HYPERTENSION • Peripheral vascular

o Absence of 1 or more pulses in the

• A sustained diastolic blood pressure of >90
mmHg accompanied by an elevated blood
pressure of >140 mmHg resulting from an
increased arteriolar resistance and
decreased capacitance of the vessels.
• WHO: BP >160/95 mmHg
• AHA: BP >140/90 mmHg
CLASSIFICATION OF HYPERTENSION ACCORDING TO
ETIOLOGY
• Primary or essential H P N
o 90-95% of cases.
o Cause: Unknown.
o Predisposing factors:
 Family history, stressful
lifestyle, increased dietary
intake of sodium, obesity.
• Secondary H P N
o 5-10% of cases.
o Causes:
 Renal artery stenosis,
Cushing’s syndrome,
pheochromocytoma.
extremities except in the dorsalis
pedis with or without intermittent
claudication
o Arterial aneurysms
• Renal
o Serum creatinine >/= 130
MALIGNANT HYPERTENSION
• An accelerated phase of severe HPN with a
rapidly progressing damage to end-organs
and rising BP which may be signaled by
deteriorating renal function,
encephalopathy, retinal hemorrhages,
angina, stroke, or MI.
MECHANISMS OF CONTROLLING BLOOD
PRESSURE
• Baroreceptor and sympathetic nervous
system
• Renin-angiotensin-aldosterone system

CLASSIFICATION OF BP FOR ADULTS 18 YRS AND

OLDER (PHIL. SOCIETY OF HPN)

• Optimal
o <120 mmHg / <80 mmHg
Recheck in 2 years.
• Normal
o 120-129 mmHg / 80-84 mmHg
Recheck in 2 years.
• High normal
o 130-139 mmHg / 85-89 mmHg
Recheck in 1 year.
• Stage 1 (mild) HPN
o 140-159 mmHg / 90-99 mmHg
Confirm in 2 months.
• Stage 2 (moderate) HPN
o 160-179 mmHg / 100-109 mmHg
Evaluate within a month.
• Stage 3 (severe) HPN
o 180-209 mmHg / 110-119mmHg TREATMENT STRATEGIES
Evaluate within a
week. Non-pharmacologic therapy
• Stage 4 (very severe) HPN • Low salt diet.
o >/=210 mmHg / >/=120 mmHg • Weight reduction.
Evaluate • Exercise.
immediately. • Cessation of smoking.
MANIFESTATIONS OF TARGET-ORGAN DAMAGE • Decreased alcohol consumption.
• Psychological methods: Relaxation /
• Cardiac
meditation.
o Evidence of CAD
• Dietary decrease in saturated fat.
o Clinical, ECG, radiologic à evidence
Drug therapy
of LVH or cardiac failure
• Stepped Care
• Cerebrovascular
o Progressive addition of drugs to a
o TIA or stroke
regimen, starting with one, usually a
 diuretic, and adding, in a stepwise  Carvedilol - Propranolol
fashion, a sympatholytic, vasodilator,  Esmolol - Timolol
and sometimes an ACE inhibitor.
• Monotherapy VASODILATORS
o Advantageous because of its • Direct vasodilators
simplicity, better patient compliance,  Diazoxide - Hydralazine
and relatively low incidence of
 Minoxidil - Nitroprusside
toxicity.
 Fenoldopam
• Calcium channel blockers
STEPPED CARE  Amlodipine - Nifedipine
 Diltiazem - Nimodipine
 Felodipine - Nisoldipine
 Isradipine - Nitrendipine
 Manidipine - Nicardipine
 Lacidipine - Verapamil
 Lercanidipine - Gallopamil

AGENTS THAT BLOCK THE PRODUCTION OR ACTION

OF ANGIOTENSIN
• ACE inhibitors
 Benazepril - Moexipril
 Captopril - Quinapril
 Enalapril - Perindopril
 Fosinopril - Ramipril
 Lisinopril - Trandolapril
• AT1-receptor blockers
CATEGORIES OF  Irbesartan - Losartan
ANTI-HYPERTENSIVE DRUGS  Telmisartan - Valsartan
 Candesartan - Eprosartan
Drugs that alter sodium and water balance à
 Olmesartan
Diuretics.
• Loop diuretics DRUGS FOR HYPERTENSIVE EMERGENCIES OR
• Thiazides CRISES
• Spironolactone and Triamterene
• Trimethaphan
o 1 mg/ml IV infusion; titrate;
Drugs that alter sympathetic nervous system instantaneous onset
function à Sympatholytic drugs. • Sodium nitroprusside
• Centrally-acting sympatholytics o 5-10 mg/L IV infusion; titrate;
 Clonidine instantaneous onset
 Guanabenz • Diazoxide
 Guanfacine o 300-600 mg Rapid IV push;
 Methyldopa instantaneous onset
• Peripherally-acting sympatholytics • Nifedipine
 Guanadrel o 10-20 mg Sublingual or chewed;
 Guanethidine onset within 5-30 min.
 Reserpine • Labetalol
• a-blockers o 20-80 mg IV at 10-minute
 Doxazosin intervals (max.dose: 300mg);
 Prazosin immediate onset
 Terazosin
• b-blockers MECHANISMS OF DRUG ACTION
 Acebutolol - Labetalol
 Atenolol - Metoprolol
 Betaxolol - Nadolol
 Bisoprolol - Penbutolol
 Carteolol - Pindolol
DRUG ADVERSE EFFECTS

• RESERPINE
o Interacts with MAO inhibitors. Used
with caution in patients with peptic
ulcers (inc. GI act.). Sedation,
nightmares, severe depression. Nasal
stuffiness.
• GUANADREL
o Orthostatic hypotension and
syncope. Edema. GI hyperactivity.
Interacts with TCAs.
• ACE Inhibitors: Captopril
o Dry cough. Hypotension and
syncope. Hyperkalemia. Accumulates
in patients with impaired renal
function. Renal damage in fetus à CI
on the 2nd and 3rd tri of pregnancy.
o CAPTOPRIL: Cough, Angioedema,
Proteinuria, Taste changes,
hypOtension, Pregnancy problems
 (teratogenic), Rash, Increased renin,
Lower angiotensin II.
• SODIUM NITROPRUSSIDE
o Hypotension, nausea, headache,
palpitation (rapid vasodilation).
Cyanide toxicity.
• THIAZIDE DIURETICS
o Potassium and magnesium loss.
Arrhythmias. Increase in cholesterol
concentration. Hyperglycemia.
• b-BLOCKERS
o Precipitates heart failure (abrupt
cessation) in patients with left
ventricular dysfunction. Use with
caution in patients with Bronchial
asthma. Decreased HDL. Psoriasis.
Abrupt withdrawal à cardiac
arrhythmias.
• VERAPAMIL
o Cardiodepression. Hypotension,
peripheral edema. Headache,
constipation.
• CLONIDINE
o Xerostomia, drowsiness, sedation.
Rebound HPN (abrupt cessation).
Fluid retention. Sudden withdrawal à
dysrhythmias.
• HYDRALAZINE
o Headache, nausea, anorexia,
dizziness, and sweating. Worsen
Coronary Artery Disease (myocardial
stimulation). Reversible lupus-like
syndrome esp. in slow acetylators.
• MINOXIDIL
o Pericardial effusion and tamponade
in patients with inadequate renal
function. Hirsutism.
• DIAZOXIDE
o Severe hypotension. Worsens
myocardial ischemia and angina
(reflex sympathetic stimulation).
Hyperglycemia (inhibits insulin
release). Edema (salt and water
retention).
• PRAZOSIN
o Sudden syncope, palpitations, fluid
retention. Vertigo, weakness,
dizziness, drowsiness, headache.
• METHYLDOPA
o Sedation at onset of treatment. Drug
fever: Chills and fever with alteration
in liver function. Edema (salt and
water retention). Rebound HPN
PRINCIPLES OF DRUG THERAPY
(abrupt cessation). Orthostatic
hypotension. Hemolytic anemia.
• Monotherapy is generally reserved for mild
• NIFEDIPINE
to moderate HPN; it has gained popularity
o Hypotension, headache. Peripheral
because of its simplicity, fewer side effects,
edema. and improved patient compliance.
• DILTIAZEM • More severe HPN may require treatment with
o Hypotension. Peripheral edema. several drugs that are selected to minimize
Cardiodepression. adverse effects of combined regimen.
• Treatment is initiated with any of 4 drugs
depending on individual patient: Diuretic, b-
blocker, ACEI, and a Ca-channel blocker; if
BP is inadequately controlled, a 2nd-drug is
then added.
• HPN may co-exist with other disease that
may be aggravated by some of the anti-HPN
agents.
• Lack of patient compliance is the most
common reason for failure of anti-HPN
therapy; it is important to enhance
compliance by carefully selecting a drug
regimen that minimizes adverse effects.
• Therapy is directed at preventing disease
that may occur in the future, rather than in
relieving present discomfort of the patient.