This document provides guidelines for the management of hypertension including: 1. Definitions of hypertension based on different blood pressure measurement methods and thresholds from recent guidelines. 2. Treatment goals for higher-risk and lower-risk populations. 3. Causes and complications of hypertension like left ventricular hypertrophy, heart failure, stroke, myocardial infarction, and renal failure. 4. Classes of antihypertensive agents used for treatment including thiazide diuretics, ACE inhibitors, ARBs, calcium channel blockers, and beta blockers. 5. Specific definitions and management recommendations for hypertension in pregnancy and its complications.

1. Management of
Hypertension

2. Definition of hypertension
SBP/DBP Clinic HBPM Daytime ABPM
Nighttime
ABPM
24-hour ABPM
ACC/AHA
Guidelines 2017
≥130/80 ≥130/80 ≥130/80 ≥110/65 ≥125/75
ESC/ESH
Guidelines 2018
≥140/90 ≥135/85 ≥135/85 ≥120/70 ≥130/80

3. TREATMENT GOAL/TARGET
Routine/conventional office blood
pressure
Unattended AOBPM, daytime
ABPM, or home blood pressure
Higher-risk population
•ASCVD
•Heart failure
•Diabetes mellitus
•Chronic kidney disease
•Age ≥65 years
•Calculated 10-year risk of ASCVD event ≥10%
125 to 130/<80 120 to 125/<80
Lower-risk
None of the above risk factors 130 to 139/<90 125 to 135/<90

4. WHY HTN IS IMPORTANT
• LVH
• HF
• STROKE
• MI
• RENAL FAILURE

5. Severe hypertension:>180/120
Emergency
• Hypertensive encephalopathy
• Retinal hemorrhages
• Papilledema
• Acute and subacute kidney
injury
Urgency
• No end organ damage

6. Resistant Hypertension
• Blood pressure GOAL is not
achieved despite concurrent use
of three antihypertensive agents
of different classes taken at
maximally tolerated doses, one
of which should be a diuretic
• Blood pressures achived at goal
while taking four or more
antihypertensive medications
are considered to have
"CONTROLLED RESISTANT
HYPERTENSION”

7. HTN CAUSES LVH

8. HTN CAUSES RENAL FAILURE

9. HTN CAUSES ISCHEMIC HEART DISEASE

10. HTN CAUSES STROKE

11. HTN INCREASES CVD MORTALITY

12. BP MEASUREMENT
Patient conditions
Posture
Initially, check for postural changes by taking readings after five minutes supine, then immediately and two minutes after standing; this is
particularly important in patients over age 65 years, diabetics, or those taking antihypertensive drugs
Sitting pressures are recommended for routine follow-up; the patient should sit quietly with the back supported for five minutes and the arm
supported at the level of the heart
Circumstances
No caffeine during the hour preceding the reading, and no smoking during the preceding 30 minutes
No exogenous adrenergic stimulants, such as phenylephrine in decongestants or eye drops for pupillary dilatation
A quiet, warm setting
Home readings should be taken upon varying circumstances
Equipment
Cuff size
The length of the bladder should be 80%, and the width of the bladder should be at least 40% of the circumference of the upper arm
Manometer
Aneroid gauges should be calibrated every six months against a mercury manometer

13. Cont.
Technique
Number of readings
Take at least two readings on each visit, separated by as much time as possible; if readings vary by more than 5 mmHg, take additional readings
until two consecutive readings are close
For the diagnosis of hypertension, take three readings at least one week apart
Initially, take blood pressure in both arms; if pressures differ, use the higher arm
If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 years
Performance
Inflate the bladder quickly to 20 mmHg above the systolic pressure as estimated from loss of radial pulse
Deflate the bladder by 3 mmHg per second
Record the Korotkoff phase V (disappearance) as the diastolic pressure except in children in whom use of phase IV (muffling) may be preferable
If the Korotkoff sounds are weak, have the patient raise the arm, open and close the hand 5 to 10 times, and then inflate the bladder quickly
Recordings
Note the pressure, patient position, arm, and cuff size: eg, 140/90, seated, right arm, large adult cuff

14. IDEAL CUFF SIZE
Arm circumference Usual cuff size
22 to 26 cm Small adult
27 to 34 cm adult
35 to 44 cm Large adult
45 to 52 cm Adult thigh

15. HISTORY TAKING
Duration of hypertension
Last known normal blood pressure
Course of the blood pressure
Prior treatment of hypertension
Drugs: types, doses, side effects
Intake of agents that may cause hypertension
Nonsteroidal antiinflammatory drugs
Estrogens
Adrenal steroids
Cocaine
Sympathomimetics
Excessive sodium
Family history
Hypertension
Premature cardiovascular disease or death
Familial diseases: pheochromocytoma, renal
disease, diabetes, gout
Symptoms of secondary causes
Muscle weakness
Spells of tachycardia, sweating, tremor
Thinning of the skin
Flank pain

16. Cont.
Symptoms of target-organ damage
Headaches
Transient weakness or blindness
Loss of visual acuity
Chest pain
Dyspnea
Claudication
Presence of other risk factors
Smoking
Diabetes
Dyslipidemia
Physical inactivity
Dietary history
Sodium
Processed foods
Alcohol
Saturated fats
Psychosocial factors
Family structure
Work status
Educational leve
Sexual function
Features of sleep apnea
Early morning headaches
Daytime somnolence
Loud snoring
Erratic sleep

17. EAMINATION
Accurate measurement of blood pressure
General appearance
Distribution of body fat
Skin lesions
Muscle strength
Alertness
Fundoscopy
Haemorrhage
Papilledema
Cotton wool spots
Arteriolar narrowing and arteriovenous nicking
Neck
Palpation and auscultation of carotids
Thyroid
Heart
Size
Rhythm
Sounds
Lungs
Rhonchi
Rales
Abdomen
Renal masses
Bruits over aorta or renal arteries
Femoral pulses
Extremities
Peripheral pulses
Edema
Neurologic assessment
Visual disturbance
Focal weakness
Confusion

18. TREATMENT GOAL/TARGET
Routine/conventional office blood
pressure
Unattended AOBPM, daytime
ABPM, or home blood pressure
Higher-risk population
•ASCVD
•Heart failure
•Diabetes mellitus
•Chronic kidney disease
•Age ≥65 years
•Calculated 10-year risk of ASCVD event ≥10%
125 to 130/<80 120 to 125/<80
Lower-risk
None of the above risk factors 130 to 139/<90 125 to 135/<90

19. SBP:J-curve

20. DBP:J-Curve

21. Lifestyle modification
Modification Recommendation
Approximate systolic BP reduction,
range
Weight reduction
Maintain normal body weight (BMI, 18.5 to
24.9 kg/m
2
)
5 to 20 mmHg per 10 kg weight loss
Adopt DASH eating plan
Consume a diet rich in fruits, vegetables, and
low-fat dairy products with a reduced content
of saturated and total fat
8 to 14 mmHg
Dietary sodium reduction
Reduce dietary sodium intake to no more
than 100 mEq/day (2.4 g sodium or 6 g
sodium chloride)
2 to 8 mmHg
Physical activity
Engage in regular aerobic physical activity
such as brisk walking (at least 30 minutes per
day, most days of the week)
4 to 9 mmHg
Moderation of alcohol consumption
Limit consumption to no more than two
drinks per day in most men and no more
than one drink per day in women and lighter-
weight persons
2 to 4 mmHg

22. Essential HTN
• Thiazide-type diuretics
• Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II
receptor blockers (ARBs)
• Calcium channel blockers
• Beta blocker in compelling indication like CAD

23. ALLHAT trial
• Compared to chlorthalidone,
there was no significant
difference with amlodipine
(relative risk 0.98) or lisinopril
(relative risk 0.99 percent) at a
mean of 4.9 years.

24. Individual medication in higher doses cause
significant side effect :

25. Individual medication in higher doses cause
significant side effect

26. Compelling indications
Indication or contraindication Antihypertensive drugs
Compelling indications (major improvement in outcome independent of blood pressure
Heart failure with reduced ejection fraction ACE inhibitor or ARB, beta blocker, diuretic, aldosterone antagonist*
Postmyocardial infarction ACE inhibitor or ARB, beta blocker, aldosterone antagonist
Proteinuric chronic kidney disease ACE inhibitor or ARB
Angina pectoris Beta blocker, calcium channel blocker
Atrial fibrillation rate control Beta blocker, nondihydropyridine calcium channel blocker
Atrial flutter rate control Beta blocker, nondihydropyridine calcium channel blocker
Likely to have a favorable effect on symptoms in comorbid conditions
Benign prostatic hyperplasia Alpha blocker
Essential tremor Beta blocker (noncardioselective)
Hyperthyroidism Beta blocker
Migraine Beta blocker, calcium channel blocker
Osteoporosis Thiazide diuretic
Raynaud phenomenon Dihydropyridine calcium channel blocker

27. Cont.
Contraindications
Angioedema Do not use an ACE inhibitor
Bronchospastic disease Do not use a non-selective beta blocker
Liver disease Do not use methyldopa
Pregnancy (or at risk for) Do not use an ACE inhibitor, ARB, or renin inhibitor (eg, aliskiren)
Second- or third-degree heart block
Do not use a beta blocker, nondihydropyridine calcium channel blocker unless a
functioning ventricular pacemaker
Drug classes that may have adverse effects on comorbid condition
Depression Generally avoid beta blocker, central alpha-2 agonist
Gout Generally avoid loop or thiazide diuretic
Hyperkalemia Generally avoid aldosterone antagonist, ACE inhibitor, ARB, renin inhibitor
Hyponatremia Generally avoid thiazide diuretic
Renovascular disease Generally avoid ACE inhibitor, ARB, or renin inhibitor
Depression Generally avoid beta blocker, central alpha-2 agonist

28. PREGRNCY HTN
Gestational hypertension
•New onset of systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least 2 occasions 4 hours apart after
20 weeks of gestation in a previously normotensive woman
•And:No proteinuria
•No severe features of preeclampsia (thrombocytopenia, renal insufficiency, elevated liver transaminases, pulmonary edema,
cerebral or visual symptoms)
Preeclampsia
•New onset of systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least 2 occasions at least 4 hours
apart after 20 weeks of gestation in a previously normotensive woman or systolic blood pressure ≥160 mmHg or diastolic blood
pressure ≥110 mmHg confirmed within a short interval (minutes) to facilitate timely antihypertensive therapy
•And:Proteinuria (≥300 mg per 24-hour urine collection [or this amount extrapolated from a timed collection], or protein:creatinine
ratio ≥0.3, or urine dipstick reading ≥1+ [if other quantitative methods are not available])
•Or, in the absence of proteinuria, new-onset hypertension with the new onset of any of the following:Thrombocytopenia
(platelet count <100,000/microL)
•Renal insufficiency (serum creatinine of >1.1 mg/dL [97 micromol/L] or a doubling of the serum creatinine concentration in the
absence of other renal disease)
•Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration
•Pulmonary edema
•Persistent cerebral or visual symptoms
Preeclampsia with severe
features
•Any of these findings in a patient with preeclampsia:Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg
on 2 occasions at least 4 hours apart while a patient is on bed rest (unless antihypertensive therapy is initiated before this time)
•Thrombocytopenia (platelet count <100,000/microL)
•Impaired liver function as indicated by liver transaminase levels at least twice the normal concentration or severe persistent right
upper quadrant or epigastric pain unresponsive to medication and not accounted for by alternative diagnoses, or both
•Progressive renal insufficiency (serum creatinine concentration >1.1 mg/dL [97 micromol/L] or a doubling of the serum creatinine
concentration in the absence of other renal disease)
•Pulmonary edema
•Persistent cerebral or visual disturbances
Eclampsia •In a patient with preeclampsia, generalized seizures that cannot be attributed to other causes

29. Cont.
HELLP syndrome
•Presence of HELLP syndrome in a pregnant woman; hypertension may be present
(HELLP in such cases is often considered a variant of preeclampsia)
Chronic (preexisting) hypertension
•Hypertension diagnosed or present before pregnancy or before 20 weeks of
gestation. Hypertension that is first diagnosed during pregnancy and persists at
least 12 weeks post-delivery is also considered chronic hypertension.
• The blood pressure criteria are systolic blood pressure ≥140 mmHg,
diastolic blood pressure ≥90 mmHg, or both. Ideally, this diagnosis is
based on at least 2 elevated blood pressure measurements taken at
least 4 hours apart. In the setting of severe hypertension, the
diagnosis can be confirmed in a shorter interval to facilitate timely
treatment.
Chronic hypertension with superimposed preeclampsia*
•Any of these findings in a patient with chronic hypertension:A sudden increase
in blood pressure that was previously well-controlled or an escalation of
antihypertensive therapy to control blood pressure
•New onset of proteinuria or sudden increase in proteinuria in a patient with
known proteinuria before or early in pregnancy
Chronic hypertension with superimposed preeclampsia with severe features
•Any of these findings in a patient with chronic hypertension and superimposed
preeclampsia:Systolic blood pressure ≥160 mmHg or diastolic blood pressure
≥110 mmHg despite escalation of antihypertensive therapy
•Thrombocytopenia (platelet count <100,000/microL)
•Impaired liver function as indicated by liver transaminase levels at least twice the
normal concentration or severe persistent right upper quadrant or epigastric pain
unresponsive to medication and not accounted for by alternative diagnoses, or
both
•New-onset or worsening renal insufficiency
•Pulmonary edema
•Persistent cerebral or visual disturbances

30. Antihypertensive agents used for urgent blood pressure
control in pregnancy:
Labetalol
20 mg IV gradually over 2 minutes.
•Repeat BP measurement at 10-minute intervals:If BP remains above
target level at 10 minutes, give 40 mg IV over 2 minutes.
•If BP remains above target level at 20 minutes, give 80 mg IV over 2
minutes.
•If BP remains above target level at 30 minutes, give 80 mg IV over 2
minutes.
•If BP remains above target level at 40 minutes, give 80 mg IV over 2
minutes.
Cumulative maximum dose is 300 mg. If target BP is not achieved, switch
to another class of agent.
A continuous IV infusion of 1 to 2 mg/minute can be used instead of
intermittent therapy or started after 20 mg IV dose.
Requires use of programmable infusion pump and continuous
noninvasive monitoring of blood pressure and heart rate.
Adjust dose within this range to achieve target blood pressure.
Cumulative maximum dose is 300 mg. If target BP is not achieved, switch
to another class of agent.
Hydralazine
5 mg IV gradually over 1 to 2 minutes.*
Adequate reduction of blood pressure is less predictable than with
IV labetalol.
•Repeat BP measurement at 20-minute intervals:If BP remains above
target level at 20 minutes, give 5 or 10 mg IV over 2 minutes, depending
on the initial response.
•If BP remains above target level at 40 minutes, give 10 mg IV over 2
minutes, depending on the previous response.
Cumulative maximum dose is 30 mg. If target BP is not achieved, switch
to another class of agent.

31. Cont.
Nifedipine extended release 30 mg orally.
If target BP is not achieved in 1 to 2 hours, another
dose can be administered.
If target BP is not achieved, switch to another class
of agent.
Nicardipine (parenteral)
The initial dose is 5 mg/hour IV by infusion pump and can
be increased to a maximum of 15 mg/hour.
Onset of action is delayed by 5 to 15 minutes; in general,
rapid titration is avoided to minimize risk of overshooting
dose.
Requires use of a programmable infusion pump and
continuous noninvasive monitoring of blood pressure and
heart rate.
Adjust dose within this range to achieve target BP.
Nifedipine immediate
release*
10 mg orally.
May be associated with precipitous drops in BP in some
women, with associated FHR decelerations for which
emergency cesarean delivery may be indicated. As such,
this regimen is not typically used as a first-line option and
is usually reserved only for women without IV access. If
used, FHR should be monitored while administering
short-acting nifedipine.
•Repeat BP measurement at 20-minute intervals:If
BP remains above target at 20 minutes, give 10 or
20 mg orally, depending on the initial response.
•If BP remains above target at 40 minutes, give 10
or 20 mg orally, depending on the previous
response.
If target BP is not achieved, switch to another class
of agent.

32. Drug doses for oral treatment of hypertension in
pregnancy
Drug Class Initial dose
Usual effective dose
range
Maximum
suggested total
daily dose
Comments
Labetalol
Combined alpha and beta
blocker
100 mg 2 times daily,
increase by 100 mg twice
daily every 2 to 3 days as
needed
200 to 800 mg in 2 divided
doses
2400 mg
Can cause
bronchoconstriction. Avoid in
women with asthma, chronic
obstructive lung disease,
heart failure, bradycardia, or
greater than first-degree
heart block.
Hydralazine
NOTE: Due to reflex
tachycardia, monotherapy
with oral hydralazine is not
recommended;
hydralazine may be
combined with
methyldopa or labetalol if
needed as add-on therapy
Peripheral vasodilator
Begin with 10 mg 4 times
per day, increase by 10 to
25 mg/dose every 2 to 5
days
50 to 100 mg in 2 to 4
divided doses
200 mg
Nifedipine extended
release
¶ Calcium channel blocker
30 to 60 mg once daily as
an extended release
tablet, increase at 7 to 14
day intervals
30 to 90 mg once daily 120 mg
Do not administer
sublingually.

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