Hypertension

LETS READ AND UNDERSTAND IT

1. Hypertension Presenter : Dr AbdulRafey MBBS

2. OUTLINE INTRODUCTION EPIDEMIOLOGY RISK FACTORS CAUSES TYPES OF HYPERTENSION MANAGEMENT: A mong young, elderly and pregnant women and diabetes DIAGNOSIS TREATMENT PREVENTION

3. INTRODUCTION Hypertension is defined by : The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure(JNC 7) a systolic blood pressure (SBP) >130mmHg and diastolic blood pressure (DBP)> 89mmHg at rest .

4. Table : Provides a classification of BP for adults 18 years N ote : Pre-hypertension is not a disease category, rather high risk individual

5. Hypertension crises Hypertensive urgency : Severely elevated BP(SBP >220 and DBP>120) without signs and symptoms of acute end organ damage Hypertensive emergency : Severely elevated BP(SBP >220 and DBP>120) with symptoms of acute end organ damage (the system most affected are cardiovascular ,Renovascular and cerebrovascular)

6. Accelerated hypertension is a recent significant increase over baseline BP that is assoc/with target organ damage. This is usually seen as vascular damage on funduscopic exam, such as flame-shaped hemorrhages or soft exudates, but without papilledema . Flame shaped

7. Other .. Malignant hypertension : is a syndrome of high BP( SBP> 180 and DBP > 120mmHg) and Papilledema on fundoscopy (retinopathy ) must be present. Papilledema

8. Resistant hypertension : is an uncontrolled HTN despite the use of three anti- hypertensives ( ACEi /ARB + CCB or BB)including diuretics eg : furosemide

9. EPIDEMIOLOGY Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals. ~ 7.1 million deaths per year may be attributable to hypertension Suboptimal BP ( > 115mmHg Systolic BP) is the number one attributable risk factor for death throughout the world. WHO reports: that suboptimal BP is responsible for 62% of cerebrovascular disease and 49% of ischemic heart disease (IHD ), with little variation by sex . Within the last two decades , better Rx of HTN has been ass/with a considerable reduction in the hospital case-fatality rate for heart failure (HF ) *WHO 2014 guideline *JNC 8 guideline

10. Causes/risk factors of HTN Non modifiable Age Gender /sex Genetic Modifiable causes Overweight BMI> 30kg/m2 Salt intake Junk foods Alcohol & tobacco use P hysical inactivity O ther secondary causes of HTN are : Chronic kidney disease Coarctation of the aorta Cushing’s syndrome and other glucocorticoid excess states including chronic steroid therapy Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular hypertension Sleep apnoea Thyroid or parathyroid disease

11. Other risk factors Barriers to prevention include cultural norms insufficient attention to health education by health care practitioners lack of access to places to engage in physical activity; larger servings of food in restaurants lack of availability of healthy food choices in many schools, worksites, and restaurants lack of exercise programs in schools; large amounts of sodium added to foods by the food industry and restaurants; The higher cost of food products that are lower in sodium and calories

12. Diagnosi s History and physical examination BP measurement using standard sized cuff cholesterol and blood sugar levels Rule out underlying disease: CVD DM THYROID GENETIC DISEASE e.g. Coarctation of aorta

13. Diagnosis

14. Treatment The Rx goal for individuals with: In Pre-hypertension - lower BP to normal levels with lifestyle changes and prevention In Hypertensive and no other compelling conditions BP goal is < 140/90 mmHg In hypertensive and diabetes or renal disease, the BP goal is <130/80 mmHg It has been estimated that for every 5mmHg reduction of SBP in the population would result in: 14 % overall reduction in mortality due to stroke , 9% reduction in mortality due to CHD , and 7% decrease in all-cause mortality * The Seventh/eight Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

15. Pharmacological medications Group Drugs Loop diuretic Furosemide 20–80 mg bd ; Torsemide 2.5-10mg od Thiazide diuretics Chlorothiazide (125-500 od / bd ) Hydrochlorothiazide (12.5-50mg od ) Angiotensin receptor blocker(ARB) Losartan (25-100mg od / bd ) ; Telmisartan (20-80mg/day od ); Candesartan (8-32mg/day od ) Angiotensin converting enzyme inhibitor (ACEI) Captopril (25-100mg) od ; Enalapril (5-40mg ) Od ; Perindopril (4-8mg) od Calcium channel blockers (CCB) Dilteazem (180-420mg od ) Verapamil (80-120mg od ) Amlodipine (2.5-10mg od ) Nifedipine (20-60mg od / bd ) Beta blockers(BB) Bisoprolol (2.5 -10mg od ) ; atenolol (25-100mg 0d) Aldosterone receptor blocker Spironolactone (25-50mg od ) In heart failure or A trial fibrillation(AF)

16. Treatment plan and recommendation Therapy begins with lifestyle modification, and if BP goal is not achieved Thiazide -type diuretics should be used as initial therapy* for most patients, either alone or in combination with one of the ( ACEIs, ARBs , BBs, CCBs) or when a diuretic cannot be used or when a compelling indication is present that requires the use of a specific drug When BP is >20 mmHg above systolic goal or 10mmHg above diastolic goal, consideration should be given to initiate therapy with 2drugs , either as separate prescriptions or in fixed-dose combinations . *JNC 7- 8 2014 guideline

17. Treatment JNC 8 2014 target BP treatment recommendations In N onblack patients with HTN, initial Rx can be a thiazide -type diuretic, CCB, ACE inhibitor, or ARB while In the general B lack population, initial therapy should be a thiazide -type diuretic or CCB and In patients > 18 years with CKD , initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status with the target of < 140/90mmHg.

18. Hypertensive emergency and urgency

19. MEDICATIONS for Hypertensive Emergencies Choose ONE of these medications based on underlying cause and check BP before / after every dose. IV LABETOLOL: preferred in aortic dissection. Avoid in CCF, asthma and bradycardia . Dose: Give 15mg over 2 minutes. Repeat every 10 minutes if needed (max total dose = 300mg). If giving infusion, start at 1 mg/min (mix 100mg in 100ml NS, then give 1 drop every 3 seconds). Titrate upward to a maximum of 4 to 5 mg/min if needed. SODIUM NITROPRUSSIDE preferred in CCF. Avoid in renal failure and pregnancy. IV / IM HYDRALAZINE : preferred in pre-eclampsia / eclampsia. Dose: give 5mg, repeat every 30 minutes if needed (max total dose = 300mg per day).

20. Prevention Community service organizations can promote the prevention of hypertension by providing culturally sensitive educational messages and lifestyle support services and by establishing cardiovascular risk factor screening and referral programs