1. Hypertension
Dr. Rima Das.
B.A.M.S. (Mum); PGDEMS (Pune); DACLS, DIHM, DDM (Pune);
FPC (M.U.H.S; Nashik).
Consulting Preventive Cardiologist.
1

2. Hypertension (HTN or HT), also known
as high blood pressure (HBP), is a long
term medical condition in which the
blood pressure in the arteries is
persistently elevated.
Hypertension definition

3.  Based on cause:
• Primary - due to genetic causes or no identifiable cause
• Secondary - due to other underlying causes such as renal problems
 Based on complications:
• Essential (primary) hypertension - High blood pressure that doesn't have a known secondary cause.
• Hypertensive heart disease - hypertensive heart disease with/ without heart failure.
• Hypertensive chronic kidney disease - Hypertensive chronic kidney disease with stage 1 through stage
4 chronic kidney disease, or unspecified chronic kidney disease.
• Hypertensive heart and chronic kidney disease - Hypertensive heart and chronic kidney disease with
heart failure and with stage 5 chronic kidney disease, or end stage renal disease.
• Secondary hypertension - High blood pressure that's caused by another medical condition
Classifications:

4. There are two other categories in high blood pressure -
• White coat Hypertension - white coat Hypertension is defined as blood pressure that is consistently
elevated by office readings but does not meet diagnostic criteria for hypertension based upon out of
office readings.
•
• Masked hypertension - Masked hypertension is defined as blood pressure that is consistently elevated by
out of office measurements but does not meet the criteria for hypertension based upon office readings.

5. Pathophysiology of hypertension

7. Common causes of secondary
hypertension:
• Obstructive sleep apnea
• Kidney problems
• Adrenal gland tumors
• Thyroid problems
• Congenital vascular defects
• Certain medications such as birth control
pills, cold remedies, decongestants, over
the counter pain relievers and some
prescription drugs.
• Illegal drugs such as cocaine and
amphetamines.
Risk factors:
• Age
• Race
• Family history
• Being overweight or obese
• Not being physically active
• Using tobacco
• Too much salt (sodium) in diet
• Too little potassium in diet
• Drinking too much alcohol
• Stress
• Certain chronic conditions like kidney disease, diabetes
and sleep apnea.

8. Complications on uncontrolled
hypertension:
• Heart attack or stroke
• Aneurysm
• Heart failure
• Weakened and narrowed blood vessels in
kidneys
• Thickened, narrowed or torn blood vessels
in the eyes
• Metabolic syndrome
• Trouble with memory or understanding
• Dementia
Clinical presentation of uncontrolled
hypertension:
• Dizziness, fainting and headaches
• Chest pain and angina
• Arrhythmia
• Difficulty breathing
• Blurred vision
• Nose bleeds
• Fatigue
• Edema

9. Possible differential diagnosis and investigations to rule them out

10. Medicines
Thiazide diuretics
Diuretics are medications that act on kidneys to help eliminate sodium and water, reducing blood volume
and eventually reducing the blood pressure.A common side effect of diuretics is increased urination. (Eg.
Hydrochlorothiazide, chlorthalidone, torsemide, metolazone)
Angiotensin converting enzyme (ACE) inhibitors
These medications help relax blood vessels by blocking the formation of angiotensin, which is a
vasoconstrictor. People with chronic kidney disease may benefit from having an ACE inhibitor as one of
their medications. (Eg. Enalapril, lisinopril, benazepril, ramipril).
Angiotensin II receptor blockers (ARBs)
These medications help relax blood vessels by blocking the action, not the formation, angiotensin. People
with chronic kidney disease may benefit from having an ARB as one of their medications. (Eg. Losartan,
valsartan)

11. Calcium channel blockers
These medications help relax the muscles of blood vessels. Some slow the heart rate. (Eg.Amlodipine,
diltiazem,Verapamil)
Alpha blockers
These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that
narrow blood vessels. (Eg. Doxazocin, prazocin)
Beta blockers
These medications reduce workload on the heart and open blood vessels, causing the heart to beat slower
and with less force. (Eg.Atenolol, carvedilol, metoprolol, nebivolol, propranolol).
Aldosterone antagonist
These drugs block the effect of aldosterone that can lead to salt and fluid retention, which can contribute
to high blood pressure. (Eg. Spironolactone, eplerenone)

12. Renin inhibitors
These drugs slow down the production of renin, an enzyme produced by kidneys that starts a chain of
chemical steps that increases blood pressure. Due to a risk of serious complications, including stroke,
these shouldn't be taken with ACE inhibitors or ARBs. (Eg.Aliskiren).
Vasodilators
These medications work directly on the muscles on the walls of arteries, preventing the muscles from
tightening and arteries from narrowing. (Eg. Hydralazine, minoxidil)
Central acting agents
These medications prevent the brain from signaling the nervous system to increase heart rate and
narrow blood vessels. (Eg. Clonidine, guanfacine, methyldopa)

13. Class Drug Dose
Diuretics Hydrochlorothiazide 6.25-50 mg qd
Chlorthalidone 12.5-50 mg qd
Indapamide 1.25-5 mg qd
Drug Classes:
Class Drug Dose
ACE inhibitors Captopril 25-450 mg bid
Enalapril 2.5-40 mg qd
Fosinopril 10-80 mg qd
Lisinopril 5-40 mg qd
Ramipril 2.5-20 mg qd
Quinapril 10-80 mg qd
Benazepril 10-40 mg qd

14. Class Drug Dose
Angiotensin II receptor
blocker
Losartan 25-100 mg in 1 or 2 doses
Irbesartan 75-300 mg qd
Candesartan 4-32 mg qd
Telmisartan 40-80 mg qd
Class Drug Dose
Calcium channel
blocker
Diltiazem CD 180-360 mg qd
Felodipine 5-20 mg qd
Nicardipine 20-40 mg tid
Nifedipine SR 30-120 mg qd
Verapamil SR 120-480 mg qd
Amlodipine 2.5-10 mg qd

15. Class Drug Dose
Beta blockers Acebutolol 400-800 mg qd
Atenolol 25-100 mg qd
Metoprolol 50-200 mg qd
Nadolol 40-320 mg qd
Pindolol 5-30 mg bid
Propranolol 20-120 mg bid
Timolol 5-20 mg bid
Betaxolol 5-40 mg qd
Bisoprolol 2.5-20 mg qd

16. Alternative drugs –
Many may be added to the above for combination therapy:
Class Drug Dose
Centrally acting
adrenergic inhibitors
Clonidine 0.1-1.2 mg bid or weekly patch
0.1 mg/ day to 0.3 mg/ day qd
Methyldopa 250-2000 mg bid
Class Drug Dose
Alpha adrenergic
agents
Prazosin 1-10 mg bid
Terazosin 1-20 mg qd
Doxazocin 1-16 mg qd
Class Drug Dose
Potassium sparing
diuretics
Amiloride 5-10 mg qd
(In patients with
hypokalaemia)
Spironolactone 25-100 mg qd
Triamterene 50-150 mg qd

17. Class Drug Dose
Peripherally acting
adrenergic inhibitors
Guanadrel 2.5-37.5 mg bid
Guanethidine 10-50 mg qd
Reserpine 0.1-0.25 mg qd
Labetalol 100-900 mg bid
Class Drug Dose
Vasodilators Hydralazine 25-150 mg bid
Minoxidil Rarely used due to adverse
effects.
Class Drug Dose
Loop diuretics Furosemide 20-320 mg qd
(For patients with
volume overload)
Bumetanide 0.5-2 mg qd
Ethacrynic acid 25-100 mg qd

18. Patient education:
• Eat healthy foods. Eat a heart healthy diet.
• Decrease the salt in your diet. Aim to limit sodium to less than 2,300 mg a day or less
• Maintain a healthy weight
• Increase physical activity
• Limit alcohol
• Don't smoke
• Manage stress
• Monitor your blood pressure at home.

21. Thank you!
21