Evaluation and Management of

Hypertension

Prof. Dr. S.C. Mandal

Dr. Nagesh Waghmare (DM student)

Cardiology, ICVS

IPGME&R, Kolkata

1. What is hypertension ?

2. Why should we treat it ?

3. Causes and mechanisms

4. Diagnosis and Initial evaluation

5. Treatment

6. Recent advances

What is hypertension ?

Hypertension paradox

• Can be easily diagnosed, but…

• Asymptomatic nature, delays diagnosis

• Advanced therapy available, but…

• Controlled in less than 1/3 rd of patients

Silent Killer

JNC 7 staging

Determinants

• Behavioral

– Nicotine

– Heavy drinkers

– Physical inactivity

– Diet low in fresh fruits and high in calories /

sodium.

• Genetic

Why should we treat it ?

• It affects 1 billion people worldwide

• India has become ―Capital of hypertension‖

• Burden is further rising

• In the ICMR study in 1994 demonstrated

25% and 29% prevalence of hypertension

among males and females respectively in urban

Delhi and 13% and 10% in rural Haryana.

• High BP causes

~ 54% of stroke

~ 47% of ischemic heart disease

• It also leads to

– Heart failure

– Peripheral vascular disease

– Renal failure

– Blindness due retinopathy, haemorrhages

Absolute benefits of treating hypertension

Impact of a 5 mmHg Reduction

Overall Reduction

Stroke 14%

Coronary Heart Disease 9%

All Cause Mortality 7%

Hypertension 2003;289:2560-2572.

So by controlling BP, we can

reduce deaths especially due to stroke

and MI.

Causes and mechanisms

• Primary hypertension

– In 90 – 95% of patients, a single reversible

cause cannot be identified

– Also called as Essential hypertension

• Secondary hypertension

– In 5 -10 % of patients

– May be curable

Primary hypertension

• It is divided in to 3 subtypes –

1. Systolic hypertension of young

• Between 17 -25 years of age

• Probably due to overactive sympathetic nervous

system

2. Diastolic hypertension in middle age

• Typically 30-50 years of age

• Elevated systemic vascular resistance

• Reduced ability to excrete sodium by kidney

3. Isolated systolic hypertension in older

adults

• After the age 55 years

• Most common form

• Due to age dependent stiffening of vessels

Mechanisms

• Neural

Sympathetic overactivity –

Deactivation of inhibitory neural inputs (e.g.

baroreceptors)

Activation of excitatory inputs (carotid body, renal

afferents)

• Vascular - endothelial cell dysfunction

• Hormonal - Renin- Angiotensin-

Aldosterone system

Diagnosis and Initial evaluation

Minimal laboratory testing required for the initial evaluation

• Blood electrolyte values,

• Fasting glucose concentration, and

• Serum creatinine level with calculated

glomerular filtration rate (GFR)

• Serum uric acid

• Fasting lipid panel

• Hematocrit

• Spot urinalysis, including urine albumin-to-

creatinine ratio

• Resting 12-lead electrocardiogram.

3 goals

• Initial evaluation should accomplish –

1. Accurate measurement of BP

2. Assessment of patients cardiovascular risk

3. Detection of secondary forms

Measurement of BP

• Office BP measurement

• Self monitoring at home

• Ambulatory monitoring

BP Measurement Techniques

Method Brief Description

In-office

• Two readings, 5 minutes apart

• Sitting in chair, not on exam table

• Confirm elevated reading in

contralateral arm

Self-

measuremen

t

• Provides information on response to

therapy

• May help improve adherence to therapy

• Evaluate ―white-coat‖ HTN

BP Measurement Techniques

Method Brief Description

In-office

Two readings, 5 minutes apart. Sitting in chair, not on

exam table. Confirm elevated reading in contralateral

arm.

Self-measurement

Provides information on response to therapy. May help

improve adherence to therapy and evaluate ―white-coat‖

HTN.

Ambulatory BP

monitoring

Indicated for evaluation of ―white-coat‖

HTN.

Can be used to confirm self-

measurement when inconsistent with in-

office measurement.

Self-Measurement of BP

Improves awareness and adherence

Instruction on proper use and technique should be

provided

Home measurement devices should:

• Have an arm cuff

• Be checked in office regularly

Validated meters:

BMJ 2001;322:531-536.

omronhealthcare.com

Dableducational.com

Daily Logs

Self-Measurement of BP

Home measurements of >135/85 mmHg

(or 125/75 in diabetes or renal disease)

are considered hypertensive

At least 50% of measurements should

be at or below goal

• Ambulatory monitoring also useful for

diagnosis of

– Nocturnal hypertension

– Baro-reflex impairment

• Wrist monitors are inaccurate and thus not

recommended

Recommended normal values

Average daytime BP < 135 / 85 mm Hg

Night time BP <120 / 70

24-hour BP < 130 / 80

Assessment of patients cardiovascular risk

• High-risk patients now includes most

cardiology patients—

1. Established CAD, CAD risk equivalents,

2. Carotid artery disease,

3. Peripheral artery disease,

4. Abdominal aortic aneurysm,

5. Heart failure, or

6. High risk for CAD (10-year framingham risk

score of >10%

Subclinical Target Organ Damage

• Left ventricular hypertrophy

• Carotid wall thickening or plaque

• Low estimated glomerular filtration rate

=60 mL/min/1.73 m

• Microalbuminuria

• Ankle-brachial BP index <0.9

This left ventricle is very thickened (slightly over 2 cm in

thickness), but the rest of the heart is not greatly enlarged.

This is typical for hypertensive heart disease. The

hypertension creates a greater pressure load on the heart to

induce the hypertrophy.

Established Target Organ Damage

• CNS: ischemic stroke, cerebral hemorrhage, transient

ischemic attack

• Heart disease: MI, angina, coronary

revascularization, heart failure

• Renal disease: diabetic nephropathy, renal impairment

• Peripheral arterial disease

• Advanced retinopathy: hemorrhages or

exudates, papilledema

Identifiable (secondary) forms of hypertension

• Renal disease is the most common cause (2-5%)

• Endocrine diseases

– Phaeochomocytoma

– Cusings syndrome

– Conn’s syndrome

– Acromegaly and hypothyroidism

• Coarctation of the aorta

• Iatrogenic

– Hormonal / oral contraceptive

– NSAIDs

Clinical clues for Renovascular HT

• Onset before 30 years or after 50 years

• Abrupt onset

• Severe or resistant hypertension

• Symptoms of atherosclerotic disease

elsewhere

• Negative family history of hypertension

• Smoker

• Worsening renal function after renin-

angiotensin inhibition

• Recurrent ―flash‖ pulmonary edema

• Examination shows -

Abdominal bruits

Other bruits

Advanced fundal changes

Hypertensive crisis

• Hypertensive emergencies –

– Malignant hypertension

– Accelerated hypertension

• Hypertensive urgencies

Treatment

"The Goal is to Get to Goal!”

Hypertension-PLUS-

Diabetes or Renal Disease

< 140/90 mmHg < 130/80 mmHg

Measurements and goals

should be provided to the

patient verbally and in writing

at each office visit

Treatment Overview

• Lifestyle modification

Same as for prevention

• Pharmacologic treatment

Initial therapy

Combination therapy

• What to do when a patient is still not at goal?

• Follow-up and monitoring

Lifestyle Modification

ModificationApproximate SBP

Reduction (range)

Weight reduction 5-20 mmHg/ 10 kg weight loss

Adopt DASH eating

plan8-14 mmHg

Dietary sodium

reduction2-8 mmHg

Physical activity 4-9 mmHg

Moderation of alcohol

consumption2-4 mmHg

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

DASH Eating Plan

• Low in saturated fat, cholesterol, and total fat

• Emphasizes fruits, vegetables, and low fat diary

products

• Reduced red meat, sweets, and sugar containing

beverages

• Rich in

magnesium, potassium, calcium, protein, and fiber

• 3 -1.5 g sodium per day

• Can reduce BP in 2 weeks

Sacks FM. NEJM. 2001; 344:3-10.

Pharmacological treatment

Algorithm for decision

Compelling indications

These are the associated comorbid

conditions, in which a particular

antihypertensive drug causes major

improvement outcome independent of BP

reduction

Condition Drug

Algorithm of therapy

When a Patient is Still Not at Goal?

• Optimize dosages or add additional drugs until

goal blood pressure is achieved

• What do you do when you are using several

effective medications?

– Consider causes of resistant hypertension

– Assure drug therapy is rational

– ―Tricks of the trade‖

Causes of inadequate response to therapy

• Pseudo-resistance

• Non-adherence to therapy

• Drug related causes

• Associated condotions

• Secondary hypertension

• Volume overload

How to improve maintenance of therapy ?

• Be aware of the problems leading to non-

compliance

• Articulate the goal of therapy - near-

normotension with few or no side effects.

• Educate the patient about the disease and its

treatment

• Maintain contact with patient

• Keep therapy inexpensive and simple

• Prescribe according to pharmacologic

principles

• Stop unsuccessful therapy and try different

drugs

• Anticipate and address side-effects

• Add effective and tolerated drugs stepwise

• Provide feedback and validation of success.

Recent advances

• Self – Management Support

• Renal sympathetic dennervation

• Baroreceptor stimulation

Thank you !