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 !