Management of newly diagnosed
hypertension
By:Maleeha Hasan
Role no:32
Types of hypertension
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Essential hypertension
Secondary hypertension
Isolated systolic hypertension
Refractory /resistant hypertension
Hypertensive emergencies/urgencies
Categories
Case
A 45 year old female presented to the OPD for an
annual insurance medical check up
She had no complaints
Past medical history:nil
Past drug history:nil
Personal history: smokes 3 cigarettes/day & drinks
alcohol occasionally
Sedentary lifestyle
Family history:Mother hypertensive
Physical examination
Pt is well oriented to time,place & person
Pulse:72 beats/min
BMI:Obese
Bp meaurement
1st reading:158/92 mmHg
2nd reading:160/88 mmHg
3rd reading:158/90 mmHg
Cvs,RS,Abdominal examination:no abnormailty detected
Pt is asked to check her BP at home/pharmacy
The patient comes after 1 month for follow up for elevated BP
Her BP is 150/90 mmHg
Evaluation of hypertensive patients
History
• Age: < 40 years (secondary cause)
• CV risk factors :gender,smoking
• Target organ damage: TIA,stroke,angina,MI,transient
blindness
• Symptoms suggestive of secondary causes
• Presence of co-morbidities: DM
• Assessment of lifestyle:exercise,diet,alcohol
• Drug history: drug induced HTN
• Family history:HTN,hyperlipidemia,DM,obesity
Physical examination
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BP: accurate measurement in both arms & lower limbs
Pulse: Radio-femoral delay seen in coarctation of aorta
BMI
Palpation of thyroid gland
Face: puffy,anemia(chronic renal failure)
CVS examination: cardiac enlargement (displaced apex), leg
oedema,signs of LVH
• Abdominal examination:abnormal aortic pulsations,
mass,enlarged kidneys
• Sites of organ damage:optic fundus (retinal hemorrhage,
papilloedema)
• Features of secondary HTN: central obesity with moon face
(Cushings syndrome)
Lab investigations
• Fasting blood glucose: DM,impaired fasting
glucose
• Blood urea, electrolytes & creatinine: detection of
hypertensive nephropathy,electrolyte disturbance
• Lipid profile: serum total & HDL cholesterol
• Urinalysis: look for protein,glucose ,casts ,RBCs
• ECG: LVH,arrythmia ,CAD
• Thyroid function test: Hypo/hyperthyroidism
Additional investigations
• CXR: detect cardiomegaly,heart
failure,coarctation of aorta
• Renal ultrasound: detect possible renal disease
• Renal angiography: detect renal artery stenosis
• Urinary catecholamines: pheochromocytoma
• Urinary cortisol & dexamethasone supression
test: detect cushings syndrome
• Plasma renin activity & aldosterone: detect
primary aldosteronism
Optimal target BP
Lifestyle modifications
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Weight reduction
DASH eating plan
Dietary sodium reduction
Physical activity
Cessation of smoking & alcohol
Discourage excessive consumption of coffee &
other caffeine rich products
Step 1 treatment
Patients < 55 years
Treat with: ACEI
(Enalapril 5-40 mg)
A/E:cough,hyperkalemia,angiooedema
OR
ARB (Losartan 50-100mg)
Do not combine ACEI with an
ARB
Patients >55 years or of African
/Caribbean family origin of any age
Treat with: CCB
(Amlodipine 5-10mg OD)
A/E:Ankle oedema,gum hyperplasia
If not tolereated or evidence of high
risk of heart failure ,
Offer a Thiazide like diuretic
(Chlorthalidone 12.5-25mg OD)
A/E:Postural
hypotension,hypokalmeia
Step 2
If BP not controlled by step 1,offer step 2 treatment
For patients < 55 years
Add CCB in combination
with ACEI or ARB
However if CCB is not suitable,
offer Thiazide -like diuretic
For patients >55years /of
African/Caribbean descent
Consider ARB or ACEI in
combination with a CCB
Step 3
• Before considering step 3 treatment,review
medication to ensure step 2 treatment is at
optimal or best tolerated doses
• If treatment with 3 drugs is required,then
combination of ACEI or ARB,CCB & thiazidelike diuretic should be used
Step 4
Clinical BP that remains higher than 140/90mmHg after treatment
of best tolerated doses of drugs in steps 1,2,3 as resistant HTN
• Consider adding a 4th drug plus seek expert advice
• If blood potassium is 4.5mmol/l or lower : Add low dose
Spironolactone(25mg OD)
• Use with caution in pts with reduced GFR because risk of
hyperkalemia
• If blood potassium is>4.5 mmol/l,consider higher dose of
thiazide like diuretic
• Monitor blood sodium,potassium & renal function
• If further diuretic therapy for resistant HTN at step 4 is not
tolerated,or contraindiacted,or ineffective ,consider alpha or
beta blocker
Influence of comorbidity on choice
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DM- ACEI/ARBS (RENOPRETECTIVE
IHD-ACEI(ventricular remodelling
Bradycardia-aCei
Pvd –CCBs
Pregnancy-methyldopa ,beta blockers,CCBs
Asthma & COPD-CCBs,ACEI
Liver disease –all except methyledopa
Gout –diuretics containdicated
Psoariasis –ACEI & B Blockers aggravate psoariasis
BPH-alpha blockers
Migraine –bb /ccb
References
• Davidson’s principles and practice of medicine
Thank you