A guide to treat hypertension

HYPERTENSION

Hypertension is a condition of elevated blood pressure above the normal value (mentioned below), requiring antihypertensive therapy. The ultimate Public Health Goal of anti-hypertensive therapy is the reduction of cardiovascular & renal morbidity and mortality.

Diagnostic Features

procedure of BP measurements and classification

How to measure BP

The device that is used to measure BP is called sphygmomanometer.
This uses an air-filled cuff wrapped around the upper arm which helps to obstruct the blood flow into the arm. By releasing the air pumped into the cuff in small and incremental quantities, eventually blood is permitted to flow back into the arm, at which point, the pressure inside the cuff is measured that is known as the systolic pressure which represents the pressure inside the arteries during contraction of the heart. When the heart relaxes between the beats the pressure drops and that is known as the diastolic pressure. Together, these two pressures are written as a ratio.
eg . 120/80 mmHg

Mean of 2 or more properly measured seated BP readings on each of two or more office visits using appropriate sized cuff.

-Search for Cardiovascular risk factors,

-Look for target organ damage i.e. Heart, brain, kidney, Peripheral arterial disease and Retinopathy.

-Try to find out the identifiable causes of hypertension : Secondary Hypertension

– Do a careful physical examination: Measurements of BP,BMI, Exam of Optic fundi, carotid, abdominal or femoral bruit, palpation of thyroid gland, thorough examination of heart and lungs, exam of abdomen for kidney enlargement , examination of lower limb for peripheral pulses and oedema.

(Hypertension as such has no specific clinical symptoms, So routine blood pressure measurement in OPD and Clinics for adult patients presenting with any other disease will help early diagnosis and management of hypertension.)

Laboratory Investigation

Haematocrit, urine analysis, blood glucose, serum potassium, calcium

& creatinine,
lipid profile
and ECG.

Principle of Management :

In hypertension treatment, the expected Bp goal is < 140/90 mm Hg.
In patients of Diabetes or Renal disease with hypertension, the BP goal is < 130 / 80 mm Hg.

Start with Life style modification. If Goal BP is not reached go for Drug Treatment.

Non-drug Treatment (Life Style Modification)

Adaptation of healthy life style decreases BP, enhances antihypertensive drug efficacy and

decreases cardiovascular risk.

excercise

They include

1. Weight reduction.

2. Eating food rich in Calcium, Potassium and reduced total fat and saturated fat.

3.Dietary Sodium restriction (6 gm of Sod. Chloride / day)

4. physical activity-Brisk Walking, Swimming and Jogging.

5. Moderation of alcohol consumption..

6. Cessation of Smoking.

Drug Treatment-

Failure to achieve the goal by life style modification necessitates for initiation of pharmacopeiapy. Classes of drug used are outlined in the following table.

Commonly used antihypertensives

CLASS OF DRUGSNAME OF GRUGSDOSE (Mg/DAY)FREQUENCY
THIAZIDE DIURETICHYDROCHLOTHIAZIDE12.5-501
INDAPAMIDE1.25-2.51
LOOP DIURETICFUROSEMIDE20-802
POTASSIUM SPARING DIURETICAMILORIDE5-101-2
BETA BLOCKERSATENOLOL25-1001
BISOPROLOL2.5-101
METOPROLOL50-1001-2
ACE INHIBITORSENALAPRIL2.5-401-2
LISINOPRIL10-401
RAMIPRIL2.5-201
ANGIOTENSIN II ANTAGONIST
(ARB)
LOSARTAN25-1001-2
CALCIUM CHANNEL BLOCKERAMLODIPINE2.5-101
NIFEDIPINE
(LONG ACTING)
30-601
ALPHA 1 BLOCKERPRAZOSIN2-202-3
CENTRALLY ACTING DRUGSCLONIDINE0.1-0.82
METHYLDOPA250-10002

Principles of Pharmacotherapy

1.Start Thiazide Diuretics alone or in combination with one of other classes i.e. (ACE inhibitora, ARBs, Beta blockers, CCBs).

2. Add a 2nd drug of another group if single drug fails to achieve BP goal,

3. When BP is more than 20 / 10 mm Hg above the expected BP goal consider initiating therapy with 2 drugs.

4. Isolated systolic hypertension to be treated alike.

Fixed drug combinations have been recommended for use in hypertension :

Such Combinations are

1. ACE Inhibitors + CCB

2. ACE Inhibitors + Diuretics

3. ARB + Diuretics

4. Beta blockers + Diuretics

5. Beta blockers + CCB

6. Centrally acting drugs + Diuretics

The Algorithm for treatment of hypertension is as follows :

Anti hypertensive drug therapy recommended for use in Special situations

(Compelling indications)

(A)Patients with IHD,

-Stable angina- Beta hlocker (preferably metoprolol), long acting CCB.

-Unstable angina and Myocardial infarction- Beta blocker (Metoprolol) + ACE inhibitors

-Postmyocardial infarction: ACE inhibitors, Beta blockers(Metoprolol), aldosterone antagonists

(B) Patients with Heart Failure

-Asymptomatic Ventricular dysfunction-ACEI, Beta blockers (preferably carvedilol)

-Symptomatic Ventricular dysfunction-ACEI, Beta blockers (Carvedilol), ARBs

Aldosterone antagonist

(C) Diabetes with Hypertension

Combination of 2 or more drugs usually required. Thiazide diuretics,

Beta blockers, ACEI, ARBs & CCBs are beneficial. In Diabetic nephropathy, ACEI or ARB or Combination favourably affects the prognosis.

(D) Pregnancy

Methyldopa, Beta blockers and CCBs are to be used. ACEI & ARBs contraindicated.

(E) Women with Hypertension

Oral contraceptives increase BP. Hypertension not a contraindication for HRT.

Patient Education,

Patiems should be made aware of possible unfavourable effects of different anti-hypertensives

and should inform the doctor if it occurs for chang over to another drug as and when required. Public health measures like diet & exercise are to, be emphasized by the treating physician.

Referral Criteria:

1)Hypertensive emergncies like encephalopathy, myocardial infarction, unstable Angina, Pulmonary Oedema, Eclampsia, Stroke, Life threatening bleeding, Aortic dissection

require hospitalization & parenteral drug therapy & need referral to higher centres.

2) Resistant hypertension, which is the failure to achieve goal BP even after adhering to full doses of an appropriate 3 drug regimen, requires multi disciplinary consultation.

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