Hypertension

      Hypertension(HTN) is a condition in which arterial BP is chronically elevated

1.Primary/essential HTN-95% of cases, a specific underlying cause of hypertension cannot be found

2.Secondary HTN(5%)

Alcohol

Obesity

Pregnancy (pre-eclampsia)

Renal disease

         Renal vascular disease

         Parenchymal renal disease, particularly glomerulonephritis

         Polycystic kidney disease

Endocrine disease

         Phaeochromocytoma

         Cushing’s syndrome

         Primary hyperaldosteronism (Conn’s syndrome)

         Hyperparathyroidism

         Acromegaly

         Primary hypothyroidism

         Thyrotoxicosis

Drugs

Oral contraceptives containing oestrogens, anabolic steroids, corticosteroids, NSAIDs, sympathomimetic agents

Coarctation of the aorta

HTN category

Category	Systolic	Diastolic
BP- Optimal Normal High Normal	<120 <130 130-139	<80 85 85-89
HTN- Grade-1/Mild Grade-2/Mod. Grade-3/Seve.	140-159 160-179 >/=180	90-99 100-109 >/=110
Isolated systemic HTN- Grade-1 Grade-2	140-159 >/=160	<90 <90

[Ref/Davidson internal medicine]

[Note:

White coat HTN-When a clinician measures ,it rises ,which is termed so

Fundoscopy

• 1.Cotton wool’ exudates are associated with retinal ischaemia or infarction, and fade in a few week  
• 2.Hard’ exudates (small, white, dense deposits of lipid) and microaneurysms (‘dot’ haemorrhages)-Diabetic retinopathy]

Few  signs of secondary HTN

Radio-femoral delay (coarctation of the aorta)

Enlarged kidneys (polycystic kidney disease)

Abdominal bruits (renal artery stenosis)

Facies of Cushing’s syndrome

Tendon  xanthomas (Central obesity and hyperlipidaemia)

Grading of HTN retinopathy(Keith Wagener Barker classification)

Grade 1 Arteriolar thickening, tortuosity and increased reflectiveness (‘silver wiring') 

Grade 2 Grade 1 plus constriction of veins at arterial crossings (‘arteriovenous nipping’)

Grade 3 Grade 2 plus evidence of retinal ischaemia (flame-shaped or blot haemorrhages and ‘cotton wool’ exudates)

Grade 4 Grade 3 plus papilloedema

Target organ of HTN/ or its complications

Vessels

CNS-Stroke ,CI ,cerebral haemorrhage ,subarachnoid haemorrhage

Retina-Retinopathy

CVS-Ischemic heart disease ,left venrticular failure ,dissecting aneurysm

Kidneys-Proteinuria , renal failure

Investigation of HTN patients 

Urinalysis for blood, protein and glucose

Blood urea, electrolytes and creatinine

Blood glucose

Serum total and HDL cholesterol

A 12-lead ECG (left ventricular hypertrophy, coronary artery disease)

[Note:

Patients taking antihypertensive therapy require follow-up at 3-monthly intervals

At least 3 BP measurement required to declare HTN

Measure 5 minutes after rest and30 minutes after smoking/coffee/drink]

Life style modification of HTN

Weight reduction Attain and maintain BMI <25 kg/m2

Dietary salt reduction <6 g NaCl/d

Adapt DASH-type dietary plan

Diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat

Moderation of alcohol consumption

For those who drink alcohol, consume ≤2 drinks/day in men and ≤1 drink/day in women

Physical activity Regular aerobic activity, e.g., brisk walking for 30 min/d

Treatment

Non drug treatment- 

                   Salt restriction(<6g/day) 
                      Stop smoking 
                           Alcohol <21 units for men ,<14 units for women) 
                              BMI <25kg/m.sq 
                                  Low fat diet ,increase veges' fruits 
                                     30 minutes dynamic exercise 
                                                                      Control diabetes and other modifiable risk factors

Drug control-

        
        Diuretics

·                                                -  Loop diuretics when HTN with RF

        ACEi

·                           -When HTN  along with post MI  or diabetes

·                           -Side effects-1st dose hypotension, cough, rash, hyperkalaemia and renal dysfunction

·                           -Contraindication-Pregnancy ,renal failure

  
        Angiotensin 2 blocker

·                                  
                                 -When ACEi causes cough

·                                   -Contraindication-Pregnancy ,renal failure

  
        Renin inhibitor

·          
                                  -When diabetic nephropathy

·                                                        -Contraindication-Pregnancy

        Ca blocker

·          
                                    -When HTN with angina

         Beta blocker

·          
                                    -When HTN with angina

Whom to treat

Malignant HTN 
Grade 2/3 
Grade 1 with 10  CVD risk or existing CVD ,or target organ dysfunction or DM 
Isolated systolic HTN(>160mmHg) 
Life style modification for grade 1 without 10 CVD risk/target organ dysfunction

Give what?

HTN with asthma-Diuretics ,Ca blocker.Avoid beta blocker

HTN with CKD-ACEi and ARB(Avoid if creatinine >2.5mmol/L ;then give Ca blocker ,loops)

HTN with pregnancy-Methyldopa ,labetalol ,nifedipin

HTN with  DM-ACEi ,ARB

HTN with angina-Beta blocker ,Ca blocker ,nitrates

HTN in elderly-Ca blocker ,avoid thiazide if DM/gout]

Resistance HTN

Failure to reach BP control in pt. who are adherent to full dose of an appropriate three drug regimen including a diuretic

Malignant/accelerated HTN

High BP(Diastolic>130mmHg) and rapidly progressive end organ damage, such as retinopathy (grade 3 or 4), renal dysfunction (especially proteinuria) and/or hypertensive encephalopathy

Even in the presence of cardiac failure or hypertensive encephalopathy, a controlled reduction to a level of about 150/90 mmHg over a period of 24–48 hours is ideal.

Refractory HTN

HTN having no response to drug therapy

The common causes of treatment failure in hypertension are non-adherence to drug therapy, inadequate therapy, and failure to recognise an underlying cause such as renal artery stenosis or phaeochromocytoma

HTN emergency/crisis

BP elevation (>180/110mmHg) with evidence of impending  target organ dysfunction

Includes-

HTN encephalopathy(HTN with neurologic abnormality like Headache ,irritable ,confusion , altered mental status vision/speech disturbance) 

HTN nephropathy(Haematuria ,proteinuria) 
Intracranial hemorrhage 
Pre eclampsia 
Eclampsia 
Unstable angina/MI

HTN urgency 

BP elevation (220/125mmHg) without  life threatening target organ dysfunction.It is asymptomatic severe HTN