Hypertension 1.pdf

Hypertension dfination and management

1. Diagnosis and Update management of
Hypertension
DR. MD. ABDUL MALEQUE
MD (Cardiology)
Clinical & Interventional Cardiologist
NICVD, Dhaka

2. Hypertension(HTN)
•Hypertension( HTN) is the most common primary diagnosis.
•Worldwide prevalence estimates for HTN may be as much as 1 billion
•Hypertension affects 29-33% of adult population –
with a prevalence of >65% in persons older than 60 yrs,
1 in 3 adults
• Attributable risk factor in 41% of all CVD deaths
•7.1 million deaths per year may be attributable to hypertension.

3. Bangladesh scenerio
❑12 million suffers from HTN
❑33.3% of HTN and 29.9% pre HTN
❑1 out of 4(>35 age) and half of them are unaware.
❑25.2% have Knowledge of HTN
❑Women> Men

4. Incidence
•25% of urban population and 10 % of rural population suffer from
hypertension
•70% of all hypertensive patients are stage I hypertension
•12% of all hypertensive suffer from isolated systolic hypertension

5. Introduction
•Graded relationship between increasing BP and risk of CVD
– Increase in BP 20 mmHg systolic or 10 mmHg diastolic associated
with a doubling of the risk of CVD death, regardless of age.
- The higher the blood pressure, the greater the risk. Untreated hypertension
shorten one's life expectancy by 10 to 20 years.
• Nearly half of the hypertensive population remains sub-
optimally controlled.

6. Introduction
•Control of HTN:
- Aware & controlled: 23%
- Aware , treated but not controlled : 28%
- Aware, not treated, not controlled : 10%
- Unaware : 39%
•About one third of every community is affected by HTN, are unaware of their
diagnosis.
•Cardiovascular mortality and morbidity rises as both systolic and diastolic
pressure rises.
•Adequate control of BP decreases
•The incidence of ACS in 20-25%
•Stroke by 30-35%
•Heart failure by 50%.

7. Why focus on hypertension treatment?
• It is affordable
• It is simple
• It is essential
# Modifiable risk factors
# Cost benefit
# Improve mortality & morbidity
Treatment of hypertension in primary care can save more lives than any
other primary care treatment programme

8. Barriers to manage HTN
•The question is, what are the barriers to the management of
hypertension???

9. Hypertension:
Predisposing factors
•Advancing Age
•Sex (men and postmenopausal women)
•Family history of cardiovascular disease
•Sedentary life style & psycho-social stress
•Smoking ,High cholesterol diet, Low fruit consumption
•Obesity & wt. gain
•Co-existing disorders such as diabetes, and hyperlipidaemia
•High intake of alcohol

10. Definition of Hypertension
•Hypertension:
•Systolic blood pressure (SBP) of 140 mmHg or more
OR
•Diastolic blood pressure (DBP) of 90 mmHg or more
OR
•Both SBP & DBP 140/90 mmHg or more
OR
•or taking antihypertensive medication.
(#Based on the average of two or more properly measured BP readings.
#On each of two or more office visits.)

11. Classification
Classification SBP (mmHg) DBP (mmHg)
______________________________________________________
Normal <120 and <80
Prehypertension 120–139 or 80–89
Hypertension >140/90
Stage 1 Hypertension 140–159 or90–99
Stage 2 Hypertension >160 or >100
________________________________________ _

12. Definition of Hypertension
UK (ESC guideline):
•Optimal : <120/80 mmHg
•Normal : <130/ 85 mmHg
•High Normal : 130-139/85-89 mmHg
•Hypertension:
Grade 1(mild): 140-159/90-99 mmHg
Grade 2 ( mod): 160-179/100-109 mmHg
Grade 3 ( severe): ≥180/110 mmHg
•Isolated Systolic Hypertension:
Grade 1: 140-159/ <90 mmHg
Grade 2: ≥160/< 90 mmHg

13. Hypertension
•Normal BP: <120/<80
•Prehypertension: 120-139/80-89
•Hypertension stage1 140-159/90-99
•Hypertension stage 2 160/100
•Emergency Evidence of acute target organ damage
•Resistant hypertension Failure of BP control with three drug regimen
Refractory hypertension Uncontrolled BP despite ≥ 5 antihypertensive
drugs
•Isolated systolic hypertension >140/<90

14. Hypertension
•USA (JNC 8):
1)Normal- SBP (<120), DBP (<80)
2) Pre hypertension - SBP (120-139), DBP(80-89)
3) Hypertension
Grade1- SBP(140-159), DBP(90-99)
Grade2- SBP(>=160), DBP(>=100)

15. Hypertension
•According to ISH ( International Society of HTN):
1. Normal- BP<130/85
2. High Normal- 130-139/85-89
3. Hypertension
Grade 1- 140-159/90-99
Grade 2- >=160/100

16. Accurate Blood Pressure Measurement
•The equipment should be validated.
•The operator should be trained.
•The patient must be properly prepared and positioned and seated quietly for at least 5
minutes in a chair.
•The auscultatory method should be used.
•Caffeine, exercise, and smoking should be avoided for at least 30 minutes before BP
measurement.
•An appropriately sized cuff should be used.
•At least two measurements should be made and the average recorded.

17. Haemodynamic Pattern in
Hypertension
BP = CO X TPR
Young :  BP = CO X TPR
Elderly :  BP =  CO X   TPR

18. ABPM
•Record BP over a defined period, usually 24 hrs
•At 15-30 min intervally
•Provide average BP value for day time, night time & 24 h
•Hypertension:
130/80 mmHg or more over 24 hrs
135/85 mmHg for day time average
120/70 mmHg for night time average
Imp:
# White coat HTN
# Masked HTN
# Episodic

19. HBPM
•For at least 3 days, preferably 6-7 consecutive days
•At morning & evening
•2 measurment at each session
•Hypertension:
135/85 mmHg or more
Imp:
# White coat HTN
# Masked HTN

20. White coat HTN/ Isolated office HTN
•BP elevated at office but normal in ABPM, HBPM or both
•About 30-40% people
•Lifestyle change
•Regular follow up
•Drug treatment if
HMOD
CV risk very high

21. Masked HTN
•BP normal in office but elevated at ABPM or HBPM
•Usually associated with metabolic syndrome
•Antihypertensive needed

22. Prehypertension
•SBP >120 mmHg and <139mmHg and/or
•DBP >80 mmHg and <89 mmHg.
•Prehypertension is not a disease category rather a designation for
individuals at high risk of developing HTN.
•Individuals who are prehypertensive are not candidates for drug therapy b
• Should be advised to practice lifestyle modification
•Those with pre-HTN, who also have diabetes or kidney disease, drug
therapy is indicated if a trial of lifestyle modification fails to reduce their BP
to 130/80 mmHg or less.

23. Isolated Systolic Hypertension
•Not distinguished as a separate entity as far as management is
concerned.
•SBP should be primarily considered during treatment and not just
diastolic BP.
•Systolic BP is more important cardiovascular risk factor after age 50.
•Diastolic BP is more important before age 50.

24. Hypertensive Crises
•Hypertensive Urgencies: No progressive target-organ dysfunction.
(Accelerated Hypertension)
•Hypertensive Emergencies: Progressive end-organ dysfunction.
(Malignant Hypertension)

25. Hypertensive Urgencies
•Severe elevated BP in the upper range of stage II/III hypertension.
•Without progressive end-organ dysfunction.
•Examples: Highly elevated BP without severe headache, shortness of
breath or chest pain evidenced by organ damage
•Usually due to under-controlled HTN.

26. Hypertensive Emergencies
•Severely elevated BP (>180/120mmHg).
•With progressive target organ dysfunction.
•Require emergent lowering of BP.
•Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

27. Types of hypertension
•Essential hypertension/primary hypertension
•95%
•No underlying cause
•Secondary hypertension
•Underlying cause

28. Causes of
Secondary Hypertension
•Intrinsic renal disease – AGN, CGN, CKD, ADPKD
•Renovascular disease – Renal artery stenosis
•Pregnancy induced hypertension- Preeclampsia, eclampsia
•Endocrine diseases-
Hyper/hypothyroidism
Primary hyperaldosteronism
Cushing syndrome
Acromegaly
Pheochromocytoma
Acromegaly
•Sleep Breathing disorder- Obstructive sleep apnea
•Exogenous hormone- OCP, Glucocorticoids
•Coarctation of Aorta

29. Complications of Prolonged Uncontrolled HTN
•Changes in the vessel wall leading to vessel trauma and
arteriosclerosis throughout the vasculature
• Complications arise due to the “target organ” dysfunction and
ultimately failure.
•Damage to the blood vessels can be seen on fundoscopy.

30. Target Organs
•CVS (Heart and Blood Vessels)
•The kidneys
•Nervous system
•The Eyes

31. Target Organ Damage
▪Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
•Aortic aneurysm & dissection
▪Brain
• Stroke or transient ischemic attack
•Haemorrhage (ICH, SAH)
•Hypertensive encephalopathy
•Dementia
▪Kidney
Chronic kidney disease
▪Peripheral arterial disease
▪Eye
Retinopathy, Blindness

32. Patient Evaluation Objectives
• (1) To assess lifestyle and identify other cardiovascular risk factors or
concomitant disorders that may affect prognosis and guide treatment
• (2) To reveal identifiable causes of high BP
• (3) To assess the presence or absence of target organ damage

33. Cardiovascular Risk factors
•Hypertension
•Cigarette smoking
•Obesity (body mass index ≥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 cardiovascular disease (men under age 55 or
women under age 65)

34. Identifiable Causes of HTN
•Sleep apnea
•Drug-induced or related causes
•Chronic kidney disease
•Primary aldosteronism
•Renovascular disease
•Chronic steroid therapy and Cushing’s syndrome
•Pheochromocytoma
•Coarctation of the aorta
•Thyroid or parathyroid disease

35. Target Organ Damage
•Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
•Brain
Stroke or transient ischemic attack
•Chronic kidney disease
•Peripheral arterial disease
•Retinopathy

36. Medical History
•Angina/MI Stroke: Complications of HTN, Angina may improve with
b-blokers
•Asthma, COPD: Preclude the use of b-blockers
•Heart failure: ACE inhibitors indication
•DM: ACE preferred
•Polyuria and nocturia: Suggest renal impairment
( consider all comorbidity for appropriate therapy)

37. History-contd.
•Claudication: May be aggravated by b-blockers, atheromatous RAS
may be present
•Gout: May be aggravated by diuretics
•Use of NSAIDs: May cause or aggravate HTN
•Family history of HTN: Important risk factor
•Family history of premature death: May have been due to HTN

38. History-contd.
•Family history of DM : Patient may also be Diabetic
•Cigarette smoker: Aggravate HTN, independently a risk factor for CAD
and stroke
•High alcohol: A cause of HTN
•High salt intake: Advice low salt intake

39. Examination
•Appropriate measurement of BP in both arms
•Optic fundi
•Calculation of BMI ( waist circumference also may be useful)
•Auscultation for carotid, abdominal, and femoral bruits
•Palpation of the thyroid gland.

40. Examination-contd.
•Thorough examination of the heart and lungs
•Abdomen for enlarged kidneys, masses, and abnormal aortic
pulsation
•Lower extremities for edema and pulses
•Neurological assessment

41. Routine Labs
•EKG/ECG
• Urinalysis.
• Blood glucose and hematocrit; serum potassium, creatinine ( or
estimated GFR), and calcium.
• HDL cholesterol, LDL cholesterol, and triglycerides.
• Optional tests
urinary albumin excretion.
albumin/creatinine ratio.

42. Goals of Treatment
•Treating SBP and DBP to targets that are <140/90 mmHg
•Patients with diabetes or renal disease, the BP goal is <130/80 mmHg
•The primary focus should be on attaining the SBP goal.
•To reduce cardiovascular and renal morbidity and mortality

43. Benefits of Treatment
•Reductions in stroke incidence, averaging 35–40 percent
•Reductions in MI, averaging 20–25 percent
•Reductions in HF, averaging >50 percent.

44. Take home message
•Hypertension is a major cause of morbidity and mortality, and needs to be
treated
•It is an extremely common condition; however it is still under-diagnosed
and undertreated
•Hypertension is easy to diagnose and easy to treat
•Aim of the management is to save the target organ from the deleterious
effect
•Life style modification should always be encouraged in all Hypertensive
patients
•Drug should be prescribed considering all factors to improve mortality &
morbidity