world hypertension day 17th may 2024

1. Hypertension:
Prevention and
management of
Complications
DR SEEBAT MASRUR
D-CARD STUDENT
CARDIOLOGY
SZRMCH

2. Global Burden Of Hypertension
Ref: https://www.who.int/news-room/fact-
sheets/detail/hypertension#:~:text=An%20estimated%2046%25%20of%20adults,cause%20of%20premature%20death%20worldwide.
▪ An estimated 1.28 billion adults aged 30–79 years worldwide have
hypertension, most (two-thirds) living in low- and middle-income
countries
▪ An estimated 46% of adults with hypertension are unaware that they
have the condition.
▪ Less than half of adults (42%) with hypertension are diagnosed and
treated.
▪ Approximately 1 in 5 adults (21%) with hypertension have it under
control.
▪ Hypertension is a major cause of premature death worldwide.

3. Hypertension in Bangladesh
▪ Prevalence: Adults (18-69 years): 23.5% Men: 24.1%
Women: 23.0%
▪ Elderly Population (>60 years): Overall: 49% Men: 42%
Women: 56%
▪ Awareness and Treatment: 50% of hypertensive adults
are unaware. Only 35% receive treatment. Blood
pressure controlled in 14%.
▪ Based on this study, we estimate that 1 out of 5
Bangladeshi adults have hypertension. The risk of
hypertension increases with older age and high BMI
▪ Ref-2018 May;32(5):334-348. doi:
10.1038/s41371-017-0018-x. Epub 2017 Dec 11

4. Epidemiology of hypertension among
Bangladeshi adults
Ref:https://www.nature.com/articles/s41371-018-0087-5

5. Impact of Hypertension
▪ Hypertensive patients are prone to develop Atrial
Fibrillation (AF), Premature Ventricular
Contractions (PVC), and Ventricular Tachycardia
(VT)
▪ The incidence of Sudden Cardiac Death (SCD) also
increases in LVH caused by HTN.
▪ HTN is strongly, independently, and linearly
associated with the risk of Stroke.
▪ Risk of Heart Failure (HF) increases 2-3 fold in HTN.

6. Impact of Hypertension
▪ In-hospital mortality in Hypertensive Heart
Failure (HHF) is 13-15% among Asians.
▪ HTN doubles CAD risk.
▪ Shear stress of HTN promotes atherosclerosis.
▪ Sexual dysfunction is a potential complication
of hypertension

7. 50%
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
20
mmHg
SBP
increase
Mortality from
IHD & Stroke
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
SBP versus Mortality

8. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
10%
2
mmHg
SBP
decrease
Mortality from
IHD & Stroke
Prospective Studies Collaboration. Lancet. 2002;360:1903-1913
Even a small decrease is
beneficial

10. Definition ofHypertension
Hypertension based on Office-, Ambulatory (ABPM)-
and Home Blood Pressure (HBPM) measurement

11. Validated equipment for blood pressure measurement

12. Office Blood Pressure Measurement
● 2-3 office visits at 1-4-week
intervals.
● Whenever possible, the diagnosis should
not be made on a single visit (unless BP
≥180/110 mmHg and CVD).
● If possible and available, the diagnosis of
hypertension should be confirmed by out-
of-office measurement.
Blood Pressure Measurementand Diagnosis ofHypertension

13. Blood Pressure Measurement and Diagnosis ofHypertension

14. Home BP monitoring, before each visit to the
health professional
2 X 2 = 4
2 measurements on
each occasion
2 occasions in a day
(morning and evening)
4 days in a week

15. Hypertension Risk Factors
Non Modifiable Modifiable
Family history
Gender
Age
Ethnicity
Obesity
Excess Salt intake
High Saturated fat intake
Low consumption of fruits and vegetables
Alcohol
Smoking
Stress
Physical inactivity
Socio-economic status
Drugs eg NSAIDs, STeroids

16. Emerging Risk factors
Sleep Duration and Quality: Conditions such as sleep apnea and insufficient sleep
duration have been associated with an increased risk of hypertension.
Air Pollution: Exposure to air pollutants, such as particulate matter (PM2.5), nitrogen
dioxide (NO2), and ozone (O3), has been identified as a potential risk factor for
hypertension.
Chemicals found in common household products, plastics, and pesticides, known as
endocrine disruptors, may interfere with hormone regulation and contribute to
hypertension. Chronic exposure to heavy metals such as lead, cadmium, and mercury,
often through environmental pollution or occupational hazards, may contribute to
hypertension development by promoting oxidative stress and endothelial dysfunction.
Imbalances in gut bacteria, known as dysbiosis, have been associated with hypertension
and related metabolic disorders.

17. Emerging Risk factors
▪ Vitamin D deficiency has also emerged as a potential risk factor for hypertension.
▪ Irregular work schedules and night shifts have been linked to hypertension risk,
likely due to disruptions in sleep patterns, circadian rhythms.
▪ Conditions like depression, anxiety, and chronic stress have been linked to
hypertension, potentially through mechanisms involving dysregulated stress
hormones and unhealthy coping behaviors.
▪ C-reactive protein (CRP) is an emerging biomarker associated with hypertension.
▪ Elevated serum uric acid (s-UA) is common in patients with hypertension.

18. Silent Killer
▪ Most of the patients with hypertension are asymptomatic.
▪ The high BP only noted during an incidental clinical examination.
▪ Small number will present with symptoms such as breathlessness and headache.
▪ A proportion of patients will present with a major preventable complications.
▪ That is why hypertension is called a Silent Killer.

19. Hypertension
Mediated Organ
Damage

20. Hypertension Mediated Organ Damage
Cardiac Complications
▪ Left Ventricular Hypertrophy
▪ Coronary Artery Disease
▪ Heart Failure
▪ Atrial Fibrillation
Cerebrovascular Complications
▪ Transient Ischemic Attack
▪ Stroke
Peripheral Vascular Complications
▪ Limb Ischemia

21. Hypertension Mediated Organ Damage
Renal Complication
▪ GFR <60 ml/min/1.73 m2
▪ Proteinuria (1+ or greater)
▪ Microalbuminuria (2 out of 3
positive tests over a period of 4-6
months)
▪ Dependent (leg) edema
Retinopathy
▪ Hemorrhages or exudates, with
or without papilledema

23. Healthy diet
Dietary Approaches to stop hypertension(DASH)
Emphasizes on: Whole grains, Fruits & vegetables, Polyunsaturated fats, Dairy products
Increase intake of vegetables( leafy green, beetroot etc). Eat ≥ 5 servings of
vegetables/fruit per day.
Use healthy oils, such as soyabean, sunflower, olive, sesame (Til).
Focus on food high in essential elements such as magnesium, calcium and
potassium
Moderate consumption of fish and poultry
Limited intake of red meat
Moderate consumption of coffee, green and black tea
Limits: Foods high in sugar(sweets, cakes, cookies, fizzy drinks, sugar sweetened beverages,
saturated fat, transfat, Alcohol

24. Salt reduction
▪ There is strong evidence for a relationship between high salt intake and increased
blood pressure.
▪ Reduce salt added when preparing foods, and at the table.
▪ Avoid or limit consumption of high salt foods such as soy sauce, fast foods and
processed food including breads and cereals high in salt.
▪ Reducing salt intake to the recommended level of <5 gm /day lowers BP in both
hypertensive and normotensive individuals.

25. Weight reduction
▪ Body weight control is indicated to avoid obesity. Particularly abdominal obesity
should be managed.
▪ A waist-to-height ratio.
▪ Approximately 60–70% of hypertension in adults is attributable to adiposity (excess
body fat). Central body fat, linked to insulin resistance and dyslipidemia, has a more
potent impact on blood pressure elevation than peripheral body fat.
▪ Every 1 kg (2.2 pounds) of weight loss, blood pressure decreases by approximately 1
mm Hg.

26. Regular physical activity
▪ Adults should do at least 150–300 minutes of moderate-
intensity aerobic physical activity; or at least 75–150
minutes of vigorous intensity aerobic physical activity; or an
equivalent combination of moderate-and vigorous-intensity
activity throughout the week, for substantial health
benefits. Examples: Brisk walking, swimming, cycling, or
yoga.
▪ Adults should also do muscle strengthening activities at
moderate or greater intensity that involve all major muscle
groups on 2 or more days a week. Examples: Weightlifting,
resistance exercises, High-Intensity Interval Training (HIIT).

27. Stop Smoking
Smoking is intricately linked to hypertension through
various mechanisms
▪ Nicotine temporarily raises BP by causing
vasoconstriction and increasing heart rate.
▪ Cardon monoxide causes hypoxia, increasing cardiac
workload contributing to elevated BP.
▪ Smoking triggers inflammatory response leading to
endothelial damage and arterial stiffness which are
associated with increased BP.
▪ Studies have shown that quitting smoking leads to a
significant reduction in BP, with some individuals
experiencing normalization of BP levels within a few
weeks to months after cessation.

28. Reduce stress and induce mindfulness
▪ Chronic stress has been associated to high blood pressure
later in life.
▪ Stress leads to the release of hormones that temporarily
increase heart rate and narrow blood vessels, causing a rise
in blood pressure.
▪ Stress Management Strategies:
Adjust your schedule to reduce
stress.
Practice deep, slow breathing
to relax.
Regular exercise (3–5 times a
week for 30 minutes) can lower stress and improve overall
health.

29. Investigation of hypertension

30. Pharmacological
treatment of
hypertension: General
scheme

34. The Therapeutic approach in special situation
Hypertensive urgencies may be treated
in an outpatient facility with oral
antihypertensives; treatment consists of
a slow lowering of BP over 24 to 48
hours. A reduction in BP of no more than
25% within the first 24 hours has been
suggested.

35. Hypertensive Emergency
Hypertensive emergencies require
immediate medical attention, including
admission to the intensive care unit. The
primary goal would be to lower the mean
arterial pressure by no more than 25%
within the first hour, followed by BP
reduction to 160/110-100 mmHg within
the next 2 to 6 hours.

36. Ischemic Stroke

37. Hemorrhagic stroke

38. High blood pressure in patients with diabetes
mellitus/DKD
Diabetic kidney disease (DKD) causes hypertension
in 30-75% of cases of CKD. The presence of
microalbuminuria and later frank proteinuria is the
effect of DKD and responsible for developing
hypertension later. Use of ACEi or ARB are the gold
standard to prevent proteinuria and DKD. The BP
target for hypertension in DKD is ≤120/80 mm Hg
according to KDOQI, ESH and ASH.
The management of blood pressure (BP) in
patients with ESRD treated with dialysis is difficult.
Up to 70-80% of dialysis patients carry a diagnosis
of hypertension. According to the 2004 National
Kidney Foundation Kidney Disease Outcome
Quality Initiative guideline when pre-dialysis BP
is>140/90 or when post dialysis BP is
antihypertensives are required.

39. Hypertension in Coronary Artery Diseases
▪ A strong epidemiological interaction exists between CAD and
hypertension that accounts for 25%–30% of acute myocardial
infarctions.
▪ A recent meta-analysis of RCTs of antihypertensive therapy
showed that for every 10-mmHg reduction in SBP, CAD was
reduced by 17%.
▪ Lifestyle changes are recommended (smoking cessation, diet
and exercise).
▪ BP should be lowered if ≥140/90 mmHg and treated to a target
<130/80 mmHg (<140/80 in elderly patients).
▪ In hypertensive patients with CAD, beta-blockers and RAS
blockers may improve outcomes in post-myocardial infarction
period and reduces the mortality in ACS. In patients with
symptomatic angina, beta-blockers and rate limiting calcium
antagonists are the preferred components of the drug treatment
strategy.

40. Hypertension in Heart Failure
▪ Hypertension is the leading risk factor for the
development of heart failure and most patients
with heart failure will have an antecedent history
of hypertension.
▪ Heart failure guideline-directed medications are
recommended for the treatment of hypertension
in patients with HFrEF. ACE inhibitors, ARBs,
Angiotensin receptor-neprilysin inhibitor (ARNI)
(i.e. sacubitril and valsartan),beta-blockers, and
MRAs (e.g.spironolactone and epleronone) are
all effective in improving clinical outcome in
patients with established HFrEF.

41. Hypertension and Chronic Obstructive Pulmonary
Disease (COPD)
▪ Hypertension is the most frequent comorbidity in
patients with COPD.
▪ BP should be lowered if ≥140/90 mm Hg and
treated to a target <130/80 mm Hg (<140/80 in
elderly patients).
▪ Environmental (air) pollution should be considered
and avoided if possible.
▪ The treatment strategy should include an
angiotensin AT1 -receptor blocker (ARB) and CCB
and/or diuretic, while beta blockers (ß1 -receptor
selective) may be used in selected patients (eg,
CAD, HF).

42. Management of Hypertension in Pregnancy
▪ Mild hypertension: Drug treatment at persistent BP >150/95 mmHg in all women.
Drug treatment at persistent BP >140/90 mmHg in gestational hypertension,
preexisting hypertension with superimposed gestational hypertension; hypertension
with subclinical HMOD at any time during pregnancy.
▪ First choices: methyldopa, beta-blockers (labetalol), and dihydropyridine-calcium
channel blockers (DHP-CCBs) (nifedipine [not capsular], nicardipine).
▪ Severe hypertension: At BP >170 mmHg systolic and/ or >110 mmHg diastolic:
immediate hospitalization is indicated (emergency). Treatment with intravenous
labetalol (alternative intravenous nicardipine, esmolol, hydralazine, urapidil), oral
methyldopa or DHP-CCBs (nifedipine [not capsular] nicardipine). Add magnesium
(hypertensive crisis to prevent eclampsia). In pulmonary edema: nitroglycerin
intravenous infusion.

43. Resistant Hypertension
▪ Resistant hypertension is defined as seated office BP
>140/90 mmHg in a patient treated with three or
more antihypertensive medications at optimal (or
maximally tolerated) doses including a diuretic.
▪ Resistant hypertension is defined as seated office BP
>140/90 mmHg in a patient treated with three or
more antihypertensive medications at optimal (or
maximally tolerated) doses including a diuretic.
▪ Resistant hypertension affects around 10% of
hypertensive individuals

44. Device-Based Therapies
2017 ESH/ESC guidelines state that
various device-based therapies are
available:-
▪ Carotid baroreceptor stimulation
(pacemaker and stent).
▪ Renal denervation.
▪ Creation of an arteriovenous fistula (ie,
ROX coupler)

45. Hypertensive Complication Summary

46. Take Home Message
▪ Hypertension is a very common serious medical condition that increase the risk of
heart, brain, kidney, blood vessel and eye damage.
▪ It is a major cause of preventable premature death.
▪ Adopting a Healthy lifestyle is the key to a healthy heart and mind.
▪ Awareness about risk factors of hypertension & Early intervention is the key to
control hypertension effectively and reduce complication.
▪ Accurate measurement of blood pressure is imperative for the detection and
diagnosis of hypertension.

47. Thank You
IN TINY STEPS WE FIND OUR
WAY, TO KEEP HYPERTENSION
AT BAY, WITH HEALTHY
CHOICES COME WHAT MAY, WE
MANAGE BLOOD PRESSURE
DAY BY DAY

48. References
▪ 2020 International Society of Hypertension Global Hypertension Practice Guidelines
▪ National Guideline on Hypertension 2023
▪ Hypertensive Crisis- (Maria Alexandra Rodriguez, Siva K. Kumar, Matthew De Caro)- Cardiology in Review
2010;18: 102–107

49. LIFESTYLE MODIFICATION ADVICE FOR ALL PATIENTS
▪ Stop all tobacco use, avoid secondhand tobacco smoke.
▪ Stop taking alcohol.
▪ Increase physical activity to equivalent of brisk walk 150 minutes per week.
▪ If overweight, lose weight.
▪ Eat heart-healthy diet:
o Reduce dietary salt intake
o Eat ≥ 5 servings of vegetables/fruit per day.
o Use healthy oils, such as soyabean, sunflower, olive, sesame (Til).
o Eat nuts, peas, whole grains and foods rich in potassium like spinach, watermelon, yogurt and banana.
o Limit red meat to once or twice a week at most.
o Eat fish or other food rich in omega 3 fa�y acids at least twice a week.
o Avoid added sugar from sweets, cakes, cookies, fizzy drinks, sugar sweetened beverages

51. Conditions constituting evidence of EOD
▪ Hypertensive encephalopathy
▪ Intracerebral heamorrhage
▪ Stroke
▪ Head trauma
▪ Ischemic heart disease (most common)
▪ AMI
▪ Acute LVF with P/oedema
▪ Unstable angina
▪ Aortic dissection
▪ Eclampsia
▪ Life threatening arterial bleed

52. Hypertensive
Emergencies

53. 2020 ISH Hypertension Practice
Guidelines
53
ISH 2020 guidelines were
developed
To be used Globally
To be fit for application low and
high resource setting
To be concise, simplified and
easy to use

54. Average Percentage of Reduction
Stroke Incidence 35-40%
Myocardial Infraction 20-25%
Heart Failure 50%
Benefits of Lowering BP

55. Hypertensive
Emergencies