Hypertension Diagnosis and Management

• This e-learning course provides a comprehensive approach to hypertension for healthcare practitioners who have the academic and clinical requirements to diagnose and manage it.
• The course covers hypertension information and application.
• Narrated presentations provide an overview of the learning outcomes, content, and assessment approach.

Learning Outcomes

• Describe the aetiology and epidemiology of hypertension.
• Diagnose and classify hypertension.
• Describe the risk factors and co-morbidity associated with hypertension.
• Demonstrate appropriate management of hypertension.
• Demonstrate the ability to identify and manage hypertension in specific populations.

Graded Assessment

• The quiz counts for 100% of the overall grade.

Acronyms

• ABI: Ankle-Brachial Index
• ABPM: Ambulatory Blood Pressure Monitoring
• ACE: Angiotensin Converting Enzyme
• ACR: Albumin-to-Creatinine Ratio
• ARB: Angiotensin AT-1 Receptor Blocker
• BMI: Body Mass Index
• BP: Blood Pressure
• CAD: Coronary Artery Disease
• CCB: Calcium Channel Blocker
• CHW: Community Health Worker
• CKD: Chronic Kidney Disease
• COPD: Chronic Obstructive Pulmonary Disease
• CVD: Cardiovascular Disease
• DBP: Diastolic Blood Pressure
• DHP-CCB: Dihydropyridine-Calcium Channel Blockers
• DM: Diabetes Mellitus
• DRI: Direct Renin Inhibitor
• ECG: Electrocardiogram
• eGFR: Estimated Glomerular Filtration Rate
• ESCESH: European Society of Cardiology/European Society of Hypertension
• HAART: Highly Active Antiretroviral Therapy
• HBPM: Home blood pressure measurement
• HCTZ: Hydrochlorothiazide
• HELLP: Haemolysis, Elevated Liver enzymes and Low Platelets
• HF: Heart Failure
• HIC: High Income Countries
• HIV: Human Immunodeficiency Virus
• HMOD: Hypertension Mediated Organ Damage
• IHD: Ischemic Heart Disease
• IMT: Intima Media Thickness
• IRD: Inflammatory Rheumatic Disease
• ISH: International Society of Hypertension
• LDL-C: Low-Density Lipoprotein – Cholesterol
• LMIC: Low and Middle-Income Countries
• LVH: Left Ventricular Hypertrophy
• MI: Myocardial Infarction
• MRI: Magnetic Resonance Imaging
• MS: Metabolic Syndrome
• NCD: Non-Communicable Disease
• NDOH: National Department of Health
• NSAIDs: Nonsteroidal Anti-Inflammatory Drugs
• PWV: Pulse Wave Velocity
• RAS: Renin-Angiotensin System
• RAAS: Renin-Angiotensin-Aldosterone System
• SBP: Systolic Blood Pressure
• SSRI: Selective Serotonin Reuptake Inhibitors
• s-UA: Serum Uric Acid
• TIA: Transient Ischemic Attack
• TSH: Thyroid Stimulating Hormone
• TTE: Two-Dimensional Transthoracic Echocardiogram
• UACR: Urinary Albumin Creatinine Ratio
• WHO: World Health Organization

Unit 1: Aetiology and epidemiology of hypertension

• Define hypertension (LO 1).
• Describe the aetiology of hypertension (LO 1).
• Describe the epidemiology of hypertension (LO 1).
• The estimated time to complete this Unit is 20 minutes.

Lesson 1: Definition, classification, and aetiology of hypertension

• In accordance with most major guidelines hypertension is defined by a Systolic Blood Pressure (SBP) ≥140 mm Hg and/ or a Diastolic Blood Pressure (DBP) of ≥90 mm Hg following repeated examination in an office (consultation room or clinic).
• High-normal BP is intended to identify individuals who could benefit from lifestyle interventions and who would receive pharmacological treatment if compelling indications are present.
• Isolated systolic hypertension is defined as elevated SBP (≥140 mm Hg) and low DBP (<90 mm Hg) and is more common in younger and elderly people.
• Hypertension is considered as Primary or Secondary (ASH 2014: 5).
• About 95% of adults with high blood pressure have primary hypertension (also known as essential hypertension).
• The cause of primary hypertension is unknown, although genetic and environmental factors that affect blood pressure regulation are continuously being studied.
• Environmental factors include excess intake of salt, obesity, and a sedentary lifestyle.
• Some genetically related factors could include inappropriately high activity of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system, as well the genetical susceptibility to the effects of dietary salt on blood pressure.
• Another common cause of hypertension is due to the stiffening of the aorta with increasing age, causing hypertension referred to as isolated systolic hypertension characterized by high SBP (often with normal DBP), primarily in elderly people.
• The main types of secondary hypertension, about 5% of all hypertension, are chronic kidney disease, renal artery stenosis, excessive aldosterone secretion, pheochromocytoma, and sleep apnoea.

Lesson 2: Epidemiology of hypertension

• Raised BP remains one of the leading cause of death globally, accounting for 10.4 million deaths per year (ISH 2020: 1335).
• BP trends show an estimated 349 million with hypertension in High Income Countries (HICs) and 1.04 billion in Lower and Middle Income Countries (LMICs) (Mills 2016: 134).
• An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension, with most (two-thirds) living in low- and middle-income countries.
• An estimated 46% of adults with hypertension are unaware that they have the condition.
• Less than half of adults (42%) with hypertension are diagnosed and treated.
• Approximately 1 in 5 adults (21%) with hypertension have it under control.
• Hypertension is a major cause of premature death worldwide.
• In Africa, only 25% of countries have hypertension guidelines, and in many instances, these guidelines are adopted from those of high-income regions.
• South Africa has a Fourfold burden of disease comprised of:
  • Communicable diseases such as HIV/AIDS and TB
  • Maternal and child mortality
  • Non-communicable Diseases (NCDs) such as hypertension and cardiovascular diseases, diabetes, cancer, mental illnesses and chronic lung diseases like asthma, and
  • Injury and trauma
• According to Statistics SA (Statistics SA: 2013), main causes of death in South include:
  • Diseases of the circulatory system (18,4%)
  • Certain infectious and parasitic diseases (17,6%) and endocrine
  • Nutritional and metabolic diseases (7,0%)
• Trends indicate that NCDs are on the rise.

Unit 2: Diagnosis and classification of hypertension

• Diagnose hypertension in a patient (LO 2).
• Classify different types of hypertension (LO 2).
• The estimated time to complete this Unit is 45 minutes.

Lesson 3: Diagnosing hypertension

• The majority of people with hypertension are often unaware of the fact that they have a raised BP, which may be picked up during a routine medical, screening opportunities/ events, or presentation with an unrelated complaint.
• Symptoms may include headaches, fatigue, nosebleeds, nausea, irregular heart rhythms, vomiting, vision changes, confusion, buzzing in the ears, anxiety, dizziness, chest pain, shortness of breath, and muscle tremors
• Patients with hypertension are often asymptomatic and thus, specific symptoms can suggest secondary hypertension or hypertensive complications for further investigation.
• A complete medical and family history is recommended:
  • Blood pressure: new onset hypertension, duration, previous BP readings, current and previous antihypertensive medication, other medications/over-the counter medicines that can influence BP, history of intolerance (side-effects) towards antihypertensive medications, adherence to antihypertensive treatment, previous hypertension with oral contraceptives or pregnancy.
  • Risk factors: personal history of Cardiovascular Disease (CVD), such as myocardial infarction, heart failure, stroke, Transient Ischemic Attacks (TIA), diabetes, dyslipidaemia, chronic kidney disease, smoking status, diet, alcohol intake, physical activity, psychosocial aspects and history of depression.
• Family history of importance may include hypertension, premature CVD, familial hypercholesterolemia and diabetes.
• Symptoms/ signs of hypertension/co-existent illnesses: chest pain, shortness of breath, palpitations, claudication, peripheral oedema, headaches, blurred vision, nocturia, haematuria and dizziness.
• Symptoms suggestive of secondary hypertension: muscle weakness/ tetany, cramps, arrhythmias (hypokalaemia/ primary aldosteronism), flash pulmonary oedema (renal artery stenosis), sweating, palpitations, frequent headaches (pheochromocytoma), snoring, daytime sleepiness (obstructive sleep apnoea), symptoms suggestive of thyroid disease.
• Office BP measurement is commonly the basis for hypertension diagnosis and follow-up, and should be measured according to given recommendations
• The diagnosis should ideally not be made on a single office visit.
• Usually, two to three office visits at 1 - 4 - week intervals (depending on the BP level) are required to confirm the diagnosis of hypertension.
• The diagnosis might be made on a single visit, if BP is ≥180/110 mmHg and there is evidence of CVD.
• If possible and available, the diagnosis of hypertension should be confirmed by out-of-office BP measurement.
• Initial evaluation involves measuring BP in both arms, preferably simultaneously.
• Standing blood pressure should be measured in treated hypertensive patients after 1 min and again after 3 min when there are symptoms suggesting postural hypotension and at the first visit in the elderly and people with diabetes.
• Out-of-office BP measurements, by patients at home or with 24-h ABPM, are more reproducible than office measurements and more closely associated with hypertension-induced organ damage and the risk of cardiovascular events - and address the white-coat and masked hypertension phenomena.
• The use of office and out-of-office (home or ambulatory) BP measurements identifies individuals with white-coat hypertension, who have elevated BP only in the office (nonelevated ambulatory or home BP), and those with masked hypertension, who have nonelevated BP in the office but elevated BP out of the office (ambulatory or home).
• About 10-30% of subjects attending clinics because of high BP have white-coat hypertension, and 10–15% have masked hypertension.
• Patients with white-coat hypertension are at intermediate cardiovascular risk between normotensive and sustained hypertensive patients.
• Their diagnosis needs confirmation with repeated office and out-of-office BP measurements.
• Patients with masked hypertension are at similar risk of cardiovascular events as sustained hypertensive patients, diagnosable with repeated office and out-of-office measurements and treatable with the aim to normalize out-of-office BP.
• A thorough physical examination can assist with confirming the diagnosis of hypertension and the identification of Hypertension Mediated Organ Damage (HMOD) and/ or secondary hypertension.
• Included measures of these involve circulation and heart, other organs and systems, and fundoscopy.
• Further investigations include blood tests, urine tests, and a 12-lead ECG.
• Additional investigations, whenever indicated and viable/ appropriate, can be undertaken to assess and confirm suspicion of HMOD, co-existent diseases, or/ and secondary hypertension.
• Imaging techniques include echocardiography, carotid ultrasound, kidneys/ renal artery and adrenal imaging, and brain CT/MRI.
• Functional tests and additional laboratory investigations include ankle-brachial index, further testing for secondary hypertension, urinary albumin/creatinine ratio, and serum-Uric Acid.

Video 1: Hypertension Diagnosis

• The video is an overview of diagnosing Hypertension in the public sector in South Africa, as presented by Dr. Simon Comley, a Registrar in Family Medicine at Walter Sisulu University in Mthatha, Eastern Cape.
• Title: Top Tut: Hypertension Diagnosis
• Author: Dr S Comley
• Year: 2025

Unit 3: Risk factors and co-morbidity associated with hypertension

• Identify and describe the risk factors for hypertension (LO 3).
• Describe and manage the co-morbidities and complications of hypertension (LO 3).
• The estimated time to complete this Unit is 45 minutes.

Lesson 4: Risk factors in hypertension

• Hypertension is a chronic NCD strongly associated with lifestyle, and there are known risks that co-occur and may give rise to the development of one or more of the NCDs.
• More than 50% of hypertensive patients have additional cardiovascular risk factors.
• Common additional risk factors include diabetes (15% – 20%), lipid disorders (elevated low-density lipoprotein-cholesterol (LDL-C) and triglycerides [30%]), overweight/ obesity (40%), hyperuricemia (25%), metabolic syndrome (40%) and certain lifestyle habits.
• The presence of one or more additional cardiovascular risk factors proportionally increases the risk of coronary, cerebrovascular, and renal diseases in hypertensive patients.
• An evaluation of additional risk factors should be part of the diagnostic workup in hypertensive patients, particularly in the presence of a family history of CVD
• Cardiovascular risk should be assessed in all hypertensive patients by easy-to-use scores based on BP levels and additional risk factors, according to guidelines.
• A reliable estimate of cardiovascular risk can be obtained in daily practice by including: -Age (>65 years), sex (male>female), heart rate (>80 beats/min), increased body weight (BMI), diabetes, high LDL-C/ triglyceride, family history of CVD and hypertension, early-onset menopause, smoking habits, psychosocial or socioeconomic factors.
  • HMOD: LVH (LVH with ECG), moderate-severe CKD (CKD: eGFR <60 ml/ min/1.73m2). -Disease: previous CHD, Heart Failure (HF), stroke, peripheral vascular disease, atrial fibrillation, CKD stage 3+.
• The therapeutic strategy must include lifestyle changes, BP control to target and the effective treatment of the other risk factors to reduce the residual cardiovascular risk.
• The combined treatment of hypertension and additional cardiovascular risk factors reduces the rate of CVD beyond BP control.
• Elevated serum uric acid (s-UA) is common in patients with hypertension.
• An increase in cardiovascular risk must be considered in patients with hypertension, chronic inflammatory diseases, Chronic Obstructive Pulmonary Disease (COPD), psychiatric disorders and psychosocial stressors where effective BP control is warranted.
• The important factors to consider when diagnosing and treating hypertension are age and gender, family history of hypertension/ CVD, BMI, waist circumference, level of physical activity, tobacco/smoking use, excessive alcohol use, stress, blood lipids/ cholesterol levels, and blood glucose level.
• It should also be remembered that hypertension may occur in pregnancy without the presence of these risk factors.
• Simple risk-based assessments help identify areas of risk for the individual and inform lifestyle modifications and/ or therapeutic treatment.

Lesson 5: Co-morbidities and complications of hypertension

• Hypertensive patients have several common and other comorbidities that can affect cardiovascular risk and treatment strategies, and the number of comorbidities increases with age with the prevalence of hypertension and other diseases.
• Common comorbidities include Coronary Artery Disease (CAD), stroke, Chronic Kidney Disease (CKD), heart failure, and COPD.
• Uncommon comorbidities include rheumatic diseases and psychiatric diseases.
• HMOD, Hypertension-Mediated Organ Damage, is defined as the structural or functional alteration of arterial vasculature and/or of the organs it supplies caused by elevated BP.
• End organs include the brain, heart, kidneys, central and peripheral arteries, and eyes.
• Assessment of overall cardiovascular risk is important for the management of hypertension.
• The following assessments to detect HMOD should be performed routinely in all patients with hypertension:
  • Serum creatinine and eGFR
  • Dipstick urine test
  • 12-lead ECG
  • Fundoscopy
• It should be noted that all other techniques mentioned can add value to optimizing management of hypertension.
• Alongside BP control, the therapeutic strategy should include lifestyle changes, body weight control, and the effective treatment of residual cardiovascular risk factors.
• A strong epidemiological interaction exists between CAD and hypertension which accounts for 25-30% of acute myocardial infarctions.
• Hypertension is the most important risk factor for ischemic or haemorrhagic stroke.
• Hypertension is a risk factor for the development of HF with reduced ejection fraction.
• Hypertension is a major risk factor for the development and progression of albuminuria and any form of CKD.
• Hypertension is the most frequent comorbidity in patients with COPD.
• Patients with hypertension and MS have a high-risk profile.
• IRD (rheumatoid arthritis, psoriasis--arthritis, etc.) are associated with an increased prevalence of hypertension under-diagnosed and poorly controlled population.
• The prevalence of hypertension is increased in patients with psychiatric disorders and, in particular, depression.
• Several medications and substances may increase BP or antagonize the BP-lowering effects of antihypertensive therapy in individuals, with individual effect highly variable

Video 2: Fundoscopy in Hypertension

• Title and author not specified

Unit 4: Comprehensive management of hypertension

• Develop a patient-specific management plan for the hypertensive patient (LO 4).
• Incorporate lifestyle modification into the management plan (LO 4).
• Prescribe the appropriate pharmacological treatment in the management plan (LO 4).
• Ensure compliance with the management plan (LO 4).
• Manage a hypertensive emergency (LO 4).
• The estimated time to complete this Unit is 2 hours.

Lesson 6: Lifestyle modifications

• Healthy lifestyle choices can prevent or delay the onset of high BP and can reduce cardiovascular risk and are also the first line of antihypertensive treatment/Modifications in lifestyle also can enhance the effects of antihypertensive treatment.
• There is strong evidence for a relationship between high salt intake and increased blood pressure.
• Ethnic-specific cut-offs for BMI and waist circumference should be used, or a waist-to-height ratio <0.5 is recommended for all populations.
• Smoking is a major risk factor for CVD, COPD, and cancer.
• Studies suggest regular aerobic and resistance exercise may be beneficial
• Chronic stress has been associated to high blood pressure later in life.
• BP exhibits seasonal variation with lower levels at higher temperatures and higher at lower temperatures (Stergiou: 2020).
• Myths concerning hypertension includes:
  • Hypertension can be controlled by lifestyle changes alone. While lifestyle modification may in some cases lower blood pressure to acceptable levels for many people this is not sufficient.
  • Hypertension is directly as a result of stress.
  • If I have high blood pressure, I am sure to have a stroke.
  • If you feel fine, you don't have hypertension
  • If you don't salt your food, salt isn't a big issue for you.
  • When medication brings your blood pressure down, you can stop taking it

Lesson 7: Pharmacological management

• The WHO protocols according to Grade of Hypertension and the National Essential Medicines Committee-approved National Department of Health (NDOH) Primary Health Care (PHC) Standard Treatment Guidelines (STG) (NDOH: 2020).
• Ideal drug treatments should be:
  • Evidence-based
  • Have a once-daily regimen
  • Affordable
  • Well-tolerated
  • Proven benefits to targeted populations

Lesson 8: Compliance and adherence

• Adherence is defined as to the extent to which a person's behaviors, such as taking a medication, following a diet, or executing lifestyle changes corresponds with agreed recommendations from a healthcare provider.
• Effective methods for management of nonadherence require complex interventions combining counseling, self-monitoring, reinforcements, and supervision.
• Nonadherence to antihypertensive treatment affects 10–80% of hypertensive patients and is one of the key drivers of suboptimal BP control.
• Poor adherence correlates with the magnitude of BP elevation and indicates poor prognosis in hypertensive patients.
• Objective monitoring is generally preferred for diagnosing nonadherence.
• Direct vs. indirect monitoring methods in place.
• Key messages to patients include:
  • Taken your medication at the right dose, frequency, and time.
  • Feeling better means your medication is working.
  • Poor adherence may be life threatening
  • Good adherence keeps you healthy
  • Tools for adherence such as a pill counter, calendar, adherence club, or relevant apps are all useful.

Lesson 9: Hypertensive emergency

• A hypertensive emergency is the association of substantially elevated BP with acute HMOD.
• Target organs include the retina, brain, heart, large arteries, and kidneys.
• High BP requires rapid diagnostic workup and immediate BP reduction to avoid progressive organ failure.
• The choice of antihypertensive treatment is predominantly determined by the type of organ damage.
• The clinical presentation of a hypertensive emergency varies and is mainly determined by the organ(s) acutely affected.
• The overall therapeutic goal in patients presenting with hypertensive emergencies is a controlled BP reduction to safer levels to prevent or limit further hypertensive damage while avoiding hypotension and related complications.
• Specific situations of sympathetic hyperreactivity and pre-eclampsia/eclampsia listed as examples.
• Patients experiencing a hypertensive emergency are at an increased risk of cardiovascular and renal disease.
• Following these episodes thorough investigation of potential underlying causes and assessment of HMOD, paired with adherence-improving advice and simplification of adjustments to antihypertensive therapy and lifestyle modification is essential.

Unit 5: Hypertension in specific populations

• Manage resistant hypertension (LO 5).
• Manage hypertension and Diabetes (LO 5).
• Manage hypertension in pregnancy (LO 5).
• Manage hypertension and HIV/ AIDS (LO 5).
• Manage hypertension in children and adolescents (LO 5).
• The estimated time to complete this Unit is 1 hour.

Lesson 10: Resistant hypertension

• Resistant hypertension is defined as seated office BP >140/90 mmHg in a patient treated with three or more antihypertensive medications at optimal (or maximally tolerated) doses including a diuretic and after excluding pseudo-resistance.
• Approximately 50% of patients diagnosed with resistant hypertension have pseudo resistance rather than true resistant hypertension.
• Resistant hypertension affects around 10% of hypertensive individuals.
• In patients with seated office BP >140/90 mmHg managed with three or more antihypertensive medications, first exclude causes of pseudo-resistance.

Lesson 11: Secondary Hypertension

• A specific cause of secondary hypertension can be identified in 5-10% of hypertensive patients.
• Basic screening for secondary hypertension should include a thorough assessment of history, physical examination, and basic blood biochemistry.
• The most common types of secondary hypertension in adults are renal parenchymal disease, renovascular hypertension, primary aldosteronism, chronic sleep apnoea, and substance/drug-induced.
• Indicated investigations may also include kidney ultrasound or imaging of the adrenals.

Lesson 12: Hypertension and Diabetes

• Diabetes Type 2 may commonly occur along with Hypertension in patients with certain risk factors
• On average, people have Type 2 diabetes before it is diagnosed
• BP lowering in hypertensive patients reduces cardiovascular risk
• The diagnosis of hypertension is confirmed if the blood pressure remains > 140/90 mmHg on two separate days.
• These patients require lifestyle changes with a BMI ≤ 25 kg/m2 with a target BP to be lowered.

Lesson 13: Hypertension in pregnancy

• Hypertension in pregnancy is a condition affecting 5-10% of pregnancies worldwide, which have certain maternal and foetal risks.
• A small proportion of women with eclampsia have normal blood pressure.
• Conditions include pre-existing or gestational hypertension, pre-eclampsia, and Eclampsia.
• First line treatments are methyldopa, beta blockers and Dihydropyridine-Calcium Channel Blockers (DHP-CCBs).

Lesson 14: Hypertension and HIV/ AIDS

• The co-existence of HIV with hypertension and diabetes is increasing.
• It is essential that BP is carefully monitored in patients receiving HAART (Highly Active Antiretroviral Therapy).
• CCBs are the major class of antihypertensives affected by drug interactions.
• Ritonavir can increase the effect of Amlodipine which may result in an increased response, i.e. lowering of the blood pressure.