HYPERTENSION

By FELISTAS WANGUI KIMATA

By Felistas Wangui
Kimata
1

HYPERTENSION MANAGEMENT
CURRICULUM FOR HEALTH CARE
PROVIDERS IN KENYA

COURSE OBJECTIVES
At the end of the training, HCP should be able to:
1. Understand hypertension
2. Classify and describe types of hypertension
3. Describe Causes of hypertension
4. Measure and diagnose hypertension
5. Describe Complications of hypertension
6. Manage and treat hypertension
7. Understand Hypertension in special groups
8. Describe Commodity and data management for
hypertension care
By Felistas Wangui
Kimata

MODULE 1: UNDERSTANDING
HYPERTENSION
XXXX

HYPERTENSION INTRODUCTION
By the end of this module, the participants
should be able to:
1.
Define hypertension
2.
Describe epidemiology and impact of
hypertension
3.
Describe the anatomy of the heart and blood
flow in the body
4.
Describe factors that affect peripheral
vascular resistance
5.
Understand the factors that affect cardiac
output
By Felistas Wangui
Kimata

HYPERTENSION

Definition: Persistently elevated, systolic

and/or diastolic blood pressure of 140/90

mmHg or more in subjects aged 18 years
and above.
Systolic blood pressure is the pressure
exerted when the heart contracts.
Diastolic blood pressure is the pressure
exerted when the heart muscle relaxes.

By Felistas Wangui
Kimata

EPIDEMIOLOGY

Overall, approximately 20% of the world's

adults are estimated to have hypertension.
Sub Saharan Africa current estimates 77 m
and will be 150 m by 2030
In SSA Patients are younger, have more
aggressive HTN, present late and with
complications.
Kenya rural prevalence 33% of adults
Urban Kenya >55 years prevalence as high as
58%
By Felistas Wangui
Kimata

IMPACT OF HYPERTENSION
Worldwide, causes 7.5 million deaths, about
12.8% of the total of all deaths.
Hypertension is the main driver of CVD
which kills twice as many women aged 60
and above in LMIC compared to developed
countries.
Accounts for 57 million disability adjusted
life years (DALYS).
For every increase in 20 mmHg systolic or
10 mmHg diastolic blood pressure the
lifetime
risk of heart disease DOUBLES.
By Felistas
Wangui

Kimata

GLOBAL TRENDS OF HTN BY

WHO REGIONS

By Felistas Wangui
Kimata

Circulatory system

Heart
Arteries
Veins

By Felistas Wangui
Kimata

10

The structure of the heart

By Felistas Wangui
Kimata

11

Physiology of blood pressure

By Felistas Wangui
Kimata

12

Physiology of blood pressure

Cardiac output is the amount of blood
the heart pumps through the circulatory
system in one minute.
Peripheral vascular resistance is
determined by the diameter and
stiffness of the arteries.
Blood pressure is determined by the
amount of blood the heart pumps and
the amount of resistance to blood flow in
the arteries.
The more blood the heart pumps and the
Bynarrower
Felistas Wangui
the arteries, the higher the
Kimata
13

Factors affecting blood

pressure: PVR

Vascular resistance is mainly

determined by the structure (anatomic)
and functional changes in small arteries
and arterioles.

There are factors that reduce vascular

diameter (constrictors) and those that
enlarge it (dilators)

Examples of vascular constrictors

include angiotensin II, catecholamine,
By Felistas Wangui
and alpha-adrenergic receptors.
Kimata
14

Factors affecting blood

pressure: Cardiac output

Cardiac

output is affected by the following factors:

Myocardial

contraction the ability of the heart muscle

to contract and relax.

stroke

volume( amount of blood pumped out in one

heart beat) - depends on the following:

Preload

(the amount of blood returning to the heart)

Force

of contraction which is increased by the sympathetic

nervous system.

Various

drug treatment modalities act to alter these

factors and ultimately reduce blood pressure in
hypertension.

By Felistas Wangui
Kimata

15

MODULE 2: CLASSIFICATION AND TYPES OF

HYPERTENSION

XXXX

OBJECTIVES:
1.

To classify hypertension

2.

To identify other major CV risk factors

3.

To identify added risk to hypertension low,

moderate, high and very high

4.

To identify Target Organ Damage (TOD)

By Felistas Wangui
Kimata

17

Classification of hypertension
Primary

Secondary

Over 90% of cases

Less than 10%

No known causes

Hypertension with a
specific cause

Develops gradually
over time

Sudden onset; often

severe and refractory

Note: Some causes of secondary hypertension include:

kidney disease,
thyroid disease,
adrenal
Multiple
associated
May
occurdisease,
in younger
coarctation of the aorta, excessive alcohol intake,
risk
factors
persons
obstructive sleep apnoea and drugs e.g. NSAIDS, steroid
By Felistas Wangui
Kimata

and herbal remedies.

18

Staging of hypertension

BP (mmHg)
Normal

High
Normal

Stage 1:
Stage 2: Stage 3:
Mild
Moderate
Severe
Hypertension Hypertens Hypertens
ion
ion

SBP 120 SBP 130

SBP 140
129
139
159
or
or
or
DBP
80 DBP 85 DBP 90 99
By Felistas Wangui
Kimata
84
89

SBP 160 SBP > 180

179
or
or
DBP >
DBP 100
110
19
109

Staging of hypertension:
CV Risk profile

Majority of people with hypertension have multiple CV

risk factors.
Presence of any of the following significantly increases
cardiovascular risk:
Diabetes mellitus
Chronic kidney disease
Stroke/TIA
Myocardial infarction
Peripheral artery disease
Smoking
Dyslipidemia
By Felistas Wangui
Kimata

20

Risk factors

The 9 risk factors account for more than

90% of ischaemic heart disease.

By Felistas Wangui
Kimata

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Classification of hypertension:
added CV risk

By Felistas Wangui
Kimata

22

Other types of hypertension

Isolated systolic hypertension: elevated systolic BP

with normal diastolic BP, mostly seen in elderly patients.

White coat hypertension : Consistently elevated BP in

the clinic setting, but reverts to normal BP out of the clinic.

Resistant hypertension: defined as BP 140/90 mmHg

despite treatment with at least 3 drugs (including a
diuretic) in adequate doses and after exclusion of false
hypertension .

By Felistas Wangui
Kimata

23

MODULE 3: CAUSES OF HYPERTENSION

XXXX

OBJECTIVES:
By the end of this module participants should be able
to:
1.
2.

3.
4.

To identify the risks for hypertension

To identify factors associated with secondary
hypertension
To define the components of metabolic syndrome
To identify signs and symptoms of hypertension

By Felistas Wangui
Kimata

25

Risks and causes for hypertension

In more than 90% of cases, the cause of

hypertension is unknown
but several factors can increase the risk of
developing the condition.
Where there is no specific cause, high blood
pressure is referred to asprimary or essential
hypertension.
This type of high blood pressure tends to develop
gradually over many years.

By Felistas Wangui
Kimata

26

Hypertension has many risk factors, which include:

1.

2.

3.

AGE-The risk of hypertension increases with age.

Through early middle age, or about age 45,
hypertension is more common in men. Women are more
likely to suffer the condition after age 60.
RACE- Hypertension is particularly common among
blacks, often developing at an earlier age than it does in
Caucasians. Serious complications, such as stroke, heart
attack, and kidney failure, also are more common in the
black population.
FAMILY HISTORY-Hypertension tends to run in families.
By Felistas Wangui
Kimata

27

4 OVERWEIGHT OR OBESITY- The more a person

weighs the more blood is required to supply oxygen and
nutrients to the tissues. As the volume of blood
circulated through the blood vessels increases, so does
the pressure on the arterial walls.
5 PHYSICAL INACTIVITY. People who are inactive tend to
have higher resting heart rates. The higher the heart
rate, the harder the heart must work with each
contraction and the stronger the force on the arteries.
Lack of physical activity also increases the risk of being
overweight.

By Felistas Wangui
Kimata

28

6.

7.

8.

TOBACCO USE-Not only does smoking or chewing

tobacco immediately raise blood pressure temporarily,
but the chemicals in tobacco can damage the lining of
the artery walls. This can cause arteries to narrow,
increasing blood pressure. Secondhand smoke also can
increase blood pressure.
HIGH DIETARY SALT (SODIUM)- Too much sodium in
the diet can cause the body to retain fluid, which
increases blood pressure.
LOW DIETARY POTASSIUM- Potassium helps balance
the amount of sodium in the cells. If a person does not
get enough potassium in the diet or retain enough
potassium, you may accumulate too much sodium in your
blood.

By Felistas Wangui
Kimata

29

Causes of hypertension
In about 5% of cases, a specific cause can be found.
This type of high blood pressure, called secondary
hypertension, tends to appear suddenly and causes
higher blood pressure than does primary
hypertension.
Various conditions and medications can lead to
secondary hypertension, including:

By Felistas Wangui
Kimata

30

Causes of hypertension
1.
2.

3.

4.
5.
6.
7.

8.
9.

Excessive alcohol use.

Renal disease (renal vascular; renal parenchymal;
polycystic kidneys).
Adrenal disease (pheochromocytoma, Cushings and
Conns syndromes, 11-alpha-hydroxylase, 17
hydroxylase deficiency).
Thyroid (Hyper-and hypothyroidism).
Coarctation of the aorta.
Obstructive sleep apnoea
Drugs anabolic steroids; estrogen; NSAIDs;
sympathomimetic drugs.
Herbal remedies, such as herbal supplements
Metabolic syndrome

By Felistas Wangui
Kimata

31

Signs and symptoms of Hypertension

One of the most dangerous aspects of hypertension is that one

may not know that they have it.
In fact, nearly one-third of people who have high blood
pressure are unaware.
The only way to know if the blood pressure is high is through
regular checkups.
If the blood pressure is extremely high, there may be certain
symptoms to look out for, including:
Severe headache
Fatigue or confusion
Vision problems
Chest pain
Difficulty breathing
Irregular heartbeat
Blood in the urine
Palpitations (pounding in the chest, neck, or ears)

A person, who has any of these symptoms, should be advised

to seek medical attention immediately. One could potentially
By Felistas Wangui
be having a hypertensive crisis that could lead to a heart
Kimata
32

MODULE 4:
MEASUREMENT OF BP AND DIAGNOSIS
OF HYPERTENSION
XXXX

OBJECTIVES
By the end of this session, participants should
be able to:
1. Correctly measure and interpret blood
pressure
2. Take a full history and physical examination
relevant to hypertension
3. Order and request relevant investigation
4. Appropriately manage hypertension

By Felistas Wangui
Kimata

34

Blood pressure measurement (Digital)

Table 1: Measurement of Blood

Pressure
Patient should sit quietly for 5 minutes before
measurement
Use correct size cuff and bladder
Measure BP while patient is sitting on a chair
with back support and with the arm supported
at the level of the heart. The patients arm must
be relaxed.
Take 2 measurements at least 2-3 minutes apart
BP in both arms should be measured at the first
visit and the arm with the highest BP should be
used for future measurements
patients, diabetics and other patients
Elderly
By Felistas Wangui
Kimata
35
complaining
of symptoms suggestive of postural

Mercury sphygmomanometer
Manual blood pressure

By Felistas Wangui
Kimata

36

By Felistas Wangui
Kimata

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The Automatic BP Machine

The BP machine:

By Felistas Wangui
Kimata

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BP cuff sizes

The bladder inside the sphygmomanometer cuff

should be the correct size for the patient. A standard
bladder is approximately 12 cm in width and 35 cm
long. Obese patients (arm circumference >32 cm)
will require a larger bladder and thin patients will
require a smaller bladder.
The bladder width should be approximately 40% of
the circumference of the arm (12cm for a normal
arm, or 15cm for an arm with mid upper
circumference >33cm)
The bladder length should be long enough to wrap
80% to 100% around the arm.
By Felistas Wangui
Kimata

39

Quality control in BP
measurement
The BP measuring device must be known to be
accurate. A manual device (sphygmomanometer)
requires regular maintenance and calibration at
least once a year. Digital machines must be
validated.
The patient should not smoke or consume any
caffeine-containing beverage (e.g., coffee, tea, cool
drinks) in the 30 minutes before BP measurement.
Very high and very low BP readings taken from a
digital machine should be confirmed using a
manual machine

By Felistas Wangui
Kimata

40

Possible Errors

(automated

machine)

By Felistas Wangui
Kimata

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Blood pressure measurement (Manual)

Action
Introduction
Consent and Explanation
Wash hands
Allow patient to rest for 3 minutes if seated, 1 minute if standing
Ensure upper arm is supported at heart level with palm facing upward
Ensure that tight or restrictive clothing is removed from the arm.
Check that the cuff is the correct size
Wrap cuff snugly around the arm with the center of the bladder covering
the brachial artery.
Inflate cuff until radial pulse can no longer be felt to provide estimation of
systolic pressure.
Deflate cuff completely and wait 15-30 seconds before continuing.
Inflate cuff to a pressure 30mmHg higher than the estimated systolic
pressure
Place diaphragm of stethoscope over brachial artery (Do not tuck
stethoscope under cuff)
By Felistas
Wangui
Deflate
cuff
at 2-3mmHg per second or per heartbeat
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Note when the first Koroktof sound is heard. This is the systolic pressure.

History relevant to hypertension

Aim of history and physical examination is to look for possible causes,

complications and associated risk factors

Note any presenting complaint

In the History of Presenting Illness explore for the following:

Headache/ confusion
Blurred vision
Epistaxis
Focal weakness
Chest pain/ cough/ palpitation/ dyspnoea/ orthopnoea/ PND
Oedema
Weight gain

Social history of cigarette smoking and alcohol use

Family history of cardiovascular disease

Past medical history (elevated cholesterol, diabetes and current

medication)
By Felistas Wangui
Kimata

43

Physical examination relevant to hypertension

Anthropometric measurements: body weight(kg), height (m), BMI,

waist circumference (cm)

Measuremen When Interpretation

ts
to
measu
re
Blood pressure

Every
visit

Body weight
Height
Body mass
index (BMI) =
Body weight
(kg /ht (m2)

By Felistas Wangui
Kimata

Every
visit

BMI >18.5-25 kg/m2=optimal

BMI >25 kg/m2=overweight
BMI >30 kg/m2=obese
Overweight and obesity are associated
with increased cardiovascular risk.
Patients should receive lifestyle advice
about maintenance of a healthy body
weight.
44

Physical examination
Should include the following examinations
General
Cardiovascular
Thyroid
Respiratory
Abdominal
Neurologic

By Felistas Wangui
Kimata

45

Baseline Investigations

Urine dipstick (look for presence of

glucose, protein and blood)
Urea/ electrolytes/ creatinine
Fasting blood glucose
Random total cholesterol
Electrocardiogram (ECG)
Other investigations as guided by history
and physical examination

By Felistas Wangui
Kimata

46

Module 5: COMPLICATIONS OF
HYPERTENSION

XXXX

OBJECTIVES
By the end of this module the
participants should be able to:
1. Describe the mechanisms of
complications (Atherosclerosis/LVH)
2. To identify acute and chronic
complications of hypertension
3. Institute measures to prevent
complications and their progression
4. Appropriately manage and refer patients
with complications in a timely manner
By Felistas Wangui
Kimata

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Complications of
hypertension: Mechanisms

Hypertension affects the heart and the blood vessels.

Effects on the arteries are due to atherosclerosis, while
effects in the heart are due to ventricular hypertrophy.
High blood pressure requires the heart to work harder
than normal to circulate blood through the blood vessels
which leads to left ventricular hypertrophy (LVH).
LVH a characteristic of hypertensive heart disease, is an
important cause of heart failure in our environment.
Hypertension contributes to 15-25% of heart failure, a
condition associated with repeated hospitalizations and
high in-hospital mortality.

By Felistas Wangui
Kimata

49

Atherosclerosis and
Definition: Atherosclerosis
is the progressive
hypertension
hardening and narrowing of the arteries.

Occurs when fat, cholesterol, and other substances

build up in the walls of arteries to form hard structures
called plaques.

Ruptured or eroded plaques lead to clot formation in

arteries resulting in blockage.

Atherosclerosis is the most frequent underlying cause

of Ischemic heart disease, stroke and peripheral
arterial disease.

By Felistas Wangui
Kimata

50

Risk Factors , Atherosclerotic Disease,

Acute coronary syndrome

Atherosclerosis
Dyslipidaemi
a
Hypertension

Age

Smoking

Diabetes

Family
History

Gender

Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 10A):23S-27S.

By Felistas Wangui
Schiffrin
EL et al. Am J Hypertens. 2002;15:115s-122s.
Kimata

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Acute and chronic complications of hypertension: Ischaemic heart disease

Typical Chest Pain

Angina
Retrosternal
Exertional
Relieved by Rest
Myocardial Infarction (Heart
attack)
Chest pain Prolonged
Severe
Unrelieved by Rest

Action: give 300mg of aspirin to chew and

refer
By Felistas Wangui
Kimata

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Clinical Features of Heart

Failure
Cardiac symptoms
Systemic
Symptoms
Chest discomfort
Leg or Ankle
swelling
Easy fatigability
Abdominal swelling
or bloating
Weakness
Weight gain despite
poor appetite
Palpitations

Respiratory symptoms
Shortness of breath on exertion
Inability
Action: refer patient as
to lie flat in bed
By Felistas
Wangui
Kimata

53

Stroke and TIA

TIA is a stroke that resolves

within 24hrs.
Stroke is loss of neurological
function in part of the body.
The blood supply to parts of
the brain is cut off which
stops oxygen and nutrients
reaching there.
Results in damage or kills
brain cells and stops parts of
the brain working properly.

Action: Refer patient as per protocol

By Felistas Wangui
Kimata

54

Signs and symptoms of a stroke

Dropping eyes, mouth, arms, legs

Blurred vision
Slurred speech
Confusion
Weakness, numbness or paralysis
Loss of consciousness
Dizziness
Sudden severe headache

By Felistas Wangui
Kimata

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Act FAST incase of a stroke

Ref: Wangui
By Felistas
Kimata

56

Kidney failure
Manifest as
Worsening

kidney function: reduced urine

output, or abnormal creatinine/urea and
electrolytes.
Edema
Hematuria
Red blood cell (RBC) cast formation on
urine microscopy.
Proteinuria on urinalysis
Action: Stop ACEi/ARB and Refer as per
57
protocol.

By Felistas Wangui
Kimata

What is PVD?
Definition:
Also known as PAD.
Occlusive disease of the
arteries of the lower
extremity.
Most common cause:
o Atherosclerosis
o Others: arteritis, aneurysm
+ embolism
Has both ACUTE and CHRONIC
presentation

By Felistas Wangui
Kimata

58

Pathophysiology of PVD/PAD:

Arterial narrowing Decreased blood flow =

Pain

Pain results from an imbalance between supply

and demand of blood flow that fails to satisfy
ongoing metabolic requirements.

By Felistas Wangui
Kimata

59

Chronic PAD History:

1. intermittent claudication

Derived from the Latin word to limp

Reproducible pain on exercise which is relieved by
rest
Pain can also be reproduced by elevating the leg
my legs get sore at night and feel better when I
hang them over the edge of the bed

2.Other Symptom/Signs:
A burning or aching pain in the feet
(especially at night)
Cold skin/feet
Increased occurrence of infection
Non-healing Ulcers
Asymptomatic

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Kimata

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3.Critical Stenosis = >60%, impending acute

ischemic limb:
rest pain
ischemic ulceration
gangrene

By Felistas Wangui
Kimata

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Treatment of PAD:
1.RISK FACTOR MODIFICATION:
a) Smoking Cessation
b) Rigorous glycemic control
c) BP reduction
d) Lipid Lowering Therapy

2. EXERCISE:
a) Claudication exercise rehabilitation
program
b) 45-60mins 3x weekly for 12 weeks
c) 6 months later +6.5mins walking time
(before pain)

By Felistas Wangui
Kimata

62

3. MEDICAL MANAGEMENT:
a) Antiplatelet therapy e.g.
Aspirin/Clopidogrel
b) Phosphodiesterase Inhibitor e.g.
Cilostazol
c) Foot Care

By Felistas Wangui
Kimata

63

Preventing complications

Appropriate treatment of hypertension

Early identification and treatment of other risk
factors;
Manage abnormal cholesterol with lifestyle and
drugs where appropriate.
Manage diabetes to target HbA1c
Appropriate use of Aspirin where indicated
Look for target organ dysfunction as per protocol
Lifestyle management as per the protocol
Timely referrals.

By Felistas Wangui
Kimata

64

Module 6: MANAGEMENT OF
HYPERTENSION

XXXX

BP: Management strategy

Objectives:
By the end of this session, participants should be
able to:
Correctly measure and interpret blood pressure
Take a full history and perform a physical
examination relevant to hypertension
Order and interpret relevant investigations
Appropriately manage hypertension as per protocol
Correctly identify hypertensive crises and institute
appropriate management and referral
Institute measures to prevent hypertension
Debunk the myths and misconceptions
By Felistas Wangui
Kimata

66

Lifestyle Modifications to manage Hypertension

Lifestyle Modifications to Manage Hypertension
Weight reduction

Attain and maintain BMI<25kg/m2

Dietary salt
reduction
Adapt DASH-type
dietary plan

<6gNaCl/d

Moderation of
alcohol
consumption

For those who drink alcohol, consume 2

drinks/day in men and 1 drink/day in
women

Physical activity

Regular aerobic activity, e.g., brisk walking

for 30 min/d
Support with tobacco cessation

Cessation
of
By Felistas Wangui
Kimata
tobacco
use

Diet rich in fruits, vegetables, and low fat

dairy products with reduced content of
saturated and total fat and reduced salt

67

Healthy Diet
Make healthy dietary choices:
Include fresh fruit and vegetables, and fish;
Limit sugar intake (especially limit consumption of
soft drinks);
Limit salt intake to less than 1 teaspoonful a day;
Safe alcohol consumption (less than 2 standard
alcoholic drinks a day).
Low fat intake
High fibre intake including whole grain cereals

By Felistas Wangui
Kimata

68

Lifestyle Recommendations

Regular Physical exercise

Thirty(30) mins, dynamic exercise on most
days of the week for at least 3 months (to
achieve physical fitness), then maintain.
Effects of exercise are additive
Exercise and weight reduction prevents
diabetes
Join a group family, workmates, etc to
improve motivation
Create exercise friendly work and living
environments
Incorporate exercise into daily activities
By Felistas Wangui
Kimata

69

Lifestyle Interventions in the

Management of Hypertension

Exercise

Possible SBP
Effect
5-10 mm Hg

Weight reduction

1-2 mm Hg/Kg

Intervention

Alcohol intake reduction1 mm Hg/drink/d

Sodium intake reduction 1-3 mm Hg/40
mmol/d
By Felistas Wangui
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Weight loss and maintenance of a

healthy weight
Encourage weight loss in overweight and obese
patients
Even small amounts of weight loss can be
beneficial to health.

Reduce the number of calories consumed:

(food and drink): reduce portion sizes and replace
cool drinks, alcoholic drinks and fruit juice with
water.

Increase activity, by participating in regular

exercise.

In some patients (especially elderly patients) it may

be more realistic to maintain current weight and to
avoid gaining additional weight.
By Felistas Wangui
71
Kimata
All patients should be advised to maintain a healthy

Dietary salt intake

Should not exceed 1 teaspoon full (6g) per

day.
Avoid adding salt to food on the table
Processed foods often contain high
amounts of salt. E.g. bread, processed
meets such as bacon, sausages, cheese,
margarine, packet soups, tomato sauce,
tomato paste, processed spices and other
food additives.

By Felistas Wangui
Kimata

72

Challenges in changing
Lifestyle
1.
2.
3.
4.
5.
6.

Socio-economic status
Social isolation
Stress
Negative emotions
Complex or confusing advice
Poor urban planning

By Felistas Wangui
Kimata

73

Pharmacological management
Introduction:

Initiation of BP lowering therapy

(pharmacological and non-pharmacological)
is decided on two criteria:
the level of SBP and DBP, and
the level of total CV risk.
Hypertension should be managed together
with other comorbidities and CV risk factors

By Felistas Wangui
Kimata

74

When to initiate
antihypertensive therapy
Confirmed BP values indicating
hypertension
treatment is warranted
Patient

Initial confirmed BP
SBP

All adult patients 140 mmHg

DBP
90 mmHg

Age 80 years and 150 mmHg

90 mmHg
N/B:Hypertension is diagnosis based on; the
older
average of two or more seated blood pressure
readings during each of two or more outpatient
visits.
By Felistas Wangui
Kimata

75

Antihypertensive medication

There are five major classes of antihypertensive agents:

I. A, Angiotensin Converting Enzyme Inhibitors (ACEIs)
and Angiotensin receptor blockers (ARBs);
II. B, -blockers (BBs);
III. C, Calcium Channel Blockers (CCBs);
IV. D, Thiazide or thiazide-like diuretics; and
V. Z, others (sympatholytic, adrenergic blockers,
centrally acting alpha 2- agonists and direct arterial
vasodilators.
This last class contains agents that are rarely used, or are
obsolete, and examples are as follows:
I.
Sympatholytic and alpha adrenergic blockers e.g.
methyldopa and prazocin
II. Direct arterial vasodilators e.g. hydralazine
By Felistas Wangui
Kimata

76

ACEI and ARBs

MOA: Blockers of Renin Angiotensin System (RAS), reduce

production of angiotensin II, and reduce sympathetic nervous
system activity resulting in vasodilation.

Captopril 25-50 BD or

TDS
Enalapril 10-20mg daily
ACE
in 2 divided
inhibitor
doses
Lisinopril 10mg 0D
Perindopril 5mg 0D
Ramipril
2.5 mg 0D

50mg TDS

ARB

8mg 0D

32 mg 0D

150mg 0D
50mg 0D
40mg 0D

300mg 0D
100mg 0D
80mg 0D

Candesart
an
Irbesartan
Losartan
By Felistas Wangui
Kimata
Telmisarta

20mg twice
daily
40mg 0D
10mg 0D
10mg 0D

Cough
(ACEI)
Hyperten
sion
Increased
serum
creatinin
e
Angioede
ma

77

B- Beta blockers

MOA: Blockers of Beta adrenergic receptors, resulting in

reduced heart rate and contractility hence reduced cardiac
output. Carvedilol and Labetalol also reduce total
peripheral resistance
Class Example Usual
Maxim Possible
Compellin
s
monother um
side effects g
apy
dose
indications
starting
dose

Beta
Atenolol
blocker Labetolol
s
Propranol
ol
Carvedilo
l
Nebivolol
Metoprol
By Felistas Wangui
ol
Kimata

25mg
200mg
40mg
6.25
2.5
25mg
2.5mg

100mg
2500mg
160mg
25mg
5mg
100mg
10mg

Bradycardia
Dizziness
Fatigue
Cold
extremities
May provoke
asthmatic
attack
E.D.

IHD
CCF
Aortic
dissection
Hyperthyroi
dism

78

C. Calcium Channel blockers

MOA: Block calcium channels hence reduce intracellular
calcium as a result cause vasodilatation(reduced
resistance)
Class peripheral
Examples
Usual
Maximum
Possible

Longacting
CCB

monotherapy daily dose

starting dose

side
effects

Amlodipine

5mg 0D

10mg 0D

Felodipine

5mg 0D

10mg 0D

Nifedipine

Retard
tabs:20mg BD
LA tabs: 30mg
0D

Retard tabs:
20mg BD
LA tabs:
60mg 0D

Oedema
Fatigue
Headach
e
Palpitati
ons

By Felistas Wangui
Kimata

79

D: Thiazides and thiazide-like

MOA: Act in the distal convoluted tubule of the kidney by
blocking Na/CL pump hence increase sodium excretion and
reduce intravascular volume. Long term , may act as
vasodilators.
Class
Examples
Usual
Maximum
Possible
monothera daily dose
side effects
py starting
dose
Thiazide Chlorthalido 25mg 0D
diuretic ne
Hydrochlorot 12.5mg 0D
hiazide
(HCTZ)

50mg 0D

Thiazide- Indapamide
like
By Felistas Wangui
diuretic

2.5mg

Kimata

1.5mg

25mg 0D

Hypokalae
mia
Hyponatrae
mia
Hyperurica
emia
Hypocalciur
ia
Hyperglyca
80
emia

Z-Others

MOA: Centrally acting alpha 2 agonist; direct

arterial dilator; alpha 1 receptor blocker
Drug

Minimal
dose

Maximum
dose

Side effects

Methyldopa

250mg

1000mg

Depression,
nightmares, anxiety,
poor concentration,
fatigue, tachycardia.

Hydralazine

25mg

150mg

Severe allergic
reactions
Tachycardia
Depression,
Dizziness
Fatigue

By Felistas Wangui
Kimata

81

Protocol

By Felistas Wangui
Kimata

82

By Felistas Wangui
Kimata

83

Hypertensive emergencies
(1)
Definition: Large elevations in SBP or DBP
(>180mmHg or >120mmHg, respectively)
associated with impending or progressive Organ
Dysfunction including:
Hypertensive encephalopathy
Hypertensive left ventricular failure
Hypertension with myocardial infarction
Hypertension with unstable angina
Hypertension with dissection of the aorta
By Felistas Wangui
Kimata

84

Hypertensive emergencies
(2)

Severe hypertension associated with

subarachnoid hemorrhage or
cerebrovascular accident
Crisis associated with
phaechromocytoma
Use of recreational drugs such as
amphetamines, LSD, cocaine or
ecstasy
Hypertension perioperatively
Severe preeclampsia or eclampsia

By Felistas Wangui
Kimata

85

Hypertensive Urgencies

Hypertensive urgencies: are isolated

large BP elevations without acute OD.
This is often associated with treatment
discontinuation or reduction as well as with
anxiety.
It should not be considered an emergency
but treated by reinstitution or intensification
of drug therapy and treatment of anxiety.

By Felistas Wangui
Kimata

86

Management of Hypertensive
Emergencies

Other than in pregnancy, if patient is

conscious and able to swallow give oral
medication and refer immediately
(preferred regimen in protocol)
If patient is unconscious refer
immediately

By Felistas Wangui
Kimata

87

Referral
How to refer; Write a summary that includes the
following information:
1.
Patients details
2.
the patients presenting symptoms,
3.
duration of symptoms,
4.
clinical findings,
5.
results of laboratory tests (if available),
6.
working diagnosis,
7.
list of medications given,
8.
reason for referral,
9.
name, designation, signature and contact, details
(address/telephone) of the person, who is referring
By Felistas Wangui
the patient.
Kimata
88

Indications for immediate referral

in hypertension (1)
Hypertensive patients aged 18 years or
younger
BP 180 mmHg systolic and/or 110 mmHg
diastolic BP
Secondary cause of hypertension is
suspected
All pregnant women
Pre-existing diabetes
New diagnosis of diabetes mellitus
Heart failure
By Felistas Wangui
Abnormal results on urine dipsticks or 89
Kimata

Indications for immediate

referral in hypertension (2)

Patients not reaching goal BP after a

reasonable trial of maximal tolerable doses
of antihypertensive therapy
Associated clinical condition: coronary heart
disease, heart failure, chronic kidney
disease, stroke or transient ischaemic
attack, peripheral arterial disease
Consider referral for patients aged 80 years
or older with a first diagnosis of
hypertension

By Felistas Wangui
Kimata

90

Combinations that should be avoided

An ACEI and ARB should never be used

together in the same patient because the
combination causes severe hyperkalemia.
Different antihypertensive medications from
the same class should not be combined
because they would cause severe side
effects with no additional benefits.

By Felistas Wangui
Kimata

91

Myths and misconceptions

Hypertension can be cured

Only occurs in overweight and obese
Disease for the rich affluent
If no symptoms, no hypertension
Cant get it if its not in your family
Its a result of curse
For elderly

By Felistas Wangui
Kimata

92

Myths and misconceptions (2)

Its for the stressed out

Its only diagnosed during post-mortem
It is a communicable disease
Herbal remedies cure it
Hypertensive medicine is addictive or
develop dependence
Only source of salt is table salt
Overweight is healthy and sign of doing
well
By Felistas Wangui
Kimata

93

Module 7: HYPERTENSION IN
SPECIAL GROUPS

XXXX

Objectives:

To identify special groups with

hypertension
To institute appropriate management
strategies for hypertension in special
groups.

By Felistas Wangui
Kimata

95

Special groups

Special groups include:

Children under 18yrs: 40% of Africas population is
under 15yrs.under age15
Pregnant women :remains a significantly high
population.
People infected with HIV/AIDs: prevalence is still
persistently high in many parts of sub-Saharan Africa.
Elderly persons above the age of 80 years: Growing
population of elderly.
Diabetes, hypertension and chronic kidney disease.
These groups present unique opportunities and
challenges in Africa and Kenya in particular.

By Felistas Wangui
Kimata

96

Hypertension and diabetes

75% of people with diabetes have

hypertension (globally)
Diabetes in a hypertensive patient is a high
added risk and an indication for referral.
Other than treatment, intense lifestyle
modification including weight loss and salt
reduction should be instituted.
Blood pressure goal is <140/85 but can go
lower if desirable.
Treatment should be started when BP is
above target or patient has proteinuria.

By Felistas Wangui
Kimata

97

Hypertension and diabetes (2)

Lowering BP also exerts a protective effect

on appearance and progression of renal
damage. Some additional protection can be
obtained by use of a blocker of the reninangiotensin system
Microalbuminuria should prompt the use of
RAS blockers irrespective of blood pressure.
Treatment strategies should consider an
intervention against all CV risk factors,
including a statin.
Because of a great chance of postural
hypotension, BP should be measured in an
position.
Byerect
Felistas Wangui
Kimata

98

Hypertension in pregnancy

Hypertension complicates 5 to 7% of all

pregnancies
Subset

of preeclampsia, characterized by newonset hypertension, proteinuria and multisystem

involvement, is responsible for:
Substantial maternal and fetal morbidity
Is a marker for future cardiac and metabolic disease.

Preeclampsia

and eclampsia are hypertensive

emergencies and should be referred immediately.

By Felistas Wangui
Kimata

99

Hypertension in pregnancy:
Classification
A.

B.

National high blood pressure education program

working group
Chronic hypertension
Preeclampsia eclampsia
Preeclampsia superimposed on chronic hypertension.
Gestational hypertension.
2008 Society of obstetric and gynecology of Canada
_ Preexisting hypertension
_ Gestational hypertension
add with Eclampsia

By Felistas Wangui
Kimata

100

Who are at risk for

preeclampsia?

Hypertensive disease during a previous

pregnancy
Chronic kidney disease
Autoimmune disease [SLE, APL syndrome]
Type 1 or type 2 diabetes
Chronic hypertension.
Any woman with the above risks; GIVE
ASPIRIN 75mg FROM 12 WEEKS GESTATION
and refer to high risk ANC
By Felistas Wangui
Kimata

101

Moderate risk for

preeclampsia!

First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
BMI of 35 kg/m or more at first visit
Family history of pre-eclampsia
Multiple pregnancy.
Patients with 2 risk factors: Aspirin 75mg/day

By Felistas Wangui
Kimata

102

Effects of chronic
hypertension on pregnancy

Premature birth (two thirds); worse with

preeclampsia
Intrauterine growth retardation ( one third)
Fetal demise: 2-4 times compared to the general
population
Without preeclampsia (5 per 1,000)
With preeclampsia (28 per 1,000)
Placental abruption
Caesarian section
Incidence of these events depend on severity
and duration of hypertension and associated
target organ damage

By Felistas Wangui
Kimata

103

Effects of pregnancy on
hypertension

Increase in blood volume and decrease in oncotic

pressure-may lead to heart failure
Physiologic decrease in blood pressure; from 12
wks, peaks at 16-18wks: masks detection of
chronic hypertension
Progression to preeclampsia and eclampsia
Peripartum cardiomyopathy
Renal failure; especially if baseline creatinine
>124 mmol/L

By Felistas Wangui
Kimata

104

Management of pregnancy
with chronic hypertension

Pre-pregnancy advice
Stop

ACE-Inhibitors, ARBs
Stop thiazides
Keep sodium intake low
Start alternative antihypertensive drugs
based on their side effect profile and
teratogenicity
Limited data on risk for the baby / mother with

other drug classes

By Felistas Wangui
Kimata

105

Drugs in pregnancy

Methyldopa safe in pregnancy and is time tested

Labetalol: safe in pregnancy: may lead to small for
gestational age (SGA) when used in mild
hypertension
No

difference in outcomes when compared to methyldopa

Limited experience with B-Blockers

Calcium channel blockers: safe: limited experience

In emergency: IV labetalol, oral methyldopa, oral
Nifedipine are indicated. IV magnesium sulphate is
indicated in preeclampsia
Avoid diuretics and hydralazine
Refer patients immediately
By Felistas Wangui
Kimata

106

Hypertension and HIV

HIV infection and its treatment are
independently associated with metabolic
syndrome
Prolonged treatment with Antiretroviral
therapy (ART) is associated with a higher
frequency of systolic hypertension.

It is also associated with increased risk of

developing hypertension related
cardiovascular complications.

Numerous drug interactions occur as a

result of ART, with the CCB the worst
affected
of all the antihypertensive agents.
By Felistas
Wangui

Kimata

107

Hypertension and HIV (2)

The first line ART regimen is based on
Nevirapine and Efavirenz which promotes
the metabolism of CCB.
Protease inhibitors decrease the metabolism
of CCBs.

It is therefore feasible to avoid the use of

CCB in patients on ART.
The metabolism of -blockers are inhibited
by Protease inhibitors, the significance of
this interaction is currently of uncertain
significance.
Refer all HIV patients newly diagnosed with
By Felistas Wangui
Kimata
108
hypertension for evaluation.

Hypertension in special cases

Remember, all children under age 18 yrs,

elderly over 80 yrs with newly diagnosed
hypertension, people with diabetes and
hypertension and hypertension in
pregnancy should be immediately and
appropriately referred.

By Felistas Wangui
Kimata

109