Diagnosis and Management of

Hypertension
Davin Haraway DO,FACOI,CWS
Associate Professor of Medicine OSU
Center for Health Sciences

Why talk about the Same Old Thing?

Those age 55 with normal blood pressure will have a 90 percent

lifetime risk of developing hypertension
Hypertension control reduces excess morbidity and mortality.
Beginning with 115/75 CVD risk doubles for each increment of
20/10mmHg
>50million americans have High Blood Pressure warranting some
form of treatment

30% adults are still unaware of their hypertension

>40% of individuals with hypertension are not on treatment

2/3 of patients on treatment are not controlled to BP levels of less

than 140/90
Hypertensive patients are 2.5 times more likely to develop
diabetes within 5 years

Lifetime Risk of Developing

Hypertension Beginning at Age 65
Risk of hypertension (%)

100
80

Men

Women

60
40
20
0

10

Years

12

14

16 18

20

Residual lifetime risk of developing hypertension

among people with blood pressure <140/90 mmHg
Vasan RS, et al. JAMA. 2002; 287:1003-1010.
Copyright 2002, American Medical Association.

www.hypertensiononline.or
g

HTN Classification

Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older

?Prehypertension

NOT a DISEASE category

Should encourage Lifestyle modification as this group

has an increased risk of becoming hypertensive

NOT candidates for drug therapy (unless

compelling indications ie DM etc goal <130/80)

Table 3. Lifestyle Modifications to Manage Hypertension*

Physician Practices in Treating

HTN With and Without Diabetes
40-60y/no DM
40-60y/with DM

>70y/no DM
>70y/with DM

% of respondents

60
50
40
30
20
10
DBP (mmHg) to Start Treatment

Hyman DJ, Pavlik VN. Arch Intern Med. 2000;160(15):2281-2286.

80-84
85-89
90-94
95-99
100-110
www.hypertensiononline.org
Reprinted by permission, American Medical Association.

Accurate BP measurement

Who checks your patients BP?

You or Staff

IF Staff Do they know what to listen for or do they use automated

equipment

Seated quietly for 5 minutes

Appropriate size cuff

Inflate 20-30 mmHg above loss of radial pulse

Deflate at 2mmHg per second

1st sound SBP ; Disappearance of Korotkoff sound (phase 5) is

DBP

Confirm Elevated blood pressure within 2months(stage 1)

shorter for stage 2 if new onset

If HTN diagnosed
Evaluate for Cardiovascular Risk Factors
Age,Fm Hx, Lipids, Obesity, microalbuminuria,
Inactivity,Smoking
Evaluate for Target Organ Damage
LVH or reduced EF,
Angina,stroke,dementia,Kidney disease,
PAD,retinopathy
Think about Secondary Hypertension with any new
onset Hypertension or uncontrolled hypertension

Identifiable causes of hypertension

Chronic kidney disease\

Coarctation of the Aorta

Cushings Syndrome

Drug induced

Obstructive uropathy

Pheochromocytoma

Primary aldosteronism and other mineralocorticoid

excess states

Renovascular HTN stenosis and fibromuscular

dysplasia
Sleep Apnea

Thyroid (either HYPER or HYPO) or parathyroid

disease

Box 3. Causes of Resistant Hypertension

Improper blood pressure measurement
Volume overload and pseudotolerance
Excess sodium intake
Volume retention from kidney disease
Inadequate diuretic therapy)
Drug-induced or other causes
Nonadherence
Inadequate doses
Inappropriate combinations
Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors
Cocaine, amphetamines, other illicit drugs
Sympathomimetics (decongestants, anorectics)
Oral contraceptives
Adrenal steroids
Cyclosporine and tacrolimus
Erythropoietin Licorice (including some chewing tobacco)
Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma
haung, bitter orange)
Associated conditions
Obesity
Excess alcohol intake
Identifiable causes of hypertension (see Box 2)

Which Drugs do you use?

Stage 1 Thiazide 1st unless compelling

indication
Stage 2 Two drugs (one of the two should be a
diuretic or ACE/ARB)
Compelling Indications for certain disease
modifying meds should be considered

Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes

OK Now what?

2/3 of patients with hypertension will need at

least two medicines for BP control

Pearls

For resistant HTN sit down and take a good

history

How much water,pop, coffee,milk,juice,tea,ice

anything liquid do you drink daily.

Food preferences and salt intake

Drugs/Alcohol

Compliance

Pearls cont.

The only thiazide that will work with an elevated creat.

Is metolazone(zaroxolyn)
If elevated creat. Than will need to use a loop diuretic
If potassium is elevated evaluate current meds and
use a diuretic

If potassium is low ask why

Check for edema and ask why

Elderly patients benefit from blood pressure management

Black patients benefit from ACE/ARB may need to use

larger doses to obtain BP lowering effect

Pearls Cont.

Metabolic acidosis and hyperkalemai? use

diuretic loop if creat. Elevated
Take blood pressure periodically lying and
standing so as not to miss supine hypertension
associated with autonomic insufficiency this is
treated differently

Escape of Angiotensin II
Despite
ACE
Inhibition
100
80
Plasma ACE 60
(nmoL/mL/min) 40
20
0

24 h

30
Plasma Ang II
(pg/mL)

20

10

0
Placebo

4h

Hospital

Months
*P <.001 vs placebo

Biollaz J, et al. J Cardiovasc Pharmacol. 1982;4(6):966-972.

www.hypertensiononline.org

Adherence to Medication According to Frequency of Doses

Osterberg, L. et al. N Engl J Med 2005;353:487-497

Barriers to Adherence

Osterberg, L. et al. N Engl J Med 2005;353:487-497

Figure. Algorithm for Treatment of Hypertension