Cardiovascular

Hypertension (OPD Approach)

ہائی بلڈ پریشر

Hypertension is BP of 140/90 or more on two separate occasions. Treat by stage, age and end-organ damage; hypertensive urgency has no end-organ damage, emergency does.

ICD-10: I10
Source: OPD handbook pp.136–145
Status: Draft

Not yet reviewed by a clinician. Check doses and brands against current national guidelines before use.

Symptoms

Often silent
Chest pain, visual loss, decreased urine output or stroke symptoms in a hypertensive emergency

Red flags Refer urgently if any are present

Stage III with end-organ damage (hypertensive emergency): stroke, decreased vision, decreased urine output, retrosternal gripping chest pain radiating to the neck

Diagnosis

BP ≥140/90 mmHg on two separate occasions
Types: secondary hypertension 5–10%; primary (idiopathic) 90–95%
Stages of primary HTN: 120/80 normal; 130–139 / 80–89 prehypertension; Stage 1: 140–159 / 90–99; Stage 2: 160–179 / 100–109; Stage 3: ≥180 / ≥110 mmHg
Stage 3 is divided into hypertensive urgency (no end-organ damage) and hypertensive emergency (with end-organ damage)
End organs: brain (stroke: haemorrhage or infarct); heart (MI, hypertrophy, failure); retina (retinopathy); kidney (nephropathy)

Treatment

Step 1 of 6

Stage I HTN (BP 140–159 / 90–99)

If age under 55 years: start an ACE inhibitor / ARB. Captopril (Tab Capace 25 mg BD) causes dry cough, so continue losartan (Tab Eziday 50 mg OD) (Urdu: continue every day)
If age over 55 years: start a calcium-channel blocker (amlodipine 5–10 mg), e.g. Tab Corsafe 5 mg once daily

Prescription

CaptoprilACE inhibitor

DoseBD

Brand Tab Capace 25 mg

Also sold as Capace, Capoten, Capril

Dry cough; ACE inhibitor

LosartanAngiotensin receptor blocker

DoseOD

Brand Tab Eziday 50 mg

Also sold as Cozaar, Eziday, Xavor, Ezidoy

Used when ACE inhibitor causes cough

Caution: Contraindicated in pregnancy; Monitor potassium and creatinine

AmlodipineCalcium channel blocker

Dose5–10 mg once daily (age over 55)

Brand Tab Corsafe 5 mg

Also sold as Norvasc, Corsafe, Zodip, Amlo-Q

Caution: Ankle oedema; Dose reduction in severe liver disease

Step 2 of 6

Stage II HTN (BP 160–179 / 100–109)

Combination of ACE inhibitor / ARB + calcium-channel blocker (A+C)
Tab Extor 5/80 OD (amlodipine + valsartan), continue daily
Can be increased to Extor 10/160 or 5/160 BD

Prescription

Amlodipine + ValsartanCCB + ARB combination

DoseOD; can increase to 10/160 or 5/160 BD

Brand Tab Extor 5/80

Step 3 of 6

Stage III: hypertensive urgency (no end-organ damage)

Tab Capace 25 mg × 2 tablets P/O stat; give when BP is below 180/110
Discharge on A + C + diuretic: Tab Triforge 5/80/12.5 once daily
Triforge = amlodipine 5 mg + valsartan 80 mg + hydrochlorothiazide 12.5 mg (diuretic)
Work up for end-organ damage: ECG, renal parameters (RPM), fundoscopy
Refer for a consultant opinion

Prescription

CaptoprilACE inhibitor

Dose2 tablets P/O stat

Brand Tab Capace 25 mg

Also sold as Capace, Capoten, Capril

Amlodipine + Valsartan + HydrochlorothiazideCCB + ARB + diuretic combination

DoseOnce daily (continue)

Brand Tab Triforge 5/80/12.5

Step 4 of 6

Stage III: hypertensive emergency (with end-organ damage)

Stroke: pass an NG tube and refer to tertiary care
Decreased vision: refer to ophthalmology
Decreased urine output / periorbital oedema: advise renal parameters and S/E; if deranged, refer for a consultant opinion

Step 5 of 6

Chest pain: ACS protocol

Severe retrosternal chest pain radiating to the neck, gripping in nature.

ECG; ischaemic changes: ST elevation, ST depression, T-wave inversion, tachycardia
Give the ACS protocol
Aspirin (Ascard) 75 mg × 4 tablets stat; clopidogrel (Progrel) 75 mg × 4 tablets stat; nitroglycerin (Angised) sublingual
Inj nalbuphine (opioid analgesic): causes CNS depression and vomiting, so give slowly with an antiemetic (Metaclon = metoclopramide)
After the ACS protocol, refer the patient to tertiary care for further management

Prescription

Aspirin (low dose)Antiplatelet

Dose4 tablets stat (300 mg)

Brand Tab Ascard 75 mg

Also sold as Loprin, Disprin, Ascard

Caution: Never use for fever in dengue or in children (Reye syndrome); GI bleeding risk

ClopidogrelAntiplatelet

Dose4 tablets stat (300 mg)

Brand Tab Progrel 75 mg

Also sold as Progrel, Lowplat

Nitroglycerin (GTN), sublingualVasodilator

Dose2 tablets sublingual (under the tongue)

Brand Tab Angised 0.25 mg (as read)

NalbuphineOpioid analgesic

DoseGive slowly with an antiemetic

Brand Inj nalbuphine (brand name partly illegible)

MetoclopramideProkinetic / antiemetic

DoseWith nalbuphine

Brand Inj Metaclon

Also sold as Maxolone, Maxolon, Metaclon, Metomide

Step 6 of 6

Lifestyle modification

Salt restriction
Use oil instead of ghee
30-minute brisk walk per 5 days (150 minutes a week)
Weight reduction (the book says each unit of weight lost lowers BP by about 1 mmHg; the unit is hard to read)
Smoking cessation
Use of fruits and vegetables
No added salt, no added sugar, no added ghee
Keep an eye on BP twice a week
Urdu notes: reduce salt; avoid chips, pakoras, samosas, salty snacks, pickles, canned foods, dal and restaurant foods; use oil in place of ghee; walk daily; fresh fruit and vegetables; reduce weight

Sample prescriptions from the book (patient details removed)

Male, 60 y, known hypertensive, pain in wrist joints and burning feet sensation; inflamed joints; BP 160/100 (HTN + gout): Tab Zodip 5 mg (amlodipine) continue, written 1+1; Tab Zaqnol 50 mg (atenolol) continue, 1+1; Tab Neoprox 500 mg (naproxen) 1+1 for 2 weeks; Tab Cobalamin 500 mcg (B12) daily for 2 weeks; after 2 weeks add Tab Go-Uric 40 mg 1+0 for 2 weeks and continue; avoid salt, spicy foods, meat and eggs (Urdu note).
Male, 50 y, smoker, neck ache off and on, BP rises sometimes; BP 170/100: Tab Eziday 50 mg daily, continue; Tab Nuberol Forte (orphenadrine + paracetamol) at night as needed; avoid salty and fried foods, reduce cigarettes, do light exercise. Urdu note: hypertension is treatable and if the patient takes BP medicines regularly he can live a healthy life.
Female, 46 y, backache; known hypertensive on Eziday with good compliance but poor control; BP 160/100 (stage II): Tab Extor 5/80 (amlodipine + valsartan) 1+0, continue; Tab Nuberol Forte at night as needed; Inj D3 200,000 IU/mL, one ampoule in milk once a week for 4 weeks.
Male, 54 y, known hypertensive on Extor 10/160 with good compliance but poor control, headache; BP 170/100 (stage III): Tab Triforge 5/80/12.5 once daily, continue; Tab Panadol 500 mg as needed for headache.