1. Hypertension (MOH guidelines 2005) Drugs Oestrogen containing OCP
Steroids
NSAIDs
R/s between BP and risk of cardiovascular disease (CVD) is continuous, consistent & Sympathomimetics
independent of other risk factors. The higher the BP, the greater the risk of MI, heart failure,
stroke and kidney disease. o
Factors indicating likely 2 HPT (and therefore need for extra invxs)
Each increment of 20mmHg in SBP or 10mmHg in DBP doubles the risk of CVD from o Clinical or biochemical features of a specific disorder
115/75 to 185/115 o Young PTs (<30YO)
o Accelerated HPT
Classification (JNC VII guidelines) o Refractory HPT
SBP DBP Management
Lifestyle
Patient Evaluation
Initial drug Rx
modification w/o compelling indication With compelling indication
Aims:
Normal <130 And <80 Encourage 1. Assess lifestyle – exercise, diet, smoking, alcohol intake
High- 130-139 Or 80-89 Yes No Rx needed Drug for compelling 2. Identify cardiovascular risk factors or concomitant disorders (TOD)
normal indication 3. Identify possible causes of hypertension (secondary HPT)
BP 4. Assess presence or absence of target-organ damage and CVD (eg angina, CVA)
Grade 1 140-159 Or 90-99 Yes Thiazide diuretic ± Drug for compelling
Examination
HPT other anti-HPT indication ± other
Measure BP
Grade 2 ≥160 Or ≥100 yes 2 drug combo: anti-HPT as needed
BMI
HPT thiazides + one Assess for risk factors: obesity, hyperlipidaemia (xanthomata, xanthelasma)
other Optic fundi
Isolated ≥140 and <90 Neurological examination
systolic Palpate for thyroid gland
HPT Auscultate for carotid, abdominal (renal artery stenosis) & femoral bruits
Examine CVS – radio-femoral delay (coarctation of the aorta)
Measurement of BP Examine lungs
Seat pt for 5 mins with feet on floor and arm supported at heart level Examine abdomen for PKD, masses & abN aortic pulsation (AAA)
Measure standing BP if postural hypotension is suspected. Lower limbs: edema and pulses (PVD)
Cuff bladder should encircle ≥80% of arm. Other causes of secondary HPT: Cushingoid features
At least 2 measurements should be made.
Ambulatory BP monitoring indicated for white-coat HPT, and pts with drug resistance, Cardiovascular Risk factors
hypotensive symptoms while on anti-HPT med, episodic HPT & autonomic dysfunction. Major risk factors
Components of Metabolic syndrome Age (males>55, females>65)
Causes HPT grades 1-2 Smoking
Primary (essential) Hypertension (95%) Obesity (BMI≥27.5 for Asians, or Physical inactivity
Secondary Hypertension (5%) else 30) Family Hx of premature CVD (men<55, women
Alcohol Total chol >6.2mmol/L (240mg/dL) <65)
Pregnancy Pre-eclampsia Raised LDL chol > 4.1mmol/L
Renal disease Renal vascular disease (160mg/dL)
Parenchymal renal disease (eg glomerulonephritis) Reduced HDL chol <1.0mmol/L
PKD (40mg/dL)
Endocrine disease Phaeochromocytoma Acromegaly DM
Cushing’s syndrome Hyperparathyroidism
o
Conn’s syndrome (1 Primary hypothyroidism Target-Organ Damage (TOD) / Associated clinical conditions
hyperaldosteronism) Thyrotoxicosis Heart LVH (by ECG/echo/CXR)
Congenital adrenal Angina / previous MI
hyperplasia Prior coronary revascularization
Coarctation of aorta Heart failure

2. Brain Ischemic Stroke Treatment
Cerebral hemorrhage Aim: reduce cardiovascular and renal morbidity and mortality
TIA Target: <140/90mmHg;
Hypertensive encephalopathy – HPT, neuro deficits, papilloedema. <130/80mmHg for DM or chronic renal disease
Reversible if HPT is controlled at least high-normal (<140/90mmHg) for elderly, provided no orthostatic hypotension
Renal Proteinuria >0.5g/24h occurs
Microalbuminaemia (albumin:creatinine ratio >30mg/g)
renal impairment (plasma creatinine concentration >132 mmol/L)
Diabetic nephropathy Algorithm for Rx of HPT Lifestyle modification
Retinopathy Grade 1: arteriolar thickening, tortuosity, silver wiring
Grade 2: Grade 1 + arteriovenous nipping
Grade 3: Grade 2 + flame or blot hemorrhages & cotton wool exudates
Target BP not achieved
Grade 4: Grade 3 + papilloedema
Atherosclerosis U/S or radiological evidence of atherosclerotic plaques (carotids, iliac,
femoral & peripheral arteries, aorta) Initial drug choices
Vascular Dissecting aneurysm
Symptomatic arterial disease
Malignant HPT Accelerated microvascular damage with necrosis in the walls of small HPT w/o compelling HPT w compelling
arteries and arterioles. indications indications
Intravascular thrombosis
Dx: HPT + rapidly progressive end-organ damage (retinopathy, renal
failure, HPT encephalopathy) Stage 1 HPT Stage 2 HPT Use drug for
L. ventricular failure may result. Poor Px if untreated. Thiazide diuretic for 2 drug combination compelling reason
most for most (usually Add diuretics, ACEI,
Consider adding thiazide diuretic + ARB, β-blocker and
Investigations ACEI, ARB, β-blocker ACEI, ARB, β-blocker CCB as needed
Routine Investigations or CCB if target not or CCB)
ECG Left ventricular hypertrophy achieved
Coronary artery disease
FBC Haematocrit
+
U/E/Cr S. potassium – hypoK alkalosis may indicate Conn’s syndrome Follow-up & Monitoring
Creatinine for GFR estimation Monthly f/u until BP goal is
Calcium reached. 3 to 6 mthly f/u thereafter.
Urinalysis Blood, protein & glucose S. potassium & creatinine
Fasting lipids monitoring 1-2X per year
Blood glucose
Additional investigation if indicated
CXR Cardiomegaly
Heart failure
Coarctation of aorta 1) Lifestyle modification
Ambulatory BP recording White-coat HPT Diet: moderation of alcohol consumption, low sodium diet, lower intake of chol and
Borderline HPT saturated fats ± Rx of hyperlipidaemia, maintenance of adequate intake of dietary K
2D echo Detect & quantify LVH Weight reduction, increased physical activity
Renal U/S Renal disease Smoking cessation
Renal angiography Renal artery stenosis
Urinary catecholamines Phaeochromocytoma
Urinary cortisol & Assessment of Cushing’s syndrome
dexamethasone suppression
test
Plasma renin activity & Detect primary hyperaldosteronism (Conn’s syndrome)
aldosterone

3. 2) Pharmacological Rx Pharmacological Rx in pregnancy
Drug choice for compelling indications Use methyldopa, β-blockers & vasodilators.
th
Diuretic β-blocker ACE-I ARB CCB Aldosterone Monitor for devt of pre-eclampsia after 20 wk of gestation (new onset/worsening HPT,
antagonist albuminuria, hyperuricaemia, coagulation abNs)
Heart failure X XX XX X X
Post-MI X X X Management of Hypertensive Emergencies
High coronary dz X X X X Do not lower BP too quickly – may compromise tissue perfusion
risk With acute TOD: hospitalize, parenteral drug therapy (labetalol, nitroglycerin, hydralazine,
Diabetes X X *X *X X Na nitroprusside)
Chronic renal dz X X Without acute TOD: immediate combination PO anti-HPT Rx, monitoring for TOD.
Recurrent stroke X X
prevention**
*ACE-I & ARB based Rx slow progression of diabetic & non-diabetic nephropathy
**Add anti-platelet agents (eg aspirin, ticlopidine, clopidogrel)
Drug Absolute CI / use with Side Effects
caution Hypertensive Emergencies
Diuretic Gout Hyperuricaemia
(chlorothiazide, Hx of hypoNa
+
Impotence Definitions:
hydrochlorothiazide) Dyslipidaemia Glucose intolerance Hypertensive crisis – no definite BP level used to define a hypertensive crisis. DBP of
β-blocker Asthma Raise concentration of 120-130 mmHg used as a guide. Includes: –
(atenolol, COPD cholesterol o Hypertensive emergency – elevated BP a/w acute or ongoing end-organ
propanolol) Heart block Aggravate asthma, HF, PVD dysfunction or damage
Dyslipidaemia o Hypertensive urgency – elevated BP a/w imminent end-organ
Athletes / physically active dysfunction or damage
PTs
Peripheral vascular disease Types of Hypertensive emergencies
ACE-I Pregnancy First dose hypotension 1. Hypertensive encephalopathy – need to d/dx from stroke, as reduction of BP is
(Captopril) Bilat renal art stenosis
+
Cough contraindicated in stroke. BP is significantly ↑ in HPT encephalopathy, but only mildly ↑
HyperK Rash in stroke
Proteinuria 2. Acute pulmonary oedema (Hypertensive left ventricular failure) – due to
Hyper K+ decompensation secondary to excessive afterload
Renal dysfunction 3. Acute aortic dissection – new AR murmur may be heard
Unpleasant metallic taste 4. AMI / acute coronary syndrome – due to increased myocardial O2 demand
*monitor U/E/Cr before and 5. Haemorrhagic/ischaemic stroke or SAH
after starting Rx 6. Acute renal failure
ARB Pregnancy *does not cause cough c.f 7. Eclampsia / preeclampsia
(losartan) Bilat renal art stenosis ACEI 8. Phaechromocytoma crises
+
HyperK 9. Recreational drugs (eg ectasy)
CCB Heart block Flushing
(nifidepine, CCF Palpitation Types of Hypertensive urgencies
amlodipine, Fluid retention 1. Elevated BP with retinal changes
diltiazem) Bradycardia (for diltiazem & 2. CRF
verapamil) 3. Preeclampsia
+
Aldosterone May cause hyperK : avoid in
+
antagonist Pts with K >5.0 mEq/L while
(Spironolactone) not on med

4. Management o Use with phentolamine for catecholamine crises
A) Initial Mx Dose: IV 1mg boluses & titrate
Stabilize ABC Esmolol Indications: aortic dissection
Low flow supplemental O2 Dose: IV 250-500μg/kg/min for 1 min, then 50-100μg/kg/min for 4mins.
Monitor Repeat as required.
ECG Phentolamine Indications: Use with phentolamine for catecholamine crises
Pulse oximetry Dose: IV 5-15mg
Vital signs q5-10 mins Hydralazine Indications: Rx of choice for predelivery eclampsia
Check BP Manual BP taking Dose: IV 5-10mg boluses q15min & titrate
Use correct cuff size Disposition – admit ICU
Check other arm
Recheck later
D/dx btwn HPT Clinical exam B2) Mx of HPT Urgencies (ie end-organ dysfunction imminent)
emergency & urgency – Fundoscopy – haemorrhage, exudates, papilloedema o Target – Lower BP over 24-48 hrs to DBP of 100mmHg
look for signs of end- Neuro exam – AMS, focal neuro deficits Felodipine Dose:
organ damage CVS exam – LVFailure, AR murmur (aortic dissectn) o >65YO: 2.5mg PO
Bedside tests o <65YO: 5.0mg PO, then 5.0mg bd
ECG Captopril Dose: 25.0mg stat, then bd or tds
Urine dipstick – haematuria & proteinuria for renal dz Disposition Responsive to Rx & BP acceptable after 4 hrs of monitoring –
UPT – eclampsia, preeclampsia discharge with F/U w/in 48 hrs
Lab invx FBC Newly dxed HPT with uncertain cause – admit to Gen Med for
U/E/Cr evaluation of secondary causes of HPT
Cardiac enzymes & Troponin T
CXR – LV failure, widened mediastinum Summary of Drugs used in Hypertensive Crises
CT head – if AMS or stroke suspected (IMPT: rule out stroke before
Drug Dose Special indications Others
lowering BP!)
HPT Emergencies
CT thorax – if aortic dissection suspected
Na Nitroprusside IV 0.25μ/kg/min All except eclampsia SE: Thiocynate
/ cyanide
toxicity
B1) Mx of HPT Emergencies (ie end-organ dysfunction present)
Labetalol IV 25-50 mg bolus IHD CI: asthma,
Target
Followed by 25-50 mg q5-10 Aortic dissection COLD, CCF,
o Lower MAP to by 20-25% or DBP to no less than 100 mmHg within a few hrs
o Then aim for 160/100 mmHg over the next 2-6 hrs
mins ↓HR, heartblk
Nitroglycerine IV 5-100μg/min Unstable angina
Na Indication: all HPT emergencies except predelivery eclampsia
nitroprusside Dose: IV 0.25μ/kg/min, titrate to response. (Max 10μg/kg/min for only Propanolol IV 1mg boluses Thoracic aortic dissect (Prop. + nitroprus)
10mins) Catecholamine crises (Prop. + phentol.)
SE: cyanide & thiocynate toxicity after prolonged used – lactic acidosis, Esmolol IV 250-500μg/kg/min for 1 min, Aortic dissection
AMS, clinical deterioration. Therefore monitor closely if used then 50-100μg/kg/min for 4mins
Labetalol Indications: failure of nitroprusside. Good for IHD (↓HR & O2 demand) Phentolamine IV 5-15mg Catecholamine crises (Prop. + Phentol.)
& aortic dissection (↓ systolic ejection force & shear stress) Hydralazine IV 5-10mg boluses q15min Eclampsia
CI: asthma, COLD, CCF, bradycardia, heart block HPT Urgencies
Dose: Felodipine >65YO: 2.5mg PO
o IV 25-50 mg bolus, <65YO: 5.0mg PO, then 5.0mg
o followed by 25-50 mg q5-10 mins (max 300mg) OR infusion rate bd
0.5-2.0 mg/min Captopril 25.0mg stat, then bd or tds
Nitroglycerine Indications: HPT complicating unstable angina
Dose: IV 5-100μg/min, titrate to response
SE: headache, vomiting Digitally signed by DR WANA HLA SHWE
DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI
Propanolol Indications: University, School of Medicine, KT-Campus,
Terengganu, ou=Internal Medicine Group,
o Use with nitroprusside for thoracic aortic dissection email=wunna.hlashwe@gmail.com
Reason: This document is for UCSI year 4
students.
Date: 2009.02.24 10:08:40 +08'00'