Management of newly diagnosed hypertension By:Maleeha Hasan Role no:32 Types of hypertension • • • • • 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 • • • • • • 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 • • • • • • 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 • • • • • • • • • • • 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