Transcript Hypertension

Case
Onset stage 25-55 years mainly in 40-50y
Occurs over 30%of persons older than 65 y
Only 34% of persons with hypertension have
their blood pressure under control.
90
80.1
Percent of Population
80
70.8
63.9
70
60
52
72.1
52
50
37.7
40
Female
24.4
30
17.6
20
9.1
10
Male
34
6.7
0
20-34
35-44
45-54
55-64
Age (years)
65-74
≥75
Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking
antihypertensive medication, or being told twice by a physician or other professional that one has
hypertension.
Trends in awareness, treatment, and control of high blood
pressure in adults ages 18–74
National Health and Nutrition Examination Survey,
Percent
1999–
2007 II
II
II
2000
2010
(Phase 1) (Phase 2)
1976–80 1988–91 1991–94
Awareness
51
73
68
70
81.5%
Treatment
31
55
54
59
74.9%
Control
10
29
27
34
52.5%
Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood
Institute; JNC 6. and American Heart Association: Statistical Fact Sheet 2013 Update
Hypertension
In 90%-95% of cases no cause can be found
primary hypertension (essential)
Secondary hypertension 5-10%
Essential HTN
Risk factors
Obesity---metabolic syndrome
Excessive salt intake---low potassium intake
Excessive alcohol intake
Polycythemia
Lack of exercise
Non-steroid anti-inflammatory drugs
Family history of essential HTN
Caffeine and smoking increase the BP acutely but are not
risk factors for the development of chronic essential HTN
Primary renal disease
Oral contraceptives
Sleep apnea syndrome
Primary hyperaldosteronism
Renovascular disease
Cushing’s syndrome
Pheochromocytoma
Other endocrine disorders
Coarctation of the aorta
U.S. Department of
Health and Human
Services
National Institutes
of Health
National Heart,
Lung, and Blood
Institute
National Heart, Lung, and Blood Institute
National High Blood Pressure Education
Program
The Seventh Report of the Joint National Committee
Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 7)
BP Classification
SBP mmHg
DBP mmHg
Normal
120
and
<80
Pre-hypertension
120-139
or
80-89
Stage 1 HTN
140-159
or
90-99
Stage 2 HTN
>160
or
>100
European Society of Nephrology
Classification of Blood Pressure Levels
Category
Optimal blood
pressure
Normal blood pressure
High-normal blood
pressure
Grade 1 hypertension
(mild)
Grade 2 hypertension
(moderate)
Grade 3 hypertension
(severe)
Isolated systolic
hypertension
Systolic blood pressure
(mmHg)
<120
Diastolic blood
pressure (mmHg)
<80
<130
<85
130-139
85-89
140-159
90-99
160-179
100-109
>/= 180
>/= 110
>140
<90
Stage 1
Clinical Blood Pressure – 140/90 mmHg
Ambulatory Blood Pressure Monitoring (ABPM) – 135/85 mmHg
Home Blood Pressure Monitoring (HBPM) - 135/85 mmHg
Stage 2
Clinical Blood Pressure – 160/100 mmHg
Ambulatory Blood Pressure Monitoring (ABPM) – 150/95 mmHg
Home Blood Pressure Monitoring (HBPM) - 150/95 mmHg
Severe hypertension (Stage 3)
Clinical Blood Pressure – 180/110 mmHg
Type of Instrument of Blood Pressure Measurement
Sphygmomanometer
Type of Instrument of Blood Pressure
Measurement
Home Blood Pressure Monitoring
Type of Instrument of Blood Pressure
Measurement
Ambulatory Pressure Monitoring
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.
Measure blood pressure to arm the high reading.
Patient should be seated with the back straight and the
arm supported at heart level
The patient should rest for 5 minutes
The bladder of the pressure cuff should encircle at least
80% of the upper arm
If BP measure =more140/90 mmHg, perform second
reading. If second reading is still high, take third
reading.
The diagnosis of mild hypertension should not be
made until the blood pressure has been measured
on at least three to six visits
Average of 10 to 15 mmHg decrease between
visits 1 and three
Approximately 20 to 25% of patients with mild office
hypertension
More common in elderly
Infrequent in patients with office diastolic pressures
≥105 mmHg
CAD, ECG,
Arrthymia, Sudden
Death
Stroke, Ischemia,
Hemorrhage,
Alzheimer’s Disease,
Cognitive
Renal Disease
Hypertension
Peripheral
Vascular Disease
Hypertensive
Emergency
And Increase
Emergency Morbidity
CHF
LVH
Aortic Dissection
24
Risk of Hypertension for each
2 mmHg increase in systolic
blood pressure
Increase risk of cardiovascular mortality by 7%
Risk of stroke by 10%
This left ventricle is very thickened (slightly over 2 cm in thickness),
but the rest of the heart is not greatly enlarged. This is typical for
hypertensive heart disease. The hypertension creates a greater
pressure load on the heart to induce the hypertrophy.
The left ventricle is markedly thickened in this patient with severe
hypertension that was untreated for many years. The myocardial fibers
have undergone hypertrophy.
Hypertensive
Emergency
Severe hypertension (diastolic blood pressure above 120
mmHg) in end organ damage (MI,STROKE,AKI,CHF)
Severe hypertension (diastolic blood pressure above
120 mmHg) in asymptomatic patients
There is no proven benefit from rapid reduction in BP
in asymptomatic patients who have no evidence of
acute end-organ and are little short-term risk
Marked hypertension with encephapapathy& retinal
hemorrhages, exudates, or papilledema
Associated with a diastolic pressure above 120
mmHg
HYPERTENSIVE RETINOPATHY
Grade
Description
Alternative
Description
A:V Ratio
I
Minimal narrowing of retinal
arteries
50%
II
Narrowing of retinal arteries in
conjunction with regions of focal
narrowing and arterio-venous
nipping
33%
III
Abnormalities seen in Grade 1
and II, as well as retinal
hemorrhages, hard exudation
and cotton wool spots.
25%
IV
Abnormalities encountered in
Grades I through III, as well as
swelling of the optic nerve head
and macular star
<20%
Hypertensive Retinopathy Grade 1
Generalized
arteriolar
constrictionseen as `silver
wiring` and
Vascular
tortuosities
Arteriovenous nicking
in association with
hypertension Grade
2
(yellow arrow)
Flame-shaped hemorrhage
in association with severe
hypertension Grade 3
(yellow arrow)
Papilledema
from
malignant hypertension.
There is blurring of the
borders of the optic disk
with hemorrhages (yellow
arrows) and exudates
(white arrow)
Clinical Presentations:
Asymptomatic
Headache
Epistaxis
Chest discomfort
Symptom of complications
Screening:
Every two years for persons with systolic and
diastolic pressures below 120 mmHg and 80 mmHg
Yearly for persons with a systolic pressure of 120 to
139 mmHg OR Diastolic pressure of 80-89 mmHg
Presence of precipitating or aggravating
factors
Natural course of the blood pressure
Extent of target organ damage
Presence secondary HTN of other risk factors
for cardiovascular disease
To evaluate for signs of end-organ damage
For evidence of a cause of secondary
hypertension
Routine Tests
Electrocardiogram
Urinalysis
Serum sodium, serum potassium, creatinine, or the
corresponding estimated GFR, and calcium
Blood glucose, and hematocrit
Lipid profile, after 9- to 12-hour fast, that includes high
density and low-density lipoprotein cholesterol, and
triglycerides
Optional tests
Measurement of urinary albumin excretion or
albumin/creatinine ratio
More extensive testing for identifiable causes is not
generally indicated unless BP control is not achieved
Who should be treated?
If the systolic pressure is persistently ≥140 mmHg and/or
the diastolic pressure is persistently ≥90 mmHg after
three to six visits.
Systolic pressure is persistently above 130 mmHg and/or
the diastolic pressure is above 80 mmHg in patients with
cardiovascular disease, post-myocardial infarction,
heart failure, CKD & DM. Lifestyle changes – no
medication
Blood Pressure Target: (UK)
Age < 80 yrs (high risk)
Age < 80 yrs (no risk)
Age > 80 yrs
<140/90 mmHg
140/90 mmHg
150/90 mmHg
Blood Pressure Target: (European)
<140/90 mmHg
Lifestyle modifications
High normal SBP >130 – 139 mmHg
DBP 85 – 89 mmHg
in high risk patients
Drug therapy
If BP is 140/90 mmHg
Average Percent Reduction
Stroke incidence
35–40%
Myocardial
infarction
Heart failure
20–25%
Renal Failure
35-50%
50%
Modification
Weight reduction
Approximate SBP
reduction (range)
Adopt DASH eating
5–20 mmHg/10 kg
weight loss
8–14 mmHg
Dietary sodium
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
Diet high in fruits and vegetables and low-fat dairy
products
Recommends 7-8 servings/day of grain/grain
products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat
dairy products, 2 or less meat, poultry, and fish.
NEJM 1997; 366: 1117-24.
Patients should return for follow-up after 4 weeks and
adjustment of medications until the BP goal is
reached
More frequent visits for stage 2 HTN or with
complicating co-morbid conditions.
Serum potassium and creatinine monitored 1–2 times
per year.
A low dose of initial drug should be used, slowly
titrating upward.
Optimal formulation should provide 24-hour
efficacy with once-daily dose.
Combination therapies may provide additional
efficacy with fewer adverse effects.
Diuretics → Hypokalemia
β-Adrenergic Blocking Agents → Bradycardia +
Angiotensin-Converting Enzyme Inhibitors →
Hyperkalemia + cough
Angiotensin II Receptor Blockers → Hyperkalemia
Calcium Channel Blocking Agents → Edema +
Tachycardia + Bradycardia
α-Adrenoceptor Antagonists → 1st dose hypotension
Drugs with Central Sympatholytic Action → Drowsiness
Arteriolar Dilators → Tachycardia + Edema
High Risk Group Therapy
Start in pre-hypertension (130 – 139)/(85 – 89) mmHg
Lifestyle change
CHF – Thiazide, ACE-1, Aldosterone, BB
Post Myocardial Infarction – BB, ACEi
Diabetes Mellitus – ACEi, ARB, Thiazide, CCB
CKD – ACEi, ABB, Thiazide
Stroke – SSB +ACEi
Aged over 55
years or black
person of
African
Aged
under
55 years
Key
Step 1
12 Choose
a low-cost ARB.
A CCB is preferred but consider
a thiazide-like diuretic if a CCB is
not tolerated or the person has
edema, evidence of heart failure
or a high risk of heart failure.
Step 2
13
Consider a low dose of
spironolactone15 or higher doses
of a thiazide-like diuretic.
14
At the time of publication
(August 2011), spironolactone did
not have a UK marketing
authorization for this indication.
Informed consent should be
obtained and documented.
C
A
A+C
an alpha- or betablocker if further diuretic therapy
is not tolerated, or is
contraindicated or ineffective.
C – Calciumchannel blocker
(CCB)13
D – Thiazide-like
diuretic
Step 3
A+C+D
Step 4
Resistant hypertension
15
16 Consider
A – ACE inhibitor
or angiotensin II
receptor blocker
(ARB)12
A + C + D + consider
further diuretic14, 15 or
alpha- or
beta-blocker16
Consider seeking expert advice
ACE inhibitors and diuretics
Angiotensin II receptor antagonists and
diuretics
Calcium antagonists and ACE inhibitors
Angiotensin II receptor antagonists &adrenergic blockers NOT RECOMMENDED
Other combinations (-adrenergic blockers
and diuretics)