
(A)
- Quantification of cardiovascular risk(CVR)
- Threshold for intervention
- Treatment targets
- Non-drug therapy
- Drug therapy – Antihypertensive drugs & their choice
- Emergency treatment of accelerated phase/Malignant hypertension
- Refractory HT
- Adjuvant drug therapy
(B)
🔅General Measures(Lifestyle Modification):
- Relief of stress
- Salt restriction – NaCl upto 5g/day help reduce BP. Diet rich in potassium & calcium should be employed
- Weight reduction
- Control of risk factors:
- Restriction of cholesterol & saturated fat in diet reduces the atherosclerotic complications
- Alcohol, smoking – ❌🚭
- Control of blood sugar level in diabetics
5. Regular exercise: Jogging & swimming – ⬇️ Arterial pressure
(1) Quantification of Cardiovascular Risk:
• Objectives
🔅 To reduce the incidence of adverse cardiovascular events viz coronary heart disease, stroke & heart failure
• Benefits:
🔅Diuretics or β blockers have shown to reduce the risk of
- CAD by 16%
- Stroke – 13%
- Cardiovascular death – 21%
- Mortality – 13%
🔅Most of the excess Morbidity & Mortality associated with HT is attributable to CAD. Total CVR = CAD risk x 4/3
(2) Threshold for intervention:
- Systolic & Diastolic BP – predictors of CVR (≥ 140/90 mm Hg)
- The threshold for initiating AHT is lower in diabetics/cardiovascular disease as they are at a higher risk
- The threshold for treatment of HT in elderly is same as in younger patient.
🔅 Hypertension in old age:
- Prevalence – half of the population over the age of 60
- Risks – MI, heart failure, stroke
- Benefit – from Anti-hypertensives is greatest in older people
- Target BP – similar to that for younger patient
- Tolerance – Well tolerated
- Drug of choice – low dose thiazides

Target BP during AHT
(3) Treatment Targets:
- Optimum BP (130/83) for reduction of major cardiovascular events
- improve screening
- Follow up every 3 months
(4) Non-drug therapy ~ General measures
(5) Drug Therapy:



NOTE: 🔎
A. ACE Inhibitors:
👉🏻Patients with renal artery stenosis/impaired Renal function (given with utmost care)
⬇️
Reduction of filteration pressure in the glomeruli
⬇️
Renal failure
👉🏻These agents also reduce the progression of Nephropathy in type II diabetes
👉🏻Level of electrolytes & creatinine should be checked before & after 1-2 weeks.
B. ARB’s
👉🏻Have lesser side effects of cough & angioedema than ACE inhibitors
C. Beta-blockers:
👉🏻These drugs are not used now as first line AHT; except in patient with Angina
👉🏻Labetalol & Carvedilol: Have better effect when combined. Labetalol is used as infusion in malignant phase HT.

D. CCB’s
👉🏻The dihydropyridines are effective, well-tolerated particularly in older people
👉🏻Rate–limiting CCB’s: HT with angina. Bradycardia may occur
- S/E – Constipation(Verapamil)
- Tachycardia(Nifedipine)
E. Thiazides & other Diuretics:
👉🏻The loop diuretics have few A/D over thiazides unless there’s renal impairment.

Chart showing Mode of Action & Side effects of AHT’s☝🏻

The influence of comorbidity on the choice of antihypertensive drug therapy

Management of hypertension: British hypertension society guidelines
🔅Choice of AHT drug:
Criteria:
- Age & ethnic background
- Cost, convenience
- Response to initial therapy
- S/E

A = ACE inhibitor (consider AT-II receptor antagonist if ACE-intolerant); C = Calcium channel blocker; D = thiazide-type diuretic)
(6) Emergency treatment of accelerated phase/Malignant hypertension
🔅 In accelerated phase HT, lowering BP too quickly may compromise tissue perfusion & can cause –
- Cerebral damage
- Occipital blindness
- Coronary/Renal insufficiency
🔅150/90 mm Hg within 48 hours is ideal along with cardiac failure/hypertensive encephalopathy
🔅Avoid parenteral therapy
- iv/im: Labetalol (2mg/min)
- iv: Glyceryl trinitrate(0.6-1.2mg/hour)
- im: Hydralazine(5-10 mg aliquots repeated at 1/2 hourly interval)
- iv: Na Nitroprusside(0.3 – 1 μg/kg body wt/min)
(7) Refractory HT:
🔅Causes of treatment failure include:
- Non-adherence to drug therapy
- Inadequate therapy
- Renal artery stenosis
(8) Adjuvant Drug Therapy:
📌Aspirin – Antiplatelet
- ⬇️ Cardiovascular risk
- S/E: Bleeding
📌Statins – Reduced risk by treating hyperlipidaemia
Dr. Mehnaz Memon🖊
References: Davidson’s Principles and Practice of Medicine Textbook