Hypertension

Introduction

• Hypertension is defined as persistently elevated arterial blood pressure (BP). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) classifies adult BP as shown below.
• Isolated systolic hypertension is diastolic blood pressure (DBP) values less than 90 mm Hg and systolic blood pressure (SBP) values of 140 mm Hg or more.
• Hypertensive crisis (BP >180/120 mm Hg) may be categorized as hypertensive emergency (extreme BP elevation with acute or progressing target-organ damage) or hypertensive urgency (high BP elevation without acute or progressing target-organ injury).

Classification of Blood Pressure in Adults:

Classification Systolic (mm Hg) Diastolic (mm Hg)

Normal <120 <80

Prehypertension 120–139 80–89

Stage 1 hypertension 140–159 90–99

Stage 2 hypertension ≥160 ≥100

CLINICAL PRESENTATION

• Patients with uncomplicated primary hypertension are usually asymptomatic initially.
• Patients with secondary hypertension may have symptoms of the underlying disorder. Patients with pheochromocytoma may have headaches, sweating, tachycardia, palpitations, and orthostatic hypotension. In primary aldosteronism, hypokalemic symptoms of muscle cramps and weakness may be present. Patients with Cushing syndrome may have weight gain, polyuria, edema, menstrual irregularities, recurrent acne, or muscular weakness in addition to classic features (moon face, buffalo hump, and hirsutism).

DIAGNOSIS

• Elevated BP may be the only sign of primary hypertension on physical examination. Diagnosis should be based on the average of two or more readings taken at each of two or more clinical encounters.
• Laboratory tests: Blood urea nitrogen (BUN)/serum creatinine, fasting lipid panel, fasting blood glucose, serum electrolytes (sodium and potassium), spot urine albumin-to-creatinine ratio, and estimated glomerular filtration rate (GFR, using the Modification of Diet in Renal Disease [MDRD] equation). A 12-lead electrocardiogram (ECG) should also be obtained.
• Laboratory tests to diagnose secondary hypertension: Plasma norepinephrine and urinary metanephrine levels for pheochromocytoma, plasma and urinary aldosterone concentrations for primary aldosteronism, plasma renin activity, captopril stimulation test, renal vein renin, and renal artery angiography for renovascular disease.

TREATMENT

• Goals of Treatment: The overall goal is to reduce morbidity and mortality by the least intrusive means possible. JNC7 guidelines recommend goal BP less than 140/90 mm Hg for most patients, less than 140/80 mm Hg for patients with diabetes mellitus, and less than 130/80 mm Hg for patients with CKD who have persistent albuminuria (>30 mg urine albumin excretion per 24 hours).

NONPHARMACOLOGIC THERAPY

• Lifestyle modifications: (1) weight loss if overweight, (2) adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, (3) dietary sodium restriction ideally to 1.5 g/day (3.8 g/day sodium chloride), (4) regular aerobic physical activity, (5) moderate alcohol consumption (two or fewer drinks per day), and (6)smoking cessation.
• Lifestyle modification alone is sufficient for most patients with prehypertension but inadequate for patients with hypertension and additional CV risk factors or hypertension-associated target-organ damage.

PHARMACOLOGIC THERAPY

• Initial drug selection depends on the degree of BP elevation and presence of compelling indications for selected drugs.
• Angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics are acceptable first-line options.
• β-Blockers are used to either treat a specific compelling indication or as combination therapy with a first-line antihypertensive agent for patients without a compelling indication
• Most patients with stage 1 hypertension should be treated initially with a first-line antihypertensive drug or a two-drug combination (Combination therapy)

PHARMACOLOGIC THERAPY

Captopril (capoten) 12.5-50mg/day

Lisinopril (Zestril) 10-40mg/day

Ramipril ( Ramipace) 2.5-10mg/day

ARBs:

Candesartan ( Canrec) 8-32mg/day

Valsartan ( Valtec)80-320mg/day

Temisartan(Cotasmi) 20-80mg/day

CCB:

Amlodipine(lodopin) 5-10mg/day

BB:

Bisoprolol (concor) 2.5-10m/day

Propanolol(Inderol) 10-50mg/day

Carvedilol(Carveda)12.5-50mg/day

Nebivolol( Nebil) 5-20mg/day

Diuretic:

Furosemide(Lasix) 20-480mg/day