HTN risk factors

1. Orientation Workshop for
first year PGs
HT – Definitions, Risk factors,
History, Investigations

2. Presentation Outline
 Epidemiology
 Definitions in Hypertension
 Types of Hypertension
 Evaluation of Secondary HTN
 Approach to Hypertension
 Ideal BP Measurement Technique

3. Rising prevalence of hypertension
3
Increase in Prevalence
Developing countries
(80%)
Hypertension affects more than a quarter of the global adult
population.
2000
2025
“Nearly one in five young adults aged 24 to 32 has
high blood pressure”

4. Definition of Hypertension
 A systolic blood pressure (SBP) ≥140mmHg
and/or
 A diastolic (DBP) ≥90 mmHg.
 Based on the average of two or more properly
measured, seated BP readings.
 On each of two or more office visits.

5. Isolated Systolic Hypertension
 Not distinguished as a separate entity as far as
management is concerned.
 SBP should be primarily considered during treatment
and not just diastolic BP.
 Systolic BP is more important cardiovascular risk factor
after age 50.
 Diastolic BP is more important before age 50.

6. JNC VII classification of Hypertension (JNC 7)
BP Classification Systolic (mm
Hg)
Diastolic
(mmHg)
Normal <120 And <80
Prehypertension 120—139 Or 80—89
Stage 1 HT 140—159 Or 90—99
Stage 2 HT >/=160 Or >/=100
Isolated systolic
HT
>/=140 And <90

7. Pre-hypertension
 Individuals who are prehypertensive are not
candidates for drug therapy, but should be
firmly and unambiguously advised to
practice lifestyle modification.

8. Hypertensive Urgencies
 Severe elevated BP in the upper range of
stage II hypertension.
 Without progressive end-organ dysfunction.
 Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
 Usually due to under-controlled HTN.

9. 'White-coat hypertension'
 Aka White-collar Hypertension or Office Hypertension
 White-coat hypertension is a condition in which people
experience high blood pressure only when they visit the
doctor's office.
 20-30% of Apparently Resistant Hypertension may be due to
‘White-Coat Hypertension’
 Use home or ambulatory monitoring differentiate.

10. Hypertensive Crises
 Hypertensive Urgencies: No progressive target-
organ dysfunction. (Accelerated Hypertension)
 Hypertensive Emergencies: Progressive end-
organ dysfunction. (Malignant Hypertension)

11. Hypertensive Emergencies
 Severely elevated BP (>180/120mmHg).
 With progressive target organ dysfunction.
 Require emergent lowering of BP.
 Examples: Severely elevated BP with:
 Hypertensive encephalopathy
 Acute left ventricular failure with pulmonary edema
 Acute MI or unstable angina pectoris
 Dissecting aortic aneurysm

12. Masked Hypertension
 Office BP is Normal but Home BP is High
 Patient has some degree of symptoms
 LVH, e/o End Organ Damage.
 ABPM/HBPM play a role in this

13. Types of Hypertension
 Primary HTN:
 Also known as essential
HTN.
 Accounts for 95% cases of
HTN.
 No universally established
cause known.
 Secondary HTN:
 Less common cause
of HTN ( 5%).
 Secondary to other
potentially rectifiable
causes.

14. Causes of Secondary HTN
 Common
 Intrinsic renal disease
 Renovascular disease
 Mineralocorticoid
excess
 Sleep Breathing
disorder
 Uncommon
 Pheochromocytoma
 Glucocorticoid excess
 Coarctation of Aorta
 Hyper/hypothyroidism

15. Secondary HTN - Clues in Medical History
 Onset: at age < 30 yrs or > 55 yrs
 Severity: Stage II
 Resistant/Refractory/Difficult to treat
 Episodic, headache and chest pain/palpitation
 Morbid obesity with history of snoring and daytime
sleepiness (sleep disorders)

16. Secondary HTN - clues on Exam
 Pallor, edema, other signs of renal disease.
 Abdominal bruit especially with a diastolic component
(renovascular)
 Truncal obesity, purple striae, buffalo hump
(hypercortisolism)

17. Secondary HTN - Clues on Routine Labs
 Increased creatinine, abnormal urinalysis
(renovascular and renal parenchymal disease)
 Unexplained hypokalemia (hyperaldosteronism)
 Impaired blood glucose
(hypercortisolism)
 Impaired TFT (Hypo/hyperthyroidism)

18. Therapeutic Objectives
(1) To assess lifestyle and identify other
cardiovascular risk factors or concomitant disorders
that may affect prognosis and guide treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of target
organ damage and CVD

19. (1) Cardiovascular Risk factors
 Hypertension/DM/Dyslipidemia/Obesity
 Cigarette smoking
 Age (older than 55 for men, 65 for women)
 Family history of premature cardiovascular
disease

20. (2) Identifiable Causes of HTN
 Sleep apnea
 Drug-induced or related causes
 Chronic kidney disease
 Primary aldosteronism
 Renovascular disease
 Chronic steroid therapy and Cushing’s syndrome
 Pheochromocytoma
 Coarctation of the aorta
 Thyroid or parathyroid disease

21. (3) Target Organ Damage
 Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
 Brain
Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy

22. History
 Angina/MI Stroke: Complications of HTN, Angina
may improve with b-blokers
 Asthma, COPD: Preclude the use of b-blockers
 Heart failure: ACE inhibitors indication
 DM: ACE preferred
 Polyuria and nocturia: Suggest DM/ renal
impairment

23. History-contd.
 Claudication: May be aggravated by β-blockers.
 Gout: May be aggravated by diuretics
 Use of NSAIDs: May cause or aggravate HTN
 Family history of HTN: Important risk factor
 Family history of premature death: May have
been due to HTN

24. History-contd.
 Family history of DM
 Cigarette smoker
 High alcohol intake
 High salt intake

25. Basic investigations for initial evaluation
 Complete Hemogram
 Renal Profile
 Serum Electrolytes
 Blood sugars
 Lipid Profile
 Urine analysis for
albumin, blood, glucose
 Chest Xray
 ECG
 USG KUB
 Fundoscopy

28. Hypertensive Retinopathy

33. Secondary HTN - Screening Tests

34. Mandatory Annual Tests
 CBC
 Renal Profile
 Electrolytes
 Urinalysis
 ECG
 Fundoscopy

35. Take-home Messages
 Young hypertensives should be screened for
secondary causes as they could be correctable
 Practice correct/ideal techniques of BP
Measurement
 Screen your hypertensive subjects for Target-
organ Damage
 Holistic/all-inclusive approach