4. Hypertension paradox
• Can be easily diagnosed, but…
• Asymptomatic nature, delays diagnosis
• Advanced therapy available, but…
• Controlled in less than 1/3 rd of patients
Silent Killer
6. Determinants
• Behavioral
– Nicotine
– Heavy drinkers
– Physical inactivity
– Diet low in fresh fruits and high in calories /
sodium.
• Genetic
7. Why should we treat it ?
• It affects 1 billion people worldwide
• India has become ―Capital of hypertension‖
• Burden is further rising
8. • In the ICMR study in 1994 demonstrated
25% and 29% prevalence of hypertension
among males and females respectively in urban
Delhi and 13% and 10% in rural Haryana.
9. • High BP causes
~ 54% of stroke
~ 47% of ischemic heart disease
• It also leads to
– Heart failure
– Peripheral vascular disease
– Renal failure
– Blindness due retinopathy, haemorrhages
15. • Primary hypertension
– In 90 – 95% of patients, a single reversible
cause cannot be identified
– Also called as Essential hypertension
• Secondary hypertension
– In 5 -10 % of patients
– May be curable
16. Primary hypertension
• It is divided in to 3 subtypes –
1. Systolic hypertension of young
• Between 17 -25 years of age
• Probably due to overactive sympathetic nervous
system
17. 2. Diastolic hypertension in middle age
• Typically 30-50 years of age
• Elevated systemic vascular resistance
• Reduced ability to excrete sodium by kidney
18. 3. Isolated systolic hypertension in older
adults
• After the age 55 years
• Most common form
• Due to age dependent stiffening of vessels
25. Minimal laboratory testing
required for the initial evaluation
• Blood electrolyte values,
• Fasting glucose concentration, and
• Serum creatinine level with calculated
glomerular filtration rate (GFR)
• Serum uric acid
26. • Fasting lipid panel
• Hematocrit
• Spot urinalysis, including urine albumin-to-
creatinine ratio
• Resting 12-lead electrocardiogram.
27. 3 goals
• Initial evaluation should accomplish –
1. Accurate measurement of BP
2. Assessment of patients cardiovascular risk
3. Detection of secondary forms
28. Measurement of BP
• Office BP measurement
• Self monitoring at home
• Ambulatory monitoring
29. BP Measurement Techniques
Method Brief Description
• Two readings, 5 minutes apart
• Sitting in chair, not on exam table
In-office
• Confirm elevated reading in
contralateral arm
• Provides information on response to
Self- therapy
measuremen
• May help improve adherence to therapy
t
• Evaluate ―white-coat‖ HTN
30. BP Measurement Techniques
Method Brief Description
Two readings, 5 minutes apart. Sitting in chair, not on
In-office exam table. Confirm elevated reading in contralateral
arm.
Provides information on response to therapy. May help
Self-measurement improve adherence to therapy and evaluate ―white-coat‖
HTN.
Indicated for evaluation of ―white-coat‖
HTN.
Ambulatory BP
monitoring Can be used to confirm self-
measurement when inconsistent with in-
office measurement.
31. Self-Measurement of BP
Improves awareness and adherence
Instruction on proper use and technique should be
provided
Home measurement devices should:
• Have an arm cuff
• Be checked in office regularly
Validated meters:
BMJ 2001;322:531-536.
omronhealthcare.com
Dableducational.com
Daily Logs
32. Self-Measurement of BP
Home measurements of >135/85 mmHg
(or 125/75 in diabetes or renal disease)
are considered hypertensive
At least 50% of measurements should
be at or below goal
33. • Ambulatory monitoring also useful for
diagnosis of
– Nocturnal hypertension
– Baro-reflex impairment
• Wrist monitors are inaccurate and thus not
recommended
36. Assessment of patients
cardiovascular risk
• High-risk patients now includes most
cardiology patients—
1. Established CAD, CAD risk equivalents,
2. Carotid artery disease,
3. Peripheral artery disease,
4. Abdominal aortic aneurysm,
5. Heart failure, or
6. High risk for CAD (10-year framingham risk
score of >10%
37. Subclinical Target Organ Damage
• Left ventricular hypertrophy
• Carotid wall thickening or plaque
• Low estimated glomerular filtration rate
=60 mL/min/1.73 m
• Microalbuminuria
• Ankle-brachial BP index <0.9
38. This left ventricle is very thickened (slightly over 2 cm in
thickness), but the rest of the heart is not greatly enlarged.
This is typical for hypertensive heart disease. The
hypertension creates a greater pressure load on the heart to
induce the hypertrophy.
40. Identifiable (secondary) forms of
hypertension
• Renal disease is the most common cause (2-5%)
• Endocrine diseases
– Phaeochomocytoma
– Cusings syndrome
– Conn’s syndrome
– Acromegaly and hypothyroidism
• Coarctation of the aorta
• Iatrogenic
– Hormonal / oral contraceptive
– NSAIDs
41. Clinical clues for Renovascular HT
• Onset before 30 years or after 50 years
• Abrupt onset
• Severe or resistant hypertension
• Symptoms of atherosclerotic disease
elsewhere
42. • Negative family history of hypertension
• Smoker
• Worsening renal function after renin-
angiotensin inhibition
• Recurrent ―flash‖ pulmonary edema
46. "The Goal is to Get to Goal!”
-PLUS-
Hypertension
Diabetes or Renal Disease
< 140/90 mmHg < 130/80 mmHg
Measurements and goals
should be provided to the
patient verbally and in writing
at each office visit
47. Treatment Overview
• Lifestyle modification
Same as for prevention
• Pharmacologic treatment
Initial therapy
Combination therapy
• What to do when a patient is still not at goal?
• Follow-up and monitoring
49. DASH Eating Plan
• Low in saturated fat, cholesterol, and total fat
• Emphasizes fruits, vegetables, and low fat diary
products
• Reduced red meat, sweets, and sugar containing
beverages
• Rich in
magnesium, potassium, calcium, protein, and fiber
• 3 -1.5 g sodium per day
• Can reduce BP in 2 weeks
Sacks FM. NEJM. 2001; 344:3-10.
52. Compelling indications
These are the associated comorbid
conditions, in which a particular
antihypertensive drug causes major
improvement outcome independent of BP
reduction
56. When a Patient is Still Not at Goal?
• Optimize dosages or add additional drugs until
goal blood pressure is achieved
• What do you do when you are using several
effective medications?
– Consider causes of resistant hypertension
– Assure drug therapy is rational
– ―Tricks of the trade‖
57. Causes of inadequate response to
therapy
• Pseudo-resistance
• Non-adherence to therapy
• Drug related causes
• Associated condotions
• Secondary hypertension
• Volume overload
58. How to improve maintenance of
therapy ?
• Be aware of the problems leading to non-
compliance
• Articulate the goal of therapy - near-
normotension with few or no side effects.
• Educate the patient about the disease and its
treatment
59. • Maintain contact with patient
• Keep therapy inexpensive and simple
• Prescribe according to pharmacologic
principles
• Stop unsuccessful therapy and try different
drugs
60. • Anticipate and address side-effects
• Add effective and tolerated drugs stepwise
• Provide feedback and validation of success.
