Epidemiology of hypertension

EPIDEMIOLOGY OF
HYPERTENSION
Presented by :Dr Saba Mansoor
Guided by : Prof Hemant Kumar
Department of Community Medicine
AJIMS& RC ,Mangalore,Karnataka (India
1

Hypertension is a silent, invisible killer that
rarely causes symptoms. Increasing public
awareness is key, as is access to early
detection. Raised blood pressure is a
serious warning sign that significant
lifestyle changes are urgently needed.
People need to know why raised blood
pressure is dangerous, and how to take
steps to control it
Dr Margaret Chan
4

 Hypertension is defined as a systolic blood
pressure equal to or above 140 mm Hg
and/or diastolic blood pressure equal to or
above 90 mm Hg
6

History of
Hypertension
History of
7

 Historical of hypertension records as far
back as 2600 B.C. hold mention of “hard
pulse disease”
 First treatments: Leeching/phlebotomy,
acupuncture
 Hippocrates recommended phlebotomy
 120 AD – cupping of the spine to draw
animal spirits down and out was
recommended
8

Lithograph showing the leeching of a patient. 9

No way to measure prior to 1700s
cupping of the spine 10

1733 – Reverend Stephen Hales measured the intra-
1733 – Reverend
Stephen Hales
measured the intra-
arterial BP of a
horse
11

 1905 – N.C. Korotkoff reported on the
method of auscultation of brachial artery, the
method which is widely used today
 Allowed auscultation of diastolic BP as well
12

CATEGORY SYSTOLIC
(mmHg)
DIASTOLIC
(mmHG)
Optimal
Normal
Grade 1
Grade 2 Hypertension
Grade 3 Hypertension ("severe")
Isolated Systolic Hypertension
<120
<130
140-159
160-179
>180
>140
<80
<85
> 90-99
>100-109
>110
<90
WHO/ISH CLASSIFICATION
OF BLOOD PRESSURE
13

Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
Isolated systolic
hypertension
>140 - <90
BP Classification SBP mmHg DBP mmHg
*JNC-7 14

 Seated quietly for 5 minutes
 Appropriate size cuff
 Inflate 20-30 mmHg above loss of radial
pulse.Deflate at 2mmHg per second
 1st sound SBP ; Disappearance of Korotkoff
sound (phase 5) is DBP.
 – Confirm Elevated blood pressure within
2months(stage 1) –shorter for stage 2 if
new onset
*JNC-7
15

 Globally cardiovascular disease
accounts for approximately 17
million deaths a year, nearly one
third of the total deaths. Of these,
complications of hypertension
account for 9.4 million deaths
worldwide every year .
 Hypertension is responsible for at
least 45% of deaths due to heart
disease and 51% of deaths due
to stroke .
16

 In terms of attributable
deaths, hypertension is one
of the leading behavioral and
physiological risk factor to
which 13% of global deaths
are attributed.
 Hypertension is reported to
be the fourth contributor to
premature death in
developed countries and the
seventh in developing
countries.
17

Recent reports indicate that nearly
1 billion adults (more than a
quarter of the world’s population)
had hypertension in 2000, and
this is predicted to increase to
1.56 billion by 2025.
Today, mean blood pressure
remains very high in many African
and some European countries.
The prevalence of raised blood
pressure in 2008 was highest in
the WHO African Region at 36.8%
.
18

Global Burden of Hypertension
2025 Projection
 26.4% of world adult
population had
hypertension
 Total of 972 million
adults
 Highest prevalence is in
established market
economies (eg, North
America, Europe)
• 29.2% of world adult
population will have
hypertension
• Total of 1.56 billion adults
20 % in developed nations,
80% in developing nations)
• Highest prevalence will be in
developing continents
(eg, Asia, Africa) will account
for 75% of world’s
hypertensive patients
Year 2000 Year 2025
Kearney PM et al. Lancet. 2005;365:217-223. 19

12-74
IHD-mortality
Rates( WHO-
2008)
CVA mortality
Rates( WHO-
2008.)
75-108109-151
Data
12-74
75-108
109-151
152-405
Data not available
12-74
75-108
109-151
152-405
Data not available
A global brief on hypertension | Why hypertension is a
major public health issue | I
Figure 01
Figure 02
20

 Recent studies from India have shown the
prevalence of HTN to be 25% in urban and 10% in
rural people in India .
 According to the WHO estimates , the prevalence
of raised BP in Indians is 32.5% (33.2% in men and
31.7% in women) .
 Andhra Pradesh (13.3%), Odisha (9%), Chhattisgarh
(8.4%) and Gujarat (6.7%) have highest prevalence
while Assam and Rajasthan (1.4%), Kerala (2.4%),
Bihar (2.7%), Madhya Pradesh (2.8%) and Uttar
Pradesh (3.6%) are low prevalence states.
Journal of Hypertension:June 2014 - Volume 32 - Issue 6 - p 1170–1177*
21

RULE OF HALVES
JAPI • VOL. 51 • FEBRUARY 2003 22

Primary (Essential) Hypertension
 - Elevated BP with unknown
cause - 90% to 95% of all
cases
Secondary Hypertension
 - Elevated BP with a specific
cause - 5% to 10% in adults
23

 NON-MODIFIABLE
 Age (> 55 for men; > 65 for women)
 Gender
 Family history
 Ethnicity (African Americans)
24

a) Alcohol
b) Cigarette smoking
c) Diabetes mellitus
d) Elevated serum lipids
e) Excess dietary sodium
f) Obesity (BMI > 30)
g) Sedentary lifestyle
h) Socioeconomic status
i) Stress
25

Frequently asymptomatic until severe and
target organ disease has occurred
 Fatigue, reduced activity tolerance
 Dizziness/Headache
 Palpitations,
 Angina
 Dyspnoea
26

§ 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
27

The pathogenesis
of primary
hypertension is still
unclear.
There are many
factors associated
with it.
28

a. Genetic factors
b. Sodium intake
c. Renin- agiotensin
systems
d. Sympathetic nervous
system
e. Endothelial dysfunction
f. Insulin resistance
g. Other factors
29

 The off springs of the
hypertensive parents
are more prone to
suffer from essential
hypertension
compared with that
without hypertensive
family.
30

 The mechanisms
leading to
hypertension are
due to increased
blood volume and
the content of the
sodium in the
smooth muscle cells
enhance following
subsequent calcium
increase.
31

 The activation of
Sympathetic
nervous can
augment periphery
resistant which
increase systemic
arterial pressure.
32

 Obesity
Smoking
Intake alcohol
OSAS
Low calcium ,
magnesium and potassium.
(Obstructive Sleep Apnea Syndrome)
33

 Systemic atherosclerosis
develops with increased
intimal-medium
thickness leading to
ischemic alterations in
target organs such as
heart, brain, kidney and
peripheral artery.
34

 In Aorta and large
arteries recurrent
pulsatile stress
produces uncoiling,
disruption and
calcification of elastic
fibres. At the same
time, relatively
inelastic collagen is
also increased.
35

This is a result of
ageing as well as
hypertension : both
processes therefore
cause loss of the
normal elastic
reservoir funtion of
arteries.
36

 Hypertensive Heart Disease/ Coronary artery
disease
 Left ventricular hypertrophy/ Heart failure
 Cerebro-vascular Disease/ Stroke
 Peripheral Vascular Disease
 Nephrosclerosis/nephropathies
 Retinal Damage
 Hypertensive emergencies
 Dissection of aorta
37

§ Routine Tests
• Electrocardiogram
• Urinalysis / Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding
estimated GFR, and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-
density and low-density lipoprotein cholesterol, and
triglycerides
§ Optional tests - Measurement of urinary albumin
excretion or albumin/creatinine ratio
§ More extensive testing for identifiable causes is not
generally indicated unless BP control is not being
achieved.
38

 Hypertension can be prevented by
complementary application of strategies
that target the general population and
individuals and groups at higher risk for
high blood pressure.
 However, prevention strategies applied
early in life provide the greatest long-term
potential for reducing the overall burden of
blood pressure related complications in the
community
43

 A population-based approach
aimed at achieving a downward
shift in the distribution of blood
pressure in the general population
and is an important component
for any comprehensive plan to
prevent hypertension.
 A small decrement in systolic
blood pressure is likely to result in
a substantial reduction in the
burden of blood pressure-related
illness
44

Average Percent Reduction
 Stroke incidence
35–40%
 Myocardial infarction
20–25%
 Heart failure
50%
45

 In an analysis based on Framingham
Heart Study experience, Cook et al.
concluded that a 2 mmHg reduction
in the population average of diastolic
blood pressure for white U.S.
residents 35 to 64 years of age would
result in a 17 percent decrease in the
prevalence of hypertension, a 14
percent reduction in the risk of stroke
and transient ischemic attacks, and a 6
percent reduction in the risk of CHD
46

 BP Reductions as Small as 2 mmHg Reduces the Risk
of CV Events by Up to 10%
 ▶ Meta-analysis of 61 prospective, observational
studies
 ▶ 1 million adults
 ▶ 12.7 million person-years 10% increase in risk
stroke Mortality
 2 mmHg
 increase in
 mean SBP
7% increase in risk of
IHD Mortality
47

 Public health approaches,
such as lowering sodium
content or caloric density in
the food supply, and
providing attractive, safe,
and convenient
opportunities for exercise
are ideal population-based
approaches for reduction of
average blood pressure in
the community
48

 More intensive targeted approaches, aimed at
achieving a greater reduction in blood pressure in those
who are most likely to develop hypertension.
 Groups at high risk for hypertension include those with a
grade –I blood pressure, a family history of
hypertension, overweight or obesity, smokers,a
sedentary lifestyle, excess intake of dietary sodium
and/or insufficient intake of potassium, and/or excess
consumption of alcohol.
49

 Sodium, through hypertension, is a major contributor to
death, disability, disparities, and costs attributable to
cardiovascular diseases (CVD)
 Globally, 8.5 million deaths could be averted over 10
years from 2006 to 2015 through a 15% reduction in
sodium intake

 An adults should consume less than 2000
milligrams of sodium, or 5 g of salt per day
 Sodium content is high in processed
foods, such as bread (approximately 250
mg/100 g), processed meats like bacon
(approximately 1500 mg/100 g), and
popcorn (approximately 1500 mg/100 g),
as well as in condiments such as soy
sauce (approximately 7000 mg/100 g), and
bouillon or stock cubes (approximately 20
000 mg/100 g).
57

WHO recommends that adults
should consume at least 3,510
mg of potassium/day.
Potassium-rich foods include :
beans and peas (approximately
1,300 mg of potassium per 100
g), nuts (approximately 600
mg/100 g), vegetables such as
spinach, cabbage and parsley
(approximately 550 mg/100 g)
and fruit such as bananas,
(approximately 300 mg/100 g).
58

How public health
stakeholders
can tackle hypertension?
59

 Integrated programmes must be
established at the primary care
level for control of hypertension.
In most countries this is the
weakest level of the health
system.
 Treatment should be targeted
particularly at people at medium
or high risk of developing heart
attack, stroke or kidney damage.
61

 The cumulative cost of implementing an
integrated primary care programme to
prevent heart attack, stroke and kidney
failure, using blood pressure as an entry
point that address cardiovascular disease and
cervical cancer in all low- and middle-
income countries is estimated to be US$ 9.4
billion a year
62

 Availability of basic technologies to manage
people with hypertension .
 Availability and appropriate use of essential
medicines to prevent complications in people
with moderate to high cardiovascular risk .
 The links between different levels of the
health system so that people can be
managed appropriately based on heir level of
risk.
63

 The basic diagnostic technologies required
for addressing hypertension include accurate
blood pressure measurement devices,
weighing scales, urine albumin strips, fasting
blood sugar tests and blood cholesterol tests.
64

 Not all patients diagnosed with hypertension
require medication but those at medium to
high risk will need one or more of eight essen-
tial medicines to lower their cardiovascular
risk.
A thiazide diuretic, an angiotensin converting
enzyme inhibitor, a long-acting calcium chan-
nel blocker, a beta blocker, metformin, insulin,
a statin and aspirin).
65

 The cost of implementing such a programme
is low, at less than US$ 1 per head in low-
income countries, less than US$ 1.50 per
head in lower middle-income countries and
US$ 2.50 in up- per middle-income countries
66

 Most cardiovascular disease in the population
occurs in people with an average risk level, because
they constitute the largest proportion of the
population.
 The population-based approach is thus based on
the observation that effective reduction of
cardiovascular disease rates in the population
usually calls for community-wide changes in
unhealthy behaviors or reduction in mean risk
factor levels.
67

 Population-wide approaches to reduce high blood
pressure are similar to those that address other
major non communicable diseases.
 They require public policies to reduce the exposure
of the whole population to risk factors such as an
unhealthy diet, physical inactivity, harmful use of
alcohol and tobacco use , with a special focus on
children, adolescents and youth.
68

 WHO considers work place health programmes to
be one of the most cost-effective
 Workplace wellness programmes should focus on
promoting worker health through the reduction of
individual risk-related behaviours, e.g. tobacco
use, unhealthy diet, harmful use of alcohol,
physical inactivity and other health risk behaviors
69

 National surveillance health information systems
must be strengthened to monitor the impact of
action to prevent and control hypertension and
other risk factors of non communicable diseases.
 Monitoring systems must collect reliable
information on risk factors and their determinants,
non communicable disease mortality and illness.
This data is critical for policy and programme
development. However, some countries still lack
surveillance data for hypertension and other risk
factors
70

 National Programme for Prevention and Control
of Diabetes, Cardiovascular Diseases and Stroke
(NPDCS) was launched on 4th Jan 2008
 Objectives
1. Risk reduction for prevention of NCDs
(Diabetes, CVD and Stroke)
2. Early diagnosis and appropriate management of
Diabetes, Cardiovascular Diseases,cancer and
Stroke
71

1. Health Promotion for the General Population
2. Disease Prevention for the High Risk
groups.
Community Based Interventions, Workplace
Interventions , Disease Prevention for the
High Risk, Setting up special clinics ,
Harnessing the Private Sector and Specific
interventions at the tertiary level to enhance
capacity to respond to the needs of NCD
72

 Awareness generated on HEALTHY LIFE
STYLES.
 Decrease in the incidence of Non –
Communicable Diseases particularly,
Diabetes, Cardiovascular Diseases,cancer and
Stroke.

73

A. At Sub centre
 1.Health promotion for behavior change
 2.‘Opportunistic’ Screening using B.P
measurement and blood glucose by strip
method
 3. Referral of suspected cases to CH
74

 1. Prevention and health promotion including
counseling
 2.Early diagnosis through clinical and laboratory
investigations (Common lab investigations: Blood
Sugar, lipid profile, ECG, Ultrasound, X ray etc.)
 3. Management of common CVD, diabetes and stroke
cases(out patient and in patients.)
 4. Home based care for bed ridden chronic cases
 5. Referral of difficult cases to District Hospital/higher
health care facilit
75

 1. Investigations: Blood Sugar, lipid profile,
Kidney Function Test (KFT),Liver Function Test
( LFT), ECG, Ultrasound, X ray, colonscopy ,
mammography etc. (if not available, will be
outsourced)
 2. Medical management of cases ( out patient ,
inpatient and intensive Care )
 3.Follow up and care of bed ridden cases
 4.Day care facility
76

A combination of increased
physical activity, moderation in
alcohol intake, and consumption of
an eating plan that is lower in
sodium content and higher in
fruits, vegetables and low fat dairy
products represents the best
approach for preventing high
blood pressure in the general
population and in high risk groups.
77

a. For persons over age 50, SBP is a more
important than DBP as CVD risk factor.
b. Starting at 115/75 mmHg, CVD risk
doubles with each increment of 20/10
mmHg throughout the BP range.
c. Persons who are normotensive at age 55
have a 90% lifetime risk for developing
HTN.
d. Those with SBP 120–139 mmHg or DBP
80–89 mmHg should be considered
prehypertensive who require health-
promoting lifestyle modifications to
prevent CVD.
78

1. WHO. A global brief on hypertension. World Health Day
2013.
2. Community Medicines with Recent Advances by A H
Suryakantha.Third Edition-2014.
3. The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES , August 2004.
4. Primary Prevention of Hypertension: Clinical and
Public Health Advisory from the National High Blood
Pressure Education Program. NIH PUBLICATION
NO. 02-5076 NOVEMBER 2002.
79

5. A short history of blood pressure measurement.
Proc R Soc Med. Nov 1977; 70(11): 793–799.
http://www.ncbi. nlm.
nih.gov/pmc/articles/PMC1543468.
6. The Updated WHO/ISH Hypertension Guidelines.
Linda Brookes. Medscape Mar 16, 2004.
http://www.medscape. com/ viewarticle/471863.
7. 2014 Evidence-Based Guideline for the Management
of High Blood Pressure in AdultsReport From the
Panel Members Appointed to the Eighth Joint National
Committee (JNC 8) .
8. AMA. 2014;311(5):507-520. doi:10.1001/jama.
2013.284427.
80

9. Kearney PM et al. Global burden of hypertension: analysis of
worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23.
10. Journal of Hypertension: June Volume 32 - Issue 6 - p 1170–
1177.
11. Anchala, Raghupathy et al.Hypertension in India: a systematic
review and meta-analysis of prevalence, awareness, and control
of hypertension. Journal of Hypertension:June 2014 - Volume 32 -
Issue 6 - p 1170–1177.
12. Gupta R. Trends in hypertension epidemiology in India. J Hum
Hypertens 2004; 18:73–78.
81

13. NATIONAL PROGRAMME FOR PREVENTION AND
CONTROL OF CANCER,DIABETES, ARDIOVASCULAR
DISEASES & STROKE ,(NPCDCS),2004
14. R Deepa et al.Is the ‘Rule of Halves’ in Hypertension Still
Valid? -Evidence from the Chennai Urban Population Study.
JAPI • VOL. 51 • FEBRUARY 2003.
15. Institute of Medicine. Dietary reference intakes for water,
potassium, sodium chloride, and sulfate. Washington, DC:
National Academies Press; 2004.
16. The Framingham Heart Study’s Impact on Global Risk
Assessment. Asaf Bitton, Thomas Gaziano Prog Cardiovasc
Dis. Author manuscript; available in PMC 2011 July 1.
82

Epidemiology of hypertension

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