to WHO criteria, i.e. a
systolic pressure equal or greater than 160 mmHg, and/or
diastolic equal or greater than 95 mmHg.
 Types of hypertension

• Essential hypertension
– 95%
– No underlying cause

• Secondary hypertension
– Underlying cause
 Causes of
Secondary Hypertension

• Renal
– Parenchymal
– Vascular
– Others
• Endocrine
• Miscellaneous
• Unknown
 Blood Pressure
Classification

BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Hypertension
Stage 2 >160 or >100
Hypertension
 Rural-urban difference in the prevalence of hypertension in Sub-Saharan Africa

• 25% of urban population and 10 % of rural population

suffer from hypertension
• 70% of all hypertensive patients are stage I hypertension

• The majority of studies reported the overall prevalence of

hypertension to be higher in urban than in rural areas.
• 12% of all hypertensive suffer from isolated systolic
hypertension
Journal of human hypertension- 2022
 Hypertension:
Predisposing (Risk) factors

• Advancing Age
• Sex (men and postmenopausal women)
• Family history of cardiovascular disease
• Sedentary life style & psycho-social stress
• Smoking ,High cholesterol diet, Low fruit consumption
• Obesity & wt. gain
• Co-existing disorders such as diabetes, and
hyperlipidemia
• High intake of alcohol
 Haemodynamic Pattern in
Hypertension

Young :  BP = CO X TPR

Elderly :  BP =  CO X   TPR
 Aetiology of Systemic Hypertension

Secondary HTN (5%)

A. Renal (80%) • AGN • Renal Artery stenosis
• CGN,
• CPN,
• Polycyst. K.D

B. Endocrine • Adrenal • Primary aldosteronism

• Cushing’s syndrome
• Pheochromocytoma
• Acromegaly

• Exogenous hormone • Oral contraceptive

• Glucocorticoids
• Hypothyroidism &
• Hyperparathyroidism

Continue…
 Diseases Attributable to
Hypertension

Heart Left Ventricular

Gangrene of the
Failure Hypertrophy Myocardial
Lower Extremities
Infarction
Aortic Coronary Heart
Aneurym Disease
HYPERTENSION
Hypertensive
Blindness encephalopathy

Chronic Cerebral
Stroke Preeclampsia/ Hemorrhage
Kidney
Eclampsia
Failure
 Target Organ Damage

 Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy.
 Clinical manifestations

• No specific complains or manifestations other than

elevated systolic and/or diastolic BP (Silent Killer )
• Morning occipital headache
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision
 Self-Measurement of BP

 Provides information on:

1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN

 Home measurement of >135/85 mmHg is generally

considered to be hypertensive.

 Home measurement devices should be checked regularly.

 Measuring
Blood Pressure
• Patient seated quietly for at least 5minutes
in a chair, with feet on the floor and arm
supported at heart level
•An appropriate-sized cuff (cuff bladder
encircling at least 80% of the arm)
•At least 2 measurements
•Systolic Blood Pressure is the point at which
the first of 2 or more sounds is heard
•Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…
 Laboratory Tests

 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose,
• Serum potassium, creatinine, or the corresponding estimated GFR, and
calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
 More extensive testing for identifiable causes is not generally indicated
unless BP control is not achieved
 Treatment Overview

 Goals of therapy
 Lifestyle modification
 Pharmacologic treatment
 Algorithm for treatment of hypertension
 Follow up and monitoring
 Goals of Therapy

 Reduce Cardiac and renal morbidity and mortality.

 Treat to BP <140/90 mmHg or BP <130/80 mmHg in

patients with diabetes or chronic kidney disease.
 Non pharmacological
Treatment of hypertension

DASH
diet

Regular exercise

Loose weight , if obese

Reduce salt and high fat diets

Avoid harmful habits ,smoking ,alcohal

 Life style modifications

• Lose weight, if overweight

• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and
cholesterol
• increase consumption of fruits and
vegetables
• Limit alcohol intake
 Antihypertensive Drugs

AT1 receptor

ARB Continue….
 Drug therapy for hypertension

Class of drug Example Initiating dose Usual maintenance

dose

DiureticsHydrochlorothiazide 12.5 mg o.d. 12.5-25 mg o.d.

-blockers Atenolol 25-50 mg o.d. 50-100 mg o.d.

Calcium Amlodipine 2.5-5 mg o.d. 5-10 mg o.d.
channel
blockers

-blockers prazosin 2.5 mg o.d 2.5-10mg o.d.

ACE- inhibitors ramipril 1.25-5 mg o.d. 5-20 mg o.d.

Angiotensin-II Losartan 25-50 mg o.d. 50-100 mg o.d.

receptor blockers
 Diuretics

Example: Hydrochlorothiazide
• Act by decreasing blood volume and cardiac output
• Decrease peripheral resistance during chronic therapy
• Drugs of choice in elderly hypertensives
Side effects-
• Hypokalaemia
• Hyponatraemia
• Hyperlipidaemia
• Hyperuricaemia (hence contraindicated in gout)
• Hyperglycaemia (hence not safe in diabetes)
• Not safe in renal and hepatic insufficiency
 Beta blockers

Example: Atenolol, Metoprolol, nebivolol,

• Block b1 receptors on the heart
• Block b2 receptors on kidney and inhibit release of renin
• Decrease rate and force of contraction and thus reduce
cardiac output
• Drugs of choice in patients with co-existent coronary
heart disease
Side effects-
• lethargy, impotency, bradycardia
• Not safe in patients with co-existing asthma and
diabetes
• Have an adverse effect on the lipid profile
 Calcium channel blockers
Example: Amlodipine
• Block entry of calcium through calcium
channels
• Cause vasodilation and reduce peripheral
resistance
• Drugs of choice in elderly hypertensives and
those with co-existing asthma
• Neutral effect on glucose and lipid levels
Side effects
Flushing, headache, Pedal edema
 ACE inhibitors

Example: Ramipril, Lisinopril, Enalapril

• Inhibit ACE and formation of
angiotensin II and block its effects
• Drugs of choice in co-existent diabetes
mellitus, Heart failure
Side effects-
dry cough, hypotension, angioedema
 Angiotensin II receptor blockers

Example: Losartan
• Block the angiotensin II receptor
and inhibit effects of angiotensin
II
• Drugs of choice in patients with
co-existing diabetes mellitus
Side effects-
safer than ACEI, hypotension,
 Alpha blockers

Example: prazosin
• Block a-1 receptors and cause vasodilation
• Reduce peripheral resistance and venous
return
• Exert beneficial effects on lipids and
insulin sensitivity
• Drugs of choice in patients with co-existing
BPH
Side effects-
Postural hypotension,
 Antihypertensive therapy:
Side-effects and Contraindications

Class of drugs Main side-effects Contraindications/

Special Precautions
Diuretics Electrolyte imbalance, Hypersensitivity, Anuria
(e.g. Hydrochloro- ­total and LDL cholesterol
thiazide) levels, ¯ HDL cholesterol
levels, ­glucose levels,
­uric acid levels
b-blockers Impotence, Bradycardia,
(e.g. Atenolol) Fatigue Bradycardia, Conduction
disturbances, Diabetes,
Asthma, Severe cardiac
failure
 Algorithm for
Treatment of Hypertension
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs (diuretics,
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
 Choice of Drug

Condition Preferred drugs Other drugs Drugs to be that can be

used avoided
Asthma Calcium channel a-blockers/Angiotensin-II b-blockers
blockers receptor blockers/Diuretics/
ACE-inhibitors
Diabetes a-blockers/ACE Calcium channel blockers Diuretics/
mellitus inhibitors/ b-blockers
Angiotensin-II
receptor blockers
High cholesterol a-blockers ACE inhibitors/ A-II b-blockers/
levels receptor blockers/ Calcium Diuretics
channel blockers
Elderly patients Calcium channel -blockers/ACE- (above 60 years)
blockers/Diuretics inhibitors/Angiotensin-II
receptor blockers/- blockers
BPH a-blockers b-blockers/ ACE inhibitors/
Angiotensin-II receptor
blockers/ Diuretics/
Calcium channel blockers
 Antihypertensive therapy: Side-
effects and Contraindications
(Contd.)

Class of drug Main side-effects Contraindications/ Special

Precautions
Calcium channel blockers Pedal edema, Headache Non-dihydropyridine
(e.g. Amlodipine, CCBs (e.g diltiazem)–
Diltiazem) Hypersensitivity,
Bradycardia, Conduction
disturbances, CHF, LV
dysfunction.

a-blockers Postural hypotension Hypersensitivity

(e.g. prazosin)
ACE-inhibitors Cough, Hypotension, Hypersensitivity, Pregnancy,
(e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis
Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy,
blockers (e.g. Losartan) Bilateral renal artery stenosis
 Condition Preferred Drugs
• Pregnancy • Nifedipine, labetalol,
hydralazine, beta-blockers,
methyldopa, prazosin
• Coronary heart disease
• Beta-blockers, ACE
inhibitors, Calcium channel
blockers
• Congestive heart failure
• ACE inhibitors,
beta-blockers
1999 WHO-ISH guidelines
 Causes of
Resistant Hypertension

 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs,
sympathomimetics, OCP)
• Over-the-counter drugs and some herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN
THE END!