Hypertension

Diagnosing hypertension

  • Definition: BP >140/90 (isolated systolic hypertension sBP>160; dBP<90)
  • No target end organ damage – 3 visits of sBP>160 or dBP>100
  • Target end organ damage (CAD, cerebrovascular disease, peripheral vascular disease, renal insufficiency) – diagnosed after 3 visits
  • Global cardiovascular risk (age, males, postmenopausal, smoking, high cholesterol, glucose intolerance, family history, obesity)

Primary vs Secondary causes

  • 90% primary (essential)
  • Secondary
    • Renal 5%
    • Endocrine 5% (BCP, primary hyperaldosteronism, pheochromocytoma, Cushing’s, hyperparathyroidism)
    • Coarctation (0.2%)
    • Drug induced (corticosteroids, NSAIDs, MAOI, cocaine, amphetamines)
    • Obstructive sleep apnea
    • Enzymatic defects
    • Neurologic disorders



 

Appropriate treatment for primary hypertension

  • Sodium reduction, weight loss, alcohol reduction, exercise, diet (DASH)
  • Lifestyle modifications – follow 3-6months
    • Sodium 90-130 mmol/day
    • Lose weight – goal BMI ≤25
    • Exercise 50-60 minutes, moderate intensity, 3-4 times/week
    • Alcohol ≤2 drinks/day (weekly: no more than 14 in men, 9 in women)
    • Canadian food guide to healthy eating
  • On medical therapy follow monthly until 2 readings below target, then at 3-6 month intervals
    • Indications: dBP>90 with target end organ damage; without target end organ damage or CAD risk factors dBP>100 or sBP>160
    • First line: thiazide diuretic, beta-blocker, ACEi, long acting dihydropyridine CCB, AR
      • Partial response: consider combination (thiazide/CCB + ACEi/ARB/BB)
    • For ISH first line: thiazide diuretic, long acting dihydropyridine CCB, ARB
    • For stable angina first line: beta blockers or long acting CCB (if >55yo consider adding ACEi)
    • Recent MI first line: beta blockers, ACEi or both
    • Heart failure first line: ACEi, beta blockers, diuretics
    • Renal disease first line: ACEi
    • Diabetes first line: ACEi or ARB; consider adding both, thiazide, long acting CCB

Common medication doses

  • Thiazide diuretics: Hydrochlorothiazide 12.5 – 25 mg/day
  • ACEi:
    • Enalapril (Vasotec) 2.5-40mg daily or divided bid
    • Ramipril (Altace) 2.5-20 mg daily or divided bid
    • Quinapril (Accupril) 10-80mg daily or divided bid
  • ARB:
    • Candesartan (Atacand)
    • Losartan (Cozaar)
    • Valsartan (Diovan)
    • Irbesartan (Avapro)
    • Telmisartan (Micardis)
  • Beta blockers: Metoprolol, Bisoprolol, Atenolol
  • Long acting CCB:
    • Amlodipine (Norvasc)
    • Nifedipine (Adalat CC)

Management of chronic hypertension

  • Goal BP: <140/90 (in DM or renal disease <130/80)

Side effects of hypertensive medications

  • Thiazide diuretics: erectile dysfunction, hypokalemia, renal dysfunction, dylipidemia, hyperglycemia
  • ACEi: cough, hyperkalemia, metallic taste, dizziness, kidney failure, decrease in WBCs, angeioedema
  • ARB: cough, hyperkalemia, metallic taste, dizziness, kidney failure, decrease in WBCs, angeioedema
  • Beta blockers: depression, fatigue, nightmares, sexual impotence in males, increased wheezing in people with asthma
  • Long acting CCB: ankle swelling, arrhythmia, tachycardia, breathing difficulty, diarrhea/constipation, flushing, headache, swollen joints

Investigations

  • Routine laboratory tests for the investigation of all patients with hypertension:
  • Urinalysis
  • Complete blood cell count
  • Blood chemistry (potassium, sodium, and creatinine)
  • Fasting glucose
  • Fasting total cholesterol and high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, triglycerides
  • ECG

For specific patient subgroups:

  • For those with diabetes or renal disease: assess urinary protein excretion, since lower blood pressure targets are appropriate if proteinuria is present.
  • For those with an increased creatinine, history of renal disease or proteinuria: renal ultrasound to assess kidney size and exclude obstruction.

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