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MEDICINE - HYPERTENSION - DISCUSSION AND MANAGEMENT - University of Colombo
Hypertension
In your history & examination, following key points should be addressed
• Basis for diagnosis of hypertension & level of hypertension at diagnosis
• Look for features suggestive of a secondary cause for hypertension
(no age limit for secondary causes
...
Make sure that diagnosis is correct
Accurate BP measurement
Patient seated comfortably for 5 minutes in a comfortable environment
...
Both arm BP
recordings taken
...

Use a standard size cuff (12- 13 cm wide & 35 cm long), may need different sizes according to
arm circumference
Cuff should be positioned at the level of heart, with back & arm supported to avoid muscle
contraction causing high BP
Measure BP 1 min & 3 min after standing from seated position in all patients to exclude
orthostatic hypertension
Definition of hypertension
Level of BP at which the benefits of treatment (lowering BP), unequivocally outweigh risks of
treatment
...
SBP ≥ 140 and/ or DBP ≥ 90 Hgmm
According to JNC 7 guidelines;
Category
Systolic
Diastolic
Follow up
Optimal
< 120
and
< 80
Measure in every 5 yrs
Normal
120
and/ or
80- 84
Measure at least in 3 yrs
High Normal
130- 139
and/ or
85- 89
Considered masked HTN
...
Can
even check ambulatory BP
Grade 1
140- 159
and/ or
90 - 99
Grade 2
160- 179
and/ or
100 - 109
Grade 3
≥ 180
and/ or
≥ 110
Isolated systolic HTN ≥ 140
and
< 90
Confirming diagnosis should not be based on a single set of readings at a single visit unless,
• BP is substantially increased (grade 3) or
• Clear evidence of hypertension mediated end organ damage (retinopathy, LV hypertrophy,
proteinuria, CVA, coronary heart disease)
White coat hypertension or masked HTN: if suspected, check ambulatory BP or home BP

Classification of hypertension (ISH 2021)

Structural
Renal artery stenosis

Endocrine:
Phaeochromocytoma
(Can have associated
MEN syndrome)
Primary
hyperaldosteronism
(Conn's Xn)
2
...
Cr
shoots up)
Here, angiotensin is driving GFR, if blocked, go
into AKI with crashing of filtration pressure
...

Might be
confusing

Low potassium
(High
angiotensin,
aldosterone
promote K+ loss)

Urine
metanephrines,
VMA
Renin
aldosterone
ratio, Low K+
(despite ACEI)
9 am cortisol,
urinary free
cortisol,
DM, low K+
Thyroid tests
Brain imaging,
IGF levels

3
...
Treatment
Lifestyle modifications
• Cessation of smoking
• Moderation of alcohol consumption (< 14 u/ wk for men & < 8 u/ wk for women)
• Diet (high potassium)
A diet plan with local & cultural acceptance is formulated with principles stated below in
consultation with a dietician where necessary
...
Factors that are considered;
• Age
• Level of hypertension
• Extent of end organ damage
• Cardiovascular risk profile
• Any patient specific factors
First line medication for management of hypertension includes;
1
...
Calcium channel blockers
3
...
Beta blockers
2
...
Direct vasodilators
4
...
Aldosterone antagonist – spironolactone (very effective in resistant hypertension)
Treatment targets
Target is controversial
...


Continuing education, follow up & compliance

Isolated systolic hypertension
Common in elderly patients
...
If a
combination required, CCB + ACEI/ ARB preferred
Resistant hypertension
When a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic & 2
other antihypertensive drugs of different classes at maximum tolerable doses fails to lower
SBP & DBP to < 140 & 90 mmHg (150 & 90 mmHg in people ≥60 years), respectively
To be absolutely certain of resistant hypertension, have to exclude few things;
• Ensure patient compliance
• Exclude white coat hypertension (preferably by ambulatory blood pressure monitoring)
When resistant hypertension is confirmed, should look for secondary causes
...
Beta blockers also useful
Hypertensive emergencies
Presentation
Target BP reduction
Malignant HTN +/Over several hours

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