فيصل الناصر - Prof faisal hypertension presentation1 4

Hypertension the Silent Killer
Epidemiology
Prof Faisal A Alnasir FRCGP, MICGP, FFPH, PhD
President, Family & Community Medicine Council Arab Board
Chairman, Department of Family & Community Medicine
Arabian Gulf University

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Hypertension
• Common
• Non Communicable disease
• Inevitable
• Preventable
• Serious complication

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WHO estimated that high blood pressure
causes one in every eight deaths, making
hypertension the third leading killer in the world.
Globally, there are one billion hypertensives and
four million people die annually as a direct result
of it.
Hussein A. Gezairy
Regional Director for the Eastern Mediterranean

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Size of the problem
1-World wide
• In 2010, 1.2 billion people were expected to be suffering from
hypertension worldwide
Sixth report of the Joint National Committee on prevention,1997
• Expected to increase to 1.56 billion by 2025
International Society of Hypertension
• Its prevalence from 20% to 30% of the adult population.
Alwan A 1993
• Incidence In USA between 14% to 40% in 35 to 64 years.
WHO 2002
• Prevalence in Canada 17.3%. Most patients had untreated
hypertension (68.6%), and only 15.8% had blood pressure
treated and controlled.

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Size of the problem
2-In the Eastern Mediterranean Region
• The average prevalence of hypertension 26% and it affects
approximately 125 million individuals.
• Each year, there are several million new cases of
hypertension and more of pre-hypertension
Report on the regional consultation on hypertension
UAE, 2003

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Size of the problem
In Bahrain
National Non-communicable Diseases Risk Factors Survey 2007

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Size of the problem
In Bahrain

In Lebanon
•23.1% are hypertensive
•Prevalence increases with age
•Occurs more in the less educated and unemployed
•Prevalence increases significantly with an increase in
body mass index particularly in female patients
•Only14.7% exercised daily
R A Tohme, A R Jurjus, A Estephan 2005

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Size of the problem
In Saudi Arabia:
The prevalence range from 4% to 15%.
Abolfotouh MA et al.
It may reach as high as 20.4% for systolic hypertension and
25.9% for diastolic hypertension.
Al-Nozha MM et al.
In south-western 11.1%.
Abolfotouh MA et al.
In Jeddah, the hypertensive were 22.6%.
Elkalifa Am et al.2011
In the UAE:
Hypertension has become one of the leading public health
problems

In Sudan
 of 6-12y children:
4.9% were pre-hypertensive and
4.9% were hypertensive
Salman Z, et al 2010

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Size of the problem
It has been estimated that individuals who are
normotensive at the age 55 years have a 90%
lifetime risk for developing hypertension.
EMR0 Technical Publications
Blood pressure is under control in less than 20% of
patients with hypertension in many countries
A joint CINDI/EuroPharm Forum project WHO

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Awareness of Hypertension
Although the prevalence of high blood pressure is high,
there is a low awareness rate (Up To 70% are unaware)
Alwan A1993

Faisal Alnasir, 2004

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In Egypt only 37.5% of hypertensives were aware of
Having it.
In United States, Chile, and Cub, 32%, 37%, and 39%
of the people were not aware.
Pan American Health

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Advantage of Controlling Hypertension
•A 5-6 mmHg reduction in diastolic BP reduces stroke by 40%.
Joint National Committee on Detection, 1992
•lowering by 5-6mmHg can reduce mortality from cerebrovascular
disease by 35%-40%, from ischemic heart disease by 15% 20%
and reduction in all deaths from cardiovascular causes by 23%.
Psaty, et al 1997
• 3 mmHg decrease in systolic BP reduces annual mortality
from stroke, coronary heart diseases and all other causes by 8%,
5% and 4%.
Whelton PK, 1994
•The chances of mortality from CVD in old hypertensive people
when taking anti hypertensive medications is decreased by 34%.
MacMahon, 1993

Advantage of Controlling Hypertension
The first long-term data from a high-blood-
pressure study, the Systolic Hypertension in the
Elderly Program (SHEP), show that each month
of chlorthalidone-based therapy was associated
with approximately one day of extension in life,
free from cardiovascular death.
The main findings are that after 22 years of
follow-up, when about 60% of the participants in
SHEP were dead, we saw a prolonged life
expectancy in those who took the active
treatment for 4.5 years.
Dr John B Kostis Journal of the American Medical Association 2011

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Economic Impact
The economic burden of chronic NCDs can
be analyzed on two levels.
•First, the effects of macroeconomic policies on
opportunities for prevention in different
population groups
•Second, the cost and overall efficiency of
interventions must be evaluated in terms of
effectiveness and health gains for the
population at large.

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Economic Impact
Direct Cost:
Including prescribing medicines, inpatient visits,
outpatient visits, emergency room visits, office-
based medical provider visits, home health
visits, and other medical expenses
Sanjeev Balu, 2001
Indirect Cost:
Productivity loss ($300 per eligible employee per year)
absence & short term disability
Goetzel (2004), the only study in the U.S.

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Economic Impact
•Poor are disproportionately affected
•more vulnerable
•Prevalence 6 time more in uneducated
•Medication cost up to US$ 100 per month
•further poverty
•Cost to Health Services
•USA total cost of CVD is 2% of the gross
domestic product
• direct medical costs estimated at nearly $55.0
billion for the year 2001
Sanjeev Balu, 2001
•Canada 21% of all diseases costs are due to
CVD (US$12 billion/Year) direct cost is $3,072
per person per year, and indirect cost is $854
Guijing Wang,2008

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Economic Impact
In Alkhobar the total direct cost of hypertension
care for patients registered in the primary health
care represented 6.32% of the estimated cost of
treating the expected number of patients.
Al-Shahri 1998

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Prevention
Primary prevention is the most cost-effective
approach to containing the emerging
hypertension epidemic.
Hussein AlGezairy
Regional Director for WHO

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Prevention
Incidence of hypertension was reduced by 20% to
50% if primary prevention were implemented
Stamler 1991
For the developing countries prevention of
hypertension should be the goal.

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Prevention
Life style Modification:
•perform aerobic exercise
•maintain a healthy body weight
•follow a healthy diet
•restrict salt intake
•stress management
•limit alcohol consumption

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Modification Recommendation Approximate systolic BP
reduction
Weight reduction Maintenance of normal body weight 5–20 mmHg/10 kg
healthy eating plan Consumption a diet rich in
vegetables, fruits, and
low-fat dairy products with a
reduced content of saturated and
total fat
8–14 mm Hg
Dietary sodium Reduction dietary sodium intake to
no more than
2.4 g sodium
2–8 mmHg
Physical activity Engagement in regular aerobic
physical activity at least 30
minutes daily, most days of the
week
4–9mmHg
Recommended lifestyle modifications

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Life style Modification
• Weight reduction
Every 1 kilogram of weight loss lower blood pressure by
1.6/1.1 mmHg
Khatib et al. EMR0 Technical Publications

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Prevalence of overweight and obesity among
some countries of the Eastern Mediterranean
Region (WHO.2004)
Country Overweight/obesity (%)
Males Females
Saudi Arabia 64.0 70.0
Lebanon 60.0 53.0
Islamic Republic of Iran 57.0 67.7
Bahrain 56.4 79.0
Jordan 46.0 43.7
Egypt 43.8 41.0
Libyan Arab Jamahiriya 42.5 74.9
Oman 40.5 43.5
Morocco 37.2 21.7
United Arab Emirates 25.5 39.9
Tunisia 13.1 41.9
Kuwait 79 56

In Bahrain

In Sudan
 of 6-12y children:
45 (14.8%) were overweight; 32 (10.5%)
were obese
Salman Z et al 2010

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• Eating habits

33
• Physical activity
Exercise lowers systolic and diastolic blood pressure by 5-10
mmHg
Arakawa

34

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• Sodium moderation
Reducing dietary sodium intake to no more than 100 mEq/L
(2.4g sodium or 6 g sodium chloride), reduces the blood
pressure by an average of 4–6 mmHg.
Khatib et al. EMR0 Technical Publications

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• Diabetes
(In Bahrain)

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• Diabetes
(In Bahrain)

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• Tobacco
(In Bahrain)

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• Lipids
(In Bahrain)

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• Cocoa ingestion
100g/day of chocolate
drink reduces the systolic BP and
diastolic BP
Taubert et al 2007

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Blood Pressure Pooled Change (mm Hg) P
Cocoa
Systolic -4.7 .002
Diastolic -2.8 .006
Tea
Systolic 0.4 .63
Diastolic -0.6 .38
Change in Blood Pressure reduction
between cocoa & Tea
Taubert et al 2007

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between cocoa & Tea
Taubert et al 2007
“The magnitude of the hypotensive effects of
cocoa is in the range that is usually achieved
with monotherapy of β-blockers or
angiotensin-converting enzyme inhibitors”

Chocolate and Coronary Heart Disease: A Systematic Review
This article reviews current evidence on the effects of cocoa/chocolate on
clinical and subclinical coronary heart disease (CHD), CHD risk factors,
and potential biologic mechanisms.
 The high content of polyphenols and flavonoids present in cocoa has
been reported to play an important protective role in the development of
CHD.
 Although studies have demonstrated beneficial effects of chocolate on
endothelial function, blood pressure, serum lipids, insulin resistance, and
platelet function, it is unclear whether chocolate consumption influences
the risk of CHD.
Khawaja O et al Current Atherosclerosis Reports, Volume 13 / September 2011

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Measurement of Blood Pressure
The "white-coat" effect
Prevalence of white coat hypertension
was 3.6% overall and 12.8% in
hypertensive patients.
Marquez Contreras et al. 2006

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Hypertension Control
Very poor control of hypertension world wide
•In Egypt 23.9% were receiving treatment & 8%
controlled
Ibrahim et al.
•In Canada 15.8% had blood pressure treated and
controlled
Petrella et al, 2007
•In Saudi Arabia, 76 % were receiving treatment, but only
20% were found controlled
Abolfotouh et al,

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•Seated in a quiet room
•Arm muscles relaxed
•Cubital fossa at heart level
•Avoid tight sleeves
•Suitable size Cuff to be used
•Repeat if BP > 140/90
•Measurement on both arms
•Mercury sphygmomanometers are most reliable
Goodman and Gilman's1993

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Management
Good management of hypertension is central to any
strategy formulated to control hypertension at the
community level. Randomized trials of drugs that
lower and control blood pressure clearly show a
reduction in mortality and morbidity.
Hussein A. Gezairy
Regional Director for the Eastern Mediterranean

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Management
2 mmHg reduction in systolic blood pressure
is likely to reduce the annual mortality from
stroke, coronary heart disease and all other
causes by 6%, 4% and 3%, respectively

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Conclusion
Hypertension is a serious problem that could
be called "the silent killer". Its prevalence is
very high especially in the GCC countries.
Effective efforts ought to be taken in order to
prevent, prevent, prevent, prevent
then diagnose and treat it.

A Wife is a Wife,
no matter who
THE HELL
you are!!

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Recommended Classification of Hypertension

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Classification of Hypertension
Normal blood pressure for adults is defined as
systolic blood pressure below 140 mmHg and
diastolic blood pressure below 90 mmHg
Protocol and Guidelines A joint CINDI/EuroPharm Forum project WHO
• Mild
• Moderate
• Severe

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Category Systolic BP (mmHg) Diastolic BP (mmHg)
Optimal < 120 < 80
Normal < 130 < 85
High-normal 130–139 85–89
Grade 1 hypertension (mild) 140–159 90–99
Subgroup: borderline 140–149 90–94
Grade 2 hypertension (moderate) 160–179 100–109
Grade 3 hypertension (severe) ≥ 180 ≥ 110
Isolated systolic hypertension ≥ 140 < 90
Subgroup: borderline 140–149 < 90
Operational classification of
hypertension by blood pressure level
European Society of Hypertension 2003

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EMR0 Technical Publications Series 29 Clinical guidelines
BP
classification
Systolic BP
(mmHg)
Diastolic BP
(mmHg)
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1
hypertension
140–159 or 90–99
Stage 2
hypertension
≥160 or ≥100
classification that is suggested by the
EMRO for adult aged > 18 years

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Classification according to the extent of
organ damage
•hypertension with no other cardiovascular risk
factors and no target organ damage
•hypertension with other cardiovascular risk
factors
•hypertension with evidence of target organ
damage
•hypertension with other cardiovascular risk
factors and evidence of target organ damage.
Ala Din Alwan WHO, 1996, CINDI/EUROPHARM Forum WHO

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Clinical assessment of people with hypertension
Objectives
•to confirm a persistent elevation of blood pressure
•to assess the overall cardiovascular risk
•to evaluate existing organ damage or concomitant
disease
•to search for possible causes of the hypertension

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Causes of hypertension
•Primary hypertension (95% of cases)
•Secondary hypertension
*Renal
*Drugs
*Endocrine
*Coarctation of the aorta and aortitis
*Pregnancy-induced hypertension

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The possibility of secondary
hypertension
•young age
•family history of renal disease
•evidence of renal disease
•hypertension due to drugs
•episodes of sweating, headache, anxiety
(phaeochromocytoma)
•episodes of muscle weakness and tetany
(hyperaldosteronism(

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Laboratory investigations
•urine analysis
•plasma creatinine and/or blood urea nitrogen
•plasma potassium
•random blood glucose
•serum cholesterol
•heamatocrit
•electrocardiogram.
•lipids
lipoprotein cholesterol
•plasma uric acid
•chest X-ray
•echocardiography.

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High BP: DBP≥90 and/or
SBP≥ 140 mmHg
Hypertension confirmed Hypertension not confirmed
SBP 140-180 mmHg DBP 90-105 mmHgBP <140/90
Low CV risk
High CV risk
DBP 90-95 mm Hg
SBP 140-160 mmHg
DBP ≥95 mmHg
SBP ≥160 mmHg
Repeated measurements
General assessment and evaluation of Check again in
CV risk and nonpharmacological six months
Therapy for 4 weeks*
Reinforce nonpharmacological
Therapy for 3-6 months
Follow up Follow up Start drug therapy Start drug therapy
Guidelines for the diagnosis and management of hypertension

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Exercise lowers systolic and diastolic blood pressure by 5-10
mmHg
Arakawa

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Of course being a doctor

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Economic Impact
“Since hypertension is associated with
cardiovascular disease and diabetes, its
management and control is potentially
costly".
Dr Hussein AlGezairy regional director, WHO

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Hypertension the Silent Killer
Prof Faisal A Alnasir FRCGP,MICGP,Phd
President, Family & Community Medicine Council Arab Board
Arabian Gulf University
Qatar Primary Health Care-2008
1st International Conference, in Partnership with the WHO

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between cocoa & Tea

فيصل الناصر - Prof faisal hypertension presentation1 4

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