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this slide was prepared for NCD programme June, 2012, the informations shown here were taken from both JN7 and NICE guideline.useful for family practitioners, community clinic doctors.Thanks

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  1. 1. HypertensionDr. Mohammad Tanvir IslamAssistant Professor (Medicine)Bangabandhu Sheikh Mujib Medical University
  2. 2. •Strict sodium restriction (for example the rice diet•Sympathectomy (surgical ablation of parts of thesympathetic nervous system)•Pyrogen therapy (injection of substances that caused afever, indirectly reducing blood pressure)
  3. 3. Sodium thiocyanate 1900 Not well toleratedHexamethonium, hydralazine and reserpine2nd World War Popular and reasonably effective Chlorothiazide, the first thiazide diuretic Major breakthrough,1st well 1958 tolerated oral agent
  4. 4. Disease burden• Globally 1 billion ( 25% of the adult population)• 50 million people in USA• In Asia, dramatic increase in last 30 years• In China, prevalence has increased from 7.8% in 1980 to 27.2% in 2001• For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there isa doubling of mortality from both IHD and stroke• High BP, the second most important cause of disability adjusted life year (DALY) loss in Asian countries.• The Framingham Heart study suggests that individuals who are normotensive at 50 years of age have a 90 % lifetime risk for developing hypertension.
  5. 5. HTN in Bangladesh Hypertension Deaths in Bangladesh reached 18,245 or 1.91% of total deaths WHO data published in April 2011•Prevalence rates of systolic and diastolic hypertension in natives > 20 years of age are14.4% and 9.1% respectively• Among the elder individuals, it is 65% BMRC
  6. 6. Todays topic includes• Understanding hypertension• Basic knowledge on measurement of BP• Common issues in management of hypertension• Treatment of hypertension in community clinics or hospitalsTopics not included• Hypertensive emergencies• Pregnancy related hypertension• Secondary hypertension
  7. 7. What is Hypertension?It is the level of blood pressure above which treatment has been shown to reduce thedevelopment or progression of disease There is no natural cut-point above which "hypertension" definitively exists and below which, it does not
  8. 8. Blood Pressure ClassificationBP Classification SBP mmHg DBP mmHgNormal <120 and <80Prehypertension 120–139 or 80–89Stage 1 Hypertension 140–159 or 90–99Stage 2 Hypertension >160 or >100 According to JNC 7
  9. 9. Systolic 120-139 mmHgPrehypertension Diastolic 80-89 mmHg Reduce BP Decrease progression of BP to hypertensive levels with age Prevent hypertension entirely According to JNC 7
  10. 10. BP Measurement Techniques Clinic/office BP measurement Home BP monitoring Ambulatory BP monitoring
  11. 11. Office/ Clinic measurement• With a properly calibrated and validated instrument• Patient is seated quietly for at least 5 minutes in a chair with feet on the floor and arms supported at the heart level• Appropriate sized cuff (Cuff – bladder encircling 80% of the arm) is used.• At least two measurements are made at separate occasion at a reasonable interval
  12. 12. Diagnosis If the clinic blood pressure is 140/90 mmHg or higher OfferAmbulatory blood pressure monitoring (ABPM) to confirm thediagnosis of hypertension. According to NICE guideline 2011
  13. 13. DiagnosisWhen using the following to confirm diagnosis, ensure:ABPM:• at least two measurements per hour during the person’s usual waking hours, average of at least 14 measurements to confirm diagnosisHBPM:• two consecutive seated measurements, at least 1 minute apart• blood pressure is recorded twice a day for at least 4 days and preferably for a week• measurements on the first day are discarded – average value of all remaining is used. According to NICE guideline 2011
  14. 14. Hypertension should not be diagnosed nor treatmentoffered on the basis of a single BP measurement
  15. 15. Types of hypertensionEssential – 95%Secondary – 5%• Sleep apnea• Pregnancy• Coarctation of aorta• Renal diseases• Endocrine diseases• Drugs
  16. 16. Patient EvaluationIdentify CV risk factors Reveal secondary Asses TOD causeds • Hypertension • Sleep apnea • Heart • Cigarette smoking • Drug-induced or related • Left ventricular • Obesity causes hypertrophy • Physical inactivity • Chronic kidney disease • Angina or prior • Dyslipidemia • Primary aldosteronism myocardial infarction • Diabetes mellitus • Renovascular disease • Prior coronary • Microalbuminuria or • Chronic steroid therapy revascularization estimated GFR <60 and Cushing’s syndrome • Heart failure ml/min • Pheochromocytoma • Brain • Age (older than 55 for • Coarctation of the aorta • Stroke or transient men, 65 for women) • Thyroid or parathyroid ischemic attack • Family history of disease • Chronic kidney disease premature CVD • Peripheral arterial disease • (men under age 55 or • Retinopathy women under age 65) TOD= target organ damage
  17. 17. Look for identifiable causesPheochromocytoma• labile or paroxysms of hypertension accompanied by• headache,palpitations, pallor, and perspirationAortic coarctation• Decreased pressure in the lower extremities or delayed or• absent femoral arterial pulsesCushing’s syndrome• truncal obesity, glucose intolerance,and purple striae
  18. 18. Look for identifiable causesChronic kidney disease• Facial or leg swelling• H/O oliguria or polyuriaThyroid disorders• Thyroid swelling• Weight loss/gain• Palpitaion/skin thickening etcRenal artery stenosis• sudden/severe/resistant HTN• H/O flash pulmonary edemaPolycystic kidney disease• Palpable kidney• H/O hematuria
  19. 19. Target organ damageCHD,LVH,Heart Stroke Chronic kidney failure disease Peripheral Hypertensive vascular disease retinopathy
  20. 20. How shall we investigate this patient
  21. 21. Investigation 1.Investigations of all patients 2. Investigation of selected patients
  22. 22. Investigation of all patients• Urinalysis for blood, protein and glucose• Blood urea, electrolytes and creatinine• Blood glucose• Serum total and HDL cholesterol• 12-lead ECG (left ventricular hypertrophy, coronary artery disease)
  23. 23. Investigation for selected patients• Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the aorta• Echocardiogram: to detect or quantify left ventricular hypertrophy• Renal ultrasound: to detect possible renal disease• Renal angiography: to detect or confirm presence of renal artery stenosis• Urinary catecholamines: to detect possible phaeochromocytoma• Urinary cortisol and dexamethasone suppression test: to detect possible Cushings syndrome• Plasma renin activity and aldosterone: to detect possible primary aldosteronism
  24. 24. Do we need to treat ??
  25. 25. Benefits of Lowering BP Average Percent ReductionStroke incidence 35–40%Myocardial infarction 20–25%Heart failure 50%
  26. 26. Benefits of Lowering BPIn stage 1 HTN and additional CVD risk factors, achievinga sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated
  27. 27. Treating hypertensionNon pharmacologic• Major life - style modification • Decreases BP • Increase a drug efficacy • Decrease cardiovascular risksDrug treatment• Effective treatment reduces • CVD – 30% • CAD – 20%
  28. 28. Life style ModificationsModification Recommendation Approximate SBP ReductionWeight Reduction BMI 18.5 – 24.9 5 – 20 mmHg/ 10 kg wt lossAdopt DASH eating plan ↑ fruits, vegetables, 8 – 14 mmHg ↓saturated and total fatDietary sodium reduction 2.4 gm Na+ or 6 gm NaCI 2 – 8 mmHgPhysical activity Brisk walking, 30 min/day 4 – 9 mmHgAlcohol (moderate) 10 oz or 30 ml ethanol for 2 – 4 mmHg men not more than 1 drink/ day.
  29. 29. DASH (Dietary Approaches to Stop Hypertension)Type of food Number of servings for Servings on a 2000 Calorie 1600 - 3100 Calorie diets dietFruits 4-6 4-5Vegetables 4-6 4-5Low fat or non fat dairy 2-4 2-3foodsLean meat, fish, poultry 1.5-2.5 2 or lessNuts, seeds, and legumes 3-6 per week 4-5 per weekFats and sweets 2-4 limitedGrains and grain products 6-12 7-8(include at least 3 wholegrain foods each day)
  30. 30. Initiating treatmentDrug should be given to -Any age with stage 2 HTN< 80 yr with stage 1 HTN who have target organdamage (TOD) - Established cardiovascular disease Renal disease Diabetes 10 yr cardiovascular risk ≥ 20%
  31. 31. Initiating treatmentGeneral principles• If possible, offer drugs taken only once a day• Prescribe non-proprietary drugs if these are appropriate and minimise cost• Offer people with isolated systolic hypertension (systolic blood pressure 160 mmHg or higher)the same treatment as people with both raised systolic and diastolic blood pressure• Offer people aged over 80 years the same antihypertensive drug treatment as people aged 55–80 years, taking into account any comorbidities.• Do not combine an angiotensin-converting enzyme (ACE) inhibitor with an angiotensin II receptor blocker (ARB)
  32. 32. Choosing antihypertensiveStep 1 treatment:age< 55 yr• ACE inhibitor 1st choice, If not tolerated , then ARBage over 55 yr or black people of any age• calcium-channel blocker is 1st choice for
  33. 33. Choosing antihypertensiveThiazide-like diuretic (chlortalidone orindapamide)• If a CCB is not suitable, or if heart failureWho already having thiazide and BP is wellcontrolled, treatment should be continued
  34. 34. Choosing antihypertensive Beta-blockers may be considered in youngerthose with an intolerance to ACE inhibitors & ARB or women of child-bearing potential or people with increased sympathetic drive
  35. 35. Choosing antihypertensiveStep 2 treatment• If BP is not controlled , a CCB is added with either an ACE inhibitor or an ARB• If a CCB is not tolerated, or there is heart failure thiazide-like diuretic is the choice• For black people, consider an ARB in preference to an ACE inhibitor, in combination with a CCB
  36. 36. Choosing antihypertensiveStep 3 treatment• Before considering step 3 , medication should be reviewed to ensure step 2 treatment is at optimal or best tolerated dose• If treatment with three drugs is required, thiazide-like diuretic should be used as 3rd drug
  37. 37. Choosing antihypertensiveStep 4 treatment• If BP not controlled with 3 drugs• A 4th drug is added and/or• Expert advice is needed• As a 4th drug, further diuretic with low-dose spironolactone , if the blood K+ < 4.5 mmoll
  38. 38. Choosing antihypertensiveHigher-dose thiazide-like diuretic is considered if the blood K+ level is higher than 4.5 mmol/l Blood Na+ and K+ and renal function should be monitored within 1 month and repeat as requiredIf further diuretic at step 4 is not tolerated, an alpha- or beta-blocker should be used
  39. 39. Aged over 55 years or black person of African or Caribbean familyAged under Summary of origin of any age 55 years antihypertensive drug treatment A C Step 1 Key A +C Step 2 A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) A+C+D Step 3 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic Resistant hypertension Step 4A + C + D + consider further diuretic or alpha- or beta-blocker Consider seeking expert advice
  40. 40. Additional recommendations • Crucial part of patient managementPatient education and adherence • information about benefits of drugs and side effects • details of patient organisations Provide: • an annual review of care.
  41. 41. Follow-up visits
  42. 42. Useful linkswww.nice.org.ukwww.nhlbi.nih.gov/guidelines/hypertensionhttp://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf
  43. 43. Thank you for being with us