History

Fact Explanation
Usually asymptomatic. Hypertension is usually asymptomatic and noticed insidiously. Therefore this is called as a 'silent killer'. Malignant hypertension is sudden and rapid development of extremely high blood pressure (BP). It affects 1% and usually accompanied with symptoms such as headache. [1],[8]
Headache. Many cases of hypertension is accompanied by a mild or severe headache. Many cases of hypertension headaches happen to occur in the mornings as opposed to other times during the day. The headache is usually felt at the back of the head and any other factor that goes with it will depend on the individual’s age as well as the status of the disease. [1],[8]
Blurred vision. Blurred vision can actually be a symptom of a more serious condition that affects the eyes called hypertensive retinopathy. [1],[8]
Frequent urination at night. Some patho physiological changes in hypertension are responsible to result in nocturia. These include the effects of hypertension on glomerular filtration and tubular transport, resetting of the kidney pressure-natriuresis relationship, atrial stretch and release of atrial natriuretic peptide when congestive heart failure complicates hypertension, and peripheral edema. [11]
Assessment of hypertensive state. In a previously diagnosed patient duration of hypertension, previous levels of BP and previous treatments are important information. [3]
Suspect secondary hypertension. Presenting age <20 years and >50 years, difficult to control BP, sudden loss of control of BP and sudden onset of hypertension suggests 2ry hypertension. [9],[10]
Symptoms of target organ damage. History of sudden onset of weakness, transient blindness, symptoms of heart failure such as breathlessness, symptoms of chronic renal failure and intermittent claudication are important symptoms of target organ damage. [7]
Past medical history. History of cardiovascular disease, cerebrovascular disease, peripheral vascular disease, diabetes, gout, dyslipidemia, bronchospasm, sexual dysfunction and renal disease must noticed specifically. They are important in risk assessment and management decisions. [5],[6]
Drug history. Drugs such as NSAIDS, oral contraceptive pill, steroids, sympathomimetics cause 2ry hypertension. [9],[10]
Family history. Family history of hypertension, diabetes mellitus, dyslipidemia, cardiovascular disease, renal disease and endocrine diseases must assessed specifically. They are important in risk assessment and management decisions. [4], [5]
Social history. Occupation, habits like smoking, alcohol consumption, narcotic use, dietary habits, engaging aerobic exercise are important factors influencing management and outcome of hypertension. [2],[4],[5],[6],[8]
References
  1. KALLIKAZAROS IE. Arterial hypertension. Hellenic J Cardiol [online] 2013 Sep-Oct, 54(5):413-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100188
  2. DA SILVA BDEL P, NEUTZLING MB, CAMEY S, OLINTO MT. Dietary patterns and hypertension: a population-based study with women from Southern Brazil. Cad Saude Publica [online] 2014 May, 30(5):961-71 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24936813
  3. KURIAKOSE A, NAIR ANISH TS, SOMAN B, VARGHESE RT, SREELAL TP, MENDEZ AM, ABRAHAM A. Rate and Risk of All Cause Mortality among People with Known Hypertension in a Rural Community of Southern Kerala, India: The Results from the Prolife Cohort. Int J Prev Med [online] 2014 May, 5(5):596-603 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24932391
  4. CORRêA-NETO VG, SPERANDEI S, SILVA LA, MARANHãO-NETO GDE A, PALMA A. [Arterial hypertension among adolescents in Rio de Janeiro: prevalence and association with physical activity and obesity]. Cien Saude Colet [online] 2014 Jun, 19(6):1699-708 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24897471
  5. LOYOLA FILHO AI, FIRMO JDE O, UCHOA E, LIMA-COSTA MF. Associated factors to self-rated health among hypertensive and/or diabetic elderly: results from Bambui project. Rev Bras Epidemiol [online] 2013 Sep, 16(3):559-71 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24896270
  6. COIS A, EHRLICH R. Analysing the socioeconomic determinants of hypertension in South Africa: a structural equation modelling approach. BMC Public Health [online] 2014 May 1:414 [viewed 23 June 2014] Available from: doi:10.1186/1471-2458-14-414
  7. OFORI SN, ODIA OJ. Serum uric acid and target organ damage in essential hypertension. Vasc Health Risk Manag [online] 2014:253-61 [viewed 23 June 2014] Available from: doi:10.2147/VHRM.S61363
  8. KOTWANI P, KWARISIIMA D, CLARK TD, KABAMI J, GENG EH, JAIN V, CHAMIE G, PETERSEN ML, THIRUMURTHY H, KAMYA MR, CHARLEBOIS ED, HAVLIR DV, SEARCH COLLABORATION. Epidemiology and awareness of hypertension in a rural Ugandan community: a cross-sectional study. BMC Public Health [online] 2013 Dec 9:1151 [viewed 23 June 2014] Available from: doi:10.1186/1471-2458-13-1151
  9. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  10. KALLISTRATOS MS, GIANNAKOPOULOS A, GERMAN V, MANOLIS AJ. Diagnostic modalities of the most common forms of secondary hypertension. Hellenic J Cardiol [online] 2010 Nov-Dec, 51(6):518-29 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169184
  11. FELDSTEIN CA. Nocturia in arterial hypertension: a prevalent, underreported, and sometimes underestimated association. J Am Soc Hypertens [online] 2013 Jan-Feb, 7(1):75-84 [viewed 24 June 2014] Available from: doi:10.1016/j.jash.2012.12.004

Examination

Fact Explanation
Blood pressure measurement. Measuring blood pressure(BP) with the correct technique using the correct cuff size. Take average of 2 or more readings. Verify BP in the contralateral arm. [1]
Body weight and height. Measure body weight and height accurately and calculate BMI to identify obesity. It is a modifiable risk factor for hypertension. [2],[7]
Signs of Complications 1.Fundoscopy Examine the fundus and grade according to severity of hypertensive retinopathy. I - Tortuous arteries with thick shiny walls. II - Arteriovenous nipping. III - Flame hemorrhages and cotton wool spots. IV - Papilloedema. [3],[4]
Signs of Complications 2.Shifted apex As a complication of chronic hypertension, hypertrophy of heart occurs. Shifted apex is a sign of cardiomegaly. Heaving apex, 3rd and 4th heart sounds are other signs of left ventricular hypertrophy. [4]
Signs of Complications 3.Peripheral pulse. Absent or weak peripheral pulse (posterial tibial and dorsalis pedis) suggests peripheral arterial disease. Must examine for Bilateral femoral pulse. Radio femoral delay suggests coarctation of aorta. [4]
Signs of Complications 4.Weakness of body. To identify signs of stroke or a transient ischemic attack, examine tone, power, reflexes, coordination and cranial nerves. [4]
Signs of Complications 5. Half half nails Due to target organ damage of to kidney chronic renal failure can occur. Signs such as pallor, uremic smell of breath, half half nails are signs of chronic renal failure. [4]
Specific signs of 2ry hypertension 1.Palpable kidneys. Palpable kidneys with hypertension suggests Polycystic kidney disease. [6],[7]
Specific signs of 2ry hypertension 2.Renal Bruit. Renal artery bruit occurs due to renal artery stenosis. [6],[7]
Specific signs of 2ry hypertension 3.Skin stigmata of neurofibromatosis. Neuofibromatosis can be associated with Phaeochromocytoma. Sweaty palms and tachycardia are other signs of Phaeochromocytoma. [6],[7]
Specific signs of 2ry hypertension 4.Purple abdominal striae. Purple abdominal striae, central obesity with moon face, buffalo hump,and bruises are signs of Cushing's syndrome. [6],[7]
Specific signs of 2ry hypertension 5.Spade like hands and feet. Spade like hands and feet, prominent supra orbital ridge, prognathism,. wide spaced teeth and large tongue are signs of acromegaly. These signs occur due to increased soft tissue growth. [6],[7]
Specific signs of 2ry hypertension 6.Tremor Tremor, tachycardia, warm vasodilated peripheries with full pulse, Exopthalmos and lid lag are signs of Hyperthyroidism. [6],[7]
References
  1. KALLIKAZAROS IE. Arterial hypertension. Hellenic J Cardiol [online] 2013 Sep-Oct, 54(5):413-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100188
  2. KATZ EG, STEVENS J, TRUESDALE KP, CAI J, NORTH KE, STEFFEN LM. Associations of body mass index with incident hypertension in American white, American black and Chinese Asian adults in early and middle adulthood: the Coronary Artery Risk Development in Young Adults (CARDIA) study, the Atherosclerosis Risk in Communities (ARIC) study and the People's Republic of China (PRC) study. Asia Pac J Clin Nutr [online] 2013, 22(4):626-34 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24231024
  3. RESCH M, SüVEGES I, NéMETH J. [Hypertension-related eye disorders]. Orv Hetil [online] 2013 Nov 10, 154(45):1773-80 [viewed 23 June 2014] Available from: doi:10.1556/OH.2013.29720
  4. OFORI SN, ODIA OJ. Serum uric acid and target organ damage in essential hypertension. Vasc Health Risk Manag [online] 2014:253-61 [viewed 23 June 2014] Available from: doi:10.2147/VHRM.S61363
  5. KALLISTRATOS MS, GIANNAKOPOULOS A, GERMAN V, MANOLIS AJ. Diagnostic modalities of the most common forms of secondary hypertension. Hellenic J Cardiol [online] 2010 Nov-Dec, 51(6):518-29 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169184
  6. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  7. CUNHA E SILVA DC, LOURENçO RW, CORDEIRO RC, CORDEIRO MR. [Analysis of the relation between the spatial distribution of morbidities due to obesity and hypertension for the State of São Paulo, Brazil, from 2000 to 2010]. Cien Saude Colet [online] 2014 Jun, 19(6):1709-19 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24897472

Differential Diagnoses

Fact Explanation
Anxiety disorders. Commonly presents with a history of restlessness, palpitations and sweating. Tremors, tachycardia, tachypnea, sweaty palms are common signs. Generalized anxiety disorder has higher prevalence compare to other anxiety disorders such as panic disorders, post traumatic stress disorder, obsessive compulsive disorder and phobias. [1],[2],[3]
Hyperthyroidism. Patients presents with a history of significant weight loss despite of increased appetite, palpitations, heat intolerance, irritability, and tremors. In graves disease eye signs can be noticed. [1],[2],[3]
Cushing's syndrome. Patients presents with increased weight, proximal muscle weakness, hirsuitism, acne and gonadal dysfunction. On examination central obesity with moon face, buffalo hump, purple abdominal striae and bruises can be noticed. [1],[2],[3]
Primary hyperaldosteronism. Usually asymptomatic. May present with features of hypokalemia such as weakness, cramps, paresthesia and polyurea. 2/3 are due to an aldosterone producing adenoma. This is called Conn's syndrome. Other 1/3 are due to adrenal hyperplasia. [1],[2],[3]
Phaeochromocytoma. Presents with episodes of sweating, flushing, palpitation and chest tightness. rarely can be associated with hereditary cancer syndromes and neurofibromatosis. [1],[2],[3]
Acromegaly. Presents with history of excess soft tissue growth such as increased ring size and shoe size and coarsening of facial features. On examination thick spade like hands, prominent supra orbital ridge, prognathism,. wide spaced teeth and large tongue can be seen. [1],[2],[3]
Renal disease. Renal diseases are the most common 2ry cause for hypertension. 75% are occurring due to intrinsic renal diseases and 25% are due to renovascular diseases. [1],[2],[3]
Drug toxicity. Drug overdose such as sympathomimetic, street drugs such as amphetamine, cocaine intake or large amount consumption of caffeine containing beverages such as coffee can mimic hypertension. [1],[2],[3]
References
  1. KALLIKAZAROS IE. Arterial hypertension. Hellenic J Cardiol [online] 2013 Sep-Oct, 54(5):413-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100188
  2. KALLISTRATOS MS, GIANNAKOPOULOS A, GERMAN V, MANOLIS AJ. Diagnostic modalities of the most common forms of secondary hypertension. Hellenic J Cardiol [online] 2010 Nov-Dec, 51(6):518-29 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169184
  3. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367

Investigations - for Diagnosis

Fact Explanation
UFR Proteinuria occur due to target organ damage. Red blood and active sediment suggests secondary hypertension. [1],[3],[4],[5]
ECG This is performed to find atypical myocardial infarction or features of heart failure. [1],[3],[4],[5]
Serum electrolytes. In primary hyperaldosteronism hypokalemia occurs. [1],[3],[4],[5]
Blood urea and Serum creatinine level. To identify renal involvement in suspected target organ damage. If Blood urea and serum creatinine levels are elevated more specific investigations such as creatinine clearance must performed. [1],[3],[4],[5]
Lipid profile Hyperlipidemia increases the cardiovascular risk. [1],[3],[4],[5]
FBS Diabetes mellitus increases the cardiovascular risk. [1],[3],[4],[5]
Chest X-ray This is done to identify cardiomegaly. [1],[3],[4],[5]
Echocardiography This is done to identify heart failure and other hypertensive cardiac disorders. [1],[3],[4],[5]
USS abdomen This is done to identify features of chronic renal failure and other causes of 2ry hypertension. [1],[3],[4],[5]
24 hour ambulatory BP monitoring. When there is an unusual variability of BP over same or different visits this is helpful. [1], [2]
Specific investigations for secondary hypertension. If suspect 2ry hypertension to identify the cause do specific investigations such as short synacthen test, 24 hour urinary VMA, plasma renin aldosterone level, Thyroid function tests. [1],[3],[4],[5]
References
  1. KALLIKAZAROS IE. Arterial hypertension. Hellenic J Cardiol [online] 2013 Sep-Oct, 54(5):413-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100188
  2. GREZZANA GB, STEIN AT, PELLANDA LC. Impact on Hypertension Reclassification by Ambulatory Blood Pressure Monitoring (ABPM) according to the V Brazilian Guidelines on ABPM. Arq Bras Cardiol [online] 2013 Oct, 101(4):372 [viewed 23 June 2014] Available from: doi:10.5935/abc.20130197
  3. KALLISTRATOS MS, GIANNAKOPOULOS A, GERMAN V, MANOLIS AJ. Diagnostic modalities of the most common forms of secondary hypertension. Hellenic J Cardiol [online] 2010 Nov-Dec, 51(6):518-29 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21169184
  4. VIERA AJ, NEUTZE DM. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician [online] 2010 Dec 15, 82(12):1471-8 [viewed 24 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21166367
  5. LOYOLA FILHO AI, FIRMO JDE O, UCHOA E, LIMA-COSTA MF. Associated factors to self-rated health among hypertensive and/or diabetic elderly: results from Bambui project. Rev Bras Epidemiol [online] 2013 Sep, 16(3):559-71 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24896270

Investigations - Followup

Fact Explanation
Arrange clinic follow up. During clinic visits assess BP level, fundoscopy, response to treatments, side effects of treatments and effectiveness of lifestyle modification. [1],[2],[3],[4],[5]
Periodic monitoring. Periodic monitoring of FBS, lipid profile helps to identify other cardiovascular risk factors early. Serum creatinine, Serum Electrolytes and 2D Echocardiography helps to identify target organ damage. Assess patients and arrange investigations accordingly to identify side effects of treatments. [1],[2],[3],[4],[5]
References
  1. KALLIKAZAROS IE. Arterial hypertension. Hellenic J Cardiol [online] 2013 Sep-Oct, 54(5):413-5 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24100188
  2. MENDES TDE A, GOLDBAUM M, SEGRI NJ, BARROS MB, CéSAR CL, CARANDINA L. Factors associated with the prevalence of hypertension and control practices among elderly residents of São Paulo city, Brazil. Cad Saude Publica [online] 2013 Nov, 29(11):2275-86 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24233042
  3. LOYOLA FILHO AI, FIRMO JDE O, UCHOA E, LIMA-COSTA MF. Associated factors to self-rated health among hypertensive and/or diabetic elderly: results from Bambui project. Rev Bras Epidemiol [online] 2013 Sep, 16(3):559-71 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24896270
  4. WEE LE, WONG J, CHIN RT, LIN ZY, GOH DE, VIJAKUMAR K, VONG KY, TAY WL, LIM HT, KOH GC. Hypertension management and lifestyle changes following screening for hypertension in an Asian low socioeconomic status community: a prospective study. Ann Acad Med Singapore [online] 2013 Sep, 42(9):451-65 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24162320
  5. OFORI SN, ODIA OJ. Serum uric acid and target organ damage in essential hypertension. Vasc Health Risk Manag [online] 2014:253-61 [viewed 23 June 2014] Available from: doi:10.2147/VHRM.S61363

Management - General Measures

Fact Explanation
Grade the hypertension Mild - Systolic BP 140-159 mmHg and Diastolic BP 90-99 mmHg- Confirm within months. Moderate- Systolic BP 160-179 mmHg and Diastolic BP 100-109 mmHg- Evaluate within 1 month. Severe- Systolic BP >180 mmHg and Diastolic BP >110 mmHg- Evaluate immediately. When a patient's systolic and diastolic BP fall into different categories, higher category should apply. [1],[2],[3],[4],[5],[6]
Risk stratification Factors used for risk stratification are age ( male>55 years, Female>65years), smoking, total cholesterol >200mg/dl, diabetes and family history of pre mature cardio vascular disease. [1],[2],[3],[4],[5],[6]
Assessment of target organ damage Left ventricular hypertrophy, proteinuria &/ plasma creatinine 1.2-2 mg/dl, Uss and radiological evidence of atherosclerotic plaque and generalized or focal narrowing of retinal arteries are important in assessment. [1],[2],[3],[4],[5],[6]
Educate the patient Explain the condition to the patient. Since treatment is lifelong establish effective communication with the patient and consider psychological status and preference treatments. [1],[2],[3],[4],[5],[6]
Stop smoking Smoking increases the cardiovascular risk. [1],[2],[3],[4],[5],[6]
Weight reduction Advise patients to maintain BMI < 25kg/m2. [1],[2],[3],[4],[5],[6]
Increase aerobic physical activity Advise to engage aerobic physical activity such as brisk walking at least 30 min per day, most days of the week. [1],[2],[3],[4],[5],[6]
Consume a healthy diet Advise toonsume a diet rich in vegetables and fruits with low salt and low saturated fat. [1],[2],[3],[4],[5],[6]
References
  1. GOFFREDO FILHO GS, LOPES CDE S, FAERSTEIN E. Does the previous diagnosis of arterial hypertension affect one s daily life? Pro-Saude Study. Rev Bras Epidemiol [online] 2013 Dec, 16(4):860-71 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24896591
  2. CLEMENT FM, CHEN G, KHAN N, TU K, CAMPBELL NR, SMITH M, QUAN H, HEMMELGARN BR, MCALISTER FA, HYPERTENSION OUTCOME AND SURVEILLANCE TEAM. Primary care physician visits by patients with incident hypertension. Can J Cardiol [online] 2014 Jun, 30(6):653-60 [viewed 23 June 2014] Available from: doi:10.1016/j.cjca.2014.03.033
  3. PETRIZ BA, FRANCO OL. Effects of Hypertension and Exercise on Cardiac Proteome Remodelling. Biomed Res Int [online] 2014:634132 [viewed 23 June 2014] Available from: doi:10.1155/2014/634132
  4. MENDES TDE A, GOLDBAUM M, SEGRI NJ, BARROS MB, CéSAR CL, CARANDINA L. Factors associated with the prevalence of hypertension and control practices among elderly residents of São Paulo city, Brazil. Cad Saude Publica [online] 2013 Nov, 29(11):2275-86 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24233042
  5. WEE LE, WONG J, CHIN RT, LIN ZY, GOH DE, VIJAKUMAR K, VONG KY, TAY WL, LIM HT, KOH GC. Hypertension management and lifestyle changes following screening for hypertension in an Asian low socioeconomic status community: a prospective study. Ann Acad Med Singapore [online] 2013 Sep, 42(9):451-65 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24162320
  6. Clinical management of primary hypertension.Quick Reference Guide. National Institute for Health and Clinical Excellence. 2011, August. [viewed 25 June 2014] Available from: www.nice.org.uk/guidance/CG127.

Management - Specific Treatments

Fact Explanation
Considering the associated clinical conditions establish target blood pressure control. Target BP for uncomplicated hypertension is <140/90mmHg. For patients with diabetes, renal failure and heart failure target BP is <130/80mmHg. For patients with Renal failure with proteinuria >1g/24hrs target BP is < 125/75 mmHg. [1],[2],[3],[4],[5]
Initiate drug therapy. The initiation of antihypertensive therapy in subjects with sustained systolic BP >= 160mmHg, or sustained diastolic BP >=100mmHg. Decide on treatment in subjects with sustained systolic BP between 140-159mmHg, or sustained diastolic BP is between 90-99mmHg, according to the presence or absence of target organ damage or 10 year cardiovascular risk >20%. In patients with diabetes mellitus, the initiation of antihypertensive drug therapy if systolic BP is sustained >=140mmHg or diastolic BP is sustained >=90mmHg. [1],[2],[3],[4],[5]
Selection of drugs. Diuretics, Beta-blockers, ACE inhibitors, Angiotensin II receptor antagonists, Calcium channel blockers and Alpha blockers are principal drug classes in management of hypertension. All six classes of antihypertensives are suitable in initiation. Important difference is in side effects of them. Start with lowest dose of the drug. If not controlled ; increase the dose provided no side effects. If side effects are common with higher doses, add a low dose second drug. If no effect or poor tolerability of low dose first drug , change to a different class. Long acting therapy is preferred because of 24 hour BP control. [1],[2],[3],[4],[5]
Step 1 For a uncomplicated, otherwise healthy Caucasian patient younger than 55 years 1st line drug is ACE inhibitor (If an ACE inhibitor is not tolerated, an angiotensin receptor agonist). For a uncomplicated, otherwise healthy Caucasian patient older than 55 years or a black patient (African or Caribbean descent and not mixed race, Asian Or Chinese patients) of any age the 1st line drug is a calcium channel blocker. [5]
Step 2 If step 1 does not achieve BP control, combine ACE inhibitor (or angiotensin receptor agonist) with a calcium channel blocker. [5]
Step 3 If step 2 does not achieve BP control, combine a thiazide diuretic with ACE inhibitor (or angiotensin receptor agonist) and a calcium channel blocker.[5]
Step 4 If step 3 does not achieve BP control, add further diuretic therapy or a alpha blocker or a beta blocker. Must consider seeking expert advice. [5]
Anti platelet therapy. Antiplatelet therapy with aspirin reduce fatal and nonfatal coronary events. It also reduce stroke and cardiovascular deaths. [1],[2],[3],[4],[5]
Lipid lowering therapy. Lipid lowering therapy with Statins reduce cardiovascular events and strokes. [1],[2],[3],[4],[5]
Management of severe or malignant hypertension. Patients with of severe or malignant hypertension, hypertensive encephalopathy or with severe hypertensive complications Should be admitted to hospital for immediate initiation of treatment. The aim is to reduce diastolic BP to 100-110 mmHg over 24-48 hours. This is achieved with oral medication Ex: Atenolol or amlodipine. The BP can be normalized over next 2-3 Days. [1],[2],[3],[4],[5]
Management of secondary causes: Phaeochromocytoma Tumor should be removed if possible. The medical preoperative and perioperative treatment is vital and includes completes alpha and beta blockade with phenoxy benzamine. When surgery is not possible combined alpha and beta blockade can be used for long term. [1],[2],[3],[4],[5]
Management of secondary causes.: Primary hyperaldosteronism. An adenoma can be removed surgically- usually laparoscopically. Those with hyperplasia should be treated with aldosterone antagonist, Spironolactone. [1],[2],[3],[4],[5]
Management of secondary causes. 3. Acromegaly Trans sphenoidal surgery is the appropriate 1st line therapy. In medical therapy somatostatin receptor agonists, dopamine agonists and growth hormone antagonists are used. [1],[2],[3],[4],[5]
Management of secondary causes. 4.Hyperthyroidism Three possibilities are available: antithyroid drugs, radio iodide and surgery. [1],[2],[3],[4],[5]
Management of secondary causes. 5. Cushing's syndrome The usual drug is metyrapone, an 11beta-hydroxylase blocker. Ketoconazole is also used with metyrapone. [1],[2],[3],[4],[5]
References
  1. LAUBSCHER T, REGIER L, STONE S. Hypertension in the elderly: new blood pressure targets and prescribing tips. Can Fam Physician [online] 2014 May, 60(5):453-6 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24829009
  2. MENDES LV, LUIZA VL, CAMPOS MR. [Rational use of medicines by individuals with diabetes mellitus and arterial hypertension in the municipality of Rio de Janeiro, Brazil]. Cien Saude Colet [online] 2014 Jun, 19(6):1673-84 [viewed 23 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24897469
  3. SCHULTZ M, AKSNES TA, HøIEGGEN A, KJELDSEN SE. [Choice of drug in hypertension]. Tidsskr Nor Laegeforen [online] 2013 Sep 17, 133(17):1802-3 [viewed 23 June 2014] Available from: doi:10.4045/tidsskr.13.0311
  4. CONEN D. Antihypertensive treatment - navigating between cost, compliance and complications. Swiss Med Wkly [online] 2013 Oct 25:w13857 [viewed 23 June 2014] Available from: doi:10.4414/smw.2013.13857
  5. Clinical management of primary hypertension.Quick Reference Guide. National Institute for Health and Clinical Excellence. 2011, August. [viewed 25 June 2014] Available from: www.nice.org.uk/guidance/CG127.