Hypertension on standard treatment protocol of Nepal

PREPARED BY
TIRTHARAJ ACHARYA
H.A
NOW THUMKI HEALTH POST
tirtharaja76@gmail.com
1
HYPERTENSION

Definition of Hypertension
Dorland’s Medical Dictionary
 “Persistently high arterial blood pressure”
Diastolic Hypertension
 Elevated diastolic blood pressure with a normal systolic
pressure
Essential Hypertension
 Elevated blood pressure “having no obvious external cause,”
or “idiopathic”
2

Classification
 So an specific cut off point is difficult
 WHO (1972) –systolic above 160/diastolic (phase V) more than 95
Currently
 Optimal-<120mmHg and<80 mmHg
3
Category Blood Pressure, mm Hg
Normal SBP 90-119 and DBP 60-79
Prehypertension SBP 120-139 or DBP 80-89
Stage 1 HTN SBP 140-159 or DBP 90-99
Stage 2 HTN SBP ≥160 or DBP ≥100
DBP = diastolic blood pressure; SBP = systolic blood pressure

Measurement of BP
Accuracy is essential
Reliability is questionable as wide variability in
individual.
Source of ERROR-
1. Observer error e.g. hearing acuity, interpretation of
Karotkow sound
2 Instrumental error eg loose cuff,leaking valve etc
3 subject error eg position , external stimuli-fear ,anxiety,
physical environment
4

WHO recommendation
Measurement of BP in individual
Uniform policy in all clinics &institutions to use rt or left
arm
Recording in sitting position than supine
Systolic at which sound first heard
Diastolic -sound muffled disappear
Measured at least 3 times over a period of 3 minutes &
lowest reading is taken
For comparability data should be taken every where in
uniform way
5

Measurement in community
Incidence has limitation due to
 individual variation,
 ambiguity of normal BP
 insidious nature of condition
Prevalence-
 Developed countries-25% in adult population
 Developing countries-10 to 20% in adult population
 High altitude & places belonging to primitive culture-very low
6

Measurement in community(cont)
The prevalence of hypertension was
44.9 percent (47.75% in male and 42.73% in females).
The higher proportion of hypertensive cases were
in age > 65 years (55.49%) than in the age group < 65 years
(36.32%).
The prevalence of hypertension was seen positively associated
with
non vegetarian eating habits, alcohol consumption, and >
25 Body max index. (Prevalence and Associated Risk Factors of Hypertension Among People Aged 50 years and more in
Banepa Municipality, Nepal)
7

Mortality
In western world: deaths due to coronary heart
disease
In eastern parts of the world: stroke deaths more
common
Decline in mortality in last 2 decades
Fall is equal in both sexes
Fall attributed to, use of effective drugs, modern
diagnosis &treatment
8

Risk Factors in HTN
Modifiable risk factors
• Stress
• Smoking and HTN
• Alcohol and BP
• Obesity
• Diabeties Mellitus
• Salt and HTN
• Occupation
• Personality
• Coffee and tea
Non modifiable
risk factors
• Family History
• Ethnicity and Race
• Age
• Sex/ Gender
9

Cardiovascular Risk Factors
Hypertension
Cigarette smoking
Obesity (BMI>30)
Inactivity
Dyslipidemia
Diabetes Mellitus
Age
 >55 for men
 >65 for women
Microalbuminuria
 Or GFR <60mL/min
FH of Premature CVD
 Men <55
 Women <65
10

Birth Weight
Birth weight is also associated with the development
of hypertension in later life.
The lower the birth weight the higher the likelihood
of developing hypertension and heart disease
Clearly in-utero factors affect health at a later stage.
11

Blood pressure is a continuous variable which
fluctuates widely during the day
 physical stress
 mental stress
The definition of hypertension has been arbitrarily
set as:
That blood pressure above which the benefits
of treatment outweigh the risks in terms of
morbidity and mortality
12

Hypertension
Hypertension is not a disease
It is an arbitrarily defined disorder to which
both environmental and genetic factors
contribute
13

Causes for Secondary Hypertension
Renal disease
 20% of resistant hypertensive patients
 chronic pyelonephritis
 renal artery stenosis
 polycystic kidneys
Drug Induced
 NSAIDs
 Oral contraceptive
 Corticosteroids
15

Drug Induced Causes of HTN
Illicit Drugs
 Cocaine, amphetamines
Oral Contraceptives
Adrenal Steroids
 Prednisone
Licorice (in some chewing tobacco)
Decongestants (sympathomimetics)
Non-adherence, inadequate doses, inappropriate
combinations
Non steroidal Anti-inflammatory drugs
16

Diagnostic features of the HTN
No symptoms in 90 of the cases even when BP is
very high i.e. > 160/100 mm of Hg
Headaches , dizziness
BP > 140/90 mm of Hg measured in the different
time and situations
17

Treatment and management
A/C STP drug T. Amlodipine 5mg OD if BP doesnot go in
the 140/90 mm of Hg add Hydrochlorothiazide 25 mg OD
in morning.
If not controlled add T. Atenolol 50mg OD(if there is no CI
for Beta blocker)
Lifestyle modification and dietary modification
Cessation of the smoking and alcohol intake
Regular physical exercise
Control salt, fat, obesity
Follow healthy life style
Continuation of the medication untill medical consultation
18

Malignant Hypertension:
 May complicate any type of HTN.
 Necrotizing arteriolitis.
 Intravascular thrombosis.
 Rapidly progressive end organ damage.
 Renal failure
 Hypertensive encephalopathy.
 Left ventricular failure.
19

Consequences of Hypertension:
 Blood Vessels
 Atherosclerosis and its complications aneurism,
Dissection, Rupture, necrosis. Arteriolosclerosis,
 Heart
 Hypertensive cardiomyopathy, IHD, MI.
 Kidney
 Benign/Malignant nephrosclerosis. Infarction
 Eyes:
 Hypertensive retinopathy
 Brain:
 Haemorrhage, infarction,
 splinter & Lacunar hemorrhages
20

Left ventricular Hypertrophy:
Left Ventricular HypertrophyLeft Ventricular Hypertrophy
21

Cerebral Infarction (Stroke) :
HaemorrhagicHaemorrhagic
NecrosisNecrosis
22

Cerebral Infarction:
23

Subarachnoid Haemorrhage:
24

Renal Artery stenosis - Atrophy
Leathery Granularity
Benign Nephrosclerosis
25

Normal Retina - Fundoscopy
26

Hypertensive Retinopathy:
 Grade I – Thickening of
arterioles.
 Grade II – Focal Arteriolar
spasms. Vein constriction.
 Grade III – Hemorrhages
(Flame shape), dot-blot and
Cotton wool and hard waxy
exudates.
 Grade IV - Papilloedema
27

TREATMENT MODALITY IN GENERAL
Principle:- “lower the pressure, the better”
Goal:- to have maximally tolerated reduction in
blood pressure
28

MILD HYPERTENSION
Monodrug therapy
Drug of choice:
1. Thiazide diuretic
eg. Hydrochlorthiazide
2. β1 blocker
eg. Propanolol
If monotherapy doesn’t work other drug can be added
eg.Thiazide+ β1blocker
29

ABCD treatment in HTN
30
A ACE inhibitor Enalapril / Captopril
B Beta blocker Atenolol / propanolol
C Calcium channel blocker Amlodipine/ Morphe
depine
D Diuretics Fursemide

Special cases
1.PREGNANCY
Toxemia of pregnancy
Drug of choice: β1blocker
vasodilator
Ca++
channel blocker
-Contraindicated drugs are
Diuretics,Resperine,Na nitroprusside,
Non selective β -blocker
31

2.Heart Disease
All A,B,C and D are useful
β1 blocker are contraindicated in left ventricular
failure & bradycardia
3.Diabetic
ACE inhibitor (Captopril)
low dose thiazide, beta 1 blocker and Ca channel
blocker for long term therapy
contraindicated diuretics
32

4. Hypertensive Emergency
Life threatening, DP > 130 mmHg
Sodium nitroprusside (vasodilator)
Diazoxide (arterial dilator )
Labetolol ( non selective adrenergic blocker )
5. Hypertensive urgency
Nifedipine (Sub lingual)
Clonidine (oral or IM every 1-2 hrs)
Captopril ( oral)
Hydralazine (IM or IV slowly)
33

AND CONTROL OF
HTN
PREVENTION
34

Lifestyle Modification: 1
Weight Reduction
 Maintain normal body weight
 BMI: 18.5 – 24.9
 BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan
 Dietary Approaches to Stop Hypertension
 Fruits, Vegetables, Low-fat dairy
 Reduce saturated and total fat
 8-14 mmHg BP reduction
35

Dietary Sodium Reduction
 2.4 grams Sodium or 6 grams Sodium Chloride
 2-8 mmHg BP reduction
Physical Activity
 Regular aerobic physical activity
 Brisk walking, treadmill, exercise bike, bicycling, swimming (30 min.
a day, most days of the week)
 4-9 mmHg BP reduction
36

Moderation of alcohol consumption
 No more than 2 drinks per day in most men
 No more than 1 drink per day in women and lighter weight
individuals
 One drink equals:
 ½ ounce liquor or
 12 oz. Beer or
 5 oz. Wine or
 1 ½ oz. 80 proof whisky
37

tirtharaja76@gmail.com 38
Be serious for
HTN pts in
following

Patient History: I
Duration and prior Rx
Pharmaceutical profile
Family history
Symptoms of secondary causes
Target organ damage
Presence of other risk factors
39

Patient History: II
Concomitant Diseases
Dietary History
Sexual Function
Features of Sleep Apnea
Ability to modify life-style
40

Physical Examination: I
Accurate measure of BP, BMI
Fundoscopy
Carotid and thyroid abnormalities
Heart sounds, rhythm, size
Rales, rhonchi on lung exam
41

THANK YOU FOR YOUR
GREAT
CONCENTRATION
42

Hypertension on standard treatment protocol of Nepal

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Hypertension on standard treatment protocol of Nepal

Similar to Hypertension on standard treatment protocol of Nepal (20)

More from Public Health Concern Nepal

More from Public Health Concern Nepal (6)

Recently uploaded

Recently uploaded (20)

Hypertension on standard treatment protocol of Nepal