A recent analysis of National Health and Nutrition Examination Survey (NHANES) data from 1999 to 2000 reported a 3.7% increase in the prevalence of hypertension compared with 1988 to 1994.1 In a recent study, data from NHANES and the US Census Bureau were used to estimate hypertension burden, prevalence rates, and trends relative to 1988 to 1994 for US adults in 1999 to 2000.2 The study found that at least 65 million US adults (nearly 1 in 3 adults, or 31.3%) had hypertension during that time period.2 Assuming continuing trends, the figures would be even higher for 2004.
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 (&lt;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.
[The purpose of this slide is to lead in to lifestyle modifications and to commiserate with the difficulty of dealing with patients over this issue.] Now let’s turn to the difficult issue of lifestyle for a moment.
As you can see, lifestyle modification can be very effective in helping to reduce blood pressure, especially if these modifications are used in combination. However, these modifications have been difficult for us to implement in many patients. There are some more effective ways to approach these changes, which we’ll discuss in a few minutes.
In a global effort, patients, providers, and the healthcare system must make their contributions to get hypertension to goal.
OPTOM FASLU MUHAMMED
What is Hypertension
Hypertension is also referred to as high blood
pressure or high BP in common terms
It is a medical condition in which the arterial
blood pressure is elevated.
It is termed as silent killer – Patients
asymptomatic - leads to fatal complications
Greater than 140 mm hg of systolic blood pressure
more than 90 mm hg of diastolic blood pressure
at least on 2 of 3 occasions while measuring the
Nokolai Korotkoff, 1905
Ascultatory method of
blood pressure measurement
How to measure Blood pressure???
Always measure B.P when the patient is completely
The instrument used is mercury
The cuff of the apparatus should cover up to three –
fourth of his arm.
How to measure Blood
The tubings must be parallel to arteries of the arm.
You must then inflate it until there is radial pulse
Then deflate and measure the value.
The sound as korotkoff sound
Details in the video link and audio link
What is Systolic blood pressure- upper limit of
the pressure at which korotko’s sounds start
appearing ---state of contraction in heart.
Diastolic blood pressure is the lower limit of
sounds heard - state of relaxation in peripheral
Systolic-90 mm hg – 120 mm hg.
Diastolic-60 mm hg -80 mm hg.
Systolic diastolic interpretation
Less than 120
Less than 80
120 to 139 80 to 89 Pre hypertensive
140 to 159 90 to 99 Stage 1 Hypertension
More than or
equal to 160
More than or
equal to 100
Stage 2 Hypertension
> 220 > 120 Hypertensive emergency
Source: Joint national committee on cardiovascular diseases 2003
Nearly 1 in 3 adults (31%) in the US has hypertension
Fields LE et al. Hypertension. 2004;44:398-404.
How Big Is the Problem?
At Least 65 Million Americans Require
Treatment for Hypertension
Magnitude of problem in India
Prevalence 1 in 3 in urban population among 40 yrs or
More than 50% among persons aged 65 or more
India is the capital of Diabetes Mellitus and the
associated HT is > 60%
The prevalence increasing with years
Types of Hypertension
The most common cause for Hypertension is
idiopathic and hence if the cause is not known it is
called as primary or essential Hypertension--90%
If it is secondary to other diseases -it is called as
The main reason is vasoconstriction which occurs due
to sympathetic over-activity
An overactive renin – angiotensin system leads to
vasoconstriction and retention of sodium and water.
Rise in B.P is slight to moderate
Complications: heart failure, cerebrovascular accident
Rapid & aggressive acceleration
Diastolic pressure in excess of 120 mmHg
Eg: haemorrhages into the retina, pappillo-edema &
progressive renal disease- cardiac failure
Kidney disease: retention of salt and water
Secretion of excess aldosterone and cortisol
stimulates the retention of excess sodium & water by
the kidneys, raising the Blood volume & pressure
Acromegaly - increased secretion of growth
hormone in adults.
Cushings syndrome – increased secretion of
steroid hormone in children and adults .
Pheochromocytoma - tumor of adrenal medulla.
Drug such as corticosteroid and hormones like
Renal causes of Hypertension
Glomerulo nephritis-- acute or chronic or / and infective
or non infective.
. Bacterial infection of kidney-chronic pylo-nephritis.
. Polycystic kidney disease – It is a genetic cystic disorder of the
Apart from these any renal disease which can cause renal
failure like Diabetes Mellitus will result in secondary hyper
Age (older the risk is higher)
Diet (High salt intake/ fatty diet)
Physical activity (sedentary life style)
Alcohol >15ml /day
Drugs (steroids, oral contraceptives)
Stress - Chronic job stress
Ethnic groups- black africans
Diagnosis of Hypertension
The gold standard for hypertension is only clinical
measurement using mercury sphygmomanometer
But we need to do investigations to rule out
Better to screen everyone above 40 years every year
and every six months if there is a risk factor
Hypertensive at first visit
In the first measurement if there is >220 mm hg of
systolic pressure and >120 mm hg of diastolic pressure
then we can call the patient as hypertensive - an
No specific symptoms in majority.
Epistaxis– nose bleed
TIA = transient ischemic attack; LVH = left ventricular
hypertrophy; CHD = coronary heart disease;
HF = heart failure.
Peripheral vascular disease
Complications of Hypertension:
LVH, CHD, HF
is a risk factoris a risk factor
• We have to rule out secondary hypertension by
investigating for other diseases.
• Renal – urine microscopy is done to detect the
presence of albumin.
• Presence of RBC, Cast is an indications of
• Excess of WBC indicates kidney infection.
• Renal doppler / technicium scan (nuclear scan) is
done to know about blood supply to the kidney.
Most patients will experience better control if they
modify diet and exercise.
Physician advice sometimes works and should
always be given along with a follow-up visit
appointment to monitor both blood pressure and
lifestyle change efforts.
Most of us do not do lifestyle counseling beyond
simple advice and admonishment – the time factor
is a problem.
Nevertheless, lifestyle modification is at the top of
Weight reduction 5-20 mmHg / 10 kg
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol
Benefits of Lifestyle Modification
Management of patients
• Use <5 gms of salt per day
• Avoid oily food / fatty diet
• Low calorie high fiber diet
• Brisk walking, jogging, Swimming etc…
Avoid smoking & alcohol.
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
TROPHY Study ACC 2006: Even lowering BP in those with pre-HTN appears
to reduce incidence of new HTN by up to 60%
Drugs For Hypertension
• Usually divided into 4 categories:
• ACE (Angiotensin converting enzyme) inhibitors and AT
• Beta blockers
• CCB (calcium channel blockers)
Blocks the conversion of Angiotensin to Renin by inhibiting
angiotensin converting enzyme Eg: Enalapril , Lisinopril.
• Side effects
• Produce dry cough
• Altered taste sensations (dysguesia)
AT receptors blocker
• More potent than ACE inhibitors - it blocks the
receptors on which enzymes will act Eg :
• Mechanism of action:
• Acts on the beta adrenergic receptors.
• Can precipitate asthma in asthmatics-Beta
receptors are present on the bronchus causing broncho
• Decreases the cardiac output as well as the heart
• Can increase the cholesterol level.
• Can mask hypoglycemia in diabetics
Calcium channel blockers(CCB)
Allows peripheral vaso dilatation
Causes decrease in the peripheral vascular
Very safe during pregnancy
Eg: Nifidepine, Amlodepine.
Side effect: Postural hypotension, Headache,
Management of Hypertension
• Depends upon the blood pressure
• If person is pre-hypertensive or stage 1 is – life
style modification should be done first.
• Diet and exercises are first modes to control
• If Blood pressure is high – Polypharmacy 3 or 4
drugs can be given.
Some guidelines for drugs
• If the patient has
• Renal problem – ACE inhibitors
• Diabetes mellitus – ACE inhibitors
• Asthma – ACE inhibitors
• Diabetic / pregnancy – CCB
• Anxiety /hyperthyroidism – Beta blockers
• They may result in end organ damage e,g., Kidney
• Blood pressure should be reduced fast to prevent
end organ damage. Drugs commonly used are:
• Alpha blockers –Prazosin
• Vasodilators – Sodium nitroprusside / Nitrates
• Alpha + beta blockers – Labatelol
• CCB - Nifedepine
Barriers to Controlling
The Initial Confrontation of the HTN
Upon making a diagnosis of HTN, tell patient
the BP reading and what it should be (provide a
Prepare patient for the probable necessity for
polypharmacy to control BP with a minimum
of side effects
Advise Home BP measurement (135/85
mmHg is considered to be hypertensive).
Table 28. JNC 7 Report. Hypertension. 2003;42(6):1240.
Self-Measurement of BP
Provides information useful for:
1. assessing response to antihypertensive Rx
2. improving adherence with therapy
3. evaluating white-coat HTN
Home BP is more strongly related to target
organ damage and has better prognostic
accuracy than office BP.