✅Hypertension in adults

🔹Definition and diagnosis

💡Diagnosing hypertension requires a series of repeated blood pressure measurements either automated office blood pressure monitoring (AOBPM) in the office, or using ambulatory blood pressure monitoring(ABPM) or self-measured blood pressure. (table)
☝🏻ABPM is the preferred method.

❗️Rather than an auscultatory device (one that requires a stethoscope), we recommend using an oscillometric blood pressure device designed specifically for the office setting.

❗️blood pressure should be measured in both arms, at least at the initial visit.

▪️In older individuals or those with potential orthostatic symptoms, postural measurements should also be taken.⤵️

1⃣ SBP readings in the left and right arms should be roughly equivalent. A discrepancy of more than 15 mmHg may indicate subclavian stenosis and, hence, peripheral arterial disease.
• If there is a significant difference in blood pressure between the two arms, the higher of the two should be used for measurement at subsequent visits.

2⃣ Postural hypotension, defined as a 20 mmHg or greater fall in systolic pressure upon rising from supine to an unassisted upright position, should be pursued in patients over age 65 years, those experiencing dizziness or weakness upon standing, or those with diabetes or Parkinson disease.


🔎A diagnosis can be made, without further confirmatory readings, in the following uncommon scenarios:
• A patient who presents with hypertensive urgency or emergency (ie, patients with blood pressure ≥180 mmHg systolic or ≥120 mmHg diastolic).
• A patient who presents with an initial blood pressure ≥160 mmHg systolic or ≥100 mmHg diastolic and who also has known target end-organ damage (eg, left ventricular hypertension [LVH], hypertensive retinopathy, ischemic cardiovascular disease)

▪️Staging of BP

▫️Normal~ SBP <120 mmHg and DBP <80 mmHg

▫️Elevated~ SBP 120 to 129 mmHg and DBP <80 mmHg

▫️Hypertension
• Stage 1 ~ SBP 130 to 139 mmHg or DBP 80 to 89 mmHg
• Stage 2 ~ SBP ≥140 mmHg or DBP ≥90 mmHg
• Severe hypertension ~ SBP >180 mmHg or DBP >120 mmHg

▫️Isolated SBP~ SBP≥130 mmHg  and DBP <80 mmHg

▪️Evaluation

• Consider precipitating or aggravating factors (including prescription medications, nonprescription NSAIDs, and alcohol consumption

▫️Lab(in all patients with newly diagnosed hypertension):
• Electrolytes ,including calcium
• Serum creatinine (to calculate the estimated glomerular filtration rate)
• Fasting glucose
• Urinalysis
• Complete blood count
• Thyroid-stimulating hormone
• Lipid profile
• Electrocardiogram
• Calculate 10-year atherosclerotic cardiovascular disease risk

💡Additional tests if needed
• Urinary albumin to creatinine ratio~in all patients with diabetes or chronic kidney disease
• Echocardiography~ if available for detecting of LVH

🔹Initial treatment by BP stage (apart from lifestyle modification)

💡We have some classes of drugs for first-line therapy(table)

1️⃣Thiazide-like or thiazide-type diuretics
• Hydrochlorothiazide(12.5mg/ 25mg)
• Indapamide(0.625mg/ 1.25mg/ 2.5mg); it is preferred over Hydrochlorothiazide.

2️⃣Long-acting CCBs (most often dihydropyridine)
• Amlodipine(2.5mg/ 5mg/ 10mg)

3️⃣ACE inhibitors
• Enalapril(5mg/ 10mg)

4️⃣ARBs
• Losartan(50mg/ 100mg)
• Telmisartan(40mg/ 80mg)
• Valsartan(80mg/ 160mg/ 320mg)

🔎که توی ایران هم داروهای ترکیبی اینارو زدن و میتونین از اپلیکیشن و سایت "دارویاب" استفاده کنید. مثلا ترکیبهای (آملودیپین+والزارتان/
تلمیزارتان)

▪️Severe hypertension (SBP >180 mmHg and/or DBP >120 mmHg):

💊Refer to the hypertension crisis topic

▪️Stage 2 hypertension (SBP 140 to 180 mmHg and/or DBP 90 to 120 mmHg):

💊We suggest initial combination therapy with low to
moderate doses of two agents (a single-pill combination is preferred rather than the two agents as separate pills)

1️⃣Combining an ACE inhibitor or ARB with a dihydropyridine calcium channel blocker is preferred.