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.