Oxford Hypertension

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OXFORD MEDICAL PUBLICATIONS
Hypertension
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Hypertension
Joseph Cheriyan
Consultant Physician and Clinical Pharmacologist,
Clinical Pharmacology Unit,
University of Cambridge,
Cambridge, UK
Carmel M. McEniery
Senior Research Associate,
Cambridge, UK
Ian B. Wilkinson
Senior Lecturer,
Honorary Consultant Physician and
Clinical Pharmacologist,
Cambridge, UK
1
1
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v
Foreword
Hypertension has been recognized as an important cardiovascular dis-

order since Korotkoff’s invention in 1905 of the auscultatory method for
sphygmomanometric measurement of arterial pressure. Since then hyper-
tension has reached pandemic proportions in both the developed and
developing nations of the world. The abundant accumulation of knowledge
pertaining to hypertensive cardiovascular disease has resulted in a series of
comprehensive textbooks that tend to have short shelf-lives because of
outdated information. To counter this problem, publishers have gone to
the handbook format—short, how-to-books with rapid publication times
and frequent updates. Unfortunately, many of these practical books that
stress brevity have lacked the depth of knowledge necessary to attract
the experienced clinician as well as the physician-in-training; the present
handbook of hypertension does not suffer from this defect.
Indeed, this book has an excellent balance of pathophysiologic under-
pinning and a practical, algorithmic approach to diagnosis, prognosis and
treatment. There are numerous illustrations, flow-diagrams, and bullet
summaries that integrate information in a useful manner—all with salient
but limited references. I am particularly impressed with the detailed inves-
tigations for evaluating essential hypertension and diagnosing secondary
hypertension, which are included in this book, but frequently given short
shrift in standard textbooks. The authors have included up-to-date infor-
mation on monogenic hypertensive syndromes, special populations, and
on optimizing antihypertensive management. There is a novel, concluding
chapter, entitled ‘Hypertension in the 21st century.’ This contains con-
troversial topics dealing with prevention and risk assessment, and the
emerging concept of arterial stiffness as an independent determinant of
cardiovascular risk. Lastly, there is a glossary of clinical trials that make
up a considerable evidence-base for therapeutic decision making. The end
product is a well organized handbook that will have a wide readership and
satisfy both primary care physicians and specialists with a keen interest in
the field of hypertension.
Stanley S. Franklin, MD
Clinical Professor of Medicine
University of California, Irvine
USA
This page intentionally left blank
vii
Preface
Over the last 100 years there has been enormous progress in the field of
hypertension. However, hypertension remains a condition of paradoxes.
We now have simple automated sphygmomanometers, effective antihy-
pertensive drugs, complex risk calculators, and a wealth of trial data telling
us whom we should treat and with what. Although this has brought enor-
mous practical benefit for the majority, hypertension remains a common
disorder–—affecting up to a 1/3 of the adult population, and a major
cause of premature morbidity and mortality worldwide. Just when we
thought we understood the results of the latest major international trial,
another contradictory study is published. Painstaking physiological and
genetic research has identified potentially remediable causes of hyperten-
sion. However, for the vast majority, the cause remains elusive. Indeed,
to borrow a quote from Winston Churchill concerning Russia, essential
hypertension remains a ‘riddle wrapped in a mystery inside an enigma’.
In writing a book, there is a fine line between producing a lengthy, com-
prehensive textbook, containing all we ever knew about hypertension,
which occupies yards of bookshelves and is rarely opened, and a brief
guide that is ultimately too superficial and fails to answer key questions
or provide supporting evidence. The aim of this book is to provide a
practical, user-friendly guide for those individuals managing hypertensive
patients in the 21st century. Although a key feature is brevity, our inten-
tion is to provide sufficient depth for even the most experienced clini-
cian, in a clearly laid-out style, and with a wealth of illustrations. The book
progresses from our current understanding about the mechanisms of
hypertension, through diagnosis, investigations, and management, as well
as a review of the current evidence base. Key references are provided,
as are practical tips on interpreting specialist investigations and using
antihypertensive drugs. We hope the reader will find this a useful and
practical book in their routine management of this important and common
condition.
Joseph Cheriyan
Carmel M. McEniery
Ian B. Wilkinson
ix
Acknowledgements
We wish to acknowledge the kind foreword by Professor Stanley S. Franklin

and for the constructive guidance provided by Professor James Ritter. We
would also like to thank Dr Kevin O’Shaughnessy (in particular for his
help with the genetics chapter), Dr Khin Swe Myint and Dr Timothy
Burton for their help with the illustrations and with the general content
of this handbook.
Joseph Cheriyan
Carmel M. McEniery
Ian B. Wilkinson
xi
Contents
Detailed contents xiii

Symbols and abbreviations xix
1 Aetiology and pathophysiology 1

2 Essential hypertension 49
3 Specific investigations for secondary hypertension 111
4 Secondary hypertension 135
5 Monogenic syndromes 169
6 Special populations 183
7 Antihypertensive drugs 211
8 Hypertension in the 21st century 239
Index 305
xiii
Detailed contents
Symbols and abbreviations xix
1 Aetiology and pathophysiology 1

Haemodynamics 2
Haemodynamics in hypertension 4
Central versus peripheral blood pressure 6
Physiology and pathophysiology of blood pressure regulation 8
Role of the autonomic nervous system 10
Role of the kidneys 16
Interplay between autonomic and renal mechanisms 20
Vascular structure and function in essential hypertension 22
Large arteries 26
Genetics of essential hypertension 28
Environmental influences on blood pressure 30
Physical activity 34
Diet 36
Salt intake 38
Potassium intake 40
Alcohol 41
Stress 42
Obesity 44
Experimental models of hypertension 46
2 Essential hypertension 49
Background
Prevalence and incidence 50
Isolated systolic hypertension 52
Systolic /diastolic hypertension 58
Isolated diastolic hypertension 59
Assessment
History 60
Examination 62
xiv DETAILED CONTENTS
Blood pressure measurement 64

Assessing end-organ damage 66
Investigations in hypertension 68
Biochemistry
Basic biochemistry 70
Renin and aldosterone 72
Dipstick urinalysis 73
Physiological measurements
Electrocardiography 74
Home blood pressure 78
24-hour ambulatory blood pressure monitoring 80
Echocardiography 83
Management
Prognosis and risk stratification 84
Non-pharmacological management
Non-pharmacological management: background 88
Salt 90
Dietary intervention, weight loss, and exercise 92
Alcohol 94
Other methods 97
Pharmacological management
Pharmacological management: background 98
Compliance 99
Stepped care versus combination therapy 100
Targets and evidence basis 101
Treatment algorithms 102
Resistant hypertension 106
Hypertensive emergencies 108
3 Specific investigations for secondary hypertension 111

Introduction 112
Phaeochromocytoma
Urine catecholamines and metanephrines 114
Plasma catecholamines and metanephrines 116
Dynamic testing 118
Clonidine suppression test 120
Pentolinium suppression test 121
DETAILED CONTENTS xv
Conn’s syndrome
Fludrocortisone suppression test 122
Saline suppression test 122
Imaging
Computed tomography 123
Magnetic resonance imaging 124
Nuclear medicine: adrenal 126
Nuclear medicine: kidney 130
Interventional radiology 132
4 Secondary hypertension 135

Vascular
Co-arctation of the aorta 136
Renal artery stenosis 138
Endocrine
Hyperaldosteronism 144
Conn’s syndrome 148
Bilateral adrenal hyperplasia 150
Cushing’s syndrome 151
Phaeochromocytoma 152
Hyperparathyroidism 156
Hyperthyroidism 157
Renal
Renal parenchymal disease 158
Adult polycystic kidney disease 160
Renal tumours 162
Drugs
Liquorice 163
Alcohol 164
Oral contraceptive pill 165
Steroids 165
Non-steroidal anti-inflammatory drugs 166
Immunosuppressives 166
Vascular endothelial growth factor inhibitors 166
Monoamine oxidase inhibitors 167
Cocaine 168
Heavy metals 168
xvi DETAILED CONTENTS
5 Monogenic syndromes 169

Introduction 170
Pathophysiology 172
Apparent mineralocorticoid excess 174
Mineralocorticoid receptor-activating mutation 175
Gordon’s syndrome 176
Hypertensive congenital adrenal hyperplasia 177
Glucocorticoid remediable aldosteronism 178
Liddle’s syndrome 179
Bartter’s syndrome 180
Gitelman’s syndrome 182
6 Special populations 183

Pregnancy 184
Pregnancy: chronic hypertension 188
Pregnancy: gestational hypertension 189
Pregnancy: pre-eclampsia 190
Diabetes 196
The elderly 200
Children 204
Post-stroke 208
Transplant patients 210
7 Antihypertensive drugs 211

Angiotensin-converting enzyme inhibitors 212
Angiotensin receptor antagonists 214
Beta-blockers 216
Calcium-channel antagonists 218
Thiazide diuretics 222
Potassium-sparing diuretics 226
Aldosterone antagonists 228
Alpha-blockers 230
Renin inhibitors 232
Central sympatholytics 234
Sodium nitroprusside 235
Minoxidil 235
Hydralazine 236
DETAILED CONTENTS xvii
Nitrates 237
Other agents 238
8 Hypertension in the 21st century 239

Prevention 240
Cardiovascular risk assessment 241
Dilemmas in modern management 242
Emerging concepts: arterial stiffness 244
Useful websites 247
Clinical trials: a glossary 248
Index 305
xix
Symbols and abbreviations
b cross reference
M website
i increase/d
d decrease/d
p primary
s secondary
> greater than
< less than
~ approximately
2D two-dimensional
3D three-dimensional
ABPM ambulatory blood pressure monitoring
ACE angiotensin-converting enzyme
ACEI angiotensin-converting enzyme inhibitor
ACTH adrenocorticotrophic hormone
AF atrial fibrillation
AGE advanced glycation end products
ALLHAT Antihypertensive and Lipid Lowering Treatment to Prevent
Heart Attack Trial
ALT alanine aminotransferase
AME apparent mineralocorticoid excess
ANA antinuclear antibodies
ANCA anti-neutrophilic cytoplasmic antibody
ARA angiotensin receptor antagonist
ARR aldosterone:renin ratio
ASCOT Anglo-Scandinavian Cardiac Outcomes Trial
AST aspartate aminotranferase
AVS adrenal vein sampling
BAH bilateral adrenal hyperplasia
BD twice a day
BHS British Hypertension Society
BMI body mass index
BP blood pressure
CAH congenital adrenal hyperplasia
CCA calcium-channel antagonist
xx SUBJECT OF
SYMBOLS ANDTHIS
ABBREVIATIONS
PAGE
CHD coronary heart disease

CNS central nervous system
COX cyclo-oxygenase
CRP C-reactive protein
CV cardiovascular
CVD cardiovascular disease
CXR chest X-ray
DASH Dietary Approaches to Stop Hypertension (trial)
DBP diastolic blood pressure
DCT distal convoluted tubule
DHBA dihydroxybenzylamine
DHP dihydropyridine
DMSA dimercaptosuccinic acid
DOC deoxycorticosterone
DTPA diethylene triamine pentacetic acid
ECG electrocardiogram
EDTA ethylenediamine tetraacetic acid
eGFR estimated glomerular filtration rate
ENaC epithelial sodium channel
EPO Erythropoietin
ESC European Society of Cardiology
ESH European Society of Hypertension
ESR erythrocyte sedimentation rate
ESRD end-stage renal disease
FBC full blood count
FDG F-18 fluorodeoxyglucose
F-DOPA 3,4-dihydroxy-6-fluoro-DL-phenylananine
FMD fibromuscular dysplasia
GBM glomerular basement membrane
GFR glomerular filtration rate
GRA glucocorticoid remediable aldosteronism
GTN glyceryl trinitrate
h hour/s
HCTZ hydrochlorothiazide
HDL high-density lipoprotein
HELLP haemolysis, elevated liver enzymes, and low platelets
HIAA hydroxyindoleacetic acid
HOCM hypertrophic obstructive cardiomyopathy
SYMBOLS
PRELIM
AND RUNNING
ABBREVIATIONS
HEAD xxi
HOT Hypertension Optimal Treatment (study)
HPLC-EChigh performance liquid chromatography electrochemical
HR hazard ratio
HYVET Hypertension in the Very Elderly Trial
IDH isolated diastolic hypertension
Ig immunoglobulin
ISH isolated systolic hypertension
ITU Intensive Therapy Unit
JBS Joint British Societies
JNC Joint National Committee on Prevention, Detection,
Evaluation and Treatment of High Blood Pressure
LCH Langerhans cell histiocytosis
LDH lactate dehydrogenase
LDL low-density lipoprotein
LFT liver function tests
LLA lipid-lowering arm
LVH left ventricular hypertrophy,
m metre/s
MAG mercapto-acetyl-triglycine
MAOI monoamine oxidase inhibitor
MAP mean arterial pressure
MEN multiple endocrine neoplasia
MI myocardial infarction
min Minute/s
MIBG meta-iodobenzylguanidine
MRI magnetic resonance imaging
NCCT NaCL co-transporter
NE noradrenaline/norepinephrine
NHANES National Health and Nutrition Examination Survey
NICE National Institute for Health and Clinical Excellence
NMN normetanephrine
NNT number needed to treat
NO nitric oxide
NSAID non-steroidal anti-inflammatory drug
OCP oral contraceptive pill
OD once a day
PHA2 pseudohypoaldosteronism type II
PIH pregnancy-induced hypertension
PO by mouth (per os)
xxii PRELIM RUNNING
SYMBOLS AND ABBREVIATIONS
HEAD
PPIH proteinuric pregnancy-induced hypertension

PTH parathyroid hormone
PVR peripheral vascular resistance
PWV pulse wave velocity
QDS 4 times a day
RAAS renin–angiotensin–aldosterone system
RCT randomized controlled trial
RR relative risk
s second/s
SBP systolic blood pressure
SDH systolic/diastolic hypertension
SHR spontaneously hypertensive rats
SIADH syndrome of inappropriate antidiuretic hormone
SPECT single photon emission computed tomography
SPRINT Systolic Blood Pressure Intervention Trial
t1/2 half life
TC total cholesterol
TDS 3 times a day
TED thromboembolic deterrent
TFT thyroid function test
TG triglyceride
TIA transient ischaemic attack
TOD target organ damage
TROPHY Trial of Preventing Hypertension
TSH thyroid-stimulating hormone
U&Es urea and electrolytes
USS ultrasound scan
VEGF vascular endothelial growth factor
VF ventricular fibrillation
VMA vanillylmandelic acid
VT ventricular tachycardia
WHO World Health Organization
Chapter 1 1
Aetiology and
pathophysiology
Haemodynamics 2
Haemodynamics in hypertension 4
Central versus peripheral blood pressure 6
Physiology and pathophysiology of blood pressure regulation 8
Role of the autonomic nervous system 10
Role of the kidneys 16
Interplay between autonomic and renal mechanisms 20
Vascular structure and function in essential hypertension 22
Large arteries 26
Genetics of essential hypertension 28
Environmental influences on blood pressure 30
Physical activity 34
Diet 36
Salt intake 38
Potassium intake 40
Alcohol 41
Stress 42
Obesity 44
Experimental models of hypertension 46
2 CHAPTER 1 Aetiology and pathophysiology
Haemodynamics
Basic haemodynamic concepts
Blood pressure (BP) is the force that the blood exerts on the vessel wall
and is continuously varying in arteries due to the intermittent nature of
the pump (heart) and elastic recoil of the arterial wall. Besides the simple
extremes of pressure, i.e. systolic and diastolic, there are 2 major physi-
ological components of the arterial BP (b Fig. 1.1):
• Static or ‘steady-state’: represented by the mean arterial pressure. The
sole determinants of the mean arterial pressure are cardiac output and
peripheral vascular resistance (PVR):
Mean pressure = cardiac output x PVR
• Pulsatile: represented by the pulse pressure (difference between
systolic and diastolic BP). The principal determinants of pulse pressure
are the stroke volume and the stiffness of the large arteries.
Cardiac
Stroke volume output
Pulse
pressure Mean
pressure
Arterial Peripheral
stiffness resistance
Fig. 1.1 Haemodynamic components of BP. Adapted with permission from Berne
RM et al. (2004). Physiology. Philadelphia, PA: Elsevier, with permission from Elsevier.
Haemodynamics in hypertension
Essential hypertension is characterized by derangements in 1 or more
of the physiological determinants of BP mentioned in b Basic haemo-
dynamic concepts, p.2 although the causal mechanisms remain contro-
versial. Interestingly, age exerts a marked influence on which component
becomes abnormal, and this corresponds closely to the form of essential
hypertension which is observed (b Fig. 1.2).
Adolescents and young adults (<30 years) with raised BP are often con-
sidered to have early, or borderline, hypertension. Here, the principal
haemodynamic disturbance is an i stroke volume, whereas PVR is rela-
tively normal. In keeping with this physiological profile, ISH is the predom-
inant form of hypertension observed in young individuals (b Table 1.1).
In contrast, in middle-aged individuals (~30–50 years), cardiac output is
normal or even reduced, but the dominant haemodynamic disturbance is
a markedly i PVR, which is most likely due to structural remodelling of the
resistance vasculature in response to continual exposure to higher pres-
sures. Isolated diastolic hypertension (IDH) or mixed (systolic/diastolic)
hypertension (SDH) are the predominant forms of hypertension observed
in these individuals. SDH is commonly viewed as the established or ‘clas-
sical’ form of essential hypertension.
In older adults (>50 years), ISH is again the predominant form of hyper-
tension. However, in contrast to the situation in younger individuals, arte-
rial stiffening is the principal haemodynamic disturbance. This causes an
exaggerated i in pulse pressure because the large arteries can no longer
effectively buffer the cyclical changes in BP during each cardiac cycle.
HAEMODYNAMICS IN HYPERTENSION 5
Frequency of hypertension (%) 100
80
60
40
20
0
30–39 40–49 50–59 60–69 70–79 80–89
Age (years)
Isolated systolic hypertension
Isolated diastolic hypertension
Diastolic and systolic hypertension
Fig. 1.2 Age-related frequency of different types of hypertension. Data from Sagie
A, et al. (1993). The natural history of borderline isolated systolic hypertension.
NEJM 329:1912–17.
Table 1.1 Age-related haemodynamic patterns underlying hypertension

Age Principal haemodynamic Predominant form of
disturbance hypertension
<30 years i stroke volume ISH
30–50 years i PVR IDH or SDH
>50 years i arterial stiffness ISH
Central versus peripheral blood

pressure
Moving from central (i.e. aorta) to peripheral (i.e. brachial) arteries, systolic
pressure i due to differences in vessel stiffness and wave reflections,
whereas mean and diastolic pressure fall by only 1–2mmHg (b Fig. 1.3).
This small fall in mean pressure causes blood to flow forwards, not back-
wards. The resultant widening or amplification of the pulse pressure—
which is more pronounced in younger individuals—means that BP assessed
at the brachial artery overestimates BP in the aorta and central arteries.
The difference between brachial and central BP is important because it is
the central pressure to which the heart, brain, and other major organs are
exposed, and certain drug therapies exert differential effects on peripheral
and central pressure. In addition, stratifying individuals by brachial pressure
reveals considerable overlap in aortic pressure (b Fig. 1.4), which holds
important implications for the future categorization of hypertension—if
central BP is more important in defining an individual’s risk and/or the
impact of therapy, then categories that are based on central rather than
peripheral pressure may be more useful.
Aorta Brachial
150
140
130
120 Younger
110
100
90
80
70
150
140
130
120
110 Older
100
90
80
70
Fig. 1.3 Amplification of BP between central and peripheral arteries.
CENTRAL VERSUS PERIPHERAL BLOOD PRESSURE 7
MALES
Stage 3
n=3603
180–189
Brachial systolic blood pressure (mmHg)
170–179
Stage 2
160–169
150–159
Stage 1
140–149
130–139 High-Normal
120–129 Normal
110–119
100–109 Optimal
80 100 120 140 160 180

Aortic systolic blood pressure (mmHg)
FEMALES
Stage 3
n=3176
180–189
Brachial systolic blood pressure (mmHg)
170–179
Stage 2
160–169
150–159
Stage 1
140–149
130–139 High-Normal
120–129 Normal
110–119
100–109 Optimal
80 100 120 140 160 180

Aortic systolic blood pressure (mmHg)
Fig. 1.4 Variation in aortic systolic pressure within categories of brachial systolic
pressure. Reproduced with permission from McEniery CM, et al. (2008). Central
pressure: variability and impact of cardiovascular risk factors. Hypertension
51:1476–82.
Physiology and pathophysiology of

blood pressure regulation
The causes underlying the haemodynamic changes observed in essential
hypertension remain controversial, although 2 hypotheses predominate.
The first is that neurally-mediated factors play a key role in the genesis
of raised BP, particularly in young individuals. Evidence of elevated sym-
pathetic nervous system activity (and inactivity of the parasympathetic
system) in individuals with mild or borderline essential hypertension
includes:
• i resting heart rate.
• i BP response to stimuli such as mental stress, exercise, or the cold
pressor test.
• i plasma catecholamine concentrations.
The second major hypothesis explaining the origins of essential hyperten-
sion concerns the role of the kidneys and their regulation of the physi-
ological balance between fluid and sodium retention/excretion. Three
major renal mechanisms leading to the development of hypertension have
been proposed:
• Glomerular filtration rate-dependent mechanisms.
• Transport mechanisms relating to sodium reabsorption.
• Mechanisms relating to renal ischaemia.
The roles of the sympathetic nervous system and renal mechanisms in the
physiological and pathophysiological regulation of BP will be discussed in
more detail in the rest of this chapter.
Role of the autonomic nervous system

Studies conducted in the 19th century demonstrated that stimulation of
peripheral sensory nerves elicited a transient elevation of BP, suggesting
that the central nervous system participated in the regulation of BP.
Further supporting evidence includes:
• Stressful stimuli (mental arithmetic, cold pressor test) induce a reflex i
in BP and heart rate.
• When autonomic drive is lowest (e.g. during sleep) there is a marked
reduction in BP and heart rate.
Indeed, tonic discharge from the central nervous system regulates periph-
eral BP via the release of noradrenaline from sympathetic nerve terminals,
acting on adrenergic receptors. In contrast, the parasympathetic nervous
system innervates target organs via the release of acetylcholine, acting on
muscarinic cholinergic receptors (b Fig. 1.5). Overall autonomic activity
is determined by the balance between sympathetic and parasympathetic
outflow.
Assessment of autonomic nervous system activity
There are a number of methods available to assess autonomic function and
the results from a large number of investigations utilizing these methods
provide good evidence that i sympathetic nervous system activity is a
common feature of individuals with essential hypertension and may even
be the initiating mechanism. Individuals exhibiting i sympathetic activity
tend to be younger (<40 years), and present with a so-called ‘hyperkinetic’
state, in which BP, heart rate, and cardiac output are raised—which is not
dissimilar to the defence response. Again, this haemodynamic profile is in
keeping with the observation that ISH, rather than SDH, is the predomi-
nant form of hypertension in younger individuals. Some individuals may
also have slightly elevated central arterial stiffness, again possibly due to
enhanced sympathetic activation.
Catecholamines (b Fig. 1.6)
Plasma and urinary catecholamine concentrations have been used as an
index for assessing sympathetic nervous system activity. However, cat-
echolamine concentrations measured in the plasma or urine depend not
only on the rate of production and release, but also on the rate of clear-
ance, and, as such, do not provide a very reliable representation of sympa-
thetic nerve activity.
Plasma concentrations of noradrenaline tend to be i in patients with
essential hypertension, although the effects are small. Interestingly, acute
stress transiently i plasma adrenaline levels and there is some evidence
to suggest that mild stressors may cause an exaggerated release of adren-
aline in hypertensive subjects whereas no such effects are observed in
normotensive individuals. This suggests that individuals with essential
hypertension may be more predisposed to the influence of external stres-
sors compared with their normotensive counterparts.
ROLE OF THE AUTONOMIC NERVOUS SYSTEM 11
Sympathetic Parasympathetic
nervous system nervous system
Preganglionic neuron
Acetylcholine
Acetylcholine
Postganglionic neuron
Noradrenaline Acetylcholine
αβ M
Fig. 1.5 Autonomic nervous system A refers to alpha adrenoceptors; B refers to
beta adrenoceptors; M refers to muscarinic cholinergic receptors.
TH AAD DBH PNMT

TYR DOPA DA NA ADR
Key
TYR = tyrosine
DOPA = 3,4, dihydroxyphenylalanine
DA = dopamine
NA = noradrenaline
ADR = adrenaline
TH = tyrosine hydroxylase
AAD = aromatic acid decarboxylase
DBH = dopamine-β-hydroxylase
PNMT = phenylethandamine methyltransferase
Fig. 1.6 Biosynthesis of catecholamines.
Noradrenaline spillover
‘Spillover studies’ measure the rate of noradrenaline entry from sympa-
thetic nerve terminals into plasma and provide a more robust measure
of sympathetic nerve activity than measurement of plasma concentrations
alone. Tritiated noradrenaline is infused at a constant rate, until a stable
arterial concentration is reached, which allows calculation of noradrena-
line spillover, clearance, and extraction ratios.
i noradrenaline spillover has been observed from the heart and kidneys
of hypertensive patients and average total spillover rates are i in patients
with essential hypertension up to ~60 years of age. In individuals >60
years, noradrenaline spillover rates tend to be similar to those in nor-
motensive individuals, providing further support for the hypothesis that
sympathetic nervous system activity plays an important role in the genesis
of hypertension in younger adults.
Microneurography
This technique provides a method of quantifying firing rates in sympathetic
nerves. Small electrodes are positioned in subcutaneous sympathetic
fibres (typically those of the common peroneal nerve).
The majority of microneurography studies show that nerve firing rates in
postganglionic sympathetic fibres passing to skeletal muscle blood vessels
are elevated in patients with borderline or mild essential hypertension
(b Fig. 1.7), and that as hypertension becomes more severe, muscle sym-
pathetic nerve activity i further.
Infusion of adrenergic agonists and antagonists
Adrenergic responsiveness can be assessed by measuring the BP response
to a systemic infusion of noradrenaline. However, such responses
are affected by endogenous noradrenaline levels, the starting BP and
baroreflex sensitivity (b see Arterial baroreceptors, p.14). Local (non-
systemic) infusions into the brachial artery provide a more precise indi-
cation of vascular reactivity. Infusion of adrenergic antagonists can also
provide useful information concerning sympathetic activity.
Infusion of propranolol in patients with borderline hypertension reduces
cardiac index and heart rate significantly more than in normotensive
individuals, indicating i beta-adrenergic drive in patients, although cardiac
index and heart rate are not normalized (b Fig. 1.8A). However, addi-
tional parasympathetic blockade with atropine normalizes cardiac index
and heart rate in hypertensives (b Fig. 1.8B), although the rise in
both indices is less marked, consistent with reduced parasympathetic
inhibition.
Normotensive Borderline hypertensive

subject subject
Low sodium
5sec
High sodium
Fig. 1.7 Diagram depicting microneurography tracings. Reproduced with permis-
sion from Anderson EA, et al. (1989). Elevated sympathetic nerve activity in border-
line hypertensive humans. Evidence from direct intraneural recordings. Hypertension
14:177–83.
A 120 Boderline hypertension B 5.0

Control subjects
Standard error ***
110 4.5
Cardiac index (L/min/m2)
100 4.0
Heart rate (bpm)
90 3.5
**
80 *** 3.0
70 2.5
*
60 2.0
Rest Propranolol Atropine Rest Propranolol Atropine

Fig. 1.8 Response to sympathetic and parasympathetic blockade in hypertensives
and normotensives. Data from Julius S, et al. (1971). Role of parasympathetic inhibi-
tion in the hyperkinetic type of borderline hypertension. Circulation 44:413–18.
Spectral analysis of heart rate

Beat-to-beat variability in heart rate is assessed using spectral analysis
which yields both low- and high-frequency components of the heart rate
variability spectrum. Assessment of high- and low-frequency components
of the spectrum allows non-invasive comparison of sympathetic (low-
frequency components) and parasympathetic activity (high-frequency com-
ponents, b see Fig. 1.9). Spectral analysis of heart rate variability indicates
that sympathetic components are i and parasympathetic components d in
patients with essential hypertension versus normotensive control subjects.
Arterial baroreceptors
Arterial baroreceptors are mechanoreceptors found in the carotid sinus and
aortic arch, and the reflexes they initiate provide the major source of short-
term regulation of BP by reducing the variability of BP around the prevailing
resting value (b Fig. 1.10A,B). Peripheral baroreceptor denervation leads
to an immediate, marked i in BP and heart rate, which then normalizes,
but with i variability. This suggests that the beat-to-beat control of the
baroreceptor reflex has been lost but BP remains essentially normal.
Baroreceptor function can be assessed in humans by measuring the
response of heart rate to changes in BP—so-called baroreflex sensitivity.
• Hypertensive individuals display reduced baroreflex sensitivity versus
normotensive individuals, meaning that for the same i in BP, there is a
smaller reduction in heart rate.
• The set point of the baroreceptor reflex (the point at which alterations
in BP will trigger alterations in sympathetic tone) operates at a higher
BP in hypertensive subjects and operates across a narrower range of
BPs with i severity of hypertension.
Power Spectrum
Low Frequency To High Frequency Ratio
High Frequency
Low Frequency
0.05 26.4 1846

0.20 73.6 5141
0.36 10199
Fig. 1.9 Spectral analysis of heart rate variability. High frequency components
indicate parasympathetic activity; low frequency components indicate sympathetic
activity.
A CORTICOHYPOTHALAMIC
CENTRES
AFFERENT EFFERENT
VMC
*3
Carotid sinus 2*
afferents Vagus nerve
1* Aortic *2
afferents # #*4
Sirus node
6
1* *5 *
Sympathetic *7
* 5 6* ganglia *
7
*
*5
*6
*7
Blood vessels
B
Arterial BP level Low Normal High
Carotid sinus nerve (no. impulses) + ++ +++
Vagus nerve (no. impulses) + ++ +++
Sympathetic cardiac nerve (no. impulses) +++ ++ +
Sympathetic vasoconstrictor nerve +++ ++ +
(no. impulses)
Fig. 1.10 Afferent and autonomic efferent pathways of the baroreflex arc. Adapted
from Mathias CJ and Banister R (2001). Autonomic failure: a textbook of clinical
disorders of the autonomic nervous system, Oxford University Press.
Role of the kidneys

The kidneys play a major role in the physiological control of BP through the
regulation of sodium and fluid balance. The renin–angiotensin system is a
key component of this regulation. However, whether the kidneys contribute
to the initiation of essential hypertension is somewhat controversial.
Renin–angiotensin–aldosterone system (RAAS)
A major physiological role of the RAAS is to maintain BP in situations
where renal blood flow or blood volume is reduced (b Fig. 1.11).
Therefore, in healthy, well-hydrated individuals, this system is relatively
inactive. However:
• Elevated renin levels have been observed in some individuals with
essential hypertension, suggesting that the RAAS may cause the ele-
vated BP in these individuals.
• Effective BP control can be achieved in some hypertensive individuals
by blocking the effects of the RAAS using beta-blockers, angiotensin
converting enzyme (ACE) inhibitors, or angiotensin receptor antago-
nists (ARAs).
Therefore, the RAAS is actively involved in at least some individuals with
essential hypertension although the precise role of the renin–angiotensin
system in the genesis of essential hypertension more generally is contro-
versial. The RAAS does, however, play an important role in secondary
forms of hypertension due to renal artery stenosis (RAS) (b see Renal
artery stenosis, p.138), or rare monogenic syndromes (b see Chapter 5
p.169).
ROLE OF THE KIDNEYS 17
Angiotensinogen
Renin
Angiotensin I
ACE
Angiotensin II
Vasoconstriction i Vascular
AT1 receptors
hypertrophy
i Vascular resistance
Renal vasoconstriction
Aldosterone
d Glomerular filtration
Na+ and water

reabsorption
i Blood volume
Fig. 1.11 The renin–angiotensin–aldosterone system. Adapted from Wilkins R, et al.
(2006). Oxford Handbook of Medical Sciences. Oxford: Oxford University Press, with
permission from Oxford University Press.
Guyton’s theory of hypertension

Salt intake and renal sodium handling form the basis of Guyton’s theory
on the long-term control of BP, which he developed nearly 40 years ago
with the use of mathematical modelling and computer programming. He
largely ignored the role of the autonomic nervous system and argued that
it was the kidneys which were of key importance in determining the arte-
rial pressure. According to Guyton, all forms of hypertension are caused
by a chronic excess of salt intake. Therefore:
• Individuals who develop hypertension have abnormal renal function
causing fluid and sodium imbalances as a direct result of excessive
sodium intake. BP then becomes elevated, leading to the development
of sustained hypertension (b Fig. 1.12).
• Individuals who remain normotensive in the face of excessive sodium
intake have preserved renal function, allowing rapid restoration of fluid
and sodium imbalances before BP starts to rise.
The major problem with Guyton’s hypothesis was that the experimental
evidence did not fully support the predictions of his model. Dogs with
surgically reduced renal mass developed sustained hypertension which
was accompanied by an i cardiac output related to volume overload,

but a gradual and unexpected rise in PVR was also observed. To explain
the unanticipated rise in PVR, Guyton devised the concept of ‘long-term
autoregulation’ where an i PVR results from adjustments in vascular
tone occurring after a long latency. However, in contrast to Guyton’s
theory, not all forms of hypertension exhibit this haemodynamic pattern.
Moreover, this pattern is most typical of early, borderline hypertension
where, ironically, sympathetic nervous system activation contributes to an
elevated cardiac output and then structural remodelling contributes to
the later rise in PVR.
n
8 sio
n
er te
e
Salt-insensitive hyp
sitiv
n
nsio
Normal
-sen
Sodium intake & output
er te
Salt
Hyp
(times normal)
4 High sodium
intake
2
Low sodium
intake
0
0 25 50 75 100 125 150
Arterial pressure (mmHg)
Fig. 1.12 Shift of the renal function curve from normotensive levels to hyperten-
sive levels, as postulated by Guyton. Redrawn with permission, from the Annual
Review of Medicine, vol. 31, ©1980 Annual Reviews, M http://www.annualreviews.org
Renal mechanisms leading to essential hypertension

Despite the flaws in Guyton’s theory, additional lines of evidence suggest
that the kidneys may indeed play a role in pathogenesis of hypertension:
• Hypertension is a common feature of renal disease.
• BP correlates with sodium intake and can be improved with sodium
restriction.
• Transplant studies in animals and humans have demonstrated that
kidneys from hypertensive donors i BP in normotensive recipients.
Conversely, kidneys from normotensive donors lower BP in
hypertensive recipients.
Several mechanisms have been proposed:
• Glomerular filtration rate (GFR)-dependent mechanisms:
• dGFR may lead to sodium retention and volume expansion.
• Animal models with removed or injured kidneys develop
hypertension rapidly.
ROLE OF THE KIDNEYS 19
• In humans, the frequency of hypertension i with dGFR. However,

with normal kidney function, a reduced rate of filtering should be
counterbalanced by reduced sodium reabsorption, implying that
the development of hypertension depends upon some degree of
impaired renal tubular sodium handling. This mechanism probably
underlies hypertension in renal disease, diabetes, and, in some cases,
ageing. However, in most cases of essential hypertension, GFR is
normal or only minimally depressed.
• Transport mechanisms related to sodium reabsorption:
• Since the collecting ducts of the nephron are key to the final
regulation of sodium excretion/reabsorption, impaired regulation
of sodium transport in the collecting ducts may result in impaired
sodium excretion. The primary action of aldosterone is to i sodium
reabsorption in the collecting ducts and, apart from being secreted
by tumours, aldosterone may also be involved in a number of forms
of low renin hypertension, such as obesity. Certain oxidized fatty
acids can stimulate aldosterone production and levels of both are
raised in some obese individuals with essential hypertension.
• Renal ischaemia:
• Renal vasoconstriction, most likely at the afferent arteriole, is
mediated by a number of mechanisms including oxidative stress,
angiotensin II, and nitric oxide (NO) deficiency. Evidence of mild
tubular ischaemia and inflammation has been observed in
hypertensive patients, leading to more severe renal arteriolar
disease over time. Two phases are likely to occur: (1) agents
causing systemic and intrarenal vasoconstriction, such as
endothelial-derived mediators, activation of the RAAS, and
overactivity of the sympathetic nervous system which cause the
onset of hypertension; (2) renal microvascular disease and
infiltration of inflammatory cells serves to prolong renal vasocon-
striction, predisposing to vascular remodelling.
Interplay between autonomic and renal

mechanisms
The evidence from renal transplant studies in animals suggests that essen-
tial hypertension is caused by a genetic or developmental renal fault, thus
prompting Dahl to utter his famous dictum ‘blood pressure travels with the
kidneys’.1 However, the majority of patients with essential hypertension
exhibit normal renal function, at least initially, suggesting that non-renal
mechanisms are probably responsible for the genesis of essential hyper-
tension, whereas renal mechanisms contribute to the sustained nature
of this condition. In contrast, resting sympathetic nervous system activity
is elevated in individuals with borderline essential hypertension and this
probably explains the initiation of most forms of essential hypertension,
at least in younger individuals. Interestingly, sympathetic nervous system
activation stimulates the RAAS, providing an important link between the
autonomic nervous system and the kidney (b Fig. 1.13).
Stress High sodium

intake
d natriuretic
i sympathetic nervous
hormones
system activity
Renal efferent i tubular

Stimulation of
arteriole i filtration fraction sodium
the RAAS
constriction reabsorption
i intravascular
volume
Hypertension
Fig. 1.13 Interplay between the sympathetic nervous system and renal mechanisms
in the development of essential hypertension. Adapted from Kaplan NM (1988).
Systemic hypertension: mechanisms and diagnosis. In Braunwald E (ed) Heart
Disease, pp.819–83. Philadelphia, PA: WB Saunders, with permission from Elsevier.
Reference
1. Dahl LK, Heine M, Thompson K. (1974). Genetic influence of the kidneys on blood pressure.
Circulation Research, 34:94–101.
Vascular structure and function in

essential hypertension
Although neural, humoral, and haemodynamic factors appear to initiate
the development of essential hypertension in younger individuals, con-
tinual exposure to elevated BP leads to a number of structural and func-
tional adaptations within the resistance vasculature. Such changes result in
sustained i in BP which, once initiated, are largely irreversible. In contrast,
in older individuals, i large artery stiffness directly contributes to the rise
in systolic and pulse pressure observed in these individuals.
Structural changes in resistance vessels
Poisseuille’s law states that the resistance of a vessel is inversely propor-
tional to the fourth power of the vessel radius. Therefore, even small
reductions in vessel diameter will have a large effect on the vascular
resistance to blood flow. In established ‘classical’ essential hypertension,
the walls of resistance vessels are characterized by thickening and/or
remodelling of the media, leading to a reduction in lumen diameter and
an i wall:lumen ratio. This adaptation contributes significantly to the i
in vascular resistance which is a dominant feature of ‘classical’ essential
hypertension. Two major mechanisms account for the reduction in lumen
diameter (b Fig. 1.14):
• Hypertrophic remodelling: pressure-induced i in medial mass associ-
ated with smooth muscle cell hypertrophy and also an i in connective
tissue, such as collagen.
• Eutrophic remodelling: vessel wall remodelling leading to a reduction
in lumen diameter, but no overall growth of cellular or connective
tissue. This form of remodelling appears to arise from hypertrophic
remodelling. The vessel wall is then subject to apoptosis in the outer
medial layer and fibrosis of the adventitia, which prevents further i in
wall mass.
A further structural change in hypertensive resistance vessels is rarefac-
tion (closure/loss of arterioles) as a consequence of sustained vasocon-
striction. Rarefaction is mostly transient although individuals with mild
to moderate essential hypertension exhibit longer periods of rarefaction
compared with normotensive individuals. Vessel rarefaction reduces the
total cross-sectional area of the resistance vasculature and thus contrib-
utes to the rise in PVR.
VASCULAR STRUCTURE AND FUNCTION 23
i pressure
Hypertrophic remodelling: Eutrophic remodelling:

i medial mass no change in medial mass
Fig. 1.14 Resistance vessel remodelling in response to high BP.
Functional changes in resistance vessels

Increased sensitivity to vasoconstrictors
i sensitivity to vasoconstrictor substances has been observed in hyperten-
sive individuals although the precise mechanisms are controversial. The
i sensitivity could be a result of i receptor sensitivity or activation of
second messenger pathways. Alternatively, structural adaptations within
the arterial wall, such as smooth muscle hypertrophy or i wall: lumen
ratios result in i force generation for a given concentration of vasocon-
strictor.
Endothelial dysfunction
A number of, but not all, studies suggest that endothelium-dependent
vasodilatation is impaired in essential hypertension. Possible mechanisms
for this impairment include reduced production/release of NO, a potent
vasodilator molecule, i degradation of NO by free radicals, or an imbal-
ance in the production of endothelium-derived vasodilatory factors versus
vasoconstrictor factors (such as endothelin). In addition, the vascular
smooth muscle may exhibit reduced responsiveness to vasodilators such
as NO, although this is not thought to be a major mechanism underlying
impaired dilatory responses observed in hypertensive individuals.
Structural changes develop gradually as essential hypertension progresses.
These changes enhance vasoconstrictor responses and i the degree of
rarefaction, further i BP. A probable initiating mechanism for these struc-
tural changes is sympathetic nervous system activation, which can remain
elevated for a number of years. The structural and functional abnormali-
ties listed earlier in this section then assume a dominant role in main-
taining the elevated BP. Once initiated, this process is largely irreversible
(b Fig. 1.15).
VASCULAR STRUCTURE AND FUNCTION 25
Initiating mechanisms
Adaptive changes in
structure and function
Vascular remodelling
Increased peripheral vascular resistance

and hypertension
Fig. 1.15 Vascular mechanisms underlying ‘classical’ essential hypertension.
Large arteries
Large arteries were once considered as inert conduits, but are now rec-
ognized to play an important physiological role in buffering the oscillatory
changes in BP resulting from intermittent ventricular ejection. This action
reduces pulse pressure, smoothes peripheral blood flow, and improves
the efficiency of the cardiovascular (CV) system as a whole. However,
stiffening of large arteries leads to a number of adverse haemodynamic
consequences, and may promote disease by a number of different mecha-
nisms including:
• Widening of pulse pressure i.e. i systolic BP (SBP)/d diastolic BP (DBP)
leading to:
• ISH.
• Left ventricular hypertrophy (LVH) and ventricular stiffening, leading
to diastolic dysfunction and heart failure (i SBP).
• Reduction in diastolic pressure, leading to a reduction in coronary
blood flow, predisposing to ischaemia (d DBP).
• i cyclical stress on arterial walls leading to accelerated elastic fibre
fatigue fracture which causes further i in arterial stiffness.
• Transmission of pulsatile stress to other large arteries e.g. carotid,
leading to wall remodelling and intima-media thickening.
• Transmission of pulsatile stress to microvascular beds of the brain and
kidney.
• d shear stress rate leading to d endothelial NO production (a key event
in atheroma formation).
Structural changes in large arteries
The large arteries undergo a number of age-related structural changes
within the arterial wall. One of the most consistent structural changes
is the gradual dilatation and hardening of the arteries (arteriosclerosis).
This is partly the result of fatigue fracture of the elastic elements within
the medial layer, and often considered a consequence of ‘wear and tear’
on the arteries. Indeed, by the age of 60 years, the average individual will
have experienced >2 billion stress cycles of the aorta (average heart rate
x age). The i pulse pressure which results from this process exerts an
additive stress on the arterial wall, further i cyclical stress and setting up
a vicious cycle.
Other structural changes occurring in large arteries include i collagen
deposition and, therefore, alterations in the ratio of elastin, collagen, and
other matrix proteins. There is also an i formation of advanced glycation
end products (AGEs), which are a heterogeneous group of protein and
lipids to which sugar residues are covalently bound, and which accumulate
slowly on long-lived matrix proteins such as elastin and collagen. Finally,
calcification of the medial layer occurs with i frequency in older individ-
uals and contributes to the i rate of arterial stiffening observed in older
individuals (b Fig. 1.16).
LARGE ARTERIES 27
16
Pulse wave velocity (m/s)
12
0
0 10 20 30 40 50 60 70 80 90 100
Age (years)
Fig. 1.16 The effect of age on aortic pulse wave velocity (squares = women; circles
= men). Reproduced from McEniery CM, et al. (2005). Normal vascular aging: differ-
ential effects on wave reflection and aortic pulse wave velocity: The Anglo-Cardiff
Collaborative Trial (ACCT). J Am Coll Cardiol 46:1753–60, with permission from
Elsevier.
Genetics of essential hypertension

It has often been stated that ~40% of hypertension is attributable to
genetic influences. However, although specific genetic variants might
determine who is susceptible to the development of hypertension, envi-
ronmental factors also exert significant effects on BP, making it difficult
to distinguish between genetic and environmental influences. Overall,
genetic factors are thought to result in i BP when interacting with permis-
sible environmental factors.
Essential hypertension is a complex condition and, as yet, there is a relatively
poor understanding of the genetic pathways involved in the development
of this condition. To date, only rare monogenic mutations which share a
relationship with altered salt homeostasis have been conclusively identified
as causes of hypertension (b see Monogenic syndromes, p.169).
Problems in understanding the genetic basis
of essential hypertension
Essential hypertension is physiologically complex
A large number of haemodynamic and biochemical mechanisms potentially
lead to the development of essential hypertension, making it a physiologi-
cally complex condition. Therefore, it is not surprising that the genetic
basis of hypertension is similarly complex. Animal models of hypertension
have aided our understanding of certain physiological and biochemical
mechanisms, but although these models mimic essential hypertension,
they do not necessarily represent the true situation in humans in vivo.
Essential hypertension is phenotypically complex
Essential hypertension has a number of different forms, arising from
distinct haemodynamic and pathophysiological mechanisms (b see
Haemodynamics in hypertension, p.4). However, many of the large-scale
genetic association studies conducted to date have treated hypertension
as a single, uniform condition, which reduces the likelihood of identifying
specific causative genes. Improving the way in which we define sub-types
of essential hypertension will be a key factor in advancing our under-
standing of its genetic causes.
Essential hypertension is associated with significant genetic heterogeneity
BP is a continuous parameter and such parameters are usually polygenic
(the product of many genes). Therefore, the development of essential
hypertension probably reflects the small, additive effects of many genes.
Indeed, finding individual gene variants with a measurable effect on BP has
been difficult. It is also likely that different subsets of genes influence BP in
different people and yet the end product (raised BP) appears to be similar
across a large number of individuals.
Major approaches to studying the genetics of essential
hypertension
Genetic linkage analysis
Many physical traits tend to be genetically transmitted together, from
1 generation to the next—a process termed genetic linkage. It is this
phenomenon which forms the basis for gene identification in large
GENETICS OF ESSENTIAL HYPERTENSION 29
families (pedigrees) with multiple generations (family-based linkage) and

in populations (linkage disequilibrium mapping). Linkage analysis allows
the identification of numerous chromosomal regions which are likely to
harbour genetic variants influencing BP. If small enough regions are iso-
lated, then specific genes and their variants can be identified using gene
sequencing methods. This approach has been successful in identifying
the mutated genes responsible for monogenic forms of hypertension.
However, due to the vast genetic and phenotypic heterogeneity associ-
ated with essential hypertension, linkage analysis has provided little insight
into the genetic basis of this condition.
Gene association studies
In these studies, genetic and phenotypic variation is compared using a
case–control design. Therefore, variants of specific genes are compared
between hypertensive and normotensive individuals, an approach which
requires careful matching for potentially confounding factors such as age,
gender, and race. Recent developments in high throughput genotyping
and statistical methods for analysing large amounts of genetic data should
theoretically allow whole-genome association studies. This is based upon
the principle that by identifying enough genetic variants in a large number
of individuals with different hypertensive phenotypes, it will be possible to
examine every gene for an association with BP variation and to identify a
set of genes which are responsible for influencing BP regulation. However,
at present, this approach is effort intensive and prohibitively expensive.
Genetic mapping
This approach involves genotyping individuals from different popula-
tions (i.e. with different geographic origins) in order to create a common
map of the human genome—a strategy which has been adopted by the
Hapmap project, which has been designed to provide a catalogue of
common genetic variants occurring within humans. The genome is made
up of a mosaic of blocks of deoxyribonucleic acid (DNA) spanning inter-
vals between recombination sites. Most of the DNA sequence within
blocks is the same between individuals, meaning that these blocks can
be characterized by small sets of sites that differ—single nucleotide poly-
morphisms (SNPs). Certain sets of SNPs tend to be inherited together
and these regions of linked SNPs are known as haplotypes. Ultimately, it
may be possible to identify blocks of DNA containing the genes associated
with essential hypertension by comparing the distribution of haplotypes
between hypertensive and normotensive individuals.
Future of genetic studies in hypertension
Despite the obvious challenges associated with examining the genetics of
hypertension, recent advances in technology are likely to improve under-
standing of the specific gene variants contributing to this condition. A
long-term aim of genetic studies will be to utilize information such as that
provided by the Hapmap project, to predict the development of hyperten-
sion before signs of the disease appear. Ultimately such an approach may
allow us to prevent the onset of this condition. There is also a great deal
of interest in pharmacogenetics—the identification of genes which influ-
ence an individual’s response to pharmacologic therapy, which may allow
treatment to be tailored more appropriately to individual requirements.
Environmental influences on blood

pressure
In almost all societies worldwide, there are marked changes in BP with age
(b Fig. 1.17):
• SBP rises throughout life—indeed, this appears to be accelerated after
the age of ~50 years.
• DBP rises until ~50 years of age and then plateaus, or even declines.
• Pulse pressure i, especially after ~50 years of age.
Although such changes in BP were once considered to be inevitable,
several lines of evidence suggest that this is not the case:
• The age-related changes in BP are absent or greatly reduced in a
number of rural populations, including Easter Islanders, Soloman
Islanders, Highlanders of Papua New Guinea, African Bushmen, and
Zulu tribes (b Fig. 1.18).
• Migration of the inhabitants of rural-dwelling communities to industrial-
ized areas results in a steeper age-related rise in BP (b Fig. 1.19).
These observations suggest that whilst genetic influences on BP are
important, lifestyle factors such as diet, physical activity level, and stress
exert a major influence on BP.
(A) 180
160
Blood pressure (mmHg)
140
120
100
80
60
0
10 20 30 40 50 60 70 80
Age in years at last birthday
Fig. 1.17 Changes in BP with age. Data from Burt V, et al. (1995). Prevalence of
hypertension in the US adult population: results from the Third National Health and
Nutrition Examination Survey, 1988–1991. Hypertension 25:305–13.
ENVIRONMENTAL INFLUENCES ON BLOOD PRESSURE 31
MALES FEMALES
180
Bushmen
170 Londoners
160
Arterial pressure (mmHg)
150
140
Systolic
130
120
110
100
90
Diastolic
80
70
60
25 35 45 55 65 75 25 35 45 55 65 75
Age (years)
Fig. 1.18 Influence of age on BP in Kung Bushmen in Northern Botswana, com-
pared with people from London, UK (‘Londoners’). Reproduced from Truswell AS,
et al. (1972). Blood pressures of Kung bushmen in Northern Botswana. Am Heart J
84:5–12, with permission from Elsevier.
Blood pressure
(mmHg)
170 170
MALES FEMALES
160 160
150 150
140 140
130 130
Systolic
120 120
110 110
100 100
90 90
80 80
Diastolic
70 70
60 60
0 15 25 35 45 55 65 0 15 25 35 45 55 65
Age (years) Age (years)
Urban Zulu
Rural Zulu
Fig. 1.19 Influence of age on systolic and diastolic BP in rural and urban Zulus
compared to the black and white populations of Georgia, USA. Adapted with
permission from Scotch NA, et al. (1963). Sociocultural factors in the epidemiology
of Zulu hypertension. Am J Public Health 53:1205–13, © American Public Health
Association.
Physical activity
Evidence from epidemiological studies shows an inverse relationship
between the amount of physical activity undertaken and level of BP,
although many of the studies did not control for other factors associ-
ated with hypertension, between active and inactive groups. However,
evidence from a recent meta-analysis demonstrates that regular aerobic
exercise (rhythmic endurance exercise involving large muscle groups) can
lower SBP by 2–7mmHg, with the greatest fall in BP observed in hyper-
tensive patients (b Fig. 1.20). Resistance training may also be beneficial
in lowering BP (reported fall in SBP between 3–6mmHg) although fewer
studies have investigated the antihypertensive effects of this form of exer-
cise. Indeed, resistance training is most likely to have beneficial effects as
part of an overall fitness regimen, but is not recommended as a sole form
of exercise. Current guidelines recommend aerobic exercise such as brisk
walking for >30min per day at a moderate intensity, equating to ~50–70%
of an individual’s maximum heart rate (220 minus age).
PHYSICAL ACTIVITY 35
0
−2
−4
−6
−8
−10
Normotensives Pre-hypertensives Hypertensiv
(28 trials) (16 trials) (30 trials)
Fig. 1.20 Results of meta-analysis of 74 randomized controlled trials testing the
effects of aerobic exercise on BP. Based on data from Cornelisson VA, et al. (2005).
Effects of endurance training on blood pressure, blood pressure–regulating mecha-
nisms, and cardiovascular risk factors. Hypertension 46:667–5.
Diet
Interaction between sodium and potassium intake
For many years, sodium has been considered to be the most influential
dietary factor in the development of essential hypertension. However, the
role of potassium should not be overlooked. Indeed, rather than consid-
ering the roles of sodium and potassium in isolation, recent attention has
focused on the interplay between these factors as being the most impor-
tant dietary cause of elevated BP.
Physiologically, humans are adapted to retain salt and lose potassium, a
mechanism which is largely due to the diets of early humans which were
low in salt and rich in potassium. However, the diets of individuals living
in modern, industrialized societies tend to be high in sodium and low
in potassium, which requires the kidneys to excrete excess sodium and
retain potassium. A failure of the kidneys to adapt to and compensate for
the modern, westernized diet results in an excess of retained sodium and
a deficit in potassium, leading ultimately to vascular smooth muscle con-
traction, i PVR, and, ultimately, elevated BP (b Fig. 1.21).
DIET 37
Modern Western diet
High sodium intake Low potassium intake

+ +
Lack of renal adaptation and Ineffective potassium
other defects in sodium excretion conservation
Excessive renal and

fecal potassium loss
Retention of sodium Deficit of potassium

by the kidneys in the body
Excess of sodium
in the body
Extracellular- Release of
fluid volume digitalis–like factor
expansion
Na+/K+−ATPase
Excess of cellular Deficit of cellular

sodium potassium
Vascular smooth-muscle cell contraction
Increased peripheral vascular resistance
Hypertension
Fig. 1.21 Interaction between sodium and potassium intake in the pathogenesis of
essential hypertension. Reproduced with permission from Adrogue HJ and Madias
NE (2007). Sodium and potassium in the pathogenesis of hypertension. NEJM
356:1966–78. Copyright © 2007 Massachusetts Medical Society. All rights reserved.
Salt intake
Physiologically, the daily requirement for salt is ~8–10mmol/day and early
humans probably consumed ~20–40mmol/day. However, the average daily
salt intake of individuals living in industrialized societies is ~140–150mmol/
day—10–20 times the physiological requirement—which then must be
excreted by the kidneys. Numerous studies suggest a positive association
between salt intake and BP. However, the best evidence of a direct rela-
tionship between the level of salt intake and level of BP comes from the
Intersalt study1 in which salt intake and BP levels were assessed in over
10,000 individuals from 32 countries. Salt intake was determined by 24-h
urinary sodium concentrations. A strong positive association between
sodium excretion and BP was observed, suggesting that salt intake does
indeed influence BP level (b Fig. 1.22).
Further studies have confirmed and extended the findings of the Intersalt
study by demonstrating that a reduction in the level of salt intake results
in lower BP. The best evidence comes from the DASH study diet2, which
is high in fresh fruit and vegetables, and low in sodium and dairy products.
The study was conducted in patients with borderline hypertension and a
reduction in BP was observed after 4 weeks on the diet. In a follow-up
study (DASH-sodium)3, 3 levels of sodium intake were included and a
dose–response relationship was observed between the level of sodium
restriction and the extent of reduction in BP. Taken together, these
observations suggest a very potent relationship between salt intake and
BP. However, a firm link between a reduction in sodium intake and a con-
comitant reduction in CV events has not yet been observed.
SALT INTAKE 39
1.4
Adjusted systolic blood pressure slope with age
1.2 52 Centres: b=0.0034

1.0 (SE 0.0006) mm Hg/year/mmol sodium***
0.8
(mm Hg/year)
0.6
0.4
0.2
0.0
−0.2
50 100 150 200 250

Adjusted sodium excretion (mmol/24h)
Fig. 1.22 Relationship between sodium excretion and systolic BP in the Intersalt
study. Reproduced from Intersalt Cooperative Research Group (1988). Intersalt: an
international study of electrolyte excretion and blood pressure. Results for 24-hour
urinary sodium and potassium excretion. BMJ 297:319–28. Copyright © 1988, with
permission from BMJ Publishing Group.
References
1. INTERSALT Cooperative Research Group (1988). INTERSALT: an international study of
electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium
excretion. BMJ 297:319–28.
2. Appel LJ, Moore TJ, Obarzanek E, et al. (1997). A clinical trail of the effects of dietary patterns
on blood pressure. NEJM, 336:1117–24.
3. Sacks FM, Svetkey LP, Volmer WM, Appel LJ, et al. (2001). Effects on blood pressure of reduced
dietary sodium and the dietary approaches to stop hypertension (DASH) Diet. NEJM, 344:3–10.
Potassium intake
Epidemiological data suggest an inverse association between potassium
intake and BP, since in rural-based populations where the typical diet is
rich in potassium, the age-related i in BP is far less marked than urban
populations. However, the Intersalt study provided firm evidence of an
inverse association between potassium intake and the level of BP, where
a 50mmol/day i in urinary potassium excretion was associated with a
3.4mmHg d in SBP and 1.9mmHg d in DBP. Clinical trials have provided
further evidence that i potassium intake results in d BP. A meta-analysis
of 33 randomized controlled trials in >2500 hypertensive and normoten-
sive subjects showed that overall, an i intake of potassium was associated
with reductions in SBP of ~4% and in DBP of 2.5%, with a larger effect on
BP observed in HT subjects. The precise mechanism by which i potas-
sium intake exerts an anti-hypertensive effect remains unclear. Proposed
mechanisms include a direct natriuretic effect, suppression of the RAAS
system and the sympathetic nervous system, and a direct arterial vasodila-
tory effect (b Fig. 1.23).
Central infusion of Potassium

potassium chloride feeding
K+CSF
Digitalis-like Renin–antio-
factor tensin system
Neuronal
sodium pump
Sympathetic
nerve activity
Blood pressure
Fig. 1.23 Central effects of potassium infusion or potassium feeding on the BP of

normotensive rats. Solid lines indicate an increase, broken lines indicate a decrease
or inhibition. Reproduced with permission from Adrogue HJ and Madias NE (2007).
Sodium and potassium in the pathogenesis of hypertension. NEJM 356:1966–78.
© 2007 Massachusetts Medical Society. All rights reserved.
ALCOHOL 41
Alcohol
Despite some evidence demonstrating that the relationship between
alcohol intake and BP is J-shaped, overall, there is a positive association
between BP and alcohol intake in both men and women. Moreover, the
risk associated with alcohol consumption i beyond moderate levels of
intake. Acute and chronic alcohol consumption causes a rise in BP, and
a recent meta-analysis reports that a reduction in alcohol intake reduces
SBP and DBP by 3 and 2 mm Hg respectively. In hypertensive patients,
reductions in SBP (5–8mmHg) and DBP (2–3mmHg) have been reported.
A reduction in alcohol consumption is also associated with weight loss
which probably aids in the BP-lowering effect. Current recommendations
are that hypertensive patients should drink less than 2 units of alcohol
per day.
mmHg
150
blood pressure
145
Systolic
140
135
130
90
blood pressure
Diastolic
85
80
−2 −1 0 1 2 3 4 5 6 7 8 9 10 11 12 Weeks
Familiarization Study period 1 Study period 2
Group mean (and SEM) supine systolic and diastolic blood pressures
= Group A = Group B = Low alcohol period
Fig. 1.24 Effect of reduction in alcohol intake on blood pressure. Reproduced

from Puddy I, et al. (1987). Regular alcohol use raises blood pressure in treated
hypertensive subjects: a randomized control trial. Lancet. 329:647–51. © 1987 with
permission from Elsevier.
Reference
1. Xin X et al. (2001). Effects of alcohol reduction on blood pressure. A meta-analysis of ran-
domised clinical trails. Hypertension. 38: 1112–17.
Stress
Acute and chronic exposure to emotional stress will elevate BP in virtually
all individuals, but BP tends to normalize when the stressful period ends.
Therefore, the precise role of stress in the genesis of essential hyperten-
sion is unclear. Nevertheless, cross-sectional and longitudinal evidence
suggests that stress is an important environmental factor which contrib-
utes to i in BP.
Cross-sectional evidence
• Acute i in stress induced by laboratory procedures (mental stress
tests, mental arithmetic) is matched by acute i in BP.
• In individuals of a given socio-economic status, BPs are higher in those
who live and/or work in stressful environments than those in less
stressful environments.
Longitudinal evidence
• In a classic observational study, age-related changes in BP were com-
pared between a community of nuns living in secluded orders and
age-matched women (many of whom were relatives) living in urbanized
society within a similar geographic region.1 Despite similar dietary and,
in particular, sodium levels between the participants, the nuns exhib-
ited markedly lower BPs at all ages. The routine, quiet lifestyle led by
the nuns suggested that the major difference between the groups was
the level of chronic stress encountered (b Fig. 1.25).
• In another longitudinal observational study, BP levels were consistently
lower in prisoners on Alcatraz than in prison guards.2 Again, ordered,
predictable lifestyles led by the prisoners, versus the more stressful
occupations of the guards, was thought to explain the differences in BP.
STRESS 43
Nuns Controls
170
150
130
mmHg
110
80
70
0
ENTRY 4th 8th 12th 16th 20th
YEARS
Fig. 1.25 Mean systolic and diastolic BPs in nuns in secluded orders versus controls.
Adapted with permission from Timio M, et al. (1988). Age and blood pressure
changes. A 20-year follow-up study in nuns in a secluded order. Hypertension
12:457–61.
References
1. Timio M, et al. (1988). Age and blood pressure changes. A 20-year follow-up study in nuns in a
secluded order. Hypertension 12:457–61.
2. Alvarez WC and Stanley LL (1930). Blood pressure in 6000 prisoners and 400 guards. Archives of
Internal Medicine, 46:17–39.
Obesity
Population studies indicate a significant association between body weight
or body mass index (BMI) and BP, even in normotensive individuals:
• The Framingham Heart Study demonstrated that SBP was i by
6.5mmHg for every 10% i in relative weight.1
• Studies examining the effects of weight loss on BP have observed that
reductions in body weight of between 4.5–9kg led to reductions in BP
of between 5–8mmHg (systolic) and 5–9mmHg (diastolic).2
The incidence of hypertension is ~50% in obese individuals (BMI >30kg/
m2) and obesity and hypertension frequently occur together in the meta-
bolic syndrome. Recent data from the NHANES III survey suggest that
BMI and weight gain over time are significant risk factors for the devel-
opment of IDH.3 Distribution of body fat may also be important, since
upper body (central) fat is more closely associated with the development
of hypertension than peripheral fat. Central obesity is also linked to insulin
resistance, providing a link between obesity and glucose intolerance in the
development of hypertension. Therefore, obesity is an important environ-
mental factor associated with BP elevation and the growing prevalence
of obesity in industrialized societies holds important implications for the
future incidence and management of essential hypertension.
The mechanisms by which obesity contributes to the pathogenesis of
hypertension are unclear but probably involve many factors (b Fig. 1.26).
One such mechanism may be that the excessive dietary energy load in
obese individuals stimulates the sympathetic nervous system, leading to
an elevation in arterial pressure. Indeed, obese individuals exhibit selec-
tive activation of the renal sympathetic nerves compared with non-obese
individuals, regardless of the level of BP. In contrast, cardiac sympathetic
nervous system activity is i in obese hypertensive individuals compared
with obese normotensive individuals, suggesting that i cardiac sympa-
thetic outflow is an important feature of obesity-associated hypertension.
An intriguing question is whether hypertension might predispose individ-
uals to the development of obesity later in life. Data from the Tecumseh
study showed that elevated BPs preceded the i in body fat in subjects with
borderline hypertension (b Fig. 1.27).4 A potential hypothesis explaining
these observations is that enhanced sympathetic activation, which was
also observed in the hypertensives at a young age, might lead to the devel-
opment of insulin resistance and subsequent obesity later in life.
References
1. Kannel WB, Brand N, Skinner JJ et al. (1967). The relation of adiposity to blood pressure and
development of hypertension. The Framingham Heart Study. Ann Intern Med. 67:48–59.
2. Blumenthal JA, Sherwood A, Gullette EC et al. (2000). Exercise and weight loss reduce blood
pressure in men and women with hypertension: effects on cardiovascular, metabolic and hemo-
dynamic functioning. Arch. Intern Med. 160:1947–58.
3. Franklin SS, Barboza MG, Pio JR, Wong ND (2006). Blood pressure categories, hypertensive
sub-types and the metabolic syndrome. J Hypertension, 24:2009–16.
4. Julius S, Jamerson K, Mejia A, et al. (1990). The association of borderline hypertension with
target organ changes and higher coronary risk: TECUMSEH blood pressure study. JAMA,
264:354–58.
OBESITY 45
iFFA
iInsulin
iLeptin
iAldosterone
iRAS
iET-1 iLeptin
dNO iAldosterone
iAldosterone iRAS
iRAS i Sympathetic nerve activity
Vasoconstriction Sodium and water retention
Obesity – associated hypertension

Fig. 1.26 Proposed mechanisms involved in obesity-associated hypertension. Data
from Rahmouni K, et al. (2005). Obesity associated hypertension. Hypertension
45:9–14.
170 2 *
Subscapular skinfold (cm)
1.75
150
*
130 1.5
* Normotensives
110 1.25 Borderline
hypertensives
90 1
70 0.75
* *
50 0.5
6.4 21.5 6.4 21.5
Fig. 1.27 Changes in BP and skinfold thickness over 15 years in normotensive and
borderline hypertensive adults. Data from Julius S, et al. (1990). The association
of borderline hypertension with target organ changes and higher coronary risk.
Tecumseh Blood Pressure Study. JAMA 264:354–8.
Experimental models of hypertension

Experimental models of hypertension allow detailed investigations into
the causes of, and clinical signs associated with hypertension, as well as
the effects of treatment to lower BP. The earliest experimental models of
hypertension are largely attributed to the work of Goldblatt, who induced
renal artery stenosis in dogs resulting in elevated BP (b Fig. 1.28):1
• One-kidney, one-clip model: one kidney is removed and a silver clip
placed on the renal artery of the remaining kidney. The resulting
occlusion causes a short-term rise in plasma renin activity, which then
normalizes, and an i plasma volume. Blockade of the RAAS does not
reduce BP; however, diuresis and sodium depletion causes a return
to the renin-dependent state, indicating a complex set of interactions
between the RAAS and sodium retention by the kidney. This model
represents bilateral renal artery stenosis in humans.
• Two-kidney, one-clip model: a silver clip is placed on one renal artery
resulting in an i renin secretion from the stenosed kidney and produc-
tion of angiotensin II. Renin secretion from the intact kidney is either
greatly reduced or absent. Administration of an angiotensin II antago-
nist normalizes BP in this model, indicating renin/angiotensin dependent
hypertension, at least in its early phase.
• Two-kidney, two-clip model: this model exerts similar effects to the
one-kidney, one-clip model except that the greater kidney mass in this
model permits i sodium excretion.
• Cellophane wrapping of the kidney: this model mimics renal capsular
fibrosis, resulting in compression of the kidney and an i in renal tissue
pressure which d renal blood flow and leads to the release of renin and
angiotensin.
One-kidney, Two-kidney, Two-kidney,

one-clip model one-clip model two-clip model
Fig. 1.28 Goldblatt’s kidney–clip models of hypertension.
Genetic models
Genetic models allow the study of hypertension which develops sponta-
neously in an animal without any apparent cause, in order to mimic the
situation in humans as closely as possible. This approach has the advantage
that animals in which hypertension is a phenotype can be selectively bred,
allowing the study of genes related to hypertension. A further advantage is
that environmental influences on hypertension can be well controlled.
• Spontaneously hypertensive rats (SHR): a widely used model for
studying hypertension. Developed by mating hypertensive ‘progenitors’
EXPERIMENTAL MODELS OF HYPERTENSION 47
originally selected from Wistar rats from Kyoto in Japan (WK rats).
WK rats are often used as normotensive controls in studies involving
SHR. The SH stroke-prone rat is often used to study hypertension,
stroke, and CVD.
• New Zealand genetically hypertensive rat: created by selective
inbreeding for high BP and used as a model of hypertension and cardiac
hypertrophy
• Dahl salt-sensitive and salt-resistant rats: selectively bred based on
a tendency to either develop hypertension, or remain unaffected by
alterations in dietary sodium intake. Salt-sensitive rats placed on a high
sodium diet die within 8 weeks. When placed on a low salt diet, they
die within 6 months.
• Milan hypertensive rat: descended from Wistar rats after selective
breeding for hypertension. These rats provide a model of mild hyper-
tension.
• Sabra hypertension-prone and hypertension-resistant rats: bred based
on the propensity to develop hypertension or remain normotensive
following 1 month on a high-salt diet.
• Lyon model of hypertension: 3 strains originally bred from Sprague–
Dawley rats—hypertensive, normotensive, and a hypotensive model.
• Other strains related to hypertension: obesity–prone Sprague–Dawley
rats, obese zucker rats, Wistar fatty rats.
• Other normotensive models: Brown Norway rats, Lewis rats, Fischer
(F344) rats.
Reference
1. Goldblatt H, Lynch J, Hunzal RF, et al. (1934). Studies in experimental hypertension: I,
The production of persistent elevation of systolic pressure by means of renal ischemia.
J Exp Med. 59:347–79.
Chapter 2 49
Essential hypertension
Background
Prevalence and incidence 50
Isolated systolic hypertension 52
Systolic/diastolic hypertension 58
Isolated diastolic hypertension 59
Assessment
History 60
Examination 62
Blood pressure measurement 64
Assessing end-organ damage 66
Investigations in hypertension 68
Biochemistry
Basic biochemistry 70
Renin and aldosterone 72
Dipstick urinalysis 73
Physiological measurements
Electrocardiography 74
Home blood pressure 78
24-hour ambulatory blood pressure monitoring 80
Echocardiography 83
Management
Prognosis and risk stratification 84
Non-pharmacological management
Non-pharmacological management: background 88
Salt 90
Dietary intervention, weight loss, and exercise 92
Alcohol 94
Other methods 97
Pharmacological management
Pharmacological management: background 98
Compliance 99
Stepped care versus combination therapy 100
Targets and evidence basis 101
Treatment algorithms 102
Resistant hypertension 106
Hypertensive emergencies 108
50 CHAPTER 2 Essential hypertension
Prevalence and incidence

Hypertension is the commonest risk factor for CVD. It affects approxi-
mately 30% of the adult population globally and is thought to account for
about 5% of adult deaths worldwide. However, it is much rarer in rural
societies and practically non-existent in a few isolated communities, such
as the natives of the Solomon Islands. In rural Indian men, hypertension is
thought to occur in 3.4%1.
The prevalence of essential hypertension rises dramatically with age in
most Western communities, affecting 30% of men and women generally
and rising up to >67% beyond the age of 75 years (b see Fig. 2.1). It also
frequently occurs with other CV risk factors, especially diabetes mellitus,
and this has formed the basis for the so-called metabolic syndrome.
There is some suggestion that the incidence of hypertension may have
declined amongst students in Glasgow, UK between 1948–19682, which
has led to a reduction in mortality from stroke. This may be due to effec-
tive population-based strategies to target CVD and may be important to
translate across to undeveloped nations, who are likely to see a rise in CV
mortality over the next few decades.
Hypertension is traditionally classified into primary (essential) or sec-
ondary (to an identifiable cause). However, this is an unsatisfactory clas-
sification because ~90% of hypertension is classified as essential, and it
is very likely that subtypes of essential hypertension exist with different
underlying mechanisms (b see Haemodynamics in hypertension, p.4).
In some respects, essential hypertension is akin to a syndrome, i.e. there is
no clear genetic, environmental, or other cause, and it is asymptomatic.
PREVALENCE AND INCIDENCE 51
Prevalence of hypertension, Normotensive treated

by age and sex Hypertensive treated
Men Hypertensive untreated
80
70
60
Percentage (%)
50
40
30
20
10
0
16–24 25–34 35–44 45–54 55–64 65–74 75+
Age group
Women
80
70
60
Percentage (%)
50
40
30
20
10
0
16–24 25–34 35–44 45–54 55–64 65–74 75+
Age group
Fig. 2.1 Prevalence of hypertension by age and sex, Health Survey for England
2003. Reproduced under the terms of the Click-Use License.
References
1. Kearney PM, et al. (2004) Worldwide prevalence of hypertension. A systematic review.
J Hypertens 22:11–19.
2. McCarron P, et al. (2001) Change sin blood pressure among students attending Glasgow
University between 1948 and 1968: analyses of cross sectional surveys. BMJ 322:885–8.
Isolated systolic hypertension

Definition
ISH refers to the finding of a high SBP in the context of a normal or
low DBP. The ‘standard’, but somewhat arbitrary, definition is a SBP
≥140mmHg, and DBP <90mmHg (BHS, WHO, JNC 7). ISH may be further
divided into stage I SBP (140–159mmHg), and stage II SBP (≥160mmHg).
Prevalence
ISH is now the commonest form of hypertension in the UK and USA.
The prevalence rises exponentially with age (Fig. 2.2), such that while
only 7.4% of 40-year-olds are affected, ~30% of 60-year-olds and ~65% of
those >80 years have ISH (140 & <90). Overall, ISH outnumbers other
forms of hypertension by a factor of 2:1, but it is relatively less common in
middle-aged people, and by far the most common form of hypertension in
the over 60s (80% of all cases). The age-prevalence curve is shifted to the
left in diabetics (b see Fig. 6.6), indicating that ISH tends to occur earlier
in life. Interestingly there is also a second, much smaller, peak in the under
30s, where again it is the commonest form of hypertension.
Pathophysiology
Primarily the result of i aortic stiffness; i peripheral resistance does not
seem to play a major role. Aortic stiffness rises exponentially with age
(arteriosclerosis) in almost all societies mirroring the i in the prevalence
of ISH. The mechanisms responsible for arteriosclerosis are unclear but
fatigue fracture of elastin, deposition of collagen, and medial calcification
are probably all involved. It should be viewed as pathological—not simply
part of normal ageing—because it is not observed in indigenous popula-
tions, and various risk factors for stiffening including female gender, dia-
betes, cigarette smoking, and previous ‘borderline’ or high normal BP have
been identified. It is also important to recognize that ISH is not simply the
‘burnt-out phase’ of previous mixed SDH, since the majority of individuals
do not have antecedent hypertension.
In young people, ISH can result from either a raised cardiac output, or
aortic stiffening. Those primarily with an elevated cardiac output are likely
to be in the early ‘hyperdynamic’ phase of essential hypertension. Previous
long-term follow-up studies conducted in the 1970s suggest that over
time, cardiac output falls back to normal, and peripheral resistance rises
in such individuals. As a result, diastolic pressure rises and the syndrome
of hypertension changes from predominant ISH to mixed SDH (b see
Haemodynamics in hypertension, p.4). The mechanisms responsible for i
aortic stiffness in younger subjects are unclear, as is their long-term fate.
ISOLATED SYSTOLIC HYPERTENSION 53
50
White men
Black men
White women
Black women
40
Prevalence of systolic hypertension (%)
30
20
10
0
30 40 50 60 70 80 90
Age (years)
Fig. 2.2 Prevalence of ISH versus age in Europe (160 & <90 mmHg). Reproduced
with permission from Staessen J, et al. (1990). Isolated systolic hypertension in the
elderly. J Hypertens 8:393–405.
Risks
Although ISH was previously considered benign, it is actually a major risk
factor for stroke and CHD. A wealth of epidemiological data indicates
that:
• There is a continuous relationship between SBP and risk of CV events
at all ages.
• After the age of 55, there is an inverse relationship between DBP and
risk, suggesting that individuals with ISH are at even greater risk com-
pared to both normotensive subjects and those with SDH.
• ISH defined as SBP ≥160mmHg carries a 3-fold i risk of stroke and a
doubling in the risk of coronary heart disease (CHD). Those with stage
I ISH are at intermediate risk.
Treatment
Benefits of BP reduction
Three randomized, placebo-controlled trials investigated the impact of BP
lowering in patients with ISH (b Table 2.1). A meta-analysis of the 8 trials
involving ISH found that overall active treatment reduced mortality by
13%, stroke by 30%, and CHD by 23%. Thus, treating older subjects with
ISH compares favourably to treating younger subjects with mild hyperten-
sion. The number needed to treat (NNT) for stroke prevention of in
older subjects is ~35 compared to a value of ~90 in younger subjects.
Importantly, the incidence of side effects appears no more common in
older subjects, including orthostatic hypotension. Limited data are avail-
able in subjects >80 years. However, a meta-analysis of ~1600 patients
aged 80+ found significant reductions in the incidence of stroke, heart

failure, but no effect of therapy on mortality. The Hypertension in the
Very Elderly Trial (HYVET) recently confirmed the benefit of treating sub-
jects >80 years of age with ISH.
Targets
No specific targets for ISH have been developed, and the majority of
guidelines recommend similar targets for all essential hypertensives
(140/85mmHg). However, SBP is more difficult to control than DBP
(b Fig. 2.3). Consequently, subjects with ISH often end up on combina-
tion therapy, which may result in excessive DBP reduction and symptoms
of breathlessness or angina. A retrospective analysis of the SHEP study1
also suggested that a DBP <70mmHg on treatment is associated with an
i risk of events (b see Fig. 6.11, p.203). Practically, one should be
cautious in producing excessive falls in DBP in older subjects with systolic
hypertension, accepting that this may leave imperfect control of SBP.
Table 2.1 Summary of the 3 randomized, placebo-controlled trials

in ISH
Trial No. Treatment d BP d events
subjects (mmHg)
SHEP 4736 Chlorthalidone 11/3 Stroke 33%
± atenolol MI 33%
CV death 20%*
Death 13%*
SystEur 4695 Nitrendipine 10/4 Stroke 42%
± enalapril MI 30%*
± diuretic CV death 27%*
Death 14%*
SystChina 1253 Nitrendipine 9/3 Stroke 38%
± captopril MI 1%*
± diuretic CV death 39%
Death 39%
* = not significant. CV, cardiovascular; MI, myocardial infarction.
ISOLATED SYSTOLIC HYPERTENSION 55
>140 mmHg
50%
<140 mmHg
<90 mmHg
50%
90%
Diastolic BP Systolic BP
Fig. 2.3 No. of subjects achieving DBP<90 mmHg or SBP <140 mmHg. Data from
Mancia G and Grassi G. (2002). Systolic and diastolic blood pressure control in
antihypertensive drug trials. J Hypertens 20:1461–4.
Reference
1. Shorr RI and Somes GW (2000). Can diastolic blood pressure be excessively lowered in the
treatment of isolated systolic hypertension? J Clini Hyper 2:134–7.
Choice of drug
Placebo-controlled evidence exists for the use of thiazide diuretics (SHEP)
and long-acting calcium blockers (SystEur/China) in ISH. However, several
other studies have included a large proportion of ISH subjects and used
other therapies first-line, including B-blockers, ACEI, and ARAs. No study
has addressed directly the question of drug superiority in ISH subjects.
STOP-2 included a large proportion of ISH subjects and found no differ-
ence between thiazides/B-blockers, ACEIs, and calcium blockers. A sub-
group analysis of ALLHAT found the same, but did not include B-blockers.
Several recent studies, the MRC Elderly Study, and meta-analyses indi-
cate that B-blockers may be less effective than other drugs. Therefore, on
balance, it seems that with the exception of B-blockers the 3 main classes
of drugs are equally effective. Three randomized studies also suggest that
nitrates may be of benefit in subjects with ISH although they have not
been subject to long-term trials. A-blockers may precipitate orthostatic
hypotension—especially in those with very wide pulse pressure and stiff
arteries—and should be used with caution. A schema for the logical
combination of drugs is shown in b Fig. 2.4.
Treatment Guideline for ISH
(SBP>140 AND DBP<90mmHg)
NOTES
CI to thiazide SBP >160 mmHg?
• Gout
• Long-term NSAID use No Asses CHD risk
• Creatinine > 150 μmol/L
CI to ACEI
Yes Treat if >15% over 10
• Known RAS years
• RAS strongly suspected e.g. renal impairment Check routine bloods Otherwise annual BP
and known atherosclerosis or bruits (may
consider MAGIII with captopril to exclude)
Exclude secondary causes if
• Significant aortic stenosis required
• Known intolerance (eg angio-oedema) CI to thiazide Yes
Points regarding ACEI
• Use sartan if cough
No
ISOLATED SYSTOLIC HYPERTENSION

• Renal impairment is NOT itself a CI to
ACEI/ARA, but they should be introduced
cautiously and RAS excluded if suspected.
• Must check U&Es after 7–10 days. Bendrofluazide 2.5mg CCA
ADD
CI to ACEI
B-blocker ACEI ACEI CI to ACEI
ADD ADD
CCA B-blocker
Fig. 2.4 Suggested treatment algorithm for ISH. ACEI, angiotension-converting enzyme inhibitor; CI, contraindications; NSAID, non-steroidal anti-
inflammatory drug. RAS, renal artery stenosis.
57
Systolic/diastolic hypertension
Definition
Mixed SDH refers to an elevation of systolic and diastolic BP. This is the
classical form of hypertension and is often viewed as ‘established’ or fixed
hypertension. SDH can be further classified into two or three stages
(b Table 2.2), depending on the definition used.
Table 2.2 Categorization of SDH

Stage 1: SBP 140–159mmHg & DBP 90–99mmHg BHS/JNC7
Stage 2: SBP ≥160mmHg & DBP ≥100mmHg BHS/JNC7
Stage 3: SBP ≥180mmHg & DBP ≥110mmHg BHS
Prevalence
SDH is the most prevalent form of hypertension in middle-aged individ-
uals, with ~18% of 40-year-olds affected. Although the prevalence i to
~30% in 60-year-olds, ISH is by far the most common form of essential
hypertension in the older population. A modest proportion of patients
(~20%) may transform from SDH into ISH in later life. Similarly, IDH and
ISH predominate in the under 30s and often change into SDH later.
Pathophysiology
Unlike ISH, SDH is associated with a marked i in PVR. In most individuals,
this is thought to evolve from an early elevation in cardiac output, causing
a rise in BP—a marked feature of patients with ‘early’ or ‘borderline’
hypertension. Cardiac output normalizes over time, giving way to a more
sustained rise in PVR, which most likely develops in response to the con-
tinuous exposure to elevated BP.
i cardiac output
i BP
i peripheral resistance
Normalization of cardiac output
Fixed hypertension
Fig. 2.5 Haemodynamic abnormalities leading to SDH.

ISOLATED DIASTOLIC HYPERTENSION 59
Isolated diastolic hypertension

Definition
IDH refers to an elevated DBP in the presence of a normal SBP. Although
this form of hypertension is frequently overlooked in general guidelines
for the classification of hypertension, in practice, IDH is defined as a SBP
of <140mmHg and a DBP ≥90mmHg.
Prevalence
When considered as a separate sub-type of hypertension, IDH is the
most common form of diastolic hypertension in individuals <40 years.
Moreover, data from NHANES III suggest that in younger individuals (<50
years) IDH accounts for ~40% of all hypertension (b see Fig. 1.2, p.5).
Pathophysiology
IDH is thought to evolve primarily from normal or high-normal BP.
Follow-up studies suggest that individuals with IDH later develop mixed
SDH. As in mixed hypertension, an i PVR is thought to be an important
haemodynamic feature of IDH. Interestingly, IDH is strongly associated
with i BMI and weight gain over time, suggesting shared links with obesity
and the metabolic syndrome. Indeed, data from the NHANES III survey in
the USA demonstrate a strong association between IDH and risk factors
for the metabolic syndrome in young adult men and women. These find-
ings contrast with previous suggestions that IDH is a benign condition,
devoid of CV risk.
History
The clinical history may provide clues as to the aetiology of hypertension
and provide a guide to subsequent management.
Background
It is important to establish when the hypertension was first noted, whether
the readings were consistently elevated or not, and the relationship to
other extraneous factors e.g. stress, anxiety, etc.
General
In the vast majority, hypertension is generally asymptomatic. Associated
symptoms often suggest 2° hypertension, e.g. sweating, palpitations, labile
BP, feelings of impending doom may suggest a phaeochromocytoma
(b see Box 2.1). A paradoxical i in BP on B-blockade also suggests a
phaeochromocytoma due to unopposed A-mediated vasoconstriction.
Box 2.1 Symptoms of phaeochromocytoma

• Headache.
• Sweating attacks accompanied by pallor.
• Palpitations.
• Feelings of anxiety.
• Chest pain.
• Abdominal pain.
• Nausea.
• Vomiting.
• Weight loss.
• Breathlessness.
• Blurred vision.
• Dizziness.
• Faints.
• Seizures.
On the other hand, tremor, palpitations, sweating, weight loss, etc. may
suggest thyrotoxicosis. A worsening renal function on ACEIs or angi-
otensin receptor antagonists (ARAs) may point to renovascular disease or
RAS. Renovascular hypertension should also be considered in those pre-
senting either aged >60 years or <30 years associated with a renal bruit,
drug-resistant hypertension or recurrent pulmonary oedema. Headaches,
non-specific abdominal pains and haematospermia are sometimes seen in
cases of accelerated phase hypertension.
Risk factors
Lifestyle issues such as a poor diet (e.g. fatty foods, processed diets) and
exercise should be interrogated. Excess salt intake as well as alcohol
may contribute to hypertension as does liquorice! A sedentary lifestyle,
smoking, and obesity i the risks for the development of CVD—so these
should be considered as important adjuncts to target in the management
of the hypertensive patient.
HISTORY 61
Past medical history

A previous history of CV event (e.g. previous angina, MI, stroke, TIA, or
peripheral vascular disease) i the risk of future events, especially if the
patient’s hypertension remains uncontrolled and alters the target pressure
to be achieved. Other concomitant features which i CV risk—including
racial origins, hypercholesterolaemia, renal failure, and diabetes mellitus—
should also be elucidated. A past medical history of pre-eclampsia or
pregnancy-induced hypertension may be useful in determining the aetiology
of hypertension.
Drug history
A previous or current drug history is vital, as well as a record of the
patient‘s side effects to particular therapies or class of therapies.
Compliance is a major factor in BP control, so this should be assessed
adequately, perhaps with a collateral history. It may be important to
emphasize the relative importance of therapy (in terms of risk reduction)
versus some, possibly trivial, side effects—although it remains important
to listen to the patient and come to an understanding of their issues per-
taining to drug therapy. Other concomitant drugs, e.g. oral contraceptives,
may exacerbate hypertension, so it may be prudent to have a trial of with-
drawing this to see if it is indeed pill-induced hypertension (b see also
Oral contraceptive pill, p.165). Other drugs include NSAIDs, steroids, and
so on (b see drugs discussed in Chapter 4, pp.165–168). Resistant hyper-
tension is defined as a failure to achieve BP targets despite 3 or more
antihypertensive agents.
Family history
This may point to an underlying genetic cause although this is very rare.
Examination
A thorough physical examination is vital at the initial consultation as it may
reveal some important clues in diagnosing s causes and underlying risk
factors. It also picks up target organ damage which lowers the target BP
to be achieved.
General
• Height, weight, and BMI (weight ÷ height2 in kg/m2).
• Presence of corneal arcus—hypercholesterolaemia in a young patient
(b see Colour plate 1).
• Xanthomata and xanthelasma (b see Colour plate 2 and 3).
• Nicotine staining—smoking.
• Cushingoid facies, a buffalo hump—Cushing’s syndrome.
• Lid lag, lid retraction, tremor with atrial fibrillation (AF)—
thyrotoxicosis.
Cardiorespiratory
• Pulse for rate, rhythm (?AF), pulse delays (radiofemoral), and check for
a full complement of pulses—a delayed pulse may indicate a coarcta-
tion of the aorta.
• BP should be checked in both arms in the seated position and when
standing—after 2–3min for any significant postural drop.
• Jugular venous pulse and signs of peripheral oedema—to assess fluid
status.
• Ventricular failure or valvular dysfunction which may represent a pre-
vious myocardial event. Type A aortic dissection—aortic regurgitation.
• Pulmonary oedema or wheeze which may restrain potential
B-blockade therapy.
Abdominal
• Renal bruits—renovascular disease or fibromuscular dysplasia.
• Expansile and pulsatile mass may suggest an abdominal aortic
aneurysm.
• Ballotable kidneys—polycystic kidney disease or hypernephroma.
Neurological
• Full neurological examination—previous stroke or in an emergency
with an acute aortic dissection.
• Mental state examination—underlying dementia, e.g. from multi-infarct
dementia.
Fundoscopy
• Hypertensive retinopathy reflects the changes seen due to systemic
hypertension and is therefore usually bilateral. Graded according to the
Keith–Wagener–Barker classification system in 1939 but now super-
seded by a newer system as detailed in b Table 2.3.
• Diabetic retinopathy—may suggest underlying previous undiagnosed
diabetes mellitus.
EXAMINATION 63
Table 2.3 Classification of hypertensive retinopathy

Grade of Changes seen
retinopathy
I Silver wiring
II Grade I + arteriovenous nipping
III Grade II + cotton wool spots, retinal oedema, haemorrhages
IV Grade III + optic disc swelling
Fig. 2.6 Grade IV hypertensive retinopathy with optic disc swelling, haemorrhages,
soft exudates, and retinal oedema (b see also Colour plates 4–6).
Blood pressure measurement

This is vital to reaching the correct diagnosis. Only validated machines
should be used. A list of these can be obtained from the BHS website.1
See also the BHS guidelines on the correct technique for measurement.2
Anaeroid sphygmomanometers should be avoided. Other automated
machines (e.g. oscillometric) should be validated—although it is worth-
while remembering that some of these machines may not be able to
measure BP accurately in AF or at extreme BP.
The BP cuff should be an appropriate size for the patient to cover 80%
of the upper arm. It may be worthwhile to measure the circumference of
the patient’s upper arm halfway up to ensure the appropriate-sized cuff is
being used. Otherwise BP may be over- or underestimated. Larger cuffs
are required for obese subjects and smaller ones in paediatrics.
The patient should be rested for at least 5–10min in the seated position
in a quiet room. They should not be talking during the measurements nor
crossing their legs. Their arm should be at the same level as their heart
and be supported.
Manual sphygmomanometry
• Ensure there is no parallax between the observer and the machine.
• Inflate the cuff to suprasystolic (to obliterate the radial pulse) to give
an idea of the SBP. Then deflate and re-inflate to 30mmHg above this
estimated figure and deflate slowly (2–3mmHg/sec).
• Korotkoff I indicating SBP is when the first sound is heard.
• The disappearance of sounds (Korotkoff V) is DBP (although in some
people, this does not ever disappear, in which case, muffling of the
sounds at Korotkoff IV is taken as the DBP).
• Record BP to the nearest 2mmHg.
References
1. Validated blood pressure monitors list from the BHS website: M http://www.bhsoc.org/
blood_pressure_list.stm
2. BHS guidelines: M http://www.bhsoc.org/how_to_measure_blood_pressure.stm
Assessing end-organ damage

End-organ damage or target organ damage (TOD) essentially implies the
end result of sustained hypertension resulting in a variety of pathophysi-
ological changes in various organs of the body. The continued shear stress
results in endothelial dysfunction, i risk of thrombogenesis, accelerated
atherosclerosis, and finally culminating in a CV event.
At a macroscopic level, the larger arteries stiffen and display reduced com-
pliance. The more peripheral arteries have reduced lumen size and result
in a continuing cycle of worsening hypertension by i systemic periph-
eral resistance. This i the afterload and left ventricular work i—leading
to LVH. The i prothrombotic state is evidenced by a variety of factors
including von Willebrand factor, fibrinogen, and so on. This may result in
occlusive events, e.g. TIAs or strokes.
Atherosclerosis may present in terms of peripheral vascular disease,
strokes, MI or angina, renal disease (b see also Colour plate 15), or
retinal occlusion.
Assessment of TOD should be directed according to the history and
examination and evidence may be obtained as per Box 2.2.
Box 2.2 Assessing end-organ damage

CV
Electrocardiogram (ECG).
Echocardiography.
Chest X-ray (CXR).
Coronary angiography.
Cardiac magnetic resonance imaging (MRI).
Renal
Dipstick urinalysis and microscopy.
Microalbuminuria.
Serum creatinine and estimated glomerular filtration rate (eGFR).
Ultrasound scan (USS)—renal.
Neurology
USS—carotids.
Computed tomography (CT)/MRI—brain.
Ophthalmology
Fundoscopy.
Visual field tests (b Fig 2.7).
Fluorescein angiography.
ASSESSING END-ORGAN DAMAGE
Left eye Right eye
Fig. 2.7 Visual field testing reveals bilateral lower visual field defects in a patient with papilloedema.
67
Investigations in hypertension
Investigations should be guided by history and examination and to search
for TOD. They can be grouped into standard screening tests to assess
other CV risk factors and those specific to screen for common s causes.
Specific investigations are generally performed to exclude 2° causes.
General (for all patients)
• Urea and electrolytes (U&Es).
• Glucose.
• Liver function tests (LFTs).
• Thyroid function tests (TFTs).
• Comprehensive lipid profile.
• Full blood count (FBC).
• Erythrocyte sedimentation rate (ESR).
• Urinalysis (protein, blood, glucose).
• 12-lead ECG.
• CXR only if suspecting aortic coarctation or dissection.
Specific
Blood
• Bicarbonate.
• Renin and aldosterone.
• Autoimmune profile:
• Anti-neutrophilic cytoplasmic antibodies (ANCAs).
• Antinuclear antibodies (ANAs).
• Double-stranded (ds)-DNA.
• Anti-glomerular basement membrane (GBM).
• Immunoglobulin (Ig) electrophoresis.
• Plasma catecholamines.
• Parathyroid hormone (PTH) and repeat calcium if initial corrected
calcium is abnormal.
Urine
• 24-h urine vanillylmandelic acid (VMA) or metanephrines.
• 24-h urine hydroxyindoleacetic acid (HIAA).
• 24-h urine Na+, K+, and creatinine clearance.
• 24-h urine free cortisol.
CV risk assessment
• Echocardiography.
• 24-h BP monitor.
• Exercise tolerance test.
Vascular hypertension
• CT angiography of subclavian vessels.
Endocrine hypertension
• Dexamethasone suppression test.
• CT/MRI adrenals.
• Adrenal vein sampling.
INVESTIGATIONS IN HYPERTENSION 69
Suppression tests for phaeochromocytoma

• Clonidine or pentolinium suppression test.
• Dexamethasone suppression test.
Other tests for phaeochromocytoma
• MIBG scan.
• 3,4-dihydroxy-6-fluoro-DL-phenylananine (F-DOPA)/F-18 fluorodeoxy-
glucose (FDG)-positron emission tomography (PET)-CT scans.
Renovascular/renally driven hypertension
• USS—abdomen.
• Mercapto-acetyltriglycine (MAG-3) renogram.
• Renal vein sampling.
• CT angiography of renal vessels.
• MR angiogram.
• Renal vein sampling.
• Dimercaptosuccinic acid (DMSA) scan.
Basic biochemistry
U&Es
Routine biochemistry for U&Es and creatinine is useful prior to therapy, to
monitor the effects of therapy and to rule out s causes.
A d K+ with or without a i Na+ and i HCO3– in the context of a patient
not on diuretic therapy must alert the clinician to the possibility of an
adrenal cause of hypertension or s hyperaldosteronism (b Box 2.3).
Box 2.3 Basic biochemistry and clues to 2° hypertension

d K+
• p and s hyperaldosteronism.
• Cushing’s syndrome.
• Liddle’s syndrome.
• RAS/disease.
i K+
• Exclude artefacts (e.g. delayed analyses).
• Unmasked by ACEI/ARA—RAS/disease.
• Renal failure.
• Immunosuppression.
• Thrombocythaemia.
d Na+
• Diuretics.
• Syndrome of inappropriate antidiuretic hormone (SIADH) secretion.
• Intracranial pathology.
• Hypothyroidism.
• Hyperparathyroidism.
i Na+
• Dehydration.
• p and s hyperaldosteronism.
i creatinine
• After commencement or dose escalation of ACEI or ARA should
prompt investigation of RAS as an underlying cause.
• At the time of presentation with malignant hypertension indicates a
poorer prognosis especially if the serum creatinine ≥300mmol/mL
(b Fig. 2.8).
BASIC BIOCHEMISTRY 71
100
>1000
100
900
800
Serum creatinine (μmol/L)
700
600
500
400
300
200
100
0
Initial Final
Fig. 2.8 Progression to end-stage renal failure in accelerated phase hypertension is

dependent on presenting creatinine. indicate patients whose serum creatinine was
<300mmol/L; are those who presented with malignant hypertension and acute
oliguric renal failure; and represent those presenting with chronic renal failure not
requiring immediate dialysis. Adapted from Isles CG (1988). Malignant hypertension.
In Catto GRD (ed.) Management of Renal Hypertension. New Clinical Applications:
Nephrology. Lancaster: MTP Press, pp. 41–78, with kind permission of Springer
Science and Business Media.
Renin and aldosterone

The availability of plasma renin activity assays and plasma aldosterone
levels has revolutionized the modern management of hypertension.
However, these should be interpreted with caution in the context of a
patient already on drug therapy, particularly B-blockade.
B-blockers d renin secretion at the juxtaglomerular apparatus so a d renin
on B-blockade is hardly surprising. However, a i renin in this setting must
raise the possibility of either non-compliance or renin-driven hyperten-
sion, e.g. RAS or nephrogenic causes including, very rarely, a reninoma.
Conversely, most other drug therapies i renin levels, so a d renin in this
setting may point to an adrenal cause of hypertension.
Similarly, an i aldosterone must be interpreted in the context of the cor-
responding renin level. 2° hyperaldosteronism is strikingly common espe-
cially in the context of accelerated phase hypertension. A d renin and i
aldosterone in a patient off B-blockade points to hyperaldosteronism as a
cause for hypertension and further investigation should be undertaken to
elucidate the cause. Beware that calcium-channel antagonists (CCAs) may
mask the diagnosis with an apparently normal plasma aldosterone.1
The ratio of plasma aldosterone to renin (ARR) has been suggested as a
useful screening tool for hyperaldosteronism. Apart from various factors
such as posture and serum K+ levels, antihypertensive therapies may cause
false positive or false negative results. It may sometimes be necessary to
alter therapies prior to making any assumptions on ARR per se.
Other biochemistry
It is also perhaps important to measure a patient’s glucose level to rule
out diabetes as a co-existing risk factor, especially in risk stratification.
Thyroid and parathyroid function is also an easy, yet clinically important
and treatable cause of hypertension that must not be forgotten, as is the
case with i Ca2+ and its underlying causes.
Reference
1. Brown MJ, et al. (1999). Calcium channel blockade can mask the diagnosis of Conn’s syndrome.
Postgrad Med J 75:235–6.
DIPSTICK URINALYSIS 73
Dipstick urinalysis
Dipstick urinalysis is a simple bedside test which can reveal underlying
frank proteinuria as well as an active urinary sediment which may point to
a renal cause for hypertension. It is also an important risk factor for sub-
sequent renal failure, CVD, and is also correlated with overall mortality in
hypertensive patients.
Microalbuminuria and proteinuria
As with diabetic patients, microalbuminuria (defined as a urinary albumin
excretion of 20–200mg/L) is considered to be a sensitive marker of early,
non-specific kidney damage. A spot urine albumin (mg)/creatinine (mg)
ratio (ACR) is a convenient method of measuring microalbuminuria.
Microalbuminuria is:
• more closely related to ambulatory BP than clinic pressure.
• correlates with left ventricular mass and retinopathy.
• reverses with effective antihypertensive therapies suggesting that
microalbuminuria (like LVH) may be a useful measure of end-organ
damage and CV risk in hypertensive patients.
However, data from large trials are lacking and at present the true predic-
tive value of microalbuminuria is uncertain. Nevertheless, the presence of
microalbuminuria in a hypertensive patient should prompt a more detailed
search for evidence of other end-organ damage.
A dipstick proteinuria of 3+ or more has a sensitivity of 96% and specifi-
city of 87% of predicting a protein:creatinine ratio of ≥1—which is as good
a surrogate of proteinuria as a 24-h urine collection.1
Haematuria
Microscopic haematuria is also a marker of hypertensive renal damage,
although it is less closely related to clinical outcome than proteinuria.
Hyaline arteriosclerosis, focal glomerular obsolescence, and thickening of
GBMs are some of the nephrogenic changes that may result in dipstick
haematuria. This can be associated with d glomerular filtration, red blood
cell casts, and persistent microscopic haematuria. Haematuria is also asso-
ciated with some forms of renal parenchymal disease, and may, therefore,
suggest an underlying cause for hypertension.
Glycosuria
Dipstick glycosuria needs little further mention apart from the obvious
need to check fasting sugar levels and glycosylated haemoglobin to
measure the long-term glycaemic control of an individual patient.
Laboratory testing for urinary albumin excretion and urine albumin:
creatinine ratios are mandatory annually in all diabetic and renal patients.
Reference
1. Agarwal R, et al. (2002). Dipstick proteinuria: can it guide hypertension management? Am J Kid
Dis 39:1190–9.
Electrocardiography
A 12-lead ECG should be performed in all patients. It is a rough-and-ready
screen for LVH and may also indicate previous myocardial damage, heart
block, or dysrhythmias.
LVH is present in longstanding hypertension. In slim patients, the presence
of LVH is often a false-positive finding when investigated further. Whilst
ECGs are easy to perform, they are not as sensitive as cardiac MRI or
modern echocardiography in picking up LVH (b Table 2.4).
LVH is the physiological result of myocardial stress pumping against an i
afterload in the form of PVR. In hypertension, this usually consists of con-
centric hypertrophy of the left ventricular wall and septum although other
forms such as eccentric or asymmetric hypertrophy may occur.
LVH remains an important endpoint when considering treatment as it is
linked to mortality outcomes in hypertension.1 It is one of the major end-
organ damage criteria in determining need for therapy in hypertension.
Hence, its diagnosis requires careful consideration and evaluation.
Criteria
A variety of criteria have been developed to classify LVH (b see Box
2.4). The easiest and most readily used one is the Sokolow–Lyon index.
A strain pattern indicated by ST depression and T-wave inversion in
V4–6 is strongly supportive of LVH and may represent an ischaemic bulky
left ventricle (b see Box 2.5). Left-axis deviation may also be present
(b Fig. 2.9).
Metabolic disturbances may also be evident on the ECG. This can provide
clues to the underlying diagnosis or side effects of therapy (b see Box 2.6).
Table 2.4 Sensitivity and specificity of ECG versus other modalities

for LVH*
ECG M-mode 2-D Echo 3-D Echo Cardiac
MRI
Cost low moderate moderate moderate high
Sensitivity low moderate high high high
Specificity high high high high high
Availability high high high low low
Complexity low low moderate moderate moderate
*Adapted with permission from Alfakih K, et al. (2006). The assessment of left ventricular
hypertrophy in hypertension. Hypertension 24:1223–30, Lippincott, Williams and Wilkins.

ELECTROCARDIOGRAPHY 75
Box 2.4 LVH classification systems

Sokolow–Lyon2
S V1 + R V5 or V6 >35mm.
Cornell criteria3
S V3 + R aVL >28mm in men.
S V3 + R aVL >20mm in women.
Framingham criteria4
R aVL>11mm, R V4–6 >25mm.
S V1–3 >25 mm; S V1 or V2 + R V5 or V6 >35mm; R I + S III >25mm.
Box 2.5 Other causes of LVH and strain pattern

• Hypertrophic obstructive cardiomyopathy (HOCM).
• Aortic stenosis.
• True posterior infarction.
• Wolff–Parkinson–White Type A.
Box 2.6 ECG manifestations of metabolic abnormalities

• d K+: U waves (b Fig 2.10)—this may be a clue to underlying hyper-
aldosteronism. ST segment depression, QRS prolongation may also
be present. Arrhythmias, e.g. ventricular ectopics, atrial tachycardia,
heart block, ventricular tachycardia (VT), and ventricular fibrillation
(VF) may also occur. d Mg2+may show similar features.
• i K+: tall, pointed T waves which are narrow, d P-wave amplitude, ST
segment changes, 1st-degree heart block, bundle branch blocks, VT,
VF, asystole! i Mg2+ may show similar features.
• i Ca2+: short QT.
• d Ca2+: long QT.
76
CHAPTER 2
Essential hypertension
Fig. 2.9 LVH on voltage criteria.
ELECTROCARDIOGRAPHY 77
I aVR VI V4
II aVL V2 V5
III aVF V3 V6
RHYTHM STRIP: II
Fig. 2.10 U waves on 12-lead ECG indicating possible d K+.
References
1. Kannel WB, et al. (1970). Electrocardiographic left ventricular hypertrophy and risk of coronary
heart disease. The Framingham Study. Ann Intern Med 72:813–22.
2. Sokolow M and Lyon T (1949). The ventricular complex in left ventricular hypertrophy as
obtained by unipolar precordial and limb leads. Am Heart J 37:161–86.
3. Casale PN, et al. (1987). Improved sex-specific criteria of left ventricular hypertrophy for clinical
and computer interpretation of electrocardiograms: validation with autopsy findings. Circulation
75:565–72.
4. Levy D, et al. (1990). Determinants of sensitivity and specificity of electrocardiographic criteria
for left ventricular hypertrophy. Circulation 81:815–20.
Home blood pressure

Home monitoring is generally reliable if patients correctly use a well main-
tained, validated automated sphygmomanometer for measuring BP at the
brachial artery (i.e. not radial etc.). A list of these can be obtained from
the BHS website.1
Home monitoring can shorten the time taken for diagnosis and to achieve
target pressure once therapy has been initiated. It is less validated for
prognosis than ambulatory BP monitoring (ABPM) and the usual differ-
ence between home and clinic readings is unclear. Thresholds should be
adjusted accordingly (b see THOP Trial2). Generally, this is accepted
as being 10/5mmHg lower than clinic pressure measurements (as with
ABPMs)—so a clinic target of 140/90mmHg is equivalent to a home target
of 130/85mmHg.
Home BPs may ultimately gain ground over ABPMs due to ease of use,
cheaper cost, and the convenience both for clinical trial purposes and
clinical use. The American Society of Hypertension has recently issued a
position statement on home blood pressure which may have implications
for future practice.3
References
1. Automatic digital blood pressure devices for clinical use and also suitable for home/self assess-
ment. Available at the BHS website: M http://www.bhsoc.org/bp_monitors/automatic.stm
2. Staessen JA, et al. (2004). Antihypertensive treatment based on blood pressure measurement at
home or in the physician’s office: a randomized controlled trial. JAMA 291:955–64.
3. Pickering TG, et al. (2008). ASH Positron Paper. Home and ambulatory blood pressure
monitoring, when and how to use self (home) and ambulatory blood pressure monitoring.
J Clin Hypertens. 10(11):850–5.
24-hour ambulatory blood pressure

monitoring
24-h ABPM is being used more widely and there are now several vali-
dated devices available (for a comprehensive list of these, please refer to
the BHS website1). However, ABPM is not necessary for either diagnosis
or management in the majority of hypertensive patients. The benefits of
antihypertensive therapy in reducing CV risk have been almost exclusively
established using seated clinic BP recordings.
Potential advantages
ABPMs offer the chance of a quicker patient diagnosis by accumulating
multiple recordings of BP over a short time period and may provide faster
monitoring of responses to changes in treatment. They are also a practical
way of excluding white coat hypertension (b see Definitions).The incon-
venience they pose comes partly from the frequency of recommended
intervals (every 30min!)—which cannot be relaxing or comfortable, espe-
cially for patients who find the inflating cuffs painful or who have high
pressure.
Whilst ABPM values may be closely associated with surrogate meas-
ures such as LVH and carotid intima-media thickness, there are insuffi-
cient outcome data concerning ABPM. However, those that are available
suggest superiority, especially of nocturnal BP, over clinic BP.
Practical points
• These are invariably lower than clinic BP and thus an individual with a
daytime ABPM average of 150/100mmHg is probably at more risk than
a subject with the same clinic pressure.
• The accepted difference is that daytime ABPMs are ~10/5–12/7mmHg
lower than clinic BP.
• Daytime average ABPM values are the most important comparator to
clinic BP for management decisions. A ‘normal’ daytime average ABPM
is defined as <135/85mmHg, but optimal values are <130/80mmHg
(lower in diabetics).
• A normal dip is thought to be around 10% of daytime readings.
Nighttime readings may be a stronger predictor than clinic, daytime, or
average ABPMs (b Fig. 2.12). However, note the reversal of pattern
in shift workers is usual. A lack of dipping may indicate poor sleep pat-
terns due to obstructive sleep apnoea, prostatism, etc.
Definitions
• White coat hypertension: the clinic BP is elevated but there is a normal
daytime average ABPM (b Fig. 2.11).
• White coat effect: both clinic BP and ABPM are elevated, but clinic BP
remains more elevated than the expected 10/5 or 12/7 mm Hg. This
could be termed true hypertension with a white coat effect.
24-HOUR AMBULATORY BLOOD PRESSURE MONITORING 81
• Masked hypertension: normal office BP but high home or 24-h ABPMs

(i.e. the reverse of white coat hypertension). It may be present in
untreated people as a prelude to the onset of hypertension. No
outcome evidence on the benefits of intervention for treating masked
hypertension is currently available.
Indications for 24-h ABPM
• Borderline hypertension without evidence of TOD.
• Resistant hypertension.
• White coat hypertension (b Fig. 2.11).
• Labile hypertension.
• Assessment of nocturnal dipping.
• Assessment of postural hypotension in symptomatic patients without
overt postural changes.
• Autonomic failure.
200
160
SBP
BP(mmHg)
120
80
MAP
40
DBP
Fig. 2.11 A 24-h ABPM depicting the white coat effect. SBP, DBP, and mean arterial
pressure (MAP) are labelled. Note the first reading is very high in the clinic but all
the subsequent readings are entirely normal. There is also a normal diurnal variation
in that the night-time readings dip as expected.
Reference
1. Automatic digital blood pressure devices for clinical use and also suitable for home/self assess-
ment. Available at the BHS website: http://www.bhsoc.org/bp_monitors/automatic.stm
15
Night-time 24-hour
14
13 Daytime
5-Year risk of CV death
12
11
10 Clinic
110 130 150 170 190 210 230

SBP mmHg
14
Night-time 24-hour
13
Daytime
12
5-Year risk of CV death
11
10
Clinic
9
60 70 80 90 100 110 120 130

DBP mmHg
Fig. 2.12 Adjusted 5-year risk of cardiovascular death in the study cohort of 1,144
older patients for CBPM and ABPM. Using multiple Cox regression, the relative risk
was calculated with adjustment for baseline characteristics including gender, age,
presence of diabetes mellitus, history of cardiovascular events and smoking status.
Five-year risks are expressed as number of deaths per 100 subjects. Reproduced
from Burr ML et al. (2008). The value of ambulatory blood pressure in older adults:
the Dublin outcome study. Age and Ageing. 37:201–6, Oxford University Press.
ECHOCARDIOGRAPHY 83
Echocardiography
Echocardiography (echo) is a non-invasive, non-radioactive, ultrasound-
based tool that helps visualize the dynamic function and anatomical struc-
ture of the heart.
Two-dimensional (2D) echo has a few advantages over other investiga-
tions in the setting of hypertension. Primarily, it is a more reliable and
sensitive method of assessing LVH than a standard 12-lead ECG.1 This
is particularly important in the setting of a patient with borderline or
resistant hypertension when the decision to treat or not treat depends
on the presence or absence of LVH. Similarly, the effectiveness of therapy
can be assessed in terms of regression of LVH post-therapy. LVH, as
already mentioned, is an independent risk factor for CV mortality above
and beyond BP per se. Echo can also distinguish LVH due to HOCM from
that due to hypertension—this is an important diagnostic point.
Echo can also estimate left ventricular mass using a variety of methods
including M-mode and 2D imaging, and newer methods including contrast
echo, three-dimensional (3D) echo, and cardiac MRI may improve this in
the future. Additionally, in some patients the presence of a coarctation
may be diagnosed using echo.
Left ventricular systolic function can be assessed using ejection fraction on
2D echo or fractional shortening on M-mode echo. Diastolic function is
assessed using a number of methods, and in particular with tissue Doppler
imaging.
In cases of Type A aortic dissection, visualization of the aortic root may
occasionally be difficult—transoesophageal echo may help determine the
type of dissection more readily.
Reference
1. Kannel WB (1972). Role of blood pressure in the development of congestive heart failure: The
Framingham Study. NEJM 287:781–7.
Prognosis and risk stratification

Hypertension is a strong risk factor for CVD—this is a continuous and
graded association (b Fig. 2.13). However, there are other risk factors
which multiply the absolute risk of developing CVD. Note the difference
between absolute risk and lifetime risk (b Box 2.7). There is no point in
estimating risk in those who have already suffered an event.
Box 2.7 Definition of risk terminology

• Absolute risk: the excess risk due to exposure to a specific hazard.
• Lifetime risk: the risk of developing a disease during an individual’s
lifetime or dying of the disease.
These risk factors may be inherited or acquired and therefore may be

modified or not depending on the risk factor itself (Box 2.8).
Box 2.8 Risk factors for CVD

Inherited risk factors
• Age.
• Sex.
• Racial origin.
• Family history.
• Type 1 diabetes mellitus.
Acquired/modifiable risk factors
• BP.
• LDL cholesterol.
• Arterial stiffness.
• Smoking.
• BMI.
• Pulse pressure.
• Exercise.
• LVH.
• Microalbuminuria.
To quantify risk, there are a number of multivariate risk formulas that

require discrete information about the individual patient that can be input
to work out an individual’s risk of developing CVD. These are only to be
used on untreated patients and are based on large populations (prima-
rily Caucasian) which mean that they are not necessarily representative of
other populations (Box 2.9).
The Joint British Societies (JBS) have issued recommendations on pre-
venting CVD, including a CVD risk prediction chart, based on the
Framingham database ( b see Figs. 2.14 and 2.15).
PROGNOSIS AND RISK STRATIFICATION 85
Box 2.9 Risk calculators

• Framingham coronary prediction score sheets.
• Dundee risk disk.
• Sheffield tables.
• PROCAM risk.
• Joint British Societies ( JBS) guidelines.
These charts have been primarily designed for p prevention and are an
aid to making clinical decisions about when to intervene on lifestyle and
whether to use antihypertensives, lipid-lowering medication, or aspirin.
Patients with persistently elevated BP >160/100mmHg with TOD should
have their BP treated, irrespective of calculated risk.
For patients from the Indian subcontinent, assume that the risk is 1.5 x
higher than that predicted from the charts. Treatment is recommended if
the 10-year CVD risk for the individual is ≥20%.
The charts are not for individuals who have:
• Overt evidence of CHD.
• Familial hypercholesterolaemia or other dyslipidaemias.
• Chronic renal dysfunction.
• Diabetes mellitus.
• Age <35 years.
A) Systolic blood pressure B) Diastolic blood pressure
Age at risk:
Age at risk:
256 80–89 256
years 80–89
years
128 70–79 128
years 70–79
(floating absolute risk and 95% CI)
(floating absolute risk and 95% CI)
years
64 60–69 64 60–69
years years
IHD mortality
IHD mortality
32 50–59 32 50–59
years years
16 16
40–49
years 40–49
years
8 8
4 4
2 2
1 1
120 140 160 180 70 80 90 100 110

Usual SBP (mmHg) Usual DBP (mmHg)
Fig. 2.13 The relationship between the risk of mortality from ischaemic heart
disease and blood pressure in a meta-analysis of >1 million subjects. The data are
similar for stroke. Redrawn from Lewington S, et al. (2002). Age-specific relevance
of usual blood pressure to vascular mortality: a meta-analysis of individual data for
one million adults in 61 prospective studies. Lancet 360:1903–13 © 2002, with
Non-smoker Smoker
Age under 50 years
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
Age 50–59 years
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
Age 60 years and over
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
CVD risk <10% over next 10 years CVD risk over SBP = systolic blood pressure mmHg
next 10 years TC : HDL = serum total cholesterol
CVD risk 10–20% over next 10 years 30% to HDL cholesterol
CVD risk >20% over next 10 years ratio
10% 20%
Fig. 2.14 JBS guidelines on CVD risk prediction for non-diabetic men. Reproduced
with permission from the University of Manchester.
PROGNOSIS AND RISK STRATIFICATION 87
Non-smoker Smoker
Age under 50 years
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
Age 50–59 years
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
Age 60 years and over
180 180
160 160
SBP 140 SBP 140
120 120
100 100
3 4 5 6 7 8 9 10 3 4 5 6 7 8 9 10
TC: HDL TC: HDL
CVD risk <10% over next 10 years CVD risk over SBP = systolic blood pressure mmHg
next 10 years TC : HDL = serum total cholesterol
CVD risk 10–20% over next 10 years 30% to HDL cholesterol
CVD risk >20% over next 10 years ratio
10% 20%
Copyright University of Manchester
Fig. 2.15 JBS guidelines on CVD risk prediction for non-diabetic women.
Reproduced with permission from the University of Manchester.
Non-pharmacological management:
background
• Non-pharmacological management remains a mainstay in the manage-
ment of all individuals—whether hypertensive or not, with or without
end-organ damage.
• The positive benefit of these interventions has a role to play in pre-
venting, ameliorating, and reducing the burden of CV risk factors across
any risk groups.
• It engenders patients to take responsibility for their own health and
should be recommended whether a patient is on or about to start
pharmacological treatment, unless contraindicated by other concomi-
tant conditions.
• Dietary alteration and exercise are the most obvious areas which may
help reduce BP without drug therapy. The evidence for this stems from
epidemiological data as discussed in b Prevalence and incidence, p.50.
• Although the individual benefits of each intervention may appear
modest at best, they may, in combination, be crucial—especially in the
borderline hypertensive patient—to avoid pharmacological therapies.
A summary of these effects are listed in b Table 2.5.
• In addition, it is important to remember that some lifestyle interven-
tions may not affect BP per se but have dramatic impact on CV risk, and
are therefore crucial to the holistic management of the hypertensive
patient. Examples include avoiding a high fat diet and smoking.
• In the Trials of Hypertension Prevention (TOHP I and II) study, the
effect of lifestyle changes in people with high normal blood pressure
was examined. Weight loss and sodium reduction significantly lowered
BP but not stress/nutritional management. This translated in the longer
term to a reduction in CV mortality and morbidity in those assigned to
sodium reduction.1
Smoking
Whilst smoking causes a temporary rise in pressure, it has not been impli-
cated in epidemiological studies with i BP per se. In fact, there is an inverse
relationship between smoking and i BP. Nevertheless, smoking remains
an important risk factor for the development of CVD and is therefore vital
in the calculation of an individual’s risk.
Smoking cessation is associated with a reduction in susceptibility to coro-
nary events by nearly 50% and this can occur within a short time frame of
2 years. Risk of CV events is thought to normalize to a non-smoker’s risk
at 15 years post cessation.
Reference
1. Cook NR et al. (2007). Long term effects of dietary sodium reduction on cardiovascular disease
outcomes: observational follow-up of the trials of hypertension prevention (TOHP). BMJ
334(7599):885.
NON-PHARMACOLOGICAL MANAGEMENT: BACKGROUND 89
Table 2.5 Effects of lifestyle modification*

Intervention Recommendation Expected SBP reduction
(range)
Weight reduction Maintain ideal BMI 5–10mmHg per 10kg weight
(20–25kg/m2) loss
Diet Consume diet rich in fruit, 8–14mmHg
vegetables, and fibre, but
low in fat
Reduced sodium <100mmol/day (<6g of 2–8mmHg
intake sodium chloride or <2.4g
of sodium/day)
Physical activity Regular aerobic physical 4–9mmHg
activity, e.g. brisk walking
for at least 30 min at least
5 days/week
Alcohol moderation No more than 3 units/day 2–4mmHg
in men; no more than 2
units/day in women
*Adapted from, US Department of Health and Human Services (2003) with permission.
The JNC 7 Report. Source: The National Heart, Lung and Blood Institute (part of the
National Institute of Health and the US Department of Health and Human Services)
Salt
Salt intake is closely linked to hypertension—the kidney is central to salt
and water retention. Western populations currently consume at least
6–10 x more salt (~9–10g/day) than required, so it is not surprising that
intervention to reduce this may have an effect. Most of this salt is from
processed foods, cereals, meat, and milk (b Box 2.10).
The Dietary Approaches to Stop Hypertension (DASH) Trial was an inter-
vention trial which showed a clear dose–response between the amount of
Na+ restriction and the level of BP achieved (b Fig. 2.16).1 Meta-analysis
of intervention trials indicate a reduction of 5/2.5mmHg in SBP and DBP
with just a 50mmol reduction in Na+ intake.2
A reduction in salt intake from 10g to 6g a day (current UK recommenda-
tions) theoretically could, via a reduction in BP, lead to a 16% reduction in
stroke mortality and 12% reduction CHD mortality. This would theoreti-
cally prevent approximately 19,000 stroke and heart attack deaths in the
UK each year and 2.6 million each year worldwide.3 There are no inter-
ventional trials to prove this outcome.
Salt sensitivity also has a profound effect—most hypertensives are salt
sensitive compared to their normotensive counterparts. There are also
racial differences with more hypertensive people of African descent being
salt sensitive than non-African hypertensives.
Box 2.10 Salt conversion

• 100mmol/day salt = 6g salt/day = ~2.3g Na+/day = 100mmol/day
Na+.
• At steady state, urinary excretion of Na+ = dietary intake, i.e. there is
100% bioavailability.
References
1. Sacks FM, et al. (2001). Effect on bloods pressure of reduced dietary sodium and the Dietary
Approaches to Stop Hypertension (DASH) diet. NEJM 344:3–10.
2. Law MR, et al. (1991). By how much does dietary salt reduction lower blood pressure? III –
Analysis of data from trials of salt reduction. BMJ 302:819–24.
3. Salt and blood pressure. Available at Consensus Action on Salt and Health (CASH) website:
M http://www.actiononsalt.org.uk/health/salt_and_health/blood_pressure.htm
SALT 91
A 135
−2.1
Control diet (−3.4 to −0.8)‡
−5.9 −4.3
130 (−8.0 to −3.7)‡ (−5.9 to −3.2)‡
SBP (mmHg)
−5.0
(−7.6 to −2.5)‡
DASH diet −2.2
(−4.4 to −0.1)*
125 −1.3
(−2.6 to −0.0)*
−1.7
(−3.0 to −0.4)‡
120
High Intermediate Low
Sodium level
B 85
−1.1
(−1.9 to −0.8)‡
Control diet
−2.9 −2.4
(−4.3 to −1.5)‡ −2.5 (−3.3 to −1.5)‡
DBP (mmHg)
(−4.1 to −0.8)†
−1.0
DASH diet
80 (−2.5 to −0.4)
−0.6
(−1.5 to −0.2) −1.0
(−1.9 to −0.1)†
75
High Intermediate Low
Sodium intake
Fig. 2.16 Dose–response to reduced salt intake in the DASH study. Adapted
with permission from Sacks FM, et al. (2001). Effect on bloods pressure of reduced
dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet.
NEJM 344:3–10, © 2001 Massachusetts Medical Society, all rights reserved.
Dietary intervention, weight loss, and

exercise
Healthy diets
A diet low in saturated fats, high in fruits, vegetables, low-fat dairy prod-
ucts, fibre, and plant-derived grains and proteins is recommended, as is
oily fish. Some of this is reflected in the recent UK Department of Health
campaign for 5 portions of fruit a day (‘5 A Day’) to reduce the burden of
CVD in the population.
There are no outcome data on how a healthy diet consisting of low fat,
high fruit and vegetables reduces mortality or morbidity from CVD—
however, vegetarians have lower BP than non-vegetarians in both popula-
tion-based and clinical trials.
Fish-oil supplementation in large doses does lower BP by around 4/2mmHg.
It has also been shown in meta-analyses that omega-3-polyunsaturated fatty
acids and oily fish reduce CV mortality. (b See also Box 2.11.)
Weight loss and obesity
The likely beneficial effects of dietary interventions on BP may not be
directly from the better diet but perhaps from the associated weight loss.
Obesity and hypertension co-exist within the metabolic syndrome—a
combination of CV risk factors that include insulin resistance and dyslipi-
daemia. This is a phenomenon that is i throughout the world—35% of the
adult population in Europe is overweight whilst 18% are obese.
Every 10kg of excess weight is associated with a 3/2mmHg i in BP sug-
gesting a 12% i in IHD and 24% i in stroke. Weight loss is associated with
a d in BP—in a meta-analysis1 of 24 randomized controlled trials (RCTs),
a 5kg weight loss is associated with a 4/3mmHg d in BP. Low calorie diets
may d SBP in some people by about 10mmHg.
Exercise
Regular aerobic exercise (30–60min, 3–5 x/week) is recommended at all
ages. The i sedentary lifestyle of westernized populations (around 70% in
the UK) means that the general CV fitness of the population is in decline.
This predisposes to an i burden of CVD especially in an ageing population
subjected to unhealthy diets and rising levels of obesity.
A recent meta-analysis2 of trials in both aerobic (72 trials) and resistance
training (9 trials) revealed a fall in BP of 3/3mmHg mediated through a
reduction in systemic vascular resistance and with positive effects on a
variety of CV risk factors.
DIETARY INTERVENTION, WEIGHT LOSS, AND EXERCISE 93
Box 2.11 Other dietary modifications

K+ supplementation
There is some evidence to suggest K+ supplementation may reduce BP
by small amounts but there is no outcome data to support its wide-
spread use.
Ca2+ supplementation
Apart from 1 review which showed a small benefit, there are no
outcome data to suggest this has any effect on outcome.
Mg2+ supplementation
There are no data to support supplementation of Mg2+ in terms of BP
or outcome, especially so in hypertensives.
References
1. Neter JE, et al. (2003). Influence of weight reduction on blood pressure: a meta-analysis of rand-
omized controlled trials. Hypertension 42:878–95.
2. Fagard RH and Cornelissen VA (2007). Effect of exercise on blood pressure control in hyper-
tensive patients. Eur J Cardiovasc Prev Rehabil 14:12–17.
Alcohol
There is a strong relationship between the pattern and quantity of alcohol
intake and hypertension and CV mortality. Since World War I, it has been
known that there is a graded relationship between alcohol intake and BP,1
although other groups reported a J-shaped curve between overall mortality
and alcohol—sometimes due to misclassification of occasional drinkers as
non-drinkers. A 23-year follow-up study by Doll et al. (b see Fig. 2.17)
has, however, proved it was J shaped—even after correcting for this
difference—and for all-cause mortality as well as ischaemic heart disease.
In a study of >80,000 people in the USA, there was a linear relationship (in
middle-aged white men drinking >2 daily drinks) of the number of drinks
consumed per day and the level of BP.2 Abstainers and light drinkers had
lower levels of BP and drinkers who stopped drinking had a fall in BP. This
correlation has been shown repeatedly in many other cross-sectional and
epidemiological studies across wide populations and independent of other
risk factors (b Fig. 2.18).
It is now thought that the ‘French paradox’ of reduced CHD despite mod-
erate red wine intake may be due to the wine’s effects on HDL choles-
terol or antithrombotic effects.
Generally, non-drinkers should not be encouraged to start drinking, but
drinkers should be advised to drink moderately whilst chronic alcoholics
should be encouraged to abstain altogether.3 A meta-analysis of 15 RCTs
showed a modest reduction of 3/2mmHg in BP when alcohol reduction
was reduced across a range of trials (b see Fig. 1.24).
References
1. Lian C (1915). L’alcoholisme, cause d’hypertension arterielle. Bulletin de l’Academie de Medicine
74:525–8.
2. Klatsky AL, et al. (1977). Alcohol consumption and blood pressure. Kaiser-Permanente
Multiphasic Health Examination data. NEJM 296:1194–2000.
3. Klatsky AL (2007). Alcohol, cardiovascular diseases and diabetes mellitus. Pharmacol Res
55:237–47.
ALCOHOL 95
All causes of death

4%
Annual death rate and 95% CI

3%
2%
Ischaemic heart disease
1%
Respiratory diseases
0
0 20 40
Alcohol consumption (units/week)
Fig. 2.17 The association between all-cause mortality and alcohol consumption
is a J-shaped curve. Reproduced from Doll R, et al. (2005). Mortality in relation
to alcohol consumption: a prospective study among male British doctors. Int J
Epidemiol 34:199–204, with permission from Oxford University Press.
Raw
Adjusted ± standard error
142
140
138
Systolic
136
134
132
130
86
84 Diastolic
82
80
78
Abstainers Light Moderate Heavy

drinkers drinkers drinkers
Alcohol consumption
Fig. 2.18 Mean systolic and diastolic blood pressure (raw and adjusted for
potential confounders) by alcohol consumption in men aged 35–64 years in
Auckland, New Zealand, 1982. Reproduced from Jackson R, et al. (1985). Alcohol
consumption and blood pressure. American Journal of Epidemiology 122:1037–44,
Oxford University Press.
OTHER METHODS 97
Other methods
Acupuncture
Acupuncture, an ancient Chinese technique, was recently subjected to a
single, blinded RCT in treated and untreated mild to moderate hyperten-
sives.1 Patients underwent a 6-week treatment course and were followed
up at 6 months. This showed that there was a 5/3mmHg difference in
ambulatory pressures initially, which then rose to pre-treatment levels at
6 months.
Another randomized trial (SHARP2) showed no difference in BP reduction
between the acupuncture and sham groups. The obvious design problems
are lack of an effective control and effective blinding of both the patient
and administering therapist.
Breathing modulation devices
The US Food and Drug administration has approved a device which allows
patients to modulate their breathing to music. The approval is for stress
reduction and as an adjunct to hypertension management. This is based
on preliminary evidence that the device may ameliorate BP. A series of
studies have shown the potential for this device to reduce BP by retraining
patients to breathe in relation to the music they hear. The mechanism
is thought to be via a reduction in sympathetic activity utilizing slowed
breathing.3
References
1. Flachskampf FA, et al. (2007). Randomized trial of acupuncture to lower blood pressure.
Hypertension 115:3121–9.
2. Macklin EA, et al. (2006). Stop Hypertension with acupuncture research (SHARP). Hypertension
48:838–45.
3. Resperate M http://www.resperate.com/us/discover/clinicalproof.aspx#peer_reviewed_articles
Pharmacological management:
background
Drug therapy is indicated when the benefit of therapy outweighs risks.
Careful estimation of this risk should be undertaken as already described,
especially when encountering a borderline patient.
Drug therapy does not obviate the need for non-pharmacological methods
(b see Non-pharmacological management, pp.88–96). Additionally, therapy
should include anything to reduce all risk factors, not just BP per se.
The drug classes to treat i BP are discussed in b Chapter 7. One major
issue, which has been resolved to some extent, is whether different drugs
are more effective than others in reducing CV mortality.
Drug choice
The ALLHAT1 trial demonstrated little difference between the diuretic,
calcium-channel antagonist (CCA), and ACEI regimens on outcome,
thereby answering this question. The A-blocker arm was, however, dis-
continued early due to the presence of ankle oedema which was thought
to represent worsening heart failure.
The ASCOT2 trial, however, suggests that newer drug regimens (ACEI
and CCA) fare better than older drug regimens (B-blocker and diuretic)
in all-cause mortality, stroke (by 25%), and coronary events (by 15%).
However, the p endpoint of non-fatal MI was not statistically significant
between the groups. ASCOT also clearly demonstrated the need for mul-
tiple risk factor management to reduce CV risk effectively.
What remains unclear is the role of B-blockers in the management of
hypertension—it is certainly not a first-line recommended drug class for
hypertension except in young people or in pregnancy.
References
1. ALLHAT Officers and Coordinators (2002). Major outcomes in high-risk patients randomized
to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: the
Antihypertensive and Lipid Lowering Treatment to prevent Heart Attack Trial (ALLHAT). JAMA
288:2981–97.
2. Dahlöf B, et al. (2005). Prevention of cardiovascular events with an antihypertensive regimen
of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as
required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm
(ASCOT-BPLA): a multicentre randomised controlled trial. Lancet 366:895–906.
COMPLIANCE 99
Compliance
Compliance refers to the patient’s adherence to their prescribed drug
regimen. It represents a major problem in medicine and in hypertension in
particular, primarily because hypertension is generally asymptomatic and
drug therapy inevitably causes side effects.
There are many factors which worsen and improve compliance; these are
listed in b Box 2.12.
Box 2.12 Factors affecting compliance

Factors causing non-compliance
• Asymptomatic disease.
• Cost of drug therapy.
• Patient’s perception surrounding risks of drug therapy.
• Patient’s perception regarding drug effectiveness.
• Drug side effect profile.
• Forgetfulness.
• Poor labelling.
• Poor packaging.
• Polypharmacy.
• Social factors.
Factors to improve compliance
• Clear explanation of risk/benefit arguments.
• Patient empowerment in decision-making process.
• Informed choices through education.
• Individualization of therapy.
• Concordance (patient and doctor agree on regimen).
• Simplify drug regimen.
• Regular contact and continuing supervision.
• Home monitoring.
Monitoring compliance
It is possible to monitor compliance through a variety of manoeuvres
including:
• Patient request for repeat prescriptions at appropriate intervals.
• Drug accountability.
• Directly observed drug therapy.
• Monitoring drug levels (for certain drugs only).
Stepped care versus combination

therapy
Stepped care refers to the current practice within national guidelines
which advocate using the lowest possible dose of an initial drug and then
titrating this compound up the dose–response curve (as tolerated by the
patient) to the maximum dose before then commencing a second-line
therapy. Its aim is to reduce polypharmacy and improve compliance.
However, improving the efficacy of the drug by i the dose is in many
ways counterintuitive as it moves in a direction which is more likely to
cause more side effects, and therefore worsen the side-effect profile
of the drug, thereby reducing patient satisfaction and i the risk of non-
compliance.
Combination therapy refers to using low doses of 2 agents, either in a
single pill or in quick succession as add-on therapy. This usually results in a
greater clinical efficacy with reduced side effects compared to uptitration.
This, may in part, be due to synergism, or may be due to the offsetting of 1
side effect by the action of the complementary drug. Combination therapy
therefore offers the clinician the opportunity to maximize clinical efficacy
and minimize adverse events to the benefit of the patient.
This concept has allowed for safer fixed-dose combination therapies to
be developed. This not only enhances clinical efficacy but simplifies the
drug regimen for the patient, and similarly the practical aspects of pre-
scribing for the clinician. In an era where it is clear that the lower the BP,
the lower the incident risk, it is probably time that most guidelines move
towards a combination therapy system.
TARGETS AND EVIDENCE BASIS 101
Targets and evidence basis

The treatment thresholds to start antihypertensive therapy are different
to the treatment targets.
The BHS recommend initiation1 of antihypertensive therapy in:
• Those with BP ≥160/100mmHg persistently on ≥2 occasions.
• In diabetics, renal impairment, established CVD, TOD, or those with a
CVD risk ≥20% and SBP 140–159mmHg and/or DBP 90–99mmHg.
The recommended treatment goals or targets are:
• SBP <140mmHg, DBP <85mmHg in non-diabetic hypertensives but
the minimum acceptable level of control is <150/90mmHg (Audit
Standard).
• SBP <130mm Hg, DBP <80mmHg in diabetic hypertensives, Audit
Standard is <140/80mmHg.
• Main benefit comes from BP achieved, not the drug used.
• Low-dose aspirin and statin therapy should be used to reduce CVD
risk—statins for all hypertensives with CVD, CVD risk ≥ 20% irrespec-
tive of baseline cholesterol.
• Good glycaemic control in diabetics with HbA1c <7%.
Note that the JBS guidelines for target BP are based primarily on the
HOT study.2 Efforts are currently underway in the USA to study whether
the benefits of lowering the threshold for target SBP to <120mmHg in
all non-diabetic patients may also be beneficial (Systolic Blood Pressure
Intervention Trial—SPRINT).
Diabetics are considered coronary equivalents since their risks of coro-
nary disease are i by virtue of their diabetes alone. Intensive lowering of
BP in diabetics, where possible, retards progression to microvascular as
well as macrovascular complications (b see Diabetes, pp.196–199)
References
1. Williams B, et al. (2004) Guidelines for the management of hypertension: report of the fourth
working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens 18:139–85.
2. Hansson L, et al. for the HOT Study Group (1998). Effects of intensive blood pressure low-
ering and low dose aspirin in patients with hypertension: principal results of the Hypertension
Optimal Treatment (HOT) randomized trial. Lancet 351:1755–62.
Treatment algorithms
Treatment guidelines are a relatively new method of implementing evi-
dence base into day-to-day practice. The beneficial effect of BP reduction,
albeit well known, remains suboptimal throughout the world.
Guidelines are available at international, national, and local levels. Whilst
they do not all conform to a similar pattern, nor provide the same informa-
tion, they should be evidence-based and adapt to the ever changing infor-
mation available. Many guidelines are based on socio-economic factors
that predicate certain treatments over others, whilst others depend on
the nature of the health system in that country.
The algorithm for essential hypertension reproduced here (b Fig. 2.19) is
from our local clinic guidelines which are based on the ‘ACD’ rule devel-
oped in Cambridge, UK (b Fig. 2.20). This was formally adopted by the
BHS and the National Institute of Health and Clinical Excellence (NICE)
in the UK and forms the basis of the current Joint BHS–NICE guidelines
(b Fig. 2.21). The same applies to the algorithm for resistant hyperten-
sion (b Fig. 2.22) in the next section b Resistant hypertension, p.106.
The most important criterion is BP reduction, irrespective of the type of
drug used. However, B-blockers should be avoided in the elderly, espe-
cially those with ISH. They may be used in the younger patient although
we would avoid the older non-selective agent such as atenolol. These
agents also i the risk of developing diabetes when used in conjunction
with thiazide diuretics, especially in high-risk groups.
Tolerability, availability, and cost form the cornerstone of therapy and we
would recommend the ACD guidelines, especially if there is no specific
indication for a particular class of agent in a particular patient.
Treatment guideline for essential hypertension
(SBP>140 AND/OR DBP>90mmHg)
SBP ≥160 SBP 140–159 AND/OR SBP 130–139
NOTES
Routine investigations AND/OR DBP 90–99 AND
• U&E, creatinine, glucose DBP ≥100 DBP 85–89
• Total, HDL, LDL cholesterol and triglycerides Assess for
• 12-lead ECG • TOD or
• Urine analysis
• 10-year CVD risk of ≥20%
Other investigations to be considered (see chart) or
• Urinary VMA
• Renal tract USS • diabetes or
• ECG • Routine investigations • renal disease
• Renin and aldosterone levels
• Exclude secondary
Additional points causes Yes No to all
• Refer patients under 20-yrs age
• If possible, avoid the combination of a
thiazide and β-blocker
• Use ARA if cough on ACEI Treat Annual
• Renal impairment is NOT itself a reassessment
contraindication to ACEI/ARA, but they
should be introduced cautiously and renal
artery stenosis excluded if suspected Young <55yr and Old ≥55yr
• Should check U&Es 7–10 days after ACEI/ non-Black or Black
ARA therapy commenced
TREATMENT ALGORITHMS
Treatment Targets
Step 1 A C or D A= ACE-Is/ARAs
No diabetes < 140/85
Diabetes or CVD B= B-blockers
<130/80 Step 2 C= CCAs
A + C or A + D
D= thizide diuretics
Step 3 A+C+D
Step 4 Reconsider secondary causes. Add further diuretic, α blockers or B-blockers. p.107
Resistant hypertension If still uncontrolled refer to hospital for further investigation.
Fig. 2.19 Algorithm for management of essential hypertension.
103
Statins and the hypertensive patient
HMG CoA-reductase inhibitors
Primary prevention
10 year CVD risk ≥ 20%
Secondary
prevention
• Active coronary
Treat artery disease
simvastatin 40mg • Peripheral vascular
disease
• Ischaemic stroke
Type 2 Diabetes
diagnosed for >10 years
and/or age >50 years
Aspirin 75mg/d and hypertension
1) Primary prevention
Consider aspirin 75mg OD if:
• Age ≥50 years
and controlled BP i.e. <150/90mmHg
and TOD or 10-year CVD risk ≥20%
and no contraindication
2) Secondary prevention
Such patients should already be on aspirin, unless there is a specific contraindication.
Fig. 2.20 Cambridge guidelines for s prevention.
Choosing drugs for patients newly diagnosed with

hypertension
Abbreviations Younger than 55 years or older
A = ACE inhibitor 55 years or black patients of any age
(consider angiotensin-II receptor
antagonist if ACE intolerant)
C = calcium-channel antagonist A C or D Step 1
D = thiazide-type diuretic
A + C or A + D Step 2
Black patients are those of African
or Caribbean descent, and not
mixed-race, Asian or Chinese A+C+D Step 3
patients.
Beta-blockers are not a preferred Add

initial therapy for hypertension but • further diuretic therapy
or
are an alternative to A in patients • alpha-blocker Step 4
younger than 55 years in whom A is or
not tolerated or is contraindicated • beta-blocker
including women of childbearing Consider seeking specialist
potential). advice
Fig. 2.21 Joint NICE–BHS guidelines on hypertension management.

Resistant hypertension
• Resistant hypertension is defined as a BP >140/90mmHg despite 3
antihypertensives.
• There are a variety of reasons that may underlie this and these are
summarized in Box 2.13.
• There is little evidence to guide the physician in this area. More studies
are required—the BHS will be launching a series of studies to examine
this in greater detail shortly, under its Pathway Project.
• In the interim, we suggest following the algorithm as described in
b Fig. 2.22.
• All patients with resistant hypertension, should, after exclusion of arti-
ficial causes, be considered for investigation of s causes; in particular,
hyperaldosteronism or renovascular disease, by a specialist.
• The role of i diuretics, particularly aldosterone antagonists, in a cohort
of these resistant patients, as effective antihypertensives, was recently
reported in the ASCOT study.1
Box 2.13 Causes of resistant hypertension

Artificial
• Poor technique—cuff sizes.
• Lack of compliance.
• Non-concordance.
• Inadequate therapy.
• Age-related arterial stiffness—pseudohypertension.
True resistance
• Concomitant medication.
• White coat effect.
• Concomitant risk factors—obesity, alcohol excess, sleep apnoea,
stress.
• Physiology—volume overload, baroreflex failure.
• s causes.
• Hereditary causes.
Reference
1. Chapman N, et al. (2007). Effect of spironolactone on blood pressure in subjects with resistant
hypertension. Hypertension 49:839–45.
Treatment algorithm for resistant hypertension (renin-based protocol)
(SBP>140 AND/OR DBP>85mmHg on 3 drugs)
NOTES Establish standard triple therapy

1. Renin A+C+D
• Low ≤ 10 mU/L
• High ≥ 100 mU/L
• Difficult to interpret on B-blocker and
beware of local variations
2. Combination of spironolactone and ACEI/ Measure plasma renin
ARA may increase the risk of
hyperkalaemia, especially if patient has Renin LOW HIGH renin
chronic renal failure, and therefore advice (≤10mU/L) (≥100mU/I)
is to monitor U&E every 4–6 months, or if
indicated, earlier (e.g. developement of
diarrhoea or vomiting, which should Add spironolactone* Add β-blocker
trigger the temporary stoppage of these
drugs anyway). There is some anecdotal *can be substituted by
evidence to suggest risk of hyperkalaemia amiloride or triamterene
Renin
is less with ARAs than it is with ACEIs.
NORMAL
RESISTANT HYPERTENSION
3. Always re-consider secondary causes
4. Clues to a Conn’s adenoma requiring
further investigation include: Add doxazosin or
• BP fall >20mmHg on spironolactone long-acting nitrate** **particularly if ISH
• K+ <3.5mmol/L is suspected
• Fall in serum K+ with thiazide therapy
5. Doxazosin should be started at a low

dose and titrated up. If postural symptoms Consider adding spironolactone or B-blocker if not on already
persist, we suggest using a slow release OR centrally acting drugs such as hydralazine or minoxidil
formulation.
Fig. 2.22 Algorithm for management of resistant hypertension.
107
Hypertensive emergencies
The terminology here is crucial—there is a lot of confusion between the
terms ‘malignant hypertension’, ‘accelerated hypertension’, ‘hypertensive
urgencies’, and ‘emergencies’.
It is perhaps best to use the terms ‘accelerated phase hypertension’ and
‘hypertensive emergencies’ only. The other terminology only adds to
confusion about what requires immediate, urgent, or a more laissez faire
approach to therapy (as in chronic hypertension). Both accelerated phase
hypertension and hypertensive emergencies usually present with symp-
toms, unlike chronic hypertension.
Definitions
Accelerated phase hypertension is an abrupt rise in BP (sometimes with
DBP ≥120mmHg), associated with retinal haemorrhages (± papilloedema)
and occasionally proteinuria—which, if left untreated, can lead to a CV
event (stroke, MI), renal failure, or blindness. This requires treatment
to reduce BP over days to weeks using oral antihypertensive therapies,
i.e. they need urgent but not immediate treatment. They should be fol-
lowed-up closely. It commonly occurs in males, people of black descent,
or in pre-existing hypertensives.
Hypertensive emergencies refer to a life-threatening situation wherein a
severe, uncontrolled BP is associated with acute impairment of an organ
system, e.g. aortic dissection, cardiac failure, hypertensive encephalopathy
(or seizures), an acute stroke, eclampsia, phaeochromocytoma crisis, micro-
angiopathic haemolytic anaemia, and so on. This requires BP to be brought
down over minutes to hours in a controlled manner, usually using intrave-
nous (IV) antihypertensives in an Intensive Care or Coronary Care Unit.
Hypertensive emergencies may present with or without changes associ-
ated with accelerated phase hypertension (i.e. there may or may not be
papilloedema/retinal haemorrhages). The same is true vice versa. Patients
with an elevated BP level without either should be defined as having
‘severe uncontrolled hypertension’.
Pathophysiology of accelerated phase and hypertensive
emergencies
This is not well understood—a rise in systemic vascular resistance due to
loss of normal autoregulation results in progressive endothelial dysfunc-
tion leading to fibrinoid necrosis and intimal proliferation. Alternatively,
there may be up-regulation of the renin–angiotensin system causing i BP,
a pressure natriuresis, and further release of vasoconstrictors which per-
petuate a cycle of i BP.
The aetiology is similar to that of hypertension in general—either essential
or s to the known causes of hypertension—but it is perhaps worthwhile
excluding a phaeochromocytoma, at least with urine screening tests in all
these patients.
HYPERTENSIVE EMERGENCIES 109
Epidemiology
It is thought to be prevalent in ~1% of hypertensives, although more effec-
tive and prompt therapy as soon as hypertension is diagnosed means that
this is now falling rapidly in modern societies. It has an incidence of 2 per
100,000 cases per annum with a M:F ratio of 2:1.
Management of hypertensive emergencies
The management of a true hypertensive emergency should be on a high
dependency unit, e.g. Intensive Care or Coronary Care. The aims are to
safely and effectively reduce BP in a timely manner whilst observing for
any change to the patient on a regular basis. Generally, short-acting, titrat-
able antihypertensives are used intravenously to achieve this in a con-
trolled manner.
Precipitous drops in BP can be catastrophic and should therefore be
avoided. Careful monitoring and regular medical reviews are paramount
to ensure proper management.
Aortic dissection
Type A dissection (which extends to the aortic root) usually requires
medical and surgical management to repair the aortic root. Type B dis-
section requires medical management only, although endovascular repair
and vascular surgery is sometimes indicated to protect vital organs, e.g.
kidneys, limbs, etc.
The aim is to reduce SBP to 110mmHg and to reduce heart rate. Agents
such as IV labetalol are recommended.
Labetalol is an A1 and non-selective B antagonist with a t1/2 of 5.5h. It has
an onset of action within 2–5min. It may reduce heart rate but maintains
cardiac output. Usual doses are a bolus dose (up to 50mg) over at least
1min or infusion at 2mg/min to a total dose of 200mg.
Hypertensive heart failure
This should be treated as left ventricular failure with IV nitrates and loop
diuretics. IV sodium nitroprusside may also be used (b see Sodium nitro-
prusside, p.235). The dose is 10–15mcg/min, i every 5–10min (usual range
10–200mcg/min) for a maximum of 3 days.
Hypertensive encephalopathy
This is rare but can present with neurological symptoms, seizures or coma
(b see Colour plates 7 and 8). Diagnosis may be confirmed on MRI
or CT. Management is with IV sodium nitroprusside, GTN, or labetalol.
Seizures should be controlled with IV agents as per usual.
For sodium nitroprusside, the usual dose is 0.5–1.5mcg/kg/min, i slowly to
0.5–8mcg/kg/min (lower if on other antihypertensives). It should be stopped
if there is an unsatisfactory response to maximum dose at 10min. The aim
is to reduce MAP by about 20% or to a DBP of ~100mmHg (whichever is
greater) over 1h. Beware the patient with a cerebral ischaemic event—it
is usual for a transient rise in BP—where the penumbra is hypoperfused
during the infarct, and may be more so if IV anti-hypertensive therapy is
used to lower pressure further (b Fig. 2.23).
Severe pre-eclampsia or eclampsia

This should be managed on a maternity ward; the main intervention is to
delivery the fetus. The medical management includes intraveouns mag-
nesium sulphate and control of BP using hydralazine or labetalol (b see
Pregnancy: pre-eclampsia p.190).
Phaeochromocytoma crisis
This is one hypertensive emergency where B-blockade is contraindicated
as it could worsen the hypertension via unopposed A-mediated vasocon-
striction. Phentolamine IV, a rapid acting A-adrenergic antagonist, is the
drug of choice.
Management of accelerated hypertension
• This should be directed at reducing BP over days to weeks. Oral agents
are generally preferred. B-blockers or long-acting CCAs should be
used as 1st-line agents.
• Short-acting CCAs (e.g. buccal nifedipine) should not be used as they
may cause precipitous drops in BP, resulting in a CV event (e.g. stroke).
• ACEIs and ARAs may also cause precipitous drops in BP in the acceler-
ated phase patient whose hypertension is being driven by renin. This
may be evidenced by hypokalaemia on admission or other clues as
mentioned in b Examination, p.62.
75 Ischaemia
Cerebral blood flow
(mL/100g/min)
50 Normal
Chronic
25 hypertension
25 50 75 100 125 150 175

Cerebral perfusion pressure (mmHg)
Fig. 2.23 Cerebral perfusion pressure is altered in chronic hypertension and cer-
ebral ischaemia, so sudden drops in BP may worsen ischaemia in cerebral infarction.
Chapter 3 111
Specific investigations for

secondary hypertension
Introduction 112
Phaeochromocytoma
Urine catecholamines and metanephrines 114
Plasma catecholamines and metanephrines 116
Dynamic testing 118
Clonidine suppression test 120
Pentolinium suppression test 121
Conn’s syndrome
Fludrocortisone suppression test 122
Saline suppression test 122
Imaging
Computed tomography 123
Magnetic resonance imaging 124
Nuclear medicine: adrenal 126
Nuclear medicine: kidney 130
Interventional radiology 132
112 CHAPTER 3 Specific investigations for hypertension
Introduction
As discussed in b Chapter 2, there may be clues from the history and
examination or basic investigations which suggest a s cause of hyperten-
sion. In such cases, it will be necessary to then screen using non-invasive
followed by invasive investigations to confirm these causes biochemically,
and finally to confirm this with imaging.
The indications for these tests may vary from centre to centre. It is impor-
tant to understand the details regarding how these tests are performed
in the local laboratory as this may influence the sensitivity and specificity
for diagnosis. A broad idea of this is provided in this chapter although
these may not approximate the true sensitivity and specificity for your
local laboratory.
Urine catecholamines and

metanephrines
Catecholamines are metabolized to metanephrine and VMA which are
then excreted in the urine (b Fig. 3.1).
3 x 24-h urine collections for urinary VMA or catecholamines have been
the standard screening test for phaeochromocytoma for many years.
However, urinary metanephrines and normetanephrines (NMNs) may give
better results. A recent retrospective analysis in Glasgow confirmed this
in a series of 159 tests done (with 25 cases subsequently confirmed).1 The
results are shown in Box 3.1 (b also see Phaeochromocytoma, p.152).
Box 3.1 Sensitivity and specificity of screening tests for

phaeochromocytoma
Sensitivity (%) Specificity (%)
Urinary free metadrenalines 100 94
Urinary catecholamines 84 99
Urinary VMA 72 96
Plasma catecholamines 76 88
In general, these tests do not give an idea of the size or location of
the phaeochromocytoma. They are useful screening tools and reason-
ably cheap, so may be used as a test in all new patients and those with
resistant hypertension as a matter of routine. The pitfalls in diagnosis
include an incomplete (i.e. <24-h) collection and false positives due to
concomitant medications (b Box 3.2).
Box 3.2 Drugs which cause false positive urine tests for
phaeochromocytoma
• Acetaminophen.
• Alcohol.
• Aminophylline, theophylline.
• Amphetamines.
• Appetite suppressants.
• Caffeine.
• Clonidine.
• Diuretics.
• Epinephrine.
• Insulin.
• Lithium.
• Nicotine.
• Salicylates.
• Steroids.
• Tricyclics.
• Vasodilators.
URINE CATECHOLAMINES AND METANEPHRINES 115
DHPR
H4B H2B
Tyrosine L-DOPA Dopamine Norepinephrine Epinephrine

TH
MAO COMT MAO COMT
COMT
3-O-methyldopa MAO Metanephrine
DOPAC MAO
Normetanephrine
COMT COMT
Vanillactic acid MAO
Homovanillic acid MHPG
MAO
Vanillylmandelic acid
Fig. 3.1 Catecholamine metabolism.
Reference
1. Boyle JG, et al. (2007). Comparison of diagnostic accuracy of urinary free metanephrines, vanillyl
mandelic acid, and catecholamines and plasma catecholamines for diagnosis of pheochromocy-
toma. J Clin Endocrinol Metab 92:4602–8.
Plasma catecholamines and

metanephrines
Plasma noradrenaline and adrenaline (i.e. catecholamines) may be meas-
ured in cases where there is a suspicion of a phaeochromocytoma. This
may be in conjunction with urinary metanephrines and NMNs or VMAs,
or in cases where the diagnosis is strongly suspected but the urine tests
are negative. However, although rare, it is unlikely that an intermittently
secreting phaeochromocytoma will be diagnostic on plasma catecho-
lamines unless these are obtained during an episode.
This is usually done by the high performance liquid chromatography elec-
trochemical (HPLC-EC) technique (b Fig. 3.2). This well established
assay relies on the extraction of catecholamines from plasma and then
separation on the basis of their retention patterns within a column in a
C18 column. A non-naturally occurring catecholamine (dihydroxyben-
zylamine, DHBA) is used as an internal standard to correct for any losses
during the extraction.
Additionally, plasma metanephrines and NMNs have been shown to be
even better predictors, especially in patients with intermittently secreting
tumours (presumably due to continued metabolization of catecholamines).
This has been reported to provide a sensitivity of 97% and specificity of
between 92–96%.1,2 Reference intervals in the local laboratory should
ensure the primacy of sensitivity over specificity.
Improvements in the analytical technology (liquid chromatography with
tandem mass spectrophotometry, radioimunnoassay, ELISA, etc.) are
already having a major impact on the diagnostic rates obtainable. The clini-
cian should also consider the possibility false negatives in patients with
either very small tumours or those which do not produce catecholamines
(e.g. dopamine)—where measurement of other markers such as plasma
dopamine or methoxytyramine may be important.2
PLASMA CATECHOLAMINES AND METANEPHRINES 117
NAdr
A 54.29 DHBA (internal
mV standard)
Adr
0.0 16.0
NAdr
B 65.10
mV
Adr
DHBA
0.0 16.0
Fig. 3.2 HPLC assays for catecholamines. A comparison is made to the internal
standard, normal (A), and a patient with adrenal phaeochromocytoma secreting
noradrenaline (B).
References
1. Eisenhofer G, et al. (1999). Plasma metanephrine and normetanephrine for detecting phaeo-
chromocytoma in Von Hippel Lindau disease and multiple endocrine neoplasia type 2. NEJM
340:1872–9.
2. Eisenhofer G, et al. (2008). Current progress and future challenges in the biochemical diagnosis
and treatment of pheochromocytomas and paragangliomas. Hormone Metab Res 40:329–37.
Dynamic testing
These are tests which are performed to unmask or rule out the presence
of a true phaeochromocytoma or paraganglionoma.
Provocation tests are performed when there are normal baseline results
in someone who is thought to have a high clinical suspicion for a phaeo-
chromocytoma. Suppression tests may be performed to establish that
borderline baseline results are truly due to a true phaeochromocytoma or
paraganglionoma (b see Box 3.3).
The provocation tests have gone out of fashion—mainly because:
• They may provoke a hypertensive crisis requiring phentolamine
therapy.
• Poor sensitivity.
• More modern methods of measuring activity are available, e.g. urinary
and plasma metanephrines which are far more sensitive.
Box 3.3 Provocation and suppression tests for suspected

phaeochromocytomas and paraganglionomas
Provocation tests
• Histamine test.
• Tyramine test.
• Glucagon test.
Suppression tests
• Clonidine test.
• Pentolinium test.
Clonidine suppression test

Suppression tests tend to be used in those patients with borderline
biochemistry for catecholamines but where the clinical suspicion is
high (plasma noradrenaline/norepinephrine (NE) 500–2000ng/L (2.9–
11.8nmol/L) or if plasma NE + E is 1000–2000ng/L (5.9–11.8nmol/L). They
should not be used in patients with severe coronary or cerebrovascular
disease or in those with hypotension.
Clonidine is an old antihypertensive agent which works as a direct agonist at
the presynaptic A2-adrenergic receptor in the brain, thereby reducing cardiac
output and systemic resistance and BP. It also inhibits noradrenaline release:
this forms the basis of its use as a suppression test1 (like pentolinium) for
diagnosing phaeochromocytomas. The procedure is described in Box 3.4.
Box 3.4 Procedure

• Patient lays supine (having emptied bladder), IV cannula inserted and
flushed.
• Rest for 30min.
• Measure BP and pulse.
• A blood sample is obtained for plasma NE (or NMN) from the
cannula and recorded as the baseline sample. Store each sample on
ice until centrifugation.
• Administer clonidine 0.3mg PO (note time).
• Patient remains supine, resting quietly. Further samples for plasma
NE (or NMN) are then taken at 60, 120, and 180min.
A 50% reduction is quoted to be the expected suppression of NE from

baseline in patients without a phaeochromocytoma. A positive response2
is defined as 1 of either:
• Plasma NE >500ng/L (2.9nmol/L).
• Plasma NE >500ng/L and Δ plasma NE <50% (specificity 98%, sensitivity
67%).
• Plasma NMN >112ng/L and Δ plasma NMN <40% (specificity 100%,
sensitivity 96%).
There is also usually no haemodynamic change in phaeochromocytoma
patients but a d in BP is seen in patients with essential hypertension or
anxious patients.
There is a higher false-positive rate in patients on tricyclic antidepressants
which should be omitted (depending on their t1/2) and those with bor-
derline NE values. The advantage is that it can be given orally. Clonidine
suppresses normal levels of NE (at baseline) but not epinephrine; it is also
long acting therefore the patient may remain hypotensive for hours (hence
best to omit ß-blockers, diuretics and other antihypertensives, antidepres-
sants) and may require overnight admission.
References
1. Bravo EL, et al. (1981). Clonidine suppression test: a useful aid in the diagnosis of phaeochro-
mocytoma. NEJM 305:623–6.
2. Eisenhofer G, et al. (2003). Biochemical diagnosis of pheochromocytoma: how to distinguish
true from false-positive test results. J Clin Endocrinol Metab 88:2656–66.
PENTOLINIUM SUPPRESSION TEST 121
Pentolinium suppression test

This is usually performed to confirm the diagnosis of a phaeochromocy-
toma. Catecholamines (NE or Epinephrine) are released from adrenergic
nerve endings by preganglionic cholinergic nerves. Pentolinium is a ganglion
blocking agent which binds to the acetylcholine receptor, thereby pre-
venting catecholamine release—hence its potential use as a suppression
test.1 Therefore failure to suppress NE or Epinephrine adequately after
injection with pentolinium suggests autonomous secretion by a tumour,
i.e. a phaeochromocytoma. The procedure is described in Box 3.5.
Box 3.5 Procedure

• Patient lays supine (having emptied bladder), IV cannula inserted and
flushed.
• Rest for 30min before the next sample (for plasma NE or Epinephrine)
is taken.
• Monitor BP and pulse at outset and every time blood taken.
• Take 2 baseline samples at 5-min intervals for catecholamines.
• At time 0, give 2.5mg pentolinium IV.
• Take blood at 10 and 20min.
• After 2h, measure BP and heart rate, supine and standing.
• Encourage patient to ‘march on the spot’ while standing in order to
reduce venous pooling in the legs.
• If/when there is no symptomatic postural hypotension, the patient
may now go home.
A positive result is 1 in which there is little or no fall in catecholamines (up

to 8%) post-pentolinium, suggesting the presence of a phaeochromocy-
toma. Most normal patients should suppress between 22–63%.1
2 Caution: after this test the patient should not drive for at least 6h and
preferably not until the following day.
The benefit of this test is that pentolinium is short acting therefore any
postural hypotension would be shortlived (up to 2h). However, it is renally
excreted therefore should be used in patients with normal renal function.
It also does not suppress NE levels much if the baseline level is normal.
This test is, generally, not used widely now.
Reference
1. Brown MJ, et al. (1981). Increased sensitivity and accuracy of phaeochromcytoma diagnosis
achieved by use of plasma-adrenaline estimations and pentolinium suppression test. Lancet
1:174–7.
Fludrocortisone suppression test

This is a test previously used to confirm the diagnosis of hyperaldos-
teronism. This is usually for patients with a suspected diagnosis of Conn’s
with either a low renin or an elevated aldosterone:renin ratio. The patient
is admitted for 4 days to be given fludrocortisone orally, correcting for
K+. A baseline plasma and 24-h urinary aldosterone is measured prior to
therapy. All diuretic therapies should have been omitted in the preceding
3 weeks.
Fludrocortisone (0.1mg) is given 6-hourly with sodium chloride 3 x a day
(1.8g slow Na = 30mmol Na+). A failure to suppress plasma aldosterone
to <166pmol/L (assuming they are potassium replete—if not, they require
supplementation) suggests p hyperaldosteronism. This is considered the
gold standard test. It is contraindicated in patients with accelerated hyper-
tension or heart failure.
Saline suppression test

• This can be used to confirm the diagnosis of hyperaldosteronism during
a 1-day admission.
• 2L of saline 0.9% is administered over 4h as an infusion. Basal aldos-
terone and plasma renin activity is measured and rechecked at hourly
intervals.
• The normal response is to suppress aldosterone <135pmol/L; if the
aldosterone is between 135–270pmol/L, the result is thought to be
borderline. A true case of p hyperaldosteronism would have values
>270pmol/L.
• Both the fludrocortisone suppression test and saline suppression tests
are not performed widely nowadays as current imaging techniques far
exceed what was previously available, and inpatient stays for investiga-
tions are no longer practical nor cost effective.
COMPUTED TOMOGRAPHY 123
Computed tomography
Computed tomography (CT) is generally reserved for patients in whom a
s cause of hypertension is suspected.
Cardiac CT (electron beam/ultrafast CT) has the advantage of capturing
images quickly and these are gated to the patient’s ECG allowing the esti-
mation of various functional parameters throughout the cardiac cycle.
Calcium quantification (b Fig. 3.3) has been proposed as a potential
screening tool for coronary artery disease—but the correlation between
calcium and active inflamed plaque is unresolved—hence the absence of
calcium does not exclude coronary disease.
Due to its radiation risks, the indication for requesting a CT has to be
robust—this may include clinical signs and symptoms or biochemical evi-
dence of underlying conditions. A CT chest may be useful to delineate
the presence or absence of a coarctation of aorta and its position. A CT
abdomen may help in the identification of an adrenal mass, e.g. phaeo-
chromocytomas and paraganglionomas—and can help in the detection of
adrenal adenomas—although frequently these are picked up as incidenta-
lomas on scans performed for other indications. A CT may also delineate
the anatomy of renal vessels when a RAS is suspected. Additionally, renal
masses arising from polycystic kidneys, hypernephromas, or other condi-
tions may be readily identified.
Fig. 3.3 3D volume rendered reconstruction on CT showing aortic calcification of

the abdominal aorta (see arrows) (b see also Colour plate 9).
Magnetic resonance imaging

MRI is a useful, new, non-radioactive modality for imaging in s hyperten-
sion. It may be indicated in the investigation of adrenal hypertension, e.g.
Conn’s adenoma and RAS, and has the advantage over CT in terms of the
lack of radiation.
Cardiac MRI allows excellent views of the anatomical structure of the
heart and other great vessels of the CV tree. It has gained wide application
in the diagnosis and treatment of congenital heart disease, coarctation,
and dissection. Cine modalities have allowed the estimation of ejection
fraction, anatomical dimensions, LVH, and mass estimations which are
more reproducible than those obtainable by echocardiography. It is there-
fore useful when monitoring progress to therapy in research studies but
its limitations are availability and expertise (as well as prolonged imaging
time)—which, currently, is still limited to large teaching hospitals.
MAGNETIC RESONANCE IMAGING 125
Fig. 3.4 MRI showing LVH (arrow) (courtesy of Dr JHF Rudd, Cambridge).
Nuclear medicine: adrenal

Nuclear medicine can provide some clues as to the underlying causes of
s hypertension—which may be requested based on the history or once
biochemistry provides a clue. The type of nuclear medicine scan depends
on the diagnosis being queried.
MIBG scan
MIBG scintigraphy is useful in the anatomical localization of phaeochro-
mocytomas especially once the biochemical diagnosis has been made on
urinary metanephrines (or VMA) or plasma catecholamines and CT scan-
ning or MRI has revealed the presence of a mass.
H
N NH
NH2
I
Fig. 3.5 Chemical structure of MIBG.
MIBG has a structure similar to NE (b Fig. 3.5) and is taken up by neu-

roendocrine tumours such as phaeochromocytomas (b see Fig. 3.6) but
also paraganglionomas, neuroblastomas, carcinoid, and medullary thyroid
carcinomas). It is usually labelled with 123I or 131I—the former is usually
used for diagnosis and the latter for therapeutic use—although this is not
exclusively so.
Drugs which interfere with the scan should be stopped (including antip-
sychotics, antihypertensives, opioids, tricyclics, and sympathomimetics)
prior to the scan. Iodine is given orally for a few days prior to injection
of MIBG to block uptake in the thyroid gland. A 5-min image is taken and
a repeat whole body scan is done within 18–24h. Whilst MIBG also accu-
mulates physiologically in certain organs, abnormal uptake in areas cor-
relating to abnormal masses on other imaging modalities helps to confirm
the diagnosis. More recently, MIBG-SPECT can be combined with images
on CT or MRI allowing for co-registration of the functional and anatomical
components (b see Fig. 3.7).
Once the diagnosis is established, MIBG uptake means that chemical treat-
ment can be deployed using higher doses of radiolabelled 131I-MIBG to
treat the tumour and monitor its progress thereafter using 123I-MIBG. It
is usually used in inoperable cases where the tumour shows uptake in
all metastatic sites. A negative MIBG scan (which can occur in 15% of
benign and 50% of malignant phaeochromocytoma) usually means thera-
peutic intervention using MIBG will not be possible. The usual reasons for
MIBG negative phaeochromocytomas include small tumour size, central
necrosis, or haemorrhage and tumour location. MIBG should not be used
as a therapeutic modality for small intra-adrenal phaeochromocytomas.
NUCLEAR MEDICINE: ADRENAL 127
MRI MIBG
Anterior Posterior
Fig. 3.6 MRI (left) showing a left-sided adrenal mass (see arrow). This was then con-
firmed on MIBG scan (arrowed on anterior and posterior views) to be a phaeochro-
mocytoma. Note also the physiological uptake in the liver, salivary glands, and bladder.
A B
Fig. 3.7 MIBG-SPECT combined with CT showing a paraganglionoma with MIBG

uptake (arrow) and a Type B dissection of the aorta (arrowheads) in the same
patient. Reproduced from Strobel K, et al. (2007). MIBG-SPECT/CT-angiography
with 3-D reconstruction of an extra-adrenal phaeochromocytoma with dissection of
an aortic aneurysm Eur J Nuc Med Mol Imaging 34:150, with permission (b also see
Colour plate 11).
PET-CT scans
MIBG scans may sometimes be negative for phaeochromocytomas.
There is i evidence that functional imaging using PET-CT scans (b Fig. 3.8)
may localize the anatomical locations of phaeochromocytomas more accu-
rately in these patients. Consideration should be given to functional imaging
if there is biochemical evidence of a phaeochromocytoma but initial imaging
with MIBG is negative. Functional imaging itself may be specific or non-
specific—therefore if a specific test is negative, then a more non-specific
test may reveal the malignant tumour, especially if metastatic (b Fig. 3.9).
18F-FDA
(fluorodopamine) has been shown to be superior to 131I-MIBG
in metastatic phaeochromocytoma—including those which are MIBG
negative. 18F-FDOPA (fluorodihydroxyphenylalanine) has 100% sensitivity
and specificity. 18F-FDG is less sensitive as it is non-specifically taken up by
metabolically active tissue.
In VHL, underexpression of NE transporter in VHL-related phaeochro-
mocytomas may explain low sensitivity 97%) with MIBG—where 18F-FDA
has a sensitivity of 100%.2 This may be important when screening for VHL.
NH2 MIBG OCT

L-tyrosine
O
HO O
TH
hNET
HO NH2
L-DOPA ST receptor
HO O
O Stop
HO NH2
L-AADC
HO Dopamine
OH DBH
OH NH2
Norepinephrine
OH
Glucose
OH transporter
PNMT OH NH
CH3
OH Epinephrine
FDG
Fig. 3.8 Potential functional imaging targets within the chromaffin cell. Specific
targets are on the left, less specific on the right. The boxed substances can be radi-
olabelled for use in PET-CT. hNET, human norepinephrine transporter; ST, soma-
tostatin Adapted from Ilias I, et al. (2005). New functional imaging modalities for
chromaffin tumors, neuroblastomas and ganglioneuromas. Trends Endocrinol Metab
16:66–72, © 2005, with permission from Elsevier.
NUCLEAR MEDICINE: ADRENAL 129
A B C
Fig. 3.9 (A) 123I-MIBG shows adrenal uptake (arrows). (B) 18F-FDOPA-PET
shows left paranephric extra-adrenal phaeochromocytoma (arrow). (C) 18FDG-PET
shows spinal, pelvic, and rib metastases (arrowed). Reproduced from Mackenzie IS,
et al. (2007). Eur J Endocrinol 157:533–7. © 2007 Society of the European Journal of
Endocrinology, with permission.
References
1. Ilias I, et al. (2005). New functional imaging modalities for chromaffin tumors, neuroblastomas
and ganglioneuromas. Trends Endocrinol Metab 16:66–72.
2. Kaji P, et al. (2007). The role of 6-[18F]fluorodopamine positron emission tomography in the
localization of adrenal pheochromocytoma associated with von Hippel–Lindau syndrome. Eur J
Endocrinol 156: 483–7.
Nuclear medicine: kidney

Isotope renography provides functional and anatomical information about
kidneys which may help in the diagnosis of kidney disorders in general and
occasionally underlying causes of hypertension—in particular RAS.
A variety of isotopes can be used including DTPA and MAG-3.
MAG 3 renogram scan
MAG-3 renal scintigrams offer information about kidney structure and
function. It provides physiologic information to complement information
gathered from other imaging modalities. It effectively provides a gauge of
effective renal plasma flow as most of it is excreted via tubular secre-
tion in the proximal tubule via an active transporter. Therefore, MAG 3
extraction is reduced in patients with impaired renal function. There are
also pitfalls when investigating patients with bilateral stenoses and those
on concurrent antihypertensives.
MAG 3 renograms are normally performed with and without an ACEI
challenge—which essentially determines the functionality of the stenosis
which may have been diagnosed using another modality. An ACEI also
dramatically i the sensitivity and specificity of the test—so the ACEI chal-
lenge is usually performed before the unchallenged scan. The second
scan is only done if the ACEI challenge is positive. A positive MAG 3 with
captopril study is also said to predict a hypertensive cure or improvement
following vascular intervention, whereas a stenotic lesion with no change
suggests poor surgical curability.
MAG 3 has a sensitivity and specificity of around 90% in centres that
perform them frequently but they are less predictive than MR angiography
which has obvious advantages especially in patients with impaired renal
function.
NUCLEAR MEDICINE: KIDNEY 131
1–left
2–right
D 3–blood
c
o
s
1
2
0 2 4 6 8 10 12 14 16 18
Minutes
E 1–left
2–right
3–blood
c 2
o
s
1
3
0 2 4 6 8 10 12 14 16 18
Minutes
Fig. 3.10 MAG-3 scintigram result (A–C) showing a functional RAS of the left renal
artery. (A) and (B) show reduced tracer uptake for the left kidney. The excretion
graphs (D) and (E) show flat uptake and release of tracer suggesting a left RAS.
(D) is pre-captopril challenge; (E) is post-captopril challenge.
Interventional radiology
In a few select patients, interventional radiological techniques may help
establish the diagnosis.
Renal arteriograms were routinely performed in the past to diagnose
RAS. With the advent of superior imaging modalities such as CT and MRI,
this has now been superseded. Nevertheless, it remains the gold standard
investigation for RAS with a 100% sensitivity and specificity for the diag-
nosis. There is still a role for invasive angiography if a decision is made to
either measure the gradient across the lesion, obtain samples for renin
(renal vein renin sampling), or to perform angioplasty to the previously
identified lesion.
Adrenal vein sampling (AVS) is a technique to determine whether the
biochemically determined syndrome of hyperaldosteronism is unilateral
or bilateral and if an apparent adenoma on CT is indeed a functioning
adenoma. Excision of unilateral adenomas may result in amelioration, if
not cure, of hypertension. It may, rarely, also be performed in adrenal
Cushing’s disease or in bilateral adrenal hyperplasia.
The technique requires cannulation of the femoral vein and the passage
of a guidewire for sampling of both adrenal veins—something requiring
the skills of an experienced interventional radiologist. A common pitfall is
failure to cannulate the adrenal vein itself, especially on the right side, as it
is smaller and comes off the inferior vena cava itself.
Cortisol levels from the adrenal veins should be twice as high as those
obtained from the inferior vena cava. If this is not the case, the sampling
should not be interpreted. An aldosterone/cortisol gradient of ≥2 (com-
pared to contralateral adrenal vein) is considered diagnostic of an adrenal
adenoma if the non-affected side is higher than the gradient measured
in the inferior vena cava. Bilateral adrenal hyperplasia tends to cause
gradients higher than peripheral samples. Complications include adrenal
infarction, thrombosis, haemorrhage, hypotension, and adrenal insuffi-
ciency. Other pitfalls include concomitant medications which may skew
the results of sampling; hence the omission of aldosterone antagonists, in
particular, is vital.
There was a vogue for performing adrenocorticotrophic hormone
(ACTH) stimulation during AVS, but this has been abandoned to some
extent, as it may make interpretation of the results more difficult.
INTERVENTIONAL RADIOLOGY 133
Fig. 3.11 A renal arteriogram performed to diagnose a left RAS.
Aorta
287
RRV LRV
259 522
IVC
Infrarenal
Infrarenal
242
Renin levels (in mU/L), normal random renin range 9–56 mU/L
Fig. 3.12 A pictorial representation of the same patient in Fig 3.11 showing results
of renal vein renin sampling. This shows lateralization to the left renal vein indicating
a higher production of renin from that side—implicating that kidney as the cause of
hypertension in this patient. IVC, inferior vena cava; LRV, left renal vein; RRV, right
renal vein.
Chapter 4 135
Secondary hypertension
Vascular
Co-arctation of the aorta 136
Renal artery stenosis 138
Endocrine
Hyperaldosteronism 144
Conn’s syndrome 148
Bilateral adrenal hyperplasia 150
Cushing’s syndrome 151
Phaeochromocytoma 152
Hyperparathyroidism 156
Hyperthyroidism 157
Renal
Renal parenchymal disease 158
Adult polycystic kidney disease 160
Renal tumours 162
Drugs
Liquorice 163
Alcohol 164
Oral contraceptive pill 165
Steroids 165
Non-steroidal anti-inflammatory drugs 166
Immunosuppressives 166
Vascular endothelial growth factor inhibitors 166
Monoamine oxidase inhibitors 167
Cocaine 168
Heavy metals 168
136 CHAPTER 4 Secondary hypertension
Co-arctation of the aorta

Background
Co-arctation refers to a congenital narrowing of the aorta, due to localized
thickening of the media, the exact pathophysiology of which is unknown.
The lesion usually occurs just distal to the origin of the left subclavian
artery (distal to the ductus arteriosus), but rarely may be in the latter part
of the descending thoracic or abdominal aorta. The degree of narrowing
may vary from a distinct tight band to a more extensive lesion involving a
segment of aorta. Co-arctation results in upper body hypertension, prob-
ably due to impaired renal artery perfusion, and consequent activation of
the RAAS.
Demographics
The prevalence of co-arctation is ~1/10,000 with a male:female ratio of 2:1.
Co-arctation is usually diagnosed in childhood, presenting as hypertension
or cardiac failure. However, a significant proportion remains undetected
until adolescence or early adulthood, and is often picked up as ‘essential’
hypertension or ‘incidental’ murmurs. Occasionally, co-arctation may
present as malignant hypertension.
Co-arctation accounts for ~5% of cases of congenital heart disease, and
is often associated with other cardiac abnormalities, including bicuspid
aortic valve (~50% of cases), ventricular-septal defect, and aortic ste-
nosis. Up to 10% of patients may also have associated cerebral aneurysms
which may be multiple. Co-arctation is also a recognized feature of
Turner’s syndrome.
Clinical features
• Upper body hypertension with a difference of at least 10mmHg in
systolic pressure between the arms and the legs.
• Diminished or delayed femoral pulses (radio-femoral delay).
• A systolic murmur heard over the back (which may be continuous if
the co-arctation is severe). An associated aortic systolic murmur may
be present if there is a bicuspid aortic valve.
• A forceful apex beat (due to LVH).
Investigations
Routine blood tests are usually normal, although renin levels may be
raised in some individuals. The ECG typically shows LVH, and CXR may
show the classical features of a dilated ascending aorta and rib notching
caused by collateral vessels eroding the ribs. Transthoracic echocardiog-
raphy may not reveal the co-arctation itself, but frequently reveals LVH or
a bicuspid aortic valve.
The definitive investigation is CT or MR angiography, which will not only
confirm the diagnosis but reveal the site and severity of the lesion (b Fig.
4.1). Conventional angiography is now rarely performed except in more
complex cases or as a prelude to non-surgical intervention.
CO-ARCTATION OF THE AORTA 137
Management
If left untreated, 20% of patients with co-arctation die before the age of 20
years, and 80% before age 50. Classically, the definitive treatment has been
surgical correction, which has the best outcome if performed in childhood
between the ages of 1–7 years. If correction is not performed until later,
long-term hypertension is more likely. Post-operatively there is occasion-
ally a marked rise in BP which is thought to be due to disruption of the
baro-reflex arc, and may be prevented by preoperative B-blockade.
Recently there has been a trend away from surgery and towards balloon
angioplasty (with or without stent insertion). Although widely accepted,
and high technical success rates have been reported, only limited long-
term follow-up data are available, and there are few head-to-head com-
parisons with surgical intervention. Angioplasty may also be associated
with an i risk of aneurysm formation and re-stenosis. Nevertheless, in
children and young adults with uncomplicated lesions, many cardiologists
opt for angioplasty 1st-line.
Despite good haemodynamic responses to intervention, ~20% of patients
will remain hypertensive, probably due to permanent structural changes in
the CV system and neurohormonal adaptation. Recurrence of the lesion
may also occur in ~10% of cases operated on in childhood, and possibly a
higher number post-angioplasty.
Fig. 4.1 Cardiac MRI of a 22-year-old with co-arctation distal to the left subclavian
artery (arrow). Note the dilatation of the inominate and subclavian arteries.
Renal artery stenosis

Background
RAS refers to a narrowing of the renal arteries, which may or may not be
causally linked with hypertension, renal impairment, or ‘flash’ pulmonary
oedema. Indeed, there is a complex relationship between these 3 clinical
presentations, and in some cases the stenosis may simply be an innocent
bystander (b Fig. 4.2). Reno-vascular hypertension refers to the situation
where RAS leads to the development of s hypertension.
The mechanism of hypertension in RAS is complex and depends on
whether one or both kidneys are involved. In classical, unilateral RAS, the
initial elevation of BP is due to reduced renal blood flow, and activation
of the renin–angiotensin system. Although renin levels may fall somewhat,
this mechanism remains important in the longer term but is augmented
by structural changes in the contralateral kidney which, together with
higher circulating levels of aldosterone, limit its ability to excrete sodium,
and hence there is an expansion of plasma volume. In bilateral RAS the
initial phase of hypertension is similar but volume expansion is much more
important in the chronic phase and renin levels are often normal or only
marginally raised.
Demographics
The true prevalence of reno-vascular hypertension is unknown, not least
because of the difficulty in establishing causality. However, estimates
range from <1% in unselected populations to 30% amongst subjects with
resistant hypertension in s care.
Causes of RAS
• Atherosclerotic disease: 85%.
• Fibromuscular dysplasia: 10%.
• Others, 5%:
• Dissecting aneurysm.
• Trauma.
• Embolism/thrombosis.
• Neurofibromatosis.
• Radiation fibrosis.
• Arteritis.
Atherosclerotic RAS
Classically, affects older individuals, especially male cigarette smokers.
Individuals frequently have widespread atherosclerosis and concomitant
peripheral vascular and coronary disease, and it is probably under-diag-
nosed (12% of patients undergoing coronary angiography have significant
RAS). It usually primarily affects the proximal 1/3 of the main renal artery,
and tends to be progressive. Total occlusion may occur, and is estimated
at between 30–60% at 4–7 years. Renal atrophy develops in ~20% of indi-
viduals with a stenosis >60%. Besides hypertension, atherosclerotic RAs
may present with a sudden deterioration in renal function or BP, or rarely
‘flash pulmonary oedema’ if bilateral.
RENAL ARTERY STENOSIS 139
Reno-vascular
Renal-artery hypertension Hypertension
stenosis
Reno-vascular
hypertension,
and renal
failure
Chronic renal
failure
Fig. 4.2 Overlap between RAS, hypertension, and renal failure.
Phase I II
Occlusion
BP
Renin
Fig. 4.3 Physiology of unilateral RAS.
Fibromuscular dysplasia (FMD)

Typically affects young females (4:1). Although most cases are sporadic,
some have a familial tendency, which tend to display a dominant pattern
of inheritance with incomplete penetrance. Any layer of the arterial
wall may be affected, but most commonly the media. The underlying
pathology remains unclear but may involve ischemia of the vasa vasorum.
Histologically, FMD is characterized by fibrotic stenosis and aneurysmal
dilatation which gives rise to the classical string of beads appearance at
angiography (b Fig. 4.4). Frequently involves the distal 2/3 of the renal
artery and their branches, and ~40% of cases have bilateral involvement.
Total occlusion and progression are uncommon (~1/3 of cases). Extra-
renal arteries may be involved too, e.g. cerebral or carotid.
Clinical features
There are no true pathognomonic features of RAS. Although a ‘renal’ bruit
is classically described, in reality this is of poor prognostic value. Many
patients have clinical evidence of atherosclerotic disease elsewhere.
Features suggestive of RAS
• Onset of hypertension <30 years with no family history or other risk
factors.
• Refractory or resistant hypertension.
• Malignant hypertension.
• Known PVD or aortic aneurysm.
• Worsening renal function (particularly after introduction of ACEI).
• Renal atrophy.
• Flash pulmonary oedema (bilateral disease).
• Abdominal (renal) bruit.
Fig. 4.4 Typical ‘string-of-beads’ or ‘corkscrew’ appearance of FMD in a 27-year-old

woman.
Investigations
Basic blood tests should be performed, together with urine analysis and
an ECG. Inflammatory markers and autoantibodies should be considered
if a vasculitic process is suspected. Investigating suspected RAS is a 2-step
process: 1st screen for the condition and, if positive, 2nd confirm the diag-
nosis and assess severity. MR-angiography is increasingly used to do both
at a single setting, especially when clinical suspicion is high, although cost
and availability limit its total adoption. An ideal 3rd step would be to assess
the physiological severity and likely impact of corrective therapy, but as
yet there is no suitable test.
Screening tests
• Renin and aldosterone (b see Renin and aldosterone, p.72). May be
helpful—classically both should be raised, but a ‘normal’ plasma renin
does not usefully exclude the diagnosis. Assessing the response to a
single dose of captopril has been suggested, but this has poor sensitivity
and specificity for detecting RAS.
• Renal ultrasound. Helps exclude obstruction if there is renal impair-
ment and to assess kidney size. Unequal size or bilaterally small kidney
may be a helpful pointer to RAS.
• Renal artery Doppler. Stenotic lesions are detected by examining the
flow velocity profile, and comparing velocities of the renal artery to the
aorta. In subjects with a high pre-test probability for RAS the sensitivity
and specificity are high, ~98%, but much less lower if the pre-test prob-
ability is low. Overall the technique is very operator- (and patient-)
dependent.
• Captopril renography (b see MAG 3, p.130). DTPA or MAG 3 isotope
scans are widely available but have a poor performance if used alone.
The sensitivity and specificity is dramatically improved when combined
with captopril administration (>90%). However, there is no direct
imaging of the renal vessels, and predictive value falls in subjects on anti-
hypertensive medication and if there is significant renal impairment.
• CT-angiography (b see p.123). Provides 3D images of the renal
arteries and aorta (b Fig. 4.5). Has a sensitivity of 98% and specificity
of 94% compared with invasive angiography, but a variable sensitivity
in FMD. Unfortunately, it involves potentially nephrotoxic contrast
medium, ionizing radiation
• MR-angiography (b see p.124). Increasingly used as 1st-line screening
test. Provides 3D images of the renal arteries and aorta, but distal
lesions are more difficult to detect. Two small studies showed a sen-
sitivity of 100% and specificity of 71–96% when compared to arteriog-
raphy. Less useful for diagnosis of FMD. There have also been recent
concerns about the long-term safety of gadolinium contrast agents in
patients with renal failure.
Confirmatory tests
The ‘gold-standard’ test remains invasive angiography, which has the
advantage that pressure gradients can also be assessed and intervention
performed at the same time in suitable patients. However, it is associated
with the use of ionizing radiation, and a small but significant risk of com-
plications, e.g. dissection and haemorrhage. Therefore, CT or MRI may be
used in some setting to confirm the diagnosis.
Fig. 4.5 CT-angiogram illustrating complete occlusion of the left renal artery (arrow).
Treatment
The key aims of therapy are to control BP , preserve or improve renal
function, and stabilize the lesion. The decision to opt for medical therapy
or revascularization will depend on a number of factors including the
nature of the lesion, patient’s age, and co-morbidity, and requires careful
consideration. Overall, it should be noted that only a few patients with
reno-vascular hypertension are truly cured by intervention.
Medical therapy
ACEI and ARAs are effective in controlling BP in the majority of individ-
uals, especially when combined with a diuretic. However, they should not
be used if there is bilateral disease, and U&Es should be closely monitored,
as acute renal insufficiency can occur even in unilateral disease (5–10% of
cases). A rise in the serum creatinine >25% should lead to withdrawal of
the agent. CCAs may also be helpful, and are less likely to induce renal
failure. There is little hard evidence that adequate BP control preserves
renal function. Moreover, a significant number of subjects will fail to
achieve targets despite multiple drug therapy. Statin therapy is also widely
used in subjects with atherosclerotic RAS. However, only 1 small study
suggests a reduction in rate progression of the stenotic lesion, and there
seems no effect on renal function1.
Revascularization
In general, the results of surgical intervention and angioplasty have been
disappointing. Although good technical results can be obtained in the
majority of patients, long-term ‘cure’ rates are low, and the effect on renal
function very modest. This must be balanced against the perceived risks of
lesion progression and also the risks of intervention (~3% risk of serious
complications).
In general, the best results are seen in younger subjects, those with FMD,
or recent onset disease. Significant renal impairment, small kidneys, and
advanced age are all associated with a worse outcome. Occasionally,
revascularization may be undertaken in subjects with refractory heart
failure and RAS. Although renal vein renin and the response to ACEI
have been suggested as predictors of the response to revascularization, in
general these are unreliable.
Angioplasty
Angioplasty, increasingly with stent insertion, is the most common form of
revascularization. Although good technical results are common, the evi-
dence base is very modest, and in atherosclerotic RAS the results have
been generally very disappointing. The DRASTIC study is the largest RCT
undertaken in this setting, and compared angioplasty with medical therapy
in 106 patients with uncontrolled hypertension. There was no difference
in BP , or the use of antihypertensives, or renal function after 12 months’
follow-up. The ASTRAL and CORAL studies are ongoing and will address
the use of stents and angioplasty in a larger cohort. In subjects with FMD,
the results are considerably better: ~50% of patients are cured, and the
majority have better BP control.
Surgery
The results are very similar to angioplasty. However, surgery may be a
better option if there is extrinsic compression, or a difficult ostial ste-
nosis. Again better results are likely in younger subjects with recent onset
disease. Occasionally, unilateral nephrectomy is performed to remove a
non-functioning kidney thought to be driving hypertension through renin
release.
Reference
1. Cheung CM, et al. (2007). The effects of statins on the progression of atherosclerotic renovas-
cular disease. Nephron Clin Pract 107:c35–c42.
Hyperaldosteronism
Production of the mineralocorticoid aldosterone by the zona glomeru-
losa is usually closely regulated by angiotensin II and serum potassium
levels, and thus depends on intravascular volume and body sodium.
Hyperaldosteronism refers to excess production of aldosterone by the
adrenal gland, and is traditionally sub-divided into p and s hyperaldos-
teronism based on the plasma renin. It is the 2nd most common form of s
hypertension after renal disorders.
p hyperaldosteronism
The excess production of aldosterone originates from within the adrenal
gland itself, and is not regulated by the normal feedback mechanisms. As
such, plasma renin is suppressed, i.e. low (mass <5mU/L; activity <0.65ng/
mL/h). This is usually accompanied by hypokalaemia, alkalosis, and
sometimes mild hypernatraemia. However, it is important to note that
the plasma K+ is normal in a substantial proportion of patients with p
hyperaldosteronism, and may only fall with diuretic therapy. Clinically,
the hypokalaemia may rarely manifest as weakness, fatigue, paraesthesia,
and cramps. Hypertension is common and results from sodium and water
retention, and a consequent expansion in plasma volume, but CNS effects
including sympathetic activation and enhanced sodium intake are also
important.
The true incidence of p hyperaldosteronism is difficult to establish, not
least because of widely varying diagnostic criteria. Although once consid-
ered rare, most current estimates suggest an incidence amongst hyper-
tensive subjects of ~5–10%. It is more common in subjects with resistant
hypertension, and obviously those with appropriate electrolyte abnor-
malities.
Causes
• Adrenal adenoma (Conn’s syndrome): ~70%.
• Bilateral adrenal hyperplasia: ~25%.
• Adrenal adenocarcinoma: rare.
• Glucocorticoid-remediable hyperaldosteronism (b see Glucocorticoid
remediable aldosteronism, p.178): very rare.
Investigations
Anyone suspected of p hyperaldosteronism, e.g. appropriate electrolyte
abnormalities, resistant hypertension, or an adrenal mass, should undergo
biochemical screening.
Screening
The key screening test is the aldosterone:renin ratio (ARR), (b see
Renin and aldosterone, p.72). Table 4.1 provides a guide for cut-off values
for diagnosing p hyperaldosteronism, with ~95% sensitivity and a ~75%
specificity.
HYPERALDOSTERONISM 145
Table 4.1 Cut-off levels for the ARR, above which a diagnosis of p
hyperaldosteronism is likely
Renin activity Renin mass
Aldosterone ng/mL/h pmol/L/min μU/mL ng/L
ng/dL 27 2.1 3.3 5.4
pmol/L 750 59 90 150

Adapted from Sealey JE, et al. (2005). Plasma renin and aldosterone measurements in low
renin hypertensive states. Trends Endocrinol Metab 16:86–91 © 2005, with permission from
Elsevier.
It is important to appreciate that the test is unreliable if the aldosterone

levels are low as a low renin level can still produce a positive result.
Therefore, most centres have an arbitrary level of aldosterone, e.g.
300pmol/L, below which the ARR should not be calculated. Moreover,
drug therapy, particularly B-blockade and spironolactone, may confound
the results. If the ARR is suggestive of p hyperaldosteronism, then con-
firmatory tests should be performed. These can be thought of biochemical
confirmation, and imaging to help confirm and localize any lesion.
Confirmatory tests
A number of confirmatory tests have been proposed including salt loading
(b see Salt suppression test, p.122), fludrocortisone suppression (b see
Fludrocortisone suppression test, p.122), infusion of angiotensin II, and
selective venous sampling. Each has its own advantages and disadvantages,
and the precise choice will depend heavily on local expertise. Although
technically demanding and invasive, selective venous sampling probably
remains the ‘gold-standard’ confirmatory test (b see Interventional radi-
ology, p.132). Generally, patients are withdrawn from mineralocorticoid
antagonists and of potential confounding medications such as CCAs for
up to 1 week before sampling. It is important to assess cortisol as well as
aldosterone to ensure cannulation of the adrenal vein (the right is particu-
larly difficult), and a positive result is generally considered to be a >3-fold
difference between sides.
One schema is to perform either salt-loading or fludrocortisone suppres-
sion, and, then if positive, to perform selective venous sampling. If there
is a high clinical suspicion and/or positive imaging then just undertaking
venous sampling may be appropriate.
Imaging
Either high resolution CT or MRI (b Fig. 4.6) can be used to assess
the adrenal glands. The choice depends on availability and local exper-
tise. Imaging is useful in identifying potential adenomas (or carcinomas),
or noting their absence, but interpretation is best in the context of the
results of the confirmatory tests noted above. Isotope scanning is now
rarely performed due to a lack of substrate, but newer PET ligands are in
development.
Treatment
Treatment is discussed under the sub-types of p hyperaldosteronism that
follow in this chapter.
s hyperaldosteronism
Here the excess aldosterone production is driven through the normal reg-
ulatory pathways by factors extrinsic to the adrenal gland. This is usually,
but not always, by an excess of plasma renin. Hypertension may or may
not be present.
Causes
• Volume depletion.
• Cardiac failure.
• RAS.
• Malignant hypertension.
• Hepatic failure.
HYPERALDOSTERONISM 147
Fig. 4.6 MRI demonstrating a right adrenal adenoma (arrow).

Conn’s syndrome
Definition
Conn’s syndrome refers to p hyperaldosteronism due to an adrenal
adenoma. Jerome Conn accurately described the clinical features of such
adenomas in 1954, noting the typical hypokalaemia and metabolic alka-
losis. The tumour is typically small, <2cm in diameter, and has a ‘canary’
yellow cut surface (b Fig. 4.7).
Secretion of aldosterone by the adenoma is independent of plasma
volume or sodium, and in most patients (80%) is unresponsive to angi-
otensin II. It is strongly dependent on ACTH, but displays incomplete sup-
pression with dexamethasone, in contrast to glucocorticoid remediable
hyperaldosteronism.
Demographics
Adrenal adenomas are responsible for ~65% of cases of p hyperaldos-
teronism. Figures on the incidence vary greatly, but estimates are 1–5% of
hypertensives. Adenomas are more common in women (2:1) and tend to
present in middle-age.
Clinical features
Conn’s syndrome usually presents as hypokalaemia in the context of hyper-
tension, or as more severe hypokalaemia after commencing a diuretic. The
hypokalaemia may result in symptoms of weakness, lethargy, and paraes-
thesia. Alternatively, subjects may present with resistant hypertension.
Investigations
• U&Es: d K+, mild i Na+, alkalosis. There is often mild hypomagna-
saemia and marked urinary K+ wasting.
• Plasma renin, aldosterone: suppressed renin, i aldosterone, i ARR
(b see p hyperaldosteronism, pp.144–145).
• Failure of salt loading or fludrocortisone to suppress plasma aldos-
terone (b see p.122).
• Adrenal vein sampling: lateralization of >2:1 (b see Interventional
radiology, p.132).
• Imaging CT (b Fig. 4.8) or MRI ( may not reveal small adenomas).
Treatment
Medical
Medical therapy may be used short term, as a prelude to surgery, to control
the BP and correct electrolyte abnormalities, or long term in patients who
are unsuitable or unwilling for surgery. Spironolactone is the drug of choice
at doses between 25–200mg/day. This is usually sufficient to normalize the
serum potassium. The main side effect is breast tenderness, which, if prob-
lematic, may necessitate changing to eplerenone. If additional therapy is
required a dihydropyridine CCA may be used.
Surgical
The definitive treatment for lateralizable Conn’s syndrome is surgical removal
of the adrenal gland. This is often undertaken laparoscopically to minimize
recovery time, but a formal laparotomy is occasionally required. Although
CONN’S SYNDROME 149
removal invariably cures the biochemical abnormalities, its effect on BP is

variable. At 1 year ~60% of subjects are normotensive, falling to ~50% at 5
years. Young patients with a short duration of hypertension and those with
a good response to spironolactone are more likely to achieve normotension.
Conversely, older subjects with long antecedent histories of hypertension,
and those with resistant hypertension, are more likely to require life-long anti-
hypertensive therapy. U&Es should be closely monitored in the postoperative
period, although hypomineralocorticodism is rare.
Fig. 4.7 Example of a Conn’s tumour (b see also Colour plate 10).
Fig. 4.8 Example of a left adrenal adenoma (arrow). Note: the classical olive shape
and low attenuation.
Bilateral adrenal hyperplasia

Definition
Bilateral adrenal hyperplasia (BAH) refers to the syndrome of p hyperal-
dosteronism in the presence of bilateral adrenal gland hyperplasia, which
may be micro- or macronodular. However, there is no discrete or later-
alizing adenoma identifiable. BAH is synonymous with idiopathic aldos-
teronism.
Demographics
The quoted proportion of p hyperaldosteronism due to BAH, varies
greatly from 10–80%. However, with better imaging techniques it is esti-
mated it account for ~25%. BAH is more common in men (4:1), and has a
peak incidence of ~60 years.
Investigations
The biochemical abnormalities are usually milder than in Conn’s syndrome,
with less hypokalaemia and renin suppression. The ARR is invariably ele-
vated, and screening tests positive, but there is a failure of lateralization
on venous sampling, and imaging is either normal or displays bulky glands
bilaterally (b Fig. 4.9). The degree of nodularity varies considerably.
Treatment
Surgery is inappropriate, and the mainstay of therapy is spironolactone.
However, it is often insufficient to control the BP alone, and addition of
other agents, particularly CCAs, is required. Eplerenone or amiloride may
be useful in subjects unable to tolerate doses of spironolactone, which is
more common if higher doses are required.
Fig. 4.9 BAH in a 67-year-old man with resistant hypertension.

CUSHING’S SYNDROME 151
Cushing’s syndrome
Hypertension and hypokalaemia are common presenting features of
Cushing’s syndrome, particularly when due to ectopic ACTH produc-
tion. Plasma renin activity and aldosterone levels are usually normal in
Cushing’s disease, and are often suppressed with ectopic ACTH produc-
tion. The mechanism of hypertension is complex, and relates to a number
of different effects of cortisol. There is up-regulation of angiotensin II
signalling and also A-adrenoceptors in vascular tissue. Chronic exposure
to excess cortisol leads to a depolarization of smooth muscle cells and
an i in intra-cellular calcium content, all favouring vasoconstriction. The
very high levels of cortisol found with ectopic ACTH production may also
exceed the capacity of the protective 11-B-hydroxysteroid dehydroge-
nase type II enzyme and result in apparent mineralocorticoid excess and
volume retention.
Investigations
• U&Es frequently reveal hypokalaemia, metabolic acidosis, and i
glucose.
• Screening for suspected Cushing’s syndrome can be undertaken with
24-h urinary cortisol estimation or an overnight dexamethasome sup-
pression test.
• A number of confirmatory tests are available, including low dose dex-
amethasone suppression, cortisol profiling, and estimation of plasma
ACTH.
• Imaging can then be used to provide localization.
Treatment
The standard therapy is surgical excision of the source of ACTH or
adrenal tumour. Radiotherapy and medical treatment are useful in non-
operable cases or with metastatic spread.
Phaeochromocytoma
Definition
Phaeochromocytomas are rare chromaffin cell tumours that secrete cat-
echolamine, which may produce life-threatening hypertension, dysrhyth-
mias, and heart failure. The majority (90%) are located in the adrenal gland.
Extra-adrenal phaeochromocytomas (also called paragangliomas) may be
located in a variety of places including the organ of Zuckerkandl, bladder
wall, heart, mediastinum, and carotid and jugular bodies, but the majority
are intra-abdominal. Overall ~10% are bilateral or multiple.
Adrenal tumours (especially smaller ones) may secrete both NE and epine-
phrine as they are exposed to high local levels of cortisol necessary to induce
transcription of the enzyme phenylethanolamine N-methyltransferase
(b Fig. 1.6). Nevertheless, noradrenaline secretion usually predominates,
except in the case of some familial tumours. Extra-adrenal tumours only
secrete NE. Phaeochromocytomas may occasionally also secrete peptides
including calcitonin gene-related peptide (CGRP), vasoactive intestinal
peptide (VIP), and neuropeptide Y (NPY).
The vast majority of phaeochromocytomas are benign (b Fig. 4.10), but
up to 10% are malignant. This is more likely with extra-adrenal tumours
and those associated with familial syndromes. Defining malignancy is
difficult as there is no clear-cut histopathological or biochemical features.
In many cases only the presence of metastases allows differentiation.
Demographics
Prevalence estimates are ~0.1–0.5% of hypertensive patients, with an
equal gender distribution. The peak age of onset is 30–50 years, but ~10%
occur in children, in whom they are more likely to be extra-adrenal or bilat-
eral. The majority of tumours are sporadic, but ~10% are familial (autosomal
dominant) or associated with familial syndromes including multiple endo-
crine neoplasia, and neurofibromatosis (b Table 4.2 and Colour plate 13).
Clinical features
Phaechromocytomas may be asymptomatic (50% are discovered inciden-
tally at autopsy), and not all are associated with hypertension. Symptoms
are common, but are often nebulous or intermittent, and mimic a variety
of other diseases:
• Hypertension: 80% (~1/4 paroxysmal).
• Headache: 80%.
• Palpitations: 70%.
• Sweating: 50%.
• Nausea: 30%.
• Flushing, panic attacks, postural hypotension, diabetes.
PHAEOCHROMOCYTOMA 153
Fig. 4.10 Example of a benign phaeochromocytoma (b see also Colour plate 12).
Table 4.2 Familial association of phaeochromocytoma

Syndrome Risk % Location Gene
MEN-2A 50 Adrenal RET proto-oncogene
MEN-2B 50 Adrenal RET proto-oncogene
Neurofibromatosis -1 1 Adrenal/abdominal NF1
Von Hippel– 10–20 Adrenal/abdominal VHL tumour suppressor
Lindau-2
Familial 20 Head and neck/ Succinate dehydrogenase
paraganglioma adrenal
Data from Dluhy RG (2002). Pheochromocytoma—Death of an axiom. NEJM 346:1486.
© 2002 Massachusetts Medical Society.
Investigations
Screening tests should be performed in all those suspected of having a
phaeochromocytoma, and is also routinely undertaken in all de novo
hypertensive in some centres. If these are positive, confirmatory tests may
then be performed, and finally the tumour localized by imaging or venous
sampling. Genetic testing should be offered for those with a positive family
history, children, and those with recurrent tumours.
Screening
Traditionally, urinary VMA was used for screening; this has a very high
specificity (96%), but low sensitivity (70%). However, more sensitive tests
(~98%) are now available, including urinary fractionated metanephrines
and plasma metanephrines. Although this means fewer phaeochromocy-
tomas are missed, this is at the expense of more false positives. In tumours
that secrete intermittently it may be necessary to repeat the screening

test during symptoms.
In subjects with very high catecholamine metabolite levels, the diagnosis
is rarely in doubt and one may move directly to localization. However,
confirmatory test are usually indicated if levels are only marginally raised.
This usually takes the form of the pentolinium or clonidine suppres-
sion test (b see Clonidine suppression test, p.120). Failure of suppres-
sion of plasma catecholamines (or normetanephrine) is indicative of a
phaeochromocytoma.
Localization
This should only be performed once a biochemical diagnosis is made. CT
or MRI may be used (b Fig. 4.11); the latter has the advantage that con-
trast agents are less likely to provoke a hypertensive crisis and thus pro-
phylactic A-blockade is not generally required. This is often coupled with
isotope scans to delineate uptake into any mass lesion, but may not be
needed if there is a high clinical suspicion, unequivocal biochemistry, and
a well-defined mass. Traditionally, 123I-MIBG has been used, but not all
tumours take this up, and alternatives include 111In-octreotide scanning, or
PET with 18F-DOPA or 18F-FDG. PET has better sensitivity and provides
better confirmation of likely metastases. Although rarely performed now,
plasma catecholamine sampling along the venous tree may be helpful in
identified small extra-adrenal tumours in usual locations.
Treatment
It is vital to ensure adequate A-blockade prior to surgery, usually with
the irreversible, long-acting antagonist phenoxybenzamine. The usual
starting dose is 10mg bd, and the dose is i until there is adequate control
of BP and symptoms. This should be initiated a minimum of 7 days before
surgery to allow restoration of plasma volume (otherwise severe hypoten-
sion can ensure immediately postoperatively). Immediately preoperatively
the dose is usually i to produce minimal orthostatic hypotension (fall in
SBP of ~20mmHg) to ensure adequate blockade. B-blockade is generally
reserved for patients with a resting tachycardia or cardiac disease, and
those with significant adrenaline production. This should only be under-
taken after adequate A-blockade because of the theoretical risk of blocking
B2 -receptor mediated vasodilatation. 131I-MIBG may be used to irradiate
malignant phaeochromocytomas if the tumour takes up the ligand.
Definitive treatment is surgical removal, which may be undertaken via a
laparoscopic or open approach. Catecholamines should be assessed ~2
weeks postoperatively, and annually from then on. A minority of individ-
uals will remain hypertensive after removal of the tumour, but they usually
are symptom-free and have better BP control.
PHAEOCHROMOCYTOMA 155
Fig. 4.11 CT of a large mixed density left adrenal phaeochromocytoma (arrow).

Hyperparathyroidism
Hypertension occurs in 30–50% of patients with hyperparathyrodism.
The exact mechanism is unclear and may reflect an interplay of factors,
including direct vascular effects of calcium and PTH and activation of the
renin–angiotensin system, with elevated circulating aldosterone levels.
Treatment should be directed at surgical cure of the condition, although
only ~20% of patients are rendered normotensive despite a biochemical
‘cure’.
HYPERTHYROIDISM 157
Hyperthyroidism
Hypertension has a prevalence of ~25% in patients with hyperthyroidism,
and is relatively more prevalent in younger subjects. The usual pattern is
systolic hypertension and a widened pulse pressure due to an i cardiac
output and plasma volume. PVR tends to be d giving rise to a hyperdy-
namic circulation. Plasma renin activity tends to be i and there is i sensi-
tivity to catecholamines.
Initial treatment with B-blockade is useful in controlling BP and symp-
toms, while definitive treatment to produce euthyroidism is introduced.
The majority of patients become normotensive after correction of the
hyperthyroidism.
Renal parenchymal disease

The association between renal disease and hypertension is strong—renal
disease is implicated as the cause or effect of poorly controlled hyper-
tension in up to 5% of cases. The Multiple Risk Factor Intervention Trial
(MRFIT)1 showed that BP is a strong, independent risk factor for the risk
of progression to ESRD. Salt and water homeostasis is presumed to be the
main determinant of this, although other mechanisms in the pathophysiology
are implicated as discussed in the rest of this section. Glomerular disease
(glomerulonephritis) and renal ischaemia (renovascular hypertension—
b see Renal artery stenosis, p.138) are the 2 main underlying pathologies in
renal parenchymal disease. Other causes include chronic pyelonephritis and
analgesic nephropathy.
Salt sensitivity and RAAS
The pressure response to salt loading or depletion determines the salt
sensitivity of that individual—although this is uniformly distributed as a
continuous variable in humans. The p determinant of this response seems
to lie within renal regulation of salt; this is seen when salt-sensitive (SS)
rodents become salt resistant (SR) when transplanted with SR kidneys and
vice versa.
The interplay between regulatory systems makes interpretation of the
cause more difficult; for example, the RAAS can be stimulated or inhibited
depending on the state of salt depletion or loading respectively. Aldosterone
per se has been implicated in the development of glomerular damage inde-
pendent of the renin–angiotensin system—such that co-administration of an
ACEI in animal models does not prevent nephrosclerosis.
Sympathetic nervous system
Plasma noradrenaline is dependent on GFR, so the causal relationship
between the role of the sympathetic system in the pathogenesis of hyper-
tension in renal failure is difficult to disentangle; however, other methods
of assessing sympathetic activity point to an activation of this system in renal
failure. This may partly explain why sympathetic blockade is more effective
in end-stage dialysis patients compared to normal subjects. The underlying
cause of this may the activation of renal chemo- and baroreceptors resulting
in i noradrenergic activity via efferent sympathetic pathways.
NO production results in vasodilatation. The role of NO inhibition through
substances such as asymmetric dimethylarginine and N-monomethyl-L-
arginine (which accumulate in uraemia) has been postulated as another
mechanism through which renal impairment results in hypertension.
Additionally, production of reactive oxygen species has been implicated in
uraemic hypertension which was then reversed by antioxidant therapy.
Erythropoietin
Some renal patients treated with erythropoietin develop hypertension,
which may be due to an exaggerated rise in total peripheral resistance
or a lack or reduction in cardiac output in response to the correction of
anaemia via volume and haematocrit. This may suggest a renal origin to
the induction/exacerbation of hypertension in such individuals.
RENAL PARENCHYMAL DISEASE 159
Diabetic nephropathy
As the incidence of diabetes and the obesity epidemic rises, concomitantly
there has been a rise in the incidence of diabetic nephropathy. Optimal
glucose and BP control in this high risk group is vital to reduce TOD—
which ultimately results in glomerulosclerosis. The mechanism is that of
reduced renal blood flow presumed to be due to i glomerular afferent
resistance—resulting in i efferent vasoconstriction and glomerular hyper-
filtration. This progresses to glomerulosclerosis, leading to microalbu-
minuria, and finally frank proteinuria (b see also Diabetes, p.196).
Treatment
Salt restriction is advised but not always adhered to, necessitating the use
of loop diuretics in most renal failure patients. Ultimately, tight control of
BP ameliorates against declining renal function—the current targets for BP
control in renal patients are lower (akin to those with CVD or diabetes)
at <130/80mmHg.
Thiazide diuretics are ineffective in patients in poor renal function—unlike
loop diuretics which can ameliorate fluid overload and BP. Large single
doses of loop diuretics may be required (up to 250mg of furosemide),
titrating to effect in terms of urine output, and if this is ineffective in
producing a natriuresis, the dose frequency can be i, monitoring for
toxicity throughout. CCAs, A-blockers, and minoxidil have been found to
be useful in renal patients also.
The renoprotective effects of ACEI to prevent progression to frank pro-
teinuria especially in diabetic populations is discussed in b Diabetes, p.196.
205.6
211.7
143.5 124.4
88.9
62.3
96.9 49.7
62.3
57.8 35.4
90.2 68.4
27.1 25.4 40.2
49.6
22.6 16.4
27.5
12.4 11.1 ≥110
22.1 9.8
≥180 12.8 8.4 100-109
160-179 13.3 6.7 4.9 90-99
6.0
140-159 6.6 85-89 )
130-139 5.3
80-84 Hg
Syst
olic 120-129 <80 c ( mm
<120 li
(mm sto
Hg) Dia
Fig. 4.12 MRFIT graph showing progression to ESRD increases with increasing BP.
Reproduced with permission from Klag MJ et al. (1996). Blood pressure and end-
stage renal disease in men. NEJM 334: 13–8. © 1996 Massachusetts Medical Society.
All rights reserved.
Reference
1. Klag MJ, et al. (1996). Blood pressure and end-stage renal disease in men. NEJM 334:13–8.
Adult polycystic kidney disease

Definition
Adult polycystic kidney disease (APKD) is an autosomal dominant dis-
order in which there is progressive focal cyst formation and dilatation in
the kidneys and other organs. It is the commonest genetic cause of renal
failure. Conversely, the autosomal recessive polycystic kidney disease is
the commonest inheritable cause of renal cysts in early childhood.
Up to 1/3 of patients <50 years newly diagnosed with APKD are found to
be hypertensive; this i depending on the age at presentation or diagnosis.
This can occur despite having normal renal function but is commoner in
those with a mutation at the PKD1 locus on chromosome 16.
There is a school of thought suggesting that i renin production contrib-
utes to the pathogenesis of hypertension in APKD.
Demographics
APKD is more severe in males compared to females. It accounts for up to
10% of cases of ESRD in the Western hemisphere. 90% of the cases are
due to a mutation in PKD1 and the rest to PKD2 or PKD3.
Clinical features
• Abdominal pain.
• Haematuria.
• Hypertension.
• Renal failure.
• Strokes—a small proportion associated with intracranial aneurysms.
Investigations
• U&Es.
• Urine microalbuminuria.
• Urine dipstick for blood and protein.
• Renin and aldosterone levels.
• 24-h urine for proteinuria.
• Renal ultrasound.
• Creatinine clearance, e.g. ethylenediamine tetra-acetic acid (EDTA)
clearance.
• Genetic testing and counselling.
The clinical diagnosis is usually established on history and ultrasound
examination. A genetic locus may be pursued in the index case in order to
determine if screening of family members is required.
Treatment
CCAs, ARAs, and ACEIs have a more pronounced effect in patients with
APKD. The role of renin inhibition in these patients is yet to be deter-
mined. Ultimately good BP control minimizes the risk of CV complications
as in any other group. Genetic screening after proper counselling helps
identify and follow-up cohorts in a more coherent manner to reduce the
risk of events.
ADULT POLYCYSTIC KIDNEY DISEASE 161
S07.05869
Fig. 4.13 A macroscopic view of a polycystic kidney (b see also Colour plate 14).
Renal tumours
Whilst hypernephromas (renal cell adenocarcinomas) are reasonably
common (especially in an older patient) and rarely linked to iBP, the
specific renin-secreting tumours per se, such as reninomas, are relatively
uncommon but closely associated with iBP. These are very rare tumours
associated with hypokalaemia and high renin. This may be difficult to dis-
tinguish in the presence of drugs which raise renin (although a lack of sup-
pression of renin on B-blockade alone in a compliant patient could raise
the suspicion), or in other cases of s hypertension due to renal ischaemia,
e.g. RAS.
Most renin-secreting tumours present as severe hypertension in a rela-
tively younger population <30 years of age (prevalence approximately
0.03% amongst hypertensive patients).
Renal cell carcinomas present as an incidental finding during routine scan-
ning or with symptoms, although usually this occurs only when the disease
is advanced. It affects a predominantly older patient cohort. Lymphatic
and haematogenous routes result in metastases to bones, liver, and lungs.
Clinical features
• Hypertension in young age—for reninoma.
• Hypokalaemia.
• Tumour haemorrhage—flank pain, anaemia, and hypotension.
Investigations
• U&Es.
• Renin—this is sometimes normal with a very high pro-renin level
• USS renal
• CT abdomen.
• Selective renin vein sampling—for reninoma.
• IV urography—now rarely performed.
Treatment is by surgical removal of the tumour.
LIQUORICE 163
Liquorice
Liquorice is commonly found in liquorice sweets and is extensively used in
food and tobacco products as well as herbal remedies. It has mineraloco-
rticoid and glucocorticoid properties. The glycyrrhetinic acid component
of liquorice causes hypertension and hypokalaemia through a mineraloco-
rticoid effect by inhibiting 11-B-hydroxysteroid dehydrogenase (type 2),
which inactivates cortisol. This is more so in chronic liquorice ingestion as
opposed to any acute intake. The biochemical picture is one of low serum
potassium associated with low renin and aldosterone levels, i urinary
free cortisol, i cortisol:cortisone ratio, and raised urinary potassium.
Rhabdomyolysis and myoglobinuria may occur through hypokalaemia as
a result of poisoning. Potassium supplementation and hydration ± urine
alkalinization may be required. The hypertension reverses on withdrawal
of liquorice.
CH2CH CH2CH
C O C O
CH3 11 β-oxoreductase CH3
O O 11 β-HSD1 OH O
CH3 NADPH CH3
11 β-dehydrogenase
(11β-HSD1) NADP+
O O
Cortisone (E) Cortisol (F)

11 β-dehydrogenase
‘inactive’ glucocorticoid 11 β-HSD2 ‘active’ glucocorticoid
NAD+
Fig. 4.14 11 B-hydroxysteroid dehydrogenase and its effects on glucocorticoids.

11B-HSD, 11 B-hydroxysteroid dehydrogenase; NADP, nicotinamide adenine
diphosphate; NADPH, nicotinamide adenine diphosphate (reduced).
Alcohol
Observational data point to the link between chronic excess alcohol
consumption and the development of hypertension and other CV
disorders. Low to moderate intake, however, is associated with a better
CV outcome. Binge drinking is associated with a worse outcome, but
generally patients should be advised to adhere to recommended alcohol
targets and to drink in moderation. Whilst the underlying mechanisms are
unclear, this may be through activation of the sympathetic nervous system,
i cortisol secretion, or altered insulin sensitivity.
Whilst causal links are not fully established, a reduction in intake has dem-
onstrated, at best, a 5 to 8/3mmHg reduction in pressures—this is evi-
denced from meta-analyses of RCTs (b Fig. 4.15).
Puddey et al, 1985 Puddey et al, 1985

Howes et al, 1986 Howes et al, 1986
Puddey et al 1986 Puddey et al, 1986
Ueshima et al, 1987 Ueshima et al, 1987
Wallace et al, 1988
Parker et al, 1990
Parker et al, 1990
Maheswaran et al, 1992
Maheswaran et al, 1992
Puddey et al, 1992
Puddey et al, 1992
Cox et al, 1993
Cox et al, 1993
Ueshima et al, 1993
Ueshima et al, 1993
Lang et al, 1995
Lang et al, 1995
Kawano et al, 1998 Kawano et al, 1998
Rakic et al (1), 1998 Rakic et al (1), 1998
Rakic et al (2), 1998 Rakic et al (2), 1998
Cushman et al, 1998 Cushman et al, 1998
Overall Overall
−15 −10 −5 0 5 10 −15 −10 −5 0 5 10
Net Changes in Systolic BP, mmHg Net Changes in Diastolic BP, mmHg
Fig. 4.15 Net change in BP after alcohol reduction across 15 RCTs (with corre-
sponding 95% confidence intervals). Reproduced with permission from Xin X, et al.
(2001). Effects of alcohol reduction on blood pressure: a meta-analysis of random-
ized controlled trials. Hypertension 38:1112–17.
STEROIDS 165
Oral contraceptive pill

Shortly after its widespread introduction in the 1960s, it became apparent
that the combined OCP was associated with the development of hyper-
tension in some women. Despite the considerable reduction in oestrogen
content of modern pills this link remains. In contrast, there does not seem
to be any association between the progesterone-only-pill (‘mini pill’) and
hypertension.
Overall, there is a modest ~2/1mmHg i in BP in women taking the com-
bined OCP. Physiologically, this is due to an expansion of plasma volume
and i cardiac output. However, a significant minority of women have a
much larger i in BP . This usually occurs in the 1st few months, and is
reversible if the drug is withdrawn. However, the risk of developing
hypertension in the longer term is also ~2-fold elevated, and is signifi-
cantly higher in older or obese women and those with borderline hyper-
tension. The combined OCP should not be prescribed to women who are
already hypertensive and regular BP checks are advised for women who
are taking it.
Steroids
The link between steroids and hypertension is probably best explained
from its mineralocorticoid action to promote salt and water retention,
which is more marked at higher doses. However, there is some suggestion
that glucocorticoids have direct actions on both glucocorticoid and miner-
alocorticoid receptors in CV tissues via the 11 B-hydroxysteroid dehydro-
genase enzyme. This is similar to the effects seen in Cushing’s syndrome
(b see Cushing’s syndrome, p.151) and in the syndrome of apparent
mineralocorticoid excess (AME). Long-term, high-dose steroid therapy is
associated with a number of adverse events—and should therefore be
discouraged. In patients who do not have the option, CV risk (in particular
BP) should be monitored closely and intervention taken sooner rather
than later. Diuretics may be useful for salt and water retention.
Non-steroidal anti-inflammatory drugs

The association between NSAIDs and hypertension has come from
changes noted from a variety of studies. Some NSAIDs are more culpable
than others—in particular, naproxen and indometacin. The mechanism
is thought to be due to cyclo-oxygenase (COX) inhibition and a reduc-
tion in prostaglandin synthesis, which are vasodilatory. There is also some
evidence to suggest COX-2 inhibitors cause poorer BP control when
compared with COX-1 inhibitors. Salt and water retention and the up-
regulation of RAS may also have a part to play in the genesis of hyper-
tension with NSAIDs, especially in at-risk individuals. NSAIDs essentially
affect the efficacy of most anti-hypertensive agents; therefore, their use
should be minimized in hypertensive patients.
Immunosuppressives
Cyclosporin-induced hypertension has been well described and is clini-
cally well apparent. This is also true for other calcineurin inhibitors, such
as tacrolimus, but to a lesser extent. Whilst sex and race do not seem to
play a role, drug dose, age, and pre-existing hypertension predisposes to
the development of drug-induced hypertension.
It is thought to be mediated through a myriad of mechanisms including
a reduction in nitric oxide production, i thromboxane A2 production,
d prostaglandin synthesis and i endothelin release. These result in a
volume-dependant hypertension with vasoconstriction at the afferent
arteriole. Consequently, drugs which affect low renin hypertension—such
as CCAs and diuretic—are most likely to have an impact on BP control.
Vascular endothelial growth

factor inhibitors
Vascular endothelial growth factor (VEGF) inhibitors are a new class of
agents which act by inhibiting angiogenesis. They are known to cause
hypertension in a dose-dependant manner which may resolve on with-
drawal of therapy. The mechanisms by which this is thought to occur are
not fully established but may include endothelial dysfunction via oxidative
stress and a reduction in NO thereby i vascular tone. Other possible
mechanisms include microvascular rarefaction, where there is a reduced
density of capillaries (also seen in essential hypertension). Whilst the man-
agement includes standard antihypertensive therapies (including ACEIs,
ARAs, dihydropyridine CCAs, and diuretics), it is unclear if some of these
drugs may be more suitable than others due to varying effects on VEGF
secretion. Non-dihydropyridine CCAs have a cytochorme p450 interac-
tion with some VEGF inhibitors.
MONOAMINE OXIDASE INHIBITORS 167
Monoamine oxidase inhibitors

Monoamine oxidase inhibitors (MAOIs) per se do not cause hyperten-
sion—however, if taken together with tyramine-rich foods (e.g. cheese,
Marmite™, wine, chocolate etc.) can result in a ‘cheese reaction’. Their
mode of action as effective antidepressants includes delaying 5-hydrox-
ytryptophan and sympathomimetic amine metabolism, but also to i cat-
echolamine stores in the postganglionic neuron. The non-selective MAOIs
bind irreversibly to MAO A and B, per se. However, when co-ingested with
tyramine-containing foodstuffs or with serotonin inhibitors, they can induce
a tyramine reaction (cheese reaction) which is essentially a hypertensive
crisis. The tyramine is more bioavailable (due to inhibition of MAO-A in
the gut mucosa) and causes release of NE from vesicle stores stimulating
post-synaptic A-adrenoceptors and causing vasoconstriction.
This reaction is less likely with the more modern MAOIs which are revers-
ible and specific (e.g. selegiline which is a MAO B inhibitor vs. moclobemide
which is a short-acting MAO A inhibitor).
More serious than this is the potentially life-threatening serotonin syn-
drome which can occur when MAOIs are combined with other serotonin
agonists (e.g. tricyclic antidepressants; opioids like pethidine and tramadol;
CNS stimulants, e.g. sibutramine, amphetamines, Ecstasy tablets, or
MDMA; triptans used in migraines, etc.). Diagnosis is clinical and severity
is based on the symptoms. It is not the same as neuroleptic malignant
syndrome. Treatment includes discontinuation of precipitant therapies,
supportive measures, control of seizures, use of serotonin antagonists,
and occasionally controlled cooling with paralysis and intubation on an
intensive care unit.
Table 4.3 Classification of the serotonin syndrome

Severity Symptoms
Mild Tachycardia
Shivering
Sweating
Myoclonus
Mydriasis
Hyper-reflexia
Moderate Hypertension
Hyperthermia (>40°C)
Borborygmi
Severe Rhabdomyolysis
Seizures
Renal failure
Metabolic acidosis
Cocaine
Cocaine use is associated with hypertension via its action of facilitating
catecholamine release and inhibiting uptake 1 at the sympathetic nerve,
thereby resulting in adrenergic hypersensitivity. It also blocks voltage-
gated sodium channels thereby working as a local anaesthetic. Patients
may present with tachycardia (B-receptor stimulation) and hypertension
(A-adrenergic receptor via noradrenaline) and associated complications
including ischaemic chest pain (coronary vasospasm), acute coronary syn-
dromes, dysrhythmias, cardiac arrest, aortic dissection, dyspnoea, pneu-
momediastinum, seizures, headaches, anxiety, extrapyramidal reactions,
rhabdomyolysis, bowel infarction, and so on. Chronic use is associated
with premature atherosclerosis.
Management in the acute setting includes methods of active elimination (by
preventing absorption), using benzodiazepines for seizures (and excluding
intracerebral events) – this may relieve some of the hypertension and agi-
tation. Alternatively, vasodilators such as nitrates, sodium nitroprusside
or A-blockers may be used. B-blockers are best avoided as they worsen
coronary spasm and promote unmitigated A-adrenergic actions such as
worsening hypertension.
Heavy metals
Heavy metals such as lead, cadmium, and arsenic can result in hyperten-
sion through a variety of mechanisms. Cadmium is possibly thought to
cause a disruption to normal angiogenesis. Arsenic causes an i in oxi-
dative stress through the production of reactive oxidative species. Lead
exposure is thought to worsen endothelial function by impairing NO pro-
duction and stimulating the RAAS system. The evidence linking these to
hypertension is, at best, modest.
Chapter 5 169
Monogenic syndromes
Introduction 170
Pathophysiology 172
Apparent mineralocorticoid excess 174
Mineralocorticoid receptor-activating mutation 175
Gordon’s syndrome 176
Hypertensive congenital adrenal hyperplasia 177
Glucocorticoid remediable aldosteronism 178
Liddle’s syndrome 179
Bartter’s syndrome 180
Gitelman’s syndrome 182
Acknowledgement
We are indebted to Dr Kevin O’Shaughnessy for his help with
this chapter.
170 CHAPTER 5 Monogenic syndromes
Introduction
Essential hypertension is most likely the result of a complex gene–
environment interaction. The results of genome wide searches to date for
the ‘underlying’ genes in hypertension have been far from fruitful, with the
conclusion that essential hypertension probably results from small effects
of multiple genetic polymorphisms.
The failure to identify any underlying causes undoubtedly reflects a lack
of power of early studies, but also probably a lack of adequately pheno-
typing subjects. Although we consider essential hypertension as a single
disorder, this is clearly far from the truth, and subjects can be subdivided
according to a number of pathways, including biochemical, physiological,
and pharmacological differences. It is likely that greater emphasis on large,
well-phenotyped cohorts may yield novel genetic candidates underlying
some of the variability of BP in the population.
In contrast, in a small number of hypertensives, a mutation in a single gene
is responsible for their condition. These so-called monogenic syndromes
have, as yet, not translated into identifying a cause for essential hyperten-
sion. They have highlighted the importance of salt and water handling in
the kidney in the genesis of hypertension, and that different pathways may
lead to the same disease in outward phenotypic appearance.
However, dissecting the underlying causes of monogenic syndromes in
hypertension highlights potential pathways that may yield new therapeutic
targets.
Other similar disorders are associated with hypotension or normoten-
sion. Nevertheless, these are discussed in this chapter as they help explain
the physiology.
Pathophysiology
Salt excess states
Salt excess is characterized by a d renin and d aldosterone profile in
combination with d K+. There are a number of genetic causes of this,
including:
• AME.
• Mineralocorticoid receptor-activating mutation.
• Gordon’s syndrome.
• Hypertensive congenital adrenal hyperplasia (CAH).
• Glucocorticoid remediable aldosteronism.
• Liddle’s syndrome.
All are associated with hypertension. The renin–aldosterone status may
provide a clue as to the underlying cause and how to proceed further with
the diagnostic test (b Fig. 5.1).
Other monogenic syndromes
Some of these syndromes reveal how loop, thiazide, and K+-sparing diu-
retics vary in their actions as they affect different parts of the nephron
(b see Table 5.1 and Fig. 5.2).
For example, loop diuretics block NKCC2 in the ascending limb of the
loop of Henle resulting in d K+, metabolic alkalosis, and fluid loss—similar
to the defect seen in Bartter’s syndrome.
Thiazides block the NaCl sensitive co-transporter in the apical membrane
of the distal convoluted tubule (DCT)—similar to the defect seen in
Gitelman’s syndrome.
Amiloride blocks the epithelial sodium channel (ENaC) thereby preventing
Na+ reabsorption in the late DCT and cortical collecting duct. In Liddle’s
syndrome, ENaC activity is i and therefore amiloride is the most effective
antihypertensive in this monogenic syndrome.
Table 5.1 Monogenic syndromes affecting the nephron and BP effects

Monogenic syndrome Anatomical site BP effect
Bartter’s Thick ascending limb of loop of d BP
Henle
Gitelman’s DCT d BP
Liddle’s Collecting duct i BP
PATHOPHYSIOLOGY 173
Low-renin hypertension
Low-renin/low- Low-renin/high-
Low-renin/normal-aldosterone
aldosterone aldosterone
Low-renin EH* Consider PA
Gordon’s syndrome
Confirmatory test (suppression)
Age >70
+
Genetic Acquired −
Low-renin Primary aldosteronism
essential
Liddle’s syndrome hypertension*
Liquorice abuse
AME
Use of NSAIDs
11βOH deficiency
Use of COX-2 inhibitors Subtype differentiation
17αOH deficiency
Ectopic ACTH production (APA/BAH)
Gordon’s syndrome
Heparin Consider genetic forms
MR-activating mutation
DOC-secesting tumours (GRA/FH)
Glucocorticold resistance
Very high salt diet
Reduced nephron population
(diabetic nephropathy, elderly etc.,)
Low-renin RH
Fig. 5.1 Diagnostic flowchart for low renin hypertension. Adapted with permission
from Mulatero P, et al. (2007). Diagnosis and treatment of low-renin hypertension.
Clin Endocrinol 67:324–34.
Distal
convoluted Urine Blood
tubule
Thiazide
Na+ CIC-Kb
NCCT
CI− CI−
Ca2+ Ca2+
Collecting duct
Loop of Henle
Na+
Urine Blood Urine Blood

+ −
Furosemide Amiloride
NKCC2 Na+
Na+ ENaC
2CI− CI−
K+ CIC-kb
K+
K+ K+ ROMK
Ca2+ ROMK CI−
Na+ 2+
Mg
Fig. 5.2 Monogenic syndromes and renal homeostasis.

Apparent mineralocorticoid excess

Prevalence
Very rare: 40 pedigrees worldwide.
Genetic inheritance
Autosomal recessive.
Pathophysiology
The defect causes inactivation of the 11BHSD2 gene which encodes the
kidney 11-B-hydroxysteroid dehydrogenase, The enzyme usually deac-
tivates cortisol to the inactive cortisone, thereby protecting the miner-
alocorticoid receptor from cortisol. A failure to do this results in excess
stimulation of the mineralocorticoid receptor by cortisol—leading to i salt
and water retention. Liquorice ingestion (also bioflavinoids and carbenox-
olone, all of which inhibit 11BHSD2) is an acquired cause of AME (b see
Liquorice, p.163).
Presentation
It usually presents in early childhood with low renin hypertension.
Biochemistry
- d K+.
- i Na+.
- d renin.
- d aldosterone.
- i urinary cortisol/cortisone ratio.
Treatment
• Spironolactone.
• Metyrapone.
MINERALOCORTICOID RECEPTOR-ACTIVATING MUTATION 175
Mineralocorticoid receptor-activating
mutation
Prevalence
Extremely rare: only 1 family described.
Genetic inheritance
Autosomal dominant.
Pathophysiology
The mutation lies in the mineralocorticoid receptor which causes it to
be activated by steroids lacking 21-hydroxyl groups, such as progesterone
and spironolactone. Both normally antagonize the receptor but have the
opposite effect on this mutant receptor.
Presentation
It usually presents as early onset hypertension in females that is exacer-
bated in pregnancy due to elevated progesterone levels.
Biochemistry
- d K+.
- d renin.
- d aldosterone.
Treatment
• Delivery of the fetus.
• Amiloride, in theory, may be useful but spironolactone worsens
hypertension.
Gordon’s syndrome
Prevalence
Rare.
Genetic inheritance
Autosomal dominant.
Pathophysiology
Also known as pseudohypoaldosteronism type II (PHA2), this is a mono-
genic syndrome linked to chromosomes 1, 12, and 17 and more recently
associated with mutations in 2 kinases called WNK1 and WNK4– wild
types usually inhibit the thiazide sensitive NaCL co-transporter (NCCT)
but the mutants cause excess Cl– and Na+ reabsorption.
Presentation
Hypertension, muscle weakness, and sometimes periodic paralysis. Other
features include short stature, mental impairment.
Biochemistry
• i K+.
• d renin.
• d aldosterone.
• Metabolic acidosis.
• i Cl–.
Treatment
• Low salt diet.
• Thiazide diuretics.
HYPERTENSIVE CONGENITAL ADRENAL HYPERPLASIA 177
Hypertensive congenital adrenal

hyperplasia
Prevalence
Overall prevalence of CAH is 1 in 16,s000 (higher in some populations: 1
in 400 in Alaska). CYP11B1 accounts for about 5% of all cases of CAH.
Genetic inheritance
Autosomal recessive
Pathophysiology
CAH is a constellation of disorders, only some of which produce hyper-
tension. The 21-hydroxylase deficiency (CYP21A2) is associated with nor-
motension whereas the 11B-hydroxylase (CYP11B1) and 17A-hydroxylase
(CYP17) deficiencies leads to excess deoxycorticosterone which causes
hypertension through a mineralocorticoid action (b see Fig 5.3).
Presentation
• Hypertension.
• Virilization (girls) or precocious puberty (boys)—CYP11B1.
• p amenorrhoea, delayed sexual maturation (girls) or ambiguous geni-
talia (boys)—CYP17.
Biochemistry
• d K+.
• d renin.
• d aldosterone.
Treatment
• Steroids.
Pregnenolone
CYP17
Progesterone 17-OH-pregnenolone
CYP17
17-OH-progesterone
CYP21A2 CYP21A2
DOC Deoxycortisol Androgens
CYP11B1 CYP11B1
Corticosterone Cortisol
Aldosterone
Fig. 5.3 The adrenal steroid pathways. CYP11B1 and CYP17 are associated with
hypertension due to excess production of deoxycorticosterone (DOC).
Glucocorticoid remediable
aldosteronism
Prevalence
Rare.
Genetic inheritance
Autosomal dominant.
Pathophysiology
Also known as familial hyperaldosteronism type I or glucocorticoid sup-
pressible aldosteronism - wherein ectopic aldosterone synthesis occurs
in the zona fasciculata under the direct influence of ACTH rather than
the renin–angiotensin feedback system or K+. It is due to a transloca-
tion resulting in a hybrid CYP11B1/CYP11B2 gene. (Familial hyperaldos-
teronism type II is an autosomal dominant condition not suppressible by
dexamethasone.)
Presentation
- Hypertension in youth resistant to standard treatment.
- Haemorrhagic strokes.
Biochemistry
• d K+.
• d renin.
• d aldosterone.
• Metabolic alkalosis may be present.
Treatment
- Salt restriction.
- Steroids.
- Spironolactone, amiloride, or triamterene.
LIDDLE’S SYNDROME 179
Liddle’s syndrome
Prevalence
Rare.
Genetic inheritance
Autosomal dominant.
Pathophysiology
This is due to a gain-of-function mutation (protein deletion/alteration) at
chromosome 16 affecting the B- or G-subunit of the ENaC channel in the
collecting duct of the nephron. This causes i Na+ reabsorption. The orig-
inal proband was cured of their hypertension by renal transplantation.
Presentation
• Presents as hypertension in childhood/young adulthood.
• Usually asymptomatic and resistant to standard antihypertensives.
Biochemistry
• i Na+.
• d K+.
• Metabolic alkalosis.
• d renin.
• d aldosterone.
• d urine Na+.
Treatment
• Low salt diet.
• K+-sparing diuretics, e.g. amiloride, triamterene which block ENaC
(not spironolactone).
Bartter’s syndrome
Prevalence
1 in 1 million.
Genetic inheritance
Pathophysiology
There are 4 different types described. The genetic defect in clas-
sical Bartter’s (type 3) causes a failure in active Cl– reabsorption in the
ascending limb of the loop of Henle. The missense mutation in the gene,
however, may be in the one of a few locations which differentiates the dif-
ferent subytypes of Bartter’s as listed in b Table 5.2.
Presentation
• Neonatal/infancy: polyhydramnios, prematurity.
• Early childhood: dehydration, nephrocalcinosis, renal stones, failure to
thrive, renal failure.
• Polyuria and polydipsia are common.
• Weakness, muscle cramps, abdominal pain.
• Type 4 Bartter’s may present with sensorineural deafness as the defect
affects a similar channel in the inner ear.
• Low to normal BP.
Biochemistry
• d K+.
• i renin.
• i aldosterone.
• i urinary excretion of Na+, K+, Mg2+, Cl–, and Ca2+.
Treatment
• i salt in diet (both Na+ and K+).
• K+ supplementation.
• Spironolactone.
• Non-steroidal anti-inflammatory agents.
• ACEIs.
BARTTER’S SYNDROME 181
Table 5.2 Subtypes of Bartter’s syndrome

Type Channel affected Location Effect in normal
state
1 NKCC2 Apical surface of Transport Na+,
ascending loop of Henle K+, 2Cl– from ECF
to cell
2 ROMK Apical surface of Transport K+ out
ascending loop of Henle of cells
3 CLCNKB Basolateral surface of Cl– transport
loop of Henle
4 BSND (co-factor for Basolateral surface of Cl– transport
CLC-KB in ear and DCT
kidney)
Gitelman’s syndrome
Incidence
1 in 40,000, prevalence of heterozygotes is ~1% in Caucasians. One of the
commonest inherited tubular disorders.
Genetic inheritance
Pathophysiology
Mutation affecting SLC12A3 encoding the NCCT (thiazide-sensitive
NCCT) in the DCT. It is a milder disease than Bartter’s.
Presentation
• Presents in early childhood late childhood or adulthood.
• Muscle weakness, tetany, paresthesiae, joint problems, vomiting,
abdominal pain.
• Hypokalaemia periodic paralysis.
• Prolonged QTc.
• May be normo- or hypotensive.
Biochemistry
• d K+, d Mg2+.
• d urinary Ca2+, i urinary Mg2+.
Treatment
• i salt in diet (both Na+ and K+).
• Mg2+ and K+ supplementation.
• Amiloride.
Chapter 6 183
Special populations
Pregnancy 184
Pregnancy: chronic hypertension 188
Pregnancy: gestational hypertension 189
Pregnancy: pre-eclampsia 190
Diabetes 196
The elderly 200
Children 204
Post-stroke 208
Transplant patients 210
184 CHAPTER 6 Special populations
Pregnancy
Hypertension in the context of pregnancy is relatively common, affecting
~15% of all pregnancies. Although usually uncomplicated, it may occur
in the context of pre-eclampsia. Maternal hypertension is the 2nd most
common cause of maternal deaths in the UK. Therefore, close monitoring
and co-operation between medical specialties is essential. It is also impor-
tant to recognize that treatment differs from standard practice.
Measuring BP
BP should be recorded in a seated position using Korotkoff I and V. The
routine use of Korotkoff 4 for diastolic pressure has been abandoned
because V is more reliably detected and closer to true diastolic pres-
sure. In the very few women in whom sounds can be heard down to
zero, Korotkoff IV should be used, but this must be recorded in the notes.
Generally, mercury devices are preferred as many oscillometric devices
have not been validated in pregnant women. Aneroid devices should be
avoided.
Haemodynamic changes in pregnancy
Pregnancy is associated with a number of dramatic changes in the CV
system that come about to meet the i metabolic demands of the mother
and fetus. Over the course of a normal pregnancy, circulating blood
volume i steadily to ~150% of normal by term. PVR falls until mid gesta-
tion and then gradually returns to normal by term (b Fig. 6.1). Cardiac
output i by 50% over the first 20 weeks of gestation, and then plateaus
until delivery. This is driven by an i in heart rate throughout pregnancy
and a marked i in stroke volume during the 1st trimester. The overall
effect is that BP tends to fall from conception until mid-pregnancy and
then returns to normal by term. This pattern of haemodynamic changes
is different in women who develop hypertension during pregnancy, and
varies depending upon the nature of the underlying condition (b Fig. 6.1).
Definitions
Hypertension in pregnancy is defined as a BP consistently (2 or more occa-
sions) >140/90mmHg. Some units also based their definition on a single
diastolic pressure over 110mmHg, or a rise of 15mmHg in diastolic or
30mmHg systolic from booking. However, the validity of such approaches
is unclear. Hypertension in pregnancy can be divided into 3 main catego-
ries (b Fig. 6.2):
• Chronic hypertension defined as an elevated BP at conception or
prior to 20 weeks’ gestation—usually ‘essential’ in nature.
• Gestational or pregnancy-associated hypertension also referred to
as non-proteinuric pregnancy-induced hypertension (PIH). Defined as
an elevated BP after 20 weeks without significant proteinuria.
• Pre-eclampsia (toxaemia) or proteinuric PIH (PPIH). Defined as an
elevation in BP after 20 weeks’ gestation with significant proteinuria
(≥1+ on dipsick, or 300mg/24h).
2 The term PIH encompasses gestational hypertension and pre-eclampsia,
the distinction being whether or not there is significant proteinuria.
PREGNANCY 185
10 1700
Cardiac output L/min
PET
Peripheral resistance
GH
dynes/sec/cm-5
1500
8
1300
Normal
6 Normal
PET 1100
GH
10–14 20–24 28–32 34–36 36+ 10–14 20–24 28–32 34–36 36+
Gestation (weeks) Gestation (weeks)
Fig. 6.1 Changes in cardiac output and peripheral resistance in normal pregnancy
and women who develop pre-eclampsia (PET) or pregnancy associated (gestational;
GH) hypertension. Redrawn with permission from Bosio PM, et al. (1999). Maternal
central hemodynamics in hypertensive disorders of pregnancy. Obstet Gynecol
94:978–84.
Fig. 6.2 The relative frequencies of the 3 types of hypertension in pregnancy.
Antihypertensive drugs therapy

Given the potential for adverse effect to both the mother and foetus the
use of any drug in a pregnant woman is a balance between risk and benefit.
Perhaps unsurprisingly, most antihypertensive agents are unlicensed for
use in pregnancy because safety and efficacy studies have not been under-
taken. Thus older agents, that were widely used before concerns about
teratogenicty were raised, tend to be the only agents with ‘proven’ safety
records. The main aim of treating hypertension is to prevent the develop-
ment of severe hypertension. There appears to be little effect on other
outcome measures in mild/moderate hypertension.
Methydopa
Widely used in pregnancy; acts to reduce sympathetic outflow by a central
mechanism. Placebo-controlled trials have confirmed the efficacy of meth-
yldopa in reducing BP, but other beneficial effects seem small. Side-effects
such as depression and sedation are its major drawbacks. Long-term fol-
low-up studies have shown that methyldopa is not associated with any risk
of teratogenicity. The usual dose range is 200mg–1g, 2–3 times daily.
B-blockers
These agents are widely used in pregnancy, and controlled trials confirm
their efficacy. Labetalol (also has A-blocking effects) is licensed in preg-
nancy and has a favourable safety and side-effect profile (care in asth-
matics). Atenolol has been associated with a fall in placental perfusion and
reduced fetal growth in older studies and should be avoided (the effects
of newer agents are unclear). The usual dose of labetaolol is 100–400mg,
2 or 3 times a day (maximum dose 2.4g daily).
CCAs
A range of agents have been used in pregnancy and data suggests that
they are at least as effective as other agents in reducing BP. Nifedipine
is the most widely used and has a good safety profile, and amlodipine is
probably also safe. Nifedipine should not be used in the short-acting form,
especially in severe hypertension; usual dose 20–90mg daily.
Other agents
Thiazide diuretics have fallen out of favour in pregnancy, particularly in
pre-eclampsia which is often associated with a reducing in plasma volume.
However, early studies suggested that thiazides were effective and showed
similar safety to other antihypertensives. Nevertheless, they cannot be
currently recommended. ACEIs are teratogenic even in the early phases
of pregnancy1 and should therefore be avoided from the outset, as should
ARAs. A-blockers may be used in more resistant cases.
Targets
There is no clear evidence about acceptable BP targets in pregnancy. Recently
there have been concerns regarding excessive reduction in BP leading to
fetal growth restriction (b Fig. 6.3). Moreover, although antihypertensive
drugs may prevent the development of severe hypertension in women with
mild–moderate BP elevation, they do not seem to improve other aspects of
maternal or fetal outcomes. Thus excessive BP lowering should be avoided,
and reasonable target pressures are 130–150/80–100mmHg.
PREGNANCY 187
500
250
Mean difference in
birthwieght (g)
0
Jannet and
−250 colleagues
−500
−750 Butters and
colleagues
−1000
−1 0
−1 . 0
0.0
.5
.0
.5
0
2.5
5.0
7.5
.0
.5
.0
.5
5.
2
−7
−5
−2
10
12
15
17
−1
Difference in MAP (mmHg)
Chronic hypertension (drug vs. placebo)

Late-onset hypertension (drug vs. placebo)
Late-onset hypertension (drug vs. drug)
Fig. 6.3 Relationship between fall in MAP and birth weight. Redrawn from von
Dadelszen P, et al. (2000). Fall in mean arterial pressure and fetal growth restriction
in pregnancy hypertension: a meta-analysis. Lancet 355:87–92, © 2000, with permis-
sion from Elsevier.
Reference
1. Cooper WO, et al. (2006). Major congenital malformations after first-trimester exposure to
ACE inhibitors. NEJM 354:2443–51.
Pregnancy: chronic hypertension

Chronic hypertension complicates ~3% of all pregnancies. The vast
majority of chronic hypertension in pregnancy is p or essential hyperten-
sion. s hypertension is rare, accounting for <2% of all cases. Occasionally
s hypertension may be diagnosed de novo in pregnancy; the most fre-
quent cause being intrinsic renal disease. It is important to exclude phaeo-
chromocytoma to avoid the potentially devastating consequences during
later pregnancy. Chronic hypertension in pregnancy is more likely in older,
obese, or black women, and those with pre-existing CV or renal disease.
Risks
Chronic hypertension is associated with adverse outcomes for the
mother and fetus, particularly in women with severe chronic hypertension
(>170/110mmHg). Overall, there is a ~3-fold i in still birth and ~2.5-fold
i in having a small-for-gestational-age baby.1 The risk of developing pre-
eclampsia is i by a factor of 10, and is more likely in women with proteinuria
in early pregnancy and if they have had previous pre-eclampsia. Chronic
hypertension also i the likelihood of developing gestational diabetes.
Treatment
Although there are no placebo-controlled trials available, historic data
suggest that treating severe chronic hypertension in pregnancy reduces
maternal and fetal risks.2 Therefore, antihypertensive therapy should be
initiated if the BP is >170/110mmHg.
In pregnant women with mild/moderate chronic hypertension there is
good evidence that antihypertensives reduce the risk of developing severe
hypertension, which is perhaps unsurprising. However, there is no clear
evidence that BP reduction reduces the risks of developing pre-eclampsia
or improves maternal or fetal outcomes.3 Current consensus guidance is
split between recommend treatment at a level exceeding 160/100mmHg,
or above 140/90mmHg. Given the potential concerns about excessive BP
reduction and intra-uterine growth retardation (b see Pregnancy, p.184),
careful consideration of individual cases is required. Lower thresholds may
be appropriate for women with other significant risk factors or previous
adverse outcomes.
The target BP is less clear but a reasonable guide would be to aim for a
pressure of 130–150/80–100mmHg.
References
1. Allen VM, et al. (2004). The effect of hypertensive disorders in pregnancy on small for gesta-
tional age and stillbirth: a population based study. BMC Pregnancy Childbirth 4:17.
2. Kincaid-Smith P, et al. (1966). Prolonged use of methyldopa in severe hypertension in preg-
nancy. BMJ 1:274–6.
3. Sibai BM, et al. (1990). A comparison of no medication versus methyldopa or labetalol in
chronic hypertension during pregnancy. Am J Obstet Gynec 162:960–6.
PREGNANCY: GESTATIONAL HYPERTENSION 189
Pregnancy: gestational hypertension

Gestational hypertension (also known as non-proteinuric PIH) is the most
common form of hypertension in pregnancy, affecting ~8% of pregnancies.
By definition women must have been normotensive up to 20 weeks’ gesta-
tion and not have significant proteinuria (<1+ on dipstick). There is clearly
an overlap with women with chronic hypertension who have simply not
been diagnosed, and also with pre-eclampsia. Although the precise aetiology
remains unclear, there is evidently a genetic component.
Known risk factors include:
• Nulliparity.
• Obesity.
• Non-smoker.
• Previous hypertension or high normal BP.
• Pre-existing or gestational diabetes.
• Family history of hypertension or hypertension in pregnancy.
Physiologically, gestational hypertension results from a hyperdynamic
circulation with a significantly higher cardiac output and lower resistance
than in a normal pregnancy. In contrast to women who go on to develop
pre-eclampsia, this state remains until term, and does not transform into a
high resistance state (b see Fig. 6.1, p.185).
Risks
Gestational hypertension i the risks of having a small-for-gestational-age
new born by 1.5 x the rate in normotensives, but does not seem to i the
risk of still birth significantly.1 Although gestational hypertension is associ-
ated with i perinatal mortality this seems largely driven by a reduced birth
weight.2 Recent data indicate that gestational hypertension i the risk of
future CV in the mother by ~2-fold.3
The risk of gestational hypertension progressing to pre-eclampsia is ~20%.
Risk factors for this include early onset of hypertension and previous mis-
carriage.
Treatment
Severe (>170/110mmHg) gestational hypertension merits antihyperten-
sive therapy. Although treatment of lower levels of BP halves the risk of
developing severe hypertension, there is little evidence that it reduces
the risk of perinatal death, premature delivery, or intra-uterine growth
retardation. Current guidance suggests initiating therapy if the BP is
>140–160/90–100mHg. Given the physiological abnormalities underlying
this form of hypertension B-blockade may be an appropriate 1st choice. A
target BP of 130–140/80–100mmHg would seem appropriate.
References
1. Allen VM, et al. (2004). The effect of hypertensive disorders in pregnancy on small for gesta-
tional age and stillbirth: a population based study. BMC Pregnancy Childbirth 4:17.
2. Steer PJ, et al. (2004). Maternal blood pressure in pregnancy, birth weight, and perinatal mor-
tality in first births: prospective study. BMJ 329:1312.
3. Ray JG, et al. (2005). Cardiovascular health after maternal placental syndromes (CHAMPS):
population-based retrospective cohort study. Lancet 366:1797–803.
Pregnancy: pre-eclampsia
Pre-eclampsia (also known as PPIH) affects ~3% of pregnancies and carries
a considerable burden of maternal and perinatal morbidity and mortality.
It i the risk of still birth by a factor of ~2, and of intra-uterine growth
retardation by ~3.
Definition
It is often considered as a triad of hypertension, proteinuria, and oedema
after 20 weeks. However it is usually defined as new onset hyperten-
sion (>140/90mmHg) in the presence of proteinuria (≥+1 on dipstick,
or >300mg/24h). Clearly, it may also complicate chronic or gestational
hypertension. It is very rare before 24 weeks’ gestation.
Pathophysiology
Pre-eclampsia is a multisystem disorder driven by the placenta that remains
incompletely understood. Ineffective placentation following abnormal
trophoblastic invasion, leads to placental hypoxia, intra-uterine growth
retardation, and release of a number of inflammatory and other factors
that trigger a cascade of events in the maternal circulation. There is wide-
spread endothelial dysfunction, a reduction in plasma volume and cardiac
output, vasoconstriction, and the development of hypertension. There is
also i platelet aggregation, intravascular coagulation, and reduced organ
perfusion particularly of the kidney, liver, and brain.
The mechanisms underlying defective placentation are complex and prob-
ably relate to a maladaptive interaction between maternal and ‘foreign’
placental antigens. There is clearly a genetic component, but this is by no
means absolute. Of recent interest has been i circulating levels of sFlt1
(a soluble secreted ectodomain) in pre-eclamptics, which leads to lower
activity of VEGF.
Risk factors
Epidemiological studies have identified a number of risk factors for devel-
oping pre-eclampsia1 including:
• Aged <20 or >35 years.
• Primigravida (relative risk (RR) 3).
• Multipara with new partner.
• Multiple pregnancy (RR for twins 4).
• Obesity (RR 9).
• Chronic hypertension (RR 3).
• Diabetes.
• Hypercholesterolaemia/triglyceridaemia.
• Renal disease.
• Family history of pre-eclampsia.
• Previous pre-eclampsia (risk of recurrence ~12%).
• Thrombophilia.
• Black.
PREGNANCY: PRE-ECLAMPSIA 191
Signs and symptoms

Pre-eclampsia usually presents after 20 weeks, and is cured by delivery
of the placenta, but there are rare reports of pre-eclampsia occurring up
to 1 month post-partum. There is considerable overlap between pre-ec-
lampsia and the HELLP syndrome (Box 6.1) and disorders such as throm-
botic thrombocytopenia and haemolytic-uraemic syndrome. b Features
of severe pre-eclampsia are given in Box 6.2.
The classic features of pre-eclampsia may occur rapidly or insidiously over
several days. It is important to ensure that BP is assessed and urine dipped
in any pregnant woman who is non-specifically unwell.
• Headache, nausea, blurred vision.
• Hypertension.
• Epigastric pain, abdominal tenderness.
• Peripheral oedema.
• Brisk reflexes, clonus.
• Retinal haemorrhages, cotton wool spots, and papilloedema.
• Confusion, seizures (eclampsia).
Box 6.1 HELLP syndrome

HELLP is considered as a variant form of severe pre-eclampsia in which
there is marked disseminated intravascular coagulation, micro-angio-
pathic haemolytic anaemia, and hepatocellular damage. Between 4–12%
of women with pre-existing pre-eclampsia may develop superimposed
HELLP. It is associated with considerable i risks, including maternal
death) and invariably necessitates urgent delivery. It is defined as:
• Haemolysis (red blood cell destruction of film and elevated lactate
dehydrogenase).
• Elevated Liver enzymes (aspartate aminotranferase (AST), alanine
aminotransferase (ALT)).
• Low Platelets (<150 x 109/L).
Investigations
• FBC ± clotting.
• Uric acid—a sensitive marker of the severity of pre-eclampsia.
• U&Es, creatinine.
• LFTs.
• Urine dipstick, midstream urine.
• Consider urinary VMA, and abdominal USS.
Doppler ultrasound of uterine artery blood flow demonstrates character-
istic abnormalities in women with pre-eclampsia (b Fig. 6.4), particularly
in the mid-trimester. It can also be used early in pregnancy to identify
women at i risk of developing pre-eclampsia.2 Accuracy may be improved
when combined with serum markers e.g. PP-13. This is of particular benefit
in those deemed to be at i risk by virtue of known risk factors.
Prevention
A number of studies have assessed the impact of a range of preventive
treatments including low dose aspirin, antioxidants, and calcium. These
have mostly been negative (except calcium supplementation if low calcium
intake), and routine administration of these agents, even in women identi-
fied at risk of pre-eclampsia, is not currently recommended.
Management
Hospitalization should be considered for women with any of the following
adverse features (women without such features may be considered for
management at home with frequent (weekly) outpatient review. Do not
forget extra scans for fetal well-being if there are signs of placental insuf-
ficiency as the fetal condition may deteriorate rapidly if pre-eclampsia
worsens):
• Clinical feature such as headache, abdominal pain
• BP >140/90mmHg.
• Proteinuria >+1.
• Hyperuricaemia.
• Platelet count <100 x 109/L.
• Oligohydramnios or inadequate fetal growth.
Management in hospital will depend on the severity of the disease, ges-
tational age, and response to therapy. Delivery is the only ‘cure’ for pre-
eclampsia but may be delayed if gestation is <34 weeks and there is a good
clinical response to therapy and few other adverse signs. Nevertheless,
close monitoring of clinical, biochemical, and fetal parameters is essential.
Steroids may also be useful in accelerating fetal lung maturation if <34
weeks. It is important to involve a multidisciplinary team at an early stage
and management should be carried out in a specialist area.
General management includes regular observations, urine output and
analysis, and bed rest. Excessive fluid replacement should be avoided as
this has been associated with an i risk of death. Urine outputs as low
as 10mL/h may be acceptable. Thromboprophylaxis with thromboembolic
deterrent (TED) stockings and low-molecular-weight heparin should be
undertaken.
(A) (B)
Fig. 6.4 Doppler flow velocity waveforms in the uterine artery. (A) normal;
(B) pre-eclampsia. (Courtesy of Dr Christoph Lees, Cambridge.)
Box 6.2 Severe pre-eclampsia

Defined as 1 or more of the following:
• Severe nausea and vomiting, headache, visual disturbance, abdominal
or chest pain, dyspnoea.
• BP >160/110mmHg, oliguria, pulmonary oedema, abruption placentae.
• Platelets <100 x 109/L, elevated liver enzymes, albumin <18g/L, heavy
proteinuria.
The onset of eclampsia is more likely if there is severe headache, brisk
reflexes or clonus, visual disturbances.
Pharmacological treatment
The main aim should be to reduce maternal BP slowly to <160/110mmHg.
There is no evidence that tighter control to <140/90mmHg results in
better outcomes and it may adversely affect placental perfusion and foetal
growth.
Severe hypertension
Depending upon the clinical situation, this may necessitate the use of IV
therapy with Labetalol or hydralazine.3 There is little difference between
the 2, although meta-analysis suggests that hydralazine may be associated
with more maternal side effects but less foetal bradycardia.4 Attempts to
reduce BP with oral short-acting nifedipine or labetolol may cause uncon-
trolled reductions in BP and are probably best avoided. Typical regimens
are:
• Labetalol slow bolus of 20–40mg, followed by an infusion of 20mg/h
max 160mg/h.
• Hydralazine 200–300mcg/min initially then 50–150mcg/min maintenance.
Mild–moderate hypertension
The aim should be to reduce the BP slowly using oral therapy to a target
of 140–160/80–100mmHg. Suitable agents include methyldopa, Labetalol,
or nifedipine. ACEIs and ARAs should be avoided.
Magnesium sulphate
The MAGPIE Study demonstrated that women with severe pre-eclampsia
should receive MgSO4 to terminate and prevent seizures. This is usually
given as 4g over 5–15min followed by an infusion of 1g/h.
Follow up
It is important to remember that maximum BP levels are achieved 3–5
days postpartum. Adequate follow-up must be arranged (e.g. 1 week after
discharge). The decision concerning if, and when, to discontinue anti-
hypertensives will depend on a number of factors including severity of BP
elevation, pre-existing hypertension, and current BP. However, women
who have experienced pre-eclampsia are at i risk of developing both
hypertension and CVD (b Fig. 6.5).
Hypertension
Study Total no. of cases/ Total no. of cases\
women who had women who did had Weight Relative risk
pre-eclampsia have pre-eclampsia (%) (random) (95% CI)
Adams 1961w1 40/53 21/185 14.26 5.91 (3.89 to 8.98)
Epstein 1964w2 37/48 7/114 8.97 5.34 (2.50 to 11.42)
Sibai 1986w3 60/406 23/409 13.52 2.63 (1.66 to 4.17)
Carleton 1988w4 3/23 2/23 2.91 1.50 (0.28 to 8.10)
Nisell 1995w5 9/45 1/44 2.12 8.80 (1.16 to 6.66)
North 1996w6 20/50 1/50 2.23 20.00 (2.79 to 143.35)
Laivuori 1996w7 2/22 0/22 1.03 5.00 (0.25 to 99.24)
Hannaford 1997w8 377/2371 922/14831 18.59 2.35 (2.08 to 2.65)
Marin 2000w9 30/94 12/86 8.88 3.70 (1.72 to 7.97)
Shammas 2000w10 23/47 3/46 5.45 7.50 (2.42 to 23.26)
Hubel 2000w11 10/30 2/30 3.81 5.00 (1.19 to 20.96)
Sattar 2003w12 7/40 2/40 3.49 3.50 (0.77 to 15.87)
Wilson 2003w13 216/443 55/206 14.74 2.62 (1.77 to 3.87)
Total (95% CI) 834/3658 1051/16086 100.00 3.70 (2.70 to 5.05)

Test for heterogeneity: x2=32.05, df=12, P=0.001, I2=62.6%
0.1 0.2 0.5 1 2 5 10
Test for overall effect: z=8.20, P<0.001
Decreased Increased
risk risk
Ischaemic heart disease

Study Total no. of cases/ Total no. of cases\
women who had women who did had Relative risk Relative risk
pre-eclampsia have pre-eclampsia (random) (95% CI) (random) (95% CI)
Hannaford 1997w8 69/2371 216/14831 1.65 (1.26 to 2.16)

Irgens 2001w15 27/24155 325/602117 3.61 (0.76 to 17.18)
Smith 2001w16 12/22781 31/106509 1.70 (0.86 to 3.35)
Wilson 2003w13 26/1043 10/796 1.95 (0.90 to 4.22)
Kestenbaum 2003w14 35/20552 64/92902 2.55 (1.70 to 3.83)
Funai 2005w17 41/1070 269/35991 3.01 (2.18 to 4.33)
Ray 2005w18 228/36982† 1262/950885 2.10 (1.82 to 2.42)
Wirkstrom 2005w19 176/12533 2306/383081 2.21 (1.56 to 3.31)†
Total (95% CI) 614/121487 4483/2187112 2.16 (1.86 to 2.52)

Test for heterogeneity: x2=9.60, df=7, P=0.21, I2=27.1%
Test for overall effect: z=10.00, P=0.001 0.2 0.5 1 2 5 10
Decreased Increased
risk risk
Fig. 6.5 Risk of developing hypertension (top) of ischaemic heart disease (bottom)
in women with previous pre-eclampsia. Reproduced from Bellamy L, et al. (2007).
Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic
review and meta-analysis BMJ 335: 974, with permission from the BMJ Publishing
Group.
References
1. Magnussen EB, et al. (2007). Prepregnancy cardiovascular risk factors as predictors of
pre-eclampsia: population based cohort study. BMJ 355:978
2. Papageorghiou AT, et al. (2001). Multicenter screening for pre-eclampsia and fetal growth
restriction by transvaginal uterine artery Doppler at 23 weeks of gestation. Ultrasound Obstet
Gynecol 18:441–9.
3. von Dadelszen P, et al. (2007). Evidence-based management for preeclampsia. Front Biosci
12:2876–89.
4. Magee LA, et al. (2003). Hydralazine for treatment of severe hypertension in pregnancy: meta-
analysis. BMJ 327:955.
Diabetes
Diabetes and hypertension frequently co-exist: 720% of those with type-1
and 780% of those with type-2 diabetes are hypertensive. Subjects with
hypertension are also more likely to develop diabetes than normoten-
sive individuals. In type-2 diabetics there is often clustering of hyperten-
sion with other components of the metabolic syndrome such as insulin
resistance, obesity, and low HDL-cholesterol. 785% of the excess CV risk
observed in diabetes may be attributed to hypertension.
Pathophysiology of hypertension
Early abnormalities in diabetics include i cardiac output and centrali-
zation of venous blood volume. This is accompanied by a loss of the
normal night-time BP ‘dipping’ which is a prelude to the development of
albuminuria and LVH. Once established, diabetic hypertension is often
‘salt-sensitive’, with a corresponding low plasma renin. Diabetes also exag-
gerates the age-related i in BP, and thus diabetics tend to develop ISH at
an earlier age (b Fig. 6.6). Postural hypothension is also more common in
diabetics due to autonomic failure which can make treating supine hyper-
tension difficult.
The kidney
The presence of micro- (or macro-) albuminuria substantially i CV risk
in diabetics. The precise relationship between renal failure, hypertension,
and diabetes is unclear but in type 1 diabetes hypertension is probably
more a consequence of renal impairment, than a cause. Nevertheless,
aggressive BP control reduces the rate of renal decline and also the
degree of proteinuria. Blockade of the renin–angiotensin system may also
have direct BP-independent reno-protective effects (b Figs 6.7 and 6.8).
Non-dihydropyridine (DHP) CCAs may also be reno-protective (b see
Calcium-channel antagonists, p.218).
Treatment
Multiple risk factor intervention is required in diabetics, particularly
because of the clustering of risk factors in type-2 patients. A number of
randomized controlled trials, such as HOT, UKPDS, and ABCD, have
confirmed the efficacy of BP lowering in hypertensive diabetics, including
those with ISH (SHEP and SystEur). They also confirm that greater BP
reduction yields additional benefits. Consequently, the BHS and JNC-7
target for diabetics is 130/80, which will require combination therapy for
most patients.
The relative merits of different antihypertensives in diabetics have been
hotly debated, and contradictory evidence has emerged from a number
of largely underpowered studies such as UKPDS, CAPP, and ABCD.
However, ALLHAT included 13,101 diabetics and 1399 subjects with
impaired fasting glucose, and found no difference in outcomes between
an ACEI, DHPs, or thiazides (b Fig. 6.9). Nevertheless, most authorities
recommend that initial therapy in diabetes includes an ACEI or ARA due
to their reno-protective effects.
DIABETES 197
140 SBP
120
100
DBP
80
60
PP
40
18–24
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
Age (years)
Fig. 6.6 Age-related changes in BP for diabetics (filled symbols) and non-diabetics
(open symbols). Redrawn with permission from Rönnback M, et al. (2004). Altered
age-related blood pressure pattern in type. Circulation 110:1076–82.
35
30 Placebo
Percent with doubling of
baseline creatinine
25
20
15
10 Captopril
5
0
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Years of follow-up
Fig. 6.7 Effect of ACEI on progression of renal dysfunction in patients with insulin-
dependent diabetes. Redrawn with permission from Lewis EJ, et al. (1993). The
effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. NEJM
329:1456–62. © 1993 Massachusetts Medical Society. All rights reserved.
Irbesartan
0.6 Amlodipine
Placebo
0.5
primary endpoint
Proportion with
0.4
0.3
0.2
0.1
0.0
0 6 12 18 24 30 36 42 48 54
Months of follow-up
Fig. 6.8 Effect of an ARA compared to placebo or a DHP CCA (control for d BP)
on progression of renal dysfunction in patients with type-2 diabetes. Redrawn with
permission from Lewis EJ, et al. (2001). Renoprotective effect of the angiotensin-
receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes.
NEJM 345:851–60. © 2001 Massachusetts Medical Society. All rights reserved.
DIABETES 199
Diabetes mellitus
0.20
RR (95% CI) Pvalue
Cumulative CHD event rate
Amlodipine/chlortalidone 0.97 (0.86–1.10) 0.64

0.16 Lisinopril/chlortalidone 0.97 (0.85–1.10) 0.59
0.12
0.08
Chlortalidone
0.04 Amlodipine
Lisinopril
0 1 2 3 4 5 6
Time to CHD event (years)
Fig. 6.9 CHD events for the three treatment groups in ALLHAT. Redrawn with
permission from Whelton PK, et al. (2005). Clinical outcomes in antihypertensive
treatment of type 2 diabetes, impaired fasting glucose concentration, and normo-
glycemia: antihypertensive and lipid-lowering treatment to prevent heart attack trial
(ALLHAT). Arch Intern Med 165:1401–9.
The elderly
The prevalence of hypertension i dramatically with age. The recent
Health Survey for England1 reported that 760% of 60–70-year-olds, and
780% of those >80 years are hypertensive. The most common form of
hypertension in the >60s is ISH, which outnumbers SDH and IDH by 72:1.
ISH is largely a consequence of arterial stiffening, and only a minority of
patients seem to progress from SDH or IDH to ISH.
BP and risk
Although SBP and DBP both predict CV risk in older individuals, SBP is
more strongly related to risk. Moreover, for a given level of SBP, DBP is
inversely related to risk. Hence, pulse pressure (SBP – DBP) is the best
predictor of risk in elderly subjects. Nevertheless, because most guide-
lines and therapeutic trials are based on systolic and diastolic pressure,
systolic pressure should be the p target in older subjects.
Risks
The proportional risk of MI and stroke associated with a given differ-
ence in BP is greater in middle-aged than older subjects by a factor of
2. However, the absolute risks are greater in older subjects due to the
substantially higher risk of CVD.
Treatment
Lifestyle modification
Non-pharmacological intervention is effective in older hypertensives. The
TONE study2 demonstrated that salt restriction and weight reduction in
the elderly both significantly reduce BP in elderly subjects, particularly
when combined (b Table 6.1). Older subjects should also be encouraged
to d alcohol intake and take regular exercise.
Pharmacological therapy
A number of placebo controlled trials including the EWPHE, MRC-Elderly,
and STOP have clearly demonstrated that BP reduction reduces CV
events in elderly subjects (b Fig. 6.10). The relative reduction in MI and
stroke is similar to that seen in middle-aged subjects (33 and 20% respec-
tively). SHEP, SystEur, and SystChina have also confirmed the benefits of
treated systolic hypertension in elderly subjects (b see Table 2.1, p.54).
Side-effects
Overall, adverse events seem no more common in elderly subjects than in
younger subjects, and concerns relating to dizziness and postural hypoten-
sion seem largely unjustified. In the SHEP pilot study and STOP trial dis-
continuation rates were similar between the placebo and active therapy
groups.
Choice of agent
Although STOP-2 suggested that there were no differences in outcome
between old and newer antihypertensive drugs, the MRC-Elderly Study
and a subgroup analysis of the LIFE trial cast doubt on the benefit of
B-blockade in older subjects. This was supported by a meta-analysis of
trials involving B-blockers or diuretics in elderly hypertensives.3 Based on
THE ELDERLY 201
the available evidence and the observation that elderly hypertensive sub-
jects usually have a low plasma renin, it seems logical to initiate therapy
with a thiazide diuretic or CCA. ACEI and ARAs may also be appropriate
1st-line therapy and are often used to good effect in combination with a
diuretic or CCA. Potent vasodilators may precipitate syncope or breath-
lessness in older subjects particularly in those with systolic hypertension
which may relate to the lowering of diastolic pressure and myocardial
ischaemia. Nitrates may prove useful in some resistant patients (b see
Nitrates, p.237).
Table 6.1 Changes in BP in the Tone study2

Intervention Change in BP (systolic/diastolic: mean ± SEM)
Sodium reduction –3.4 ± 0.8/–1.9 ± 0.5
Weight loss –4.0 ± 1.3/–1.1 ± 0.8
Combined intervention –5.3 ± 1.1/–0.34 ± 0.6
Control group –0.8 ± 0.8/–0.8 ± 0.5
100 Cardiovascular mortality p = 0.023
90
Active
80
Placebo
70
0 1 2 3 4 5 6 7
Follow-up (years)
Fig. 6.10 Results of the EWPHE study of hydrochlorothiazide/triamterene versus
placebo in elderly patients. Redrawn from Amery A, et al. (1985). Mortality and
morbidity results from the European Working Party on High Blood Pressure in the
Elderly trial. 6105 individuals with previous stroke or transient ischaemic attack.
Lancet 1:1349–54, ©1985, with permission from Elsevier.
Targets
JNC 7 recommends a target of <140/90 and the BHS <140/85mmHg.
However, the systolic target is often difficult to achieve in elderly sub-
jects and particularly those with ISH.4 Nevertheless, placebo controlled
trials indicate that modest (10/5) reductions in BP produce substantial d in
events (d CV events by 1/3rd).
Although epidemiological data have consistently disproved the existence
of a J-shape curve at least down to 115/75mmHg, a retrospective analysis
of the SHEP study5 suggested that lowering DBP to <70mmHg was asso-
ciated with an i risk of events (b Fig. 6.11). Practically, one should be
cautious in producing excessive falls in DBP in older subjects with systolic
hypertension, accepting that this may leave imperfect control of SBP.
The very elderly
Few data exist regarding the benefits of BP reduction in the very elderly
(>80 years) with ISH. A recent meta-analysis of ~1600 patients >80 years
of age6 demonstrated significant reductions in the incidence of stroke and
heart failure with antihypertensive therapy, but no reduction in mortality.
The recently published HYVET trial confirmed the substantial benefits of
BP d in older subjects.
References
1. Primatesta P and Poulter NR (2006). Improvement in hypertension management in England:
results from the Survey for England 2003. J Hypertens 24:1187–92.
2. Stamler R, et al. (1987). Nutritional therapy for high blood pressure. Final report of a four-year
randomized controlled trial – the Hypertension Control Program. JAMA 257:1484–8.
3. Messerli FH, et al. (1998). Are beta-blockers efficacious as first-line therapy for hypertension in
the elderly? A systematic review. JAMA 279:1903–7.
4. Mancia G and Grassi G (2002). Systolic and diastolic blood pressure control in antihypertensive
drug trials. J Hypertension 20:1461–4.
5. Somes GW, et al. (1999). The role of diastolic blood pressure when treating isolated systolic
hypertension. Arch Intern Med 159:2004–9.
6. Gueyffier F, et al. (1999). Antihypertensive drugs in very old people: a subgroup meta-analysis
of randomised controlled trials. INDIANA Group. Lancet 353:793–6.
THE ELDERLY 203
10
Relative risk
95% Confidence
9 interval
P(trend)<0.001
6
Relative risk
0
80 75 70 65 60 55 50 45 40 35 30 25
DBP cutoff, mmHg
Fig. 6.11 Relationship between achieve diastolic pressure and relative risk of CV
disease in the SHEP study. Reproduced with permission from Somes GW, et al.
(1999). The role of diastolic blood pressure when treating isolated systolic hyper-
tension. Arch Intern Med 159: 2004–9.
Children
BP in children is considerably lower than in adults, and i steadily
throughout childhood (b Fig. 6.12). Systolic and diastolic pressures i
more steeply in puberty, particularly in boys, and are positively related
to weight and inversely to height. There is also considerable (although
not complete) tracking of BP throughout childhood and into adult life.
Hypertension in children is rare and should prompt a thorough search for
s causes, especially if the child is not overweight.
Definitions
Defining hypertension in children is even more problematic than in adults,
due to the variability in BP, the clear age-dependency, and the lack of
outcome data. While the ‘usual’ adult definition of 140/90mmHg can be
applied, the standard approach is to use age-related percentile data as
a reference (b Fig. 6.12). Hypertension is usually defined as a pressure
consistently above the 98th centile for age and ‘high normal pressure’ if
consistently between the 90–95th centiles. However, as is apparent for the
centile graph, after the age of 16 years the 95th centile for systolic pressure
approximates to a value of 140mmHg, suggesting that the 140/90 cut-off
may be more appropriate after this age.
Prevalence of hypertension
Using the 98th age-related centile as a cut-off, the estimated prevalence
of hypertension in children is 72%, and 77% are classified as ‘high normal
BP. 1 The predominant form of hypertension is ISH and is physiologically
driven largely by an i cardiac output and, to a lesser extent, stiffening of
the large arteries.2 Mixed systolic/diastolic and diastolic are relatively rare,
and more suggestive of an underlying cause.
BP measurement
The most important aspect is to select an appropriately-sized cuff,
rather than rely on the standard adult cuff (80–100% of the arm
circumference)—too small a cuff will lead to an over estimation of
BP. Systolic pressure is taken as Korotkoff I and diastolic as V (not IV).
Oscillometric devices may be used, but most are rarely validated in chil-
dren. The role of ABPM in children is unclear and it is not recommended
as a standard part of the clinical assessment at present.
Aetiology
The vast majority of childhood hypertension is essential. The main risk
factors for essential hypertension in childhood appear to be weight,
obesity (weight adjusted for height), and family history. There is little influ-
ence of gender and race. Recent data from the USA suggest that the rate
of hypertension amongst children is rising in parallel with the i levels of
obesity. Although relatively rare, s hypertension is the predominant form
of hypertension in younger children. The most frequent underlying cause
is renal parenchymal disease (b Table 6.2).
CHILDREN 205
Table 6.2 Causes of hypertension by age group.

Pre-puberty Pubertal-adolescence
Renal parenchymal disease Essential hypertension
Renovascular disease General illness
Endocrine causes Renal parenchymal disease
Co-arctation Renovascular disease
Essential hypertension Endocrine causes
Co-arctation
Drugs e.g. contraceptive pill
Centiles
99.6 75 9
98 50 2
91 25 0.4
A A
170 100
Diastolic blood pressure (mm Hg)
Systolic blood pressure (mm Hg)
160
90
150
140 80
130 70
120
110 60
100 50
90
40
80
70 30
4 8 12 16 20 24 4 8 12 16 20 24
B B
170 100
Diastolic blood pressure (mm Hg)
Systolic blood pressure (mm Hg)
160 90
150
140 80
130 70
120
110 60
100 50
90
40
80
70 30
4 8 12 16 20 24 4 8 12 16 20 24
Fig. 6.12 BP centiles for children in the UK. Reproduced from Jackson LV, et al.
(2007). Blood pressure centiles for Great Britain. Arch Dis Child 92:298–303, with
permission from the BMJ Publishing Group.
Investigations
The precise investigation will depend on the severity of the hypertension,
clues to a possible underlying cause (b Table 6.3), and the results of
screening tests. All patients need a thorough examination and fundoscopy.
Screening/general
• FBC, ESR.
• U&Es, Ca2+, CRP, TSH.
• Renal ultrasound.
• Urine analysis.
• ECG.
Specific
• Urinary VMA/catecholamines.
• Renin/aldosterone.
• Echo.
• MR-angiogram.
• Isotope renal scan.
Treatment
For those with essential hypertension, targeted lifestyle intervention can
be of considerable benefit especially for those with borderline or mildly
elevated BP. This includes weight control, regular exercise, a reduction in
salt intake, and i in fruit and vegetables in the diet. Obvious precipitants
such as the contraceptive pill and illicit drugs should be stopped.
Pharmacological therapy may be required if lifestyle changes fail, or in
more severe cases of hypertension. Unfortunately, in the UK most anti-
hypertensives are not licensed for use in children, and relatively few data
concerning efficacy and side effects are available. However, the Food and
Drug Administration Modernization Act in the USA has led to a number
of studies of new antihypertensive agents in children being performed.
Nevertheless, most recommendations are extrapolation of observations
in adults and previous clinical experience.
The initial choice of therapy should be based on experience, and docu-
mented safety and efficacy. Evidence of efficacy in children is now avail-
able for the 4 main classes of antihypertensive drug, and all should be
considered as suitable initial therapy. Comorbidities may be a compelling
indication for use of a particular class of drug e.g. diabetic nephropathy and
ACEi, or co-arctation and a B-blocker. The underlying pathophysiology,
e.g. raised renin, may also help in the initial choice of drug. Suggested
doses and indications are listed in b Table 6.4. Some agents are also
available as suspensions which aid accurate dosing, but this is usually as
‘specials’ and not ‘off the shelf’.
CHILDREN 207
Table 6.3 Features suggestive of s hypertension

Cause Features
Phaeochromocytoma Sweating, tachycardia, flushing
Co-arctation Murmur
Renal artery stenosis Abdo bruit, i creatinine on ACEI, i renal mass,
active urinary sediment
Endocrine cause Acne, hirsutism, muscle weakness, obesity, d K+
Vasculitis Rash, joint pain swelling, i ESR/CRP, active urinary
sediment
Table 6.4 Examples of drugs which may be used in the management of

hypertension in children
Class Examples Dose*
Diuretics Bendroflumethiazide 50–100mcg/kg OD; 12–18 years 2.5–5mg
B-blockers Atenolol 0.5–2mg/kg OD; 12–18 years 50mg OD
Propranolol 0.25–1mg/kg TDS; 12–18 years 80mg
BD initially
ACEIs Lisinopril 70mcg/kg OD; 12–18 years 2.5–20mg OD
AT1 receptor Losartan 20–50kg 25mg OD; ≥50kg 50mg OD
antagonists
CCAs Amlodipine 100–400mcg/kg OD; 12–18 years 5–10mg
OD
*Dose assumes age <12 years, unless otherwise stated. Always check the dose in the British
National Formulary for Children. None of the drugs are licensed for use in children and
should be used under specialist care only.
References
1. Jackson LV, et al. (2007). Blood pressure centiles for Great Britain. Arch Dis Child 92:298–303.
2. McEniery CM, et al. (2005). Increased stroke volume and aortic stiffness contribute to isolated
systolic hypertension in young adults. Hypertension 46:221–6.
Post-stroke
Hypertension is the most potent risk factor for ischaemia and haemor-
rhagic stroke, and the role of BP reduction in the p prevention of stroke
is firmly established. Recent studies have also demonstrated the role of BP
lowering in s prevention. However, the management of hypertension in
the acute setting remains controversial.
Acute stroke
The majority of individuals who survive the immediate event will be hyper-
tensive, due in part to pre-existing hypertension but also the acute pressor
effects of cerebral ischaemia, hypoxia, pain, etc. Physiologically, raised BP
may help to i perfusion in the area surrounding the area of ischaemic
necrosis (the penumbra), thus limiting the extent of neurological damage.
Conversely, an excessive rise in BP may i the risk of haemorrhagic
transformation following cerebral infarction, or lead to an extension of
a haemorrhagic event. It is these 2 opposing views that have led to consid-
erable variation in the BP management following an acute stroke. Studies,
including CHIPS, are ongoing and will address the impact of BP lowing but
at present most of the guidance is based on consensus opinion.
Mild or moderate hypertension (~200/120mmHg) in the context of
an acute cerebral event probably requires no medical intervention.
Aggressive sudden BP reduction may lead to an extension of cerebral
injury and is probably best avoided. However, pre-existing antihyperten-
sive medication is probably best continued (assuming previous compliance
with medication is likely). Slow acting oral antihypertensive therapy may
be initiated after the initial 24–48 h.
Severe hypertension is more controversial. Although there is no hard
evidence either way, cautious reduction of BP with IV agents may be
justified especially in the context of a haemorrhagic stroke and a DBP
>120mmHg. For ischaemic events a higher cut-off of 220/130mmHg may
be appropriate. Whatever the decision, controlled cautious BP reduction
is probably safest, and rapid drops in BP using sodium nitroprusside should
be avoided.
s prophylaxis
Lowering BP to prevent recurrent strokes would seem a logical inter-
vention based on epidemiological data and a meta-analysis of small
intervention trials would support this view.1 The PATS study confirmed
the efficacy of the thiazide diuretic indapamide in this situation, and the
PROGRESS Study demonstrated a significant reduction in recurrent
stroke for the combination of ACEI and thiazide but not ACEI alone (b
Fig. 6.13). Based on these data, and the fact that most stroke patients are
elderly and tend to have low plasma renin, a thiazide would seem a sen-
sible initial choice for BP reduction, although co-existing conditions such
as diabetes should also be taken into consideration. A target pressure of
130/80 post-stroke is recommended by the BHS.
POST-STROKE 209
Events/patients Favours Favours Relative risk

Active Placebo active placebo reduction (95% CI)
Stroke
Combination 150/1770 255/1774 43% (30 to 54)
Single drug 157/1281 165/1280 5% (−19 to 23)
Hypertensive 163/1464 235/1452 32% (17 to 44)
Non-
hypertensive 144/1587 185/1602 27% (8 to 42)
Total stroke 307/3051 420/3054 28% (17 to 38)
Major vascular events

Combination 231/1770 367/1774 40% (29 to 49)
Single drug 227/1281 237/1280 4% (−15 to 20)
Hyprtensive 240/1464 331/1452 29% (16 to 40)
Non-
hypertensive 218/1587 273/1602 24% (9 to 37)
Total stroke 458/3051 604/3054 26% (16 to 34)
0.5 1.0 2.0

Hazard ratio
Fig. 6.13 Results of the PROGRESS study examining the effect of placebo, perin-
dopril or the combination of indapamide and perindopril post stroke. Reproduced
from PROGRESS Collaborative Group (2001). Randomised trial of a perindopril-
based blood-pressure-lowering regimen among 6105 individuals with previous
stroke or transient ischaemic attack. Lancet 358: 1033–41, © 2001, with permission
from Elsevier.
Reference
1. Rodgers A, et al. (1997). The effects of blood pressure lowering in individuals with cerebrovas-
cular disease: an overview of randomised controlled trials. Neurol Rev Int 2:12–15
Transplant patients
Hypertension post-transplantation is common, affecting up to 80%
of organ recipients, and is an important cause of excess morbidity and
mortality. The long-term survival of renal grafts is dependent on post-
transplant BP, which also predicts the risk of acute rejection. Hypertension
also i the likelihood of allograft vasculopathy and the development of
diffuse coronary atherosclerosis in cardiac transplants.
A number of mechanisms are responsible for post-transplant hyperten-
sion, including pre-existing hypertension, CVD, impaired kidney func-
tion, and the use of immunosuppressants including calcineurin inhibitors
and corticosteroids. Hypertension appears to be more common with
ciclosporine than with tacrolimus but this may relate to differences in
potency and concomitant steroid use.
Physiologically, early post-transplant hypertension is often related to
a hyperdynamic circulation and salt and water retention. This usually
translates into an i peripheral resistance and return of cardiac output
to normal. Calcineurin inhibitors have also been associated with impaired
endothelial function and activation of the sympathetic nervous system.
Treatment
There are no large RCTs comparing the efficacy of different classes of anti-
hypertensive agents in the post-transplant situation. DHP CCAs are often
favoured in this setting because they reverse the peripheral vasoconstric-
tion associated with calcineurin inhibitors. Some inhibit the metabolism of
specific calcineurin inhibitors and, therefore, monitoring plasma levels of
the inhibitor may be required.
ACEIs and ARAs tend to be less effective in reducing BP, when used
alone, but are more effective when combined with a thiazide diuretic.
They also reduce the degree of proteinuria in renal transplant patients,
independently of BP, suggesting that they may have additional benefits in
this group of patients. However, whether such effects will translate into
longer graft survival needs to be formally assessed. It is particularly impor-
tant to monitor plasma K+ and creatinine in transplant patients following
blockade of the renin–angiotensin system.
B-blockers and thiazide diuretic may also be used, and the former may be
particularly useful post-cardiac transplantation, or in patients with estab-
lished CVD.
No specific targets are set in the post-transplant situation, but it would
seem prudent to aim for a lower target of 130/80mmHg in subjects with
manifest CVD or diabetes, and following renal transplantation.
Chapter 7 211
Antihypertensive drugs
Angiotensin-converting enzyme inhibitors 212

Angiotensin receptor antagonists 214
Beta-blockers 216
Calcium-channel antagonists 218
Thiazide diuretics 222
Potassium-sparing diuretics 226
Aldosterone antagonists 228
Alpha-blockers 230
Renin inhibitors 232
Central sympatholytics 234
Sodium nitroprusside 235
Minoxidil 235
Hydralazine 236
Nitrates 237
Other agents 238
212 CHAPTER 7 Antihypertensive drugs
Angiotensin-converting enzyme
inhibitors
Agents
The first ACEI, captopril, was introduced in 1981. Currently, 11 agents
are licensed in the UK and most are available in generic form. ACEIs are a
chemically heterogeneous group, but this seems to make little difference
to their clinical effects. All except captopril and lisinopril, are pro-drugs
that require enzymatic conversion in the liver. Usual starting dose is the
equivalent of 5–10mg of lisinopril OD (max dose 40mg): check U&Es after
7–10 days.
Mechanism of action
ACEIs inhibit ACE which catalyses the conversion of the inactive decapep-
tide angiotensin I to the active octapeptide angiotensin II, and also the
breakdown of bradykinin (b see Fig. 1.11 p.17). Angiotensin II is a pow-
erful vasoconstrictor and also promotes aldosterone synthesis, sympa-
thetic activity, thirst, and has effects on cell growth and differentiation.
Bradykinin is a vasodilating peptide, and i levels contribute to the anti-
hypertensive effect of ACEIs. In hypertension, ACE inhibition produces a
balanced reduction of both cardiac pre-load and after-load, through direct
and indirect arteriolar dilatation. ACEIs also blunt stress-induced i in cat-
echolamines via their sympatholytic effects, and thus heart rate changes
with ACE inhibition are not significant.
Evidence base
There are no large RCTs comparing ACE inhibition to placebo in patients
with hypertension, but BP comparator studies indicate that ACEIs are
as effective as other drugs. In general ACEIs are less effective in certain
sub-groups, including low-renin, salt-sensitive individuals such as older
people and blacks. The largest hypertension trial to date, ALLHAT, did
not show any difference in the p outcome (MI) between lisinopril and
chlortalidone or amlodipine (b Fig. 7.1). However, lisinopril was slightly
less effective in preventing stroke and total CVD (s outcomes) than the
diuretic. Data from several placebo-controlled studies indicate that ACEIs
should be used in patients with any degree of heart failure (e.g. SOLVD),
and post-MI ( AIRE, ISIS) . ACEI also reduce the rate of proteinuria, and
renal decline in diabetic and non-diabetic subjects with renal impairment
independently of BP reduction (REIN). Recent evidence form ASCOT and
other studies also suggests that ACEIs may reduce the rate of new-onset
diabetes (b see Fig. 7.7).
Indications
ACEIs are thought to be more effective at BP reduction in younger sub-
jects due to the higher levels of circulating renin, and relatively less effec-
tive in older hypertensives and blacks. However, they are commonly used
across all ages of patients.
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 213
Compelling indications
• Heart failure.
• Nephropathy.
• Diabetes or insulin resistance.
• Co-existing CVD, especially MI.
Contra-indications
• Pregnancy: associated with pulmonary hypoplasia, fetal skull hypo-
plasia, growth retardation and renal failure in the fetus.
• Hypersensitivity to ACEIs: including angio-oedema.
• RAS: may be used with expert advice in unilateral disease.
Side effects
• Cough: common up to 10%; a class effect.
• Renal impairment: 2 always check U&Es 7–10 days after initiating an
ACEI. A limited i in serum creatinine of up to 25% is acceptable, unless
hyperkalaemia develops. Monitor electrolytes at regular intervals if any
significant rise occurs.
• Hypotension: 1st dose hypotension is rare unless on large doses of diu-
retics or concomitant heart failure.
• Angio-oedema: <0.1%, but potentially life threatening. Onset may be
delayed.
• Rash, loss of taste, GI disturbance, altered LFTs.
20
Chlortalidone
Amlodipine
16 Lisinopril
Cumulative event rate (%)
12
0 1 2 3 4 5 6 7
Time to event (years)
No. at Risk
Chlorthalidone 15255 14477 13820 13102 11362 6340 2956 209
Amlodipine 9048 8576 8218 7843 6824 3870 1878 215
Lisinopril 9054 8535 8123 7711 6662 3832 1770 195
Fig. 7.1 The ALLHAT study demonstrated no difference between an ACEI,

diuretic and CCA for the p outcome of MI. Redrawn from The ALLHAT Officers
and Coordinators for the ALLHAT Collaborative Research Group (2002). Major
outcomes in high-risk hypertensive patients randomized to angiotensin-converting
enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive
and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA
288:2981–7. Copyright © 2002 American Medical Association. All rights reserved.
Angiotensin receptor antagonists

Agents
The antihypertensive effect of a peptide-based ARA (saralasin) was 1st
described in the 1970s, but the 1st orally available agent (losartan) was
not introduced until 1995. 7 agents are licensed in the UK, and they have
differing pharmacological properties. Irbesartan and valsartan are compet-
itive antagonists, whereas candestrtan and losartan are effectively irrevers-
ible inhibitors. Losartan is a pro-drug and requires metabolism for most of
its clinical effect. There are also differences in bio-availability. However,
such differences seem to have little effect on clinical efficacy. Most drugs
have a relatively shallow dose–response curve, and require little dose-
titration. The usual starting dose is the equivalent of 50mg of losartan OD
(max dose 100mg): check U&Es after 7–10 days.
Mechanism of action
Angiotensin II acts on 2 subtypes of receptor, the AT1 receptor and the
AT2 receptor. Virtually all the biological effects of angiotensin II result
from stimulation of the AT1 receptor. By antagonizing this receptor the
ARAs or ‘sartans’ produce vasodilatation, and tend to lower sympathetic
activity and aldosterone secretion.
Evidence base
There are no large, RCTs comparing ARAs to placebo in patients with
hypertension, but BP comparator studies indicate that ARAs are as effec-
tive as other drugs. The LIFE Study compared atenolol and losartan in
older high risk hypertensive subjects, and found a clear advantage in those
randomized to losartan, despite equivalent BP reduction. In contrast, the
VALUE study showed no difference in the p endpoint between valstartan
and amlodipine (b Fig. 7.2). Overall, the superiority of ARAs appears
to be limited to comparisons with B-blockers, and ARAs are probably
no more effective than other classes of drug if equivalent BP reduction is
achieved. Interestingly, in VALUE and LIFE, there were fewer new cases of
diabetes in the ARA cohort; suggesting, that like ACEI, ARAs may prevent
the development of diabetes (b see Fig. 7.5, p.224). ARAs also reduce
the rate of proteinuria, and renal decline in diabetic subjects with renal
impairment independently of BP reduction (RENAL and IDNT). Data
from several studies also support the use of ARAs in patients with heart
failure (ELITE and ValHEFT).
Indications
ARAs are probably more effective at BP reduction in younger subjects
due to the higher levels of circulating renin, and relatively less effective
in blacks. However, they are commonly used across all ages of patients,
particularly if intolerant to ACEIs.
• Heart failure.
• Nephropathy.
• Diabetes or insulin resistance.
ANGIOTENSIN RECEPTOR ANTAGONISTS 215
Contra-indications
• Pregnancy: associated with pulmonary hypoplasia, fetal skull hypoplasia,
growth retardation, and renal failure in the fetus.
Side effects
Relatively few, generally very well tolerated.
• Hypotension: 1st dose hypotension is rare unless on large doses of diu-
retics or concomitant heart failure.
• Angio-oedema: <0.01%, but potentially life threatening. Onset may be
delayed.
• Renal impairment: 2 always check U&Es 7–10 days after initiating an
ARA. A limited i in serum creatinine of up to 35% is acceptable, unless
hyperkalaemia develops. Monitor electrolytes at regular intervals if any
significant rise occurs.
14
Valsartan-basded regimen
Proportion of patients with first event (%)
12 Amlodipine-based regimen
10
2
HR = 1.30; 95% CI 0.94–1.14; p = 0.49
0
0 6 12 18 24 30 36 42 48 54 60 66
Time (months)
Number at risk
9 9 7 0 5 6 2 6 9 1 5 4
Valsartan 764 745 740 725 708 690 673 653 634 591 376 147
5 9 6 4 6 9 4 2 4 2 6 7 1 1 7 9 5 5 7 7 2 5 7 6 3 9 1 9 5 9 7 2 5 4 7 4
Amlodipine 7 7 7 7 7 6 6 6 6 5 3 1
Fig. 7.2 Results from the VALUE study for the primary endpoint of cardiac mor-
bidity and mortality. Redrawn from Julius S et al. (2004). Outcomes in hypertensive
patients at high cardiovascular risk treated with regimens based on valsartan or
amlodipine: the VALUE randomised trial. Lancet 363:2022–31 © 2004, with permis-
sion from Elsevier.
Beta-blockers
Agents
B-blockers, first synthesized by James Black in the 1950s (for which he
won the Nobel Prize) were introduced into clinical practice in the 1970s.
The degree of selectivity for A- versus B-adrenoceptor varies, but with
the exception of labetalol and carvediolol, most available agents have little
physiological effect on A-adrenoceptors. Propranolol is a non-selective
antagonist blocking both B1 and B2 adrenocpetors. Most of the other
agents in the class are varyingly B1-selective, nebivolol being the most
B1-selective. Some agents also display intrinsic sympathomimetic activity
(e.g. pindolol)—meaning that they are partial agonists at B1 adrenoceptors.
B-blockers also vary considerably in their pharmacokinetics, including t1/2
and lipid solubility. Despite the very diverse nature of this class of antihy-
pertensive drug, there are few clinical differences except that B1-selective
and vasodilating agents tend to produce fewer side effects. BP reduction
seems comparable. Usual dose range is the equivalent of 2.5–5mg of biso-
prolol OD—higher doses are no more effective.
Mechanism of action
Act as antagonists at the B-adrenoceptor, but the mechanism by which
this leads to a reduction in BP is unclear. It is likely to be the result of
several different effects including a short-term reduction in cardiac output,
followed by baro-receptor resetting and effective peripheral vasodilata-
tion. Inhibition of central sympathetic outflow and a reduction in plasma
renin levels are also important. Direct vasodilatation may also contribute
to BP lowering with drugs that also antagonize A-adrenoceptors, or that
display intrinsic sympathomimetic activity, or that release NO (nebivolol).
Evidence base
Many studies have demonstrated comparable BP reduction with B-blockers
to other antihypertensive drugs, but despite widespread clinical use there
are no RCTs that demonstrate a reduction in mortality with B-blockers
compared with placebo. Recently, a number of studies and a meta-analysis
(b Fig. 7.3) have cast doubt on the efficacy of atenolol in essential hyper-
tension. The MRC-Elderly study found atenolol no better than placebo
in older hypertensives, and the more recent LIFE and ASCOT studies
suggested that it was inferior to ‘newer’ agents, despite similar falls in BP.
A number of explanations have been offered for this apparent paradox but
2 are favoured. Atenolol, particularly in combination with diuretics seems
to i the rate of new-onset diabetes, which may i CV risk and offset
the benefits of BP reduction. Alternatively, atenolol seem less effective
at reducing central (aortic) BP, despite being equally effective at reducing
brachial BP, which may, in part be due to the associated bradycardia
(CAFE). Whether we can extrapolate these observations to all B-blockers
(particularly the vasodilating ones) is unclear, but based on these data the
BHS/NICE guidance has removed them from 1st-line use. However the
recent ESH/ESC guidelines have retained them, and they remain useful in
young subjects and those with CVD.
BETA-BLOCKERS 217
Indications
B-blockers may be useful 1st-line in young subjects who are in the hyper-
kinetic phase of hypertension, and in those with CVD, where they reduce
symptoms and may prevent events. They are also indicated in congestive
cardiac failure. B-blockers are relatively less effective in older, low-renin
subjects and blacks. Despite concerns, B-blockers remain a useful antihy-
pertensive drug and are frequently used in combination with other drugs,
although dual therapy with a diuretic is probably best avoided.
• CVD .
• Dysrhythmias.
• Pregnancy (labetalol).
• Aortic dissection.
Contra-indications
• Asthma: if absolutely required use most B1-selective agent available.
• Uncontrolled heart failure.
• 2nd- or 3rd-degree heart block.
Side effects
• Bradycardia, heart failure.
• Bronchospasm.
• Tiredness.
• Cold peripheries.
• Impotence.
• Nightmares.
Atenolol Placebo Relative risk (fixed) (95% CI) Weight Relative risk
Cardiovascular mortality (n/N) (n/N) (%) (fixed) (95% CI)
Dutch TIA 41/732 33/741 13.66 1.26 (0.80–1.97)

HEP 35/419 50/465 19.74 0.78 (0.51–1.17)
MRC Old 95/1102 180/2213 49.83 1.06 (0.84–1.34)
Test 34/372 39/348 16.78 0.82 (0.53–1.26)
Total 2625 3767 100.00 0.99 (0.83–1.18)
Total events: 205
(atenolol), 302 (placebo)
Test for heterogeneity: X2=3.51,
p=0.32 0.5 0.7 1.0 1.5 2.0
Favours atenolol Favours placebo
Fig. 7.3 A meta-analysis of antihypertensive studies involving atenolol. There is no

difference between atenolol and placebo in preventing CV mortality (neither was
there for total mortality, stroke, nor MI). Redrawn from Carlberg, B, et al. (2004).
Atenolol in hypertension: is it a wise choice? Lancet 365:1684–9, © 2004 with
Calcium-channel antagonists
Agents
The CCAs are a structurally and pharmacologically diverse group of
agents that can be divided into 2 major categories: the dihydropyridine
(DHP), and the non-DHPs (the phenylalkylamines and benzothiazepines).
There are currently 9 CCAs licensed in the UK , including nifedipine and
amlodipine, many of which are available generically. They vary in the phar-
macokinetics, particularly t1/2, and extended release preparation of some
short-acting ones are available (e.g. Adalat-LA®). Only 2 non-DHPs are
available: diltiazem and verapamil. Despite the physiological and pharma-
cological differences BP d seems comparable.
2 Usual dose is the equivalent of 5–10 mg of amlodipine OD. Short acting
nifedipine should never be used, as it can produce a rapid reduction in BP,
leading to stroke, and myocardial ischaemia.
Mechanism of action
All currently available drugs in this class block the L-type calcium channel.
The p antihypertensive effect results from peripheral vasodilatation due
to resistance vessel smooth-muscle relaxation. This is usually associated
with a reflex tachycardia and sympathetic activation. In addition, verapamil
and diltiazem have negative ionotropic and chronotropic effects (due to
blockade of cardiac L-type channels) which leads to fall in cardiac output
that contributes to BP d.
Evidence base
A number of studies have clearly shown that CCAs have comparable
efficacy to other antihypertensive agents (ALLHAT, NORDIL, INSIGHT
studies). They have been subject to a placebo-controlled RCT in older
subjects with ISH (SystEur) which demonstrated good efficacy—strokes
were reduced by 740% and CV morbidity/mortality by 730% (Fig. 7.4).
Early concerns regarding the safety of CCAs with regard to heart disease,
cancer, and bleeding seems unfounded. Although amlodipine was found to
be neutral in patients with heart failure (PRAISE), in ALLHAT it was less
effective in preventing heart failure than chlortalidone. Thus CCAs should
be used with caution in subjects with overt heart failure. The non-DHP
agents seem able to reduce proteinuria to a similar degree as ACEIs, but
the DHP have no effect. Overall, CCAs seem neutral with regard to the
development of new-onset diabetes (b see Fig. 7.5).
Indications
CCAs are particularly effective in older subjects, especially those with
ISH, and those with low-renin hypertension, such as blacks. The non-DHP
CCAs may be useful in patients who need rate control or who have dys-
rhythmias. CCAs may also be useful in patients with angina, migraine, or
Reynaud’s phenomenon. Nifedipine is also used in the management of
hypertension in pregnancy (unlicensed indication).
CALCIUM-CHANNEL ANTAGONISTS 219
• Reynaud’s phenomenon.
• Dysrhythmias (non-DHP).
• Angina.
• Subarachnoid haemorrhage.
Contra-indications
• Severe heart failure.
• Severe aortic stenosis.
• 2nd- or 3rd-degree AV block (non-DHP).
2 Take care when combining a non-DHP with a B–blocker as it may pre-
cipitate AV block and congestive cardiac failure.
Side effects
• Flushing, headache, ankle swelling—all more common in women.
• Dizziness.
• Palpitations.
• Gum hyperplasia.
• Rash.
• Constipation.
6 Fatal and non-fatal stroke*

Placebo
5 Active treatment
1
Events per 100 patients
4 Fatal and non-fatal myocardial infarction†
0
0 1 2 3 4
Time since randomization
(years)
Fig. 7.4 Key results of the SystEur Study a placebo-controlled trial of nitrendipine
(a DHP) in ISH. Redrawn from Staessen JA, et al (1997). Randomised double-blind
comparison of placebo and active treatment for older patients with isolated systolic
hypertension. Lancet 350:757–64, © 1997 with permission from Elsevier.
Thiazide diuretics
Agents
Thiazide diuretics were synthesized in the early 1950s, and were the 1st
truly effective oral antihypertensive available. 6 thiazide/thiazide-like
diuretics are available in the UK, including bendroflumethiazide, indapa-
mide, and chlortalidone (particularly long acting). They are relatively mild
diuretics and are used at low doses in hypertension (there is probably a
modest dose–response effect). The usual dose range is the equivalent of
2.5–5mg of bendroflumethiazide OD.
Mechanism of action
The exact mechanism of action remains unclear. The acute fall in BP is due
to salt and water loss and a reduction in extra-cellular volume. This is a
direct result of inhibition of the NCCT in the distal part of the nephron
(b see Fig. 7.6, p.227). However, with chronic use plasma volume returns
to normal and there is a state of peripheral vasodilatation. The mechanism
underlying this effect is thought to relate to inhibition of carbonic anhy-
drase, changes in smooth muscle cell pH, and thus calcium handling. It is
not related to inhibition of the NCCT.
Evidence base
Thiazide diuretics were the 1st agents subject to RCTs in hypertension,
and they proved effective in reducing stroke and MI (VA trials, b Table
7.1). Meta-analysis confirmed this and suggested that low-dose diuretics
were more effective than high doses. The ground-breaking SHEP study
confirmed the efficacy of thiazides in older subjects with isolated hyper-
tension in a placebo-controlled RCT. The ALLHAT study confirmed the
equivalence of thiazides to new drugs (there was actually a greater d in
CV events, stroke, and heart failure with chlortalidone than lisinopril).
Recently evidence from ASCOT and a subsequent meta-analysis (b Fig.
7.5), suggest that long-term therapy with thiazides may significantly i the
risk of new-onset diabetes compared to placebo or new agents. However,
it is unclear if this is associated with a significant i in CV risk, or whether it
is irreversible. Moreover, combination therapy (particularly with an ACEI)
may offset this potential risk.
Indications
Thiazides are most effective in older subjects (particularly those with ISH),
and in blacks. They work well in combination with ACEIs or ARAs.
• ISH.
• Blacks.
Contra-indications
• Pregnancy—neonatal thrombocytopenia, oligohydramnios.
• Gout.
• Hypercalcaemia.
• Refractory hypokalaemia or hyponatraemia.
THIAZIDE DIURETICS 223
Side effects
• Gout.
• Hypokalaemia/natraemia.
• Postural hypotension.
• Impotence.
• Photosensitivity.
Table 7.1 Results of the VA Co-operative Study which compared

hydrochlorothiazide (plus reserpine plus hydralazine) against placebo
in subjects with a diastolic pressure of 115–129mmHg.
Placebo Active Rx*
n = 194 n = 186
Accelerated hypertension 4 0
Stroke 20 5
Total coronary event 13 11
Fatal coronary event 11 6
Congestive heart failure 11 0
Renal damage 3 0
Deaths 19 8
Data from Veterans Administration Co-operative Study Group on antihypertensive agents.
Effects of treatment on morbidity in hypertension: results in patients with diastolic blood
pressures averaging 115 through 129 mmHg. JAMA 1967; 202:1028–1034.
ARA 0.57 (0.46–0.72) p<0.0001
ACE inhibitor 0.67 (0.56–0.80) p<0.0001
CCA 0.75 (0.62–0.90) p=0.002
Placebo 0.77 (0.63–0.94) p=0.009
β-blocker 0.90 (0.75–1.09) p=0.30
Diuretic Referent
0.50 0.70 0.90 1.26

Odds ratio of incident diabetes Incoherence=0.000017
Fig. 7.5 Relative risk of developing new-onset diabetes for different classes of
antihypertensive drug. Reprinted from Elliott WJ and Meyer PM (2007). Incident
diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet
369:201–7, © 2007 with permission from Elsevier.
Potassium-sparing diuretics
Agents
Only 2 agents are available in the UK : amiloride and triamterene (rarely
used). They are relatively weak diuretics, and may be used alone or in
combination with other diuretics to maintain plasma K+. Usual dose of
amiloride 2.5–10mg OD, although higher doses may be used in hyperal-
dosteronism.
Mechanism of action
Inhibit Na+ uptake in the distal tubule (b Fig. 7.6) by blocking the ENaC.
This results in less Na+ reabsorption, and consequently less K+ excretion
(passively via the ROMK channel). The hypotensive effect is thought to
be due to a combination of reduced extra-cellular volume and a direct
vasodilator action.
Evidence base
There are no large RCT of K+-sparing diuretics, but a number of smaller
trials suggest roughly equivalent BP d to other antihypertensive agents.
Indications
They may be used to maintain plasma K+ levels, or in the treatment of
hyperaldosteronism, when considerably larger doses may be required.
They may also be effective in synergy with other diuretics or ACEIs/ARAs
(care with K+ levels) in the management of low-renin patients.
• Hyperaldosteronism.
Contra-indications
• Hyperkalaemia.
• Renal failure.
Side effects
• Hyperkalaemia.
• GI upset.
• Dry mouth.
POTASSIUM-SPARING DIURETICS 227
Na
Bendroflumethiazide Thiazides
Cl
K+
sparing
Loop
Na
Furosemide Cl
K
Spironolactone
ENaC – –
Na+ Na
Amiloride
Triamterene K
K+
ROMK
Fig. 7.6 Site of action of the diuretics used to treat hypertension.

Aldosterone antagonists
Agents
Two agents are licensed in the UK : spironolactone and the newer drug
eplerenone. Spironolactone is less specific than eplerenone, partly blocking
androgen and activating progesterone receptors—which accounts for
some of its side effects such as gynaecomastia. However, spironolactone
is a more potent antagonist at the mineralocorticoid receptor, and high
doses of eplerenone are required to produce the same degree of receptor
blockade. The usual dose of spironolactone is 25–100mg OD. Low doses
(25–50mg) seem as effective as higher doses (>100mg) for most patients,
and produce fewer side effects, although considerably higher doses may
be needed in hyperaldosteronism.
Mechanism of action
Block the intra-cellular aldosterone receptor, thus antagonizing the salt-
and water-retaining effects of aldosterone (b Fig. 7.7). This leads to a
reduction in extra-cellular fluid volume and fall in BP. It has also been
suggested that aldosterone blockade may prevent or reverse cardiac and
vascular remodelling, particularly fibrosis which may be important in end-
organ damage and the development of fixed hypertension.
Evidence base
There are no large RCTs of aldosterone antagonists, but a number of
smaller trials suggest roughly equivalent d in BP to other antihypertensive
agents. Spironolactone has been used in combination with thiazides diu-
retics or as add-on therapy in a number of large studies including ASCOT
and appears effective, even in subjects with refractory hypertension. In
the RALES study, spironolactone was associated with a significant reduc-
tion in events when given as add-on therapy to subjects with heart failure.
Eplerenone seems effective in reducing BP in essential hypertension, and
also reduces events in subjects with heart failure post-MI (EPHESUS).
Indications
Spironolactone is routinely used in the management of hyperaldos-
teronism, and doses of up to 200mg may be required. It is undergoing
something of a renaissance in the management of essential hypertension,
and is often used as add-on therapy in resistant cases. It is particularly
effective in subjects with low-renin hypertension, such as older people
and blacks, and in diabetics. It has also been advocated for subjects with
polycystic ovary disease and those with the metabolic syndrome.
• Hyperaldosteronism.
• Blacks.
• Polycystic ovary disease
Contra-indications
• Hyperkalaemia.
• Hyponatraemia.
• Renal failure.
ALDOSTERONE ANTAGONISTS 229
Side effects
• Hyperkalaemia—more common if chronic renal failure or diabetic.
• GI upset.
• Impotence.
• Gynaecomastia.
180
160 156.9
140
135.1
120
100
85.3
80
75.8
60
40
20
0
Start End
Fig. 7.7 Effect of spironolactone on resistant hypertensive subjects in the ASCOT
Study (average dose 25mg). Data from Chapman N, et al. (2007). Effect of spironol-
actone on blood pressure in subjects with resistant hypertension Hypertension
49:839–45.
Alpha-blockers
Agents
Non-selective A-blockers include phentolamine and phenoxybenzamine.
Phentolamine is mainly used in the management of hypertensive crisis
associated with catecholamine excess. Phenoxybenzamine, a non-compet-
itive, irreversible, antagonist, is used in the chronic management of phaeo-
chromocytoma. A1-selective antagonists include prazosin, indoramin,
terazosin, and doxazosin. Prazosin is now seldom used due to a relatively
short t1/2, which can lead to rapid reductions in BP. Most BP reduction
occurs at low-mid dose: usual dose of doxazosin is 1–8mg OD, titrated
slowly, or 4–8mg of the slow-release preparation.
Mechanism of action
Antagonists at A-adrenoceptors: A1-adrenoceptors are predominantly
post-synaptic and mediate catecholamine-induced vasoconstriction.
α2-adrenoceptors are mainly pre-synaptic and inhibit neuronal catecho-
lamine release. BP d results from peripheral vasodilatation, and there tends
to be concomitant salt and water retention with high doses (i renin). Non-
selective α-blockers tend to i central sympathetic drive (via α2 inhibition)
which results in a reflex tachycardia and more marked elevation in renin.
Thus, A1-selective are usually used in essential hypertension.
Evidence base
As effective in reducing BP as most of the other main classes of antihy-
pertensive drug; seem slightly more effective in low-mid renin states. The
doxazosin-arm of the ALLHAT study was stopped prematurely due to an
excess of heart failure (66%) and CVD (25%) compared with those rand-
omized to chlortalidone (b Fig. 7.8). However, there was no difference
in the p endpoint of MI or overall mortality. Nevertheless, this led most
groups to suggest that α1-blockers were used as add-on therapy rather
than 1st-line.
Indications
Rarely used as monotherapy now, but can be combined with all the major
classes of antihypertensive. May be particularly useful in subjects with
prostatism—help to reduce outflow obstruction. A1-blockers have a mild
insulin-sensitizing effect, and may slightly improve the lipid profile.
• Prostatism.
Contra-indications
• Caution in patients with heart failure.
Side effects
• 2 Care with 1st dose: may case profound hypotension.
• Drowsiness.
• Headache.
• Rhinitis.
ALPHA-BLOCKERS 231
Combined CVD
0.30
0.25 Doxazosin
Chlortalidone
Cumulative event rate
0.20
0.15
0.10
0.05
0 1 2 3 4
Follow-up (years)
Fig. 7.8 Comparison of doxazosin and chlortalidone in the ALLHAT study. There
was a significant excess of CV events (and heart failure) in those receiving doxa-
zosin. Reproduced with permission from The ALLHAT Officers and Coordinators
for the ALLHAT Collaborative Research Group (2000). Major cardiovascular
events in hypertensive patients randomized to doxazosin vs. chlortalidone: The
Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial
(ALLHAT). JAMA 283:1967–75. Copyright © 2000 American Medical Association.
All rights reserved.
Renin inhibitors
Agents
Direct renin-inhibitors are the newest class of antihypertensives. Aliskiren is
the only available agent in the UK and was licensed in 2007, following many
years of research for an orally active agent. Usual dose is 150–300mg OD.
Mechanism of action
Renin is an enzyme that cleaves circulating angiotensinogen to angiotensin I
(b Fig. 7.9). Direct renin inhibitors bind to renin and reduce its enzymatic
activity. This leads to lower levels of circulating angiotensin II and aldos-
terone, and consequently vasodilatation and a reduction in extra-cellular
volume.
Evidence base
Head-to-head comparisons demonstrate that aliskiren produces equiva-
lent BP d to the main other antihypertensive drugs. It is also produces
additional BP d when used in combination—even with an ACEI or ARA.
As yet there are no comparative outcome studies with aliskiren.
Indications
Likely to be useful in patients with an activated renin–angiotensin system,
and may be of benefit in reducing proteinuria (studies awaited).
Contra-indications
• Pregnancy.
Side effects
• Hyperkalaemia.
• Diarrhoea.
RENIN INHIBITORS 233
ARA
Sympathetic Blood
activation pressure
ARA
rises
Vasoconstriction Salt retention
ARA
Aldosterone
Angiotensin II
Spironolactone
ACE Amiloride
ACEI
Angiotensin I
Renin
inhibitors Renin
Angiotensinogen
Blood
pressure
falls
Fig. 7.9 The renin–angiotensin system.

Central sympatholytics
Agents
Centrally-acting sympatholytics were amongst the 1st drugs used to treat
hypertension, but, with the exception of moxonidine, are now rarely used
due to an adverse side-effect profile. 3 drugs fall into this class: meth-
yldopa, moxonidine, and clonidine. Methyldopa is still widely used in
pregnancy due to a proven safety profile; usual dose 250mg to 1g TDS.
Moxonidine is less sedating; usual dose 200–400mcg OD. Clonidine can
be administered IV or PO but must be withdrawn slowly to avoid hyper-
tensive crisis; usual dose 50–200mcgTDS PO.
Mechanism of action
All 3 drugs reduce central sympathetic outflow, thereby lowering PVR.
Cardiac output tends to remain the same or d slightly. Methyldopa is taken
up by sympathetic neurons and converted into A-methylnoradrenaline,
which is then concentrated into vesicles and released. A-methyl-
noradrenaline is a false transmitter: being inactive at A1-adrenoceptors,
but is an agonist at presynaptic α2-adrenoceptors, thus inhibiting its own
release. Moxonidine is a selective I1-imidazoline receptor agonist and is
thought to act mainly in the rostral ventrolateral medulla oblongata to
reduce sympathetic outflow. Clonidine is an A2-adrenoceptor agonist with
some action at I1-receptors. However, at high doses it becomes an agonist
at the α1-adrenoceptor, paradoxically i BP.
Evidence base
Centrally-acting sympatholytics have been included in a number of antihy-
pertensive studies mainly as add-on therapy but have not been the focus
of large RCT.
Indications
Methyldopa is safe in pregnancy and frequently used despite its adverse
side-effect profile. Clonidine is rarely used except IV in ITU or theatre.
Moxonidine may be used as add-on therapy in resistant patients.
Theoretically, centrally-acting drugs may be useful in patients with sympa-
thetic activation including those with the ‘metabolic syndrome’.
Contra-indications
• Depression, acute liver disease, phaeochromocytoma (methyldopa).
• Conduction defects, severe heart failure, angio-oedema (moxonidine).
Side effects
• Dry mouth.
• Depression.
• Haemolytic anaemia (methyldopa).
• Liver dysfunction (methyldopa).
2Always withdraw clonidine slowly to avoid a hypertensive crisis.
MINOXIDIL 235
Sodium nitroprusside
SNP is a nitrovasodilator drug, which spontaneously decomposes in vivo
to release NO. Only used for the management of hypertensive emergen-
cies such as encephalopathy. Given by continuous IV infusion, and capable
of producing rapid and profound reductions in BP. Intra-arterial BP moni-
toring is essential. The compound and solution must be protected from
light as this i the rate of decomposition.
Side effects
• Tachycardia.
• Headache.
• Excessive d BP.
2Cyanide toxicity may occur, especially with prolonged infusion due to a
build-up of the cyanide metabolite. This may lead to tachycardia, sweating,
hyperventilation etc.: stop the infusion and administer cyanide antidote.
Minoxidil
A potent direct vasodilator (opens adenosine triphosphate-sensitive
potassium channels in vascular smooth muscle cells). BP d is due to a sub-
stantial reduction in peripheral resistance. However, this leads to a reflex
tachycardia and activation of the renin–angiotensin system with resultant
salt and water retention, which tends to offset the BP fall leading to pseu-
dotolerance. For this reason, and to reduce side effects (ankle oedema
and palpitations), all but the smallest doses of minoxidil require concomi-
tant use of B-blockers and loop diuretics (often 80–120mg of furosemide
a day).
Largely reserved for the management of resistant hypertension due to its
side-effect profile. It is unusual to find a patient unresponsive to the intro-
duction of minoxidil if adequately B-blocked and salt and water retention
are prevented. Usual dose: 5–40mg per day.
Contra-indications
• Phaeochromocytoma.
Side effects
• Peripheral oedema, weight gain.
• Tachycardia.
• Excessive hair growth.
• LVH and myocardial ischaemia (especially if not combined with a
B-blocker).
Hydralazine
A less potent direct vasodilator than minoxidil, with an unknown mechanism
of action. Introduced for the management of hypertension in the 1950s but
now rarely used outside obstetrics due to pseudotolerance and an adverse
side-effect profile. Occasionally still used in resistant hypertension.
When used orally for resistant hypertension it is often combined with a
B-blocker and loop diuretic. Usual dose: 25–50mg QDS (start with 25mg
BD). Higher doses dramatically increase the risk of side effects.
IV infusion may be used in a hypertensive crisis –especially pre-eclampsia.
Usual dose range 50–150mcg/min.
Contra-indications
• Systemic lupus erythematosus
• Severe tachycardia.
Side effects
• Tachycardia, fluid retention.
• Flushing, headache.
• Rashes, peripheral neuritis.
• Lupus-like syndrome—especially women and slow acetylators.
2 Metabolism is genetically determined, and fast acetylators have fewer
side effects.
NITRATES 237
Nitrates
Organic nitrate such as isosorbide dinitrate are unlicensed for the
treatment of essential hypertension and have not been subject to outcome
trials in hypertensives. However, they do lower BP and may be particularly
useful in older subjects with ISH as they act mainly on SBP at low doses,
due to venodilatation and a reduction in wave reflection. DBP tends to
be little affected. Moreover, the effect on aortic systolic pressure is even
more pronounced than that observed at the brachial artery. Similarly they
may be double benefit in subjects with angina.
Although, theoretically, tolerance is an issue with continued oral adminis-
tration, this is not supported by the few RCTs that have been conducted
(b Fig. 7.10). The usual dose is 20–40mg BD of isosorbide dinitrate MR.
Side effects
• Headache.
• Flushing.
Placebo
SBP (mmHg)
ISDN
190
180
170
160
0 2 4 6 8 10 12
Week after ISDN
Fig. 7.10 Isosorbide dinitrate (ISDN) produces a sustained reduction in systolic
pressure in subjects with ISH. Redrawn from Duchier J, Safar M (1987) Autocrine-
paracrine mechanisms of vascular myocytes in systematic hypertension. Am J Cardiol
60:99–102, with permission from Elsevier.
Other agents
Peripheral sympatholytics
Guanethidine and reserpine (now withdrawn in the UK) block noradrena-
line release from postganglionic sympathetic neurons by depleting vesicles
of catecholamines. Although effective in reducing BP they are now rarely
used due to their side-effect profile. In particular, they impair the ability
to respond to postural haemodynamic changes, and may lead to postural
hypotension. Other side effects include nasal stuffiness, failure of ejacula-
tion, and drowsiness. Reserpine also has a CNS action and may lead to
depression. They should not be used in conjunction with MAOIs as they
may precipitate a hypertensive crisis.
Endothelin antagonists
Endothelin-1 is a potent long-lasting vasopressor, and a range of ETA selec-
tive or mixed ETA/ETB receptor antagonists have been synthesized and
trialled in human essential hypertension. Although moderately effective in
reducing BP, they have not been developed further due to concerns over
side effects and teratogenicity. However, a number are available for use in
pulmonary hypertension
Chapter 8 239
Hypertension in the
21st century
Prevention 240
Cardiovascular risk assessment 241
Dilemmas in modern management 242
Emerging concepts: arterial stiffness 244
Useful websites 247
Clinical trials: a glossary 248
240 CHAPTER 8 Hypertension in the 21st century
Prevention
Hypertension is a major cause of morbidity and mortality throughout the
world. This carries considerable economic cost, and treatment is set to
rise as the developing nations adapt and adopt modern lifestyles and more
people receive treatment.
One of the main ways in reducing this burden would be prevention.
We have examined the effects of diet and exercise, weight loss, d Na+
and i K+ intake, stress reduction, as well as pharmacological methods on
BP in b Chapter 2, but the issue of hypertension prevention using these
methods has not been addressed yet in clinical trials—mainly as it has not
shown long-lasting effects, either due to a failure to comply or a lack of
sustained effort in maintenance of these non-pharmacological methods.
Only 1 trial has examined the effects of prevention of onset hyperten-
sion using pharmacological means; this was the Trial of Prevention
Hypertension (TROPHY). 800 pre-hypertensive adults (mean age 49,
SBP 130–139mmHg, DBP ≤89mmHg or SBP ≤139mmHg and DBP
85–89mmHg) were randomized in a double-blind manner to 2 years
of candesartan 16mg OD or placebo and then all patients were put on
placebo for a further 2 years.
New hypertension developed in 40% of placebo but only 13% of the can-
desartan group in the first 2 years (66% RR reduction in favour of cande-
sartan group), but at 4 years the percentages were 63% and 53% (a 16 %
RR reduction for the candesartan group).
Critics argue that the pre-treatment in the active arm masked the onset
of hypertension and that the incidence of hypertension in the final 2 years
was not different between the groups. Moreover, given that BP is a con-
tinuous variable, it is perhaps not surprising that an antihypertensive drug
d BP in prehypertensives whilst they remain on it. New, more aggressive
strategies ought to be explored in perhaps younger subjects.
CARDIOVASCULAR RISK ASSESSMENT 241
Cardiovascular risk assessment

There are a number of tools to help determine CV risk (b see Prognosis
and risk stratification, pp.84–87). These are useful to predict a 10-year risk
based on variables such as age, gender, cholesterol, and BP.
A lot of the data are based on Framingham datasets and these are not
applicable to various cohorts of people. The data were based on Caucasian
populations—therefore they cannot really translate across to other races.
In addition, they require pre-treatment baseline values, which are not
always obtainable. Current risk therefore is indeterminable using these
methods. They do not predict risk in children, the young, in pregnancy, or
situations of accelerated hypertensive states.
Most importantly, there is a bias towards treatment of the elderly in
these methods, thereby minimizing the lifetime risk associated with a CV
event 20 or 30 years in the future. This may occur in the younger patient
with a constellation of minimally raised risk factors, all of which are bor-
derline and not requiring therapy. This negates the importance of non-
pharmacological interventions, such as a healthy diet and exercise, until
atherosclerosis has probably already begun.
Therefore, efforts need to be focused on developing new tools which
assess risk continually and on current therapy. This may be a composite
of biomarkers and physiological parameters which give an individual risk
score, rather than one centred on population-based datasets. In addition,
an individual’s lifetime risk should be the focus of initiating management of
risk early on, rather than waiting for the atherosclerotic process to set in.
Dilemmas in modern management

There are a few areas which, despite the trials that have been conducted,
have not been fully understood or evaluated.
Target blood pressure
Over the last 3 decades, the target BP has gradually reduced as i evidence
points to a d BP as being a major determinant of length of life. This is
largely based on 1 study, namely HOT—which was essentially negative for
its p outcome and failed to achieve target BPs of the study. Although BP
is continuously related to risk down to 115/70mmHg, we need evidence
if lower pressures are better; this may be addressed in the SPRINT trial.
A concept that has not yet emerged—but is likely to—is that of an age-
related target BP. This would require a lot more research, adjusting for a
variety of factors including race, salt intake, gender, and so on.
Borderline hypertension
The diagnosis of hypertension is arbitrary and there is a continuum of risk,
but where the boundary lies between normality and a diagnosis of hyper-
tension continues to mean that a cohort of people remain at risk but have
to achieve TOD before therapy is instituted. This may have important
consequences in the longer term, and therefore is an important area in
younger people with borderline hypertension. The usual rules for initi-
ating therapy in this cohort of patients mean that their lifetime risk of an
event is underestimated by the lack of fluidity within current guidelines.
s hypertension
There is still a huge debate on whether every patient diagnosed with
hypertension should undergo a battery of tests to rule out s causes. One
the one hand, this would be advantageous, since the earlier a cause is
found, the more likely a cure is likely to benefit the patient. However,
as it is such a common condition, and 80–90% is still defined as essential
hypertension, critics argue this is not a cost-effective investigation. More
economical tests and guidelines which stratify which cohorts of patients
require further evaluation are currently being introduced to help this
process.
BP measurement site
The debate as to whether brachial BP, which has long been the standard
measurement of BP, should, in fact be replaced by newer methods of pre-
dicting and measuring central aortic BP, continues as the evidence for the
latter grows. The fact that wave reflections and the stiffness of the vas-
cular tree contribute to varying central BP, independent of brachial BP,
means that this will continue to be the focus of this century’s research in
hypertension.
DILEMMAS IN MODERN MANAGEMENT 243
Role of ambulatory monitoring

There is still no robust interventional evidence to show that treatment
based on home or ambulatory monitoring outperforms clinic BP using a
validated machine. More work is also required to determine the relative
importance of issues such as masked and white coat hypertension—and
whether these patients should be treated in a more or less aggressive
manner.
Emerging concepts: arterial stiffness

The large elastic arteries act to cushion the highly pulsatile blood flow
resulting from intermittent cardiac ejection, by expanding during systole
and providing elastic recoil during diastole. However, in almost all socie-
ties worldwide, there is progressive stiffening of the large arteries with age,
resulting in a widening of the pulse pressure and leading to the develop-
ment of ISH, as well as a number of other adverse haemodynamic conse-
quences (b see Isolated systolic hypertension, p.52). CV risk factors such
as hypertension, hypercholesterolaemia, smoking, and diabetes are also
associated with i arterial stiffness, leading to the notion that individuals
with such risk factors experience premature vascular ageing. Moreover,
aortic stiffness is now recognized as an important, independent, determi-
nant of CV risk in a variety of patient groups (b Table 8.1).
Arterial stiffness can be assessed using a variety of different techniques.
These broadly fall into measures of stiffness at one discrete location, e.g.
ultrasound-derived distensibility and compliance; or more regional meas-
ures, such as the pulse wave velocity. This is a measure of the speed with
which the pressure waveform propagates along a segment of the arterial
tree; the stiffer the vessel the faster the wave travels. The aortic pulse
wave velocity is often considered as the current ‘gold-standard’ measure
of arterial stiffness.
An i in arterial stiffness also i the speed at which pressure waves are
reflected back towards the heart from major bifurcations and sites of vas-
cular impedance mismatch. When such reflected waves arrive back in the
ascending aorta in early systole, they augment the central (aortic) systolic
pressure (augmentation pressure). The contribution of reflected pressure
waves to central pressure is quantified by the augmentation index, which
is itself, an independent determinant of CV risk. There is a progressive i in
augmentation pressure and, therefore, central pressure, with ageing. This
explains why the difference between peripheral and central pressure is
more marked in younger individuals than in older individuals, as discussed
in Chapter 1 (b see Central versus peripheral blood pressure, p.6).
Clinical use
Pulse wave velocity, augmentation index, and central pressure are all
independent determinants of CV risk. However, the wide-spread adop-
tion of these measurements into routine clinical practice will ultimately
depend on the availability of appropriate devices and the development of
guidelines on which clinical decisions may be based. The most recent ESH/
ESC guidelines for the management of hypertension recommend meas-
uring the aortic pulse wave velocity. A value of 12m/s has been identified
as a threshold with which to identify the presence of sub-clinical organ
damage. Further research is required to identify appropriate treatment
thresholds for pulse wave velocity, augmentation index, and central BP.
EMERGING CONCEPTS: ARTERIAL STIFFNESS 245
Table 8.1 Longitudinal studies reporting the independent predictive

value of arterial stiffness, according to the site of measurement*
Measurement First author Events Follow- Type of patient
site (year, up (number)
country) (years)
Aortic PWV Blacher CV mortality 6.0 ESRD (241)
(1999, Fr)
Laurent CV mortality 9.3 Hypertension
(2001, Fr) (1980)
Meaume CV mortality 2.5 Elderly (>70)
(2001, Fr) (141)
Shoji (2001, Jp) CV mortality 5.2 ESRD (265)
Boutouyrie CHD events 5.7 Hypertension
(2002, Fr) (1045)
Cruickshank All cause 10.7 IGT (571)
(2002, GB) mortality
Laurent Fatal strokes 7.9 Hypertension
(2003, Fr) (1715)
Sutton-Tyrrell CV mortality 4.6 Elderly (2488)
(2005, USA) and events
Shokawa CV mortality 10 General
(2005, Jp) population (492)
Willum- CV mortality 9.4 General
Hansen population
(2006, Dk) (1678)
Mattace-Raso CV mt, CHD 4.1 Elderly (2835)
(2006, Neth.)
Ascending Stefanadis Recurrent 3 Acute CHD (54)
aorta (invasive) (2000, Gr) acute CHD
Carotid Blacher All cause 2.1 ESRD (79)
distensibility (1998, Fr) mortality
Barenbrock CV events 7.9 ESRD (68)
(2001, Ge)
ESRD, end-stage renal disease; Fr, France; GB, Great Britain; Ge, Germany; Gr, Greece;
Neth, The Netherlands; PWV, pulse wave velocity; USA, United States of America.
*Reproduced with permission from Laurent S, et al. (2006) Expert consensus document on
arterial stiffness: methodological issues and clinical applications. Eur Heart J 27:2588–605.
Table 8.2 Recommended clinical variables to stratify total CV risk*

Risk factors Subclinical organ damage
• Systolic and diastolic BP levels • Electrocardiographic LVH
(Sokolow-Lyon > 38 mm;
• Levels of pulse pressure (in the
Cornell > 2440 mm/ms)
elderly)
or:
• Age (M > 55 years; W > 65 years)
• Echocardiographic LVH ♦ (LVMIM
• Smoking ≥ 125 g/m2, W ≥ 110 g/m2)
• Dyslipidaemia • Carotid wall thickening (IMT > 0.9
• TC > 5.0 mmol/l (190 mg/dl) mm) or plaque
or:
• LDL-C > 3.0 mmol/l (115mg/dl) • Carotid-femoral pulse wave
or: velocity > 12 m/sec
• HDL-C: M < 1.0 mmol/l • Ankle/Brachial BP index < 0.9
(40 mg/dl)
• W < 1.2 mmol/; (46 mg/dl) • Slight increase in plasma creatinine:
or: M: 115–133 μmol/l (1.3–1.5 mg/dl)
• TG > 1.7 mmol/l (150 mg/dl) W: 107–124 μmol/l (1.2–1.4 mg/dl)
• Fasting plasma glucose 5.6–6.9 • Low estimated glomerular filtration
mmol/l (102–125 mg/dl) rate ♦♦ (< 60 ml/min.1.73 m2) or
creatinine clearance ♦♦♦
• Abnormal glucose tolerance test (< 60 ml/min)
• Abdominal obesity (waist circumfer- • Microalbuminuria 30–300 mg/24 h
ence > 102 cm (M), > 88 cm (W)) or albumin-creatinine ratio: ≥ 22
• Family history of premature CV (M); or ≥ 31 (W) mg/g creatinine
disease (M at age < 55 years; W at
age < 65 years)
Diabetes mellitus Established CV or renal disease
• Fasting plasma glucose ≥ 7.0 mmol/l • Cerebrovascular disease: ischaemic
(126 mg/dl) on repeated stroke; cerebral haemorrhage;
measurement transient ischaemic attack
or: • Heart disease: myocardial
infarction; angina; coronary
• Postload plasma glucose > 11.0
revascularization; heart failure
mmol/l (198 mg/dl)
• Renal disease: diabetic nephrop-
Note: the cluster of three out of 5 risk factors athy; renal impairment (serum cre-
among abdominal, obesity, altered tasting atinine M > 133; W > 124 μmol/l);
plasma glucose, BP ≥ 130/85 mmHg, low proteinuria (> 300 mg/24 h)
HDL cholesterol and high TG (as defined
above) indicates the presence of metabolic • Peripheral artery disease
syndrome. • Advanced retinopathy: haemor-
rhages or exudates, papilloedema
*Reproduced with permission from Mancia G, et al. (2007). 2007 ESH-ESC Practice
Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the
Management of Arterial Hypertension. J Hypertens 25:1751–62.
USEFUL WEBSITES 247
Useful websites
• American College of Cardiology: M http://www.acc.org/
• American Heart Association: M http://www.americanheart.org/
• American Society of Hypertension: M http://www.ash-us.org/
• British Cardiovascular Society: M http://www.bcs.com/pages/default.
asp
• British Heart Foundation: M http://www.bhf.org.uk/
• British Hypertension Society: M http://www.bhsoc.org/
• European Society of Hypertension: M http://www.eshonline.org/
• European Society of Cardiology: M http://www.escardio.org/Pages/
index.aspx
• International Society of Hypertension: M http://www.ish-world.com
• Phaeochromocytoma Research Organisation: M http://www.pressor.
org/
Clinical trials: a glossary

The rest of this chapter provides a summary of all the major clinical trials
listed (as acronyms or otherwise) in this book and some other landmark
trials related to hypertension and CVD.
Whilst this is not an extensive list, we hope it provides some useful points
about each trial and highlights the important milestones achieved as a
result of these trials.
ABCD 249
ABCD
Trial name
Appropriate Blood Pressure Control in Diabetes.
Reference
NEJM 1998; 338:645–52.
Design
Prospective, randomized, double blind.
Sample size (n)
950.
Question addressed
Effect of moderate vs. intensive BP control using either enalapril (ACEI) or
nisoldipine (CCA) in NIDDM patients (normotensive and hypertensive)
on complications of diabetes.
1°endpoint
Morbidity.
Results
s endpoint of CV outcome showed a significant reduction in MI rates
with those on enalapril than on nisoldipine in the hypertensive cohort
(both in the moderate and intensive arms of BP reduction).
ACE
Trial name
Aspirin and Carotid Endarterectomy.
Reference
Lancet 1999; 353:2179–84.
Design
Randomized, double-blind, parallel-group.
Sample size (n)
2849.
Question addressed
Effect of high- vs. low-dose aspirin (ASA) on stroke rates in carotid
endarterectomy.
1°endpoint
Mortality and morbidity.
Results
Low-dose ASA (81 or 325mg) had a lower incidence of stroke, MI, and
death than high-dose at 30 days (5.4% vs. 7.0%; p = 0.07) and at 3 months
(6.2% vs. 8.4%; p = 0.03). A posthoc analysis showed greater differences
when patients taking high-dose ASA before randomization and patients
randomized within 1 day of surgery: combined incidences in the low-dose
and high-dose groups were 3.7% and 8.2% at 30 days (p = 0.002) and 4.2%
and 10.0% at 3 months (p = 0.0002).
AIRE 251
AIRE
Trial name
Acute Infarction Ramipril Efficacy study.
Reference
Lancet 1993; 342:821–8.
Design
RCT, double-blind, placebo-controlled, parallel-group.
Sample size (n)
2006.
Questions addressed
• 1°: effect of ramipril on total mortality in patients surviving acute MI
with early clinical evidence of heart failure.
• 2°: effect of ramipril on progression of heart failure, non-fatal reinfarc-
tion and stroke between the 2 groups.
1°endpoint
Mortality.
Results
Ramipril reduced total mortality by 27% (p = 0.002), sudden death by 30%
(p = 0.011) and death from circulatory failure by 18% (p = 0.237). There
was no change to stroke or non-fatal reinfarction.
ALLHAT
Trial name
Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack
Trial.
Reference
JAMA 2002; 288:2891–97 and 2998–3007.
Design
• Antihypertensive arm: randomized, double-blind.
• Lipid-lowering arm (LLA): randomized, open.
Sample size (n)
• Antihypertensive arm: 33,357 aged ≥55 years with hypertension and at
least 1 other risk factor for CHD.
• LLA: 10,355 aged ≥55 years, fasting LDL cholesterol 3.1–4.9mmol/L
(patients without CHD) or 2.6–3.3mmol/L (with known CHD), and
fasting TG levels <3.9mmol/L.
Questions addressed
• Antihypertensive arm: incidence of fatal and non-fatal MI in patients
treated with chlortalidone, amlodipine, lisinopril, or doxazosin.
• LLA: all-cause mortality in patients treated with either pravastatin or
‘usual care’
1°° endpoint
Results
• Antihypertensive arm: No significant difference was observed between
drugs. Events occurred in 2956 patients.
• Amlodipine (RR 0.98, 95% CI 0.90–1.07; p = 0.65) or lisinopril
(RR 0.99, 95% CI 0.91–1.08; p = 0.81) vs. chlortalidone.
• Doxazosin arm discontinued prematurely for possible i incidence
of heart failure.
• LLA: all-cause mortality did not differ significantly between the pravastatin
and usual care treatment groups (RR 0.99, 95% CI 0.89–1.11; p = 0.88).
ALPINE 253
ALPINE
Trial name
Antihypertensive Treatment and Lipid Profile in a North of Sweden Efficacy
Evaluation.
Reference
J Hypertens 2003; 21:1563–74.
Design
Randomized, double-blind, controlled, parallel-group.
Sample size (n)
392.
Questions addressed
Metabolic outcomes of treatment with low-dose diuretic (hydrochloro-
thiazide, HCTZ), alone (or in combination with atenolol), with that of an
angiotensin II type 1 receptor blocker (candesartan), alone (or in combi-
nation with felodipine), in newly diagnosed patients with p hypertension.
1°° endpoint
Morbidity.
Results
Despite similar BP reductions, fasting serum insulin and plasma glucose
levels i in the HCTZ group unlike the candesartan group. Diabetes mel-
litus was diagnosed in 4.1% of the HCTZ group and 0.5% in the cande-
sartan group (p = 0.03). The LDL:HDL was worse in the HCTZ group and
conversely in the candesartan group (p <0.01). TG was i in HCTZ group
(p <0.001).
ANBP2
Trial name
Australian National Blood Pressure study 2.
Reference
NEJM 2003; 348:583–92.
Design
Randomized, open.
Sample size (n)
6083.
Questions addressed
Difference in total CV events (fatal and non-fatal) between ACEI vs.
diuretic-based regimen over a 5-year treatment period in 65–84-year-old
hypertensives.
1°° endpoint
Mortality.
Results
There were fewer deaths in the ACEI-based arm than diuretic group (p =
0.05) and non-fatal CV events (p = 0.03). This was evident more so in men.
ASCOT 255
ASCOT
Trial name
Anglo-Scandinavian Cardiac Outcomes Trial
References
Lancet 2003; 361:1149–58.
Lancet 2005; 366:895–906.
Design
• Antihypertensive arm: randomized, parallel-group, 2 × 2 factorial.
• LLA: double-blind, placebo-controlled, 2 × 2 factorial.
Sample size (n)
• Antihypertensive arm: 19,257 mean age 63 years, with BP
≥160/100mmHg untreated or ≥140/90mmHg treated + ≥3 of 11
specified CV risk factors.
• LLA: 10,305 with total cholesterol ≤6.5mmol/L and a TC:HDL
cholesterol ratio ≤4.5.
Questions addressed
• Antihypertensive arm: non-fatal MI and fatal CHD rates of a old
regimen (atenolol ± bendroflumethiazide) vs. new regimen (amlodipine
± perindopril) in hypertensive patients,
• LLA: atorvastatin vs. placebo in hypertensive patients with dyslipidaemia.
1°° endpoint
Results
• Antihypertensive arm: no significant difference between the groups:
4.5% of patients in the amlodipine group compared to 4.9% of patients
in the atenolol group (hazard ratio (HR) 0.90, 95% CI 0.79−1.02;
p = 0.1052). However, fatal and non-fatal stroke, total CV events/
procedures, and all-cause mortality were significantly better in the
amlodipine group, as was the incidence of diabetes.
• LLA: significant difference in 1° endpoint: 1.9% of patients in the atorv-
astatin group compared to 3.0% in the placebo group (HR 0.64, 95% CI
0.50−0.83; p = 0.0005).
ASTRAL
Trial name
Angioplasty and Stent for Renal Artery Lesions.
Reference
J Hum Hypertens 2007; 21:511–15 (study design). Formal results yet to be
published.
Design
Randomized.
Sample size (n)
806.
Question addressed
Does renal artery stenting for atherosclerotic renovascular disease offer
more benefits than medical therapy?
1°° endpoint
Decline in renal function over time.
Results (preliminary)
No difference in the levels of renal function between those allocated a
stent vs. medical management. There were also no differences in the s
endpoints of blood pressure, first MI, stroke, vascular death, hospitaliza-
tion for angina, fluid overload, and cardiac failure. 3% of the stent patients
had experienced a procedure-related complication.
CAFE 257
CAFE
Trial name
Conduit Artery Function Evaluation.
Reference
Circulation 2006; 113;1213–25.
Design
Randomized, parallel group.
Sample size (n)
2073.
Questions addressed
• 1°: ASCOT substudy testing the hypothesis that the effects of antihy-
pertensives differ in their effects on central pressures despite similar
brachial pressures.
• 2°: these differences in central pressure explains differences in CV
outcomes.
1°° endpoint
Physiological endpoint.
Results
Antihypertensives have differing effects on central BP despite similar
brachial BP. Central aortic pulse pressure and differences in central pres-
sure may explain differences in CV outcomes despite similar brachial BP
changes.
CAPPP
Trial name
Captopril Prevention Project.
Reference
Lancet 1999; 353:611–16.
Design
Prospective randomized open blinded endpoint (PROBE).
Sample size (n)
10,985.
Question addressed
Does captopril treatment differ in CV outcomes compared to conven-
tional antihypertensives (diuretics and B-blockers)?
1°° endpoint
Results
The p endpoint for fatal/non-fatal MI and stroke, and other CV deaths
was negative. The study had 698 events in total.
CHARM 259
CHARM
Trial name
Candesartan in Heart failure: Assessment of Reduction in Mortality and
morbidity – Overall.
Reference
Lancet 2003; 362:759–66.
Design
Randomized, double-blind, placebo-controlled, parallel-group.
Sample size (n)
7599.
Question addressed
Effects of an angiotensin-receptor blocker on mortality and morbidity in
chronic heart failure.
1°° endpoint
Results
CV deaths were fewer in the candesartan group than in the placebo group
(HR 0.88, 95% CI 0.79–0.97; p = 0.012). Time to CV death or hospital
admission for worsening chronic heart failure was reduced by 16% (30%
with candesartan and 35% with placebo; p <0.0001). No change in total
mortality from any cause.
DASH
Trial name
Dietary Approaches to Stop Hypertension.
Reference
NEJM 1997; 336:1117–24.
Design
Randomized, controlled.
Sample size (n)
459.
Question addressed
To assess the effects of dietary patterns on BP.
1°° endpoint
BP.
Results
• Compared to the control diet, the combination diet significantly
reduced BP 5.5/3mmHg (both p <0.001), while the fruit and vegetable
diet reduced BP by 2.8/1.1mmHg.
• Compared to the fruit and vegetable diet, the combination diet
reduced BP by 2.7/1.9mmHg.
• In the hypertensive group, the combination diet reduced BP by
11.4/5.5mmHg compared to the control diet (both p <0.001).
• The corresponding additional reductions were 3.5mmHg (p <0.001)
and 2.1mmHg (p = 0.003), respectively, in the normotensive subjects.
DRASTIC 261
DRASTIC
Trial name
Dutch Renal Artery Stenosis Intervention Cooperative study.
References
NEJM 2000; 342:1007–14.
J Hum Hypertens 2001; 15:669–76.
Design
Randomized.
Sample size (n)
1205 (prevalence study) and 106 (intervention study).
Questions addressed
• To compare the effects of balloon angioplasty and antihypertensive
medication on BP in patients with ≥50% atherosclerotic RAS.
• To study the usefulness of standardized 2-drug regimens for identifying
drug-resistant hypertension as a predictor of RAS.
1°° endpoint
BP.
Results
• Prevalence study: 772 patients were included in the randomiza-
tion. Drug-resistant hypertension was observed in 32.2% of patients
receiving amlodipine with/without atenolol and in 41.7% of those
receiving enalapril with/without hydrochlorothiazide (p = 0.006).
However, there was no significant difference between the groups in
the incidence of RAS.
• Intervention study: at 3 and 12 months, BP was similar in the 2 groups
as was drug dose and kidney function. 22 patients in the medical treat-
ment group underwent angioplasty because of persistent hypertension.
Dublin Outcome Study

Trial name
Dublin Outcome Study.
Reference
Hypertens 2005; 46:156–61.
Design
Prospective.
Sample size (n)
5292.
Question addressed
The additional predictive value of ABPM over clinic BP in predicting
outcome.
1°° endpoint
Prediction of mortality.
Results
Ambulatory measurements are superior to clinic measurements in pre-
dicting CV mortality and night-time BP is a better predictor than daytime
pressure.
ELITE 263
ELITE
Trial name
Evaluation of Losartan In The Elderly.
Reference
Lancet 1997; 349:747–52.
Design
Randomized, double-blind, controlled, parallel-group.
Sample size (n)
722 patients.
Question addressed
To determine whether specific angiotensin II receptor blockade with losa-
rtan offers safety and efficacy advantages in the treatment of heart failure
over ACE inhibition with captopril in the elderly.
1°° endpoint
Results
Death and/or hospital admission for heart failure occurred in 9.4% of the
losartan and 13.2% of the captopril patients (RR 32%; 95% CI –4% to +55%;
p = 0.075). This RR was primarily the result of a d in all-cause mortality
(4.8% vs. 8.7%; RR 46%; 95% CI 5–69%; p = 0.035). Admissions with heart
failure were the same in both groups as was improvement in NYHA class
from baseline. Admission to hospital for any reason was less frequent with
losartan treatment.
EPHESUS
Trial name
Eplerenone Post-AMI Heart failure Efficacy and Survival Study.
Reference
Cardiovasc Drugs Ther 2001; 15:79–87.
Design
Randomized, double-blind, placebo-controlled.
Sample size (n)
6632.
Question addressed
To compare the effect of eplerenone plus standard therapy to placebo
plus standard therapy on mortality and morbidity in patients with heart
failure after AMI.
1°° endpoint
Results
All-cause mortality was lower in patients on eplerenone placebo (14.4
vs. 16.7%, p = 0.008). The combined incidence of CV mortality or hos-
pitalization for CV events was also lower in the active group (26.7% vs.
30.0%, p = 0.002).
EWPHE 265
EWPHE
Trial name
European Working Party on High Blood Pressure in the Elderly.
Reference
Lancet 1985; 1:1349–54.
Design
Randomized, double blind, placebo-controlled.
Sample size (n)
840.
Question addressed
To compare the effect of hydrochlorothiazide and triamterene treatment
versus placebo on mortality in the elderly.
1°° endpoint
Results
There was a 21/10 difference in BP between active and placebo arms.
CV mortality was reduced in the actively treated group (–38%, p =
0.023), owing to a reduction in cardiac deaths (–47%, p = 0.048) and a
non-significant d in cerebrovascular mortality (–43%, p = 0.15). In the
patients randomized to active treatment there were 29 fewer CV events
and 14 fewer CV deaths per 1000 patient years during the double-blind
part of the trial.
EUROASPIRE II
Trial name
European Action on Secondary Prevention through Intervention to
Reduce Events II.
Reference
Eur Heart J 2001; 22:554–72.
Design
Observational.
Sample size (n)
8181.
Question addressed
To determine in patients with established CHD whether the Joint
European Societies’ recommendations on coronary prevention are being
followed in clinical practice.
1°° endpoint
Practice audit across Europe of CV risk factors.
Results
• 5556 patients; 21% smoked, 31% were obese, 50% had SBP ≥140mmHg
and/or DBP ≥90mmHg, 58% had serum total cholesterol ≥ 5mmol/L,
and 20% reported diabetes mellitus. 87% of diabetic patients had
plasma glucose >6.0mmol/L.
• There was variable use of proven therapies—most were on aspirin/
other antiplatelets and B-blockers but a smaller proportion on ACEIS
and statins (data are for admission, at discharge and at interview):
• Aspirin/other antiplatelets: 47%, 90% and 86%.
• B-blockers 44%, 66%, and 63%.
• ACEI 24%, 38%, and 38%.
• Lipid lowering 26%, 43%, and 61%.
• The proportion of patients overall taking statins was 55.3%.
HOPE 267
HOPE
Trial name
Heart Outcomes Prevention Evaluation study.
Reference
NEJM 2000; 342:145–53.
Design
Randomized, double-blind, placebo-controlled parallel-group, 2 x 2 factorial.
Sample size (n)
9541.
Question addressed
Does ramipril reduce the incidence of MI, stroke or CV death?
1°° endpoint
Results
• There was a significant reduction in events in the ramipril group for the
1° endpoint (14.0% vs. 17.8% placebo, p <0.001).
• Active therapy reduced MI (9.9% vs. 12.3%), stroke (3.4% vs. 4.9%)
and CV death (6.1% vs. 8.1%), compared to placebo (p <0.001 for all
endpoints).
HOT
Trial name
Hypertension Optimal Treatment Study.
Reference
Lancet 1998; 351:1755–62.
Design
Randomized, open, single-blind (antihypertensive treatment) and double-
blind (aspirin).
Sample size (n)
18,790.
Question addressed
• Does target DBP affect major CV events (non-fatal, acute, and silent
MI, non-fatal stroke, and all CV causes of death)?
• 2°: does low-dose aspirin, in addition to antihypertensive therapy
reduce the incidence of major CV events?
1°° endpoint
Mortality and morbidity
Results
• The DBP was reduced to 85.2, 83.2, and 81.1mmHg in the target
groups ≤90, ≤85 and ≤80mmHg, respectively.
• The lowest incidence of major CV events occurred at a mean achieved
DBP of 82.6mmHg and SBP of 138.5mmHg and the lowest risk of CV
mortality at DBP 86.5mmHg and at SBP 138.8mmHg.
• There was no J-shaped relationship with mortality.
• There was a 51% reduction in major CV events in diabetics with a
target ≤80mmHg compared to ≤90mmHg.
• Aspirin reduced major CV events by 15% and all MI by 36%.
• There was no effect on the incidence of stroke or fatal bleeds by
aspirin, but non-fatal major bleeds were twice as common with aspirin
HYVET 269
HYVET
Trial name
Hypertension in the Very Elderly Trial.
Reference
NEJM 2008; 358:1887–98.
Design
Sample size (n)
3845.
Question addressed
To determine whether active treatment (with indapamide ± perindopril)
of hypertension in patients >80 years with SBP >160mmHg to target
150/80 reduces stroke.
1°° endpoint
Results
• 30% reduction in the rate of fatal or non-fatal stroke (p=0.06), 39%
reduction in the rate of death from stroke (p=0.05), 21% reduction
in death from any cause (p=0.02), 23% reduction in the CV death
(p=0.06), and 64% reduction in the rate of heart failure (p<0.001).
• Careful BP lowering in the very elderly is beneficial.
IDNT
Trial name
Irbesartan type 2 Diabetic Nephropathy Trial.
Reference
NEJM 2001; 345:851–60.
Design
Sample size (n)
1715.
Question addressed
To determine whether irbesartan and amlodipine slow the progression of
nephropathy in patients with type 2 diabetes independent of their ability
to lower SBP.
1°° endpoint
Results
• Irbesartan reduced doubling of serum creatinine, end-stage renal failure
and death from any cause by 20% compared to placebo (p = 0.02) and
23% lower than in the amlodipine group (p = 0.006). These differences
were not explained by changes in BP.
• The serum creatinine concentration i 24% more slowly in the irbe-
sartan group than in the placebo group (p = 0.008) and 21% more
slowly than in the amlodipine group (p = 0.02).
INTERSALT 271
INTERSALT
Trial name
Intersalt: an international study of electrolyte excretion and blood pressure.
Reference
BMJ 1988; 297:319–28.
Hypertension 1991; 17(1 Suppl.):I9–15.
Design
Observational.
Sample size (n)
10,079.
Question addressed
Relationship between electrolyte excretion and BP.
1°° endpoint
Correlation between sodium excretion and BP.
Results
• Na+ excretion ranged from 0.2 to 242mmol/24h. In individual subjects
(within centres) it was significantly related to BP. In 48 centres of 52,
Na+ was significantly related to the slope of BP with age but not to
median BP or prevalence of high BP.
• K+ excretion was negatively correlated with BP in individual subjects
after adjustment for confounding variables. BMI and heavy alcohol
intake had strong, significant independent relations with BP in individual
subjects.
INSIGHT
Trial name
International Nifedipine GITS Study Intervention as a Goal in Hypertension
Treatment.
Reference
Lancet 2000; 356:366–72.
Design
Sample size (n)
6321.
Question addressed
To compare 1° endpoint in high-risk hypertensive patients treated with
nifedipine GITS or amiloride plus hydrochlorothiazide.
1°° endpoint
Results
• Mean BP fell by 35/17mmHg. The combined incidence of MI, heart
failure, stroke, and CV death was not different for nifedipine GITS or
co-amilozide (p = 0.34).
• Total mortality was the same in both groups (4.8%) but there were
fewer vascular deaths than non-vascular deaths
ISIS IV 273
ISIS IV
Trial name
ISIS-4: a randomized factorial trial assessing early oral captopril, oral
mononitrate, and intravenous magnesium sulphate in 58,050 patients with
suspected acute MI. ISIS-4 (Fourth International Study of Infarct Survival)
Collaborative Group.
Reference
Lancet 1995; 345:669–85.
Design
Randomized, 2 x 2 x 2 factorial, placebo controlled.
Sample size (n)
58,050.
Question addressed
To determine if an ACEI (captopril), nitrate, or magnesium alters mor-
tality in patients post MI.
1°° endpoint
Results
ACEI: small but significant reduction in 5-week mortality with survival
advantage maintained at 1 year especially in high-risk patients. Neither
nitrates nor magnesium caused significant changes to the endpoints.
LIFE
Trial name
Losartan Intervention For Endpoint reduction in hypertension.
Reference
Lancet 2002; 359:995–1003.
Design
Randomized, double-blind, double-dummy, parallel-group.
Sample size (n)
9193.
Question addressed
Effects of losartan vs. atenolol on CV mortality and morbidity in hyperten-
sive patients with LVH.
1°° endpoint
Results
• There was no significant difference in brachial BP reduction between
the 2 groups.
• Losartan had a lower 1° endpoint than atenolol (p = 0.021).
• New-onset diabetes mellitus was 25% lower with losartan and there
was greater reduction of LVH (p <0.0001).
MAGPIE 275
MAGPIE
Trial name
Magnesium sulphate for prevention of eclampsia.
Reference
Lancet 2002; 359:1877–90.
Design
Sample size (n)
10,110.
Question addressed
Does magnesium sulphate reduce the risk of eclampsia?
1°° endpoint
Mortality and morbidity
Results
• Active treatment reduced the risk of eclampsia (p<0.0001) and
maternal mortality.
• There was no difference in neonatal mortality or any antihypertensive
effects.
MRC Elderly
Trial name
Medical Research Council trial of treatment of hypertension in older
adults.
Reference
BMJ 1992; 304:405–12
Clin Exp Hypertens 1993; 15:941–2.
Design
Randomized, single-blind, placebo-controlled, parallel-group.
Sample size (n)
4396.
Questions addressed
• Do antihypertensives in patients (65–74 years) reduce mortality and
morbidity due to stroke and CHD and mortality from all causes?
• 2° endpoint: to compare the effects of hydrochlorothiazide (or amilo-
ride) and atenolol and to see whether responses to treatment differed
between men and women.
1°° endpoint
Results
• Active treatment reduced BP more than placebo.
• Patients in the active treatment groups had a 25% reduction in stroke,
a 19% reduction in coronary events, and a 17% reduction in all CV
events.
• The diuretic group had significantly reduced risks of stroke, coronary
events, and all CV events compared to the placebo group.
• The beta-blocker group showed no significant reduction in these end-
points.
MRC/BHF HPS 277
MRC/BHF HPS
Trial name
Medical Research Council and British Heart Foundation Heart Protection
Study.
Reference
Lancet 2002; 360:7–22.
Design
Randomized, placebo-controlled, 2 × 2 factorial.
Sample size (n)
20,536.
Question addressed
To assess the effects on mortality and major morbidity of cholesterol-
lowering therapy and of antioxidant vitamin supplementation in patients
at high risk of CVD.
1°° endpoint
Results
• There were fewer deaths in the simvastatin group compared to
placebo (1328 [12.9%] vs. 1507 [14.7%], p = 0.0003); the death rate
from vascular causes was also significantly reduced (7.6% vs. 9.1% in the
placebo group, p <0.0001).
• Coronary death rate was 5.7% and 6.9%, respectively (p = 0.0005), and
the death rate from other vascular causes was 1.9% and 2.2%, respec-
tively (p = 0.07).
• First non-fatal MI rate (3.5% vs. 5.6%, p <0.0001) and first stroke rate
(4.3% vs. 5.7%, p <0.0001) were also markedly reduced as were the
need for revascularization (9.1% vs. 11.7%; p <0.0001).
• Vitamin supplementation did not alter all-cause mortality (14.1% vs.
13.5%), deaths due to vascular (8.6% vs. 8.2%) or non-vascular (5.5% vs.
5.3%) causes, nor the incidences of non-fatal MI, coronary death, non-
fatal/fatal stroke, revascularization procedure, or cancer incidence.
MRFIT
Trial name
Multiple Risk Factor Intervention Trial.
Reference
JAMA1982; 248:1465–77.
Design
Randomized, open, usual care controlled.
Sample size (n)
12,866.
Question addressed
To test the efficacy of a multifactor intervention programme in CHD.
1°° endpoint
Mortality.
Results
• Mortality from CHD was 17.9 deaths/1000 in the special intervention
group and 19.3 deaths/1000 in the group receiving usual care.
• Total mortality rates were 41.2 deaths/1000 in the special intervention
group and 40.4 deaths/1000 in the group receiving usual care.
• At 10.5 years, CHD mortality was still 10.6% lower in the special inter-
vention group compared to the usual care group, and the AMI rate was
24.3% lower.
• At 16 years, the differences remained about the same. Only the differ-
ences in AMI rate were statistically significant.
NHANES III 279
NHANES III
Trial name
National Health and Nutrition Examination Survey III.
Reference
Hypertens 2001; 37:869–74.
Design
Observational.
Sample size (n)
19,661.
Questions addressed
• To assess frequency of ISH and other subtypes of hypertension, hyper-
tension awareness, and treatment target goals.
• Does subtypes and staging vary between age groups?
1°° endpoint
Prevalence.
Results
ISH commonest in older groups (aged 50–59, frequency 87%). This
requires greater attention to treatment of SBP.
NORDIL
Trial name
Nordic Diltiazem study.
Reference
Lancet 2000; 356:359–65.
Design
Randomized, open, blinded-endpoint, parallel-group.
Sample size (n)
10,881.
Question addressed
Effects of diltiazem on CV morbidity and mortality compared to other
antihypertensive agents.
1°° endpoint
Results
• SBP and DBP were lowered in the diltiazem and B-blocker/diuretic
groups (reduction, 20.3/18.7 vs. 23.3/18.7mmHg; p <0.001 for SBP
reduction)
• There was no significant difference between the groups for the p
endpoint of fatal and non-fatal MI but there was a difference in favour
of diltiazem for fatal and non-fatal stroke (p = 0.04).
• Diltiazem was as effective as other therapies in the combined p
endpoint of fatal/non-fatal MI and stroke or other CV death.
ONTARGET 281
ONTARGET
Trial name
Ongoing Telmisartan Alone and in Combination with Ramipril Global
Endpoint Trial.
Reference
NEJM 2008; 358:1547–59.
Design
Double blind, randomized
Sample size (n)
25,620
Question addressed
Effects of ACE and ARA or the combination in patients who have vascular
disease or high-risk diabetes without heart failure on mortality and mor-
bidity. The p composite outcome was death from CV causes, MI, stroke,
or hospitalization for heart failure.
1°° endpoint
Results
• Mean BP was lower in both the telmisartan group (a 0.9/0.6mmHg
greater reduction) and the combination-therapy group (a 2.4/1.4mmHg
greater reduction) than in the ramipril group.
• Telmisartan caused lower rates of cough (1.1% vs. 4.2%, p <0.001) and
angioedema (0.1% vs. 0.3%, p = 0.01) and a higher rate of hypotensive
symptoms (2.6% vs. 1.7%, p <0.001); the rate of syncope was the same.
• In the combination-therapy group, the p outcome occurred in 1386
patients (16.3%; RR, 0.99; 95% CI, 0.92–1.07); as compared with the
ramipril group, there was an i risk of hypotensive symptoms (4.8% vs.
1.7%, p <0.001), syncope (0.3% vs. 0.2%, p = 0.03), and renal dysfunc-
tion (13.5% vs. 10.2%, p <0.001).
• Telmisartan was equivalent to ramipril in patients with vascular disease
or high-risk diabetes and was associated with less angioedema.
• The combination of the 2 drugs was associated with more adverse
events without an i in benefit.
PATS
Trial name
Post-stroke antihypertensive treatment study.
Reference
Chin Med J 1995; 108:710–7.
Design
Sample size (n)
5665.
Question addressed
Does antihypertensive therapy with a diuretic after a stroke reduce sub-
sequent events?
1°° endpoint
Results
BP reduction by 5/2mmHg with indapamide in patients with a history of
stroke/TIA reduced the incidence of fatal/non-fatal stroke by 29%.
PROGRESS 283
PROGRESS
Trial name
Perindopril Protection against Recurrent Stroke Study.
Reference
Lancet 2001; 358:1033–41.
Design
Sample size (n)
6105.
Question addressed
To determine the effects of BP reduction on stroke risk in patients with a
history of cerebrovascular disease.
1°° endpoint
Results
• Treatment reduced BP by 9/4mmHg compared to placebo.
• 10% of patients on active treatment suffered a stroke compared to 14%
on placebo (RR reduction 28%; p <0.0001).
• The risk of total major vascular events in the active treatment group
was 15% compared to 20% in the placebo group.
• Active treatment also reduced the risk of stroke in hypertensive and
non-hypertensive subgroups (p <0.01).
• Perindopril plus indapamide reduced SBP by 12mmHg and DBP by
5mmHg, and the risk of stroke by 43%.
• Perindopril alone reduced SBP by 5mmHg and DBP by 3mmHg, but not
the risk of stroke.
PRAISE
Trial name
Prospective Randomized Amlodipine Survival Evaluation.
Reference
NEJM 1996; 335:1107–14.
Design
Randomized, double-blind, placebo-controlled, parallel-group.
Sample size (n)
1153.
Question addressed
To assess the efficacy and safety of amlodipine in patients with severe
chronic heart failure.
1°° endpoint
Results
• A p fatal or non-fatal event occurred in 42% of patients in the placebo
group and 39% in the amlodipine group.
• The mortality rate was 38% in the placebo group and 33% in the
amlodipine group.
• However, there was no difference in these rates between the
amlodipine and placebo treatments in patients with ischaemic
conditions; the risk of death and the combined risk of fatal and
non-fatal events were reduced only in patients with non-ischaemic
dilated cardiomyopathy.
• Oedema and orthostatic hypotension were more frequent in the
amlodipine group.
RALES 285
RALES
Trial name
Randomized Aldactone Evaluation Study.
Reference
NEJM 1999; 341:709–17.
Design
Sample size (n)
1663.
Question addressed
To test the hypothesis that treatment with spironolactone would reduce
all-cause mortality in patients with severe heart failure who were receiving
standard therapy.
1°° endpoint
Mortality.
Results
Spironolactone had a significantly reduced all-cause mortality rate com-
pared to placebo (35% vs. 46%, RR 0.70, p <0.001).
REIN
Trial name
Ramipril Efficacy In Nephropathy.
Reference
J Nephrol 1991; 3:193–202.
Design
Randomized, double-blind, placebo-controlled (2 years) plus open (3-year
extension).
Sample size (n)
352.
Question addressed
• Effects of ramipril vs. placebo on the rate of decline of GFR in patients
with chronic non-diabetic nephropathy and proteinuria.
• 2° endpoints: 24-h proteinuria, end-stage renal events plus CV events
and death, and lipid profile.
1°° endpoint
Morbidity.
Results
• Mean rate of GFR decline was significantly lower in the ramipril-
treated patients than in the placebo group, 0.53 vs. 0.88mL/min/month
(p = 0.03).
• Urinary protein excretion d significantly (p <0.01) by month 1 in the
ramipril group and remained lower than baseline throughout the study
period (no change in placebo group).
• The need for transplantation or dialysis and doubling of serum
creatinine were significantly d in the ramipril group (p = 0.02).
• BP control and the overall number of CV events were similar in the
2 treatment groups.
• Baseline urinary protein excretion rate was the best single predictor of
renal disease progression.
• Progression to end-stage renal failure (RR 2.72; p = 0.01) and progres-
sion to overt proteinuria (RR 2.40; p = 0.005) were significantly more
common in the placebo group than in the ramipril group.
• Ramipril significantly d proteinuria by 13% whilst placebo i it by 15%
(p = 0.003). The rate of decline of GFR (p = 0.0001) and the incidence
of end-stage renal failure (RR 5.44; p = 0.0001) were much higher in
stratum 2 than in stratum 1.
RENAAL 287
RENAAL
Trial name
Effects of Losartan on renal and CV outcomes in patients with Type 2
Diabetes and nehropathy.
Reference
NEJM 2001; 345:861–9.
Design
Randomized, double blind.
Sample size (n)
1513.
Question addressed
The role of the angiotensin-II–receptor antagonist losartan in patients
with type 2 diabetes and nephropathy. 1° outcome was the composite
of a doubling of the base-line serum creatinine concentration, end-stage
renal disease, or death.
2°end points included a composite of morbidity and mortality from CV
causes, proteinuria and the rate of progression of renal disease.
1°° endpoint
Morbidity.
Results
• Losartan reduced the incidence of a doubling of the serum creatinine
concentration (RR 25%; p = 0.006) and ESRD (RR 28%; p=0.002) but
had no effect on the rate of death. This benefit was independent of
changes in BP.
• The rate of 1st hospitalization for heart failure was significantly lower
with losartan (RR 32%; p=0.005).
• The level of proteinuria declined by 35% with losartan (p <0.001 for
the comparison with placebo).
• Losartan conferred significant renal benefits in patients with type 2
diabetes and nephropathy and it was generally well tolerated.
SENIORS
Trial name
The effect of nebivolol on mortality and CV hospital admission in elderly
patients with heart failure.
Reference
Eur Heart J 2005; 26: 215–25.
Design
Randomized, double blind, placebo controlled, parallel group.
Sample size (n)
2128.
Question addressed
Effects of nebivolol on elderly heart failure patients.
1°° endpoint
Mortality or CV hospitalization.
Results
Nebivolol significantly reduced all cause mortality or CV hospitalization
(31% vs. 35%, p = 0.039).
SHARP 289
SHARP
Trial name
Stop Hypertension with the Acupuncture Research Program (SHARP):
results of a randomized, controlled clinical trial.
Reference
Hypertension 2006; 48:838–45.
Design
Prospective, double bline, randomized, sham controlled, parallel group.
Sample size (n)
192.
Question addressed
To determine if acupuncture can effectively treat hypertension.
1°° endpoint
BP.
Results
• The mean BP d from baseline to 10 weeks, the p end point, did not
differ significantly between participants randomly assigned to active
(individualized and standardized) versus sham acupuncture (SBP: –3.56
versus –3.84mmHg, respectively; 95% CI for the difference: –4.0 to
4.6mmHg; p = 0.90; DBP: –4.32 versus –2.81mmHg, 95% CI for the
difference: –3.6 to 0.6mmHg; p = 0.16).
• Categorizing participants by age, race, gender, baseline BP, history
of antihypertensive use, obesity, or p traditional Chinese medicine
diagnosis did not reveal any subgroups for which the benefits of active
acupuncture differed significantly from sham acupuncture.
• Active acupuncture provided no greater benefit than invasive sham
acupuncture in reducing SBP or DBP.
SHEP
Trial name
Systolic Hypertension in the Elderly Program.
Reference
JAMA 1991; 265:3255–64.
Design
Sample size (n)
4736.
Question addressed
Does antihypertensive drug treatment with chlortalidone reduce the risk
of total stroke (both non-fatal and fatal) with ISH, aged ≥ 60 years?
1°° endpoint
Results
• At 5 years, there was a 12/4mmHg difference in BP between the groups
(lower in the active group).
• The 5-year incidence of total stroke was 5.2% in the active treatment
group and 8.2% in the placebo group (RR 0.64, p = 0.0003).
• The RR of clinical non-fatal MI plus coronary death, which was the s
endpoint, was 0.73. Major CV events were also reduced (RR 0.68). The
RR of death from all causes was 0.87.
• Patients >75 years and women underwent fewer intensive CV inter-
ventions than did patients 60–75 years and men.
• Active treatment was significantly associated with d use of coronary
artery by pass graft and percutaneous transluminal coronary angioplas-
tyin patients <75 years with CHD.
• The incidence of both haemorrhagic (9 vs. 19; risk ratio = 0.46) and
ischaemic (85 vs. 132; risk ratio = 0.63) strokes were reduced in the
active treatment group.
• The effect of treatment on haemorrhagic strokes was seen in the
1st year, but the effect on ischaemic strokes was not seen until the
2nd year.
SOLVD
Trial name
Studies Of Left Ventricular Dysfunction.
Reference
NEJM 1991; 325: 293–302.
Design
Sample size (n)
4228.
Questions addressed
• Does enalapril improve long-term survival in patients with left ven-
tricular dysfunction with and without a history of overt congestive
heart failure?
• 2° objective: to demonstrate its effects in different subgroups of
patients, e.g. group according to plasma sodium, vasodilator treatment,
ejection fraction, aetiology, and NYHA class. Also to study effects on
left ventricular function and volume, arrhythmias, quality of life, and
pharmacoeconomy.
1°° endpoint
Mortality.
Results
• Prevention trial: the reduction in mortality from CV causes was larger
but still not statistically significant. However, the combined incidence of
death and development of overt congestive heart failure showed a risk
reduction of 29% (p <0.001).
• Treatment trial: there were 510 deaths in the placebo group and 452
in the enalapril group. This represents a risk reduction of 16% (p =
0.0036). The greatest reduction was seen in the number of deaths
attributed to progressive heart failure.
• The following analyses were performed in patients from both trials:
• No apparent changes in quality of life for ≥1 year and only modest
benefits in quality of life occurred in the enalapril-treated patients in
the treatment trial
• No significant differences in ventricular arrhythmia development
over 1 year.
• Left ventricular end-diastolic and end-systolic volumes i in placebo-
but not active treatment (p <0.05 for both). Left ventricular mass
tended to i in placebo patients and to d in enalapril-treated
patients (p ≤0.001)
SOLVD 293
• For the 48 months within the treatment trial, study participants

who received enalapril lived an average of 0.16 undiscounted years
longer. The lifetime projection of this indicated that participants
who received enalapril would be expected to live, on average,
0.40 years longer than those on placebo. Within the trial, the
patient receiving enalapril costed on the average about US$720 less
than the patient receiving placebo, due to higher costs for hospitali-
zations. In lifetime projections, the costs per year of life saved and
per quality-adjusted year of life saved were estimated to be US$80
and US$115, respectively.
STOP HYPERTENSION 2
Trial name
Swedish Trial in Old Patients with Hypertension 2.
Reference
Lancet 1999; 354:1751–6.
Design
Randomized, open, blinded endpoint (PROBE design).
Sample size (n)
6614.
Question addressed
To evaluate classical antihypertensive agents, diuretics, and B-blockers,
vs. the newer antihypertensive agents, lisinopril, enalapril, isradipine, and
felodipine, on CV mortality and events in elderly hypertensives.
1°° endpoint
Results
• There were no significant differences between the groups in fatal CV
events (B-blocker/diuretic group vs. calcium antagonist and ACEI
group, RR 0.99; p = 0.89).
• The combined endpoint of fatal and non-fatal stroke, fatal and non-fatal
MI, and other CV mortality was also not significant comparing conven-
tional therapy vs. newer agents (RR 0.96; p = 0.49).
SYST-CHINA 295
Syst-China
Trial name
Systolic hypertension in China.
Reference
J Hum Hypertens 1998; 16:1823–9.
Design
Sample size (n)
2394.
Questions addressed
• To assess whether nitrendipine, if necessary combined with captopril
and hydrochlorothiazide, is suitable for maintaining long-term BP
control in older Chinese patients with ISH.
• Furthermore, whether this therapy can reduce the incidence of stroke
and other CV complications.
1°° endpoint
Results
• Therapy reduced BP by 9/3mmHg more in than the placebo group.
• This translated to a significant reduction in stroke by 38% (p = 0.01),
stroke mortality by 58% (p = 0.02), all-cause mortality by 39% (p =
0.003), CV mortality by 39% (p = 0.03), and all fatal and non-fatal CV
endpoints by 37% (p = 0.004).
Syst-Eur
Trial name
Systolic hypertension in Europe.
Reference
Lancet 1997; 350:757–64.
Design
Sample size (n)
4695.
Question addressed
Does antihypertensive treatment (nitrendipine) in elderly patients with
ISH reduce CV events, primarily fatal and non-fatal stroke?
1°° endpoint
Results
• Treatment reduced all strokes by 42% (p = 0.003) and non-fatal strokes
by 44% (p = 0.007). However, there was no effect on the incidence of
TIA by active treatment (–12%; p = 0.62).
• In the active treatment group, all fatal and non-fatal cardiac endpoints,
including sudden death, d by 26% (p = 0.03).
THOP 297
THOP
Trial name
Treatment of Hypertension according to home or Office blood Pressure.
Reference
Am J Hypertens 2003; 16:63A.
Design
Randomized, parallel-group.
Sample size (n)
400.
Question addressed
Is antihypertensive treatment guided by self-measured BP more beneficial
than treatment based on clinic BP?
1°° endpoint
Morbidity.
Results
• BP was higher in patients with home measurement than in patients with
office measurement (p<0.001).
• Antihypertensive treatment was discontinued significantly more
frequently in patients with home measurement than in patients with
office measurement (25.2% vs. 12.3%; p = 0.001).
• Fewer patients with home measurement progressed to multiple drug
treatment than patients with office measurement (38.7% vs. 46.4%;
p = 0.08).
TNT
Trial name
Treating to New Targets.
Reference
NEJM 2005; 352:1425–35.
Design
Randomized, double blind, parallel-group.
Sample size (n)
10,001.
Question addressed
To assess efficacy and safety of moderate and intensive statin therapy with
a goal of reducing CV risk by reducing LDL cholesterol below recom-
mended targets of 2.6mmol/L in patients with CHD.
1°° endpoint
Results
• Mean cholesterol levels were 2.6mmol/L with atorvastatin 10mg/day
and 2.0mmol/L with atorvastatin 80 mg/day.
• p endpoint of CV death, non-fatal MI, resuscitation after cardiac arrest,
fatal or non-fatal stroke occurred less in the 80mg/day group (10.9% vs.
8.7%, RRR 22%, p <0.001).
• There was no significant difference in overall mortality between the
2 groups.
TONE 299
TONE
Trial name
Sodium Reduction and Weight Loss in the Treatment of Hypertension
in Older Persons. A Randomized Controlled Trial of Nonpharmacologic
Interventions in the Elderly (TONE).
Reference
JAMA 1998; 279:839–46.
Design
Randomized.
Sample size (n)
875.
Question addressed
To determine whether weight loss or reduced sodium intake is effective
in the treatment of older persons with hypertension.
1°° endpoint
Morbidity.
Results
• The combined outcome measure was less frequent among those
assigned vs. not assigned to reduced sodium intake (relative HR, 0.69;
95% CI, 0.59–0.81; p <.001) and, in obese participants, among those
assigned vs. not assigned to weight loss (relative HR, 0.70; 95% CI,
0.57–0.87; p <.001).
• Relative to usual care, HRs among the obese participants were 0.60
(95% CI, 0.45–0.80; p <.001) for reduced sodium intake alone, 0.64
(95% CI, 0.49–0.85; p = 0.002) for weight loss alone, and 0.47 (95% CI,
0.35–0.64; p <0.001) for reduced sodium intake and weight loss
combined.
• The frequency of CV events during follow-up was similar in each of the
6 treatment groups.
• Reduced sodium intake and weight loss constitute a feasible, effective,
and safe non-pharmacologic therapy of hypertension in older persons.
UKPDS/HDS
Trial name
UK Prospective Diabetes Study – Hypertension in Diabetes Study.
Referece
BMJ 1998; 317:713–20.
Design
Randomized, open, factorial.
Sample size (n)
• 4209 in UKPDS.
• 1148 in HDS.
Questions addressed
To determine whether improved blood glucose control and tight control
of BP will prevent complications and reduce morbidity and mortality in
patients with type 2 diabetes, and to determine which, if any, therapies
have a particular advantage in improving prognosis.
Results
• Over 10 years, intensive blood glucose control significantly reduced
HbA1c compared to conventional treatment (7.0% vs. 7.9%; p <0.0001),
with non-significant reductions in the risk of diabetes-related death
(10%) and all-cause mortality (6%), and a reduction in risk of MI of bor-
derline significance (p = 0.052).
• None of the intensive antidiabetic agents showed an advantage over
the others.
• Mortality in overweight patients receiving metformin was 36% lower
than in overweight patients receiving conventional treatment
(p = 0.011), with a significant 39% reduction in the incidence of MI
(p = 0.01).
• Tight control of BP significantly reduced the risk of diabetes-related
death by 32% (p = 0.019), of any diabetes-related endpoint by 24%
(p = 0.0046), and of stroke by 44% (p = 0.013).
• The risk of MI was reduced in the tight BP control group by 21%, and
the combined risk of all macrovascular diseases (including MI, sudden
death, stroke, and peripheral vascular disease) was significantly reduced
by 34% (p = 0.019).
• The risk of heart failure was significantly reduced by 56% (p = 0.0043)
by tight BP control.
• By 7.5 years, the tight BP control group showed a 48% reduction in risk
of a Q-wave ECG abnormality (p = 0.007).
• BP reduction is key to reducing the risk of either single or aggregate
macrovascular endpoints.
VA COOPERATIVE STUDY 301
VA Cooperative Study
Trial name
Veteran’s Administration Co-operative Study.
Reference
JAMA 1967; 202:1028–34.
Design
Randomized, double blind, placebo controlled.
Sample size (n)
143.
Question addressed
Does antihypertensive treatment (hydrochlorothiazide, reserpine, and
hydralazine) reduce events in patients with hypertension with end-organ
damage (DBP 115–129mmHg).
1°° endpoint
Mortality.
Results
There were 27 deaths in the placebo arm and only 2 in the active arm
(p <0.01).
VALHEFT
Trial name
Valsartan Heart Failure Trial.
Reference
NEJM 2001; 345:1667–75.
Design
Randomized, placebo-controlled.
Sample size (n)
5010.
Question addressed
To investigate the effects of valsartan on mortality, morbidity, and quality
of life in patients with chronic heart failure treated with ACEIs with or
without background B-blocker therapy.
1°° endpoint
Results
• The rate of all-cause mortality was similar in the two groups.
• Valsartan significantly reduced combined mortality and morbidity from
heart failure (p = 0.009).
• Valsartan also improved NYHA class, ejection fraction, signs and symp-
toms of heart failure, and quality of life compared to placebo (p <0.01).
• A post-hoc analysis of the data in subgroups defined according to base-
line treatment with ACEIs or B-blockers showed that valsartan had a
favourable effect in patients who received none or one of these drugs,
but had an adverse effect on mortality in patients who received both
types of drugs.
VALUE 303
VALUE
Trial name
Valsartan Antihypertensive Long-term Use Evaluation.
Reference
Lancet 2004; 363:2022–31.
Design
Sample size (n)
15,245.
Question addressed
Is valsartan more effective than amlodipine in reducing cardiac mortality
and morbidity for the same level of BP control?
1°° endpoint
Results
There were no differences between the treatment groups in either cardiac
mortality (p = 0.90) or cardiac morbidity (p = 0.71).
305
Index
ABCD study 196, 249 African descent 90 IDNT 270

absolute risk 84 age 50, 52 PRAISE 284
accelerated phase changes in blood special populations
hypertension 108, 110 pressure 30, 31, 32 186, 207
ACD rule 102 effect on aortic pulse ANBP2 study 254
ACE study 250 wave velocity 11 angiography 141
acquired/modifiable risk AIRE study 251 angioplasty 137, 143
factors 84 alcohol 41, 200 angiotensin-converting
acupuncture 96, 289 essential hypertension 94– enzyme (ACE)
Adalat-LA 218 95, 89, 95 212, 281
adrenal adenomas 123, 147, secondary angiotensin-converting
148, 149 hypertension 164 enzyme inhibitors
adrenaline 121 aldosterone: (ACEI) 212, 224
adrenal nuclear antagonists 106, 228 ABCD 249
medicine 126 essential hypertension 72 accelerated
adrenal steroid renal parenchymal hypertension 110
pathways 177 disease 158 adult polycystic kidney
adrenal vein sampling renin ratio 144, 145 disease 160
(AVS) 132 secondary hypertension ANBP2 254
adrenergic agonists and 122, 144–5 Bartter’s syndrome 180
antagonists 12–13, 110 aliskiren 232 children 206–7
α1- and ALLHAT study 252 diabetes 196
α2-adrenoreceptors 230 angiotensin converting elderly people 201
adult polycystic kidney enzyme (ACE) essential hypertension 56,
disease 160 inhibitors 212–13 60, 98
advanced glycation end antihypertensive EUROASPIRE II 266
products (AGEs) 26 drugs 213, 230, 231 ISIS IV 273
aetiology and calcium-channel kidney nuclear
pathophysiology 1 antagonists 218 medicine 130
alcohol 41 essential hypertension kidneys, role of 16
arteries, large 26 56, 98 post-stroke 208
autonomic and renal special populations pregnancy 186
mechanisms interplay 196, 199 renal artery
between 20 thiazide diuretics 222 stenosis 142
central versus peripheral alpha blockers 230 renal parenchymal
blood pressure 6 essential hypertension disease 159
diet 36–7 56, 98 renin inhibitors 232
environmental influences phaeochromocytoma 154 special populations 198
on blood pressure 30 pregnancy 186 STOP HYPERTENSION
essential hypertension renal parenchymal 2 294
genetics 28 disease 159 thiazide diuretics 222
experimental models 46 ALPINE study 253 transplant patients 210
haemodynamics 2, 4 ambulatory blood pressure VALHEFT 302
obesity 44–5 monitoring (ABPM) angiotensin II 46, 212, 214
physical activity 34–5 78, 243 angiotensin receptor
physiology and 24 hour 80–1, 81 antagonists (ARAs)
pathophysiology amiloride 226, 272 198, 214
of blood pressure monogenic accelerated
regulation 8 syndromes 175, 182 hypertension 110
potassium intake 40 MRC Elderly 276 diabetes 196
sodium intake 38–9 secondary elderly people 200
stress 42–3 hypertension 150 essential hypertension 56
vascular structure and amlodipine 212, 214, kidneys, role of 16
function 22, 25 218, 218 and pregnancy 186
see also autonomic ALLHAT 252 renal artery stenosis 142
nervous system; ASCOT 255 renin inhibitors 232
kidneys DRASTIC 261 transplant patients 210
306 INDEX
angiotensin receptor aspirin 192, 266, 268 British Hypertension

blockers (ARBs) 60, ASTRAL study 143, 256 Society 101, 106, 196,
137, 160, 224, 281 AT1 receptor 06.s8.2
antagonists: antagonists 207 bilateral adrenal
adrenergic 12–13, 110 atenolol 214, 216–17 hyperplasia (BAH) 150
aldosterone 106, 228 ALPINE 253 bioflavinoids 174
AT1 receptor 207 ASCOT 255 bisoprolol 216
see also angiotensin essential hypertension 54 blood investigations 68
receptor; calcium LIFE 274 blood pressure:
channel MRC Elderly 276 brachial 6, 242
antihypertensive drugs 211 special populations central and peripheral 6
aldosterone 186, 207 home 78
antagonists 228 atorvastatin 255, 298 pulsatile 2
alpha-blockers 230 atropine 12 static/steady-state 2
angiotensin converting autonomic nervous target 242
enzyme (ACE) system 10 see also ambulatory;
inhibitors 212 adrenergic agonists and diastolic; measure-
angiotensin receptor antagonists 12–13 ment; systolic
antagonists (ARA) 214 arterial baroreceptors borderline
beta-blockers 216 14, 15 hypertension 242
calcium-channel assessment of activity 10 autonomic nervous
antagonists catecholamines 10–11 system 12
(CCAs) 218 and kidneys, interplay echocardiography 82
central between 20 haemodynamics 4
sympatholytics 234 microneurography 12–13 non-pharmacological
endothelin noradrenaline spillover 12 management 88
antagonists 238 spectral analysis of heart obesity 44
hydralazine 236 rate 14 salt intake 38
minoxidil 235 systolic/diastolic hyper-
nitrates 237 baroreceptor reflex 14 tension (SDH) 58
peripheral Bartter’s syndrome 172, brachial blood pressure
sympatholytics 238 180, 181 6, 242
potassium-sparing bendrofluazide 207, 222 bradykinin 212
diuretics 226 bendroflumethiazide 255 breathing modulation
in pregnancy 185 benzothiazepines 218 devices 96
renin inhibitors 232 beta-blockers 216, 224
sodium nitroprusside 235 accelerated cadmium 168
thiazide diuretics 222 hypertension 110 CAFE study 257
antioxidants 192 aortic dissection 109 calcineurin inhibitors 210
antiplatelets 266 CAPPP 258 calcium 123, 192
aortic dissection 109 children 206–7 ECG manifestations
aortic pulse wave co-arctation of the of metabolic
velocity 11, 244, 245 aorta 136 abnormalities 75
aortic stiffening 52 elderly people 200 supplementation 93
ARR 150 essential hypertension 56, see also calcium-channel
arsenic 168 72, 98, 110 calcium-channel antagonists
arterial baroreceptors 14, 15 EUROASPIRE II 266 98, 213, 218, 294
arterial stiffness 244 gestational accelerated
clinical use 244 hypertension 189 hypertension 110
independent predictive and hydralazine 236 adult polycystic kidney
value according to site hyperaldosteronism 145 disease 160
of measurement 245 hyperthyroidism 157 bilateral adrenal
recommended clinical kidneys, role of 16 hyperplasia 150
variables to stratify and minoxidil 235 children 207
cardiovascular risk 246 MRC Elderly 276 Conn’s syndrome 148
arteries, large 26 NORDIL 280 elderly people 201
ASA study 250 phaeochromocytoma 154 immunosuppressives 166
ascending aorta 245 renin and aldosterone 72 renal artery stenosis 142
ASCOT study 212, 216, STOP HYPERTENSION renin and aldosterone 72
228, 229, 255 2 294 transplant patients 210
essential hypertension transplant patients 210 calcium-channel
98, 106 treatment algorithms 102 antagonists 56, 159, 186,
thiazide diuretics 222 VALHEFT 302 224, 249
INDEX 307
Cambridge guidelines 104 causes of hypertension by SHEP 290

candesartan 214, 253, age group 205 SOLVD 292
259 definitions 204 STOP HYPERTENSION 2
CAPPP study 196, 258 drugs used in management 294
captopril of hypertension 207 Syst-China 295
CAPPP 258 investigations 205 Syst-Eur 296
ELITE 263 prevalence of THOP 297
essential hypertension 54 hypertension 204 TNT 298
ISIS IV 273, 08.s31.5 secondary hypertension, TONE 299
renography 141 features UKPDS/HDS 300
Syst-China 295 suggestive of 207 VA Cooperative
carbenoxolone 174 treatment 206 Study 301
cardiac output, raised 52 CHIPS study 208 VALHEFT 302
cardiovascular disease 246 chlorthalidone 212, 218 VALUE 303
diet 92 222, 230, 231 clonidine 234
dipstick urinalysis 73 ALLHAT 252 suppression test 120, 154
essential hypertension essential hypertension 54 co-amilozide 272
86, 87, 50, 60 SHEP 290 co-arctation of the
exercise 92 chronic hypertension 110, aorta 136
prognosis and risk strati- 184, 185, 188 cocaine 168
fication 84 clinical trials 248 combination care versus
targets and evidence ABCD 249 stepped care 100
basis 101 ACE 250 compliance and essential
cardiovascular end-organ AIRE 251 hypertension 99
damage 66 ALLHAT 252 computed tomography 123
cardiovascular mortality ALPINE 253 CT-angiography 141–2
82, 94, 98 ANBP2 254 confirmatory tests 152
cardiovascular risk ASCOT 255 congenital heart
factors 241 ASTRAL 256 disease 136
ambulatory blood CAFÉ 257 Conn’s syndrome 122, 148
pressure CAPPP 258 CORAL study 143
monitoring 80 CHARM 259 Cornell criteria 75
drug choice 98 DASH 260 coronary heart disease 53,
essential hypertension DRASTIC 261 90, 94, 199
61, 68 Dublin Outcome corticosteroids 210
non-pharmacological Study 262 cortisol 151, 174
management 88 ELITE 263 creatinine 70–1
weight loss and EPHESUS 264 Cushing’s syndrome 151
obesity 92 EUROASPIRE II 266 cyclo-oxygenase (COX)
carotid distensibility 245 EWPHE 265 inhibition 166
catecholamines 10–11 HOPE 267
metabolism 115 HOT 268 Dahl salt-sensitive and salt-
phaeochromocytoma 154 HYVET 269 resistant rats 47
plasm 116–17 IDNT 270 DASH study 38, 90, 260
secondary INSIGHT 272 deoxyribonucleic acid
hypertension 114, INTERSALT 271 (DNA) 29
121, 126 ISIS IV 273 diabetes 196, 246
urine 114 LIFE 274 and antihypertensive
cellophane wrapping of MAGPIE 275 drugs 224
kidney 46 MRC/BHF HPS 277 and essential
central sympatholytics 234 MRC Elderly 276 hypertension 50, 52
central versus peripheral MRFIT 278 targets and evidence
blood pressure 6 NHANES III 279 basis 101
cerebral perfusion NORDIL 280 treatment algorithms 102
pressure 110 ONTARGET 281 UKPDS/HDS 300
CHARM study 259 PATS 282 diabetic nephropathy 159
cheese reaction 167 PRAISE 284 diabetic retinopathy 62
children 204 PROGRESS 283 diastolic blood pressure:
aetiology 204 RALES 285 accelerated phase
blood pressure centiles in REIN 286 hypertension 108
the UK 205 RENAAL 287 alcohol 41
blood pressure SENIORS 288 aortic dissection 109
measurement 204 SHARP 289 children 204
308 INDEX
diastolic blood pressure: early hypertension 58 genetics 28

(cont.) echocardiography 82 haemodynamics 4
elderly people 200, 201, eclampsia 110 history 60
202, 203 ectopic ACTH home blood pressure 78
environmental production 151 hypertensive
influences 30 elderly people 200 emergencies 108
HOT 268 electrocardiography 74–7 investigations 50
hypertensive ELITE study 263 isolated diastolic
encephalopathy 109 enalapril: hypertension 59
isolated diastolic ABCD 249 kidneys, role of 16
hypertension 59 DRASTIC 261 measurement of blood
isolated systolic essential hypertension 54 pressure 64
hypertension 52–4 SOLVD 292 neurological
measurement 64 STOP HYPERTENSION 2 examination 62
nitrates 237 294 non-pharmacological
NORDIL 280 endocrine hypertension 68 management 88–9
post-stroke 208 end-organ damage 66, 67 past medical history 61
potassium intake 40 endothelial dysfunction pharmacological
pregnancy 184 24, 158 management 56, 57, 98
prevention 240 end-stage renal prevalence and
PROGRESS 283 disease 158–9 incidence 50, 51
salt 90 environmental influences on prognosis and risk
targets and evidence blood pressure 30 stratification 84–6, 87
basis 101 EPHESUS study 228, 264 renal mechanisms leading
diet 36–7, 206 eplerenone 228 to 18
essential hypertension EPHESUS 264 renin and aldosterone 72
88, 89, 92–3 secondary resistant
dihydropyridine (DHP) 148, hypertension 150 hypertension 106, 107
196, 210, 218 erythropoietin 158 risk factors 60
diltiazem 218, 280 essential hypertension 49 sodium 90–1
dipstick urinalysis 73 24-hour ambulatory stepped care versus
diuretics 224 blood pressure combination care 100
ANBP2, 254 monitoring 80–1 systolic/diastolic hyper-
CAPPP 258 abdominal tension (SDH) 58
children 207 examination 62 targets and evidence
essential hypertension acupuncture 96 base 101
54, 98 alcohol 94–5 treatment algorithms 102,
immunosuppressives 166 autonomic nervous 103, 104
Liddle’s syndrome 179 system 10, 12 vascular structure and
loop 109, 159, 235, 236 autonomic and renal function, 22, 25
MRC Elderly 276 mechanisms, 20 weight loss and
NORDIL 280 biochemistry, basic obesity 92
potassium-sparing 226 70, 71 see also isolated systolic
renal artery stenosis 142 breathing modulation hypertension (ISH)
resistant devices 96 EUROASPIRE II study 266
hypertension 106 cardiorespiratory eutrophic remodelling 22–3
steroids 165 examination 62 evidence base 101
STOP HYPERTENSION compliance 99 EWPHE study 200–1, 265
2 294 dietary intervention exercise see physical
see also thiazide 92, 93 activity/exercise
diuretics dipstick urinalysis 73 experimental models 46
dopamine 116 drug history 61
Doppler ultrasound 191 echocardiography 82 false positive urine tests,
doxazosin 230–1, 252 electrocardiography 74, drugs causing for phaeo-
DRASTIC study 143, 261 75, 75–6, 77 chromocytoma 114
drug therapy 98 end-organ damage felodipine 253, 294
and children 207 assessment 66, 67 fibromuscular dysplasia
elderly people 200 examination 62 (FMD) 139–40
essential exercise 92 fludrocortisone suppression
hypertension 56–7 family history 61 test 122, 145
Dublin Outcome Study 262 fundoscopy 62–3 fluorodihydroxy
dynamic testing 118 general examination 62 phenylalanine 128
INDEX 309
fluorodopamine 128 and essential drug, choice of 56

Framingham Heart hypertension 72, 106 elderly people 200,
Study 44, 75, 84, 241 primary 144 201, 202
frusemide 235 secondary 146 NHANES III 279
and secondary hyper- nitrates 237
gene association tension 122, 144, 148 pathophysiology 52
studies 29 hyperdynamic phase 52 prevalence 52–3
genetic linkage analysis 28 hyperkinetic state 10 risks 53
genetic mapping 29 hypernephromas (renal cell treatment 53–5
genetic models 46–47 adenocarcinomas) 162 isosorbide dinitrate 237
genetic screening 160 hyperparathyroidism 156 isradipine 294
genetics and essential hypertensive congenital
hypertension, 28 adrenal JNC-7 target 196, 202
genetic testing 152 hyperplasia 177 Joint British Societies
gestational/pregnancy- hypertensive (JBS) 84
associated emergencies 108
hypertension 184–5, hypertensive kidneys 16
185, 189 encephalopathy 109 and autonomic nervous
Gitelman’s syndrome hypertensive heart system, interplay
172, 182 failure 109 between 20
glomerular disease (glo- hypertensive and diabetes 196
merulonephritis) 158 retinopathy 62, 63 Guyton’s theory of
glomerular filtration hyperthyroidism 157 hypertension 17–18
rate 18[pg1-2] hypertrophic obstructive and nuclear medicine 130
glucocorticoid remediable cardiomyopathy 82 renal mechanisms
aldosteronism 178 hypertrophic leading to essential
glycosuria 73 remodelling 22, 23 hypertension 18
Gordon’s syndrome 176 hypokalaemia 148 renin-angiotensin-
guanethidine 238 HYVET study 54, 202, 269 aldosterone system
Guyton’s theory of (RAAS) 16–17
hypertension 17–18 IDNT study 270 see also renal
I-MIBG 154 Korotkoff 184, 204
haematuria 73 immunosuppressives 166 Kung Bushmen
haemodynamics 2, 4, 184 indapamide 208–9, 222 (Botswana) 31
haemolytic uraemic HYVET 269
syndrome 191 PATS 282 labetolol 186, 193
Health Survey for PROGRESS 283 essential
England 200 India 50, 85 hypertension 109–10
heart rate, spectral analysis indomethacin 166 Langerhans cell
of 14 indoramin 230 histiocytosis 82
heavy metals 168 inherited risk factors 84 lead 168
HELLP syndrome 191 INSIGHT study 218, 272 left ventricular hyper-
home blood pressure 78 INTERSALT study 271 trophy 74, 75–6, 82
HOPE study 267 interventional Liddle’s syndrome 179
HOT study 101, 196, radiology 132, 133 LIFE Study 200, 214, 216,
242, 268 iodine 126 274
HPLC-EC technique 116 irbesartan 214, 270 lifestyle modification 89,
hydralazine 110, 193, ischaemic heart disease 85, 200, 206
236, 301 94 lifetime risk 84
hydrochlorothiazide ISIS IV study 273 liquorice 163, 174
201, 223 isolated diastolic hyper- lisinopril 207, 212,
ALPINE 253 tension (IDH) 4, 59 252, 294
DRASTIC 261 definition 59 loop diuretics 109, 159,
EWPHE 265 pathophysiology 59 235, 236
INSIGHT 272 prevalence 59 losartan 207, 214
MRC Elderly 276 isolated systolic ELITE 263
Syst-China 295 hypertension (ISH) 4, 52 LIFE 274
VA Cooperative calcium-channel RENAAL 287
Study 301 antagonists 218 low renin
hyperaldosteronism: children 204 hypertension 173
bilateral adrenal definition 52 Lyon model of
hyperplasia 150 diabetes 196 hypertension 47
310 INDEX
MAG 3 renogram mineralocorticoid peripheral

scan 130–1 receptor-activating sympatholytics 238
magnesium sulphate 193 mutation 175 peripheral vascular
essential and renal resistance (PVR) 2, 4, 18
hypertension 110 homeostasis 173 diet 36
ISIS IV 273 salt excess states 172 electrocardiography 74
MAGPIE 275 mononitrate 273 pregnancy 184
magnesium moxonidine 234 systolic/diastolic hyper-
supplementation 93 MRC/BHF HPS study 277 tension (SDH) 58
magnetic resonance- MRC Elderly Study 56, 200, PET 154
angiography 141 216, 276 PET-CT scans 128–9
magnetic resonance MRFIT study 278 phaeochromocytoma:
imaging 124, 125 adrenal nuclear
MAGPIE Study 193, 275 naproxen 166 medicine 126, 128
manual nebivolol 216, 288 benign 153
sphygmomanometry 64 neurological end-organ clinical features 152
masked damage 66 clonidine suppression
hypertension 81 New Zealand genetically test 120
mean arterial pressure hypertensive rat 47 computed
109, 187 NHANES III study 44, tomography 123
measurement of blood 59, 279 crisis 110
pressure 64, 184, NICE-BHS guidelines 104 definition 152
204, 242 nifedipine 186, 193, 218 demographics 152
metabolic syndrome 44, essential and essential
50, 59 hypertension 110 hypertension 60, 69
metadrenalines 114 INSIGHT 272 familial association 153
metanephrines 114, nisoldipine 249 investigations 153
116–17, 126, 153 nitrates 56, 109, 201, 237 localization 154
methoxytyramine 116 nitrendipine 54, 220, 295, 296 mixed density left
methyldopa 185, 193 non-steroidal anti- adrenal 155
central inflammatory drugs, 61, pentolinium suppression
sympatholytics 234 166, 180 test 121
MIBG scan 126–7 noradrenaline 10, 12, plasma catecholamines and
microneurography 12–13 120–1, 152 metanephrines 116
micro- (or macro-) NORDIL study 280 provocation and
albuminuria 73, 196 normetanephrines suppression tests 118
Milan hypertensive rat 47 (NMNs) 114, 116, 120 screening 153
mild-moderate nuclear medicine 126, 130 and secondary hyper-
hypertension 193 tension 127, 114, 152
mineralocorticoid obesity 44–5, 59, 92 suppression tests 69
excess 174 one-kidney, one-clip symptoms 60
mineralocorticoid receptor- model 46 treatment 154
activating mutation 175 ONTARGET study 281 phenotypical complexity
minoxidil 159, 235 ophthalmological end-organ essential hypertension 28
monoamine oxidase damage 66–7 phenoxybenzamine
inhibitors 167 oral contraceptives 61, 165 154, 230
monogenic syndromes 169 organ damage 246 phentolamine 110, 230
Bartter’s syndrome 172, see also end-organ phenylalkylamines 218
180–1 physical activity/exercise
Gitelman’s syndrome papilloedema 67 34, 35, 200, 206
172, 182 paragangliomas 123, 127, essential hypertension 88,
glucocorticoid remediable 152 89, 92
aldosteronism 178 pathophysiology: physiological complexity
Gordon’s syndrome 176 of hypertension in of essential
hypertensive congenital diabetes 196 hypertension 28
adrenal see also aetiology and physiology of blood
hyperplasia 177 pathophysiology pressure regulation 8
Liddle’s syndrome Pathway Project 106 pindolol 216
172, 179 PATS study 208, 282 post-stroke 208
low renin pentolinium suppression potassium 36–7, 40, 271
hypertension 173 test 121, 154 ECG manifestations
mineralocorticoid perindopril 209, 255, of metabolic
excess 174 269, 283 abnormalities 75, 77
INDEX 311
and essential causes 138 Sabra hypertension-prone

hypertension 70 clinical features 140 and hypertension-
and secondary computed resistant rats 47
hypertension 122 tomography 123 saline suppression test 122
-sparing diuretics 226 confirmatory tests 141 salt:
supplementation 93 demographics 138 excess states 172
PRAISE study 284 DRASTIC 261 intake 206
pravastatin 252 and essential -loading 145
prazosin 230 hypertension 60 restriction 200
pre-eclampsia 184–5, fibromuscular dysplasia sensitivity and
188, 190 (FMD) 139–40 renin-angiotensin-
definition 190 interventional aldosterone system
Doppler flow velocity radiology 132 (RAAS) 158
waveforms in uterine investigations 140 see also sodium
artery 192 kidney nuclear saralasin 214
follow-up 193 medicine 130 screening tests 152
HELLP syndrome 191 medical therapy 142 secondary hypertension 50,
investigations 191 overlap with hypertension 111, 135, 242
management 192 and renal failure 139 adult polycystic kidney
pathophysiology 190 physiology 139 disease 160
pharmacological renin and aldosterone 72 alcohol 164
treatment 193 revascularization 142 bilateral adrenal
prevention 192 screening tests 141 hyperplasia (BAH) 150
risk of developing and secondary clonidine suppression
hypertension or hypertension 138 test 120
ischaemic heart disease 194 surgery 143 co-arctation of the
risk factors 190 treatment 142 aorta 136
severe 110, 193 renal disease 158–9, 246 cocaine 168
signs and symptoms 191 renal end-organ damage 66 computed
pregnancy 184 renal homeostasis 173 tomography 123
antihypertensive drugs renal ischaemia 19, 158 Conn’s syndrome
therapy 185 renal masses 123 122, 148
and chronic renal parenchymal Cushing’s syndrome 151
hypertension 188 disease 158 dynamic testing 118
definitions 184 renal tumours 162 features suggestive
haemodynamic renal ultrasound 141 of 207
changes 184 renin 72 heavy metals 168
measuring blood and aldosterone 141, 172 hyperaldosteronism 144
pressure 184 -angiotensin system 233 hyperparathyroidism 156
prevention of inhibitors 232 hyperthyroidism 157
hypertension 240 -secreting tumours 162 immunosuppressives 166
primary hypertension 50 see also interventional
PROGRESS study 208–9, 283 renin-angiotensin- radiology 132, 133
propranolol 12, 207, 216 aldosterone system liquorice 163
proteinuria 73 (RAAS) magnetic resonance
provocation tests renin-angiotensin- imaging 124
for suspected aldosterone system monoamine oxidase
phaeochromocytomas (RAAS) 16–17 inhibitors 167
and paragangliomas 118 autonomic and renal non-steroidal
pulsatile blood pressure 2 mechanisms 20 anti-inflammatory
experimental models 46 drugs 166
RALES study 228, 285 potassium intake 40 nuclear medicine 126, 130
ramipril 251 and salt sensitivity 158 oral contraceptive pill 165
HOPE 267 reninomas 162 pentolinium suppression
ONTARGET 281 renovascular disease 60, 106 test 121
REIN 286 renovascular PET-CT scans 128, 129
REIN study 286 hypertension 69, 138, phaeochromocytoma
RENAAL study 287 158 114, 152
renal artery Doppler 141 reserpine 238, 301 plasma catecholamines and
renal artery stenosis: resistance vessels 22, 23, 24 metanephrines 116
angioplasty 143 resistant hypertension 82, renal parenchymal
atherosclerotic 138 106, 107 disease 158
background 138 revascularization 142 renal tumours 162
312 INDEX
secondary hypertension SPRINT study 101, 242 target blood pressure 242
(cont.) static/steady-state blood target organ damage
saline suppression pressure 2 68, 85
test 122 statins 142, 266, 298 targets 101
steroids 165 stepped care versus Tecumseh study 44
vascular endothelial combination care 100 telmisartan 281
growth factor (VEGF) steroids 61, 165, 177 terazosin 230
inhibitors 166 STOP HYPERTENSION 2 thiazide diuretics 56, 222
see also renal artery study 200, 294 aldosterone
stenosis STOP study 200 antagonists 228
secondary strain pattern 75 diabetes 196
prophylaxis 208 stress 42–3 elderly people 201
SENIORS study 288 stroke 53, 208 Gordon’s syndrome 176
serotonin syndrome 167 suppression tests 69, 118 post-stroke 208
severe hypertension 193 clonidine 120, 154 pregnancy 186
SHARP study 96, 289 fludrocortisone renal parenchymal
SHEP study 196, 200, c03.s5.7.1, 122, 145 disease 159
202–3, 290 pentolinium 121, 154 transplant patients 210
essential hypertension saline 122 treatment algorithms 102
54, 56 sympathetic nervous THOP study 78, 297
thiazide diuretics 222 system 158 thrombotic
simvastatin 277 sympatholytics 234, 238 thrombocytopenia 191
single nucleotide poly- Syst-China study 54, 56, thyrotoxicosis 60
morphisms (SNPs) 29 200, 295 TNT study 298
smoking 88 Syst-Eur study 196, 200, TONE study 200–1, 299
sodium 17, 36, 37, 38–9 220, 296 transplant patients 210
essential hypertension calcium-channel treatment algorithms
70, 90, 89, 91 antagonists 218 102–3, 104
INTERSALT 271 essential hypertension triamterene 201, 226, 265
nitroprusside 109, 235 54, 56 TROPHY study 240
reabsorption, transport systolic blood pressure: Turner’s syndrome 136
mechanisms alcohol 41 two-dimensional echo 82
related to 19 children 204 two-kidney, one-clip
TONE 299 elderly people 200, 202 model 46
Sokolow-Lyon environmental two-kidney, two-clip
classification 74, 75 influences 30 model 46
Solomon Islands 50 HOT 268 tyramine 167
SOLVD study 292 isolated diastolic
special populations 183 hypertension 59 UKPDS 196
children 204 isolated systolic UKPDS/HDS 300
diabetes 196 hypertension 52–3, 54 United Kingdom 31,
elderly people 200 measurement 64 52, 206
gestational NHANES III 279 United States 204
hypertension 189 nitrates 237 alcohol intake 94
post-stroke 208 NORDIL 280 changes in blood pressure
pre-eclampsia 190 obesity 44 with age 30, 32
pregnancy 184 physical activity 34 essential hypertension
pregnancy and chronic potassium intake 40 52, 59
hypertension 188 pregnancy 184 Food and Drug
transplant patients 210 prevention 240 Administration 96
spectral analysis of heart PROGRESS 283 Food and Drug
rate 14 salt 90 Administration
spironolactone 228, 229 targets and evidence Modernization Act 206
Bartter’s syndrome 180 basis 101 targets and evidence
bilateral adrenal systolic/diastolic hyper- basis 101
hyperplasia 150 tension (SDH) 4, 58 urine investigations 68
hyperaldosteronism 145 definition 58
RALES 285 isolated systolic VA Co-operative
secondary hypertension 52 Study 223, 301
hypertension 148 pathophysiology 58 VALHEFT study 302
spontaneously hypertensive prevalence 58 valsartan 214, 302–3
rats 46[pg1-2] treatment algorithms 102 VALUE study 214–15, 303
INDEX 313
vanillylmandelic acid 114, vasodilators 201 TONE 299

116, 126 venous sampling 145 white coat effect 80
vascular endothelial verapamil 218 white coat hypertension 80
growth factor (VEGF) VHL 128
inhibitors 166 visual field testing 66–7 Zulus 32
vascular hypertension 68
vascular structure and websites 247
function 22 weight loss 200, 206
vasoconstrictors, increased essential hypertension
sensitivity to 24 89, 92
Colour plate 1 Corneal arcus (arcus senilis) (b see p.62)
Colour plate 2 Xanthelasma (b see p.62)

Colour plate 3 Tendon xanthomata (b see p.62)
Colour plate 4 Grade 3 hypertensive retinopathy—silver wiring, AV nipping and

soft exudates (b see also p.63)
Colour plate 5 Grade IV hypertensive retinopathy with papilloedema (b see also,
Fig. 2.6, p.63)
Colour plate 6 Grade IV hypertensive retinopathy with papilloedema, retinal

haemorrhages, soft exudates/cotton wool spots and retinal oedema (b see also,
Fig. 2.6, p.63)
Colour plate 7 Posterior reversible leukoencephalopathy syndrome (PRES)—
disordered cerebral autoregulation leading to vasogenic oedema presenting with
altered mental state, headaches, seizures, and visual loss or other variable
neurological abnormalities with classical radiological abnormalities—especially in the
parieto-occipital regions. Severe uncontrolled hypertension or immunosuppression
leading to endothelial dysfunction is implicated in the pathogenesis (b see p.109)
Colour plate 8 The same patient with PRES—who presented with a right sided
Horner’s syndrome (b see p.109)
Colour plate 9 3D volume rendered CT reconstruction demonstrating aortic cal-
cification of the abdominal aorta (see arrows) (b see Fig. 3.3, p.123)
Colour plate 10 Example of a Conn’s tumour (b see also Fig. 4.7, p.149)
Colour plate 11 MIBG-SPECT combined with CT showing a paraganglionoma with
MIBG uptake (arrow) and a Type B dissection of the aorta (arrowheads) in the same
patient. Reproduced from Strobel K et al. (2007). MIBG-SPECT/CT-angiography with
3-D reconstruction of an extra-adrenal phaeochromocytoma with dissection of an
aortic aneurysm. Eur J Nuc Med Mol Imaging 34: 150, with permission (b see also
Fig 3.7, p.127)
Colour plate 12 Example of a benign phaeochromocytoma (b see also Fig. 4.10,
p.153)
Colour plate 13 Neurofibromatosis—which can be associated with phaeochro-

mocytoma (b see p.152)
S07.05869
Colour plate 14 A microscopic view of a polycystic kidney
(b see also Fig. 4.13, p.161)
Colour plate 15 Fibrinoid necrosis from accelerated hypertension on a kidney biopsy

(b see also p.66)

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Hypertension has been recognized as an important cardiovascular dis-

We wish to acknowledge the kind foreword by Professor Stanley S. Franklin

Detailed contents xiii

1 Aetiology and pathophysiology 1

Symbols and abbreviations xix

1 Aetiology and pathophysiology 1

Blood pressure measurement 64

3 Speciﬁc investigations for secondary hypertension 111

4 Secondary hypertension 135

5 Monogenic syndromes 169

6 Special populations 183

7 Antihypertensive drugs 211

8 Hypertension in the 21st century 239

Symbols and abbreviations

CHD coronary heart disease

PPIH proteinuric pregnancy-induced hypertension

Frequency of hypertension (%) 100

Table 1.1 Age-related haemodynamic patterns underlying hypertension

Central versus peripheral blood

80 100 120 140 160 180

80 100 120 140 160 180

Physiology and pathophysiology of

Role of the autonomic nervous system

TH AAD DBH PNMT

Normotensive Borderline hypertensive

A 120 Boderline hypertension B 5.0

Rest Propranolol Atropine Rest Propranolol Atropine

Spectral analysis of heart rate

0.05 26.4 1846

Role of the kidneys

Na+ and water

Guyton’s theory of hypertension

was accompanied by an i cardiac output related to volume overload,

Renal mechanisms leading to essential hypertension

• In humans, the frequency of hypertension i with dGFR. However,

Interplay between autonomic and renal

Stress High sodium

Renal efferent i tubular

Vascular structure and function in

Hypertrophic remodelling: Eutrophic remodelling:

Functional changes in resistance vessels

Increased peripheral vascular resistance

Genetics of essential hypertension

families (pedigrees) with multiple generations (family-based linkage) and

Environmental inﬂuences on blood

Modern Western diet

High sodium intake Low potassium intake

Excessive renal and

Retention of sodium Deficit of potassium

Excess of cellular Deficit of cellular

Vascular smooth-muscle cell contraction

Increased peripheral vascular resistance

1.2 52 Centres: b=0.0034

50 100 150 200 250

Central infusion of Potassium

Fig. 1.23 Central effects of potassium infusion or potassium feeding on the BP of

Fig. 1.24 Effect of reduction in alcohol intake on blood pressure. Reproduced

Vasoconstriction Sodium and water retention

Obesity – associated hypertension