Managing Raised Blood Pressure : Clinical practice Guidelines

BP ≥180/110 Asymptomatic : Asymptomatic

BP ≥ 130/85 and ≤180/110 severe hypertension Grade 3
Dedicated clinic visit for hypertension ( previously known
BP ≤ 130/85(Non-DM) 1. Clinical history
BP ≤ 130/80( DM pts) as Hypertension Urgency)
2. Physical examination ( including correct measurement of BP) Box2,3
3. Basic Investigations ( ECG,F Fasting sugar, Lipid profile, Renal Panel , eGFR, Electrolytes, TSH, Urinalysis) Symptomatic (Acute

Comprehensive lifestyle changes Box4

4. Out –of –office measurement- Home BP series/ ABPM series requested ToD): Consider
Emergency Hypertension
No hypertension
Commence treatment and review every 1-3
Monitor blood pressure over 4 weeks and invite for 2nd
clinic visit days until ≤ 160/100
Annual follow up Assess for cardiovascular risk factors box1

Treat all to a target of ≤ 140/90 except :

BP 130-139/ 85-89(Non-DM) BP 140-159 /90-99 BP ≥160/90 A target of ≤ 130/80 In

BP 130-139/80-89 (DM pts) ( stage 1 hypertension ) ( stage 2 hypertension ) 1. CKD with proteinuria
(High normal ) 2. Selected diabetic patients

Consider a target of ≤ 150/90

Any Risk Factors Box if older than 80 years old
3RFs or target organ Damage
Review every 6 m No or Cardiovascular Disease
If no RF review in 6 months yes
Commence treatment , review monthly tell
or Diabetes box target is met then 3-6 months

BOX 1 : cardiovascular Risk factors BOX 2 : Key Elements of Office Blood Pressure Assessment
• Age (men >55 years; women >65 years), smoking, obesity,  Avoid caffeine, exercise, smoking at least 30 minutes before the visit
dyslipidemia, diabetes, prediabetes, family history of premature  Relax, feet on floor with back supported for at least five minutes
CVD(men aged <55 years; women aged <65 years)  Empty bladder
 Refrain from talking during the rest period and measurement
• Target Organ damage: LVH, Atherosclerosis, CKD, (CKD stage1-  Remove all clothing covering the area where the cuff will be placed
3,ÄCR 30-300mg/g.),,  Use the correct cuff size and Support the patient’s arm Box2
 Position the middle of the cuff at the level of the heart
• Associated clinical conditions: CVA, IHD,HF, (CKD4-5 or  Repeated measurements by one to two minutes
ACR>300mg/g), PVD, Advanced hypertensive retinopathy.  Average of at least two measurements

BOX 4
BOX3 : cuff sizes
when to refer to secondary care
Arm Circumference Usual Cuff Size
22–26 cm Small adult
 Resistant HTN
27–34 cm Adult  Suspicion of secondary HTN
35–44 cm Large adult  Sudden onset of HTN References and further details, refer to
 HTN diagnosed at young age (30 years old) SHMS Clinical practice Guidelines https://bit.ly/SHMScpg18.
45–52 cm Adult thigh  Worsening of HTN
 Malignant HTN
“Home Blood Pressure measurement, using validated device is
highly Recommended”
Box 5 : common blood pressure medications pharmacological intervention

Thiazide diuretics Aldosterone Antagonist Alpha-adrenoceptor blockers

Common Agents: Hydrochlorothiazide, bendroflumethiazide, chlorthalidone Common Agents: spironolactone Common Agents: doxazosin , prazosin
Dose : Hydrochlorothiazide- 12.5-25mg daily, indapamide 1.5mg Dose : 25mg-100mg daily Dose : 1 mg once daily for 1 week then increase
Monitoring : check electrolytes regularly Contraindications : hyperkalemia, renal to 2 mg up to 4 mg once daily.
Contraindications: Hypercalcemia, Hyponatremia, symptomatic hyperuricemia failure Contraindications : history of micturition
Side Effects: Constipation, Diarrhea, Dizziness, Nausea, Postural Hypotension, electrolyte imbalance, urticarial Side Effects: Diarrhea, stomach cramps, syncope, postural hypotension.
Cautions: Hypokalemia, Elderly, Hepatic Failure Gynecomastia, headaches, rashes Cautions: postural hypotension with initial dose,
Hepatic Impairment: Avoid if severe irregular hair growth, impotence, low cataract surgery ( risk of floppy iris syndrome)
Renal Impairment: Avoid if eGFR is <30. platelets, liver dysfunction Side Effects: arrhythmias, chest pain, cough,
Pregnancy: Contraindicated Hepatic impairment: contraindicated cystitis, dizziness, dyspnea, GI discomfort,
Sick day rule: stop if vomiting and diarrhea until no risk of dehydration Renal Impairment: contraindicated headache, flu like illness, muscle complaint,
Pregnancy: Contraindicated palpitations, vertigo
Centrally acting antihypertensive Hepatic impairment: avoid in severe impairment
Common Agents: clonidine, methyldopa Renal Impairment: can be used
Dose : Clonidine 50-100 Micrograms 3 times a day , increase every second or third day . Maximum dose 1.2 mg
daily. methyldopa 250mg three times a day increase to maximum of 3 g per day every 2 -3 days. Beta blockers
Contraindications : 2nd or 3rd degree heart block , sick sinus syndrome. Common Agents: Atenolol, bisoprolol, carvedilol.
Caution: CVA, constipation, heart failure, depression, Raynaud's syndrome, PVD. Dose : Bisoprolol 5-10mg daily, Atenolol 25-100mg daily
Side Effects: clonidine: depression, GI upset, dry mouth , fatigue, headache, sedation, sexual disorders, sleep Contraindications : Severe Asthma and COPD.
disorders, postural hypotension. Methyldopa: amenorrhea, angioedema, bone marrow failure, breast Caution: Peripheral vascular disease
enlargement, cognitive impairment, facial paralysis, hepatic disorders, lupus- like syndrome, parkinsonism, Side Effects: Diarrhea, stomach cramps, blurring of vision, headaches, insomnia, hair loss,
psychosis. dizziness.
Treatment cessation: clonidine must be withdrawn gradually to avoid severe rebound hypertension. Renal Impairment: can be used.
Monitoring: Methyldopa – CBS & LFT before treatment and at intervals during first 6-12 weeks of if unexplained Pregnancy: Contraindicated except labetalol.
fever occurs.
Renal Impairment: can be used, start with smaller dose.
Pregnancy: use methyldopa

Box6: Life style modifications:

Calcium channel blockers ACE inhibitors/ARBs
Common Agents: Amlodipine, nifedipine, Common Agents: ACEi Ramipril, Lisinopril, Enalapril,
Intervention Effect on BP
felodipine ARB:losartan,valsartan,perindopril,Irbersartan,
Dose : Amlodipine- 5-10mg daily. Telmisartan Weight loss/ Healthy diet ,alcohol restriction 1 mm Hg for every 1-kg
Contraindications: Significant Aortic Stenosis. Dose : losartan-50-100mg daily, Enalarpil-10-20mg reduction in body weight
Nifedipine avoid within one month of MI daily
Caution: Avoid Nifedipine in elderly and Monitoring : check electrolytes regularly Low sodium intake (<1500 mg/d) -5/6 mm Hg
longstanding Diabetes(can cause reflex Contraindications: angioedema, bilateral renal artery
tachycardia) stenosis, allergic or adverse reaction to the drug.
More potassium (3500–5000 mg/d) -4/5 mm Hg
Side Effects: Headache, peripheral edema, Side Effects: Cough, hyperkalemia Dizziness,
dizziness, flushing, nausea and vomiting and Nausea, Hypotension, electrolyte imbalance, urticarial
vomiting, tachycardia, rashes, palpitations, rarely rashes, rarely pancreatitis Physical activity ( 150 min/week of moderate to high intensity ) -5/8 mm Hg
gingival hyperplasia Cautions: Hyperkalemia, eGfr< 30mg/dl, symptomatic (Avoid if BP very High)
Hepatic Impairment: start at lower dose. hypotension
Renal Impairment: can be used. Renal Impairment: Avoid if eGFR is <30.
Pregnancy: Avoid in general , Nifedipine can be Pregnancy: Contraindicated References and further details, refer to
used. SHMS Clinical practice Guidelines https://bit.ly/SHMScpg18.
Sick day rule: if risk of dehydration and AKI then stop
Breast Feeding: Avoid. Nifedipine can be used. them and restart once stable.
 Box 5 : common blood pressure medications pharmacological intervention

Thiazide diuretics Aldosterone Antagonist Alpha-adrenoceptor blockers

Common Agents: Hydrochlorothiazide, bendroflumethiazide, chlorthalidone Common Agents: spironolactone Common Agents: doxazosin , prazosin
Dose : Hydrochlorothiazide- 12.5-25mg daily. Dose : 25mg-100mg daily Dose : 1 mg once daily for 1 week then increase
Monitoring : check electrolytes regularly Contraindications : hyperkalemia, renal to 2 mg up to 4 mg once daily.
Contraindications: Hypercalcemia, Hyponatremia, symptomatic hyperuricemia failure Contraindications : history of micturition
Side Effects: Constipation, Diarrhea, Dizziness, Nausea, Postural Hypotension, electrolyte imbalance, urticarial Side Effects: Diarrhea, stomach cramps, syncope, postural hypotension.
Cautions: Hypokalemia, Elderly, Hepatic Failure Gynecomastia, headaches, rashes Cautions: postural hypotension with initial dose,
Hepatic Impairment: Avoid if severe irregular hair growth, impotence, low cataract surgery ( risk of floppy iris syndrome)
Renal Impairment: Avoid if eGFR is <30. platelets, liver dysfunction Side Effects: arrhythmias, chest pain, cough,
Pregnancy: Contraindicated Hepatic impairment: contraindicated cystitis, dizziness, dyspnea, GI discomfort,
Sick day rule: stop if vomiting and diarrhea until no risk of dehydration Renal Impairment: contraindicated headache, flu like illness, muscle complaint,
Pregnancy: Contraindicated except palpitations, vertigo
Centrally acting antihypertensive labetalol. Hepatic impairment: avoid in severe impairment
Common Agents: clonidine, methyldopa Renal Impairment: can be used
Dose : Clonidine 50-100 Micrograms 3 times a day , increase every second or third day . Maximum dose 1.2 mg
daily. methyldopa 250mg three times a day increase to maximum of 3 g per day every 2 -3 days. Beta blockers
Contraindications : 2nd or 3rd degree heart block , sick sinus syndrome. Common Agents: Atenolol, bisoprolol, carvedilol.
Caution: CVA, constipation, heart failure, depression, Raynaud's syndrome, PVD. Dose : Bisoprolol 5-10mg daily, Atenolol 25-100mg daily
Side Effects: clonidine: depression, GI upset, dry mouth , fatigue, headache, sedation, sexual disorders, sleep Contraindications : Severe Asthma and COPD.
disorders, postural hypotension. Methyldopa: amenorrhea, angioedema, bone marrow failure, breast Caution: Peripheral vascular disease
enlargement, cognitive impairment, facial paralysis, hepatic disorders, lupus- like syndrome, parkinsonism, Side Effects: Diarrhea, stomach cramps, blurring of vision, headaches, insomnia, hair loss,
psychosis. dizziness.
Treatment cessation: clonidine must be withdrawn gradually to avoid severe rebound hypertension. Renal Impairment: can be used.
Monitoring: Methyldopa – CBS & LFT before treatment and at intervals during first 6-12 weeks of if unexplained Pregnancy: Contraindicated except labetalol.
fever occurs.
Renal Impairment: can be used, start with smaller dose.
Pregnancy: use methyldopa

Box6: Life style modifications:

Calcium channel blockers ACE inhibitors/ARBs
Common Agents: Amlodipine, nifedipine, Common Agents: ACEi Ramipril, Lisinopril, Enalapril,
Intervention Effect on BP
felodipine ARB: losartan, valsartan
Dose : Amlodipine- 5-10mg daily. Dose : losartan-50-100mg daily, Enalarpil-10-20mg Weight loss/ Healthy diet 1 mm Hg for every 1-kg
Contraindications: Significant Aortic Stenosis. daily reduction in body weight
Nifedipine avoid within one month of MI Monitoring : check electrolytes regularly
Caution: Avoid Nifedipine in elderly and Contraindications: angioedema, bilateral renal artery Less sodium intake (<1500 mg/d) -5/6 mm Hg
longstanding Diabetes(can cause reflex stenosis, allergic or adverse reaction to the drug.
tachycardia) Side Effects: Cough, hyperkalemia Dizziness,
More potassium (3500–5000 mg/d) -4/5 mm Hg
Side Effects: Headache, peripheral edema, Nausea, Hypotension, electrolyte imbalance, urticarial
dizziness, flushing, nausea and vomiting and rashes, rarely pancreatitis
vomiting, tachycardia, rashes, palpitations, rarely Cautions: Hyperkalemia, eGfr< 30mg/dl, symptomatic Physical activity ( 150 min/week of moderate to high intensity ) -5/8 mm Hg
gingival hyperplasia hypotension
Hepatic Impairment: start at lower dose. Renal Impairment: Avoid if eGFR is <30.
Renal Impairment: can be used. Pregnancy: Contraindicated
Pregnancy: Avoid in general , Nifedipine can be Sick day rule: if risk of dehydration and AKI then stop References and further details, refer to
used. them and restart once stable. SHMS Clinical practice Guidelines https://bit.ly/SHMScpg18.
Breast Feeding: Avoid. Nifedipine can be used.