High blood pressure, also known as hypertension, is a common medical condition where the force of blood against the walls of your arteries remains consistently too high.
Systemic Hypertension| High Blood Pressure
| Blood Pressure Category | Systolic mmHg (upper number) | Diastolic mmHg (lower number) | Treatment |
| Normal Bp | Less Than 120 | less than 80 | Follow up Every year |
| Elevated | 120—-129 | less than 80 | life style modification follow up in 6 month |
| Hypertension(HTN) | |||
| Hypertension Stage1 | 130—-139 | 80—–89 | No comorbidities: life style modification and follow up in 3 months. Co-morbidities: start medication, follow up in 1 month. |
| Hypertension Stage 2 | 140 or higher | 90 or Higher | Medication, life style modification. |
| Hypertensive Crisis | Higher than 140 | higher than 120 |
Diagnosis of HTN:
- If BP higher than 140/90 mmHg than conform it on ABPM (Ambulatory BP Monitoring) or HBPM (Home BP monitoring) if average Blood Pressure higher than 150/95 mmHg start treatment.
- If Blood Pressure higher than 180/110 mmHg — start treatment.
AMBLATORY BP MONITORING (ABPM):
- At least 2 measurement per hour during the person usually awake hours (8am,10am)
- Use the average of at least 14 measurement.
- If ABPM is not tolerate or decline: home BP monitoring should be offered.
Home BP Monitoring:
Blood Pressure measurement at home twice daily on both hand for at least 4 days (ideally: 7 days).
TARGET BP:
Age less than …….. 80 140/90mmHg
Age greater than 80 or without DM,CKD …….. 150/90mmHg
With DM or CKD: ………………… 130/90mmHg
| BASIC INVESTIGATIONS | INVESTIGATION OF SELECTED PATIENTS |
| RBS, serum creatinine | x-ray chest to detect cardiomegaly, |
| Serum electrolyte | Ambulatory BP recording to assess white coat hypertension |
| Serum calcium, ECG | Echo to detect left ventricular hypertrophy |
| Fasting lipid profile | ultrasound abdomen to detect renal parenchymal disease |
| Free t4 TSH | Renal Doppler/Renal angiography to detect renal artery stenosis |
| CBC to rule out Polycythemia | Plasma renin activity and aldosterone to detect primary aldosterone’s |
| Serum uric acid | Urinary catecholamines to detect Pheochromocytoma |
| urine routine examination (Protein) | Urinary cortisol and dexamethasone suppression test to detect crushing’s syndrome |
Management:
1.life style Modification
| Modification | Recommendation | Systolic BP Reduction |
| Weight Reduction | maintain normal body weight (BMI 18.5-24.9) | 5-20 mmHg/10kg weight loss |
| DASH Diet | Diet rich in fruit, Vegetable, and low fat dairy products with a low content of saturated fat and total fat | 8-14 mmHg |
| Alcohol | Stop Alcohol. | |
| Exercise | Regular aerobic exercise such as brisk walking at least 30 mint/day most days of the week. | 4-9 mmHg |
| Dietary Salt | Reduce dietary salt (<6g/day ideally 3g/day) | 2-8mmHg |
| Smoking | Stop smoking | |
| caffeine | Decrease caffeine intake |
2.Anti-Hypertensive Drugs: (ACDB)
A: Angiotensin converting enzymes inhibitors, Angiotensin receptor blocker
C; Calcium channel blockers,
D: diuretics
B; B-blockers,
Step 1:
If AGE< 5years: start ACEI or ARB
ACEI=> Enalapril 20mg, Lisinopril 10mg, or 40mg , Ramipril 5mg or 10mg.
ARBS= Tab Losartan (losanta) 25mg or 50mg OD.
[Valsartan 40mg or 160mg, Irbesartan 150mg or 300mg, olmesartan 20mg or 40mg]
If AGE >55Years; Start calcium channel blocker (CCB)
TAB Amlodipine (sofvas) 5mg ,10mg OD
[Nifedipine 30mg or 90mg,Verapamil 240mg, Diltiazem: 200mg or 300mg]
Step 2:
If Desire or target not achieved with ACEI or ARB then add CCB (A+C).
Tab Amlodipine+Valsartan 5/80, 5/160, 10/160 (Extor, Avsar) OD or
Tab Amlodipine+Olmesartan 5/20,5/40 OD
Step 3:
If target BP not achieved with (A+C) then add Diuretics ( A+C+D)
(Diuretics: Chlorthalidone and indapamide Hydrochlorothiazide)
Tab Amlodipine+Valsartan+Hydrochlorothiazide
(co-extor, avsar plus 10+160m+12.5mg OD).
Step 4:
If target BP not achieved with A+C+D then we called resistance HTN for the treatment add another diuretic if tolerated and not contraindicated.
- If k+< 4.5 then add Spironolactone 25mg … OD
- If k+> 4.5 then add high dose thiazide like diuretics
- If further diuretic non tolerate or contraindicate or ineffective then consider alpha blocker or beta blocker.
NOTE: Adding 2nd drug is more effective than increase dose of first drug.