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An important non-communicable disease and a risk factor for cerebro-vascular(CVA), cardio-vascular(CAD), end stage renal disease(ESRD)

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  • Hypertension is an important contributing risk factor for morbidity and mortality from both cardiovascular (CV) and renal disease. Hypertension is one of the most significant contributing factors to the development of CV and renal disease. Complications of hypertension include coronary artery disease, congestive heart failure, stroke, renal disease (including end-stage renal disease), and peripheral vascular disease. These diseases account for significant disability, loss of productivity, and decreased quality of life for many Americans. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med. 1993;153:186-208.
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  • Hypertension

    1. 1. Hypertension: Prevention and Control Dr Prabir Ranjan Moharana Community Medicine
    2. 2. Cardio Vascular Disease Risk Factors <ul><li>Hypertension* </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Obesity* (BMI > 30 kg/m 2 ) </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Dyslipidemia* </li></ul><ul><li>Diabetes mellitus* </li></ul><ul><li>Microalbuminuria or estimated GFR <60 ml/min </li></ul><ul><li>Age (older than 55 for men, 65 for women) </li></ul><ul><li>Family history of premature CVD </li></ul><ul><li>(men under age 55 or women under age 65) </li></ul>*Components of the metabolic syndrome.
    3. 3. Disease Burden <ul><li>Accounts for 6% of deaths worldwide </li></ul><ul><li>Major risk factor for- CVA, CHD, Heart Failure and Renal failure. </li></ul><ul><li>World: 10-25% of population </li></ul><ul><li>28.7% of U.S. population </li></ul><ul><li>India: 6.5% urban population </li></ul><ul><ul><ul><li>3.5% Rural Population </li></ul></ul></ul><ul><ul><ul><li>More Prevalent among women </li></ul></ul></ul>
    4. 4. Hypertension: A Significant CV and Renal Disease Risk Factor Peripheral vascular disease  Morbidity  Disability Renal disease CAD CHF LVH Stroke Hypertension National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.
    5. 5. Target Organ Damage <ul><li>Heart </li></ul><ul><ul><li>Left ventricular hypertrophy </li></ul></ul><ul><ul><li>Angina or prior myocardial infarction </li></ul></ul><ul><ul><li>Prior coronary revascularization </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><li>Brain </li></ul><ul><ul><li>Stroke or transient ischemic attack </li></ul></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Peripheral arterial disease </li></ul><ul><li>Retinopathy </li></ul>
    6. 6. Benefits of Lowering BP Average Percent of Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
    7. 7. Types <ul><li>1. Primary (Essential) (90%) . </li></ul><ul><li>2. Secondary (10%) from- </li></ul><ul><li>Chronic Glomerulo Nephritis </li></ul><ul><li>Chronic Pyelonephritis </li></ul><ul><li>Tumors of Adrenal Glands </li></ul><ul><li>Congenital Aortic Stenosis </li></ul><ul><li>Toxemia of pregnancy </li></ul><ul><li>Etc </li></ul>
    8. 8. Risk Factors for HPTN( Non-Modifiable): <ul><li>1. Age: BP rises with age ( More than 66% of people over 65 have HTN). </li></ul><ul><li>2. Sex- Early adolescence: men show higher </li></ul><ul><li> Late life: Women show higher </li></ul><ul><li>3. Genetic Factors: Polygenic inheritance (monozygotic twins show strong correlation than dizygotic twins) </li></ul><ul><li> Normotensive parents have 3% and 2 Hypertensive parents have 45% chance of begetting hypertensive children. </li></ul><ul><li>4.Ethinicity- Black Americans and Africans have higher BP levels than whites. </li></ul>
    9. 9. Age Distribution of Hypertensives in US Population (NHANES III and the 1991 Census) 3.7 9.5 13 21.3 23.7 19.2 9.6 Hypertensives Within Age Group (%) Franklin SS. J Hypertension. 1999;17(suppl 5):S29-S36. Age Groups (y) 47.4 million hypertensives 26.0% of US population 26% 74% 0 5 10 15 20 25 30 18-29 30-39 40-49 50-59 60-69 70-79 80+
    10. 10. <40 40-49 50-59 60-69 70-79 80+ Age (y) 17% 16% 16% 20% 20% 11% Distribution of Hypertension Subtype in the untreated Hypertensive Population in NHANES III by Age Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age. Franklin et al. Hypertension 2001;37: 869-874 . Frequency of hypertension subtypes in all untreated hypertensives (%) ISH (SBP  140 mm Hg and DBP <90 mm Hg) SDH (SBP  140 mm Hg and DBP  90 mm Hg) IDH (SBP <140 mm Hg and DBP  90 mm Hg) 0 20 40 60 80 100
    11. 11. Risk Factors for HPTN( Modifiable): <ul><li>1. Obesity: Central Obesity indicated by increased WC/WHR positively correlated with increased BP. </li></ul><ul><li>2. Salt Intake- (> 5 gms per day). Modern Japanese taking >7gms NaCl per day show more BP than primitive Japanese consuming <1 gm per day. </li></ul><ul><li>Potassium, Calcium, Magnesium, Cadmium reduce BP. </li></ul><ul><li>3. Saturated Fats: Increase serum cholesterol, body weight and BP. </li></ul><ul><li>4. Dietary Fibres: Most fibres serum cholesterol, body weight and BP. </li></ul>
    12. 12. Risk Factors for HPTN( Modifiable): <ul><li>5. Alcohol: Increased intake increases BP and reversible one. </li></ul><ul><li>6. Environmental stress & Heart Rate: Anxiety and sympathetic over-activity increase heart rate and BP. </li></ul><ul><li>7. Physical Activity: Regular aerobic exercise reduces body weight and BP. It also promotes positive mental health. </li></ul><ul><li>8. Socio-economic Status: Low SES higher BP( in community with Post-transitional stage of economic growth) . </li></ul><ul><li>9.Others: Drugs(OCP), Noise, Vibration, Temperature and Humidity etc. </li></ul>
    13. 13. The Metabolic Syndrome* * Diagnosis is established when  3 of these risk factors are present. † Abdominal obesity is more highly correlated with metabolic risk factors than is  BMI. ‡ Some men develop metabolic risk factors when circumference is only marginally increased. <40 mg/dL <50 mg/dL Men Women >102 cm (>40 in) >88 cm (>35 in) Men Women  110 mg/dL Fasting glucose  130/  85 mm Hg Blood pressure HDL-C  150 mg/dL TG Abdominal obesity † (Waist circumference ‡ ) Defining Level Risk Factor
    14. 14. Blood Pressure Measurement <ul><li>Observer Error- Correct hearing acuity and interpretation of Kortokow sounds. </li></ul><ul><li>Instrumental Errors- Leaking Valves, inappropriate cuff size. </li></ul><ul><li>Subject Errors- Circumstances of examination, physical(after exertion) and mental status(fear, anxiety etc) of the person and position of subject(supine/sitting/standing). </li></ul>
    15. 15. Blood Pressure Measurement (WHO Recommendation) <ul><li>Uniformity in clinics: </li></ul><ul><li>Position : Sitting </li></ul><ul><li>Arm- measure over both Left & Right arm at first visit. </li></ul><ul><li>Time- 3 times over a period of 3 minutes. </li></ul><ul><li>Record- The lowest reading with specifying arm and position </li></ul><ul><li>eg. 140/84 mm of Hg over left arm in sitting position. </li></ul><ul><li>Follow-up: at least 3 visits required for final classification. </li></ul>
    16. 16. Blood Pressure Classification Normal <120 <80 Prehypertension 120 – 139 or 80 – 89 Stage 1 Hypertension 140 – 159 or 90 – 99 Stage 2 Hypertension 160-179 or 100-109 BP Classification SBP mmHg DBP mmHg Stage 3 Hypertension > 180 or > 110
    17. 17. Prevention & Control Primary Prevention <ul><li>A- Population Strategy: </li></ul><ul><li>Nutrition- Appropriate Calorie, Moderate fats, No Alcohol, Low salt intake and adequate fibres. </li></ul><ul><li>Weight Reduction </li></ul><ul><li>Regular Physical Exercise </li></ul><ul><li>Behavioral Changes: No smoking, reduction of stress, Yoga & Transcendental Meditation. </li></ul><ul><li>Health Education & Self Care </li></ul>
    18. 18. Lifestyle Modifications <ul><li>Lose weight if overweight </li></ul><ul><li>Limit alcohol intake </li></ul><ul><li>Increase aerobic physical activity </li></ul><ul><li>Reduce sodium intake </li></ul><ul><li>Maintain adequate intake of potassium </li></ul><ul><li>Maintain adequate intake of calcium and magnesium </li></ul><ul><li>Stop smoking </li></ul><ul><li>Reduce dietary saturated fat and cholesterol </li></ul>For Prevention and Management For Overall and Cardiovascular Health
    19. 19. Lifestyle Modification Modification Approximate SBP reduction (range) Weight reduction 5 – 20   mmHg/10 kg weight loss Adopt DASH Diet 8 – 14 mmHg Dietary sodium reduction 2 – 8 mmHg Physical activity 4 – 9 mmHg Moderation of alcohol consumption 2 – 4 mmHg
    20. 20. Dietary Approaches to Stop Hypertension (DASH) <ul><li>Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet. </li></ul><ul><li>Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. </li></ul>
    21. 21. Prevention & Control Primary Prevention <ul><li>B- High Risk Strategy: </li></ul><ul><li>Subject with any one of risk factor. </li></ul><ul><li>Tracking of BP in a subject with suggestive familial HPTN from childhood. </li></ul>
    22. 23. Prevention & Control Secondary Prevention <ul><li>A- Early Diagnosis & Case Detection: </li></ul><ul><li>Screening of population in the absence of symptoms eg. Every individual should go for at least once a year for BP check up like every European who go once in 2 years. </li></ul><ul><li>Mass screening is fruitless. </li></ul>
    23. 24. Secondary Prevention (Patient Evaluation) <ul><li>Evaluation of patients with documented HTN has three objectives: </li></ul><ul><li>Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. </li></ul><ul><li>Reveal identifiable causes of high BP. </li></ul><ul><li>Assess the presence or absence of target organ damage and CVD. </li></ul>
    24. 25. Laboratory Tests <ul><li>Routine Tests </li></ul><ul><ul><li>Electrocardiogram </li></ul></ul><ul><ul><li>Urinalysis </li></ul></ul><ul><ul><li>Blood glucose, and hematocrit </li></ul></ul><ul><ul><li>Serum potassium, creatinine, or the corresponding estimated GFR, and calcium </li></ul></ul><ul><ul><li>Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides </li></ul></ul><ul><li>Optional tests </li></ul><ul><ul><li>Measurement of urinary albumin excretion or albumin/creatinine ratio </li></ul></ul><ul><li>More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved </li></ul>
    25. 26. Secondary Prevention <ul><li>B-Prompt & Adequate Treatment </li></ul><ul><li>Essential Hypertension- non treatable but effectively controllable. Aim-140/90 mm of Hg. </li></ul><ul><li>Reveal identifiable causes of high BP. </li></ul><ul><li>Assess the presence or absence of target organ damage and CVD. </li></ul>
    26. 27. Classes of Antihypertensive Drugs <ul><li>ACE inhibitors </li></ul><ul><li>Adrenergic inhibitors </li></ul><ul><li>Angiotensin II receptor blockers </li></ul><ul><li>Calcium antagonists </li></ul><ul><li>Direct vasodilators </li></ul><ul><li>Diuretics </li></ul>
    27. 28. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease ) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 m mHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
    28. 29. Rule of Halves <ul><li>Hypertension is an iceberg disease. </li></ul><ul><li>Half (50%) of hypertensive patients in general population of most developed countries are aware of the problem. </li></ul><ul><li>Half (50%) of aware persons take treatment.. </li></ul><ul><li>Half (50%) of treated persons are adequately controlled. </li></ul>
    29. 30. Secondary Prevention C: Patient Compliance <ul><li>The most effective therapy prescribed by the careful clinician will control HPTN only if patients are motivated. </li></ul><ul><li>Motivation for drug adherence, following diets, executing healthy life styles and regular follow-up. </li></ul><ul><li>Motivation improves when patients have positive experiences with and trust in the clinician. </li></ul><ul><li>Empathy builds trust and is a potent motivator. </li></ul><ul><li>The physician’s judgment of patients’ cultural beliefs and individual attitudes in formulating therapy is most important. </li></ul>
    30. 31. Guidelines for Improving Adherence to Therapy <ul><li>Be aware of signs of non adherence. </li></ul><ul><li>Educate patients about the disease and therapy & Establish goal of therapy. </li></ul><ul><li>Encourage a positive attitude about achieving goals. </li></ul><ul><li>Maintain contact with patients. </li></ul><ul><li>Encourage lifestyle modifications. </li></ul><ul><li>Keep care inexpensive and simple. </li></ul>
    31. 32. Guidelines for Improving Adherence to Therapy (continued) <ul><li>Integrate therapy into daily routine. </li></ul><ul><li>Prescribe long-acting drugs. </li></ul><ul><li>Adjust therapy to minimize adverse effects. </li></ul><ul><li>Continue to add drugs systematically to meet goal. </li></ul><ul><li>Consider using nurse case management. </li></ul><ul><li>Utilize other health professionals. </li></ul><ul><li>Try a new approach if current regime is inadequate. </li></ul>
    32. 33. Drug Therapy <ul><li>A low dose of initial drug should be used, slowly titrating upward. </li></ul><ul><li>Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. </li></ul><ul><li>Combination therapies may provide additional efficacy with fewer adverse effects. </li></ul>
    33. 34. Combination Therapies <ul><li> -adrenergic blockers and diuretics. </li></ul><ul><li>ACE inhibitors and diuretics. </li></ul><ul><li>Angiotensin II receptor antagonists and diuretics. </li></ul><ul><li>Calcium antagonists and ACE inhibitors. </li></ul><ul><li>Other combinations. </li></ul>
    34. 35. Follow-up <ul><li>Follow-up within 1 to 2 months after initiating therapy. </li></ul><ul><li>Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications. </li></ul><ul><li>Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose. </li></ul><ul><li>Consider reducing dose and number of agents after 1 year at or below goal. </li></ul>
    35. 36. Follow-up and Monitoring <ul><li>Patients should return for follow-up and adjustment of medications until the BP goal is reached. </li></ul><ul><li>More frequent visits for stage 2 HTN or with complicating co-morbid conditions </li></ul><ul><li>Serum potassium and creatinine monitored 1–2 times per year. </li></ul><ul><li>After BP at goal and stable, follow-up visits at 3- to 6-month intervals. </li></ul><ul><li>Co-morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits. </li></ul>
    36. 37. The End