LETS READ AND UNDERSTAND IT

1. Presenter : Dr AbdulRafey
MBBS

2.  INTRODUCTION
 EPIDEMIOLOGY
 RISK FACTORS
 CAUSES
 TYPES OF HYPERTENSION
 MANAGEMENT:
 Among young, elderly and pregnant women and
diabetes
 DIAGNOSIS
 TREATMENT
 PREVENTION

3.  Hypertension is defined by :
The Seventh report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure(JNC 7) a systolic blood pressure
(SBP) >130mmHg and diastolic blood
pressure (DBP)> 89mmHg at rest.

4. Table : Provides a classification of BP for adults 18 years
Note : Pre-hypertension is not a disease category, rather high
risk

5.  Hypertensive urgency: Severely elevated
BP(SBP >220 and DBP>120) without signs and
symptoms of acute end organ damage
 Hypertensive emergency: Severely elevated
BP(SBP >220 and DBP>120) with symptoms of
acute end organ damage (the system most
affected are cardiovascular ,Renovascular and
cerebrovascular)

6.  Accelerated hypertension is a recent
significant increase over baseline BP that is
assoc/with target organ damage.
 This is usually seen as vascular damage on
funduscopic exam, such as flame-shaped
hemorrhages or soft exudates, but without
papilledema.
 Flame shaped

7.  Malignant hypertension : is a syndrome of high
BP( SBP> 180 and DBP > 120mmHg) and
Papilledema on fundoscopy (retinopathy ) must be
present.
 Papilledema

8.  Resistant hypertension : is an uncontrolled
HTN despite the use of three anti-
hypertensives (ACEi/ARB + CCB or
BB)including diuretics eg: furosemide

9.  Worldwide prevalence estimates for hypertension may be
as much as 1 billion individuals.
 ~ 7.1 million deaths per year may be attributable to
hypertension
 Suboptimal BP ( > 115mmHg Systolic BP) is the number
one attributable risk factor for death throughout the world.
 WHO reports: that suboptimal BP is responsible for 62% of
cerebrovascular disease and 49% of ischemic heart disease
(IHD), with little variation by sex.
 Within the last two decades, better Rx of HTN has been
ass/with a considerable reduction in the hospital case-
fatality rate for heart failure (HF)
*WHO 2014 guideline

10. Causes/risk factors of HTN
Non modifiable
Age
Gender /sex
Genetic
Modifiable causes
Overweight BMI>
30kg/m2
Salt intake
Junk foods
Alcohol & tobacco
use
Physical inactivity
 Other secondary causes of HTN are :
 Chronic kidney disease
 Coarctation of the aorta
 Cushing’s syndrome and other
glucocorticoid excess states
 including chronic steroid therapy
 Obstructive uropathy
 Pheochromocytoma
 Primary aldosteronism and other
mineralocorticoid excess states
 Renovascular hypertension
 Sleep apnoea
 Thyroid or parathyroid disease

11. Barriers to prevention include
 cultural norms
 insufficient attention to health education by health care
practitioners
 lack of access to places to engage in physical activity;
 larger servings of food in restaurants
 lack of availability of healthy food choices in many
schools, worksites, and restaurants
 lack of exercise programs in schools;
 large amounts of sodium added to foods by the food
industry and restaurants;
 The higher cost of food products that are lower in sodium
and calories

13.  History and physical examination
 BP measurement using standard sized cuff
 cholesterol and blood sugar levels
 Rule out underlying disease:
 CVD
 DM
THYROID
GENETIC DISEASE e.g. Coarctation of aorta

15.  The Rx goal for individuals with:
 In Pre-hypertension - lower BP to normal levels with lifestyle
changes and prevention
 In Hypertensive and no other compelling conditions BP goal is
<140/90 mmHg
 In hypertensive and diabetes or renal disease, the BP goal is
<130/80 mmHg
 It has been estimated that for every 5mmHg reduction
of SBP in the population would result in:
 14 % overall reduction in mortality due to stroke,
 9% reduction in mortality due to CHD, and
 7% decrease in all-cause mortality
* The Seventh/eight Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure

17. Group Drugs
Loop diuretic Furosemide 20–80 mg bd ; Torsemide 2.5-10mg
od
Thiazide diuretics Chlorothiazide (125-500 od/bd)
Hydrochlorothiazide (12.5-50mg od)
Angiotensin receptor
blocker(ARB)
Losartan (25-100mg od/bd) ; Telmisartan (20-
80mg/day od); Candesartan (8-32mg/day od)
Angiotensin converting
enzyme inhibitor (ACEI)
Captopril(25-100mg) od ; Enalapril (5-40mg )Od
; Perindopril (4-8mg) od
Calcium channel blockers
(CCB)
Dilteazem (180-420mg od)
Verapamil (80-120mg od)
Amlodipine (2.5-10mg od)
Nifedipine (20-60mg od/bd)
Beta blockers(BB) Bisoprolol (2.5 -10mg od) ; atenolol (25-100mg
0d)
Aldosterone receptor blocker Spironolactone (25-50mg od)
In heart failure or
Atrial
fibrillation(AF)

18.  Therapy begins with lifestyle modification, and
if BP goal is not achieved
 Thiazide-type diuretics should be used as
initial therapy* for most patients, either alone or
in combination with one of the (ACEIs, ARBs,
BBs, CCBs) or when a diuretic cannot be used
or when a compelling indication is present that
requires the use of a specific drug
 When BP is >20 mmHg above systolic goal or
10mmHg above diastolic goal, consideration
should be given to initiate therapy with 2drugs,
either as separate prescriptions or in fixed-dose
combinations.

20.  JNC 8 2014 target BP treatment
recommendations
 In Nonblack patients with HTN, initial Rx can be a
thiazide-type diuretic, CCB, ACE inhibitor, or
ARB
while
 In the general Black population, initial therapy
should be a thiazide-type diuretic or CCB
and
 In patients >18 years with CKD, initial or add-on
therapy should be an ACE inhibitor or ARB,
regardless of race or diabetes status with the target

22.  Choose ONE of these medications based on underlying cause
and check BP before / after every dose.
 IV LABETOLOL: preferred in aortic dissection. Avoid in CCF,
asthma and bradycardia.
 Dose: Give 15mg over 2 minutes. Repeat every 10 minutes if needed
(max total dose = 300mg).
 If giving infusion, start at 1 mg/min (mix 100mg in 100ml NS, then
give 1 drop every 3 seconds). Titrate
 upward to a maximum of 4 to 5 mg/min if needed.
 SODIUM NITROPRUSSIDE preferred in CCF. Avoid in renal
failure and pregnancy.
 IV / IM HYDRALAZINE: preferred in pre-eclampsia /
eclampsia.
 Dose: give 5mg, repeat every 30 minutes if needed (max total dose =
300mg per day).

23.  Community service organizations can promote
the prevention of hypertension by providing
culturally sensitive educational messages and
lifestyle support services and by establishing
cardiovascular risk factor screening and
referral programs