– The essential hypertension of an adult is defined as a blood pressure (BP) of greater than or equal to 160 mm Hg for systolic and / or greater than or equal to 90 mm Hg for diastolic.
The elevation must be permanent: Measure 2 times at rest during 3 consecutive consultations over a period of 3 months.
Is a risk factor for stroke (stroke), heart and kidney failure and atherosclerosis.
– The pregnancy-induced hypertension is defined by a higher TA or equal to 140 mm Hg systolic or greater than or equal to 90 mm Hg diastolic (patient at rest and sitting). It can be isolated or associated with proteinuria or edema in cases of pre-eclampsia.
It exposes the risk of eclampsia, placental abruption and premature delivery.
Treatment of essential hypertension in adults:
– In case of medication-induced hypertension (oral contraceptives, hydrocortisone, MAO inhibitors, NSAIDs, etc.) stop or replaced.
– Otherwise, start with lifestyle changes: reducing salt intake, overweight if necessary, regular physical activity.
– If despite these measures the blood pressure remains consistently above 160/100 mmHg (or 140/80 mm Hg in patients with diabetes or after a stroke), antihypertensive treatment may be associated.
– Start with monotherapy. The optimal dosage depends on the patient; halving the initial dose in the elderly.
– The three classes of antihypertensive drugs used as first line 1 are the thiazide diuretics (hydrochlorothiazide), beta blockers (atenolol) and angiotensin converting enzyme inhibitors (enalapril, captopril). For information:
– The treatment must be taken regularly. Side effects may occur with abrupt withdrawal of beta-blockers (malaise, angina) 2. Do prescribe treatment if it can be continued by a regularly monitored patient.
* 1 The diuretics, beta-blockers and ACE inhibitors have shown their ability to prevent the complications of hypertension. Prefer them to other antihypertensive agents, including calcium channel blockers (nifedipine).
* 2 In addition, the abrupt termination of central antihypertensives (eg methyldopa, clonidine) may cause a rebound effect.
The goal is to lower BP below 160/90 mmHg (or 140/80 in diabetics) causing the least possible adverse effects.
For uncomplicated hypertension:
• Start with a thiazide diuretic: hydrochlorothiazide PO 25 to 50 mg / day in one take.
• In the absence of improvement after 4 weeks or tolerated: check compliance and in the absence of cons-indications (asthma, uncontrolled heart failure), change to a beta blocker atenolol PO 50 to 100 mg / day in one take.
• If still no or little benefit: recheck compliance; consider combination therapy (thiazide or thiazide diuretic + beta-blocker + IEC).
Note: If enalapril 3 is used as monotherapy (see table of indications), start with 5 mg / day in one take. Increase the dose every 1 to 2 weeks, depending on the blood pressure, up to 10 to 40 mg / day in one or two outlets. In elderly patients or treated with a diuretic or renal impairment, starting with 2.5 mg / once daily because of the risk of hypotension and / or acute renal failure.
Special case: treatment of hypertensive crisis
An occasional rise in BP is usually harmless, whereas aggressive treatment, including sublingual nifedipine, can cause a serious accident (syncope, myocardial ischemia, cerebral or renal).
– In patients with hypertensive crisis
• Reassure the patient and put to rest.
• If despite these measures the blood pressure remains high, the addition of furosemide PO (20 mg / once daily) allows in some cases to progressively reduce Tæn 24 to 48 hours and prevent complications.
– In case of a hypertensive crisis complicated OAP:
• The aim is not to standardize at all costs TAmais treat the PAO.
• Start or adjust the basic treatment once the crisis is resolved.
Treatment of hypertension in pregnancy:
During pregnancy, regularly monitor: blood, weight, edema, proteinuria, uterine height.
– If the diastolic is less than 110 mmHg: rest, monitoring, diet and normal-normocalorique soda.
– Antihypertensive treatment is started when the diastolic pressure is 110 mm Hg.
It is intended only to prevent maternal complications of HTAsévère.
– During treatment, the diastolic pressure should always be maintained above 90 mm Hg: too sharp decline would result in the death of the fetus by placental hypoperfusion.
– The treatment of hypertension is delivery, the mother must be transferred to a hospital for it to be triggered.
– Diuretics and angiotensin converting enzyme inhibitors (captopril, enalapril, etc.) are cons-indicated in the treatment of hypertension in pregnancy.
3 * The enalapril (10 to 40 mg / day in one or two doses) may be replaced by captopril (100 mg / day in 2 divided doses).
– In case of isolated hypertension or mild pre-eclampsia
• Before 37 weeks of amenorrhoea: rest and observe as above.
• After 37 weeks, there is an intra-uterine growth retardation: vaginal delivery or caesarean section depending on the cervix. If there is no growth retardation, trigger as soon as the cervix is favorable.
• If the diastolic pressure is ≥ 110 mmHg: methyldopa PO or atenolol PO as below.
– In case of severe pre-eclampsia (hypertension + massive proteinuria + significant edema)
• Urgent delivery within 24 hours, vaginally or by caesarean section depending on the cervix.
• Attempt to decrease the risk of eclampsia prior to delivery:
magnesium sulfate by IV infusion: 4 g diluted in sodium chloride 0.9% to be administered over 15 to 20 minutes, then 1 g / hour to 24 hours following delivery or the last crisis.
Monitor urine output. Stop processing if the volume of urine is less than 30 ml / hr or 100 ml / 4 hours.
Before injection, verify the concentration written on the ampoules: there is a risk of potentially fatal overdose. Always have calcium gluconate to cancel the effect of magnesium sulfate overdose.
Monitor every 15 minutes the patellar reflex during the infusion. If you feel unwell, drowsiness, speech disorders or if loss of patellar reflex, stop the magnesium sulfate and inject 1 g of calcium gluconate by slow, direct IV (5 to 10 minutes).
• If the diastolic pressure is ≥ 110 mmHg:
methyldopa PO: 500 to 750 mg / day in 2 divided doses for 2 or 3 days. Increase gradually if necessary by 250 mg every 2 to 3 days, until the effective dose, usually 1,5 g / day. Do not exceed 3 g / day.
or atenolol PO: 50 to 100 mg / day in the morning taking
Do not stop treatment abruptly, reduce doses gradually.
If unable to orally:
hydralazine by slow IV infusion (ampoule of 20 mg / ml, 1 ml): 4 bulbs in 500 ml of sodium chloride 0.9% (no glucose solution). Gradually increase the speed up to 30 drops / minute. Change the infusion rate according to the TA never go below 90 mm Hg diastolic.
– In case of eclampsia
• Urgent delivery within 12 hours, vaginally or by caesarean section depending on the cervix and the fetus.
• Treatment of seizures: magnesium sulfate IV infusion.
• Nursing, hydration, monitoring of urine output (indwelling catheter); oxygen (4-6 liters / minute).
• Anti-hypertensive treatment only if the diastolic BP ≥ 110 mmHg as in pre-eclampsia (see above).
• Postpartum: continue the magnesium sulfate 24 hours after delivery or the last seizure, continue antihypertensive treatment if the diastolic pressure remains above 110 mmHg, monitor urine output.