Hypertension, Stroke. An overview of prevention of hypertension and stroke

Prevention of hypertension and stroke

1. Non communicable diseases Dr. Mahnoor Department of Community Medicine

2. Learning objectives Define hypertension and classify Identify the epidemiology and global burden of hypertension, with an emphasis on its prevalence in the community. Discuss the importance of lifestyle modifications in hypertension prevention. Explain the global and national burden of stroke, including its morbidity and mortality. Identify the major risk factors for stroke and their relation to community health. Describe the prevention strategies for stroke at the individual and community levels. Explain the role of rehabilitation and long-term care in stroke survivors.

3. What do you know remember about prevention of non communicable diseases?

4. Hypertension Hypertension is a chronic condition of concern due to its role in the causation of coronary heart disease, stoke and other vascular complications. Commonest cardiovascular disorder. One of the major risk factors for cardiovascular mortality, which accounts for 20-50 percent of all deaths.

5. Hypertension is an “iceberg” disease. Only half of the hypertensive subjects in the general population are aware of the condition. Only about half of those aware are being treated, and only half of those treated are considered adequately treated. Worldwide raised blood pressure is estimated to cause 7.5 million deaths, about 12.8 percent of all deaths. This accounts for 57 million DALYs or 3.7 percent of total DALYs It is a major risk factor for coronary heart disease and ischemic as well as hemorrhagic stroke. In some age groups, the risk of cardiovascular disease doubles for each incremental increase of 20/10 mmHg of blood pressure.

6. Complications Complications of raised blood pressure include: Heart failure. Peripheral vascular disease. Renal impairment. Retinal hemorrhage. Visual impairment.

7. Tracking of blood pressure If the blood pressure of individuals are followed over a period of years from early childhood into adult life, then those individuals whose blood pressure are initially high in the distribution, would probably continue in he same “track” as adults. In other words, low blood pressure levels tend to remain low, and high blood pressure tends to become higher as individuals grow older.

8. Risk factors Hypertension itself is a risk factor for many forms of cardiovascular disease, but it has many risk factors of its own. Risk factors are divided into: Non modifiable risk factors. Modifiable risk factors.

9. Risk Factors for Hypertension Modifiable Risk Factors Non-Modifiable Risk Factors Unhealthy diet (high salt, processed foods) Age (risk increases with age) Sedentary lifestyle (lack of exercise) Genetics (family history) Obesity and overweight Ethnicity (higher risk in some populations) Smoking and tobacco use Gender (males at younger ages, postmenopausal women) Excessive alcohol consumption Congenital conditions (e.g., coarctation of the aorta) Stress and poor mental health Poor sleep quality (sleep apnea, insomnia) Diabetes and metabolic syndrome High cholesterol levels

10. Prevention Hypertension is a preventable disease. The WHO has recommended the following approaches in the prevention of hypertension: 1. Primary prevention Population strategy High-risk strategy 2. Secondary prevention

11. Primary prevention Although control of hypertension can be achieved by medication, the goal in general is prevention. Primary prevention includes both population strategy and high-risk strategy.

12. Population strategy The population approach is directed at the whole population, irrespective of individual risk levels. the concept of population strategy is based on the fact that even a small reduction of average blood pressure would produce a large reduction in the incidence of cardiovascular complications such as stroke and CHD. The goal of population approach is to shift the community distribution of blood pressure towards lower levels or “biological normality”. This involves a multifactorial approach, based on the following non-pharmacotherapeutic interventions: Nutrition Weight reduction Exercise promotion Behavioral changes Health education Self care

13. Nutrition: a) reduction of salt intake to an average of no more than 5g per day b)moderate fat intake. c) avoidance of alcohol intake d) restriction of energy intake appropriate to body needs Weight reduction: prevention and correction of over weight/obesity. Exercise promotion: leads to fall in body weight, blood lipids and blood pressure. Behavioral changes: reduce stress and smoking. Modification of personal life style. Health education: the general public require preventive advice on all risk factors and related health behavior. Self care: the patient is taught self care, i.e., to take his own blood pressure and keep a log-book of his reading.

14. High risk strategy The aim of this approach is “to prevent the attainment of levels of blood pressure at which the institution of treatment would be considered”. This approach is appropriate if the risk factors occur with very low prevalence in the community. Detection of high-risk subjects should be encouraged for optimum use of clinical methods. Family history and tracking of blood pressure.

15. Secondary prevention The goal of secondary prevention is to detect and control high blood pressure in affected individuals. The control measures comprise: Early case detection Treatment Patient compliance.

16. Early case detection: Early detection is a major problem. This is because high blood pressure rarely causes symptoms before organ damage. The only effective method is to screen population. But screening, that is not linked to follow-up and sustained care, is fruitless. Treatment: The aim of treatment should be to obtain a blood pressure below 140/90, and ideally a blood pressure of 120/80. control of hypertension has been shown to reduce the incidence of stroke and other complications. Care of hypertensive should also involve attention to other risk factors such as smoking and elevated elevated blood cholesterol levels. Patient compliance: The treatment of high blood pressure must normally be life long and this presents the problems of patient compliance, which is defined as “the extent to which patient behaviour coincides with clinical prescription”. The compliance rates can be improved through education directed to patients, families and community.

17. Stroke

18. Stroke

19. What do you know about stroke?

20. Stroke The term “Stroke” is applied to acute severe manifestations of cerebrovascular disease. It causes both physical and mental crippling. WHO has defined stroke as: “rapidly developed clinical signs of focal disturbances of cerebral function; lasting more than 24 hours or leading to death with no apparent cause other than vascular origin.”

21. Classification 1. Ischemic Stroke (80-85%) – Due to blockage of blood flow Atherosclerosis (major cause) Thrombosis (formation of blood clot in cerebral arteries) Embolism (clot or debris from heart or large arteries) Cardioembolic stroke (e.g., atrial fibrillation, valvular heart disease) Small vessel disease (Lacunar infarcts due to hypertension, diabetes) Hypercoagulable states (e.g., antiphospholipid syndrome, polycythemia) Vasculitis (e.g., Takayasu arteritis, giant cell arteritis) Dissection of arteries (carotid or vertebral artery dissection)

22. 2. Hemorrhagic Stroke (15-20%) – Due to rupture of blood vessels Hypertension (most common cause) Aneurysms (Berry aneurysm rupture in subarachnoid hemorrhage) Arteriovenous malformations (AVMs) Trauma-induced intracranial hemorrhage Coagulation disorders (e.g., hemophilia, anticoagulant overdose) Brain tumors (secondary hemorrhage due to metastasis) Drug-induced (cocaine, amphetamines leading to hypertensive crisis)

23. Presentation Dysfunction of the brain (neurological deficit) manifests itself by various neurological signs and symptoms: Coma Hemiplegia Paraplegia Monoplegia Multiple paralysis Speech disturbances Nerve Paresis Sensory impairment

24. Morbidity and Mortality Cerebrovascular disease remain a leading cause of death Cerbrovascular disease is the leading cause of disability in adults. In demographically developed countries, the average age at which stroke occurs is around 73 Stroke patients are at highest risk of death in the first week after the event, and 20-25 % die within the first month depending on type, severity, age, co-morbidity and effectiveness of treatment. The proportion of patients achieving independence in self-care by one year after a stroke range from around 60-83 percent.

25. Risk factors The main risk factor is hypertension. Additional risk factors include: Cardiac abnormalities Diabetes Elevated blood lipids Obesity Smoking Glucose intolerance Blood clotting and viscosity Oral contraceptives

26. Host Factors Age: Incidence increases steeply with age Sex: The incidence rates are higher in males Personal History: Nearly three-quarters of all registered stroke patients had associated diseases, mostly cardiovascular disease.

27. Prevention Priority goes to controlling hypertension. TIA may be the earliest manifestation of stroke, their early detection and treatment is important for prevention of stroke. Control of all risk factors. Facilities for long term follow up patients

28. prevention 1. Primordial Prevention – Preventing risk factor development Public health policies to reduce salt and trans fats Health education on stroke risk factors Promotion of a healthy lifestyle from childhood 2. Primary Prevention – Preventing first stroke Lifestyle modifications: Healthy diet (DASH diet, low salt, high potassium) Regular physical activity (30 min/day, 5 days/week) Smoking and alcohol cessation Control of risk factors (hypertension, diabetes, dyslipidemia)

29. 3. Secondary Prevention – Preventing recurrence Early detection through regular blood pressure and cholesterol screening Medication adherence (antihypertensives, antiplatelets, anticoagulants) Lifestyle modifications to prevent recurrence 4. Tertiary Prevention – Reducing complications Rehabilitation and physiotherapy for stroke survivors Supportive care and long-term monitoring

30. Case Presentation A 62-year-old male presents to the emergency department with a sudden onset of right-sided weakness and slurred speech for the past two hours . His wife reports that he has a history of uncontrolled hypertension for the past 15 years but is non-compliant with his medications . On examination: BP: 190/110 mmHg Pulse: 88 bpm, regular Neurological Examination: Right-sided hemiparesis (motor power 2/5 in upper & lower limb) Slurred speech (dysarthria) Facial asymmetry (right-sided facial droop) No signs of head trauma or fever What is your next line of action?