Hypertension in Adults

Clinical Description

Classification of Adult Hypertension

Type of Hypertension Systolic Blood Pressure Diastolic Blood Pressure

Mild 140-159 90-99

Moderate 160-179 100-109

Severe >180 >110

Signs and Symptoms

• Usually none
• Occasionally headaches, palpitations, dizziness, easy fatiguability
• high Blood pressure ≥ 140/90 mmHg
• +/-Displaced apex beat
• Signs pointing to a specific cause for secondary hypertension

Investigations

• FBC, Urinalysis, Blood urea, electrolytes, and creatinine, Blood glucose, Serum lipids, Serum uric acid, Chest X-ray, 12-lead ECG
• Ultrasound scan of kidneys and adrenals (in suspected secondary hypertension)
• Echocardiogram

Non-pharmacological

• Reduce salt intake
• Stop smoking
• Regular monitored exercise
• lose weight
• Avoid excessive alcohol consumption
• Prevent complications (stroke, heart failure, Myocardial infarction, chronic kidney disease etc.
• Explain to the patient that treatment should be regular (every day), closely monitored and generally must be taken for life
• Lifestyle changes mentioned above

Pharmacological

• Use the following stepped treatment approach with the medicines in this order unless there are specific contraindications, co- morbidities, or side- effects

Note: Consider medicine treatment for mild hypertension only if the above general measures are unsuccessful

Stepped anti-hypertensive treatment approach

Step 1:

• Hydrochlorothiazide 25 mg each morning, increasing the dose is not advised.

Explain to the patient that treatment must be regular (every day), closely monitored and generally must be taken for life

• Alternatively, give Bendrofluazide 5mg daily or Indapamide 2.5mg daily

Note: Avoid in pregnancy feeding and breastfeeding

Step 2:

• Give Hydrochlorothiazide 25mg once daily and Amlodipine 5- 10mg once daily
• Where Amlodipine is not available Nifedipine 10-20mg slow-release tablets once or twice a day can be used.

Step 3:

• Give Hydrochlorothiazide 25mg once daily, Amlodipine 5-10 mg once daily and Enalapril 10- 20mg once daily (increase dose slowly)
• Where Enalapril is not available Captopril 12.5-50mg (start with low dose) every 8 hours or lisinopril 10mg od can be used.
• Best to start with a lower dose of Enalapril 5mg and increase to 10mg after observation of the BP response over a few days.
• Avoid Enalapril and Captopril in pregnancy and breast-feeding

Step 4:

• Give Hydrochlorothiazide 25mg once daily and Amlodipine 5- 10mg once daily (or Nifedipine 10-20mg), Enalapril 10-20mg once daily and Atenolol 50-100mg once daily
• Where Atenolol is not available Propranolol 40mg - 80mg every 8 hours can be used (start with low dose) or carvedilol 12.5mg bd (and increase to 25mg bd if need be) or Nebilong 5-10mg daily.

Step 5:

• Refer to Medical Specialist

Note: Side-effects may outweigh benefits. In patients with severe hypertension or complications (heart failure, renal failure) start medicine treatment immediately.

• In patients without co-morbidity, aim for a BP of around 140/90 and aim around 130/80 if co-morbidity (Diabetes, chronic kidney disease)
• For patients taking ART, because of the interactions between Calcium Channel

Blockers, and NNRTIs, please consider Enalapril or Atenolol before a Calcium

Channel Blocker.

• If not tolerating ACE inhibitors give ARBs e.g. Losartan 50-100mg daily or Telmisartan 40-80mg daily

Compelling indications for the choice of antihypertensives

• Left ventricular hypertrophy: ACE-I or ARB, CCB preferably Amlodipine.
• Microalbuminuria: ACE-I or ARB.
• Renal dysfunction: ACE-I or ARB; Caution- if eGFR <15min/ml without renal replacement therapy.
• Previous stroke: Any of the first-line drugs, especially ACE-I.
• Coronary artery disease (Angina/Myocardial infarction): ACE-I or ARB, Beta-blocker, CCB.
• Heart failure: ACE-I or ARB, Cardio-selective B-Blockers- bisoprolol, metoprolol, carvedilol; Loop diuretics, Spironolactone in advanced heart failure.
• Peripheral artery disease: CCB, ACE-I or ARB.
• Diabetes mellitus: ACE-I or ARB.
• Atrial fibrillation: ARB or ACE-I or B-blockers

Compelling Contraindications.

• Gout: Thiazide diuretics.
• Asthma: Beta-blockers.
• AV block (2nd and 3rd degree): Beta blockers and calcium channel blockers.
• Bilateral renal artery stenosis and hyperkalemia: ACE Inhibitor and ARBs

Referral Criteria:

Refer the following categories of hypertensive patients to an appropriate specialist:

Note

• Those not achieving the target blood pressure (BP) level after several months of

Treatment

• Those on three or more anti-hypertensive drugs yet have poor BP control y Those with worsening of BP over a few weeks or months.
• Those with plasma creatinine levels above the upper limit of normal.
• Those with multiple risk factors (diabetes, dyslipidemia, obesity, family history of heart disease).
• Those not on diuretics but have persistently low potassium on repeated blood tests.

All children, young adults, and pregnant women with elevated BP