HTN AF CVA END ORGAN DAMAGE

1. End Organ Damage
In Hypertension
Dr Ihab suliman
Sept 2022

2. Treatment In the Morning or
Evening: The TIME Study
Results
A large randomised study of 21,104 subjects with treated high BP to find
out if taking tablets in the evening is better than in the morning
Funded by the British Heart Foundation and BIHS
Prof Tom MacDonald, University of Dundee, UK
25th August 2022

3. Our study findings
O Taking prescribed BP tablets in the evening
was no better or worse than taking them in
the morning for the prevention of
cardiovascular disease.
O Taking medication in the evening was not
harmful. Patients can take their BP
medication in either the
O morning or evening as the timing
makes no difference to
cardiovascular outcomes.

4. Methods
• A large decentralised study of patients
treated in the UK NHS
• 21,104 randomised and followed up for
over 5 years (longest 9.3 years)
• Outcome tracked from patients,
clinicians and UK NHS hospital
databases and death records
• Independently verified heart attacks,
strokes and CV deaths
• Intention to treat analysis

5. Results –MI, stroke or vascular
death

6. Results – other outcomes not
different

7. Key messages
• Taking tablets for high BP in the evening
was not different to morning dosing in
prevening heart attacks, strokes and
vascular deaths
• Evening dosing was not harmful
• Patients can take their BP tablets
whenever convenient

8. O Definitions and epidemiology.
O End organ damage in HTN

9. Definition
O Hypertension in adults (stage 1)
O 2017 ACC/AHA: persistent systolic
O blood pressure (SBP
O ) ≥ 130 mm Hg and/or diastolic
O blood pressure (DBP) ≥ 80 mm Hg [1]
O 2020 International Society of Hypertension (ISH) and 2014 JNC 8:
persistent SBP
O ≥ 140 mm Hg and/or DBP ≥ 90 mm Hg [2]
O Hypertension in children (< 13 years of age) (stage 1): blood pressure ≥
95thpercentile
O or ≥ 130/80 mm Hg, whichever is lower
O
O Primary hypertension: hypertension with no identifiable cause
O Secondary hypertension
O : hypertension caused by an identifiable underlying condition
O Resistant hypertension: hypertension that remains uncontrolled (≥
130/80 mm Hg) despite treatment with ≥ 3 antihypertensives
O OR requires ≥ 4 medications to be controlled

10. Prevalence
O Hypertension affects between approximately one-third and one-half of adults
in the US.
O Primary hypertension: accounts for ∼ 90% of cases of hypertension in
adults and prevalence
O is increasing in children and adolescents
O .
O Secondary hypertension
O : accounts for ∼ 10% of cases of hypertension in adults [1]
O Prevalence
O increases with age: Approximately 65–75% of adults develop hypertension
by 65–74 years of age.
O [11]
O Rates are highest in African American individuals, followed by white
individuals, and lowest in Asian American and Hispanic individuals.
O ∼ 60–87% of overweight
O and ∼ 73–95% of obese
O patients are affected.

13. Assessment of the overall cardiovascular risk and
Search for target organ damage
O Brain
O Cerebrovascular disease
O transient ischemic attacks
O ischemic or hemorrhagic stroke
O vascular dementia
O Eyes
O Hypertensive retinopathy
O Heart
O Left ventricular dysfunction
O Left ventricular hypertrophy
O Coronary artery disease
O myocardial infarction
O angina pectoris
O congestive heart failure
O Kidney
O Chronic kidney disease
O hypertensive nephropathy (GFR < 60 ml/min/1.73 m2)
O albuminuria
O Arteries
O Peripheral artery disease
O intermittent claudication
O ankle brachial index < 0.9

17. Effect of Long-Term Modest Reductions in CV
Risk Factors
Emberson et al. Eur Heart J. 2004;25:484-491.
10%
Reducti
on
in BP
10%
Reduct
ion
in
Total-C
+
45%
Reducti
on
in CVD
=

18. Routine Laboratory Tests
Preliminary Investigations of patients with
hypertension
1. Urinalysis
2. Blood chemistry (potassium, sodium and
creatinine)
3. Fasting glucose
4. Fasting or Non Fasting lipid profile
5. Standard 12-leads ECG
6. Optional tests
a. Urinary albumin excretion or
albumin/creatinine ratio
b. Limited Echo for LVH

19. O The classic manifestations of hypertensive
end organ damage include the following:
vascular and hemorrhagic stroke,
retinopathy, coronary heart
disease/myocardial infarction and heart
failure, proteinuria and renal failure and in
the vasculature, atherosclerotic change
including the development of stenoses
and aneurysms

20. Hypertensive Emergencies :
Definition
O A rapid decompensation of vital organ
function secondary to an inapropriately
elevated BP
O Require lowering of BP within 1 hour to
decrease morbidity
O Not determined by a BP level, but
rather the imminent compromise of
vital organ function

21. Hypertensive
Emergencies
O CNS - Hypertensive encephalopathy
O CVS
O Acute myocardial ischemia
O Acute cardiogenic pulmonary edema
O Acute aortic dissection
O Post-op vascular surgery
O Renal - Acute renal failure
O Eclampsia
O Catechol excess- Pheochrom, Drugs

22. Hypertensive
Emergencies
OHigh BP WITHOUT
acute end-organ
dysfunction IS
NOT a hypertensive
emergency
O“Hypertensive
Pseudoemergency”

23. Schmieder, R E
End Organ Damage In Hypertension
Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

24. Echocardiography
2013 ESH/ESC Guidelines. J Hypertens 2013

25. Echocardiography should be considered in hypertensive patients in
different clinical contexts and with different purposes:
• in hypertensive patients at moderate total CV risk, it may refine the risk
evaluation by detecting LVH undetected by ECG
• in hypertensive patients with ECG evidence of LVH it may more
precisely assess the hypertrophy quantitatively and define its geometry
and risk
• in hypertensive patients with cardiac symptoms, it may help to diagnose
underlying disease.
2013 ESH/ESC Guidelines. J Hypertens 2013
Cardiac Damage

26. Schmieder, R E
End Organ Damage In Hypertension
Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

27. Schmieder, R E
End Organ Damage In Hypertension
Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

28. Schmieder, R E
End Organ Damage In Hypertension
Dtsch Arztebl Int 2010; 107(49): 866-73; DOI: 10.3238/arztebl.2010.0866

29. Atherosclerosis and Vascular Stiffness
Ng et al. Am J Physiol Renal Physiol 2011
Wikipedia.org

30. Vascular Stiffness and Mortality
Relative Risk of Cardiovascular Mortality According to PWV and Cardiovascular
Risk Factors: Univariate Analysis
Parameters OR Lower 95% CI Higher 95% CI P
PWV, 5 m/s 2.35 1.76 3.14 <0.0001
Previous CVD, yes/no 14.81 7.98 27.47 <0.0001
Age, 10 y 2.32 1.78 3.01 <0.0001
PP, 10 mm Hg 1.53 1.31 1.80 <0.0001
SBP, 10 mm Hg 1.26 1.12 1.42 <0.001
Diabetes, yes/no 4.23 1.96 9.15 <0.001
Laurent S et al. Hypertension 2001