MANAGEMENT OF

HYPERTENSION
AFFAN SYAFIQI | NURUL HUSNA | AUDI RAHMAN
 INTRODUCTION
 Hypertension is defined as persistent elevation of systolic BP of 140
mmHg or greater and/or diastolic BP of 90 mmHg or greater
 The National Health and Morbidity Survey (NHMS) 2011 has shown
that the prevalence of hypertension in Malaysia for adults ≥18 years
has increased from 32.2% in 2006 to 32.7%in 2011.
 For those >30 years old, the prevalence has increased from 42.6% to
43.5%
 About 60.6% of total hypertensive were “undiagnosed”
 Hence BP should be measured at every opportunity. No significant
difference between gender was observed
 In terms of the main ethnic groups, the Bumiputra from Sabah &
Sarawak have the highest prevalence at 36.4%, followed by the Malays
at 34.0%, Chinese at 32.3% and lastly the Indians at 30.6%
 RISK FACTORS
 Cardiovascular disease
 Diabetes mellitus
 Chronic kidney disease
 Central obesity (37 %)
 Hypercholesterolemia (24%)
 Hyperglycaemia (15 %)
 Smoking
 Too much salt diet
 Alcohol
 Physically inactive
 Stress
CLASSIFICATION
 CLASSIFICATION
I S O L AT E D S Y S TO L I C H Y P E R T E N S I O N
 Defined as SBP of ≥140 mmHg and DBP <90mmHg
 It is common after the age of 50, and carries with it a poor prognosis
 Clinical trials have demonstrated that control of ISH reduces total mortality,
cardiovascular mortality, stroke and heart failure events
 Changing patterns of BP occur with increasing age

I S O L AT E D O F F I C E ( “ w h i t e - c o a t ” ) H Y P E R T E N S I O N
 Isolated office hypertension is characterised by an elevation in clinic blood
pressure but normal home or ambulatory blood-pressure values
 In these subjects the clinic BP is persistently above 140/90 mmHg but the
home or 24-hour ambulatory systolic diastolic BP measurements are lower
than 130/80 mmHg
 It is still debatable whether isolated office hypertension is an innocent
phenomenon or whether it carries an increased cardiovascular risk
 CLASSIFICATION

MASKED HYPERTENSION
 Patients with masked hypertension have normal clinic blood pressure but
elevated 24-hour ambulatory or home blood-pressure load (≥135/85 mmHg)
 Prognosis of masked hypertension is worse than isolated office hypertension
 DIAGNOSIS &
ASSESSMENT
Evaluation of patients with documented hypertension has three
objectives:

1. To exclude secondary causes of hypertension

2. To ascertain the presence of target organ damage or
complication
3. To assess lifestyle and identify other CVS factors or co existing
condition that affect prognosis and guide treatment
 HISTORY TAKING
 Duration and level of elevated BP if known
 Symptoms of secondary causes of hypertension
 Symptoms of target organ complications (i.e. renal failure
and heart failure)
 Symptoms of cardiovascular disease (e.g. CHD and
cerebrovascular disease)
 Symptoms of concomitant disease that will affect prognosis
or treatment (e.g. diabetes mellitus, heart failure, renal disease
and gout)
 Family history of hypertension, CHD, stroke, diabetes, renal
disease or dyslipidaemia
 HISTORY TAKING
 Dietary history including salt, caffeine, liquorice and alcohol
intake
 Drug history of either prescribed or over-the-counter
medication (NSAIDs, nasal decongestants) and traditional or
complementary medicine treatment
 Lifestyle and environmental factors that will affect treatment
and outcome (e.g. smoking, physical activity, work stress and
excessive weight gain since childhood)
 Presence of snoring and or day time somnolence which may
indicate sleep apnoea
PHYSICAL EXAMINATION

 General examination including height, weight and waist

circumference
 Two or more BP measurements separated by 1-2 minutes with
the patient either supine or seated; and after standing for at least
one minute
 Take standing BP at 2 minutes and again at 5 minutes in the
elderly, diabetics and other conditions where postural
hypotension is frequent or suspected
 Measure BP on both arms
 Fundoscopy
PHYSICAL EXAMINATION
 Examination for carotid bruit, abdominal bruit, presence of
peripheral pulses and radio-femoral delay
 Cardiac examination
 Abdominal examination for renal masses and bruit, aortic
aneurysm and abdominal obesity
 Neurological examination to look for evidence of stroke
 Signs of endocrine disorders (e.g. Cushing syndrome,
acromegaly and thyroid disease)
 Ankle brachial index (where available)
SECONDARY CAUSES OF
HYPERTENSION
 TARGET ORGAN
COMPLICATION (TOC)
CONCOMITANT CVS RISK
FACTORS
 INVESTIGATIONS
The minimum initial investigation aim to screen for presence of
secondary causes of hypertension, determine the presence of CV
risk factors, target organ damage and target organ complication.
Should include:

 Urinalysis (dipstick; proteinuria and microscopic hematuria)

 Renal function test (creatinine, GFR, serum electrolytes)
 Blood glucose
 Lipid profile (total cholestrol, HDL, LDL abd trigelycerides)
 ECG
MANAGEMENT
NON PHARMACOLOGICAL MANAGEMENT

PHARMACOLOGICAL MANAGEMENT

TYPES OF ANTIHYPERTENSIVE AGENTS

NON-PHARMACOLOGICAL
MANAGEMENT
WEIGHT REDUCTION
SODIUM INTAKE
ALCOHOL CONSUMPTION
REGULAR PHYSICAL ACTIVITY
HEALTHY EATING
CESSATION OF SMOKING
RELAXATION THERAPY
DIETARY POTASSIUM INTAKE
OTHERS
 PHARMACOLOGICAL
MANAGEMENT

 Decision to initiate
pharmacologic treatment
depends on the global
cardiovascular risk
 It is the reduction of BP
which provides the main
benefits in the general
hypertensive population
 PHARMACOLOGICAL
MANAGEMENT
C H O O S I N G A N T I H Y P E R T E N S I V E D R U G T R E AT M E N T

 Newly diagnosed uncomplicated hypertension patient with no

compelling indications, choice of first line monotherapy
includes ACEIs, ARBs, CCBs and diuretics
 Based on recent meta-analyses have suggested B-blockers can
be given as first line agent
 Almost all guidelines recommend that B-blockers should be
considered in younger patients in particular:
i. Those with an intolerance or contraindication to ACEIs
and ARBs or
ii. Women of child-bearing potential or
iii. Patients with evidence of increased sympathetic drive
 PHARMACOLOGICAL
MANAGEMENT
S TA G E I H Y P E R T E N S I O N

 Monotherapy at low dose

 It can lower BP to <140/90 mmHg in 20-50% of patients with
mild to moderate hypertension
 If after a sufficient period of treatment (up to 6 weeks) is still
not controlled, 3 options are available:
i. The dose of the initial drug can be increased
ii. The drug can be substituted with another class of drug
iii. A second drug can be added
CHOICES OF COMBINATION
THERAPY
CHOICES OF COMBINATION
THERAPY
 PHARMACOLOGICAL
MANAGEMENT
S TA G E I I H Y P E R T E N S I O N o r B E YO N D

 Combination therapy as first line is recommended

 Combination therapy can be considered as first line in high risk
hypertension especially for secondary prevention

S I N G L E P I L L C O M B I N AT I O N S ( S P C )

 Very convenient to use and promote treatment adherence by

reducing pill burden & simplifying the treatment regimen
 It takes less time to achieve BP control using a combination than
monotherapy
 However, generic SPC are generally not available in Malaysia but
patented SPC are available (and more expensive)
 PHARMACOLOGICAL
MANAGEMENT
TA R G E T B L O O D P R E S S U R E

AGE TARGET
<80 years old <140 mmHg / <90 mmHg
>80 years old <150/90 mmHg
High/very high risk individuals <130/80 mmHg

If BP is still >140/90 mmHg with 3 drugs, need to exclude

medication non-adherence and isolated office hypertension
After exclusion, patient is the defined as resistant
hypertension
 FOLLOW-UP VISIT
 Follow up intervals should be individualized based on:
i. Global CV risk ADVISABLE TO BRING THE
ii. Pre treatment BP levels BP TO TARGET WITHIN
PERIOD
iii. Drugs used
High and very high risk patient 3 – 6 months
Once target BP is achieved 3 – 6 months

 Once BP is controlled, most patients will require life-long

treatment
 Even BP is control, 6 monthly follow up must be counseled.
During the visits, doctor should assess:
i. Persistence of BP control
ii. Adverse reaction to treatment
iii. Global vascular risk
iv. Complication of hypertension
 WHEN TO REFER?
Indications for referral to the appropriate specialists include:

i. Severe hypertension (>180/110 mmHg)

ii. Suspected secondary hypertension
iii. Resistant and refractory hypertension
iv. Recent onset target organ damage
v. Pregnancy
vi. Office hypertension with additional CV risk
vii. Children and adults <30 years
viii. Secondary prevention with multiple co-morbidities/risk
factors
TYPES OF ANTIHYPERTENSIVE
AGENTS

RENIN-ANGIOTENSIN-SYSTEM (RAS) BLOCKER

CALCIUM CHANNEL BLOCKERS
DIURETICS
BETA - BLOCKERS
MISCELLANEOUS DRUGS
RENIN-ANGITENSIN-SYSTEM (RAS)
BLOCKERS

ACE INHIBITORS (ACEIs)

 Effective antihypertensive agents which can lower
cardiovascular risk, reducing mortality and morbidity
 More effective at preventing coronary artery disease
 It is generally well tolerated and do not have adverse effects
on lipid and glucose metabolism
 Good safety profile
 Adverse effect include cough and rarely angioedema
 Contraindicated in pregnancy and breast feeding
RENIN-ANGITENSIN-SYSTEM (RAS)
BLOCKERS

ACE INHIBITORS (ACEIs)

RENIN-ANGITENSIN-SYSTEM (RAS)
BLOCKERS

ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)

 Specifically block angiotensin II receptors
 ARBs are recommended for risk reduction in ACEI intolerant
patients
 They are effective in preventing progression of diabetic
nephropathy and reduce the incidence of major cardiac
events in heart failure patient
 The safety profile of ARB is very similar to ACEI except for a
lower incidence of cough
RENIN-ANGITENSIN-SYSTEM (RAS)
BLOCKERS

ANGIOTENSIN RECEPTOR BLOCKERS (ARBs)

RENIN-ANGITENSIN-SYSTEM (RAS)
BLOCKERS
CALCIUM CHANNEL BLOCKERS

 The main mechanism of action is vasodilation

 Certain subtypes of dihydropyridine (DHP) CCBs, e.g. T type
CCBs have been shown to dilate both afferent and efferent
arterioles which may play a role in prevention of kidney
damage and preservation of renal function
 In view of the effective BP lowering property and excellent
safety profile, CCBs especially DHP type have been
recommended as first line antihypertensive agents
CALCIUM CHANNEL BLOCKERS
 DIURETICS
 Specifically thiazide diuretics, have been the mainstay of
hypertension treatment, alone or in combination with other
anti-hypertensive agents
 Works via inducing natriuresis which alter long term sodium
balance
 Leading to reduced peripheral resistance and sustained the
blood pressure reduction
 Can be classified into:
I. Thiazide (hydrochlorothiazide (HCTZ))
II. Thiazide-like diuretics (chlorthalidone (CTD), indapamide)
DIURETICS
 BETA - BLOCKERS
 Particularly useful in hypertensive patients with effort
angina, tachyarrhythmias or previous myocardial infarction
where they have been shown to reduce cardiovascular
morbidity and mortality
 Absolute contraindicated in patients with uncontrolled
asthma and relatively contraindicated in other forms of
obstructive airways disease as well as in patients with severe
peripheral vascular disease and heart block (2nd and 3rd
degree)
 Adverse effect reported include dyslipidemia, masking of
hypoglycemia, and increase incidence of new onset diabetes
mellitus, erectile dysfunction and others
BETA - BLOCKERS
 SEVERE HYPERTENSION

 Defined as persistent elevated SBP >180 mmHg and/or

DBP >110 mmHg
 These patients may present with:
i. Incidental finding in an asymptomatic non-
previously diagnosed patient
ii. Treated hypertension on follow-up who are
asymptomatic
 SEVERE HYPERTENSION
iii. Patients with symptoms which may include:
 Non-specific symptoms
• Headache, dizziness, lethargy
 Symptoms and signs of acute target organ
damage/complication
• Acute heart failure
• Acute coronary syndromes
• Acute renal failure
• Dissecting aneurysm
• Subarachnoid haemorrhage
• Hypertensive encephalopathy
• Preeclampsia/eclampsia
HYPERTENSIVE CRISES
Categories into 2 types:

1. HYPERTENSIVE URGENCIES
2. HYPERTENSIVE EMERGENCIES

 In a recent large series, only a minority of patients

admitted (5.1%) had hypertensive crises.
 Of those, more than three quarters (76.6%)
constitute hypertensive emergencies
 COMMON CAUSES OF
SEVERE HYPERTENSION
SPECIFIC MANAGEMENT
Aim of management is:
1. To reduce BP in a controlled, predictable and safe
manner
2. To avoid provoking or aggravating acute coronary
syndrome, cerebral or renal ischaemia

HYPERTENSIVE URGENCIES
HYPERTENSIVE EMERGENCIES
 HYPERTENSIVE
URGENCIES
 Defined as severe increase in BP which is not
associated with acute end organ
damage/complication and these include patients with:
• Grade III or IV retinal changes (also known as accelerated
and malignant hypertension)
 Precipitating factors for hypertensive urgency include
non-adherence to anti-hypertensive medications,
less effective outpatient blood pressure control,
acute pain, herbal supplement and emotional stress
 MANAGEMENT
 Initial treatment should aim for about 25% reduction in
BP over 24 hours but not lower than 160/100 mmHg.
 Therapeutic strategies for previously undiagnosed
patients include:
i. Rest in quiet room for at least 2 hours
ii. Initiate oral anti-hypertensive agents if BP remains
>180/110 mmHg
iii. Hypertensive urgency discharge plan
 In hypertensive urgencies, aim for 10-20 mmHg SBP
reduction after 2 hours of rest
 Failing this, pharmacotherapy should be initiated
 MANAGEMENT
Initiate oral anti-hypertensive agents if BP remains >180/110 mmHg

Treat hypertensive urgencies with combination oral

therapy targeting BP to reduce by around 25% within 24
hours.
HPT URGENCY DISCHARGE PLAN
HYPERTENSIVE EMERGENCY
 Severe elevation of blood pressure associated with
new or progressive end organ damage/complication
such as acute heart failure, dissecting aneurysm,
acute coronary syndromes, hypertensive
encephalopathy, acute renal failure, subarachnoid
haemorrhage and/or intracranial haemorrhage

 These may occur in patients with BP <180/110

mmHg, particularly if the BP has risen rapidly
 MANAGEMENT
• Should be admitted for immediate intervention and
monitoring.
• Need to be reduce their BP rapidly based on clinical
scenarios.
• Should have their BP reduced by 10%-25% within
certain minutes to hours but not lower than 160/90
mmHg.
• This is best achieved with parenteral drugs
 MANAGEMENT
 The selection of an antihypertensive agent should be
based on the drug’s pharmacology, pathophysiological
factors underlying the patient’s hypertension, degree of
progression of target organ damage, the desirable rate
of BP decline, and the presence of comorbidities

 The therapeutic goal is to minimise target organ damage

safely by rapid recognition of the problem and early
initiation of appropriate antihypertensive treatment
Reduce SBP by no more than 25% within the first hour;
then, if stable, to 160/100 mmHg within the next 2 to 6
hours; and then cautiously to normal during the
following 24 to 48 hours in all other situations.
DANGERS OF RAPID REDUCTION IN
BLOOD PRESSURE

Rapid reduction of BP (within minutes to hours)

in hypertensive urgencies should be avoided as
it may precipitate ischaemic events occur in
vascular beds that have grown accustomed to
the higher level of blood pressure (i.e.,
autoregulation)
 AUTOREGULATION OF
CEREBROVASCULAR RESISTANCE
HYPERTENSION IN
SPECIAL GROUP
 DIABETES MELLITUS
 In 2016 the prevalence of hypertension in Malaysian
diabetics was 76%.
 Pharmacological treatment should be initiated in patients
with diabetes when the BP is persistently ≥140 mmHg
systolic and/or ≥90 mmHg diastolic.
 The presence of microalbuminuria or overt proteinuria
should be treated even if the BP is <140/90 mmHg.
 microalbuminuria may be normalised by high doses of
ACEI or ARBs.
 Normalisation of microalbuminuria is associated with a
reduction in the rate of decline in glomerular filtration
rate.
 NON-DIABETIC CKD
 In hypertension in CKD, control of BP and proteinuria are
the most important factors in terms of retarding CKD
progression.
 BP goals depend on urinary protein excretion.
 The target BP should be <140/90 mmHg for patients
with CKD and <130/80 mmHg for those with proteinuria
≥1g/24hours.
 Choose RAS blockers as initial antihypertensive therapy
for patients with micro- or macroalbuminuria.
 Consider concurrent diuretic therapy and dietary salt
restriction as salt and water retention are important
determinants of hypertension in CKD.
 Add non-dihydropyridine CCBs if BP goal is still not
achieved and there is persistent proteinuria.
CORONARY HEART DISEASE
 The blood pressure target in patients with hypertension
and CHD is <130 / <80 mmHg.
 Clinical studies have also shown that coronary events in
hypertensive patients with CHD are reduced in those
whose blood pressure is controlled.
 Following any coronary event, patients will be at high
risk of subsequent events, especially if the
hypertension is not controlled.
 Cardio-selective ß-blockers are preferred. In CHD
patients with symptomatic & stable angina, the
treatment of choice should be a ß-blocker or a CCB.
 HEART FAILURE

 Chronic, uncontrolled hypertension can cause heart

failure with reduced ejection fraction.
 ACE inhibitors and ß-blockers are recommended for
initial therapy. ß-blockers are contraindicated in the
presence of acute heart failure.
 Treat blood pressure to <140 / <90 mmHg
 ATRIAL FIBRILLATION

 Hypertension further increases the risks of stroke and

arterial embolism in patients with chronic atrial
fibrillation.
 For elderly patients (>75 years old) who are on
anticoagulation for atrial fibrillation, both ACEI and ARB
reduce mortality.
 For rate-control of permanent atrial fibrillation, ß-
blockers or non-dihydropyridine CCBs (verapamil and
diltiazem) should be considered.
 The blood pressure target is <140/90 mmHg
 PERIPHERAL ARTERIAL
DISEASE (PAD)
 Hypertension and peripheral arterial disease (PAD) can co-
exist.
 2-5% of patients with hypertension have intermittent
claudication and 25-55% of patients with peripheral arterial
disease present with hypertension.
 The aim of treatment in PAD is both symptom relief and
prevention of cardiovascular events.
 There is no consensus on the treatment of choice for
hypertensive patients with PAD. However, in major trials
showed benefits of ACEI in patients with PAD.
 ß-blockers may cause vasoconstriction and worsen
frequency of intermittent claudication.
 The blood pressure target is <140/90 mmHg
 LEFT VENTRICULAR
HYPERTROPHY (LVH)
 Left Ventricular hypertrophy is caused by pressure load
and often regresses through long-term antihypertensive
treatment.
 The most important factor in the regression of cardiac
hypertrophy is good BP control.
 Regression of LVH can be achieved by all antihypertensive
drugs and also by weight reduction and salt restriction.
 ARBs are preferred in hypertension with LVH.
 Target BP <130/80 mmHg.
 STROKE
 Hypertension is the most important modifiable risk
factor for ischaemic stroke (IS) and haemorrhagic stroke
(HS).
 Consider aggressive reduction of BP in HS patients
presenting with SBP >220mmHg with continuous
intravenous infusion of antihypertensive and frequent
BP
 monitoring
 Lower BP to <130/80 mmHg for secondary prevention in
lacunar stroke.