A presentation given at First Health Associates on the basics of hypertension classification.

1. Taking the Hype out of Hypertension

2. Start with going back Back to basics -Anatomy -Physiology -Pathology

3. The Pump

4. The Pump (deconstructed)

6. The Pipes

7. The Delicate Organs

8. Damages - eye

9. Damages - brain

10. Damages - kidney

11. Damages – blood vessels

12. Damages - heart

13. Damages - fingers

14. No one is safe

15. Universal sign – Levine Sign

16. Sometimes obvious Chris Farley

17. Sometimes “silent” Billy Mays

18. Sometimes too late

19. Disease or Symptom? Lets first classify what Hypertension is (High Blood Pressure)…..

20. Who makes the guidelines? US Department of Health and Human Services (gov) NIH National Institute of Health (gov) National Heart Lung and Blood Institute (gov) 1972 Expert Panel to write guidelines (unpaid NHLBI panel) +Internal review panel considers conflict of interest +Methodologist hired to graph Clinical practice guidelines created for px and clinician to develop diagnostic and treatment modalities

21. Current guidelines for: Asthma High cholesterol Overweight and Obesity Von Willebrand’s Disease High Blood Pressure

22. High Blood Pressure Guidelines High Blood Pressure in Children and Adolescents High Blood Pressure Guildelines (JNC7) 2003

23. How long has the JNC been? 1997 JNC6 1992 JNC5 1988 JNC4 1984 JNC3 1980 JNC2 1976 JNC1

24. JNC 6 …….the introduction of new combination antihypertensive medications and new angiotensin II receptor blockers…. oh yeah!!

25. The JNC 7 The 7TH Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure (Evidence based medicine and consensus to make recommendations to clinicians) (Mission to create awareness, prevention, treatment and control of hypertension)

26. Success? According to the National Health and Nutrition Examination Survey (NHANES) II -1976 to 80 and III –1988 to 91 …..awareness went from 51-73% …age adjusted mortality rate from stroke and CHD decreased CDC

27. JNC 6 Optimal BP <120 s <80 d Normal BP <130 s <85 d High NL 130-139 85-89 Hypertension Stage 1 140-159 90-99 Stage 2 160-179 100-109 Stage 3 >180 >110

28. JNC 7 Created because of 1. Publication of many new hypertension observational studies and clinical trials 2. Need for a new, clear and concise guideline that would be useful for clinicians 3. Need to simplify the classification of blood pressure 4. Clear recognition that the JNC reports were not being used for their maximum benefit (the unpublished NHNESP 1999-2000 study showed increase in awareness from 68-70 only) ClaudLenfant, MD Director NHLBI

29. New “stuff” ABPM – ambulatory blood pressure monitoring for white coat hypertension and effective drug therapy White Coat Hypertension mentioned again Initiation of dual therapy from the start of dx http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

30. Drug treatment (when not at goal <140/90 or <130/80 with DM or Chronic Renal Disease) Stage 1 140-159 or 90-99 single med Stage 2 >160 or >100 dual med With compelling indications: Heart Failure Post Myocardial Infarction Diabetes Chronic Renal Disease Recurrent Stroke Prevention

31. Lifestyle changes determine how long the future will last Weight reduction Adopt DASH eating plan Dietary sodium restriction Physical activity Moderation of alcohol consumption

32. Weight Reduction Maintain normal body weight BMI of 18.5-24.9 kg/m2 http://www.nhlbisupport.com/bmi/ 5-20mmHg per 10 kg wt loss

33. DASH diet Consume a diet rich in fruits, vegetables and low fat dairy products with reduced content of saturated and total fats 8-14 mmHg

34. DASH Dietary Approaches to Stop Hypertension Their findings showed that blood pressures were reduced with an eating plan that is low in saturated fat, cholesterol, and total fat and that emphasizes fruits, vegetables, and fat-free or low-fat milk and milk products. This eating plan—known as the DASH eating plan—also includes whole grain products, fish, poultry, and nuts. It is reduced in lean red meat, sweets, added sugars, and sugar-containing beverages compared to the typical American diet.

35. 1st DASH diet trial 459 people with BP’s 160/80-95 3 groups -average American diet -average American diet with fruits and vegetables -DASH diet Blood pressure reductions in two weeks with F&V / DASH (note all diets were with 3000mg sodium restriction per day)

36. The four hospitals Brigham and Women’s Hospital, Boston Duke Hypertension Center and the Sarah Stedman Nutrition and Metabolism Center, Durham Johns Hopkins Medical Institutions, Baltimore Pennington Biomedical Research Center, Baton Rouge http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

37. http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

38. Dietary sodium restriction Reduce dietary sodium intake to no more than 100mmol per day (2.4 gm sodium or 6gm sodium choloride) 2-8mmHg

39. Physical Activity Engage in regular aerobic physical such as brisk walking (at least 30 min per day most days of the week) 4-9mmHg

40. Moderate consumption of alcohol Limit consumption to no more than 2 drinks per day in most men and to no more than 1 drink per day in women and lighter weight persons 2-4mmHg

41. The Saguil Approach Know the JNC7 guidelines Behavioral support/ spirituality/ grounding Think plant based diet, the color of your diet The anti-inflammatory diet, animal protein if there’s room Movement that suits you but think dual purpose, run to compete, climb to get into nature, yoga for spirituality and breath, tai chi for self defense and TCM healing Utilize the insurance but be truthful

42. In a nutshell… Review numbers Compile risk factors Ambulatory blood pressure monitoring at walmart, jewel, target or dominics and record. See with abpm record in 3 months Soft suggestion of lifestyle change Keep safe with meds until 6-12 months (noting all the side effects) Refer to special forces……

43. One size does not fit all Primary care eval risk factor stratification Physical therapy eval to introduce movement Exercise eval to drive motivation Dietary eval diet diary and education Behavior health eval to prepare for withdrawal Specialist eval to prepare for surgery Physical med eval to assess injury/limitation (Ortho, Sports Med, PMR, Chiro, PT, Massage, Reflex, Reiki….)

44. My lifestyle changes:

45. A Heart friendlyactivity!

46. Stress reduction - meditation

47. Relaxation induction The Relaxation Response – Herb Benson blood pressure heart rate respiratory rate temperature

48. You are what you eat!

49. Preventive Medicine Research Institute Approved by medicare for an 18 week program as of summer 2010 Criteria: acute MI within 12 months bypass surgery stable angina heart valve replacement or repair ptcaplasty or stenting heart or heart lung transplant http://www.pmri.org/certified_programs.html

50. Knowledge is power …It’s our responsibility to share this power.

51. Americans are leading the world! (into oblivion)

52. Weapons of mass destruction

53. Save one life, save the world–The Talmud Time to change the world!