Hypertension is a condition in which the force of blood against artery walls is high enough to cause health complications. The more blood the heart pumps and the narrower the arteries, the higher the blood pressure. Many a times, you can have hypertension for years without any symptoms. If the blood pressure is uncontrolled, it increases the risk of serious health problems, including heart attack and stroke. Fortunately, hypertension can be easily detected. And if diagnosed, you can work with your doctor to control it. To know more, read on Hypertension by our Consultant Internal Medicine, Dr. Anil Ballani.

1. Dr. Anil Ballani
M.D.
Consultant Physician
Hinduja Hospital
HYPERTENSION

2. Hypertension – Silent Killer
• Silent killer because it produces no symptoms till late stages
• Major misconception that with hypertension patient should
have headache, giddiness, etc.,
• Most of these symptoms come up only when the B.P. reaches
above 180 mm Hg
• The incidence of Hypertension in community is almost
30-40%
• As age increases the incidence of hypertension also increases
exponentially
2

3. 3
HYPERTENSION
The Truth is
It is only a marker of the bigger problem
Hypertension is a multi-organ systemic disease
What we record as B.P.
The Problem is
Hypertension is asymptomatic in 85% of cases

4. 4
How to be wise in HT?
The Truth is
To consider Hypertension as an isolated disease
Hypertension, DM, Dyslipidemia, Obesity often coexist
They are the 4 pallbearers to the grave of CHD, CVD
For all of them
Primary and secondary prevention by TLC is the answer
Afflicted with one, must be screened for all other thieves
It is wrong

5. 5
Treatment Goal
The Truth is
Keep B.P. < 140/90 mm Hg in each patient
This may be revised to 120/80 may be ? 110/70
MRFIT’s cut off values are 115/75 mm Hg
It is essential to keep the B.P at or below the goal
But, It also matters how the goal B.P. is achieved !
Goal BP

6. 6
Definitions
As per JNC VII and ISH (WHO) 2004
1. What is normal B.P ?
Normal SBP < 120 and DBP < 80
2. What is pre hypertension ?
Pre HT SBP 120 to 139 mm Hg
DBP 80 to 99 mm Hg

7. 7
Definitions
1. What is stage 1 HT ?
2. What is stage 2 HT ?
Stage 1 SBP 140 to 159
DBP 90 to 99
Stage 2 SBP 160 and more
DBP 100 and more

8. 8
JNC VII Classification
CategoryCategory SBP (mm Hg)SBP (mm Hg) DBP (mm Hg)DBP (mm Hg)
Normal < 120 < 80
Pre – hypertension 120-139 80-90
Hypertension
Stage 1 140 – 159 90 – 99
Stage 2 160 and above 100 and above

9. 9
Definitions
Are the values same for Diabetics , CKD?
No, for DM, IHD and CKD the criteria
are more stringent
The cut off values are 10 mm lower
Stage 1 SBP 130 to 149
DBP 80 to 89
Stage 2 SBP 150 and more
DBP 90 and more

10. 10
Rule of Halves
What is this rule of halves in HT ?
• For every 800 adults in the community
• 400 are HT (either ↑ SBP or ↑ DBP or both)
• Of them only 200 are diagnosed HT
• Of them only 100 are started on treatment
• Of them only 50 are on correct drug
• Of them in only 25 the goal B.P. is attained
• Means 25 ÷ 400 = 6% only have goal BP

11. 11
Normotensives (78%)
Hypertensives
(22%)
Under control (40%)
(7.5% of the total
hypertensives)
Uncontrolled
hypertension (60%)
Diagnosed
HT Under
treatment
(50%)
Undiagnosed
HT
How many are really Dx. and Rx.ed ??
37%
63%
Un Rx.
HT
A study from Europe on 23,339 patients

12. 12
Isolated Systolic Hypertension
1. What is ISH ? –
2. What percentage of 65+ aged have ISH ?
3. Which is more harmful – ↑ SBP or DBP ?
4. Why is ISH important ?

13. 13
Isolated Systolic Hypertension
1. What is ISH ? –
SBP 140+ , DBP < 90
1. What percentage of 65+ aged have ISH ?
More than 90%
1. Which is more harmful – ↑ SBP or DBP ?
Of course ↑ SBP
1. Why is ISH important ?
Because of ↑↑ CVA and CHD mortality

14. 14
For adequate control of B.P.
Do you think we can control most of the
patients of hypertension with –
One drug
Two drugs
Three drugs
Can’t control
In most of the patients of hypertension
Two drugs are required for adequate control
More so if the initial BP is 20/10 above the goal

15. TODAY’S PARADIGM
Gone are the days of monotherapy
It is the era of combination therapy
Why is it so?
15

16. Dr.Sarma@works
16
Global Risk Profile and HT
25)

17. 17
Diseases Attributable to Hypertension
Hypertension
Heart failure
Stroke
Coronary heart disease
Myocardial infarction
Left ventricular
hypertrophy
Aortic aneurysm
Retinopathy
Peripheral vascular disease
Hypertensive
encephalopathy
Chronic kidney failure
Cerebral hemorrhage
Adapted from: Arch Intern Med 1996; 156:1926-1935.
All
Vascular

18. 18
Target Organ Damage (TOD)
• Heart
Left ventricular hypertrophy (LVH)
Angina or prior myocardial infarction (CHD)
Prior Coronary revascularization PTCA or CABG
Heart failure (Systolic / Diastolic dysfunction)
• Brain
CVA Stroke or Transient Ischemic Attack (TIA)
• Kidney : Chronic kidney disease and CRF
• Vessels : Peripheral arterial disease PVD
• Eyes : Hypertensive Retinopathy

19. 19
Target Organ Damage - Assessment
Routine Tests
• Electrocardiogram, Echocardiography (desirable)
• Urinalysis for proteinuria, Microalbuminuria
• Blood glucose (F and PP), and Hematocrit
• Serum Na and K, Creatinine or GFR, Calcium
• Lipid Profile complete, Eye examination, ABI
Optional tests
• X-Ray Chest PA
• 24 hr. urine albumin excretion or ACR
• More extensive testing is not generally indicated

20. Ambulatory Blood Pressure Monitoring - ABPM
20
1. 24 hour B.P monitoring (every 15 minutes)
2. Today - 24 hour B.P. control is essential
3. Identifies dippers and non-dippers
4. Excludes white coat hypertension

21. 21
What is MOST essential ??
 Not that ‘my drug is superior to yours’
 Not that ‘this trial is better than that’
 Nor ‘this combination is better than that’
 But to get AS MANY PEOPLE as we
can to goal SBP < 140 & DBP < 90
 And prevent or halt TOD.
 Of course, tailor the treatment as per
individual patient’s co-morbidities.

22. So, What is new in Hypertension ?
1. High B.P recorded is only a clinical marker disease
2. HT is a multi-organ disease, often asymptomatic
3. Not to consider in isolation- Must look for ‘Co-Thieves’
4. Today’s goal BP is 140/90 – It will sure be less tomorrow
5. It matters to attain goal; matters more how it is attained
6. In DM, CKD, IHD the cut off values are 10 mm less
7. Remember rule of ½ in HT– Adequate control only in 7%
22

23. 23 Dr.Sarma@works

24. Dr.Sarma@works
24

25. 25
Lifestyle Modification
Modification Approximate BP reduction
(range)
Weight reduction 5–20 mm/10 kg wt loss
Adopt DASH eating plan 8–14 mmHg
Dietary sodium reduction 2–8 mmHg
Physical activity 4–9 mmHg
Abstinence from alcohol 2–4 mmHg
All put together reduce BP by 20 to 55 mmHg

26. DASH
26
Dietary Approach to Stop Hypertension
1.Eating more fruits, vegetables, high fiber diet and low fat
dairy foods
2.Reduce fried food, red meat, organ meat, sweets, direct
sugars and bakery products
3.More whole grain products, fruits, nuts (almonds & walnuts)
4.Approximately 1 tsp. of salt/ day, which is 6gms or 2400mg
of salt/ day

27. 27
Hypertension – Why Combinations ?
 If goal BP is not achieved by a single drug in full dose
 Then adding another agent will help achieve the goal BP
 Two agents sometimes nullify each others side effects
 Fixed dose combinations will reduce the no. of tablets
 Once daily formulations are good for compliance
 Sustained release or LA formulations for 24 h BP control
 If three drugs can’t achieve goal BP – Resistant HT

28. Thank You!!
For any query, write us
on-
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