2. Clinical Scenario
• A 57 year old gentleman presented in the
emergency department with H/O sudden onset
of headache, L sided weakness, fits followed by
loss of consciousness for the last 2 hours.
2098 Franklin #2
3. • On examination the patient is in coma grade II.
His vitals are pulse: 96/min, BP: 220/100
• He has L hemiplegia with L plantar up going
• Fundoscopy reveals Grade III hypertensive
retinopathy with haemorrhages & exudates
2098 Franklin #3
7. Defining Hypertension
• By the numbers?
– ≥95 DBP
– >120/80
“A number at which the benefits of intervention
exceed those of inaction”
2098 Franklin #7
9. Why is hypertension considered a major
Public health problem?
Firstly, hypertension is very
common In the adult population
2098 Franklin #9
10. Increased Prevalence of Hypertension in the United
States from 1988-1994 (NHANES III) to 1999-2000
NHANES
100
30% increase, p<.001
Population With
Hypertension (millions)
80
60
65
50
40
20
0
1988-1994
1999-2000
Nat ional Healt h and Nut rit ion Survey ( NHANES)
Nearly 1 in 3 Adults (31%) in the US Has Hypertension
Fields, et al. Hypertension. 2004;44:398f
11. 1976-98 Cumulative Incidence of HTN
in Women and Men Aged 65 Years
Risk of Hypertension %
100
80
Men
Women
60
40
20
0
0
2
4
6
8
10
12
14
16 18
20
Years of Follow-up
Vasan, et al. JAMA.2002;287:1003
13. Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors
High blood pressure
Tobacco
High cholesterol
Underweight
Unsafe sex
High BMI
Physical inactivity
High mortality, developing region
Alcohol
Lower mortality, developing region
Indoor smoke from solid fuels
Developed region
Iron deficiency
0
1000 2000 3000 4000 5000 6000 7000 8000
Attributable Mortality
Ezzati et al. Lancet. 2002;360:1347-1360. (In thousands; total 55,861,000) 2098 Franklin #13
14. CV Mortality Risk Doubles with
Each 20/10 mm Hg BP Increment*
8
7
6
CV
mortality
risk
5
4
3
2
1
0
115/75
135/85
155/95
175/105
SBP/DBP (mm Hg)
*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.
CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure
Lewington S, et al. Lancet. 2002; 60:1903-1913.
JNC 7. JAMA. 2003;289:2560-2572.
2098 Franklin #14
15. Thirdly, there is considerable
reduction in cardiovascular risk
with effective lowering of blood
pressure with therapy.
2098 Franklin #15
17. Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of
“idiopathic”
• Secondary – about 5% of cases
– Renal or renovascular disease
– Endocrine disease
–
–
–
–
Phaeochomocytoma
Cusings syndrome
Conn’s syndrome
Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
– Hormonal / oral contraceptive
– NSAIDs
2098 Franklin #17
18. Clinical Features
• Hypertension is termed as the “SILENT
KILLER”
• Headache is a common manifestation
• Mostly patients present with complications of
hypertension
2098 Franklin #18
24. JNC Reclassification of BP
Based on Risk
JNC VI
Category SBP
(mm Hg)
Optimal
<120
JNC 7
DBP
(mm Hg)
and
Normal
120-129 and
Hi-normal
130-139
80
80-84
or
85-89
90-99
Category
SBP
(mm Hg)
Normal
<120
DBP
(mm Hg)
and
Prehypertension 120-139 or
80
80-89
Hypertension
Stage 1
140-159
or
Stage 2
160-179
or 100-109
Stage 3
≥ 180
or
≥ 110
Stage 1
140-159 or
90-99
or
≥ 100
Stage 2
Source for JNC VI: Arch Intern Med. 1997;157:2413-2446.
Adapted with permission from Chobanian AV et al. Hypertension. 2003;42:12061252.
≥ 160
2098 Franklin #24
25. JNC 7 Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mm Hg)
(<130/80 mm Hg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
Stage 1 Hypertension
(SBP 140-159 or DBP 90-99 mm
Hg)
Thiazide-type diuretics for most
May consider ACEI, ARB, BB, CCB,
Stage 2 Hypertension
(SBP >160 or DBP >100 mm Hg)
2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
With Compelling
Indications
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed
or combination
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved
Consider consultation with hypertension
specialist
Chobanian et al. JAMA. 2003;289:2560-2572.
2098 Franklin #25
26. Compelling and possible indications for the major classes of antihypertensive
drugs
INDICATIONS
α-blockers
COMPELLING
Prostatism
POSSIBLE
ACEI
HF, LV dysfunction
DM
ARBs
Cough induced by ACE inhibitor
CLASSS OF DRUG
Dyslipidaemia
Myocardial infarction
Angina
Heart failure
CCBs
ISH in elderly patients
Calcium antagonists (rate
limiting)
Angina
Elderly patients
Angina
Myocardial infarction
β−blockers
Thiazides
ISH, HF
2098 Franklin #26
29. Case #1
A 76 year old female comes to her family
doctor complaining of constipation and
pigastric pain as well as weakness and
painful cramps (due to hypokalemia).
2098 Franklin #29
30. History: She has a history of hypertensio
or which she has been taking propranolo
nd hydrochlorothiazide for the past
everal months.
Observation: Mild hypertension
(BP 145/90);
2098 Franklin #30
31. Treatment: Potassium rich foods
(chickpeas, bananas, papaya), potassium
supplement, or switch to
potassium-sparing diuretics such as
spironolactone or triamterene.
2098 Franklin #31
32. Case #2
A 62 year old female is referred to a
pulmonary specialist by her family
physician because of a chronic dry cough
that has been unresponsive to medications.
2098 Franklin #32
33. History: On careful questioning the
specialist discovers that she had been
taking captopril for hypertension for
six months.
Observation: Normal BP
2098 Franklin #33
The Comparative Risk Assessment module of the World Health Organization (WHO)’s Global Burden of Disease 2000 study performed a systematic assessment of changes in population health that would result from modifying exposure to environmental and physiological health risk factors. The methodology used to determine the attributable mortality and attributable burden of disease due to each risk factor was a counterfactual analysis in which the contribution of 1 or a group of risk factors is estimated by comparing the current disease burden with the magnitude that would be expected in an alternative scenario characterized by a theoretical minimal exposure. In the case of high BP and cholesterol, the theoretical minimal exposures were levels of 115 mm Hg and 3.8 mmol/L, respectively.
This analysis of the contribution of 26 selected risk factors to global disease burden found that high BP was the leading cause of mortality in both developing regions and developed regions of the world. The study looked at the impact of risk factors on mortality.
High mortality, developing regions such as many countries in Africa and Southeast Asia.
Lower mortality, developing regions such as Latin America and countries in the Western Pacific.
Developed regions including Europe, Japan, and North America.
In high mortality, developing regions, the leading causes of death were reported to be childhood and maternal undernutrition, including being underweight. However, despite the large contribution of communicable, maternal, perinatal, and nutritional conditions and their underlying risk factors to disease burden in the high mortality, developing regions, the “industrialized” risks of high BP, tobacco, and blood cholesterol levels also resulted in significant loss of life in these regions.
Across developed regions, high BP, tobacco use, alcohol, high cholesterol, and high body mass index (BMI) were reported to be consistently the leading causes of loss of life.
Slide Summary
According to a meta-analysis of over 60 prospective studies, the risk of cardiovascular mortality doubles with each rise of 20 mm Hg in systolic blood pressure (BP) and 10 mm Hg in diastolic BP.
Background
In a meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline, the researchers found that between the ages of 40-69 years, each incremental rise of 20 mm Hg systolic BP and 10 mm Hg diastolic BP was associated with a twofold increase in death rates from ischemic heart disease and other vascular disease.
The researchers also noted that when attempting to predict vascular mortality risk from a single BP measurement, the average of systolic and diastolic BP was “slightly more informative” than either alone, and that pulse pressure was “much less informative.”
The seventh report Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) notes this study result as yet more information linking hypertension to high risk for cardiovascular events.
Lewington S, Clarke R, Qizilbash H, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2003;361:1903-1913.
JNC 7. JAMA. 2003;289:2560-2572.
Hypertension is an important contributing risk factor for end-organ damage and subsequent increases in morbidity and mortality. The goal in treating hypertension is to prevent cardiovascular and renal complications. Even small elevations above optimal blood pressure (BP) values (<120/80 mm Hg) increase the likelihood of developing hypertension (BP ≥140/90 mm Hg) and incurring target-organ damage.
Chronic elevations of BP lead to target-organ damage and the development of cardiovascular and renal diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, left-ventricular hypertrophy, and renal failure.
Signs of target-organ damage herald a poorer prognosis and may present in the heart, blood vessels, kidneys, brain, or eyes. Later consequences include cardiac, cerebrovascular, vascular, and renal morbidities and death.
Because of the complex nature of hypertension, it is not surprising that single antihypertensive agents normalize BP for less than a majority of hypertensive patients.
Reference
Cushman WC. J Clin Hypertens. 2003;5(suppl):14-22.
This slide shows the changes in classification of blood pressure from JNC VI to JNC 7.1,2
“Optimal” blood pressure in JNC VI became “normal” in JNC 7, while “normal” and “borderline” blood pressures in JNC VI were combined as “prehypertension” in JNC 7.1,2
Stage 1 hypertension remained constant from JNC VI to JNC 7.1,2 However, JNC 7 grouped JNC VI Stage 2 and Stage 3 hypertension into one stage (Stage 2).1,2 This change reflected the fact that the approach to patient management for both former categories is similar.1
As recommended by JNC 7, hypertension treatment should start with lifestyle modifications. If the patient is not at goal BP of <140/90 mm Hg (<130/80 mm Hg for those with diabetes or chronic kidney disease), pharmacologic therapy should be initiated. Initial drug choices for patients without compelling indications should be a thiazide diuretic for most patients with stage 1 hypertension. Typically, combination therapy with 2 drugs is required for stage 2 hypertension. When use of a single drug fails to achieve the BP goal, addition of a second drug from a different class should be initiated. A 2-drug combination usually consists of a thiazide-type diuretic plus an ACEI, an ARB, a -blocker, or a CCB.
Specific antihypertensives are designated for compelling indications (ie, HF, post-MI, high coronary artery disease [CAD] risk, diabetes, etc.).
If a patient is still not at goal BP following the treatment algorithm, optimize the patient’s dosages or add additional drugs until goal BP is achieved. Also consider consulting with a hypertension specialist.
