Table of Contents
Introduction to Hypertension
Hypertension is a chronic medical condition in which the force of blood against the walls of arteries remains high, it is commonly known as high blood Pressure.
It is measured in millimetres of mercury (mmHg) and recorded in to the two numbers:
- Systolic Pressure (Upper Value): The pressure when heart beats and pushes blood into the arteries.
- Diastolic Pressure (Lower Value): The pressure when the heart rests between the beats.
Normal Blood Pressure: 120/80 mmHg
120 – Systolic Blood Pressure.
80 – Diastolic Blood Pressure.
Classifications of Hypertension
Hypertension is classified into the following types:
- Primary (Essential) Hypertension: It is the most type of hypertension, the cause is unknown in 90 to 95% cases. It develops gradually over the time due to the lifestyle or genetic factors.
- Secondary Hypertension: It is caused by an underlying health conditions like kidney disease, hormonal disorder or certain medications,
Grades of Hypertension
| Grades | Systolic & Diastolic Blood Pressure |
|---|---|
Normal |
120-129 / 80-84 mmHg |
Prehypertension |
130-139 / 85-89 mmHg |
Grade I Hypertension |
140-159 / 90-99 mmHg |
Grade II Hypertension |
160-179 / 100-109 mmHg |
Grade III Hypertension |
≥ 180 / ≥ 110 mmHg |
Isolated Systolic Hypertension |
≥ 140 / < 90 mmHg |
Hypertensive Urgency |
> 180 / > 110 mmHg |
Etiopathogenesis of Hypertension
Etiology (Causes of Hypertension)
- Genetic Factors
- Lifestyle Factors
- Hormonal Imbalance
- Kidney Disease
- Vascular factors
- Anxiety and stress
Pathogenesis (Mechanism of Hypertension)
The development of Hypertension involves:
- Increased cardiac output: The heart pumps more blood than normal, it rises the pressure.
- Increased peripheral resistance: Narrowed or stiffed arteries make it harder to flow the blood.
- Renin – Angiotensin – Aldosterone System (RAAS): This system regulate blood pressure by increasing sodium retention and vessel constriction. Overactivity of RAAS leads to Hypertension.
- Systemic Nervous System overactivity.
- Endothelial Dysfunction.
Management of Hypertension
Management of Hypertension not only aims to reduce blood pressure but also reduce the Cardiovascular risk. Management target is 150/90 mmHg in elderly persons and 140/90 mmHg in all others.
Non - Pharmacological Management of Hypertension
Managing Hypertension without medication involves lifestyle changes that help control blood pressure naturally.
- Dietary Modification:
- Reduce salt intake (< 5g / day)
- DASH (Dietary Approaches to Stop Hypertension): Eat more fruits, vegetables, whole grains, low fat dairy product.
- Less Processed foods, avoid packaged food.
- Regular Physical Activity:
- 30 – 45 min moderate exercise e.g. walking, cycling, swimming. At least 4-5 days in a week.
- Weight management: maintain a healthy BMI(Body Mass Index).
- Reduce stress: Yoga, Meditation, Deep Breathing.
- Liming Alcohol and Avoid Smoking.
- Take proper Sleep at least 7-8 hours.
- Increase Potassium Intake: Eat Banana, Oranges, Spinach, Potatoes, it will balance the sodium level.
Pharmacological Management of Hypertension
Pharmacological management of Hypertension includes:
- Angiotensin Converting Enzyme Inhibitors (ACEI) e.g. Enalapril 2.5, 5, 10, 20 mg tab OD/BD
- Angiotensin II Receptor Blockers (ARBs) e.g. Losartan 25 – 50 mg tab OD.
(Do not combine ACEI with ARBs) - Beta Blockers (Bb) e.g. Atenolol 50-100 mg tab OD.
- Calcium Channel Blockers (CCBs) e.g. Amlodipine 2.5 – 5 mg tab OD.
- Thiazide Diuretics(TD) e.g. Hydrochlorothiazide 12.5 – 25 mg OD.
- Mineral Corticoid Receptor Antagonist (MRA) e.g. Spironolactone.
Hypertension during pregnancy can be treated with the following medicines:
- Methyldopa
- Nifedipine
- Labetalol
- Hydralazine
- Beta Blockers
(Avoid ACEI, ARBs, and Aldosterone Antagonist in Pregnancy)
Management of Grade I Hypertension
Patient should follow lifestyle modification in grade I Hypertension, if it is not controlled after 3-4 months, and patient have risk factors like age > 50, smoking, obesity, dyslipidaemia, impaired fasting glucose, family history or early coronary artery disease, then drug therapy should be started with
- ACEI (Angiotensin Converting Enzyme Inhibitor)
- CCB (Calcium Channel Blockers)
- TD (Thiazide Diacritics)
If result is not adequate in next 3-4 weeks second drug should be added
- CCB + ACEI or,
- ACEI + TD or,
- CCB + TD.
If still does not show any improvement then lastly add third drug
- ACEI + CCB + TD.
Management of Grade II Hypertension
Drug therapy should be started initially when Grade II Hypertension is detected and therapy should be started with:
- ACEI or,
- CCB or,
- TD
If not improvement after 3-4 weeks should be added second drug
- CCB + ACEI or,
- CCB + ARBs
- CCB + TD or,
- ACEI + TD
If still no improvement add third drug to the therapy:
- ACEI + CCB + TD
Management of Grade III Hypertension
Initially starts with the two drugs
- ACEI + CCB or,
- CCB + TD or,
- ACEI + TD
if the therapy does not shows any adequate result in next 2-4 weeks, add third drug to the therapy
- ACEI + CCB + TD
Hypertension with Clinical Condition
- Coronary artery disease: Bb + ACEI, CCB (CCB could be added if required to achieve target BP).
- Congestive Heart Failure (CHF): TD + ACEI + Bb, MRA (Mineral Corticoid receptor antagonist).
- Diabetes Mellitus: ACI or CCB or TD.
- Chronic Kidney Disease: ACEI or CCB or TD.
Contradiction
- Amlodipine (CCB): Cardiogenic shock, unstable angina, significant aortic stenosis, worsening angina, and increased risk of MI.
- Enalapril (ACEI): Should not used any ACEI in pregnancy, Bilateral renal artery stenosis.
- Hydrochlorothiazide: Severe hypokalaemia, hyponatremia, hypercalcemia.
Note: Do no combine ACEI + ARBs and do not combine Bb and Diuretics, they can increase risk of diabetes mellitus.