Hypertension, Blood pressure, Systolic Hypertension, Diastolic Hypertension, Epidemiology, Classification of hypertention, Type of hypertension, aetiology of hypertension, Clinical features, complications of hypertension, ambulatory blood pressure monitoring, Resistant hypertension, anti hypertensives,
Circulatory Shock, types and stages, compensatory mechanisms
Epidemiology , diagnosis and treatment of Hypertension
1. HYPERTENSIONHYPERTENSION
AND ITSAND ITS
MANAGEMENTMANAGEMENT
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP,
FSCAI, FAPSC, FAPSIC, FAHA
Associate Professor of Cardiology
National Institute of Cardiovascular
Diseases
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova,
Malbagh branch.
2. Hypertension
A World Wide Epidemic
Nearly 1 billion hypertensive in the world
Hypertension is poorly controlled, with less than
25% controlled in developed countries and less
than 10% in developing countries.
Hypertension which is responsible for 3 million
death annually.
May 14th
is World Hypertension Day
4. Hypertension is a hemodynamic disorder
A well accepted definition of hypertension was
suggested by Evans and Rose:
“Hypertension should be defined in the terms of blood
pressure level above which investigation and treatment
do good more than harm”
A patient is said to be hypertensive when his SBP≥
140 mm Hg & DBP ≥ 90 mm Hg provided that the
patient is not on antihypertensive drugs.
Hypertension: DefinitionHypertension: Definition
5. Varieties OF HTNVarieties OF HTN
Labile HTN
Isolated diastolic hypertension
Isolated systolic hypertension
Malignant or accelerated Hypertension
Refractory/ Resistant hypertension
Hypertensive emergencies/ urgencies
6. Classification of BP for AdultsClassification of BP for Adults
JNC-VI;1997JNC-VI;1997
BP Classification Systolic BP Diastolic BP
Optimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT 160-179 or 100-109
Stage 3 HT ≥ 180 or ≥ 110
BP Classification Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT ≥ 160 or ≥ 100
JNC-VII;2003JNC-VII;2003
7. Classification of BP LevelsClassification of BP Levels
ESH-ESC Guidelines, 2003
BP Classification
Optimal
Normal
High Normal
Grade 1 HT (mild)
Grade 2 HT (moderate)
Grade 3 (severe)
Isolated systolic HT
Systolic BP
<120
120-129
130-139
140-159
160-179
>180
>140
Diastolic BP
<80
80-84
85-89
90-99
100-109
>110
<90
9. Haemodynamic Pattern inHaemodynamic Pattern in
HypertensionHypertension
Young : ↑ BP = ↑CO X TPR
Middle Aged : ↑ BP = CO X TPR
Elderly : ↑ BP = ↓ CO X ↑ ↑ TPR
10. Aetiology of SystemicAetiology of Systemic
HypertensionHypertension
A) Essential or Primary HTN (95%)
A. ↑ Age
B. Genetic • Both parents (45%)
• Single (25%)
C. Environment • Diet Fat
Salt
alcohol
• Obesity
• Physical inactivity
• Stress
• Smoking
D. Hormonal
12. C) Others
Coarctation of the aorta
Pregnancy Induced HTN (Pre-eclampsia)
Sleep Apnea Syndrome.
Aetiology of SystemicAetiology of Systemic
HypertensionHypertension
13. Clinical ManifestationClinical Manifestation
• Asymptomatic in the majority of patients. Can
remain undetected for many years
• Headache may occur when SBP rises above
200mmHg or when blood pressure is rapidly
elevated.
14. Measuring Blood PressureMeasuring Blood Pressure
• Patient seated quietly for at least
5minutes in a chair, with feet on the
floor and arm supported at heart level
•An appropriate-sized cuff (cuff bladder encircling at
least 80% of the arm)
•At least 2 measurements
Continue…
15. Measuring Blood PressureMeasuring Blood Pressure
• Systolic Blood Pressure is the point at which the
first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…
16. Measuring Blood PressureMeasuring Blood Pressure
• Ambulatory BP Monitoring - information about BP
during daily activities and sleep.
• Correlates better than office measurements with
target-organ injury.
Continue…
18. The scope of the problemThe scope of the problem
– Heart Attack (MI)
– Heart Failure
– Stroke
– Kidney Disease
THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO
MINIMISE CARDIOVASCULAR RISK AND DAMAGE
TO TARGET ORGANS
19. Hypertension even today is aHypertension even today is a
triple paradox which is :triple paradox which is :
Easy to diagnose OFTEN remains undetected
Simple to treat OFTEN remains untreated
Despite availability of potent drugs, treatment
all too OFTEN is ineffective
20. The "Rule of Halves" inThe "Rule of Halves" in
HypertensionHypertension
Only 1/2 have been
diagnosed
Only 1/2 of those
diagnosed have been
treated
Only 1/2 of those treated
are adequately controlled
Only 12.5% overall are adequately controlled
Not
diagnosed
Not treated
Not
controlled
Controlled
21. Evaluation of hypertensive patientsEvaluation of hypertensive patients
Objectives:
To know accurate and representative
measurement of BP
To identity any known cause of Hypertension
To assess presence or absence of TOD
To assess response to therapy
To identity cardiovascular risks factor
To know concomitant disorders
Continue….
22. Evaluation of hypertensive patientsEvaluation of hypertensive patients
Evaluation by
Medical history
Physical Examination
Laboratory investigation
Routine tests
Optional tests.
23. Effects of Antihypertensive Drug Treatment onEffects of Antihypertensive Drug Treatment on
CV Mortality and MorbidityCV Mortality and Morbidity
Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated
compared to control
Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478
-52%
-38%
-35%
-25%
-16%
-60%
-50%
-40%
-30%
-20%
-10%
0%
CHF Strokes
(fatal/nonfatal)
LVF CVD Deaths CVD events
(fatal/nonfatal
Management of HTNManagement of HTN
24. 140
120
100
80
60
40
20
0
50
40
30
20
10
0
Historical Lessons About HypertensionHistorical Lessons About Hypertension
Hypertension
Increases Morbidity
and Mortality
Men Women
CHDIncidenceRate/1000
personsperyear
THE FRAMINGHAM STUDY
Cumulativefatal&
NonfatalEndpoints
Treatment Decreases
Morbidity and
Mortality
Men Women Placebo Active
Treatment
THE VET.ADM. STUDY II
Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152
Normotension
Hypertension
25. Implication of reduction in Diastolic BP forImplication of reduction in Diastolic BP for
Primary PreventionPrimary Prevention
30
20
%Reduction
Change in DBP
0
-10
-20
-30
-40
-50
7.5 mm Hg 5-6 mm Hg 2 mm Hg
-21
-46
-16
-38
-6
-15
CHD
Stroke
Cook, et al. Arch Int med. 1995; 155:711-109
26. Millimeters Matter……Millimeters Matter……
“ A 2-mm Hg reduction in DBP would
result in…
a 6% reduction in the risk of CHD and a 15%
reduction
in the risk of stroke and TIAs”
Cook, et al. Arch Int med. 1995; 155:711-109
27. Impact of High Normal BP on CVImpact of High Normal BP on CV
Disease Risk in MenDisease Risk in Men
High Normal
130-139/ 85-89 mm Hg
Normal
120-129/ 80-84 mm Hg
Optimal
<120/ 80 mm Hg
CumulativeIncidence(%)
Time (Years) N Engl J Med. 2001;345:1291-97
28. Benefits of Lowering BPBenefits of Lowering BP
Average percent
reduction
Stroke reduction 35-40%
Myocardial infarction 20-25%
Heart failure 50%
29. Goals of TherapyGoals of Therapy
• Reduction of cardiovascular and renal
morbidity and mortality. 1
• The primary focus should be on achieving the systolic
BP goal.
• Systolic BP and diastolic BP to targets < 140/90
mmHg = decrease in CVD complications.
• In patients with hypertension with diabetes or renal
disease, the BP goal is < 130/80 mmHg 1
1
JNC - VII Report, JAMA , 2003;289:2560-2572
30. JNC VII Algorithm for Treatment of
Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle
Modifications
Not at Goal BP
(< 140/90 mmHg or < 130/80 mmHg
for Those with Diabetes or Chronic
Kidney Disease
Initial Drug Choices
31. Lifestyle Modification: 1Lifestyle Modification: 1
⇒ Socioeconomic condition in the world suggest that
prevention through Lifestyle Modifications is the
universal “vaccine” against Hypertension
⇒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
33. Lifestyle Modification: 3Lifestyle Modification: 3
⇒Smoking Cessation
•Any independent chronic effect of smoking on BP is small
•Smoking cessation does not decrease BP
•BUT total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke
should be counselled on smoking
cessation
36. JNC VII Algorithm for
Treatment of Hypertension
Hypertension without
compelling indications
Hypertension with
compelling indication
(Systolic Bp 140-159
mmHg
or Diastolic BP 90-99
mmHg)
Thiazide-Type
Diuretics for Most
May Consider ACE
inhibitor, ARB, ß-
blocker, CCB or
combination
Systolic Bp >160
mmHg
or Diastolic BP > 100
mmHg)
2- Drug Combination
for Most
(Usually Thiazide -
Type Diuretic and
ACE Inhibitor or ARB
or ß-blocker, CCB)
Drug (s) for the
Compelling
Indications
Other
Anithypertensive
Drugs
(Diuretics, ACE
inhibitor, ARB, ß-
blocker, CCB) as
Initial Drug Choices
37. ChoiceChoice of antihypertensiveof antihypertensive
• Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors,
angiotensin receptor antagonists) are suitable for the initiation and
maintenance of therapy
• Choice:
→ Previous experience of the patient
→ Cost
→ Risk profile, target organ damage, clinical cardiovascular or renal
disease or diabetes or lung disorder
→ Patient’s preference
• Long acting preparations providing 24-h efficacy on a once daily
basis
(2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).
38. Special ConsiderationsSpecial Considerations
Guideline Basis for Compelling Indications for
Individual Drug Classes
High Risk Conditions
With Compelling
Indication
Heart failure
Post-myocardial
infarction
High coronary disease
risk
Diabetes
Chronic Kidney Disease
Recurrent stroke
prevention
Recommended Drugs
Diuretic β-blocker ACE inhibitor ARB CCB Aldosterone Antagonist
JNC - VII Report, JAMA , 2003;289:2560-2572
40. Possible Combination ofPossible Combination of
Antihypertensive AgentsAntihypertensive Agents
Diuretics
Beta
Blocker
∝-Blocker
ACE inhibitor
CCBs
ARBs
EHS-ESC Guidelines, 2003;
41. Indications and Contraindications forIndications and Contraindications for
the Major Classes of Antihypertensiuethe Major Classes of Antihypertensiue
DrugsDrugs
Class Conditions favouring
the use
Compelling
contraindications
Possible
contraindications
ACEIs CHF
LV dysfunction
Post-MI
Nondiabetic nephropathy
Type 1 diabetic nephropathy
Protienuria
Pregnancy
Hyperkalaemia
Bilateral RAS
ARBs Type 2 diabetic nephropathy
Diabetic microalbuminuria
Proteinuria
LVH
ACE inhibitor cough
Pregnancy
Hyperkalaemia
Bilateral RAS
a-Blockers Prostatic hyperplasia (BPH)
Hyperlipidaemia
Orthostatic
hypotension
CHF
EHS-ESC Guidelines, 2003;
42. EVOLUTION OF HYPERTENSIONEVOLUTION OF HYPERTENSION
MANAGEMENTMANAGEMENT
JNC I
1977
JNC II
1980
JNC III
1984
JNC IV
1988
JNC V
1993
JNC VI
1997
JNC VII
2003
High
Dose
diuretic
High
Dose
diuretic
Lower
Dose
diuretic
Or
β-blocker
Lower
Dose
diuretic
Or
β-blocker
Or
ACEI
Or
CCB
Lower
Dose
diuretic
Or
β-blocker
Or
ACEI
Or
CCB
α-blocker
Or
α / β blocker
•
Individulised
Therapy
•Single-agent
titration
preferred
•Loe-dose
combo
therapy as a
secondary
option
•Focus on
Systolic
BP Control
•Thiazide-
type
diuretics
preferred
as initial
drug
treatment
•Emphasis
on
combinatio
n therapy
High-dose Monotherapy Low-dose Combination
43. Management of HTN in SpecialManagement of HTN in Special
SituationSituation
1. Hypertension Crises
Hypertension Emergencies
Hypertension Urgencies
2. Refractory/ Resistant hypertension
3. HTN in Pregnancy
4. HTN with coexisting Cardiovascular & other disorders
4. Management of Secondary HTN
44. Resistant Hypertension
• Not uncommon : 15-20%
• Persistence of elevated systo-diastolic pressure in
spite of at 3 anti-hypertensive drugs ( including
diuretics)
• Pre-requisites: Exclusion of pseudo-hypertension;
white-coat hypertension,use of not-appropriate
cuffs.
46. Therapeutic intervention
• Exclude undiagnosed secondary
hypertension
• Compliance of drugs
• Adherence to life style changes
• Consider use of 3 or more anti-hypertensive
drugs
• Consider the use of drugs such as
spironolactone
47. Failure of reduction of DBP<90 mm Hg
despite the use of three or more drugs
which include a diuretic
Resistant hypertension
Braunwald’s Heart Disease, 2005
48. Volume overload & pseudotolerance
“White coat”
Pseudohypertension in the elderly
Excess sodium intake
Inadequate diuretic therapy
Volume retention
Drug related
Dosage too low
Inappropriate combination
Drug interaction
Associated conditions
Smoking
Obesity
Excess alcohol
Sleep apnea
Secondary hypertension
Resistant hypertension
Causes:
Braunwald’s Heart Disease, 2005
49. Current recommendations for primary
prevention of hypertension involve:
a population based approach, and
an intensive targeted strategy focused on
individuals at high risk for hypertension.
Primary Prevention of Hypertension
Hypertension Primer, AHA, 2004
50. Conclusion
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from
the deleterious effect
• Pharmacological armament of antihypertensive drugs so
rich that we have wide range of options. And this makes
the physicians comfortable in varied situations.
Conversely one needs to be judicious regarding the
choice of the drug
• Besides pharmacology we have other choices and one
has to be acquainted with that choice
• Primary prevention of hypertension should be highlighted
and it should get more priority than it is getting now.
51. Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in developing
countries
Early diagnosis & management can prevent end organ damage from HTN
Target goal of BP in hypertensive patients:-
< 140/90 mm Hg
< 130/80 mm Hg for patients with DM & renal disease
Lifestyle modification is the universal “Vaccine” against Hypertension
ConclusionConclusion
Good morning ladies and gentlemen, it is my pleasure to be able to present and discuss with you this morning in such a prestigious international meeting.
My presentation on Hypertension shall include the following aspects.
I
Definition of hypertension
The scope of the problem
Systolic & Diastolic blood pressure
Aetiology
Clinical Manifestation
End Organ Damage
Guidelines
Blood pressure measurement
Goals of therapy
Lifestyle modifications
Pharmacological treatment
Hypertension can be defined as persistently high arterial blood pressure
The continuous relationship between the level of blood pressure and cardiovascular risk makes any numerical definition and classification of hypertension arbitrary and in fact whenever guidelines are updated we see a change in the numerical definition.
But what is the problem with hypertension?
Looking at both guidelines and their current classification of blood pressure:
We can see that were as less than 120 / 80 is considered optimal for the ESH it is considered normal for JNC7. But both agree that blood pressure should ideally be less than 120/80 mmHg
ISH is currently defined as a SBP of 140mmHg with a DBP 90mmHg. High SBP especially affects elderly subjects.
Looking at both guidelines and their current classification of blood pressure:
We can see that were as less than 120 / 80 is considered optimal for the ESH it is considered normal for JNC7. But both agree that blood pressure should ideally be less than 120/80 mmHg
ISH is currently defined as a SBP of 140mmHg with a DBP 90mmHg. High SBP especially affects elderly subjects.
What is the clinical manifestation of hypertension?
Actually hypertension is asymptomatic in the majority of patients and can remain undetected for many years.
Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated, as in malignant hypertension
To measure a patient’s blood pressure, the patient should be seated quietly for at least 5minutes in a chair rather than on an examination table, with feet on the floor and arm supported at heart level
A sphygmomanometer with an appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) should be used to ensure accuracy
At least 2 measurements should be made
Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard
Diastolic Blood Pressure is the point before the disappearance of the sounds
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
High blood pressure is the most common reason for attendance at medical clinics in Europe and US.
The higher the BP, the greater the risk of :
Heart Attack (MI)
Heart Failure
Stroke
Kidney Disease
So lets take a look at the two blood pressure readings we need to consider.
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
Ambulatory BP Monitoring provides information about BP during daily activities and sleep. This monitoring correlates better than office measurements with target-organ injury.
What do we doctors or doctors base ourselves on when tackling hypertensive patients?
The ultimate public health goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality 1
The primary focus should be on achieving the systolic BP goal. Treating systolic BP and diastolic BP to targets that are less than 140/90 mmHg is associated with a decrease in CVD complications. In patients with hypertension with diabetes or renal disease, the BP goal is less than 130/80 mmHg 1
According to the JNC7 one should start with lifestyle modifications. If the blood pressure is not less than 140 on 90 mmHg or 130 on 80mmHg for patients with diabetes or chroinc kidney disease, than drug treatment should be started.
Life style modifications as we have seen are a necessity in order to correct one’s blood pressure whether alone or in combination with drug treatment.
The following are important lifestyle modifications: weight reduction and a correct eating plan reducing saturated and total fat
Dietary sodium reduction and regular physical activity of 30 minutes a day most days of the week.
Any independent chronic effect of smoking on BP is small and smoking cessation does not decrease BP but total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke should be counseled on smoking cessation
When it comes to the choice of an antihypertensive, the ESH state that: the major classes of antihypertensive agents (diuretics, beta-blockers, calcium antagonists, ACE-inhibitors, angiotensin receptor antagonists) are suitable for the initiation and maintenance of therapy
The choice of drugs will be influenced by many factors, including:
previous experience of the patient with antihypertensive agents
cost of drugs (not to predominate over individual efficacy&tolerability)
risk profile, target organ damage, clinical cardiovascular or renal disease or diabetes
patient’s preference
They specifically recommend the use of long acting preparations providing 24-h efficacy on a once daily basis
Here we can see the main classes with there compelling indications. The only class which has heart failure, post-MI, high coronary disease risk, diabetes, chronic kidney disease and recrrent stroke prevention all as compelling indications is the ACE inhibitor class.
In conclusion ladies and gentlemen, we have seen that...
Although hypertension is asymptomatic, early diagnosis is essential to minimise cariovascular risk and end organ damage.
We should aim at achieving a BP of less than 140 over 90 mmHg to decrease cardiovascular complications and less than 130 over 80 for patients with diabetes or renal disease.
Hence emerges the important role of the doctor.