Problem statement of Hypertension. Measurement of blood pressure. Recent diagnostic criteria and management guidelines. Prevention of Hypertension. National Programme for Prevention and Control of Cancer, Diabetes,Cardiovascular Diseases and Stroke

1. HYPERTENSION
Dr. Migom Doley
Registrar
Dept. of Community Medicine
Assam Medical College and Hospital
Dibrugarh

2. WHAT IS HYPERTENSION?
 Hypertension, also known as high or raised blood pressure, is a condition in which the blood vessels
have persistently raised pressure.
 Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the
major blood vessels in the body.
 Blood is carried from the heart to all parts of the body in the vessels. Each time the heart beats, it
pumps blood into the vessels. Blood pressure is created by the force of blood pushing against the
walls of blood vessels (arteries) as it is pumped by the heart. The higher the pressure, the harder the
heart has to pump.
 Blood pressure is the force exerted by circulating blood against the walls of the body’s arteries, the
major blood vessels in the body.
 Blood pressure is written as two numbers. The first (systolic) number represents the pressure in
blood vessels when the heart contracts or beats. The second (diastolic) number represents the
pressure in the vessels when the heart rests between beats.

3. DEFINITON
Systolic and Diastolic BP
(mm Hg)
JNC 7 2017 ACC/AHA
< 120 and < 80 Normal BP Normal BP
120 – 129 and < 80 Prehypertension Elevated BP
130 – 139 or 80 - 89 Prehypertension Stage 1 hypertension
140 -159 or 90 – 99 Stage 1 hypertension Stage 2 hypertension
≥ 160 or ≥ 100 Stage 2 hypertension Stage 2 hypertension

4. BP MEASUREMENT DENITIONS
BP Measurement Definition
SBP First Korotkoff sound
DBP Fifth Korotkoff sound
Pulse pressure SBP minus DBP
Mean arterial pressure DBP plus one third pulse pressure
Mid – BP Sum of SBP and DBP, divided by 2

5. STEPS FOR PROPER BP MEASUREMENT
Step 1: Properly prepare the patient
• Have the patient relax, sitting in a chair (feet on floor, back supported) for >5 min
• Patient should avoid caffeine, exercise, and smoking for at least 30 min before measurement
• Ensure patient has emptied his/her bladder
• Neither the patient nor the observer should talk during the rest period or during the measurement
• Remove all clothing covering the location of cuff placement
• Measurements made while the patient is sitting or lying on an examining table do not fulfill these
criteria
Step 2:
• Use a BP measurement device that has been validated, and ensure that the device is calibrated
periodically
• Support the patient’s arm
• Position the middle of the cuff on the patient’s upper arm at the level of the right atrium (the mid
point of the sternum)
• Use the correct cuff size, such that the bladder encircles 80% of the arm
• Either the stethoscope diaphragm or bell may be used for auscultatory readings

6. STEPS FOR PROPER BP MEASUREMENT
Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/Hypertension
• At the first visit, record BP in both arms
• Separate repeated measurements by 1-2 min
• For auscultatory determinations, use a palpated estimate of radial pulse obliteration pressure to
estimate SBP. Inflate the cuff 20-30 mm Hg above this level for an ausculatatory determination of the
BP level
• For auscultatory reading, deflate the cuff pressure 2 mm Hg per second, and listen for Korotkoff
sounds
Step 4: Poperly document accurate BP readings
• Record SBP and DBP, as onset of first Korotkoff sound and disappearance of all Korotkoff sounds,
using the nearest even number
• Note the time of most recent BP medication taken before measuements
Step 5: Average the readings
• Use an average of ≥2 readings obtained on ≥2 occasions
Step 6: Provide BP readings to patient
• Both verbally and in writing

7. SELECTION CRITERIA FOR BP CUFF SIZE IN ADULTS
Arm Circumference Usual Cuff Size
22 – 26 cm Small adult
27 – 34 cm Adult
35 – 44 cm Large adult
45 – 52 cm Adult thigh

8. PROBLEM STATEMENT - WORLD
 Hypertension - or elevated blood pressure - is a serious medical condition that significantly
increases the risks of heart, brain, kidney and other diseases.
 Globally, the overall prevalence of raised blood pressure in adults aged 25 and over was
around 40% in 2008.
 WHO rates Hypertension as one of the most important causes of premature death worldwide.
 Hypertension is a major cause of premature death worldwide.
 Worldwide, raised blood pressure is estimated to cause 7.5 million deaths, about 12.8% of the
total of all deaths. This accounts for 57 million disability adjusted life years (DALYS) or
3.7% of total DALYS

9. PROBLEM STATEMENT - WORLD
 An estimated 1.13 billion people worldwide have hypertension, most (two-thirds) living in low- and
middle-income countries.
 In 2015, 1 in 4 men and 1 in 5 women had hypertension.
 Fewer than 1 in 5 people with hypertension have the problem under control.
 One of the global targets for non-communicable diseases is to reduce the prevalence of hypertension
by 25% by 2025 (baseline 2010).

10. PROBLEM STATEMENT - INDIA
 NCDs are estimated to account for 63% of all deaths in India according to World Health
Organization.
 HTN is directly responsible for 57% of all stroke deaths and 24% of all coronary heart
disease (CHD) deaths in India *Non-communicable Diseases (NCD) Country Profiles, 2018
 According to the WHO 2008 estimates, the prevalence of raised BP in Indians was 32.5%
(33.2% in men and 31.7% in women).
 Global Burden of Diseases study reported that hypertension led to 1.63 million deaths in
India in 2016 as compared to 0.78 million in 1990 (+108%).

11. PROBLEM STATEMENT - INDIA
 Overall prevalence of hypertension was 30.7% (The Great India blood pressure survey) –
MEN – 34.2 and Female – 23.7
 The Great India BP Survey was conducted in 24 Indian states, from 9 am to 5 pm on a
single day. Blood pressure was measured in public places such as metro stations, bus stops,
and marketplaces. Readings were repeated in those with high blood pressure (more than
140/90 mmHg). Participants were asked about risk factors for hypertension including
smoking and chewing tobacco, diabetes, and high cholesterol, as well as previous heart
attack or stroke, and whether they were taking blood pressure drugs.

12. RISK FACTORS FOR HYPERTENSION
Modifiable risk factors Non - modifiable risk factors
 Unhealthy diets (excessive salt consumption, a diet
high in saturated fat and trans fats, low intake of
fruits and vegetables)
 Physical inactivity
 Consumption of tobacco, alcohol and smoking
 Being overweight or obese
 Diabetes
 High blood cholesterol
 Poor stress management
 Family history of hypertension,
 Age over 65 years and
 Co-existing diseases such as diabetes or kidney
disease, ethnic background, genetic predisposition

13. TYPES OF HYPERTENSION
 Primary HTN:
 Primary hypertension has no clear cause and is thought to be linked to genetics, poor diet, lack
of exercise and obesity.
 The pathogenesis of essential hypertension is multifactorial and complex
 Secondary HTN: high blood pressure that's caused by another medical condition
 Causes of Secondary HTN:
Renal causes (2.5-6%) Vascular causes Endogenous hormonal causes
• Polycystic kidney disease
• Chronic kidney disease
• Urinary tract obstruction
• Renin-producing tumor
• Liddle syndrome
• Coarctation of aorta
• Vasculitis
• Collagen vascular disease
• Primary hyperaldosteronism
• Cushing syndrome
• Pheochromocytoma
• Congenital adrenal hyperplasia

14. TYPES OF HYPERTENSION
 Causes of Secondary HTN:
Neurogenic causes Drugs and toxins
• Brain tumor
• Autonomic dysfunction
• Sleep apnea
• Intracranial hypertension
• Alcohol
• Cocaine
• Cyclosporine, tacrolimus
• NSAIDs
• Erythropoietin
• Adrenergic medications
• Decongestants containing ephedrine
• Herbal remedies containing licorice (including
licorice root) or ephedrine (and ephedra)
• Nicotine

15. COMMON SYMPTOMS OF HYPERTENSION
 Hypertension is called a "silent killer".
 Most people with hypertension are unaware of the problem because it may have no warning
signs or symptoms.
 When symptoms do occur, they can include early morning headaches, nosebleeds, irregular
heart rhythms, vision changes, and buzzing in the ears.
 Severe hypertension can cause fatigue, nausea, vomiting, confusion, anxiety, chest pain,
and muscle tremors.
 The only way to detect hypertension is to have a health professional measure blood
pressure.

16. COMPLICATIONS OF UNCONTROLLED HYPERTENSION
 Hypertension can cause serious damage to the heart. Excessive pressure can harden
arteries, decreasing the flow of blood and oxygen to the heart. This elevated pressure and
reduced blood flow can cause Chest pain, also called angina.
 Heart attack, which occurs when the blood supply to the heart is blocked and heart muscle
cells die from lack of oxygen. The longer the blood flow is blocked, the greater the damage
to the heart.
 Heart failure, which occurs when the heart cannot pump enough blood and oxygen to other
vital body organs.
 Irregular heart beat which can lead to a sudden death.
 Hypertension can also burst or block arteries that supply blood and oxygen to the brain,
causing a stroke.
 In addition, hypertension can cause kidney damage, leading to kidney failure.

17. PREVENTION OF HYPERTENSION
 Reducing salt intake (to less than 5g daily)
 Eating more fruit and vegetables
 Being physically active on a regular basis
 Avoiding use of tobacco
 Reducing alcohol consumption
 Limiting the intake of foods high in saturated fats
 Eliminating/reducing trans fats in diet

18. MANAGEMENT OF HYPERTENSION
 Reducing and managing mental stress
 Regularly checking blood pressure
 Treating high blood pressure
 Managing other medical conditions

19. HYPERTENSION TREATMENT GUIDELINES – JNC 8
Recommendation 1:
In the general population aged 60 years, initiate pharmacologic treatment to lower blood
pressure (BP) at systolic blood pressure (SBP)150 mmHg or diastolic blood pressure
(DBP)90mmHg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.
Recommendation 2:
In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP
90mmHg and treat to a goal DBP<90mmHg.
Recommendation 3:
In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP
140mmHg and treat to a goal SBP <140mmHg.

20. HYPERTENSION TREATMENT GUIDELINES – JNC 8
Recommendation 4:
In the population aged 18 years with chronic kidney disease (CKD), initiate pharmacologic
treatment to lower BP at SBP 140mmHg or DBP90 mmHg and treat to goal SBP<140mmHg
and goal DBP<90mmHg.
Recommendation 5:
In the population aged 18years with diabetes, initiate pharmacologic treatment to lower BP at
SBP 140mmHg or DBP 90mmHg and treat to a goal SBP <140mmHg and goal DBP
<90mmHg.
Recommendation 6:
In the general nonblack population, including those with diabetes, initial antihypertensive
treatment should include a thiazide-type diuretic, calcium channel blocker (CCB),
angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB).

21. HYPERTENSION TREATMENT GUIDELINES – JNC 8
Recommendation 7:
In the general black population, including those with diabetes, initial antihypertensive
treatment should include a thiazide-type diuretic or CCB.
Recommendation 8:
In the population aged 18 years with CKD, initial (or add-on) antihypertensive treatment
should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients
with hypertension regardless of race or diabetes status.

22. HYPERTENSION TREATMENT GUIDELINES – JNC 8
Recommendation 9:
If goal BP is not reached within a month of treatment, increase the dose of the initial drug or
add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB,
ACEI, or ARB).
If goal BP cannot be reached with 2 drugs, add and titrate a third drug. Do not use an ACEI
and an ARB together in the same patient.
If goal BP cannot be reached using only the drugs in recommendation 6 because of a
contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs
from other classes can be used.
Referral to a hypertension specialist if goal BP cannot be attained using the above strategy or
for the management of complicated patients for whom additional clinical consultation is
needed.

23. HYPERTENSION MANAGEMENT GUIDELINE ALGORITHM – JNC 8
Adults aged ≥ 18 years with HTN
Implement lifestyle interventions
(Continue throughout management)
Set blood pressure goal and initiate blood pressure lowering-medication based on
age, diabetes, and chronic kidney disease (CKD)
Age ≥ 60 Years Age < 60 Years
BP Goal
SBP < 150 mm Hg
DBP < 90 mm Hg
BP Goal
SBP < 140 mm Hg
DBP < 90 mm Hg
All ages
Diabetes present
No CKD
All ages
CKD present with or
without diabetes
BP Goal
SBP < 150 mm Hg
DBP < 90 mm Hg
BP Goal
SBP < 140 mm Hg
DBP < 90 mm Hg
Initiate thiazide-type diuretic or ACEI or
ARB or CCB, alone or
in combination
Initiate thiazide-type diuretic or CCB,
alone or
in combination
Initiate ACEI or ARB, alone
or in combination

24. Select a drug treatment titration strategy
A. Maximise first medication before adding second or
B. Add second medication before reaching maximum dose of first medication or
C. Start with 2 medication classes separately or as fixed-dose combination
Reinforce medication and lifestyle adherence.
For strategies A and B, add and titrate thiazide-type diuretics or ACEI or ARB or CCB (use medication
class not previously selected and avoid combined use of ACEI and ARB)
For strategy C, titrate doses of initial medications to maximum
Reinforce medication and lifestyle adherence.
Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use medication class
not previously selected and avoid combined use of ACEI and ARB).
Reinforce medication and lifestyle adherence.
Add additional medication class (e.g. β-blocker, aldosterone antagonist, or others)
and/or refer to physician with expertise in hypertension management.
At goal BP?
At goal BP?
At goal BP?
At goal BP?
Continue current
treatment and
monitoring
Yes
Yes
Yes
Yes
No
No
No
No

25. HYPERTENSION MANAGEMENT GUIDELINE ALGORITHM – JNC 8
Notes:
• SBP - systolic blood pressure;
• DBP - diastolic blood pressure;
• ACEI - angiotensin-converting enzyme;
• ARB - angiotensin receptor blocker; and
• CCB - calcium channel blocker.
• ACEIs and ARBs should not be used in combination.
• If blood pressure fails to be maintained at goal, reenter the algorithm where appropriate
based on the current individual therapeutic plan.

26. GUIDELINES FOR PHYSICALACTIVITIES FOR ADULTS
 Adults should move more and sit less throughout the day.
 At least 150 min (2 h and 30 min) to 300 min (5 h) a week of moderate-intensity, OR
 75 min (1 h and 15 min) to 150 min (2 h and 30 min) a week of vigorous-intensity aerobic physical
activity, OR
 An equivalent combination of moderate- and vigorous-intensity aerobic activity.
 Preferably, aerobic activity should be spread throughout the week.
 Additional health benefits are gained by engaging in physical activity beyond the equivalent of 300
min (5 h) of moderate-intensity physical activity a week.
 Adults should do muscle-strengthening activities of moderate or greater intensity, and that involve
all major muscle groups on ≥2 days a week.

27. Dietary Approaches to Stop Hypertension (DASH)
DASH Eating Plan – for 2000 calories per day
The number of servings may vary, depending on caloric need
Food group Daily Servings Serving Sizes
Grains 6 – 8
1 slice bread
1 oz dry cereal
½ cup cooked rice, pasta, or cereal
Vegetables 4 – 5
1 cup raw leafy vegetable
½ cup cut-up raw or cooked vegetable
½ cup vegetable juice
Fruits 4 – 5
1 medium fruit
1/4 cup dried fruit
1/2 cup fresh, frozen, or canned fruit
½ cup fruit juice
Fat - free or low –fat milk
and milk products
2 – 3
1 cup milk or yogurt
1½ oz cheese

28. Dietary Approaches to Stop Hypertension (DASH)
Food group Daily Servings Serving Sizes
Lean meats, poultry, and
fish
6 or less
1 oz cooked meats, pultry, or fish
1 egg
Nuts, seeds and legumes 4 – 5 per week
1/3 cup or ½ oz nuts
2 tbsp. peanut butter
2 tbsp or ½ oz seeds
½ cup cooked legumes (dry beans and peas)
Fats and oils 2 – 3
1 tbsp. soft margarine
1 tbsp. vegetable oil
1 tbsp. mayonnaise
2 tbsp. salad dressing
Sweets and added sugars 5 or less per week
1 tbsp. sugar
1 tbsp. jelly or jam
½ cup sorbet, gelatin
1 cup lemonade

29. Dietary Approaches to Stop Hypertension (DASH)
Food group
Servings per Day
1,600 calories/day 2,600 calories/day 3,100 calories/day
Grains 6 10 -11 12 - 13
Vegetables 3 - 4 5 - 6 6
Fruits 4 5 - 6 6
Fat-free or low-fat milk and milk
products
2 - 3 3 3 - 4
Lean meats, poultry and fish 3 - 6 6 6 -9
Nuts, seeds, and legumes 3/week 1 1
Fats and oils 2 3 4
Sweets and added sugars 0 ≤ 2 ≤ 2
DASH Eating Plan – Number of daily servings for other calorie levels
*Whole grains are recommended for most grain servings as a good source of fiber and nutrients.

30. Make a Dash for DASH
Thirty minutes of moderate-intensity physical activity each day can help.
 If your blood pressure is moderately elevated, 30 minutes of brisk walking on most days a
week may be enough to keep you off medication.
 If you take medication for high blood pressure, 30 minutes of moderate physical activity
can make your medication work more effectively and make you feel better.
 If you don’t have high blood pressure, being physically active can help keep it that way. If
you have normal blood pressure—but are not active—your chances of developing high
blood pressure increase, especially as you get older or if you become overweight or obese
or develop diabetes.

31. NATIONAL PROGRAMME FOR PREVENTION AND CONTROL
OF CANCER, DIABETES, CARDIOVASCULAR DISEASES AND
STROKE (NPCDCS)

32. OBJECTIVES
1. Health promotion through behavior change with involvement of community, civil society,
community based organizations, media etc.
2. Outreach Camps are envisaged for opportunistic screening at all levels in the health care
delivery system from sub-centre and above for early detection of diabetes, hypertension
and common cancers.
3. Management of chronic Non-Communicable diseases, especially Cancer, Diabetes, CVDs
and Stroke through early diagnosis, treatment and follow up through setting up of NCD
clinics.
4. Build capacity at various levels of health care for prevention, early diagnosis, treatment,
IEC/BCC, operational research and rehabilitation.
5. Provide support for diagnosis and cost effective treatment at primary, secondary and
tertiary levels of health care.
6. Provide support for development of database of NCDs through a robust Surveillance
System and to monitor NCD morbidity, mortality and risk factors.

33. STRATEGY
 Health promotion, awareness generation and promotion of healthy lifestyle
 Screening and early detection
 Timely, affordable and accurate diagnosis
 Access to affordable treatment
 Rehabilitation

34. PACKAGE OF SERVICES
Health Facility Package of Services
Sub – centre
Health promotion for behaviour change and counselling
‘Opportunistic’ Screening of Diabetes using glucometer kits and Blood Pressure
measurement.
Awareness generation of early warning signals of common cancer
Referral of suspected cases to CHC/ nearby health facility
PHC
Health promotion for behaviour change and counselling
‘Opportunistic’ Screening of Diabetes using glucometer kits and Blood Pressure
measurement.
Clinical diagnosis and treatment of common CVDs including Hypertension and
Diabetes
Identification of early warning signals of common cancer
Referral of suspected cases to CHC
CHC/FRU Prevention and health promotion including counselling
Early diagnosis through clinical and laboratory investigations
Management of common CVDs, diabetes and stroke cases
Lab. investigations and Diagnostics: Blood sugar, Total Cholesterol ,Lipid Profile,
Blood Urea, XR, ECG,USG (To be outsourced, if not available)
‘Opportunistic’ Screening of common cancers (Oral, Breast and Cervix)
Referral of complicated cases to District Hospital/higher health care facility

35. PACKAGE OF SERVICES
Health Facility Package of Services
District Hospital Diagnosis and management of cases of CVDs, Diabetes, Stroke and Cancer (outpatient,
inpatient and intensive Care ) including emergency services particularly for Myocardial
Infarction & Stroke.
Lab. investigations and Diagnostics: Blood sugar, Lipid Profile, KFT, XR, ECG,USG
ECHO, CT Scan, MRI etc. (To be outsourced, if not available)
Referral of complicated cases to higher health care facility
Health promotion for behaviour change and counselling
‘Opportunistic’ Screening of NCDs including common cancers(Oral, Breast and Cervix)
Follow up chemotherapy in cancer cases
Rehabilitation and physiotherapy services
Medical College Mentoring of District Hospitals
Early diagnosis and management of Cancer, Diabetes, CVDs and other associated illnesses
Training of health personnel
Operational Research
Tertiary Cancer Centre Mentoring of District Hospital and outreach activities
Comprehensive cancer care including prevention, early detection,
diagnosis, treatment, palliative care and rehabilitation
Training of health personnel
Operational Research

36. WORLD HEALTH ORGANISATION RESPONSE
 In 2016, WHO and the United States Centers for Disease Control and Prevention launched
the Global Hearts Initiative to support governments to prevent and treat cardiovascular
diseases.
 Global Hearts Initiative, the HEARTS technical package five modules:
 Healthy-lifestyle counselling,
 Evidence-based treatment protocols,
 Access to essential medicines and technology,
 Team-based care, and
 Systems for monitoring provide a strategic approach to improve cardiovascular health
in countries across the globe.

37. WORLD HEALTH ORGANISATION RESPONSE

38. SUMMARY

46. THANK YOU