MANAGEMENT OF

HYPERTENSION
BY: DR SITI SYUKRIAH BINTI SHAHARUDIN

KK SELANDAR

9/9/2022
DEFINITION

• Hypertension is defined as persistent elevation of systolic blood pressure (BP) of 140

mmHg or greater and/or diastolic BP of 90 mmHg or greater, taken at least twice on two
separate occasions.
EPIDEMIOLOGY

Non-Communicable Diseases is already the main cause of death in Malaysia and the biggest
contributor in terms of disability life-years (DALYs), with high blood pressure the biggest
contributor for both males and females.
EPIDEMIOLOGY CONT’

• Based on National Heath and Morbidity Survey for NCD risk factors in 2015
• Prevalence 35.3% among adults 18 years and above
• An increase from 33.6% in 2011 as compared to 34.6% in 2006.
• In terms of awareness, only 37.5% were aware in 2015, a drop from 40.7% in 2011. In 2006, the awareness
rate was 35.6%.
• There is a general increasing trend in prevalence with age, from 6.7% in the 18-19 years age group,
reaching a peak of 75.4% among the 70-74 years age group
• Prevalence highest among other bumiputra (37.3%) > Malay (36.4%) > Indian (34.9%) > Chinese
(34.2%)
• HPT more prevalent at rural area 39.2% versus 34.1% (2015)
• More prevalent among males (35.9%) than females (34.8%) for year 2015
CLASSIFICATION
CLASSIFICATION
CLASSIFICATION

• Isolated systolic hypertension

• Defined as SBP of ≥140 mmHg and DBP < 90mmHg, common in age > 50 years.
• Has poor prognosis however control of ISH reduces total mortality, CVS mortality, stroke and
heart failure event .

• “White coat” hypertension

• Defined as elevation in clinic BP but normal home/ambulatory blood pressure measurement.

• Masked hypertension
• Defined as normal clinic BP but elevated daytime ambulatory/home BP level (>135/85mmHg)
DIAGNOSIS
– TO OBTAINED COMPLETE HISTORY
DIAGNOSIS
- PHYSICAL EXAMINATION
DIAGNOSIS
- INVESTIGATION

• Initial investigations aim to screen for presence of secondary causes of hypertension,

determine the presence of CV risk factors, target organ damage (TOD) and target organ
complication (TOC).
RISK STRATIFICATION
Recommendations for follow-up visit based on initial blood
pressure measurements for adults.
MANAGEMENT
NON-PHARMACOLOGICAL
Non- Recommendations
pharmacological
management
BMI or weight
• Achieve a weight loss of as little as 1kg from baseline to reduce BP by 1mmHg SBP.
Salt intake
• Reduce salt intake to <2g of sodium or <5g of salt a day (equivalent to 1 teaspoon of salt).
Alcohol
• Refrain from alcohol intake, advice to patient who insist to continue drinking to consume ≤ two
drinks per day.
Exercise
• Advice patient to perform physical activity (e.g moderate intensity aerobic exercise of at least
150 minutes per week.
Diet
• Encourage diet rich in fruits, vegetables and dairy product with reduced saturated and total fat.
Smoking
• Stop smoking reduces all cardiovascular risk
Relaxation
• Encourage patient to manage stress although evidence has not been convincing.
PHARMACOLOGICAL MANAGEMENT
All patients must be risk stratified to guide management. Decision to initiate treatment
depends in the global cardiovascular risk.
CHOOSING ANTI-HPT DRUG
• Choice of first line monotherapy include ACEIs, ARBs, CCBs and diuretics in newly
diagnosed uncomplicated HPT.
• Beta-blockers not use as first line monotherapy in this group of patient – not effective in
lowering BP and stroke prevention as compared to other drugs.
• Recent studies showed B-blockers can be given as first line agent – even in
uncomplicated newly diagnosed HPT.
• Almost all guidelines recommend that B-blockers should be consider in younger patient,
in particular:
• Intolerance or contraindication to ACEIs and ARBs or
• Women of child bearing potential or
• Patients with evidence of increased sympathetic drive.
STAGE 1 HYPERTENSION
• Stage 1 hypertension with low CV risk – advice healthy living 3-6 months
• Patient should be seen twice (ideally monthly) during this period to assess the efficacy of
the non-pharmacological intervention.
• Stage 1 hypertension with medium to high risk should be offered drug treatment upon
diagnosis.
• Start treatment – monotherapy and at low dose, which can lower BP to <140/90mmHg in
approx. 20-50% of patients.
• If BP not controlled up to 6 weeks of monotherapy treatment options are:
• Dose of initial drug can be increased **dose related adverse effect
• Substitute with another class of drug
• Second drug can be added
CONT’

• If the patient does not show response or does not tolerate the initial drug, substituting
with a drug from another class is recommended.
• In patients presenting with stage II hypertension or beyond, combination therapy as first
line is recommended.
• Combination therapy can be considered as first line in high risk stage 1 hypertension
especially for secondary prevention.
• Single pill combination – improve adherence, however costly and not readily available at
KK.
TARGET BLOOD PRESSURE

Group Target blood pressure

< 80 years old SBP <140mmHg and DBP <90mmHg
> 80 years old SBP <150/90 mmHg
High/very high risk < 130/80 mmHg
FOLLOW UP VISIT

• For high and very high risk patient – advisable to bring BP to target within 3-6 months.
• Once target BP achieved follow-up interval 3-6 months
• At least 6 monthly follow-up even BP well controlled
• Assess persistence of BP control
• Adverse reaction to treatment
• Global vascular risk – new onset and pre-existing
• Complication of HPT
STEP DOWN THERAPY

• Step down therapy is discouraged in majority of patients. However if patient insist, must
fulfill criteria:
• Patient’s BP must not be higher than stage 1 HPT (mild) with low global CV risk
• BP well-controlled for at least 1 year on the same medication at the same dosage.
• Must agree to be followed-up at least 3-6 monthly.
• Must be motivated to adopt healthy living
MANAGEMENT OF SEVERE HYPERTENSION

• Severe hypertension defined as persistent elevated SBP > 180mmHg and/or DBP
>110mmHg
• May present
• Incidental finding in asymptomatic undiagnosed patient
• Treated HPT patient who are asymptomatic
• Patient with symptoms
• Non-specific symptoms i.e headache, dizziness, lethargy
• Signs and symptoms of TOD i.e acute heart failure, ACS, acute renal failure. Etc…

• Most common reason is long standing poorly controlled HPT

HYPERTENSIVE URGENCY

• Defined as severe increase in BP which is not associated with acute end organ damage/complication.

• No overt symptoms and signs of acute TOD/C

• BP measurement should be repeated after 30 minutes of bed rest.

• Initial treatment should aim 25% reduction of BP over 24 hours, but not lower than 160/100mmHg.

• Oral drug is proven to be effective. No role IV drug

• Management
• Rest in quite room for at least 2 hours
• Initiate oral anti-HPT if BP remains > 180/110mmHg
• Hypertensive urgency discharge plan
HYPERTENSIVE EMERGENCY

• Defined as severe elevation of BP associated with new or progressive end organ

damage/complication i.e. heart failure, dissecting aneurysm, ACS, hypertensive
encephalopathy, acute renal failure, subarachnoid haemorrhage and/or intracranial
haemorrhage.
• May occur in patient with BP <180/110mmHg, particularly if BP risen quickly.
• Management
• Admitted for intervention and monitoring.
• Reduce BP by 10-25% within minutes to hours but not lower than 160/90mmHg.
• Best achieved with parenteral drugs.
DANGER OF RAPID REDUCTION IN BP

• Rapid reduction of BP (minutes to hours) in HPT urgency may

precipitate ischaemic events.
• Oral or sublingual drugs with rapid onset of action can result in
uncontrolled BP reduction.
• Oral Nifedipine – recommended as first line therapy for HPT
urgency
HYPERTENSION IN SPECIAL GROUP
HYPERTENSION AND DIABETES MELLITUS

• Pharmacological treatment should be initiated in patients with diabetes when the BP is

persistently ≥140 mmHg systolic and/or ≥90 mmHg diastolic.
• The presence of microalbuminuria or overt proteinuria should be treated even if the BP is
<140/90mmHg. ACEIs and ARBs preferred.
• ACEIs preferred due to reno-protective effects and cardiovascular benefits.
• Prevent the onset of nephropathy in normoalbuminuric diabetic patients with or without
hypertension

• Management include healthy living changes as well as drug treatment

HYPERTENSION AND RENAL DISEASES

• Hypertension may be a cause or consequence of chronic kidney disease (CKD).

• Control of BP and proteinuria are the most important factors in terms of retarding CKD
progression
HYPERTENSION AND HEART DISEASE
HEART FAILURE
• HPT is most frequent cause of heart failure
• Aggravates heart failure by increasing left ventricular afterload, promoting left ventricular
remodeling and progression of myocardial damage. Treatment is important to improve long-term
prognosis
HPT & AF
• Hypertension is important risk factor for new onset of atrial fibrillation whereby it increases the
risk of cardiogenic cerebral embolism.
• The incidence of cardiovascular events and mortality increases by 2.5-fold with AF.
• In particular, left ventricular hypertrophy and left atrial enlargement are independent risk factors
for new onset of atrial fibrillation.
• When antihypertensive treatment leads to the regression of left ventricular hypertrophy, the incidence
of atrial fibrillation decreases

• Hypertension further increases the risks of stroke and arterial embolism in patients with chronic
atrial fibrillation
• Although anticoagulants are used to reduce the risk of stroke in patients with AF, it also increases
the incidence of hemorrhagic complications, especially intracranial hemorrhage. Strict blood
pressure control is necessary in patients taking antithrombotic drugs
HPT & PERIPHERAL ARTERIAL DISEASE

• Hypertension and peripheral arterial disease (PAD) can co-exist. The risk factors for PAD
include hypertension, diabetes, current smoking and dyslipidaemia.
• Patients with PAD have almost three times the risk of a cardiovascular event and death.
• The aim of treatment is both symptom relief and prevention of cardiovascular events.
• No consensus on the treatment of choice for hypertensive patients with PAD although sub
analysis of major trials showed benefits of ACEI in patients with PAD.
• ß-blockers may cause vasoconstriction and worsen frequency of intermittent
claudication
• Patients should stop smoking. Other therapies including LDL-cholesterol lowering and
better control of diabetes are also recommended.
HPT AND LVH
• LVH is caused by pressure load and often regresses through long-term antihypertensive
treatment.
• Risk of premature cardiovascular events or death.
• The most important factor in the regression of cardiac hypertrophy is good BP control
using anti-HPT agents and also by weight reduction and salt restriction.
• Echocardiography is more sensitive than ECG for detection of LVH.
HYPERTENSION IN THE OLDER ADULT

• Definition of hypertension in the older adult (>65 years old) is the same as that of the
general adult population.
• In older adults, the risk of cardiovascular events and death is twice as that observed in
younger individuals at same levels of BP.
• SBP increases linearly with age, leading to an increase in prevalence of isolated systolic
hypertension in the older adult.
TYPES OF ANTIHYPERTENSIVE AGENTS
ANGIOTENSIN CONVERTING ENZYMES INHIBITOR -
ACEI
• ACEIs are effective antihypertensive agents, which can lower CV risk, reducing mortality
and morbidity in hypertensives and those at high CV risk.
• Works by preventing body form producing angiotensin II hormone which causes
narrowing of blood vessels. This then causes increase in BP and forces the heart to work
harder.
• Adverse effects include cough and, rarely, angioedema. In patients with renovascular
disease or renal impairment, deterioration in renal function may occur.
• Serum creatinine and potassium should be checked before initiation and within 2 weeks
after starting.
• If there is hyperkalemia (>5.6 mmol/L) or a persistent rise of serum creatinine of more than
30% from baseline within two months, the dose of the ACEI should be reduced or
discontinued.
ANGIOTENSIN RECEPTOR BLOCKER - ARB
• Works by blocking angiotensin receptor
• Recommended for those ACEI intolerant patient.
• Combination of ACEIs and ARBs is not recommended and should be avoided.
BETA-BLOCKERS
• Useful in hypertensive patients with effort angina, tachyarrhythmias or previous MI
where they have been shown to reduce cardiovascular morbidity and mortality.
• Absolutely contraindicated in patients with uncontrolled asthma and relatively
contraindicated in other forms of obstructive airways disease (including controlled
bronchial asthma).
• Also absolutely contraindicated in patients with severe peripheral vascular disease
and heart block (2nd and 3rd degree).
• Adverse effects reported include dyslipidemia, masking of hypoglycemia, and
increased incidence of new onset diabetes mellitus, erectile dysfunction, cold
extremities and nightmares (especially for lipophilic ß-blockers), increased
triglyceride levels and reduced HDL levels (especially for non-selective ß-blockers).
 CALCIUM CHANNEL BLOCKERS

• Main mechanism of action

is vasodilation, which
decreases peripheral
resistance.
• CCBs especially
dihydropyridine (DHP)
type have been
recommended as first-line
anti-hypertensive agents
DIURETICS
• Diuretics work via inducing natriuresis which alter long term sodium
balance, leading to reduced peripheral vascular resistance and sustained
blood pressure reduction.
• Diuretics provide synergistic effect to almost all anti-hypertensive agents,
particularly renin-angiotensin system (RAS) blockers.
• There were also outcome data that supported the potential cardiovascular
benefits of thiazide diuretics, particularly in those with preserved renal
function.
DIURETICS
• Thiazide diuretics are classified into thiazide (e.g. HCTZ) and thiazide like
diuretics, e.g. chlorthalidone (CTD) and indapamide. Locally, HCTZ is the
most commonly used thiazide diuretic
• HCTZ is effective in the range of 12.5mg – 50mg daily dose. However a
dose above 25mg per day is more likely to cause electrolyte and metabolic
adverse effects.
• A significant increase in the risk of skin and lip squamous cell carcinoma
among thiazide diuretics users (dose-response effect)
MISCELLANEOUS DRUGS - THE ∂-BLOCKERS AND
THE COMBINED ∂, ẞ-BLOCKERS

• ∂-Blockers
• The peripheral ∂1-adrenergic blockers lower BP by reducing peripheral
resistance.
• They also reduce prostatic and urethral smooth muscle tone and
provide symptomatic relief for patients with early benign prostatic
hyperplasia (BPH).
• ∂-blockers have favorable effects on lipid metabolism. However
postural hypotension is a known side effect, especially at initiation of
therapy. Used with care in the elderly
MISCELLANEOUS DRUGS - THE ∂-BLOCKERS AND
THE COMBINED ∂, ẞ-BLOCKERS

• Combined ∂ and ß-blockers

• Offer enhanced neurohormonal blockade. Labetalol has been in use for
over 20 years and is safe in pregnancy.
• The intravenous formulation is useful in hypertensive emergencies,
including pre-eclampsia and eclampsia.
• Carvedilol is effective in hypertension and improve mortality and
morbidity in patients with heart failure.
• It has no adverse effects on insulin resistance and lipid metabolism.
However, its safety in pregnancy has not been established
REFERENCE

• CPG Management of Hypertension 5th Edition (2018)