Usually asymptomatic and discovered on routine measurement of blood pressure. Secondary hypertension presents as a part of a symptom complex as in acromegaly, cushings disease, renovascular or renal parenchymal disease, connective tissue disorders or coarctation of aorta

Features:

·       Non-specific symptoms are fatigue, headache, epistaxis

·       Uncontrolled hypertension can lead to target organ damage such as coronary artery disease(CAD), LVH, CVA, TIA, retinopathy, PVD, renal disease

·       Associated risk factors are age >55years in males and >65 years in females, smoking, diabetes mellitus, hyperlipidemia, family history, obesity, sedentary lifestyle and ethnic group

Precautions to be taken while measuring BP:

The auscultatory method of BP measurement with a properly calibrated and validated instrument should be used. BP should be measured using an appropriate size cuff, bladder length 80% of arm circumference and width 40% of arm length in both upper limbs and atleast one lower limb in both supine and erect posture. Patient should have been resting for atleast 5 minutes and should not have consumed coffee or smoked during the last 30 minutes before measuring the BP. At least 2 measurements should be made. Systolic BP is the point at which the first of 2 or more sounds are heard and diastolic BP is the point before the disappearance of sounds

Management:

1. Reduce dietary sodium intake to no more than 100 mmol per day

2. Lifestyle modification- exercise like brisk walking, swimming or jogging at-least 20-30 minutes in a week

3. Weight control using a combination of dietary and exercise measures to maintain normal body weight

4. Moderation of alcohol consumption

5. Cessation of smoking

6. Control of other risk factors

7. Antihypertensive drug choices:

a)     Diuretics-elderly, obese, heart failure

b)     Beta blockers-young, CAD, vascular headache, AF

c)     Calcium channel blockers-old age, CAD, AF, PSVT

d)     ACE inhibitors-young, LVF, diabetes

e)     Alpha blockers-potassium, diabetes, dyslipidemia

8. Thiazide diuretics should be used with caution in patients with diabetes, gout or history of hyponatremia

9. Beta blockers should be avoided in patients with bronchial asthma, reactive airway diseases or second- or third-degree heart block

10. ACE inhibitors should not be used in patients with history of angioedema

11. Drug combination used for additive effect and minimization of the side effects

12. Hypertension in pregnancy is treated with alpha methyldopa, beta blockers, vasodilators for safety of the foetus

Commonly used antihypertensive drugs are:

1.     Tab Hydrochlorothiazide 12.5-25 mg OD or BD

2.     Tab Benzthiazide 25mg+Triamterene 50 mg per day

3.     Tab Indapamide 2-5 mg daily

4.     Tab Atenolol 25-100 mg daily or Metoprolol 25-150 mg BD (Caution- contraindicated in asthma, peripheral artery disease, uncontrolled hypothyroidism, myocardial defects)

5.     Tab Amlodipine 2.5-20 mg daily or Cap nifedipine 20-80 mg as sustained release daily (caution- may cause peripheral edema in some individual)

6.     Tab Enalapril 2.5 mg and maybe increased to 40 mg daily or Lisinopril 2.5- 20 mg daily (may cause dry cough in some individual)

7.     Tab Losartan 25-50 mg OD or BD or Telmisartan 40 mg orally OD

8.     Tab Prazosin 1-20 mg/day in divided doses; first dose given at bedtime

9.     Tab Terazosin 1-5 mg daily bedtime

10.  Tab Clonidine 0.1-0.6 mg BD

11.  Tab Methyldopa 25-1000 mg BD

12.  Accelerated Hypertension with sudden rise in BP 220/130mmHg or more without papilloedema - Hospitalize

-Inj Enalapril 1.25-5mg IV 6 hourly Or Inj Nitroprusside 0.25-1microgram/kg/min iV infusion (dose to be titrated Or Inj Nitroglycerin 5-100 microgram/min infusion Or Inj Labetalol 20-80 mg IV every 5-10 min up to a total of 300 mg Follow up should always be adviced to the patient of hypertension