1

Management of Hypertension in
special groups
Assoc. Prof. Peera Buranakitjaroen
Siriraj Hospital
S.D. Avenue Hotel
29 July 2009
Male 58 yrs abdominal circumference 102 cm.
BP 156/96 mmHg FBS 90 mg/dl, Cr 1.0 mg/dl
chol 280 mg/dl TG 160 mg/dl HDL-C 33 mg/dl
LDL-C 200 mg/dl
U/A: normal
Which level of cardiovascular risk he has?
1. Low risk
2. Medium risk
3. High risk
4. Very high risk
5. Not enough information to determine
Problem 1.1:
2
According to the new IDF definition, for a person to be defined as
having the metabolic syndrome they must have:
Central obesity (defined as waist circumference > 90 cm for Asian men and
80 cm for Asian women, with ethnicity specific values for other groups)
Plus any two of the following four factors:
raised TG level: > 150 mg/dL (1.7 mmol/L), or specific treatment for
this lipid abnormality
reduced HDL cholesterol: < 40 mg/dL (0.9 mmol/L
*
) in males and
< 50 mg/dL (1.1 mmol/L
*
) in females, or specific treatment for this
lipid abnormality
raised blood pressure: systolic BP > 130 or diastolic BP > 85 mmHg,
or treatment of previously diagnosed hypertension
raised fasting plasma glucose (FPG) > 100 mg/dL (5.6 mmol/L), or
previously diagnosed type 2 diabetes
If above 5.6 mmol/L or 100 mg/dL, OGTT is strongly recommedded
but is not necessary to define presence of the syndrome
*
These values have been updated from those originally presented to ensure consistency with ATP III cut-points IDF 2005
New Criteria for Metabolic Syndrome
Stratification of Risk to Quantify Prognosis
Blood pressure (mmHg)
Normal
SBP 120-129
or DBP 80-84
High normal
SBP 130-139
or DBP 85-89
Grade 1
SBP 140-159
or DBP 90-99
Grade 2
SBP 160-179
or DBP 100-109
Grade 3
SBP > 180
or DBP > 110
Other RF
OD or
Disease
No other RF
1-2 RF
> 3 RF MS
OD or DM
Average
Low
Moderate
Very High Established
CV or renal
disease
Average
Low
High
Very High
Low
Moderate
High
Very High
Moderate
Moderate
High
Very High
High
Very High
Very High
Very High
Repeated blood pressure measurements should be used for stratification.
2007 ESH/ESC guidelines
3
Male 58 yrs abdominal circumference 102 cm
BP 156/96 mmHg FBS 90, Cr 1.0 chol 280
TG 160 HDL 33 LDL 200
U/A: normal
Apart from lifestyle modification, antihypertensive
drug of choice is
1. Diuretic
2. -blocker
3. -blocker
4. CCB
5. ACE-I / ARB
Problem 1.2:
The Metabolic Syndrome (1)
The metabolic syndrome is characterized by the variable
combination of visceral obesity and alterations in glucose
metabolism, lipid metabolism and BP. It has a high
prevalence in the middle age and elderly population
Subjects with the metabolic syndrome also have a higher
prevalence of microalbuminuria, left ventricular
hypertrophy and arterial stiffness than those without the
metabolic syndrome. Their cardiovascular risk is high
and the chance of developing diabetes markedly
increased
2007 ESH/ESC guidelines
4
The Metabolic Syndrome (2)
In patients with a metabolic syndrome diagnostic
procedures should include a more in-depth assessment
of subclinical organ damage. Measuring ambulatory and
home BP is also desirable
In all individuals with metabolic syndrome individuals
intense lifestyle measures should be adopted. When
there is hypertension drug treatment should start with a
drug unlikely to facilitate onset to diabetes. Therefore, a
blocker of the renin-angiotensin system should be used
followed, if needed, by the addition of a calcium
antagonist or a low-dose thiazide diuretic. It appears
desirable to bring BP to the normal range
2007 ESH/ESC guidelines
The Metabolic Syndrome (3)
Lack of evidence from specific clinical trials prevents firm
recommendations on use of antihypertensive drugs in all
metabolic syndrome subjects with a high normal BP.
There is some evidence that blocking the renin-
angiotensin system may also delay incident hypertension
Statins and antidiabetic drugs should be given in the
presence of dyslipidemia and diabetes, respectively.
Insulin sensitizers have been shown to markedly reduce
new onset diabetes, but their advantages and
disadvantages in the presence of impaired fasting glucose
or glucose intolerance as a metabolic syndrome
component remain to be demonstrated
2007 ESH/ESC guidelines
5
Antihypertensive Treatment: Preferred Drugs
General rules: lower SBP and DBP to goal. Use any effective agent at adequate doses,
if useful in combination. Use long acting agents to lower BP throughout 24 hours. Avoid
or minimize adverse effects.
Subclinical organ damage
LVH ACE-I, CCB, ARB
Asymptomatic atherosclerosis CCB, ACE-I
Microalbuminuria ACE-I, ARB
Renal dysfunction ACE-I, ARB
Clinical event
Previous stroke Any BP lowering agent
Previous MI -blockers, ACE-I, ARB
Angina pectoris -blockers, CCB
Heart failure diuretics, -blockers, ACE-I, ARB
,antialdosterone agents
Atrial fibrillation
Recurrent ACE-I, ARB
Continuous -blockers, non-dihydropiridine CCB
Renal failure/proteinuria ACE-I, ARB, loop diuretics
Peripheral artery disease CCB
Condition
ISH (elderly) Duretics, CCB
Metabolic syndrome ACE-I, ARB, CCB
Diabetes mellitus ACE-I, ARB
Pregnancy CCB, methyldopa, -blockers
Blacks diuretics, CCB
2007 ESH/ESC guidelines
Possible combinations between some classes
of antihypertensive drugs
Thiazide diuretics
ACE inhibitors
-blockers Angiotensin
receptor
antagonists
Calcium
antagonists
- blockers
The preferred combinations in the general hypertensive population are represented as thick lines.
The frames indicate classes of agents proven to be beneficial in controlled intervention trials
2007 ESH/ESC guidelines
6
Male 70 yrs, BMI 18 kg/m
2
BP 180/90 mmHg
CC: URI
Apart from lifestyle modification, the appropriate
antihypertensive drug should include
1. Diuretic
2. -blocker
3. ACE-inhibitor
4. DHP-CA
5. -blocker
Problem 2:
Factors influencing prognosis (1)
Systolic and diastolic BP levels
Levels of pulse pressure (in the elderly)
Age (M >55 years; W >65 years)
Smoking
Dyslipidaemia
- TC >190 mg/dl or:
- LDL-C >115 mg/dl or:
- HDL-C: M <40 mg/dl, W <46 mg/dl or:
- TG >150 mg/dl
Fasting plasma glucose 102-125 mg/dl
Abnormal glucose tolerance test
Abdominal obesity (Waist circumference >102 cm (M),
>88 cm (W))
Family history of premature CV disease (M at age <55 years;
W at age <65 years)
Risk factors
2007 ESH/ESC guidelines
7
Antihypertensive Treatment: Preferred Drugs
General rules: lower SBP and DBP to goal. Use any effective agent at adequate doses,
if useful in combination. Use long acting agents to lower BP throughout 24 hours. Avoid
or minimize adverse effects.
Subclinical organ damage
LVH ACE-I, CCB, ARB
Asymptomatic atherosclerosis CCB, ACE-I
Microalbuminuria ACE-I, ARB
Renal dysfunction ACE-I, ARB
Clinical event
Previous stroke Any BP lowering agent
Previous MI -blockers, ACE-I, ARB
Angina pectoris -blockers, CCB
Heart failure diuretics, -blockers, ACE-I, ARB
,antialdosterone agents
Atrial fibrillation
Recurrent ACE-I, ARB
Continuous -blockers, non-dihydropiridine CCB
Renal failure/proteinuria ACE-I, ARB, loop diuretics
Peripheral artery disease CCB
Condition
ISH (elderly) Duretics, CCB
Metabolic syndrome ACE-I, ARB, CCB
Diabetes mellitus ACE-I, ARB
Pregnancy CCB, methyldopa, -blockers
Blacks diuretics, CCB
2007 ESH/ESC guidelines
8
Hypertension in the elderly
Hypertension in the elderly
A. The sick elderly
Those who also suffer from
-dementia
- malignant disease
- severe chronic disease
Patient Selection
B. The medically complicated elderly
Those who also suffer from
- chronic bronchitis
- gout
- angina
- heart failure
- peripheral vascular disease
- cerebrovascular disease
C. The fit elderly
9
Pharmacodynamic response in elderly hypertensive patients
1. PRA decreases progressively with age in both normotensive
and hypertensive subjects
2. Plasma noradrenalin rises slightly with age
3. Responsiveness to catecholamine stimulation is impaired
4. adrenoreceptor number and sensitivity may be reduced
5. Baroreflex function is impaired
6. Pretreatment BP particularly SBP is often higher in elderly
hypertensives
A knowledge of the likely pattern response in a particular
type of patient is useful in making a rational choice of firstline
agent
Newman CM and Dollery CT
Pharmacokinetic Consideration
in The Elderly (1)
Changes in drug pharmacokinetics with age could
explain some of the differences between drug
pharmacodynamics in young and elderly patients
1. BW falls with advanding age
2. Body composition alters with age eg total body water
decreases by 10-15% between the ages of 30 and 80 years
Lean body mass declines and adipose tissue mass increases
in relation to total body weight in the elderly
3. Average renal function declines with age GFR may fall by
as much as 50% from young adult hood to extreme old age
and RPF falls predictably by about 1.9% per year after the
age of 30
Newman CM and Dollery CT
10
Pharmacokinetic Consideration
in The Elderly (2)
4. Some aspects of hepatic function decline with age Many
drugs are converted into pharmacologically inactive andor
watersoluble metabolites by the action of hepatic
microsomal enzymes There is some evidence that
microsomal enzyme function declines with age Tobacco
smoking induces the synthesis of some forms of hepatic
cytochrome P450, thereby increases the rate of metabolism
of drugs which are substrates for these forms There is
some evidence that the degree of inducibility declines with
age
5. Hepatic blood flow is considerably reduced in the elderly
Total liver blood flow may be 40%-50% lower in elderly
patients than that observed in young adults
Newman CM and Dollery CT
Elderly
Cardiovascular events can be reduced by antihypertensive
treatment also in older patients with isolated systolic
hypertension
BP lowering should be gradual particularly in frail patients
Measure BP also in the erect posture to evaluate excessive
postural effects
Tailor therapy on concomitant risk factors and disease
(frequent in the elderly)
Use two or more drugs, if necessary
In subjects aged >80 years, evidence of benefit from anti-
hypertensive therapy is still weak
11
Principles of Antihypertensive drug therapy
in the elderly
institute therapy at the lowest recommended
dose and highest dose interval, increasing by small
increments at infrequent intervals until control of
hypertension is achieved
What do guidelines say?
!n subjects aged 80 years or over, evidence for
antihypertensive treatment is as yet inconclusive"
ESHJESC
2007
offer patients over 80 years of age the same treatment
as other patients over 55, taking account of any
comorbidity and their existing burden of drug use, but
patients over 80 years of age are poorly represented in
clinical trials and the effectiveness of treatment in this
group is less certain"
NICE 2007
No mention of over-80s, treated as other patients
JNC7 2003
Statement Guidelines
12
Blood pressure separation
70
80
90
100
110
120
130
140
150
160
170
180
0 1 2 3 4 5
Follow-up (years)
B
l
o
o
d

P
r
e
s
s
u
r
e

(
m
m
H
g
)
Placebo
Indapamide SR +/-
perindopril
Median follow-up 1.8 years
15 mmHg
6 mmHg
Patients at BP target after 2 years
48.0% with Indapamide SR +/- Perindopril
19.9% with placebo (P<0.001)
-1+.5 mm Hg
-29.5 mm Hg
BP reduction
at 2 years
average follow-up
-6.8 mm Hg
-12.9 mm Hg
Indapamide SR/
placebo
15/6 mm Hg
SBP reduction over 25 mm Hg is easily achieved
with !ndapamide SR
Beckett N, et al. NEJN 2008;358:1887-1898.
1 2 0.5 0.2 0.1
95 C! RRR
(0.53, 0.82) -3+
(0.22, 0.58) -6+
(0.+2, 1.19) -29
(0.60, 1.01) -23
(0.62, 1.06) -19
(0.65, 0.95) -21
(0.38, 0.99) -39
(0.+9, 1.01) -30
Cv events
Heart failure
Cardiac death
Cv death
NonCvfUnknown death
All-cause mortality
Stroke death
All strokes
ITT - Summary
Beckett N, et al. NEJN 2008;358:1887-1898.
13
Per protocol
0.17 - 0.+8
0.55 - 0.97
0.33 - 0.93
0.59 - 0.88
0.+6 - 0.95
95% CI
0.03 -27% Cardiovascular mortality
-72%
-45%
-2S%
-34%
RRR
<0.001
0.02
0.001
0.03
P
All strokes
Total mortality
Fatal strokes
Heart failure
Results are linked to !ndapamide SR's protection of
the heart and brain
Beckett N, et al. NEJN 2008;358:1887-1898.
Male 60 yrs, has been smoking cigarette 1 pack/day
for 20 yrs. He can not comply with lifestyle modification
CC: Headache for 2 days.
PE: BP 136/86 mmHg, abd. cir. 86 cm., wt. 60 Kgs.,
Heart-WNL, eyeground-normal
Lab: FBS 120 mg/dl, Cr 1.2 mg/dl, Chol 240 mg/dl,
TG 100 mg/dl, HDL-C 42 mg/dl, LDL-C 180 mg/dl,
EKG-WNL, urine exam-neg
Proper management for this patient is/are
1. continue lifestyle modification intensively
2. start antihypertensive drug
3. start antilipemic drug
4. start ASA
5. all of the above
Problem 3:
14
In hypertensive patients, the primary goal of treatment is to
achieve maximum reduction in the long-term total risk of CVD.
This requires treatment of the raised BP per se as well as of all
associated reversible risk factors.
BP should be reduced to at least below 140/90 mmHg (SBP/DBP),
and to lower values, if tolerated, in all hypertensive patients.
Target BP should be at least <130/80 mmHg in diabetics and in
high or very high risk patients, such as those with ACC (stroke,
MI, renal dysfunction, proteinuria).
Despite use of combination treatment, reducing SBP to <140
mmHg may be difficult and more so if the target is a reduction to
<130 mmHg. Additional difficulties should be expected in elderly
and diabetic patients, and, in general, in patients with CV damage.
In order to more easily achieve goal BP, antihypertensive treatment
should be initiated before significant CV damage develops.
Goals of treatment
2007 ESH/ESC guidelines
TROPHY: Reduction in new-onset
hypertension over time
N = 772
Cumulative
incidence
(%)
Julius S et al. N Engl J Med. 2006;354:1685-97.
RRR 16%
HR = 0.84 (0.750.95)
P = 0.007
RRR 66%
HR = 0.34 (0.250.44)
P < 0.001
Placebo Candesartan 16 mg qd
Candesartan vs
placebo
Placebo only
100
80
60
40
20
0
0 1 2 3 4
Study year
15
Initiation of Antihypertensive Treatment
Blood pressure (mmHg)
Normal:
SBP 120-129
or DBP 80-84
High normal:
SBP 130-139
or DBP 85-89
Grade 1:
SBP 140-159
or DBP 90-99
Grade 2:
SBP 160-179
or DBP 100-109
Grade 3:
SBP > 180
or DBP > 110
Other RF
OD and Dis.
No other RF
1-2 RF
> 3 RF, MS
or OD
No BP
intervention
Lifestyle
change
Established
CV or renal
disease
No BP
intervention
Lifestyle
change
Lifestyle
change
Lifestyle changes
and consider
drug Rx
Lifestyle changes
for several m.
then drug Rx if
BP uncontrolled
Lifestyle changes
+
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle change
+
drug Rx
Lifestyle changes
for several wks.
then drug Rx if
BP uncontrolled
Lifestyle changes
for several wks.
then drug Rx if
BP uncontrolled
Lifestyle changes
for several wks.
then drug Rx if
BP uncontrolled
Lifestyle changes
+ Immediate
drug Rx
DM Lifestyle
changes
Lifestyle change
+ drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
Lifestyle changes
+ Immediate
drug Rx
2007 ESH/ESC guidelines
Male 52 yrs, BMI 24 kg/m
2
BP 180/110 mmHg, P 80/min,
Moderate anemic, no edema
FBS 90 BUN 40 Cr 2.3 Uric acid 9.0
U/A pH 6.0, sp.gr. 1.010, alb +3, sugar-neg,
wbc 1-2/HPF, rbc 3-5/HPF.
24 hr urine protein 3.5 gm/d.
CC:- Headache and dyspnea on exertion 2 wks
- Nocturia for 2 months
The proper management includes
1. Target BP of 130/80 mmHg
2. ACE-inhibitor/ARB is contraindicated
3. Dihydropyridine calcium antagonist is preferred
4. Furosemide is indicated
5. None of the above
Problem 4:
16
Relationship between systolic BP achieved and decline in kidney function.
Summary of Studies on the progression of nephropathy.
17
Target BPs
- young, middle aged, or diabetic patients
(<130/80 mmHg)
- elderly patients (<140/90 mmHg)
- chronic renal failure patients with proteinuria
> 1 gram/day (<125/75 mmHg)
< 1 gram/day (<130/80 mmHg)
Patients with CKD
Renal protection in diabetes requires strict BP control
(to less than 130/80 mmHg), but also in patients with
non-diabetic nephropathy it appears prudent to lower BP
intensively
Proteinuria should be lowered to values as near to normal
as possible
To reduce proteinuria either an angiotensin receptor
antagonist or an ACE-inhibitor (or the combination of both)
is required
To achieve the BP goal, combination therapy is usually
required, with the addition of a diuretic, a calcium antagonist
and other antihypertensive agents
Consider an integrated therapeutic intervention (anti-
hypertensives, statins, antiplatelet therapy, etc.)
18
Blood pressure > 130/80 mmHg
Start ARB or ACE inhibitor titrate upwards
If BP still not at goal (130/80 mmHg)
Add either thiazide diuretic or long-acting CCB
BP still not at goal (130/80 mmHg)
If BP achieved, convert to fixed-dose
combinations (ACE-I / CCB or an ACE-I / diuretic)
Baseline heart rate > 84 beats/min Baseline heart rate < 84 beats/min
Add low-dose -blocker
or / -blocker
Add other subgroup of CCB
i.e. amlodipine-like agent if
verapamil or diltiazem already being
used, and the converse)
BP still not at goal (130/80 mmHg)
Refer to a clinical hypertension specialist
Treatment of HT with CKD and albuminuria
Female 60 yrs, severe headache and sudden right
hemiplegia and vomited once
BP 180/100 mmHg, P 60/min regular, R 16/min
Semicoma , equal peripheral pulses
Heart-LVH, no murmur
Pupil 3 mm., equal,react to light
Eyeground grade III, right hemiplegia
The proper management is
1. Mannitol intravenously
2. Furosemide intravenously
3. Sodium nitroprusside intravenously
4. Follow up vital signs and pupil size
5. All of the above
Problem 5:
19
Female 60 yrs, severe headache and sudden right
hemiplegia and vomited once
BP 220/130 mmHg, P 60/min regular, R 16/min
Semicoma , equal peripheral pulses
Heart-LVH, no murmur
Pupil 3 mm., equal,react to light
Eyeground grade III, right hemiplegia
The proper management is
1. Mannitol intravenously
2. Furosemide intravenously
3. Sodium nitroprusside intravenously
4. Follow up vital signs and pupil size
5. All of the above
Problem 5:
Hypertension and stroke
20
Autoregulation of cerebral vessels
Blood pressure changes after cerebrovascular events
The phases of blood pressure change
Acute phase (the first 4 days)
Blood pressure rises rapidly at the onset of the stroke
and usually remains high until the subacute phase.
Subacute phase (Day 4 to 10 or 14)
When in most cases the blood pressure gradually returns
spontaneously to normal levels.
Chronic phase (succeeding months or years)
The blood pressure course is more unpredictable, with
some patients exhibiting a significant fall and others a
significant rise from the blood pressure level at discharge.
Shinton R, Panayiotou B. Difficult hypertension. Martin Dunitz 1995.
21
Labetalol, 10 mg i.v. over 1-2 min, repeat or double every
10-20 min, up to 300 mg
SBP >185 or DBP >110, before
treatment
Sodium nitroprusside, i.v., 0.5-1 ug/kg/min
Labetalol, 10 mg i.v. over 1-2 min, repeat or double every
10-20 min, up tp 300 mg. Alternate: enalaprilat, 1 mg
over 5 min, then 1-5 mg every 6 h
No acute treatment, unless hemorrhagic transformation,
hypertensive encephalopathy, AMI, ARF from
accelerated hypertension, acute pulmonary edema, or
aortic dissection.
Treat factors that may contribute to increased BP,
including pain, agitation, headache, bladder distension,
and hypoxia
No acute treatment
DBP >140
SBP >220 or DBP 121-140;
mean BP >120
SBP 185-220 or DBP 105-120
SBP <185 or DBP <105
Cerebral infarction, candidate for thrombolysis
Cerebral infarction, not a candidate of thrombolysis
Management BP level (mmHg)
Hypertension management in acute cerebrovascular disorders (1)
2008 AHA
Sodium nitroprusside, i.v.
Labetalol or enalaprilat, i.v., as noted for
cerebral infarction and intracerebral
hemorrhage
No acute treatment
Subarachnoid hemorrhage
DBP >140
Mean BP >130 and DBP <140
Mean BP <130
Sodium nitroprusside, i.v., 0.5-1 ug/kg/min
Labetalol, 10 mg i.v. over 1-2 min, repeat
or double every 10-20 min, up tp 300
mg. Alternate: enalaprilat, 1 mg over 5
min, then 1-5 mg every 6 h.
No acute treatment
Intracerebral hemorrhage
SBP >230 or DBP >140
Mean BP >130 mmHg, SBP 180-230
or DBP >105-140
Mean BP <130, SBP <180
or DBP <105
Management BP level (mmHg)
Hypertension management in acute cerebrovascular disorders (2)
2008 AHA
22
Patients with previous CVD
Patients who have suffered a previous stroke or transient
ischaemic attack have a reduced recurrence of stroke if
they receive antihypertensive therapy (diuretics and ACE-
inhibitors), even if their BP is in the normal or high normal
range only
Whether BP in acute stroke should be lowered is still disputed
Several antihypertensive agents have been proven beneficial
in post-myocardial infarction
In congestive heart failure, diuretics, anti-aldosterone agents,
beta-blockers, ACE-inhibitors, and angiotensin receptor
antagonists have been prove beneficial
Female 40 yrs, BMI 21 kg/m
2
BP 160/90 mmHg, P 100/min, eyeground - normal
CC: Frequent headache, tense at posterior neck
for 2 wks
On bisoprolol (5) 1x1, then added HCTZ 1/2x1
BP 160/90 mmHg P 72/min after monthly
follow up for 3 months
Problem 6:
23
White Coat Hypertension Remains
Therapeutic Dilemma
Confirm that clinic blood pressure is persistently
elevated and that 24-hour ambulatory or home
blood pressure is really normal.
Check for target organ damage and presence of
concomitant risk factors (if present, the patients
should be treated).
In the absence of target organ damage, the decision
to treat is left to the physicians discretion.
However, if the patient is not treated, close follow-up
and implementation of lifestyle changes are indicated.
Verdecchia P, et at. Hypertension. 2005;45:203-8.
Cumulative hazard for stroke in the 3 groups (normotensive subjects,
WCH, amd ambulatory hypertension)
24
Male 45 yrs, BMI 22 kg/m
2
BP 220/130 mmHg, eyeground Lt grade II, LVH
CC: vitreous hemorrhage Rt
BP 150/100 mmHg, on 4 drugs, high dosages
What is the likely diagnosis ?
1. Essential HT
2. Pheochromocytoma
3. Renovascular HT
4. Primary aldosteronism
5. Coarctation of aorta
Problem7:
Resistant hypertension
Definition: when lifestyle measures and combination of at least
three drugs in adequate doses have failed to lower systolic and
diastolic BP sufficiently
Causes:
- unsuspected secondary cause
- poor adherence to therapeutic plan
- intake of drugs raising BP (steroids, anti-inflammatory drugs,
oral contraceptives, cocaine, etc.)
- failure to modify lifestyle (weight gain, alcohol, etc.)
- volume overload (insufficient diuretic dose, renal insufficiency,
high salt intake)
- sleep apnea
- spurious hypertension (e.g. small cuff on large arms, isolated
office hypertension)
25
Captopril renogram (14 June 01)
Suspected renal artery stenosis left side.
Renal angiogram (7 August 01)
Stenotic lumen at left renal artery middle
part with long segment narrowing and
irregularity of aorta
Left renal artery
dilatation with Rocket
4x20, partial result
provisional stenting with
Corinthian IQ 5.0x14,
6x70 and 9x20 inflation
MLD/RD (%DS)
pre 1.54/5.88
post 4.87/6.15
(20.9%)
26
Resistant hypertension
1. Review all treatment including self-medication:
remove interacting drugs whenever possible.
2. Simplify treatment and assess compliance.
3. Exclude white-coat element to treatment
resistance by 24 hr ABPM.
4. Review history, examination and initial
investigations for clues to an underlying cause.
Plan for managing resistant HT. (1)
27
5. Exclude renal abnormality (by rapid sequence
intravenous urogram) and phaeochromocytoma.
6. Add frusemide 40 mg to regimen for false tolerance,
titrate as required, with strict biochemical
monitoring.
7. Use drugs of high potency.
8. Exclude pseudohypertension, and perform renal
arteriography simultaneously even if earlier
investigations normal.
9. Reset blood pressure target.
Plan for managing resistant HT. (2)
History
Paroxysmal features (phaeochromocytoma)
Renal disease - current symptoms
- past history
- family history (APKD)
Liquorice use
Examination
General appearance (Cushings)
Kidneys palpable (polycystic, hydronephrosis,
neoplasm)
Abdominal or loin bruit (renal artery stenosis)
Radiofemoral delay (coarctation of the aorta)
Points to review in patients with resistant
hypertension (1)
28
Investigation
Review
Serum creatinine (renal disease)
Urine protein, blood (renal disease)
Serum K (Conns synd., liquorice use)
Arrange
Screen for phaeochromocytoma
(e.g. urine vanillylmandelic acid)
Rapid sequence IVP (referral to a
physician with special interest in HT
is recommended at this stage)
Points to review in patients with resistant
hypertension (2)
Female 48 yrs, BMI 31 kg/m
2
, HT & DM 3 yrs
BP 140/80 mmHg
Fair control of diabetes with glibenclamide 1x1
On HCTZ 1x1, Nifedipine (5) 1x3 for HT
CC: continued treatment after urban migration
The proper management is
1. Metformin administration
2. Decrease the dosage of HCTZ and replace
nifedipine (5) with long acting CA
3. ASA administration
4. ACE-I/ARB administration
5. All of the above
Problem 8:
29
Hypertension in diabetes
mellitus
Diabetic patients
Encourage lifestyle measures (particularly weight loss and
reduction of salt intake in type 2 diabetics)
Goal BP is below 130/80 mmHg
Most often combination therapy is required
All antihypertensive agents can be used, generally in
combination
Renoprotection benefits from the inclusion in these
combinations of an ACE-inhibitor in type 1 diabetes, and of
an angiotensin receptor antagonist in type 2 diabetes
Microalbuminuria should be tested in all type 1 and type 2
diabetics, as it is an indication for antihypertensive
treatment especially by a blocker of the renin-angiotensin
system, irrespective of BP
30
Hypertension in pregnancy
Female 41 yrs. G
4
P
2
A
1
LMP 10 July 99
1
st
ANC 5 Oct 99 GA 12
+
wks
Wt. (kgs)
Urine protein
sugar
BP (mmHg)
GA (wks)
Pre-eclampsia 1
65.7
neg
neg
110/70
13
66
neg
neg
110/70
16
65.5
neg
neg
100/60
20
70
-
-
120/80
24
75
+4
neg
180/120
28
Date 12 Oct 2 Nov 30 Nov 28 Dec 25 Jan 00
31
Admit 25 Jan 00
BP 210/130 mmHg P 110/min R 35/min
CC: edema 2 m
cough 5 days
dyspnea, orthopnea; pain RHC 1 day
Lab: CBC Hct 37.9% Plts 197,000/mm
3
PTT 40.8 PT 11.8
U/A sp.gr. 1.008 protein +4, sugar - neg
FBS 80 mg% BUN 13 mg% Cr 0.4 mg%
Alb 2.5 g% Na 134 mEq/L K 3.4 mEq/L
HCO
3
21 mEq/L
28 Jan 00 Echocardiography EF 60%, finally C/S
Pre-eclampsia 2
25 Jan 26 Jan 27 Jan 28 Jan
Hydralazine 5 mg IV
50 mg/500 ml 40 d/min 70 d/min 80 d/min
Methyldopa 250 mg x 3 500 mg x 4
Furosemide 40 mg IV
MgSO
4
4 g IV
10 gm/500 ml 50 cc/hr
Nitroglycerine
100 mg/500 ml 10 d/min
Morphine 3 mg IV
Pre-eclampsia 3
32
Pregnancy with hypertension
For pregnant women with pre-existing hypertension:
- non-pharmacological treatment when BP is 140-149/90-99 mmHg
- weight reduction contraindicated (associated with reduced
neonatal weight)
- low-dose aspirin in women with a history of early pre-eclampsia
Thresholds for initiating antihypertensive treatment are:
- systolic BP 140 mmHg or diastolic BP 90 mmHg in gestational
hypertension or pre-existing hypertension with organ damage
- thresholds in other circumstances are 150/95 mmHg
- systolic BP >170 or diastolic BP >110 mmHg in pregnancy
should be considered an emergency (hospitalization essential)
Methyldopa, labetalol, calcium antagonists and (though less
effective) beta-blockers are the drugs of choice
THANK YOU
FOR
YOUR ATTENTION