A brief overview of hypertension and its management based on the JNC 7 report and protocol. Ideal for Final year MBBS Undergraduates.

1. HYPERTENSION
Approach & Management
- Dr.Mohammed Sadiq Azam M .D.
Assistant Professor,
Department of Medicine,
Prof Siraj’s Unit (M – 1)
Deccan College of Medical Sciences

2. PROBLEM
MAGNITUDE

Hypertension( HTN) is the most common primary
diagnosis.

35 million office visits are as the primary diagnosis of HTN.

50 million or more Americans have high BP.

Worldwide prevalence estimates for HTN may be as much as
1 billion.

7.1 million deaths per year may be attributable to
hypertension.

3. Definition

A systolic blood pressure (SBP) ≥ 140mmHg
and/or

A diastolic (DBP) ≥ 90 mmHg.

Based on the average of two or more properly
measured, seated BP readings.

On each of two or more office visits.

4. Accurate Blood Pressure
Measurement

The equipment should be regularly inspected and validated.

The operator should be trained and regularly retrained.

The patient must be properly prepared and positioned and
seated quietly for at least 5 minutes in a chair.

The auscultatory method should be used.

Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.

An appropriately sized cuff should be used.

5. BP Measurement

At least two measurements should be made
and the average recorded.

Clinicians should provide to patients their
specific BP numbers and the BP goal of
their treatment.

6. JNC 7 Classification of
HTN

7. Follow-up based on initial BP measurements for
adults*
*Without acute end-organ damage

8. Prehypertension

SBP >120 mmHg and <139mmHg and/or

DBP >80 mmHg and <89 mmHg.

Prehypertension is not a disease category
rather a designation for individuals at high risk
of developing HTN.

9. Pre-HTN

Individuals who are prehypertensive are not candidates
for drug therapy, BUT,

Should be firmly and unambiguously advised to practice
lifestyle modification

Those with pre-HTN, who also have diabetes or kidney
disease, drug therapy is indicated IF a trial of lifestyle
modification fails to reduce their BP to 130/80 mmHg or
less.

10. Isolated Systolic
Hypertension

Not distinguished as a separate entity as far as
management is concerned.

SBP should be primarily considered during treatment
and not just diastolic BP.

Systolic BP is more important cardiovascular risk factor
after age 50.

Diastolic BP is more important before age 50.

11. Hypertensive Crises

Hypertensive Urgencies: No progressive
target-organ dysfunction. (Accelerated
Hypertension)

Hypertensive Emergencies: Progressive
end-organ dysfunction. (Malignant
Hypertension)

12. Hypertensive Urgencies

Severe elevated BP in the upper range of
stage II hypertension.

Without progressive end-organ dysfunction.

Examples: Highly elevated BP without severe
headache, shortness of breath or chest pain.

Usually due to under-controlled HTN.

13. Hypertensive Emergencies

Severely elevated BP (>180/120mmHg).

With progressive target organ dysfunction.

Require emergent lowering of BP.

Examples: Severely elevated BP with:

Hypertensive encephalopathy

Acute left ventricular failure with pulmonary edema

Acute MI or unstable angina pectoris

Dissecting aortic aneurysm

14. Types of Hypertension

Primary HTN:

Also known as essential

Secondary HTN:

Less common cause
HTN.

Accounts for 95% cases of
HTN.

of HTN ( 5%).

Secondary to other
No universally established
potentially rectifiable
cause known.
causes.

15. Causes of Secondary HTN

Common

Uncommon

Intrinsic renal disease

Pheochromocytoma

Renovascular disease

Glucocorticoid excess

Mineralocorticoid

Coarctation of Aorta
excess

Hyper/hypothyroidism

Sleep Breathing
disorder

16. Secondary HTN - Clues in Medical
History

Onset: at age < 30 yrs ( Fibromuscular dysplasia) or
> 55 (athelosclerotic renal artery stenosis), sudden
onset (thrombus or cholesterol embolism).

Severity: Grade II, unresponsive to treatment.

Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).

Morbid obesity with history of snoring and daytime
sleepiness (sleep disorders)

17. Secondary HTN - clues on
Exam

Pallor, edema, other signs of renal disease.

Abdominal bruit especially with a diastolic
component (renovascular)

Truncal obesity, purple striae, buffalo hump
(hypercortisolism)

18. Secondary HTN - Clues on Routine
Labs

Increased creatinine, abnormal urinalysis
(renovascular and renal parenchymal disease)

Unexplained hypokalemia (hyperaldosteronism)

Impaired blood glucose
(hypercortisolism)

Impaired TFT (Hypo/hyperthyroidism)

19. Secondary HTN - Screening
Tests

20. Renal Parenchymal
Disease

Common cause of secondary HTN (2-5%)

HTN is both cause and consequence of renal
disease

Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins imbalance

Renal disease from multiple etiologies.

21. Renovascular HTN



Atherosclerosis 75-90% ( more common in older
patients)
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Other
•
•
•
•
•
•
Aortic/renal dissection
Takayasu’s arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation

22. Complications of
Prolonged Uncontrolled HTN

Changes in the vessel wall leading to vessel
trauma and arteriosclerosis throughout the
vasculature

Complications arise due to the “target organ”
dysfunction and ultimately failure.

Damage to the blood vessels can be seen on
fundoscopy.

23. Target Organs

CVS (Heart and Blood Vessels)
 The kidneys
 Nervous system
 The Eyes

24. Effects On CVS

Ventricular hypertrophy, dysfunction and
failure.
 Arrhithymias
 Coronary artery disease, Acute MI
 Arterial aneurysm, dissection, and
rupture.

25. Effects on The Kidneys

Glomerular sclerosis leading to impaired kidney
function and finally end stage kidney disease.

Ischemic kidney disease especially when renal
artery stenosis is the cause of HTN

26. Nervous System

Stroke, intracerebral and subaracnoid
hemorrhage.
 Cerebral atrophy and dementia

27. The Eyes

Retinopathy, retinal hemorrhages and
impaired vision.
 Vitreous hemorrhage, retinal detachment
 Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction

28. Retina Normal and Hypertensive
Retinopathy
A
B
C
Normal Retina
Hypertensive Retinopathy
A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)

29. Stage I- Arteriolar Narrowing
Arteriolar Narrowing

30. Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking

31. AV Nicking

32. Stage III- Hemorrhages (H), Cotton
Wool Spots and Exudates (E)
H
E

33. Stage IV- Stage III+Papilledema

34. Patient Evaluation
Objectives



(1) To assess lifestyle and identify other
cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD

35. (1) Cardiovascular Risk
factors









Hypertension
Cigarette smoking
Obesity (body mass index ≥30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)

36. (2) Identifiable Causes of
HTN









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

37. (3) Target Organ Damage





Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy

38. History





Angina/MI Stroke: Complications of HTN,
Angina may improve with b-blokers
Asthma, COPD: Preclude the use of bblockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia : Suggest renal
impairment

39. History-contd.





Claudication: May be aggravated by bblockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May
have been due to HTN

40. History-contd.

Family history of DM : Patient may
also be Diabetic
 Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
 High alcohol: A cause of HTN
 High salt intake: Advice low salt intake

41. Examination





Appropriate measurement of BP in both arms
Optic fundi
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
bruits
Palpation of the thyroid gland.

42. Examination-contd.

Thorough examination of the heart and
lungs
 Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
 Lower extremities for edema and pulses
 Neurological assessment

43. Routine Labs

ECG.

Urinalysis.

Blood glucose (FPG/PPG) and hematocrit; serum
potassium, creatinine ( or estimated GFR), and
calcium.

HDL cholesterol, LDL cholesterol, and triglycerides.

Urinary albumin excretion or Spot Albumin/creatinine
ratio.

44. Goals of Treatment

Treating SBP and DBP to targets that are <140/90
mmHg

Patients with diabetes or renal disease, the BP goal is
<130/80 mmHg

The primary focus should be on attaining the SBP
goal.

To reduce cardiovascular and renal morbidity and
mortality

45. Benefits of Treatment

Reductions in stroke incidence,
averaging 35–40 percent

Reductions in MI, averaging 20–25
percent

Reductions in HF, averaging >50 percent.

46. Lifestyle
modifications

47. Lifestyle Changes Beneficial in Reducing
Weight

Decrease time in sedentary behaviors such as
watching television, playing video games, or spending
time online.

Increase physical activity such as walking, biking,
aerobic dancing, tennis, soccer, basketball, etc.

Decrease portion sizes for meals and snacks.

Reduce portion sizes or frequency of
consumption of calorie containing beverages.

48. DASH Diet

Dietary Approach to Stop Hypertension

As effective as one medication

50. Management of HTN

54. THANK
YOU