Hypertension is elevation of Blood Pressure(BP) measured on at least three separate occasions. There is strong association between hypertension and CAD. Hypertension is a major independent risk factor for the development of CAD, stroke, and renal failure 20, 21, 22
Diagnostic Criteria
If blood pressure measurements performed on three separate occasions when either
- The initial Systolic Blood Pressure (SBP) is ≥ 140mmHg or
- The Diastolic Blood Pressure (DBP) is ≥ 90mmHg
Measured on three separate occasions, a minimum of 2 days apart and/or taken over period of two months
Minimum of 3 blood pressure readings must be taken at the first visit to confirm hypertension
- If SBP is ≥ 160mmHg or DBP ≥100mmHg Stage II of JNC –VII – especially when SBP >180 mmHg and/or DBP >110 mmHg immediate drug treatment is needed – See a section on hypertensive crisis – Urgency/Emergencies section
Consider secondary hypertension with identifiable cause in young patients < 40 years or elderly patient > 60 years presenting for first time with hypertension.
Key points
- Hypertension control has shown to have significant benefit for patients. Existence of risk factors should be detected and treated. Assess cardiovascular risk. Lifestyle modification and patient education are essential in all patients. Antihypertensive treatment is required for life in truly hypertensive patients.
- Hypertension often has no symptoms: the aim of treatment is to lower the risk of end organ damage, especially stroke
- Compliance is the most important determinant of blood pressure control.
- Explanation, education and minimizing side-effects of drugs are important
- Extra care should be taken with antihypertensive drugs administered to those over 60 years of age, because of increased side-effects. Lower doses are needed
- Recommend an alternative contraceptive method for women using oestrogen containing oral contraceptive.
- Evidence of end organ damage, i.e. cardiomegaly, proteinuria or uraemia, retinopathy or evidence of stroke, dictates immediate treatment.
- Patients should be reviewed every 1–3 months, till blood pressure controlled then every 6 months and more often if necessary. The aim of treatment is to bring the systolic BP below 140mmHg and diastolic BP below 90 mm Hg, without unacceptable side effects.
Treatment goal of Hypertension
- Achieve and maintain the target BP: In most cases the target BP should be: systolic below 140 mmHg and diastolic below 90 mmHg.
- Achieve target BP in special cases as: in diabetic patients and patients with cardiac or renal impairment, target BP should be below 130/80mmHg;
Prevent and treat associated cardiovascular risks such as dyslipidemia.
Non–Pharmacological Treatment
Lifestyle modification:
- Weight reduction: Maintain ideal body weight BMI 18.5–24.9kg/m²
- Adopt DASH* eating plan: Consume a diet rich in fibre-fruits, vegetable, unrefined carbohydrate and low fat dairy products with reduced content of saturated and total fat
- Dietary Sodium: Reduce dietary sodium intake no more than 1000 mmmol/L (2.4gm sodium or 6gm sodium chloride per day)
- Physical Activity: Engage in regular activity such as a brisk walking at least 30 min/day most days a week
- Stop using all tobacco products
- Moderation of alcohol consumption: Limit consumption to no more than 2 drinks per day in men and no more than one drink per day in women and light person
*DASH–Dietary Approaches to Stop Hypertension
Assess or stratify according to risk factors and target organ damage see table 20.1 below
Table 20.3: Major risk factors, target organ damage and associated clinical condition
| Major risk factors | Target organ damage | Associated clinical condition |
| Level of SBP & DBP | 1. Left Ventricular based on the ECG | 1. Coronary artery disease |
| Smoking | 2. Heart failure | |
| Dyslipidemia
Total Cholesterol < 5mmol/l or LDL >3.0mmol/l or HDL < 1mmol/l men, <1.2mmol/l women |
2. Micro-albuminuria:
Albumin/Creatinine 30mg/mmol Slightly elevated Creatinine: Men 115– 133μmol/l; Women 107124μmol/l |
3. Chronic kidney disease
Albumin creatinine ratio >30mg/mmol |
| 1. Diabetes mellitus | 4.Stroke or Transient ischaemic attack | |
| 5. Family history of premature
Ischaemic Heart Disease/Coronary Artery Disease Men <55 years, Women <60years |
5. Peripheral vascular disease | |
| 6. Waist circumference –
Abdominal obesity: Men ≥ 102cm; Women ≥ 88cm |
6. Advanced retinopathy haemorrhage, or Exudates papilloedema |
Figure 20.1: Non-Pharmacological Management flow diagram of hypertension
Pharmacological Therapy
First-line treatment without compelling indications: Low dose Thiazide diuretics e.g.
A: Hydrochlothiazide 12.5mg/d
OR
A: Bendroflumethiazide 5mg/d
Second-line treatment with compelling indications:
Combination therapy may be considered if SBP>20mmHg or DBP> 10mmHg above target. Refer table 20.2 and figure 20.2 below show appropriate choice of combination therapy.
Table 20.4: Compelling indications and anti-hypertensive drug combination
| Compelling indications | Drug class |
| Angina
Prior or Post–myocardial infarct |
• ß–blocker or Long acting calcium channel blocker
• ß–blocker and ACEI or ARB if patient sensitive to ACEIs • If ß–blocker contraindicated: Long acting calcium channel blocker eg verapamil |
| Heart failure
For volume overload: Congestion |
• ACE inhibitor and ß–blocker eg carvedilol
• Diuretics–Loop diuretics eg furosemide and/or spironolactone *(exclude Renal Failure before adding spironolactone) |
| Left ventricular hypertrophy (confirmed by ECG) | ACE inhibitor or ARB if patient sensitive to ACEIs |
| Stroke: secondary prevention | Hydrochlorothiazide or Indapimide and ACE inhibitor |
| Diabetic mellitus | ACE inhibitor or ARB, usually in combination with diuretic |
| Chronic kidney disease | ACE inhibitor, usually in combination with diuretic |
| Isolated systolic hypertension | Hydrochlorothiazide or Long acting calcium channel blocker |
| Pregnancy | Methyldopa or Hydralazine (Avoid ACEI/ARB tetratogenic) |
| Prostatism | alpha–blockers |
| Elderly | Calcium channel blocker CCB |
Figure 20.2: Approach of Pharmacological Treatment of hypertension
Recommended initial medication doses for hypertension treatment.
Thiazide diuretics
A: Hydrochlothiazide 12.5mg/daily
OR
A: Bendroflumethiazide 5mg/daily
OR
C: Indapamide 5mg/daily preferred for patient with previous stroke/TIA
Loop diuretics
B: Furosemide initial dose 40mg twice a day
OR
S: Torsemide 5mg/daily
Dose can be up scaled depending on congestive status to maximum dose
Mineralocorticoid (Aldosterone) Receptor antagonist
C: Spironolactone 25mg/daily
OR
S: Eplerenone 25mg/daily
Angiotensin-Converting Enzyme Inhibitor (ACEI)
B: Captopril 6.125mg, 12.5mg or 25mg three times daily
OR
C: Enalapril 10mg twice a day
OR
S: Perindopril 8mg/daily orally
Angiotensin Receptor Blocker–ARB (*Don’t combine with ACEI contraindications, indicated in patient sensitive to ACEIs)
C: Losartan 50mg/daily*
Beta–blocker
B: Atenolol 50mg/daily
OR
C: Metoprolol 50mg/daily
Calcium Channel Blocker
- Dihydropyridines:
C: Nifedipine (Slow Release/Long Acting) 20mg/30mg/ 60mg/90mg/daily
OR
C: Amlodipine 5mg or 10mg/daily
- Non–dihydropyridine
D: Verapamil 30mg twice–three times a daily
OR
D: Diltiazem 30mg twice–three times a day
Referral indicated when:
- Resistant (Refractory) hypertension suspected,
- Secondary hypertension is suspected
- Complicated hypertensive urgency/emergencies, Hypertension with Heart failure.
- When patients are young (<30 years).
- Blood pressure is severe or refractory to treatment.