page126
tion 2.5.5)
can be added if
necessary.
Patients
with
severe postural
hypotension should not
receive blood
pressure lowering drugs.
Isolated systolic hypertension in younger
patients is
uncommon but
treatment
may be indicated in those
with a threshold systolic pressure of 160 mmHg (or less
if at increased risk of cardiovascular disease, see above).
Hypertension in diabetes
For patients with diabetes,
the
aim should
be
to
maintain
systolic
pressure
< 130 mmHg and diastolic pressure < 80 mmHg.
How-
ever,
in some individuals,
it
may not
be possible to
achieve this level of control despite appropriate therapy.
Most patients require a combination of antihypertensive
drugs.
Hypertension is common in type 2 diabetes,
and anti-
hypertensive
treatment
prevents
macrovascular
and
microvascular complications. In type 1 diabetes, hyper-
tension
usually
indicates
the
presence
of
diabetic
nephropathy.
An ACE inhibitor
(or
an angiotensin-II
receptor
antagonist)
may have a specific role in the
management
of
diabetic nephropathy (section 6.1.5);
in patients with type 2 diabetes,
an ACE inhibitor (or
an angiotensin-II
receptor
antagonist)
can delay pro-
gression of microalbuminuria to nephropathy.
Hypertension in renal
disease
The threshold for
antihypertensive
treatment
in
patients
with
renal
impairment
or
persistent
proteinuria
is
a
systolic
blood pressure 140 mmHg
or
a diastolic blood pres-
sure 90 mmHg.
Optimal
blood pressure is a systolic
blood pressure < 130 mmHg and a diastolic pressure
< 80 mmHg,
or lower if
proteinuria exceeds 1 g in 24
hours.
An ACE inhibitor (or an angiotensin-II receptor
antagonist) should be considered for patients with pro-
teinuria;
however,
ACE inhibitors should be used with
caution in renal
impairment,
see section 2.5.5.1.
Thia-
zide diuretics may be ineffective and high doses of loop
diuretics may be required.
A dihydropyridine calcium
channel blocker can be added.
Hypertension in pregnancy
Hypertensive complica-
tions in pregnancy can be hazardous for both the mother
and the fetus,
and are associated with a significant risk
of morbidity and mortality;
complications can occur in
pregnant
women
with
pre-existing
chronic
hyper-
tension,
or in those who develop hypertension in the
latter half of pregnancy.
Labetalol (section 2.4) is widely used for treating hyper-
tension in pregnancy.
Methyldopa (section 2.5.2)
is
considered safe for use in pregnancy.
Modified-release
preparations of
nifedipine [unlicensed]
are also used,
but see section 2.6.2 (p.
132) for warnings on use during
pregnancy.
The following advice takes into account the recommen-
dations of
NICE Clinical
Guideline 107 (August 2010),
Hypertension in Pregnancy.
Pregnant
women with chronic hypertension who are
already receiving antihypertensive
treatment
should
have their
drug therapy reviewed.
In uncomplicated
chronic
hypertension,
a
target
blood
pressure
of
<150/100 mmHg is recommended;
women with tar-
get-organ damage as a result of
chronic hypertension,
and in women with chronic hypertension who have
given birth,
a target blood pressure of <140/90 mmHg
is
advised.
Long-term antihypertensive
treatment
should
be
reviewed
2
weeks
following
the
birth.
Women managed with methyldopa during pregnancy
should discontinue treatment and restart their original
antihypertensive medication within 2 days of the birth.
Pregnant
women are at
high risk of
developing pre-
eclampsia if they have chronic kidney disease, diabetes
mellitus, autoimmune disease, chronic hypertension, or
if
they
have
had
hypertension
during
a
previous
pregnancy;
these women are advised to take aspirin
(section 2.9) in a dose of 75 mg once daily [unlicensed
indication] from week 12 of pregnancy until the baby is
born.
Women with more than one moderate risk factor
(first
pregnancy,
aged 40 years,
pregnancy interval
>10
years,
BMI
35 kg/m
2
at
first
visit,
multiple
pregnancy, or family history of pre-eclampsia) for devel-
oping pre-eclampsia are also advised to take aspirin
75 mg once daily [unlicensed indication] from week 12
of pregnancy until the baby is born.
Women with pre-eclampsia or gestational hypertension
who
present
with
a
blood
pressure
over
150/
100 mmHg,
should receive initial
treatment
with oral
labetalol
to
achieve
a
target
blood
pressure
of
<150 mmHg systolic,
and diastolic 80–100 mmHg.
If
labetalol
is unsuitable,
methyldopa or modified-release
nifedipine may be considered.
Women with gestational
hypertension or pre-eclampsia who have been managed
with methyldopa during pregnancy should discontinue
treatment
within 2 days of
the birth.
Women with a
blood pressure of 160/110 mmHg who require critical
care during pregnancy or
after
birth should receive
immediate treatment
with either
oral
or
intravenous
labetalol,
intravenous
hydralazine (section 2.5.1),
or
oral
modified-release nifedipine to achieve a target
blood pressure of
<150 mmHg systolic,
and diastolic
80–100 mmHg.
For
use of
magnesium sulphate in pre-eclampsia and
eclampsia,
see section 9.5.1.3.
Hypertensive crises
If blood pressure is reduced too
quickly in the management of hypertensive crises, there
is a risk of reduced organ perfusion leading to cerebral
infarction, blindness, deterioration in renal function, and
myocardial ischaemia.
A
hypertensive emergency
is defined as severe hyper-
tension with acute damage to the target
organs (e.g.
signs of
papilloedema or
retinal
haemorrhage,
or
the
presence of clinical
conditions such as acute coronary
syndromes,
acute aortic dissection,
acute pulmonary
oedema,
hypertensive encephalopathy,
acute cerebral
infarction,
intracerebral
or subarachnoid haemorrhage,
eclampsia, or rapidly progressing renal failure);
prompt
treatment with intravenous antihypertensive therapy is
generally required. Over the first few minutes or within
2 hours, blood pressure should be reduced by 20–25%.
When
intravenous
therapy
is
indicated,
treatment
options include sodium nitroprusside [unlicensed] (sec-
tion 2.5.1),
labetalol
(section 2.4),
glyceryl
trinitrate
(section 2.6.1),
phentolamine (section 2.5.4),
hydral-
azine (section 2.5.1),
or
esmolol
(section 2.4);
choice
of
drug is dependent
on concomitant
conditions and
clinical status of the patient.
Severe hypertension (blood pressure 180/110 mmHg)
without
acute target-organ damage is
defined as
a
hypertensive urgency
; blood pressure should be reduced
gradually over 24–48 hours with oral
antihypertensive
therapy, such as labetalol, or the calcium-channel block-
106
2.5 Hypertension and heart failure
BNF 61
2
Cardiovascular system