Transcript Hypertension was defined as a blood pressure ≥140/90 mmHg

hypertension is the most common reason for
office visits of non-pregnant adults to
physicians in the United States and for use of
prescription drugs.
Despite the prevalence of hypertension and its
associated complications, control of the
disease is far from adequate .
Data from NHANES show that only 45 percent
of persons with hypertension have their
blood pressure under control, defined as a
level below 140/90 mmHg
DEFINITIONS
Hypertension was defined as a blood pressure ≥140/90 mmHg
Normal BP: systolic <120 mmHg and diastolic <80
Prehypertension: systolic 120-139 mmHg or diastolic 80-89
Hypertension:
Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg
Stage 2: systolic ≥160 or diastolic ≥100 mmHg
Isolated systolic hypertension
isolated diastolic hypertension
These definitions apply to adults on no
antihypertensive medications and who are not
acutely ill.
If there is a disparity in category between the
systolic and diastolic pressures, the higher
value determines the severity of the
hypertension.
ESSENTIAL (PRIMARY) HYPERTENSION
Pathogenesis — is poorly understood. ;
Increased sympathetic neural activity, with enhanced betaadrenergic responsiveness.
Increased angiotensin II activity and mineralocorticoid excess.
Hypertension is about twice as common in subjects who have one
or two hypertensive parents
genetic factors account for approximately 30 percent of the
variation in blood pressure in various populations
Reduced adult nephron mass may predispose to hypertension,
which may be related to genetic factors, intrauterine
developmental disturbance (eg, hypoxia, drugs, nutritional
deficiency)
RISK FACTORS:
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Race
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salt intake :increased salt intake is a necessary but
not sufficient cause for hypertension.

excess alcohol intake

Obesity is associated with an increased prevalence
and incidence of hypertension
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Physical inactivity
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Dyslipidemia : may also be associated with the
development of hypertension, and is independent of
obesity
COMPLICATIONS —The likelihood of developing the
complications varies with the blood pressure. The
increase in risk begins as the blood pressure rises
above 110/75 mmHg in all age groups.
In older patients, systolic pressure and perhaps pulse
pressure are more powerful determinants of risk than
diastolic pressure .
SCREENING
The optimal interval for screening for hypertension is not
known.
guidelines on screening for high blood pressure
recommend screening every two years for persons with
systolic and diastolic pressures below 120 mmHg and 80
mmHg, respectively
and yearly for persons with a systolic pressure of 120 to
139 mmHg or a diastolic pressure of 80 to 89 mmHg
DX
In the absence of end-organ damage, the diagnosis of
mild hypertension should not be made until the blood
pressure has been measured on at least three to six
visits, spaced over a period of weeks to months.
the blood pressure drops by an average of 10 to 15
mmHg between visits one and three in patients who
appear to have mild hypertension on a first visit to a
new doctor, with a stable value not being achieved
until more than six visits in some cases
Thus, many patients considered to be hypertensive at
the initial visit are in fact normotensive.
Technique of blood pressure
measurement in the
diagnosis of hypertension
Correct measurement and interpretation of
the blood pressure is essential in the
diagnosis and management of hypertension.
Proper BP machine calibration, training of
personnel, positioning of patient, and
selection of cuff size are all essential.
TIME OF MEASUREMENT
— For the diagnosis of
hypertension, multiple readings should be taken at various times.
Extraneous variables that can influence the BP should be avoided
in the 60 minutes prior to evaluation. These include food intake,
strenuous exercise ,smoking, and the ingestion of caffeine.
Smoking transiently raises the BP; thus, the office BP may
underestimate the usual BP in a heavy smoker who has not
smoked for more than 30 minutes before the measurement is
made.
Caffeine intake can raise the BP acutely,
Taking the BP in a cool room (12ºC or 54ºF) or while the patient
is talking can raise the measured value by as much as 8 to 15
mmHg.
TYPE OF MEASUREMENT DEVICE
Mercury sphygmomanometers provide the most accurate
measurement of BP.
Aneroid sphygmomanometers, which are used in many offices,
should be checked against a mercury device since the air gauge may
be in error.
Automated oscillometric BP measuring devices are increasingly
being used in medical offices, and for home monitoring. The
readings are typically lower than BP obtained with the
auscultatory method..
The disadvantages are that the oscillometric method has somewhat
greater inherent error and epidemiologic data are based on
auscultatory methods.
advantages are that observer error and training are minimal.
CUFF SIZE — Use of a proper-sized cuff is essential. If
too small a cuff is used, can lead to overestimation
of the systolic pressure by as much as 10 to 50
mmHg in obese patients.
The length of the BP cuff bladder should be 80 percent,
and the width at least 40 percent of the
circumference of the upper arm.
This width recommendation cannot be practically
maintained in obese patients.
PATIENT POSITION — The BP is ideally taken in the sitting
position with the back supported
Supine values tend to be slightly different,
Supine and standing measurements should always be taken in the
elderly to detect postural hypotension
The arm should be supported at the level of the heart.
The mercury manometer should be visible but does not have to be
at the level of the heart
The patient should sit quietly for five minutes before the BP is
measured .
Even under optimal conditions, many patients are
apprehensive when seeing the physician, resulting in an acute rise
in BP.
CUFF PLACEMENT — The blood pressure cuff
should be placed with the bladder midline over the
brachial artery pulsation, with the arm without
restrictive clothing (the patient's sleeve should not be
rolled up as this may act as a tourniquet)
If possible, the lower end of the blood pressure cuff
should be two to three centimeters above the
antecubital fossa to minimize artifactual noise related
to the stethoscope touching the cuff.
TECHNIQUE OF MEASUREMENT — The cuff should be
inflated to a pressure approximately 30 mmHg greater
than systolic, as estimated from the disappearance of the
pulse in the brachial artery by palpation
The auscultatory gap is associated with increased arterial
stiffness and carotid atherosclerosis; it may therefore
identify patients at increased risk of cardiovascular
disease
Once the cuff is adequately placed and inflated, the
following steps should be followed;
Neither the patient nor the observer should talk during the
measurement
The BP should be taken with the patient's arm supported at the
level of the heart.
The mercury manometer should be visible but does not have to be at
the level of the heart
The stethoscope should be placed lightly over the brachial artery,
since the use of excessive pressure can increase turbulence and delay
the disappearance of sound. The net effect is that the diastolic
pressure reading may be artifactually reduced by up to 10 to 15 mmHg
The cuff should be deflated slowly at a rate of 2 to 3 mmHg per
heartbeat
The systolic pressure is equal to the pressure at which
the brachial pulse can first be palpated .
or the pressure at which the pulse is first heard by
auscultation (Korotkoff phase I).
As the cuff is deflated below the systolic pressure, the
pulse continues to be heard until there is abrupt
muffling (phase IV) and, approximately 8 to 10 mmHg
later, disappearance of sound (phase V)
The diastolic pressure is generally equal to phase V
the point of muffling should be used in those
patients in whom there is more than a 10
mmHg difference between phases IV and V
This can occur in children, and in high-output
states such as thyrotoxicosis, anemia, and
aortic regurgitation.
The BP should be measured initially in both arms .If there is a
disparity due to a unilateral arterial lesion, the arm with higher
pressure should be used.
The BP should be taken at least twice on each visit, with the
measurements separated by one to two minutes to allow the
release of trapped blood.
If the second value is more than 5 mmHg different from the first,
continued measurements should be made until a stable value is
attained.
Leg blood pressure — There are occasional patients
in whom the blood pressure needs to be measured in the
legs. The classic example is with suspected coarctation
of the aorta in which there is an arm-to-leg gradient.
Blood pressure should be taken in the leg among women
with breast cancer who have undergone bilateral
axillary lymph node dissection,
If there has been unilateral axillary node dissection, it is
recommended that the BP should always be taken in the
contralateral arm.
The principles of blood pressure measurement
in the leg are similar to the arm.
An appropriate-sized thigh cuff is essential.
The systolic pressure in the leg in normal
subjects is usually 10 to 20 percent higher
than that in the brachial artery.
Wrist blood pressure — may be more practical in
obese people, since wrist diameter is not significantly
affected.
Systolic BP rises, and diastolic BP falls, in more distal
arteries.
In the wrist, the hydrostatic pressure related to the lower
position of the wrist relative to the heart can result in a
further false elevation of BP.
This can be minimized by taking the BP with the wrist kept
at the level of the heart.
MULTIPLE BLOOD PRESSURE
MEASUREMENTS
in the absence of end-organ damage, the diagnosis of
mild hypertension should not be made until the blood
pressure has been measured on at least two additional
visits, spaced over a period of one week or more .
Sequential studies have shown that the BP drops by an
average of 10 to 15 mmHg between the first and third
visits in newly diagnosed patients with a stable value
not being achieved until more than six visits in some cases
Thus, many patients considered to be hypertensive at the
initial visit are in fact normal.
in patients diagnosed as being hypertensive on a first
visit to a new physician, there is a mean 15 and 7 mmHg
fall in the systolic and diastolic BP, respectively, by the
third visit with some patients not reaching a stable value
until the sixth visit
Thus, it has been recommended that a patient with mild
to moderate elevation in BP should not be diagnosed
with hypertension unless the BP remains elevated after three
to six visits, unless there is evidence of ongoing end-organ
damage.
the prevalence of white coat hypertension ranges from 10 to
more than 20 percent, and appears to be higher in children and
the elderly
White coat hypertension can also be seen in patients
with apparently resistant hypertension
The likelihood of normal ambulatory pressures is low
(less than 5 percent) in patients with office diastolic
pressures ≥105 mmHg but such patients may still have
a white coat effect underestimates the efficacy of
therapy
the optimal approach to patients with white
coat hypertension is uncertain.
If therapy is withheld because of a normal
ambulatory BP, careful monitoring is still
indicated for the possible development of
worsening hypertension or of end-organ
damage, while the patient is encouraged to
modify unhealthy lifestyle habits.
ABPM
INTERPRETATION OF ABPM — One of the unresolved
issues in ambulatory monitoring is the definition of what
constitutes normal and elevated blood pressure
Most experts agree that 24 hour blood pressure <130/80
mmHg is probably normal, and ≥135/85 mmHg is
probably abnormal
A daytime ambulatory average BP below 135/85 is
normotension.
INDICATIONS FOR ABPM

Suspected white coat hypertension

Suspected episodic hypertension (eg,pheo)

Hypertension resistant to increasing medications

symptoms while taking antihypertensive
medications

Autonomic dysfunction

To establish nondipper status or nocturnal
hypertension

Large variations in self-measured blood pressure
values
PROGNOSTIC VALUE OF ABPM
Prediction of cardiovascular risk — the risk of hypertensive
cardiovascular complications (including both the
development and regression of LVH with treatment)
correlates more closely with 24-hour or daytime ABPM than
with the office pressure
However, the difference in prognostic accuracy between
ABPM and office readings might be diminished by
obtaining repeated BP measurements during the same visit,
or by measuring BP in a standardized fashion with
appropriate equipment
BLOOD PRESSURE DURING SLEEP AND
ON AWAKENING
NORMAL PATTERN
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The usual fall in BP at night is largely the result of sleep
and inactivity rather than the time of day
Whereas the nocturnal fall averages approximately 15% in
those who are active during the day, it is only about 5% in
those who remain in bed for the entire 24 hours
The usual falls in BP and heart rate that occur with sleep
reflect a decrease in sympathetic nervous tone.
In healthy young men, plasma catecholamine levels fell
during rapid-eye-movement sleep, whereas awakening
immediately increased epinephrine, and subsequent
standing induced a marked increase in norepinephrine
ASSOCIATIONS WITH NONDIPPING
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Older age (Staessen et al., 1997)
Cognitive dysfunction (Van Boxtel et al., 1998)
Diabetes (Björklund et al., 2002)
Obesity (Kotsis et al., 2005)
African Americans (Jehn et al., 2008) and Hispanics
(Hyman et al., 2000)
Impaired endothelium-dependent vasodilation (Higashi et
al., 2002)
Elevated levels of markers of cellular adhesion and
inflammation (Von Känel et al., 2004)
Left ventricular hypertrophy (Cuspidi et al., 2004)
Intracranial hemorrhage (Tsivgoulis et al., 2005)
Loss of renal function (Fukuda et al., 2004)
Mortality from cardiovascular disease (Redon & Lurbe,
2008)
NOCTURNAL BLOOD PRESSURE AND NONDIPPERS
The average nocturnal BP is approximately 15 percent lower than
daytime values in both normals and hypertensive patients
Failure of the BP to fall by at least 10 percent during sleep is
called nondipping.
Independent of the degree of hypertension, nondipping is a risk
factor for the development of LVH as well as HF and other
cardiovascular complications
Nondipping has also been associated with microalbuminuria and
faster progression of nephropathy in patients with diabetes
mellitus.
nondipping may be a risk factor for decline in GFR, and ESRD
and death among patients with CKD
HOME BP MEASUREMENTS
In view of the cost and limited availability of ambulatory
monitoring, increasing attention is being given to home
Such self-recorded casual BP measurements taken at home or
daytime or work correlate more closely with the results of 24hour ambulatory monitoring than with the BP taken in the
office.
home BP measurements may be more predictive of adverse
outcomes (eg, stroke, end-stage renal disease) than clinic
blood pressures
patient self-monitoring of BP at home may improve BP control,
especially if combined with behavioral interventions

HBPM should become a routine component
of BP measurement in the majority of patients
with known or suspected hypertension.
Two to three readings should be taken while the
subject is resting in the seated position, both in
the morning and at night, over a period of 1 W .
 A total of ≥12 readings are recommended for
making clinical decisions.
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The target HBPM goal for treatment is less than
135/85 mm Hg
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Use a 7-day measurement period with two to
three measurements each morning and two to
three measurements in the evening at
prestipulated times (an average of 12 morning
and 12 evening measurements).
Exclude the first-day measurements from the
analyses to remove the alerting reaction.
It is recommended that the BP should be regularly
measured (by either the patient or other person) at
work and at home
In addition to improved control of the BP, potential
advantages of home BP monitoring include
identification of white coat hypertension,
assessment of the response to antihypertensive
medications, and improvement in patient
compliance.
The potential problems with outpatient BP
measurements can be minimized by providing
adequate training, and periodically checking the
machine for accuracy .
As with ambulatory monitoring, the BP taken by the
patient varies widely during the day, being influenced
by factors such as stress (particularly at work),
smoking, caffeine intake, natural circadian variation,
and exercise .
Thus, multiple readings should be taken to determine
the average level.
The timing of antihypertensive medications must
also be considered.
With short-acting drugs (eg, captopril, atenolol), the
BP may fall to normal or even below normal one to
two hours after therapy and then gradually
increase to elevated levels until the next dose is
taken.
This problem can be minimized by having the
outpatient BP measured 30 to 60 minutes before
taking medications, preferably in the early
morning to assess for possible inadequate
overnight BP control.
the BP should be measured at roughly the same time
each day and the relation to meals and
medications noted.
The patient should be instructed to wait to measure
the BP if they have recently eaten a meal or
exercised.
Cuff inflation hypertension — A possible problem with
self-measurement of BP is that the muscular activity
used to inflate the cuff can acutely raise the BP by as
much as 12/9 mmHg, an effect called cuff inflation
hypertension that dissipates within 5 to 20 seconds
(average 7 seconds . )
Thus, inflating the cuff to at least 30 mmHg above
systolic and then allowing the sphygmomanometer to
fall no more than 2 to 3 mmHg per heartbeat is
desirable both for accurate measurement and to
permit this exertional effect to disappear
If the blood pressure is taken at home to
establish the diagnosis of hypertension or to
assess blood pressure control, the optimal
schedule is unclear.
at least 12 to 14 measurements should be
obtained, with both morning and evening
measurements taken over seven workdays
SHOULD WE RECOMMEND
HOME-SELF MEASUREMENT?
• Advantages
• Disadvantages
• Goal
Initial evaluation for HTN
1- Staging of the BP
2- Assessment of the patients overall
cardiovascular risk
3- Detection of clues indicating potential
identifiable causes of HTN that require
further evaluation
Staging of the BP
ACCURATE ASSESSMENT OF BP
Office BP→ The united states preventive services taskforce
recommends measuring BP at each office visit for patients over the age of 21
• Is accurate BP measurement important?
• Time of measurement
• Patient position
• Cuff type and size
• technique of measurement
• How many readings and visits are needed to
diagnose HTN?
• Measuring in one arm versus two
• Measuring seated versus supine
• Using large versus small cuff
• Using mercury versus aneroid
sphygmomanometer
• Korotkoff phase IV versus phase V for DBP
EVALUATION
- History
- Physical examination
- Laboratory testing
Hematocrit
Urinalysis
routine blood chemistries
Glucose
Creatinine
electrolytes
Fasting (9 to 12 hours) lipid profile
- Total cholesterol
- HDL-cholesterol
- Triglycerides
- Electrocardiogram
Follow up
WHO SHOULD BE TREATED?
WHEN SHOULD DRUG THERAPY BE
STARTED?
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Before addressing the question, “When should
drug therapy be started?” one caveat must
always be recalled: An initially elevated BP,
above 140 mm Hg systolic or 90 mm Hg
diastolic, must always be remeasured at least
three times over at least 4 weeks to ensure that
hypertension is present.
Only if the level is very high (>180/110 mm Hg)
or if symptomatic target organ damage is present
should therapy be begun before the diagnosis is
carefully established.
2014 Evidence-Based Guideline for the anagement
of High Blood Pressure in Adults
Report From the Panel Members Appointed
to the Eighth Joint National Committee (JNC 8)
RECOMMENDATION 1:
In the general population aged 60 years or older,
initiate pharmacologic treatment to lowerBP at
systolic blood pressure (SBP) of 150 mmHg or
higher or diastolic blood pressure (DBP) of
90mmHg orhigher and treat to a goal SBP lower
than 150mmHg and goal DBP lower than
90mmHg.
These members concluded that the evidence
was insufficient to raise the SBP target from lower
than 140 to lower than 150 mm Hg in high-risk
groups, such as black persons, those with CVD
including stroke, and those with multiple risk
factors.
The panel agreed that more research is needed to
identify optimal goals of SBP for patients with
high BP
RECOMMENDATION 2 :
In the general population younger than 60 years,
initiate pharmacologic treatment to lower BP at
DBP of 90 mm Hg or higher and treat to a goal
DBP of lower than 90mmHg.
RECOMMENDATION 3 :
In the general population younger than 60 years,
initiate pharmacologic treatment to lower BP at
SBP of 140 mm Hg or higher and treat to a goal
SBP of lower than 140mmHg
RECOMMENDATION 4 :
In the population aged 18 years or older with CKD,
initiate pharmacologic treatment to lower BP at
SBPof 140mmHg or higher or DBP of 90mmHg or
higher and treat to goal SBP of lower than
140mm Hg and goal DBP lower than 90mmHg.
this recommendation applies to individuals
younger than 70 years with an estimated GFR or
measured GFR less than 60 mL/min/1.73 m2 and
in people of any age with albuminuria defined as
greater than 30 mg of albumin/g of creatinine at
any level of GFR.
RECOMMENDATION 5 :
In the population aged 18 years or older with
diabetes, initiate pharmacologic treatment to
lower BP at SBP of 140mmHg or higher or
DBP of 90 mm Hg or higher and treat to a goal
SBP of lower than 140mmHg and goal DBP lower
than 90mmHg.
RECOMMENDATION 6 :
In the general nonblack population, including those
with diabetes, initial antihypertensive treatment
should include a thiazide-type diuretic,
calcium channel blocker (CCB), angiotensinconverting enzyme inhibitor (ACEI), or
angiotensin receptor blocker (ARB).
Each of the 4 drug classes recommended by the
panel in recommendation 6 yielded comparable
effects on overall mortality and cardiovascular,
cerebrovascular, and kidney outcomes,
with one exception: heart failure.
Initial treatment with a thiazide-type diuretic was
more effective than a CCB or ACEI, and an ACEI
was more effective than a CCB in improving
heart failure outcomes
The panel also acknowledged that the evidence
supported BP control, rather than a specific agent
used to achieve that control, as themost relevant
consideration for this recommendation.
The panel did not recommend β-blockers for the
initial treatment of hypertension because in one
study use of β-blockers resulted in a higher rate
of the primary composite outcome of
cardiovascular death,myocardial infarction, or
stroke compared to use of an ARB, a finding that
was driven largely by an increase in stroke
α-Blockers were not recommended as first-line
therapy because
in one study initial treatment with an α-blocker
resulted in worse cerebrovascular, heart failure,
and combined cardiovascular outcomes than
initial treatment with a diuretic
Similar to those for the general population, this
recommendation applies to those with diabetes
because trials including participants with
diabetes showed no differences in major
cardiovascular or cerebrovascular outcomes from
those in the general population
RECOMMENDATION 7 :
In the general black population, including those
with diabetes, initial antihypertensive treatment
should include a thiazide-type diuretic or CCB
RECOMMENDATION 8 :
In the population aged 18 years or older with CKD
and hypertension, initial (or add-on)
antihypertensive treatment should include
An ACEI orARB to improve kidney outcomes.
This applies to all CKD patients with hypertension
regardless of race or diabetes status.
The evidence is moderate that treatment with an
ACEI or ARB improves kidney outcomes
for patients with CKD.
This recommendation applies to CKD patients
with and without proteinuria, as studies using
ACEIs or ARBs showed evidence of improved
kidney outcomes in both groups.
This recommendation is based primarily on kidney
outcomes because there is less evidence favoring
ACEI or ARB for cardiovascular outcomes in
patients with CKD.
Neither ACEIs nor ARBs improved cardiovascular
outcomes for CKD patients compared with a βblocker or CCB.
Recommendation8 applies to adults aged 18 years
or older with CKD, but there is no evidence to
support renin-angiotensin system inhibitor
treatment in those older than 75 years.
Although treatment with an ACEI or ARB may be
beneficial in those older than 75 years, use of a
thiazide-type diuretic or CCB is also an option for
individuals with CKD in this age group.
Use of an ACEI or an ARB will commonly increase serum
creatinine and may produce other metabolic effects such as
hyperkalemia, particularly in patients with decreased
kidney function.
Although an increase in creatinine or potassium level does
not always require adjusting medication, use of reninangiotensin system inhibitors in theCKDpopulation
requires monitoring of electrolyteand serum creatinine
levels, and in some cases, may require reduction in dose or
discontinuation for safety reasons.
RECOMMENDATION 9
The main objective of hypertension treatment is to
attain and maintain goal BP. If goal BP is not
reached within a month of treatment, increase
the dose of the initial drug or add a second drug
from one of the classes in recommendation 6
(thiazide-type diuretic, CCB, ACEI, or ARB).
The clinician should continue to assess BP and
adjust the treatment regimen until goal BP is
reached.
If goal BP cannot be reached with 2 drugs, add and titrate a third
drug from the list provided.
Do not use an ACEI and an ARB together in the same patient.
If goal BP cannot be reached ,using the drugs in recommendation 6
because of a contraindication or the need to use more than 3
drugs to reach goal BP, antihypertensive drugs from other classes
can be used.
Referral to a hypertension specialist may be indicated for patients in
whom goal BP cannot be attained using the above strategy or for
the management of complicated patients for whom additional
clinical consultation is needed