Sunday 23 October 2011421 Primary Health Care Course Under the supervision of Dr. Hussein Saad
Definition of BP Epidemiology of HT Diagnosis of HT Measuring & confirming of HT Approach to hypertensive patients Risk factors of HT Complications of HT Lowering & prevention of HT Investigation Management Highlights Cases
The pressure of blood flowing through your blood vesselsagainst the vessel wallsSystolic BP: during heartbeat “written on top”Diastolic BP: during heartrelaxation “written onbottom”
It is a sustained elevated blood pressure more than 140 mmHg systolic and more than 90 mmHg diastolic
World epidemiology: Based on data collected in the 1999 to 2000 National Health and Nutrition Examination Survey (NHANES), the estimated overall prevalence of hypertension in 2000 was 28.7%. Among 1565 participants with hypertension, 68.9% were aware of the problem, and 58.4% were under pharmacological treatment. Overall, only 31.0% of individuals had hypertension controlled to a blood pressure of <140 mm Hg systolic and 90 mm Hg diastolic. This figures implies that >40 million adults have uncontrolled hypertension in the United States.Us epidemiology: Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA. 2003; 290: 199–206 .
KSA epidemiology : In Saudi Arabia at a recent study it was found that the prevalence of hypertension was found to be 26.1% in general in subjects between 30 to 70. prevalence in males was at 28.6 %. In females it was at 23.9 %. Prevalence of CAD between hypertensive subjects was 8.2 %. In normotensive patients it was 4.5 %.ksa epidemiology : Al-Nozha MM, Abdullah M, Arafah MR, et al. Hypertension in Saudi Arabia. Saudi Med J. 2007 Jan;28(1):77-84.
4758 subjects participated in recent study. 51% was female. The prevalence was 25.5%. 27.1% males, 23.9% females. 55.3% of the patients were unaware of their disease.(5) Abdalla A. Saeed, Nasser A. Al-Hamdan, Ahmed A. Bahnassy, et al. Prevalence, Awareness, Treatment, and Control of Hypertension among Saudi Adult Population: A National Survey. International Journal of Hypertension. Volume 2011 (2011): 8.
The American Heart Association hasrecommended guidelines to definenormal and high blood pressure. Normal blood pressure less than120/80 Pre-hypertension 120-139 / 80-89 High blood pressure (stage 1) 140-159 / 90-99 High blood pressure (stage 2)higher than 160/100
Blood pressure is measured with a blood pressurecuff (sphygmomanometer). This may be doneusing a stethoscope and a cuff and gauge or byan automatic machineIMPORTANT : measuring alone isnot completely enough, it hasto go hand in hand with a properhistory regarding ….??
To measure the blood pressure correctly thepatient has to be :1) sitting2) has not smoked orconsumed caffeine productsin the last 30 min3) rest for 5 minutes prior tomeasuring4) if it is elevated recheck the other arm* use a cuff of a proper size for the particularpatient, place it 3 cm over the elbow crease.
Patient has a reading of 145/95 mmHg is he hypertensive? 145 95
1) Medical History Age, sex & race Family Hx (1st degree relatives) Chronic dis. (CV, diabetes, renal, vascular, …) Diet, smoking, alcohol Medications (like OCP) previous and current feeling tired, dizzy, blurred vision, headache at the back of the head,… Activity and lifestyle
3) Routine & optional lab tests4) Treatment with and without drugsCanadian Guidelines of Hypertension 2011 updated• www.hypertension.ca CHEP 2011 guidelines• JNC 7 May 2003
Family history Age > 60 (after menopause) Sex (M>F) Race (black > white) Diabetes Pregnant and OCP Renal diseases Vascular ,, Obesity Inactivity (lack of physical activities) Smoking Alcohol Stress Diet: salt & fat (indirectly) ------------------------------------------ • Canadian guidelines of HT 2011 • JNC7
Cardiac events (HF, angina and strokes) Vascular (Heart, brain and peripheral vascular disease) Eye (including blindness) Angina Retinopathy
Renal (kidney damage) Role of kidney in keeping healthy BP HT CKD HT heart work harder damage blood vessels including renal ↓ removing wastes & extra fluids increase fluids in blood vessels HT Dangerous cycle HT one of the leading causes of KF (ESRD) Canadian guidelines of Hypertension 2011 • JNC7 • www.medicinenet.com
The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality.
BP targets are (systolic/diastolic): ≤140/90 mmHg in all patients with hypertension. ≤130/80 mmHg in patients with diabetes and in high-risk. It may be difficult to achieve BP targets, especially in elderly and diabetic patients, and in patients with CV damage.
Life style : * Weight Reduction * Dietary sodium reduction * Physical Activity * Avoid alcohol consumption * Type of food
Modification Recommendation Approximate SBP Reduction (Range) Weight reduction Maintain normal body 5–20 mmHg/10 kg weight weight loss 23,24Adopt DASH eating plan Consume a diet rich in 8–14 mmHg fruits, vegetables, and 25,26 low fat dairy products with a reduced content of saturated and total fat. Dietary sodium Reduce dietary sodium 2–8 mmHg reduction intake to no more than 25–27 100 m mol per day (2.4 g sodium or 6 g sodium chloride). Physical activity Engage in regular 4–9 mmHg aerobic physical 28,29 activity such as brisk walking (at least 30 min per day, most days of the week).Moderation of alcohol Limit consumption to 2–4 mmHg consumption no more than 2 drinks s 30
There are five major classes of such agents licensed for initiation or maintenance of hypertension, alone or in combination: Angiotensin converting enzyme inhibitors (ACEIs) Angiotensin receptor blockers (ARBs) Beta-blockers (BBs) Calcium channel blockers (CCBs) Thiazide-type diuretics
WithoutCompellingindication With compelling Indication
Initial therapy should be monotherapy with a thiazide diuretics.Hypokalemia?? if target BP not achieved with standard dose of monotherapy?combination : thiazide diuretic - CCB CCB + ACEI Other combination ACEI –ARB – not recommended
# Ischemic Heart Disease most common form of target organ damage associated with hypertension. Pt. with hypertension and coronary artery disease , an ACE inhibitor or ARB is recommended Pt. with stable angina → B blocker Pt. had a recent MI → B blocker and ACEI
Combinations of two or more drugs are usually needed to achieve the targetgoal of <130/80 mmHg.Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in patients with diabetes. ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria have been shown to reduce progression to macroalbuminuria.
target BP <130/80 mmHg Initial therapy should be an ACEI or ARB if there is intolerance to ACEI Thizide diuretic are recommended as additive therapy
Gestational hypertension: pregnant woman developing high blood pressure after 20 weeks of pregnancy
Who is at more risk1) Obese women2) Women who have chronic hypertension3) Pregnant women under the age of 20 or overthe age of 40.4) Women who are pregnant with more than onebaby5) Women with diabetes, kidney disease,rheumatoid arthritis, lupus or scleroderma
Resistant hypertensionBlood hypertension in despite of use of 3Concurrent antihypertensive of different classes.One of the agents is diuretics and all of theagents should be used at optimal doses.
A 55 year old man, who is known case of diabetes on insulin. BP: 160 ∕ 100 P: 92 ∕ min. Wt: 86 kg Ht: 1.68 cm. How are you going to manage this patient ?
A 63 year old man who is a known case of hypertension, came for follow up. He is regular on lisinopril 10 mg daily. His BP is 156 ∕ 104 . How are you going to manage this patient ?
A 22 year young patient present to your clinic with high blood pressure after 2 documented reading. BP:160 ∕ 110 How are you going to manage this patient ?
1) American Heart Association http://circ.ahajournals.org/content/112/11/1651.full 2)http://www.medicinenet.com/pregnancy_induced_hypertension/page2.htm 3) Canadian Hypertension Guidelines 4) European Association of Hypertension 5) JNC 7