MANAGEMENT OF HYPERTENSION

(A)

  1. Quantification of cardiovascular risk(CVR)
  2. Threshold for intervention
  3. Treatment targets
  4. Non-drug therapy
  5. Drug therapy – Antihypertensive drugs & their choice
  6. Emergency treatment of accelerated phase/Malignant hypertension
  7. Refractory HT
  8. Adjuvant drug therapy

(B)

🔅General Measures(Lifestyle Modification):
  1. Relief of stress
  2. Salt restriction – NaCl upto 5g/day help reduce BP. Diet rich in potassium & calcium should be employed
  3. Weight reduction
  4. 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:

  1. Prevalence – half of the population over the age of 60
  2. Risks – MI, heart failure, stroke
  3. Benefit – from Anti-hypertensives is greatest in older people
  4. Target BP – similar to that for younger patient
  5. Tolerance – Well tolerated
  6. 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

👉🏻Ratelimiting 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:

  1. Non-adherence to drug therapy
  2. Inadequate therapy
  3. 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

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