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Hypertension (Ref. Hari. 18th ed., pg - 2047)

Extra Edge: Hypertension (also known as Silent killer disease) Rule of half applies to it (MCQ)

Recent Advances: 
(Ref. Hari. 18th ed., pg -2047, table 241-1) 


Measuring blood pressure 
  1. Cuff width should be > 80%Q of the arm circumference. (AIPG 2012)
  2. Systolic pressure. The appearance of sustained repetitive tapping sound (Korotkoff 1 Q)
  3. Diastolic pressure usually the disappearance of sounds (Korotkoff V Q)
  4. In some individual (eg. pregnant women) sounds are present until the zero point.
  5. In this case the muffing of sounds (Korotkoff IV Q) should be used. 

White coat hypertension = BP is high in the hospital / clinic but BP is normal at home.


Ankle brachial index (LQ 2012)

  1. It is the ratio of Systolic BP at ankle / systolic BP of arm.
  2. It indicate the degree of lower extremity arterial occlusive disease.
  3. ABI < 0.9 = abnormal
  4. ABI < 0.3 = critical ischemia for peripheral arterial disease. 

Recent Advances
Cilostazol is used in the alleviation of the symptom of intermittent claudication in individuals with peripheral vascular disease

Recent Advance -  J-curve phenomenon

  1. People with high BP and/or high blood cholesterol levels have a greater risk of developing cardiovascular diseases (CVD).
  2. The higher the BP and/or cholesterol level, the greater the risk. We also know that lowering blood pressure and cholesterol levels lowers the risk for CVD.
  3. When the BP or blood cholesterol levels of large groups of people are plotted on a graph against CVD mortality, it often results in a J-shaped curve.
  4. This curve shows that those with higher BP and/or cholesterol levels, closer to the top of the curve, are more likely to die from CVD.
  5. The curve also shows that those at the lowest end of the curve (with very low BP and/or low cholesterol levels) also have higher CVD mortality. This accounts for the J shape and is known as the J-curve phenomenon. (Ref. Hari. 18th ed., Pg-2058)  

Pseudohypertension (Osler’s Sign) Isolated systolic hypertension (ISH):

  1. Pseudohypertension is when only systolic blood pressure (>140) is elevated.
  2. Pseudohypertension is almost always found in older patients.
  3. As people get older, the walls of the arteries sometimes get very thick, and calcium may be deposited in the arterial wall (arteriosclerosis). This makes the arteries very stiff and difficult to compress.
  4. Because measuring blood pressure depends on measuring how much force it takes to compress an artery, having thick, difficult-to-compress arteries falsely elevates the sphygmomanometer reading.
  5. It is not benign Q: It has doubles risk of MI, triples risk of CVA

Treatment : Diuretics, Calcium channel blocker

Essential hypertension
(primary, cause unknown). Seen in 95% of cases of HT.

Secondary hypertension
"5% of cases.


Table 247-2 Systolic Hypertension with Wide Pulse Pressure (Ref. Hari. 18th ed., Page - 1554,Table 247-2)

  1. Decreased vascular compliance (arteriosclerosis)
  2. Increased cardiac output
    1. AR (LQ 2012)
    2. Thyrotoxicosis
    3. Hyperkinetic heart syndrome
    4. Fever
    5. Arteriovenous fistula
    6. Patent ductus arteriosus
    7. Pregnancy
    8. Beri Beri

Causes of secondary hypertension

Renal disease: The most common Q secondary cause.

  1. Glomerulonephritis, (Acute & Chronic)
  2. Chronic pyelonephritis,
  3. Renovascular disease (Renal artery stenosis)  most frequently atheromatous (elderly, cigarette smokers with periphery vascular disease) or fibro muscular dysphasia Q  in young patients.
    RAS, can occur in Takayasu disease but it does not occur in PAN. (LQ, AIPG 2010)
  4. Polycystic kidneys.
  5. Renin secreting tumor. 

Extra Edge:

  1. Renovascular Hypertension (Ref. Hari. 18th ed., pg - 2049)
    1. As a screening test, renal blood flow may be evaluated with a radionuclide [131I]-orthoiodohippurate (OIH) scan or glomerular filtration rate may be evaluated with a DTPA scan before and after a single dose of captopril (or another ACE inhibitor).
    2. Gadolinium-contrast magnetic resonance angiography offers clear images of the proximal renal artery but may miss distal lesions.
    3. Contrast arteriography remains the "gold standard" for evaluation and identification of renal artery lesions.
  2. Endocrine disease: Cushing's Q, Conn's syndromes Q, pheochromocytoma Q, acromegaly Q , Hyperparathyroidism. Q Hypothyroid, Hyperthyroid.
  3. Connective tissue disorders - PAN, systemic sclerosis, Takayasu disease.
  4. Others: Coarctation Q, porphyria Q, Guillain Barre syndrome
  5. Pregnancy Q
  6. Drugs : steroids Q, MAOI, oral contraceptive Pill', Amphetamine, Alcohol, NSAID

Table 247–4. Example of Mendelian Forms of Hypertension (Ref. Hari. 18th ed., pg - 2051) 

Autosomal recessive

Autosomal dominent

1. 17α-hydroxylase deficiency

2. 11β-hydroxylase deficiency

3. 11β-hydroxysteroid dehydrogenase deficiency (apparent mineralocorticoid excess syndrome)

1. Liddle's syndrome

2. Pseudohypoaldosteronism type II (Gordon's syndrome)

3. Polycystic kidney disease

4. Pheochromocytoma


Hypertensive retinopathy


  1. Tortuous with thick shiny walls                                
  2. A-V nipping (narrowing where arteries cross veins)
  3. Flame hemorrhages and cotton wool spots               
  4. Papilledema 

Hypertension – Management

Basic Physiology of BP

Physiological Parameters on which BP depends

  1. Cardiac output
  2. Peripheral resistance            
  3. Blood volume
BP = Cardiac output (COP) x Peripheral resistance (PR)
COP = Heart Rate (HR) x Stroke volume (SV)

BP =  HR x SV x PR

(Mean Arterial Pressure = Diastolic BP + 1/3 pulse presence)


  1. Drugs which reduce HR
    1. Beta blockers
    2. Ivabridine ( acts on funny Na channels)

Uses of Beta blockers (In hypertensive patients)

  1. Angina (LQ 2012)             
  2. MI                
  3. Hyperthyroidism

Contraindication of beta blockers

  1. Erectile dysfunction Q
  2. Peripheral vascular disease Q
  3. Pheochromocytoma, (If given alone). Should be given only with alpha blockers. Q
  4. CHF Q 
  1. Drugs which reduce stroke volume
    1. Beta blockers (beta blockers have negative inotropic & negative chronotropic effects) so beta blocker should be used with cautious or should be avoided in CHF with HT.
    2. Diuretics: They reduce blood volume so they reduce the preload Q
      1. Uses in hypertension
        1. HT with CHF
      2. Contraindication in HT
        1. HT with hyperuricemia Q
        2. Pheochromocytoma Q
        3. Thiazides are Contra Indicated in diabetes Q  
    3. Nitrates: They primarily dilate the venules thereby they cause peripheral pooling of the blood. So they reduce the preload.
Uses of nitrates in HT (AIIMS Nov 2012)
  1. HT with CHF Q
  2. HT with CAD Q
  3. Severe hypertension Q 
  1. Drugs which reduce the peripheral resistance
    1. Alpha blockers          
    2. Calcium channel blockers        
    3. ACEI          
    4. Direct vasodilators
  1. Alpha blockers: They act on the peripheral alpha receptors thereby dilate the arteriole.
    Examples: Prazosin,
    Uses of alpha blockers in hypertension
    1. Elderly Q                            
    2. HT with BHP
    3. HT with CRF              
    4. HT with hyperuricemia
  2. Calcium channel blockers : They dilate the arteriole so reduce the peripheral resistance
    Example: Nifedipin
  1. Elderly hypertensive                        
  2. HT with CRF
  3. HT with PVD                              
  4. HT with SAH (Nimodipine is used) (MCQ)
  1. HT with CAD        
  2. Malignant hypertension            
  3. HT with CHF 

New Drug: Clevidipine is a dihydropyridine calcium channel blocker indicated for the reduction of blood pressure when oral therapy is not feasible or not desirable. (Its name is not given in 18th Edition of Harrison)!!!

  1. ACEI:
    Examples: Captopril, Lisinopril
    Uses in HT
    1. Young patients          
    2. Unilateral renal artery stenosis                    
    3. HT with DM
    4. HT with CHF            
    5. HT with MI                                    
    6. HT with hyperuricemia
    7. HT with erectile dysfunction

Side Effects: Cough (M/C), Hyperkalemia (LQ, AIIMS Nov 2010), Angioneurotic edema, First dose hypotension.

Captopril causes leukopenia & nephrotic syndrome.


  1. Bilateral renal artery stenosis                    
  2. CRF
  3. With potassium sparing diuretics                
  4. Pregnancy
  1. Direct Vaso dilators
    Example:  Hydralazine, alpha Methyl dopa, Sodium nitroprusside, indapamide
    1. Hydralazine
      Pregnancy with HT
      Side effect : SLE like syndrome
    2. Alpha methyl dopa
      Pregnancy with HT
      Side effects: Coombs positive hemolytic anemia, black tongue
    3. Sodium nitroprusside
      Uses:  Hypertensive emergencies, Malignant hypertension
    4. d Indapamide
      1. HT with hyperuricemia            
      2. HT with CRF
      3. HT with diabetes                    
      4. Elderly hypertensive 

Extra Edge: (Ref. Hari. 18th ed., pg - 2010)  

  1. Verapamil ordinarily should not be combined with beta blockers because of the combined adverse effects on heart rate and contractility.
  2. Diltiazem can be combined with beta blockers in patients with normal ventricular function and no conduction disturbances.
  3. Amlodipine and beta blockers have complementary actions on coronary blood supply and myocardial oxygen demands. 

Recent Advances:

  1. Bosentan is a new drug. It is a endothelin receptor antagonist. It is a vaso dilator It has been approved for PAH and for Raynaud’s phenomena.
  2. Aliskiren is a new drug. It is a non-peptide renin inhibitor that acts by inhibiting conversion of angiotensin-I to angiotension-II. It is used in hypertension. (Ref. Hari. 18th ed., pg - 2055) 
  3. Fenoldopam has a peripheral vasodilatory action which acts as a peripheral selective D1 receptor weak partial agonist.  It is given as continuous IV infusion for the treatment of hypertensive emergencies. (It is a new drug not given in Harrison 18th Edition)
  4. Naftopidil – It is an antihypertensive drug which acts as a selective α1-adrenergic receptor antagonist or alpha blocker.
  5. Urapidil –It acts as an α1-adrenoceptor antagonist and as an 5-HT1A receptor agonist (It is a new drug not given in Harrison 18th Edition) 
Resistant Hypertension
  1. It refers to patients with BP persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in reasonable combination and at full doses.
  2. Resistant hypertension may be related to
    1. "Pseudoresistance" (high office blood pressures and lower home blood pressures),
    2. Non adherence to therapy,
    3. Identifiable causes of hypertension (including obesity and excessive alcohol intake), and use of any of a number of nonprescription and prescription drugs.
    4. Rarely, in older patients, pseudohypertension may be related to the inability to measure blood pressure accurately in severely sclerotic arteries. This condition is suggested if the radial pulse remains palpable despite occlusion of the brachial artery by the cuff (Osler maneuver).
  3. The actual blood pressure can be determined by direct intraarterial measurement (Ref. Hari. 18th ed., pg - 2058)
Malignant hypertension
  1. A hypertensive emergency (formerly called "malignant hypertension") is severe hypertension with acute impairment of one or more organ systems (especially the central nervous system, cardiovascular system and/or the renal system) that can result in irreversible organ damage.
  2. So in Malignant hypertension. Abrupt increasing in BP, clinically has very high BP associated with papilledema, proteinuria, microangiopathic hemolytic anemia and encephalopathy.)
  3. In a hypertensive emergency, the blood pressure should be substantially lowered over a period of minutes to hours with an antihypertensive agent.
  4. Complications of malignant hypertension  Q :
    1. acute renal failure,
    2. heart failure,
    3. encephalopathy,
    4. CAD
  5. Pathological hallmark is fibrinoid necrosis Q.
  6. Treatment: Avoid sudden drops in BP as cerebral autoregulation is poor

Table 247–10. Antihypertensive Agents Used in Hypertensive Emergencies. (Ref. Hari. 18th ed., pg - 2058)


  1. Nitroprusside (LQ 2012)
  2. Nicardipine
  3. Labetalol (LQ 2012)
  4. Esmolol
  5. Phentolamine
  6. Nitroglycerin (LQ 2012)
  7. Hydralazine
  8. Fenoldopam (LQ 2012)

Recent Advances:

  1. Previously sublingual nifedipine and injection frusemide were used in severe hypertension. But now both these drugs are contraindicated in severe hypertension. 
  2. Never use sublingual nifedipine Q to reduce BP (big drop in BP and increase CAD risk) (PNQ)
  3. Injection frusemide should not be used in severe HT But can be used in severe HT with LVF. (PNQ)

Hypertensive urgency

  1. Sometimes, patients can have very high blood pressure but have no symptoms.
    In these cases, the elevated BP is discovered incidentally. These cases – severe high BP without serious symptoms – are called hypertensive urgency.
  2. Hypertensive urgency indicates that the blood pressure is high enough to cause serious risk of sudden, life threatening events, but that no such events are currently occurring.
  3. In other words, these patients have no organ failure or other immediately life threatening conditions, but could quickly develop them if their blood pressure isn’t quickly brought under control.
  4. Patient should be treated on the OPD basis.(i.e. Hospitalization not needed)
Diet in Hypertensive patient:
The DASH Diet Eating Plan
The DASH (Dietary Approaches to Stop Hypertension) diet is recommended to many people with hypertension.
The DASH diet provides more than the traditional low salt or low sodium diet to reduce blood pressure. It is based on an eating plan rich in fruits and vegetables, and low-fat or non-fat diet

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