Htn

1. HYPERTENSION
Detection, Evaluation
and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA

2. Problem Magnitude
 Hypertension( HTN) is the most common
primary diagnosis in America.
 35 million office visits are as the primary
diagnosis of HTN.
 50 million or more Americans have high BP.
 Worldwide prevalence estimates for HTN may
be as much as 1 billion.
 7.1 million deaths per year may be attributable
to hypertension.

3. Definition
 A systolic blood pressure ( SBP) >139
mmHg and/or
 A diastolic (DBP) >89 mmHg.
 Based on the average of two or more
properly measured, seated BP
readings.
 On each of two or more office visits.

4. Accurate Blood Pressure Measurement
 The equipment should be regularly inspected and
validated.
 The operator should be trained and regularly retrained.
 The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
 The auscultatory method should be used.
 Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
 An appropriately sized cuff should be used.

5. BP Measurement
 At least two measurements should be
made and the average recorded.
 Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.

6. Follow-up based on initial BP
measurements for adults*
*Without acute end-organ damage
www.nhlbi.nih.gov

7. Classification
www.nhlbi.nih.gov

8. Prehypertension
 SBP >120 mmHg and <139mmHg and/or
 DBP >80 mmHg and <89 mmHg.
 Prehypertension is not a disease category
rather a designation for individuals at high risk
of developing HTN.

9. Pre-HTN
 Individuals who are prehypertensive are not
candidates for drug therapy but
 Should be firmly and unambiguously advised to
practice lifestyle modification
 Those with pre-HTN, who also have diabetes or
kidney disease, drug therapy is indicated if a
trial of lifestyle modification fails to reduce their
BP to 130/80 mmHg or less.

10. 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.

11. Frequency Distribution of Untreated HTN by Age
Isolated Systolic
HTN
Isolated Diastolic
HTN
Systolic Diastolic
HTN

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

13. 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.

14. 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

15. 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.

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

17. Secondary HTN-Clues in Medical
History
 Onset: at age < 30 yrs ( Fibromuscular
dysplasi) or > 55 (athelosclerotic renal artery
stenosis), sudden onset (thrombus or
cholesterol embolism).
 Severity: Grade II, unresponsive to treatment.
 Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
 Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)

18. 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)

19. 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-/hyper- thyroidism)

20. Secondary HTN-Screening
Tests
www.nhlbi.nih.gov

21. Renal Parenchymal Disease
 Common cause of secondary HTN (2-5%)
 HTN is both cause and consequence of
renal disease
 Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
 Renal disease from multiple etiologies.

22. Renovascular HTN
 Atherosclerosis 75-90% ( more common in
older patients)
 Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
 Other
• Aortic/renal dissection
• Takayasu’s arteritis
• Thrombotic/cholesterol emboli
• CVD
• Post transplantation stenosis
• Post radiation

23. Complications of Prolonged
Uncontrolled HTN
 Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
 Complications arise due to the “target
organ” dysfunction and ultimately failure.
 Damage to the blood vessels can be seen
on fundoscopy.

24. Target Organs
 CVS (Heart and Blood Vessels)
 The kidneys
 Nervous system
 The Eyes

25. Effects On CVS
 Ventricular hypertrophy, dysfunction and
failure.
 Arrhithymias
 Coronary artery disease, Acute MI
 Arterial aneurysm, dissection, and
rupture.

26. Effects on The Kidneys
 Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
 Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN

27. Nervous System
 Stroke, intracerebral and subaracnoid
hemorrhage.
 Cerebral atrophy and dementia

28. The Eyes
 Retinopathy, retinal hemorrhages and
impaired vision.
 Vitreous hemorrhage, retinal detachment
 Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction

29. Retina Normal and Hypertensive
Retinopathy
Normal Retina Hypertensive Retinopathy A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)
A B
C

30. Stage I- Arteriolar Narrowing
Arteriolar Narrowing

31. Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking

32. AV Nicking

33. Stage III- Hemorrhages (H), Cotton
Wool Spots and Exudats (E)
H
E

34. Stage IV- Stage III+Papilledema

35. Patient Evaluation 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

36. (1) Cardiovascular Risk factors
 Hypertension
 Cigarette smoking
 Obesity (body mass index ≥30 kg/m2)
 Physical inactivity
 Dyslipidemia
 Diabetes mellitus
 Microalbuminuria or estimated GFR <60 mL/min
 Age (older than 55 for men, 65 for women)
 Family history of premature cardiovascular disease (men
under age 55 or women under age 65)

37. (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

38. (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

39. 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 renal
impairment

40. History-contd.
 Claudication: May be aggravated by b-
blockers, atheromatous RAS may be present
 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

41. History-contd.
 Family history of DM : Patient may also
be Diabetic
 Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
 High alcohol: A cause of HTN
 High salt intake: Advice low salt intake

42. Examination
 Appropriate measurement of BP in both arms
 Optic fundi
 Calculation of BMI ( waist circumference also
may be useful)
 Auscultation for carotid, abdominal, and femoral
bruits
 Palpation of the thyroid gland.

43. Examination-contd.
 Thorough examination of the heart and
lungs
 Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
 Lower extremities for edema and pulses
 Neurological assessment

44. Routine Labs
 EKG.
 Urinalysis.
 Blood glucose and hematocrit; serum
potassium, creatinine ( or estimated GFR),
and calcium.
 HDL cholesterol, LDL cholesterol, and
triglycerides.
 Optional tests
urinary albumin excretion.
albumin/creatinine ratio.

45. Goals of Treatment
 Treating SBP and DBP to targets that are
<140/90 mmHg
 Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
 The primary focus should be on attaining the
SBP goal.
 To reduce cardiovascular and renal morbidity
and mortality

46. Benefits of Treatment
 Reductions in stroke incidence,
averaging 35–40 percent
 Reductions in MI, averaging 20–25
percent
 Reductions in HF, averaging >50 percent.

47. Lifestyle modifications
www.nhlbi.nih.gov

48. Lifestyle Changes Beneficial in Reducing Weight
 Decrease time in sedentary behaviors such
as watching television, playing video games, or
spending time online.
 Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
 Decrease portion sizes for meals and snacks.
 Reduce portion sizes or frequency of
consumption of calorie containing beverages.

49. DASH Diet
 Dietary approaches to Stop Hypertension
 As effective as one medication

51. JNC 7 Summary
 Joint National Commission 7th Report
 PDF File on website
 50 page document

52. Other JNC 7 Resources
 Software for use with Palm and Pocket
PC

53. JNC 7 Reference Card

54. Other Resources
 Chronic Kidney Disease Information
 GFR Calculator
 www.nephron.com
 Hyperlipedemia Information
 Adult Treatment Panel 3 Guidelines
 www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

55. Questions
 mkeen@fammed.washington.edu