Hypertension Review Cases

ByMayssa Ibrahim Aly

Professor of Internal Medicine-Cairo University

2009

A 50-year-old black manA 50-year-old black man

has a blood pressure of 160/110 has a blood pressure of 160/110 mm Hg on repeated mm Hg on repeated measurements.measurements.

He is 9 kg overweight, He is 9 kg overweight, has a family history of has a family history of

hypertension, and smokes one hypertension, and smokes one pack of cigarettes daily. pack of cigarettes daily.

Classification according to Classification according to BP levelBP level

•Normal <120/80Normal <120/80

•Pre-hypertension 129/80Pre-hypertension 129/80—139/89—139/89

•Hypertension >140/90Hypertension >140/90

HypertensionHypertension

Stage I 140-159/90-Stage I 140-159/90-9999

Stage 2 >160/100Stage 2 >160/100

Stage II HTNStage II HTN

The five-year risk of a major The five-year risk of a major cardiovascular event in a 50-cardiovascular event in a 50-year-old man with a blood year-old man with a blood pressure of 160/110 mm Hg pressure of 160/110 mm Hg is is 2.5 to 5.0 percent2.5 to 5.0 percent; ;

The risk The risk doublesdoubles if the man if the man has a high cholesterol level has a high cholesterol level and and triplestriples if he is also a if he is also a smoker smoker

The primary goal of the The primary goal of the

treatment of hypertension is to treatment of hypertension is to

prevent cardiovascular disease prevent cardiovascular disease and and

deathdeath

In stage 1 or 2 hypertension lowering In stage 1 or 2 hypertension lowering systolic pressure by 10 to 12 mm Hg systolic pressure by 10 to 12 mm Hg and diastolic pressure by 5 to 6 mm Hg and diastolic pressure by 5 to 6 mm Hg reducesreduces the risk of the risk of

stroke by stroke by 40 %,40 %,

coronary disease by coronary disease by 16 %,16 %, and and

death from any cardiovascular cause death from any cardiovascular cause byby 20 %.20 %.

<135/85<135/85

Risk FactorsRisk Factors

• 1. Smoking1. Smoking• 2. Dyslipidemia2. Dyslipidemia• 3. DM3. DM• 4.>60ys4.>60ys• 5. Men& postmenopausal women5. Men& postmenopausal women• 6. Obesity6. Obesity• 7. FH of CVD: 7. FH of CVD: • Men<55ys or Women<65ysMen<55ys or Women<65ys

Obesity Obesity

BMI BMI Range Range Underweight Underweight <18.5 Kg/m<18.5 Kg/m22

Normal Normal 18.5- 24.918.5- 24.9Overweight Overweight 25-29.9 25-29.9

Obesity Obesity grade I grade I

30-34.930-34.9

Obesity Obesity grade IIgrade II

>35 >35

Patients with Patients with stage 1stage 1 HTN can be HTN can be treated with lifestyle treated with lifestyle modifications alone for up to modifications alone for up to one one yearyear, if they have , if they have no no other risk other risk factors, or factors, or

for up to for up to six monthssix months, if they have , if they have other risk factors.other risk factors.

Lifestyle modifications and Lifestyle modifications and antihypertensive therapy are antihypertensive therapy are indicatedindicated for: for:

patients with cardiovascular or patients with cardiovascular or other target-organ disease other target-organ disease (renal, cardiac, cerebrovascular, (renal, cardiac, cerebrovascular, or retinal disease) and or retinal disease) and

those with stage 2those with stage 2

Patients with Patients with diabetesdiabetes are at high risk, and are at high risk, and drugdrug therapy is therapy is indicatedindicated in such in such patients patients eveneven if if BP BP is at is at the the high endhigh end of the of the normalnormal range range

Restriction of sodium intake Restriction of sodium intake to to 2 g2 g /d/d lowers lowers systolic systolic pressure, on average, by pressure, on average, by 3.7 3.7 to 4.8to 4.8 mm Hg and lowers mm Hg and lowers diastolic pressure, on diastolic pressure, on average, by average, by 0.9 to 2.50.9 to 2.5 mm mm Hg.Hg.

Salt sensitivity is Salt sensitivity is commoncommon in in elderly patients with elderly patients with hypertensionhypertension

• Most antihypertensive drugs reduce blood pressure by 10 to 15 percent.

• Monotherapy is effective in about 50 percent of unselected patients

• Those with stage 2 HTN often need more than one drug.

• Evaluation for 2ry HTN should Evaluation for 2ry HTN should be considered when three or be considered when three or more antihypertensive drugs more antihypertensive drugs of different classes do of different classes do notnot control blood pressurecontrol blood pressure

AlgorithmAlgorithmfor for

Manag. Manag. of HTNof HTN

StepStep11

StepStep22

StepStep33

StepStep44

•Diuretics Diuretics are appropriate as are appropriate as first-line therapyfirst-line therapy for patients for patients withoutwithout coexisting conditions coexisting conditions

•ACE inhibitors or angiotensin-ACE inhibitors or angiotensin-receptor antagonistsreceptor antagonists are are recommended for patients recommended for patients with type 2 diabetes, kidney with type 2 diabetes, kidney disease, or both and are also disease, or both and are also useful in patients with heart useful in patients with heart failure.failure.

•Beta-blockers and ACE Beta-blockers and ACE inhibitorsinhibitors are recommended are recommended in patients with prior in patients with prior myocardial infarction, and myocardial infarction, and

•Calcium-channel antagonistsCalcium-channel antagonists benefit elderly patients at benefit elderly patients at risk for strokerisk for stroke

Which Stage of HTN?Which Stage of HTN?

The patient should be The patient should be advisedadvised to: to: A) lose weight, A) lose weight, B) stop smoking, B) stop smoking, C) engage in regular exercise, and C) engage in regular exercise, and D) modify his diet and D) modify his diet and

He should be screened for vascular He should be screened for vascular disease and other cardiovascular disease and other cardiovascular risk factors.risk factors.

• The increase in dietary salt may The increase in dietary salt may also have contributed to the also have contributed to the growing obesity problem by growing obesity problem by causing increased intake of fluids, causing increased intake of fluids, particularly of high-calorie soft particularly of high-calorie soft drinksdrinks

If If NoNo coexisting disease was coexisting disease was detecteddetected

Hydrochlorothiazide at a dose ofHydrochlorothiazide at a dose of 12.512.5 mg dailymg daily..

If this dose did not control his If this dose did not control his blood pressure blood pressure increaseincrease it or it or addadd a second druga second drug

for example, an ACE inhibitor to for example, an ACE inhibitor to prevent the adverse metabolic prevent the adverse metabolic effects of higher doses of effects of higher doses of diureticsdiuretics

Use of Diuretics in Patients Use of Diuretics in Patients with Hypertensionwith Hypertension

The upstream portion of the The upstream portion of the distal convoluted tubule is the distal convoluted tubule is the major sitemajor site of action of the of action of the thiazidesthiazides, where they interfere , where they interfere with sodium re-absorption.with sodium re-absorption.

Sodium is reabsorbed in the Sodium is reabsorbed in the distal tubule and collecting distal tubule and collecting ducts through an aldosterone-ducts through an aldosterone-sensitive sodium channel and by sensitive sodium channel and by activation of an ATP-dependent activation of an ATP-dependent sodium–potassium pump.sodium–potassium pump.

Through both mechanisms, potassium is secreted into the lumen.

"K+-sparing agents" collectively refers to the epithelial sodium-channel inhibitors (e.g., amiloride and triamterene) and mineralocorticoid-receptor antagonists (e.g., spironolactone and eplerenone).

The onset of action occurs after The onset of action occurs after approximately approximately 2 to 3 hours2 to 3 hours for most for most thiazides, with little natriuretic effect thiazides, with little natriuretic effect beyond 6 hours. beyond 6 hours.

Most thiazides have a half-life of Most thiazides have a half-life of approximately 8 to 12 hours, just permitting approximately 8 to 12 hours, just permitting effective effective once-daily dosingonce-daily dosing

Initial decreases in blood pressure are attributed to the reductions in extra-cellular fluid and plasma volumes, leading to depressed cardiac preload and output.

Activation of the sympathetic NS and the

renin–angiotensin–aldosterone system induces a transient rise in peripheral vascular resistance but not sufficient to negate the blood-pressure reduction

Combining a Thiazide with (ACE) inhibitor or an angiotensin II–receptor blocker (ARB) can oppose this transient rise in resistance and increase the antihypertensive response.

• Thiazides induce a reduction in Thiazides induce a reduction in

the systolic and diastolic blood the systolic and diastolic blood

pressures of pressures of 10 to 1510 to 15 mm Hg and mm Hg and

5 to 105 to 10 mm Hg, respectively mm Hg, respectively

• Hypertension responding preferentially to thiazides is considered to be low-renin or salt-sensitive hypertension.

• The elderly, blacks, and patients with characteristics associated with high cardiac output (e.g., obesity) tend to have this type of HTN.

Hydrochlorothiazide at a dose of Hydrochlorothiazide at a dose of 12.512.5 to to 25 mg25 mg /d./d.

Approximately 50% of patients will Approximately 50% of patients will respond initially to these low doses.respond initially to these low doses.

IncreasingIncreasing the dose of hydrochlorothiazide the dose of hydrochlorothiazide from from 12.5 to 25 mg12.5 to 25 mg /d/d may result in a may result in a response in an additional response in an additional 20%20% (approximately) of patients.(approximately) of patients.

At At 50 mg /d50 mg /d, , 80 to 90%80 to 90% of patients should of patients should have measurable decreases in blood have measurable decreases in blood pressure.pressure.

Increased electrolyte losses at the higher Increased electrolyte losses at the higher doses of diuretics may doses of diuretics may precludepreclude their their routine useroutine use

Case IICase II

A 68-year-old man visits his physician

• He was told a year earlier that his He was told a year earlier that his blood pressure was somewhat elevated blood pressure was somewhat elevated and was advised to reduce salt intake and was advised to reduce salt intake and increase physical activity.and increase physical activity.

• OtherwiseOtherwise no history or signs of no history or signs of cardiovascular or renal diseasecardiovascular or renal disease.

ExaminationExamination

BP isBP is 178/72178/72 mm Hg, with nomm Hg, with no clinically significant differences clinically significant differences between arms or on standing.between arms or on standing.

Body-mass indexBody-mass index isis 28.428.4..

The examination is otherwise The examination is otherwise unremarkableunremarkable

Obesity Obesity

BMI BMI Range Range Underweight Underweight <18.5 Kg/m<18.5 Kg/m22

Normal Normal 18.5- 24.918.5- 24.9Overweight Overweight 25-29.9 25-29.9

Obesity grade Obesity grade I I

30-34.930-34.9

Obesity grade Obesity grade IIII

>35 >35

InvestigationInvestigation

Urinalysis is normal. Urinalysis is normal.

The non-fasting blood glucose The non-fasting blood glucose level is 98 mg /dl .level is 98 mg /dl .

Creatinine 1.2 mg /dl.Creatinine 1.2 mg /dl.

Isolated Systolic Isolated Systolic HTNHTN

Grade 1 140-145/<80Grade 1 140-145/<80

Grade 2 >160/<80Grade 2 >160/<80

Above Above 115/75 115/75 CVD risk CVD risk doubles doubles For each of For each of 20/1020/10

Investigation Investigation Laboratory testsLaboratory tests

Urinalysis, Urinalysis, Blood glucose, Blood glucose, Estimated GFR, and Estimated GFR, and Lipoprotein profileLipoprotein profile

ECG studies should be ECG studies should be performed to evaluate performed to evaluate cardiovascular risk.cardiovascular risk.

• The recommended target level of blood pressure is below 140/90 mm Hg,

•except

• in diabetes or CRF disease, for whom a lower goal (130/80 mm Hg or lower) is advised.

Evaluation Evaluation

Treatment Treatment

Optimize dosage or Add other drug till Optimize dosage or Add other drug till Target BPTarget BP

Not at target BPNot at target BP

Smoking a cigarette within the previous 15 to 30 minutes, can cause an elevation in systolic blood pressure of 5 to 20 mm Hg.

increase in systolic blood pressure occur after one cup

of caffeinated coffee is usually only 1 to 2 mm Hg.

Long-term smoking or coffee drinking does not cause persistently elevated blood pressure

In most older In most older patients, patients, elevation of elevation of systolic blood systolic blood pressure occurs pressure occurs because of because of reduced elasticity reduced elasticity of conduit of conduit arteries.arteries.

Age related changes in BPAge related changes in BP

SBPSBP rises linearly with age: rises linearly with age:

25 mmHg25 mmHg in in menmen and and 23 mmHg23 mmHg in in womenwomen between 4 between 4thth and 9 and 9thth decades.decades.

DBPDBP tends to plateau tends to plateau beforebefore 60ys 60ys

and drops and drops afterafter 60ys. 60ys.

Strong predictor of CV complications

Lowering SBP is associated with significant reduction in :

–CV mortalityCV mortality–StrokeStroke–HF HF –MI MI –DementiaDementia

The patient described has The patient described has stage 2stage 2 systolic hypertensionsystolic hypertension (160 mm Hg). (160 mm Hg).

Non-pharmacologic interventions Non-pharmacologic interventions

should be recommended (can reduce should be recommended (can reduce the number and dosage of blood-the number and dosage of blood-pressure medications required).pressure medications required).

Therapy : why? Greater benefit than in younger Greater benefit than in younger

patients.patients.

Stroke reducedStroke reduced 30%30%

CV eventsCV events 20% 20%

Dementia Dementia 50%50%

Morality Morality 13%13%

Target of therapy in Target of therapy in elderlyelderly

DBPDBP < 90mmHg< 90mmHg

SBPSBP < 160mmHg< 160mmHg

TherapyNon pharmacology

therapy1- Life style modification :

elderly respond as younger patients .

2- Salt restriction : elderly especially women have increased sensitivity to salt.

3- Moderate exercise.

4- Relaxation therapy.

Pharmacology therapyStarted when• Hypertension noted in multiple visits

• Non phamocological therapy have not lower BP level into desired range

• Evidence of end organ damage

Therapy

AB-CD TrialsStep1: Younger A or B Elderly C or DStep2: A or B +C or D Step3: A or B+ C +DStep 4: Add either a blocker or other

diuretics A= ACEI B= B blocker C= Ca channel blocker D= Thiazide diuretics

Initially treat with a Initially treat with a ThiazideThiazide-type -type diuretic.diuretic.

If aIf a second or third drug is requiredrequired,

Second drug of choice : Second drug of choice : Ca channel blockersCa channel blockers..

ARBs and ACEIsARBs and ACEIs are are effective in preventing effective in preventing

complications.complications.

The choice will The choice will depend ondepend on

the patient's clinical statusthe patient's clinical status

Follow up after start of treatment of Follow up after start of treatment of HTNHTN

Low/intermediate Low/intermediate RiskRisk

High riskHigh risk

Every 2MsEvery 2Ms

Remains at target level Remains at target level For 2 consecutive visitsFor 2 consecutive visits

Every 6MsEvery 6Ms

Every 1MEvery 1M

Remains at target level Remains at target level For 2 consecutive visitsFor 2 consecutive visits

Every 3MsEvery 3Ms

Initial follow-up can be carried Initial follow-up can be carried out at approximatelyout at approximately monthlymonthly intervalsintervals untiluntil the target blood the target blood pressure ofpressure of lessless than than 140/90140/90 mm Hg ismm Hg is achieved.achieved.

Once the target blood pressureOnce the target blood pressure isis achieved, follow-up can achieved, follow-up can occuroccur everyevery 3 to 63 to 6 months.months.

Serum potassium, Creatinine, and Serum potassium, Creatinine, and blood glucose levels should be blood glucose levels should be measured at leastmeasured at least annually.annually.

Low serum potassium levels Low serum potassium levels should be managed withshould be managed with potassiumpotassium supplementation, use of asupplementation, use of a potassium-sparing diureticpotassium-sparing diuretic, , or both.or both.

Drugs to be avoidedDrugs to be avoidedCentrally acting drugsCentrally acting drugs : :

drowsinessdrowsiness

depressiondepression

Impaired cognitive function.Impaired cognitive function.Adrenergic antagonistsAdrenergic antagonists : :

postural hypotension.postural hypotension.NSAIDNSAID : :

exacerbate hypertension.exacerbate hypertension.

Risk of therapyRisk of therapy Risk of therapy is increased with age.

Drugs Drugs

Hyponatremia & hypokalemia with Hyponatremia & hypokalemia with diureticsdiuretics

Confusion & depression with drugs Confusion & depression with drugs affecting CNS as affecting CNS as B blockerB blocker

Postural hypotension which may lead to Postural hypotension which may lead to fall & fracturefall & fracture

Cerebral hypoperfusion if BP is Cerebral hypoperfusion if BP is acutely loweredacutely lowered

Increased glucose intolerance, Increased glucose intolerance, Creatinine and uric acid with Creatinine and uric acid with Thiazide treatmentThiazide treatment

Benefit of therapyBenefit of therapyGreater benefit than in younger patientsGreater benefit than in younger patients.

Stroke reducedStroke reduced 30%30%

CV eventsCV events 20%20%

Dementia Dementia 50%50%

Morality 13%13%

1- start with 1- start with half half standard doses.standard doses.

2- 2- increaseincrease dose dose graduallygradually over over several weeks.several weeks.

3- 3- checkcheck BP in BP in bothboth supine and supine and standing position.standing position.

4- 4- AdjustAdjust dose according to dose according to standingstanding position. position.

5- Monitor 5- Monitor renalrenal function and function and electrolyte status.electrolyte status.

6- A adverse drug reaction are 6- A adverse drug reaction are 2-2-3 times3 times more common. more common.

7- Consider 7- Consider co-morbidco-morbid condition. condition.

When to stopWhen to stop

Withdrawal of antihypertensive drugs Withdrawal of antihypertensive drugs should be done carefullyshould be done carefully if if :

The original level of BP was The original level of BP was mild to moderatemild to moderate

BP of patient has been in good BP of patient has been in good control for continues period control for continues period 1212 monthsmonths

Follow up Follow up

for life long with or without for life long with or without medical treatmentmedical treatment

A 36-Year-Old ManA 36-Year-Old Man

was admitted to the hospital was admitted to the hospital because of seizures and severe because of seizures and severe hypertension. hypertension.

had an 18-year history of had an 18-year history of intravenous drug abuse (heroin)intravenous drug abuse (heroin)

One year before admission, he One year before admission, he discontinued his use of illicit drugsdiscontinued his use of illicit drugs

Three months before admission, Three months before admission, tingling developed in the left toes tingling developed in the left toes and progressed to numbness in the and progressed to numbness in the foot; foot;

these symptoms were accompanied these symptoms were accompanied by recurrent vomiting, night sweats, by recurrent vomiting, night sweats, intermittent diarrhea, abdominal intermittent diarrhea, abdominal pain, subjective fever, and a weight pain, subjective fever, and a weight loss of 16 kg.loss of 16 kg.

He noted erythematous lumps over He noted erythematous lumps over the shins and anklesthe shins and ankles

Five weeks before admission Five weeks before admission HTNHTN was diagnosed. was diagnosed.

Tests for Tests for HBVHBV and and HCVHCV were were +ve+ve..

The initial blood pressure was The initial blood pressure was 240/130240/130 mm Hg. mm Hg.

Lungs and heart were normal on Lungs and heart were normal on auscultation.auscultation.

No peripheral edema was found.No peripheral edema was found.On neurologic examination the On neurologic examination the

strength was 5/5 strength was 5/5 exceptexcept at the left at the left gastrocnemius 2/5gastrocnemius 2/5

The tone was normal The tone was normal All sensation was normalAll sensation was normal

The deep-tendon reflexes were + in The deep-tendon reflexes were + in the arms, ++ at the knees and right the arms, ++ at the knees and right ankle, and ankle, and absentabsent at the left ankle; at the left ankle;

Plantar responses were flexor.Plantar responses were flexor.

Fundus showedFundus showed optic-disk optic-disk edema.edema.

InvestigationsInvestigations

UrineUrine was was positive (+++) for protein positive (+++) for protein and trace-positive for glucose; the and trace-positive for glucose; the sediment contained 0 to 2 white sediment contained 0 to 2 white cells and no red cells/HPFcells and no red cells/HPF

CreatinineCreatinine was 2.5 and rising to was 2.5 and rising to 3.5mg/dl.3.5mg/dl.

ECGECG showed a normal rhythm with showed a normal rhythm with voltage criteria for left ventricular voltage criteria for left ventricular hypertrophyhypertrophy

ESR wasESR was 107mm /hr107mm /hr

ImagingImagingA chest radiograph was

unremarkable. An U/S of the abdomen showed

that the gallbladder was distended and contained gallstones, without evidence of cholecystitis.

The liver was normal, and the spleen unremarkable;

the kidneys were unchanged.

What will you doWhat will you dowith our case?with our case?

REFERREFER

intensive care unit

for control

of his hypertension.

Hypertensive Hypertensive Urgencies and Urgencies and EmergenciesEmergencies

Hypertensive crisisHypertensive crisis

•BP > 220/120 mmHg + acute TOD BP > 220/120 mmHg + acute TOD

(encephalopathy or cereberal (encephalopathy or cereberal

hemorrhage).hemorrhage).

–Emergency, refer to hospital.Emergency, refer to hospital.

–Reduce BP to 160/100 over Reduce BP to 160/100 over several hoursseveral hours

IV diuretics should not be used IV diuretics should not be used as initial therapy in as initial therapy in hypertensive crisis unless hypertensive crisis unless acute pulmonary edema. acute pulmonary edema.

Sublingual nifedipine plus IV Sublingual nifedipine plus IV loop diuretic should be avoided loop diuretic should be avoided it as it may result in organ it as it may result in organ hypoperfusion.hypoperfusion.

A single dose of sublingual A single dose of sublingual captopril 12.5 mg can be used captopril 12.5 mg can be used until the patient transfer to until the patient transfer to hospital.hospital.

BP > 220/120 mmHg but no acute BP > 220/120 mmHg but no acute

TOD.TOD.

– Urgency, refer to hospital

–Treatment by combination of rapidly

acting oral antihypertensive drugs.

The distinction The distinction dependsdepends upon upon

the clinical assessment of the clinical assessment of the degree , the degree ,

the rate of rise of blood the rate of rise of blood pressure and pressure and

the presence of potential the presence of potential for end-organ damagefor end-organ damage

Management of Rapid Severe Management of Rapid Severe HTNHTN

Rapid BP>220/130

Severe S of acute TODSevere S of acute TOD

YES YES NONO

CAPTOPRILCAPTOPRILSL(SL(½ tab)½ tab)

Refer Refer

Retinal He/exudates/ papilloedemaRetinal He/exudates/ papilloedema(malignant HTN)(malignant HTN)

YESYES NONO

Combination of rapid Combination of rapid Acting oral anti-HTNActing oral anti-HTN

Start oral anti-HTNStart oral anti-HTN

Assessment of end organ damageAssessment of end organ damage

Examination of retina for hypertensive Examination of retina for hypertensive

changeschanges Examination of peripheral pulsesExamination of peripheral pulses

Chest x-ray & ECG for signs of LVHChest x-ray & ECG for signs of LVH

Kidney function testsKidney function tests

• This patient had involvement of the NS, This patient had involvement of the NS, the skin, kidneys, the liver, and the the skin, kidneys, the liver, and the heart, and heart, and

• He also had malignant hypertension, as He also had malignant hypertension, as evidenced by the headache and optic-evidenced by the headache and optic-disk edemadisk edema

• ESR was 107mm /hr107mm /hr

• positive tests for hepatitis C & B positive tests for hepatitis C & B virus Ab.virus Ab.

Management Management

ReferRefer