Hypertension is elevation of Blood Pressure (BP) measured on at least three separate occasions. There is strong association between hypertension and CAD. Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure.

Treatment goal of Hypertension

• Achieve and maintain the target BP: In most cases the target BP should be: systolic below 140 mmHg and diastolic below 90 mmHg.

• Achieve target BP in special cases as: in diabetic patients and patients with cardiac or renal impairment, target BP should be below 130/80mmHg;

• Prevent and treat associated cardiovascular risks such as dyslipidemia

Diagnostic criteria

If blood pressure measurements performed on three separate occasions when either

• The initial Systolic Blood Pressure (SBP) is ≥ 140mmHg or

• The Diastolic Blood Pressure (DBP) is ≥ 90mmHg

  
  

Measured on three separate occasions, a minimum of 2 days apart and/or taken over period of two months

Minimum of 3 blood pressure readings must be taken at the first visit to confirm hypertension

If SBP is ≥ 160mmHg or DBP ≥100mmHg Stage II of JNC –VII – especially when SBP >180 mmHg and/or DBP >110 mmHg immediate drug treatment is needed

See a section on hypertensive crisis – Urgency/Emergencies topic

Consider secondary hypertension with identifiable cause in young patients < 40 years or elderly patient > 60 years presenting for first time with hypertension.

Key points

• Hypertension control has shown to have significant benefit for patients. Existence of risk factors should be detected and treated. Assess cardiovascular risk. Lifestyle modification and patient education are essential in all patients. Antihypertensive treatment is required for life in truly hypertensive patients.

• Hypertension often has no symptoms: the aim of treatment is to lower the risk of end organ damage, especially stroke

• Compliance is the most important determinant of blood pressure control.

• Explanation, education and minimizing side-effects of drugs are important

• Extra care should be taken with antihypertensive drugs administered to those over 60 years of age, because of increased side-effects. Lower doses are needed

• Recommend an alternative contraceptive method for women using oestrogen containing oral contraceptive.

• Evidence of end organ damage, i.e. cardiomegaly, proteinuria or uraemia, retinopathy or evidence of stroke, dictates immediate treatment.

• Patients should be reviewed every 1–3 months, till blood pressure controlled then every 6 months and more often if necessary. The aim of treatment is to bring the systolic BP below 140mmHg and diastolic BP below 90 mm Hg, without unacceptable side effects

Pharmacological treatment

Recommended initial medication doses for hypertension treatment.

Thiazide diuretics

Hydrochlothiazide 12.5mg/daily

OR

Bendroflumethiazide 5mg/daily

OR

Indapamide 5mg/daily preferred for patient with previous stroke/TIA

Loop diuretics

Furosemide initial dose 40mg twice a day

OR

Torsemide 5mg/daily Dose can be up scaled depending on congestive status to maximum dose

Mineralocorticoid (Aldosterone) Receptor antagonist

Spironolactone 25mg/daily

OR

Eplerenone 25mg/daily

Angiotensin-Converting Enzyme Inhibitor (ACEI)

Captopril 6.125mg, 12.5mg or 25mg three times daily

OR

Enalapril 10mg twice a day

OR

• Perindopril 8mg/daily orally

Angiotensin Receptor Blocker–ARB (*don’t combine with ACEI contraindications, indicated in patient sensitive to ACEIs)

Losartan 50mg/daily*

Beta –blocker

Atenolol 50mg/daily

OR

Metoprolol 50mg/daily

Calcium Channel Blocker

Dihydropyridines:

Nifedipine (Slow Release/Long Acting) 20mg/30mg/ 60mg/90mg/daily

OR

Amlodipine 5mg or 10mg/daily

Non–dihydropyridine

Verapamil 30mg twice–three times a daily

OR

Diltiazem 30mg twice–three times a day

Referral indicated when:

• Resistant (Refractory) hypertension suspected,

• Secondary hypertension is suspected

• Complicated hypertensive urgency/emergencies,

• Hypertension with Heart failure.

• When patients are young (<30 years).

• Blood pressure is severe or refractory to treatment

For combination therapy refers to image 2 and 3 above

Non-pharmacological treatment

Lifestyle modification:

• Weight reduction: Maintain ideal body weight BMI 18.5–24.9kg/m²

• Adopt DASH* eating plan: Consume a diet rich in fibre-fruits, vegetable, unrefined carbohydrate and low fat dairy products with reduced content of saturated and total fat

• Dietary Sodium: Reduce dietary sodium intake no more than 1000 mmmol/L (2.4gm sodium or 6gm sodium chloride per day)

• Physical Activity: Engage in regular activity such as a brisk walking at least 30 min/day most days a week

• Stop using all tobacco products

• Moderation of alcohol consumption: Limit consumption to no more than 2 drinks per day in men and no more than one drink per day in women and light person *DASH–Dietary

• Approaches to Stop Hypertension Assess or stratify according to risk factors and target organ damage see image 1 above