2.  In this overview, we draw inspiration from the
article titled "Managing Hypertension in
Primary Care“, published in the Canadian Family
Physician journal (Vol 65: October 2019).
 The article, edited by Khrystine Waked PharmD,
Jeff Nagge PharmD, and Kelly Grindrod PharmD
MSc,.
 It provides valuable insights and evidence-based
approaches to tackle Hypertension
Management In Primary Care.
 By incorporating the recommendations
discussed in this article, we can enhance our
ability to manage hypertension and ultimately
improving patient outcomes and quality of life.

3.  Hypertension is one of the most
common reasons for patients to
visit their family physicians.
 Most patients with HTN are
managed in a primary care
setting by family physicians
rather than other specialists.
 With cardiovascular disease
being one of the leading causes
of death, improved
management of HTN is key in
reducing CV risk.
 Authors considered evidence
from landmark trials and
recommendations from
Canadian and American
guidelines.
 The article supports primary
care physicians with the
management of HTN.
 It support patients with self-
measurement of blood pressure
at home.

4.  ACC: American College of Cardiology.
 NYHA: New York Heart Association.
 JNC: Joint National Committee.
 AHA: American Heart Association.
 ESC: European Society of Cardiology.
 ESH: European Society of Hypertension.
 ASH: American Society of Hypertension.
 ISH: International Society of Hypertension.
 NICE: The National Institute for Health and Care
Excellence.

5.  For Primary Prevention (no history of
CV risk factors), start HTN drugs once
the BP exceeds 160/100 mm Hg.
 For Secondary Prevention (history of
heart attack or stroke) or patients
with a 10-year CV risk score of 15% or
higher, start HTN drugs once the BP
exceeds 140/90 mm Hg.
 For patients with DIABETES (type 1 or
2), HTN drugs should be started once
the BP exceeds 130/80 mm Hg.

6.  To start, prescribe the
lowest available dose of a
first-line antihypertensive
drug and schedule a follow-
up visit 4 weeks later.
 This is the approach used in
several landmark
antihypertensive trials such
as ALLHAT and SPRINT.

7.  ALLHAT study demonstrated
that CHLORTHALIDONE lowers
CV risk more than amlodipine
and lisinopril.
 Chlorthalidone is longer acting
and has more consistent
evidence supporting its blood
pressure lowering and CV risk
lowering effects than
Hydrochlorothiazide.

8.  Strong evidence suggests that most
patients taking an
antihypertensive medication
should aim for a BP level below
140/90 mm Hg.
 Evidence suggests that patients
who have diabetes should aim for a
level below 130/80 mm Hg.
 High-risk patients with specific CV
risk factors might aim for a systolic
goal of 120 mm Hg.

12.  Doctors might find it helpful to ask
patients to monitor their blood
pressure at home if they suspect a
White-Coat effect.
 To ensure accurate results are
obtained, patients should be
taught proper technique.
 The patient can also check his
blood pressure before a doctor’s
appointment or after starting anew
medication for blood pressure.

13.  Before initiating or adjusting the
doses of ACEIs, ARBs, or diuretics,
electrolyte and serum creatinine
levels should be measured at
baseline.
 Once the drug or new dose has been
started, the same laboratory
parameters should be measured
within 1 to 2 weeks.
 Patients at higher risk of
hyperkalemia or acute kidney injury
should get bloodwork within 7 days.
s. creatinine
s. electrolyte

14.  If serum creatinine levels rise higher than 30% over baseline after starting an
ACEI or ARB, the drug should be stopped and recheck creatinine in 3 days.
 If the level increase is from a temporary cause such as dehydration, the drug
can be restarted once the event is resolved.
 If no cause is identified, consider the possibility of renal artery stenosis or a
drug-induced kidney injury.
 With both options, the drug should be discontinued, an appropriate lab workup
should be requested and the patient might require referral to nephrology.
 ACE inhibitors and ARBs can also increase serum potassium concentrations.
 A serum potassium level higher than 5.6 mmol/L generally requires a dose
reduction or discontinuation of the medication.

15.  Hypertension is considered resistant if BP
remains above goal in spite of the
concurrent use of 3 antihypertensive
agents of different classes at optimal or
best tolerated doses.
 The common causes include patient
nonadherence to the prescribed
medications and diet, a suboptimal
medication regimen, drug interaction, and
office hypertension. Secondary
hypertension should also be considered.
 Spironolactone has been shown to lower BP
in patients with resistant hypertension.

16.  If you suspect your patient is
experiencing a hypertensive
emergency, refer him to the hospital.
 Hypertensive emergencies are
characterized by acute target organ
damage (kidneys, heart, or brain) with
elevated blood pressure level.
 There is no specific blood pressure
measurement that defines a
hypertensive emergency, as it is
dependent on the signs or symptoms of
organ damage.
 Nausea
 Vomiting
 Confusion
 Sudden shortness of breath
 Heavy chest pain
 Sharp tearing chest and back pain
Signs or Symptoms

17.  It is “The Antihypertensive Lipid-Lowering Treatment to Prevent Heart
Attack Trial”
 It is a landmark clinical trial conducted in the US under the auspices of
the National Heart Lung and Blood Institute (NHLBI).
 The trial began in 1994 and concluded in 2002 and enrolled over 40,000
participants with hypertension aged 55 years or older.
 It was designed to compare the effectiveness of 3 different types of
antihypertensive medications, Chlorthalidone, Amlodipine, and
Lisinopril, in preventing heart disease and reducing CV events.
 It demonstrated the efficacy of diuretics as a first-line treatment for
hypertension and CVD prevention.

18. Pharmacological
Management of
Hypertension
in Older Adults

19.  Comorbidities.
 Frailty of the patient.
 Ability to follow instructions.
 Complexity of the current
regimen.
 Supporting care (spouses and
family).
 Electrolytes and renal function.

20.  Thiazide diuretics are the preferred
first-line treatment in older adults as
they lower CV morbidity and
mortality.
 Thiazide diuretics, ACEI, ARB, and CCB,
have all shown benefit on CVD
outcomes in older age patients.
 Elderly are less responsive than
younger adults to β blockers as a sole
agent.
 β blockers are effective in patients
with CAD, AF, and left ventricular
systolic dysfunction.

21.  Usually, a combination of
different agents is needed to
achieve adequate BP control in
elderly.
 Any of the 4 first line BP
medications can be combined.
 RAAS blockers and CCB/Thiazide
is the preferred combination.
 Guidelines recommend treat
Isolated HTN with a CCB or
Diuretic.
RAAS
blockers
+
Amlodipine
+
Thiazide

22.  Single pill combination (polypill) can
be utilized with the added benefit of
improving medication compliance.
 The medications should then be up
titrated, with additional medications
added as needed to achieve BP
targets.
 Initiation of any medication should be
done with assessment of orthostatic
hypotension and gradual titration
according to tolerance.

23.  Renal Function should be assessed
to detect BP-related reductions in
renal perfusion.
 Hypokalemia is also an important
side effects of Thiazide diuretics
which needs to be monitored.
 The doctors needs to be cognizant
of treatment related Side Effects
which may occur more frequently.