Hypertension

A blood pressure (BP) measurement is made up of two values, one being systolic and the other being diastolic. Normal BP is <120 systolic and <80 diastolic. Elevation in BP is categorized into different stages that can be managed accordingly. This article discusses the management of primary or essential hypertension which is not caused by any identifiable disease processes but rather happens on its own. 

Table 1. Blood pressure stages

Stage	Systolic	Diastolic	Management
Normal	<120	<80	Annual follow up
Elevated BP	<130	<80	Lifestyle changes Diet NaCl reduction (<2.4g/day) DASH (Dietary Approaches to Stop Hypertension) diet Etoh reduction (2 for men, 1 for women /day) Exercise  30 mins a day, 4 times a week Weight loss BMI<25 Follow up every 6 months
Stage 1	<140	<90	Lifestyle changes as above Medical treatment if there are other risk factors Smoking  Dyslipidemia  Family history  Diabetes  Obesity  Male >45 and Female >55 HTN resistant to lifestyle changes Follow up after 1 month  Important for titration and side effects  Need 2 visits, 2 weeks apart with 2 readings to diagnose Home blood pressure monitoring can be very helpful
Stage 2	>140	>90	Lifestyle changes as above Two medications  Depend on the other comorbidities Follow up after 1 month  Titration and diagnosis  Home blood pressure monitoring
Hypertensive urgency	>180	>120	No end-organ damage  IV antihypertensives and then oral
Hypertensive emergency	>180	>120	End organ damage present  Elevated Cr Altered mental state SOB  CP or elevated troponin Elevated liver enzymes Start on IV antihypertensives Reduce MAP ~25% for 2-6 hrs Oral antihypertensives after

Pharmacology 

There are many different classes of antihypertensives and what determines which one you should use depends on the patients' other comorbidities. Another important factor with antihypertensives is to titrate the dose effectively to avoid hypotension:

Comorbidities	Medications	Examples
CHF CAD	Beta-blocker ACEi/ARB	Metoprolol Carvedilol Nebivolol
Stroke	ACE + thiazide diurethic
CKD	ACEi/ARB (except in stage 4) Hydralazine (Stage 5)
Diabetes	ACEi
No other comorbidity	Hydrochlorothiazide  Calcium channel blocker  ACEi

Medication uses and side effects by class 

• Calcium channels 
  • Uses 
    • Angina 
  • Dihydropyridines 
    • Peripheral edema
  •  Non-dihydropyridines 
    • Verapamil
    • Diltiazem 
    • Uses
      • AFib for rate control
• ACEi/ARB
  • Creatinine elevation >20%
  • Cough and angioedema (ACEi only)
  • Hyperkalemia 
• Thiazide 
  • Uses
    • Kidney stones by reducing urinary calcium
  • Decreased potassium 
• Beta-blockers 
  • Decreased heart rate 
• Aldosterone antagonists 
  • Uses 
    • Resistant hypertenison 
    • CHF class 3
  • Hyperkalemia 
  • Gynecomastia 
• Dilaters 
  • Arterial 
    • Uses
      • Stage 5 CKD
    • Hydralazine
      • Reflex tachycardia 
      • Drug-induced lupus 
  • Venous 
    • Nitrate 
      • Uses
        • Angina
      • Don't use with other nitrates 
      • Don't use with PDE-i 
• Alpha-antagonists 
  • Generally used for BPH
  • Can lead to orthostatic hypotension 
• Central acting meds 
  • Clonidine 
    • Rebound hypertension 
    • Can use the transdermal patch to avoid hypertension issues