Hypertension

Friday, July 05, 2013

Dr Maurice Waka

Definition of Hypertension
Blood pressure is a continuous variable which fluctuates widely during the day physical stress mental stress The definition of hypertension has been arbitrarily set as: That blood pressure above which the benefits of treatment outweigh the risks in term of morbidity and mortality
HTN = office BP 140 / 90 mm Hg

Friday, July 05, 2013

Definition of Hypertension

Friday, July 05, 2013

Hypertension: prevalence and control

20%

3-29%

HTN Normotensive people

BP Goal achieved BP Goal not achieved

Edward J. Rocella, PhD, MPH. National Heart, Lung and Blood Institute. Bethesda, Maryland. Friday, July 05, 2013 Paper given at ASH. New York, May 1999.

Hypertension Prevalence In Europe and North America

60
Prevalence of Hypertension in % 50.7

50
42.1

46.8 41.1

47.4

40 30
21.8 24.3

20 10

0
USA
Friday, July 05, 2013

Canada

England

Finland

Germany

Spain

Italy

Hypertension Causes
Primary Disease
Secondary Syndrome of other disease
Renal artery stenosis Chronic renal disease Endocrine disease, Cushings,Conns Syndrome,

90%

Phaeochromocytoma, etc.

10%
Friday, July 05, 2013

High Blood Pressure Causes

Friday, July 05, 2013

Blood Pressure Classification JNC-VII Report

LEVEL Optimal Normal Borderline Hypertension STAGE 1 STAGE 2 STAGE 3 SYSTOLIC <120 120-129 130-139 >140 140159 160179 >180 DIASTOLIC <80 80-84 85-89 >90 9099 100109 110

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Friday, July 05, 2013 Treatment of High Blood Pressure. JAMA 2003;289:256071.

Symptoms of High BP
Headaches- often radiating to the back of the head, upper neck. Severe splitting headaches may be a sign of stroke Fatigue- without any identifiable cause Visual disturbances esp. in end organ damage Frequent palpitations without any other cause Dizzy spells Chest pains (left sided) Back pains( also in those with kidney disease)

Friday, July 05, 2013

Evaluation of patients with documented HTN has three objectives: Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. Reveal identifiable causes of high BP. Assess the presence or absence of target organ damage and CVD
Friday, July 05, 2013

Office BP Measurement
Use auscultatory method with a properly calibrated and validated instrument.

Be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made. Clinicians should provide explain verbally and in writing, Friday, July 05, 2013 specific BP numbers and BP goals.

Ambulatory BP Monitoring
ABPM is warranted for evaluation of white-coat HTN in the absence of target organ injury.

Ambulatory BP values are usually lower than clinic readings. Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg. BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.
Friday, July 05, 2013

Friday, July 05, 2013

CVD Risk Factors

Hypertension Cigarette smoking Obesity (BMI >30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65)

Friday, July 05, 2013

Identifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushings syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

Friday, July 05, 2013

Target organ Damage in Hypertension

Cerebrum
Stroke, TIA, Encephalopathy Retinopathy

Eyes

HTN
Heart Kidneys Vessels
Friday, July 05, 2013

LVH, MI, CHF, Arrhythmias, sudden death ESRD

Vascular remodeling and accelerated arteriosclerosis

Left Ventricle Hypertrophy (1)

Friday, July 05, 2013

Left Ventricle Hypertrophy (2)

Friday, July 05, 2013

Friday, July 05, 2013

Retinal damage in Hypertension

Friday, July 05, 2013

Association of blood pressure, risk factors and target organ damage

Blood pressure (mmHg)
Other risk factors and disease history Normal SBP 120-129 or DBP 80-84 High normal SBP 130-139 or DBP 85-89 Grade 1 SBP 140-159 or DBP 90-99 Grade 2 SBP 160-179 or DBP 100-109 Grade 3 SBP 180 or DBP 110

I. No other risk factors

Average risk

Average risk

Low added risk Moderate added risk

Moderate added risk Moderate added risk

High added risk Very high added risk

II. 1-2 risk factors

Low added risk

Low added risk

III. 3 risk factors or target organ damage or diabetes IV. Associated clinical conditions

Moderate added risk

High added risk

High added risk

High added risk

Very high added risk

Friday, July 05, 2013

High added risk

Very high added risk

Very high added risk

Very high added risk

Very high added risk

Laboratory Tests
Routine Tests Electrocardiogram Urinalysis Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides Optional tests 1. Measurement of urinary albumin excretion or albumin/creatinine ratio 2. Echocardiography More extensive testing for identifiable causes is not indicated Friday, July 05, 2013 unless BP control is not achieved or specific symptoms present

Goals of Treatment
Reduce CVD and renal morbidity and mortality. Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years of age.

Friday, July 05, 2013

Lifestyle Modification
Modification Recommendation
Approximate SBP reduction (range) weight 520 mmHg/10kg92,93

Weight reduction Maintain normal body (body mass index 18.5 24.9 kg/m2). Adopt DASH eating plan Consume a diet rich in fruits, 814 mmHg94,95 vegetables, and lowfat dairy products with a reduced content of saturated and total fat.

520 mmHg/10 kg weight loss

814 mmHg

Friday, July 05, 2013

Lifestyle Modification
Modification

Recommendation
Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day, most days of the week).

Approximate SBP reduction (range) weight 520 mmHg/10kg 28 mmHg

Dietary sodium reduction

Physical activity

49 mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80- proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter Friday, July 05, 2013 weight persons.

24 mmHg

Lifestyle Recommendations for Hypertension: Physical Activity

Should be prescribed to reduce blood pressure

F I T

Frequency- Four or five times per week Intensity Time Type - Moderate - 45-60 minutes Dynamic exercise - Walking - Cycling - Non-competitive swimming

T
Friday, July 05, 2013

For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive therapy

Benefits of Lowering BP

Average Percent Reduction Stroke incidence Myocardial infarction 3540% 2025%

Heart failure

50%

Friday, July 05, 2013

Something About DASH

Scientists supported by the National Heart, Lung, and Blood Institute (NHLBI) conducted two key studies. Findings showed that blood pressures were reduced with an eating plan that is low in saturated fat, cholesterol, and total fat and that emphasizes fruits, vegetables, and fat-free or lowfat milk and milk products. Known as the DASH eating plan - Dietary Approaches to Stop Hypertension Also includes whole grain products, fish, poultry, and nuts. Reduced in lean red meat, sweets, added sugars, and sugarcontaining beverages. It is rich in potassium, magnesium, and calcium, as well as protein Friday, July 05,and 2013 fiber.

Following the DASH Eating Plan

Food Group
Grains*

Daily Servings
68

Serving Sizes
1 slice bread 1 oz dry cereal 1/2 cup cooked rice, pasta, or cereal 1 cup raw leafy vegetable 1/2 cup cut-up raw or cooked vegetable 1/2 cup vegetable juice

Vegetables

4-5

Fruits

4-5

Friday, July 05, 2013

1 medium fruit 1/4 cup dried fruit 1/2 cup fresh, frozen, or canned fruit 1/2 cup fruit juice

Following the DASH Eating Plan

Food Group Daily Servings Serving Sizes

Fat-free or low-fat milk and milk products

Lean meats, poultry, and fish Nuts, seeds, and legumes

2-3

1 cup milk or yogurt 11/2 oz cheese

1 oz cooked meats, poultry, or fish 1 egg 1/3 cup or 11/2 oz nuts 2 Tbsp peanut butter 2 Tbsp or 1/2 oz seeds 1/2 cup cooked legumes (dry beans and peas)

6 or less

45 per week

Friday, July 05, 2013

Following the DASH Eating Plan

Food Group Daily Servings Serving Sizes

Fats and oils

2-3

Sweets and added sugars

5 or less per week

1 tsp soft margarine 1 tsp vegetable oil 1 Tbsp mayonnaise 2 Tbsp salad dressing 1 Tbsp sugar 1 Tbsp jelly or jam 1/2 cup sorbet, gelatin 1 cup lemonade

Friday, July 05, 2013

Thank You
Friday, July 05, 2013