Download Blood Pressure Classification

APPROACH TO
HYPERTENSION IN PRIMARY
CARE
• Doç. Dr. Nurver Turfaner
• Department of Family Medicine
Benefits of Controlling
Hypertension
• By controlling hypertension, the risk of
myocardial infarction is reduced up to
25%, the risk of stroke can be reduced
by up to 40% and the risk of congestive
heart failure can be reduced to the half.
The treatment of isolated systolic
hypertension in the elderly reduces
overall mortality by 13%.
Pathologic Consequences of
Hypertension
• Hypertension is an independent
predisposing factor for heart failure,
coronary artery disease, stroke, renal
disease and peripheral arterial disease.
HEART
• Heart disease is the most common cause
of death in hypertensive patients.
Hypertensive heart disease is the result
of structural and functional adaptations
leading to left ventricular hypertrophy,
(CHF), abnormalities of blood flow due
to atherosclerotic coronary artery
disease or microvascular disease, and
cardiac arrhythmias..
HEART
• Individuals with left ventricular
hypertrophy are at increased risk for
CHD, stroke, CHF, and sudden death.
Aggressive control of hypertension can
regress or reverse left ventricular
hypertrophy and reduce the risk of
cardiovascular disease
BRAIN
• Stroke is the most frequent cause of
death in the world; it accounts for 5 million
deaths each year, with an additional 15
million persons having non-fatal strokes.
Elevated blood pressure is the strongest
risk factor for stroke. The incidence of
stroke rises progressively with increasing
blood pressure levels, particularly systolic
blood pressure in individuals >65 years.
Treatment of hypertension convincingly
decreases the incidence of both ischemic
and hemorrhagic strokes.
KIDNEY
• The kidney is both a target and a cause of
hypertension. Primary renal disease is the
most common etiology of secondary
hypertension. Renal risk appears to be
more closely related to systolic then to
diastolic blood pressure. Proteinuria is a
reliable marker of the severity of chronic
renal disease and is a predictor of its
progression. Patients with high urine
proteine excretion (> 3 gr/24 hours) have a
more rapid rate of progression.
KIDNEY
• Clinically, macroalbuminuria (a random
urine albumine/creatinine ratio>300
mg/g) or microalbuminuria (a random
urine albumine/creatinine ratio 30300mg/g) are early markers of renal
injury. These are also risk factors for
renal disease progression and
cardiovascular disease.
Peripheral Arteries
• In addition to contributing to the pathogenesis
of hypertension, blood vessels may be a target
organ for atherosclereotic disease secondary
to long- standing elevated blood pressure.
Intermittant claudication is the classic
symptom of PAD (Peripheral arterial disease).
The ankle-brachial index is defined as the ratio
of non-invasively assessed ankle to brachial
(arm) systolic blood pressure. An ankle-brachial
index < 0.90 is considered diagnostic of PAD
and is associated with > 50% stenosis in at least
one major lower limb vessel.
Clinical Disorders of
Hypertension
• Depending on methods of patient
ascertainment 80-95% of hypertensive
patients are diagnosed as having
essential hypertension (also referred to
as primary or idiopathic hypertension).
In the remaining 5-20 % of
hypertensive patients, a specific
underlying disorder causing the
elevation of blood pressure can be
identified.
ESSENTIAL HYPERTENSION
• Essential hypertension tends to be
familial and is likely to be the
consequence of an interaction between
environmental and genetic factors. The
prevalance of essential hypertension
increases with age.
OBESITY AND METABOLIC
SYNDROME
• There is a well documented association
between obesity (body mass index > 40
kg/m2) and hypertension. Centrally
located body fat is a more important
determinant of blood pressure
evaluation than is peripheral body fat.
It has been established that 60-70% of
hypertension in adults may be directly
attributable to adiposity.
OBESITY AND METABOLIC
SYNDROME
• Hypertension and dyslipidemia
frequently occur together and in
association with resistance to insulinstimulated glucose uptake.
• The constellation of insuline resistance,
abdominal obesity, hypertension, and
dyslipidemia has been designated as the
metabolic syndrome.
RENAL PARENCHYMAL
DISEASES
• Nearly all disorders of the kidney may cause
hypertension and renal disease is the most
common cause of secondary hypertension.
• Hypertension is present in more than 80% of
patients with chronic renal failure. Conversely,
hypertension may cause nephrosclerosis,and in
some instances it may be difficult to determine
whether hypertension or renal disaease was the
initial disorder. Proteinuria >1000mg/day and an
active urine sediment are indicative of primary
renal disease.
RENOVASCULAR
HYPERTENSION
• Hypertension due to an occlusive lesion
of a renal artery, renovascular
hypertension, is a potentially curable
form of hypertension.
• It is mostly seen in older
atherosclerotic patients who have a
plaque obstructing the renal artery and
patients with fibromuscular dysplasia.
RENOVASCULAR
HYPERTENSION
• Although fibromuscular dysplasia may occur
at any age, it has a strong predilection for
young women. The prevalance in females is 8
fold than in males.
• Contrast arteriography is the gold standard
for evaluation and identification of renal
artery lesions.
• PTRA (Percutaneus Transluminal Renal
Angioplasty) is the initial treatment. Surgical
revascularization may be undertaken if PTRA
is unsuccessful.
PRIMARY ALDOSTERONISM
• Primary aldosteronism should be
considered in all patients with refractory
hypertension. In a hypertensive patient
with unprovoked hypokalemia (i.e,
unrelated to diuretics,vomiting or
diarrhea), the prevalance of primary
hyperaldosteronism approaches 40-50%.
• In patients on diuretics, serum potassium
<3.1 meq/L also raises the possibility of
primary hyperaldosteronism.
Blood Pressure Classification
Systolic
Blood
mmHg
Pressure
Classificati
on
Normal
<120
Diastolic
mmHg
and <80
Prehypertension
120-139
or 80-89
Stage 1
hypertension
140-159
or 90-99
Stage 2
hypertension
≥160
or≥100
Isolated
systolic
hypertension
≥140
and <90
Measurement of Blood Pressure
• The primary test used to screen for
hypertension is measurement with mercury
or a calibrated aneroid or electronic
sphygmomanometer by a trained technician
• The patient should be properly positioned
after at least a 5-minute rest
• Continuous 24- hour blood pressure
monitoring has been shown to be more
predictive of end-organ damage than
standard office measurement.
Measurement of Blood Pressure
• Office-based measurements are typically
done with sphygmomanometer. The
accuracy depends on the examiner, patient
factors, and the instrument used.
• Two measurements at seperate visits are
necessary for diagnosis.
• Alternatives to office measurements:
• Home monitors
• Ambulatory measurement: Identifies
patients with ‘White coat Hypertension’
Proper training of observers,
Positioning of the patient
Selection of cuff-size are essential.
Recent regulations prevent the use of
mercury potential toxicity!!
• Office measurements are made with
aneroid sphygmomanometers or with
oscillometric devices.
• Instruments should be calibrated
periodically and their accuracy should
be confirmed.
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•
•
•
Measurement of Blood Pressure
• The center of the cuff should be at heart
level and the width of the bladder cuff
should equal at least 40% of the arm
circumference; the length of the cuff
bladder should be enough to encircle at
least 80% of the arm circumference.
• Systolic blood pressure is the first of at
least two regular ‘tapping’ Korotkoff
sounds, and diastolic blood pressure is the
point at which the last regular Korotkoff
sound is heard.
Patient’s Relevant History
• Duration of hypertension
• Previous therapies: responses and side
effects
• Family history of hypertension and
cardiovascular disease
• Dietary and psychosocial history
• Other risk factors: weight change,
dyslipidemia, smoking, diabetes,physical
inactivity
Patient’s Relevant History
• Evidence of secondary hypertension: history of
renal disease; change in appearance; muscle
weakness; spells of sweating,
palpitations,tremor; erratic sleep, snoring,
daytime somnolence; symptoms of hypo-or
hyperthyroidism; use of agents that may
increase blood pressure
• Evidence of target organ: history of TIA,
stroke, transient blindness; angina, myocardial
infarction, congestive heart failure; sexual
function
• Other comorbidities
Basic Laboratory Tests for
Initial Evaluation
System
Renal
Test
Microscopic urinalysis,
albumin excretion, serum
BUN and/or creatinine
Endocrine
Serum sodium, potassium,
calcium, TSH
Fasting blood glucose, total
cholesterol, HDL and LDL
T.cholesterol, triglycerides
Metabolic
Other
Hematocrit,
electrocardiogram
Lifestyle Modifications to Manage
Hypertension
Weight reduction
Dietary salt reduction
Adapt DASH-type dietary
plan
Attain and maintain
BMI<25 kg/m2
<6 g NaCl/d
Diet rich in fruits,
vegetables, and low-fat
dairy products with
reduced content of
saturated and total fat
Moderation of alcohol
consumption
For those who drink
alcohol, consume ≤2
drinks/day in men and ≤1
drink/day in women
Physical activity
Regular aerobic activity,
e.g., brisk walking for 30
Risk Factors For Hypertension
• Hypertension increases with age and a
normotensive adult at age 55 has up to 90%
lifetime risk of becoming hypertensive.
• Tobacco
• Alcohol
• Overweight and obesity
• Sedentary life-style
• Inadequate fruit, vegetable, K intake
• Excess sodium intake
• all contribute to hypertension.
TREATMENT
• In uncomplicated hypertension:
the specific choice of drug is less
important than the attainment of goal
blood pressure.
• If blood pressure is more than 20/10
mm Hg above target level : two
antihypertensive medications
• One should usually be
hydrochlorothiazide
TREATMENT
• JNC 7 encourages the use of specific
antihypertensive agents for
hypertension.
• Life-style modification is an important
component of hypertension management.
• Treatment with ACE inhibitors and
ARB’s is associated with decreased risk
of new-onset diabetes mellitus in
patients with hypertension.
TREATMENT
Pre-hypertension: SBP: 120-139 mmHg
DBP: 80-89 mmHg
Stage 1 hypertension: SBP: 140-159 mmHg
DBP: 90-99 mmHg
Life-style and diet modification (only)
Stage 1 Hypertension+ Diabetes or
cardiovascular disease:
Pharmacotherapy+Diuretics
• Aerobic Exercise: (45-60 min.), at least 3
days/per week, preferably daily
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Diet in Hypertension
• Low salt, low-fat, high-fruit, high vegetable diet,
limited alcohol consumption (fever than two
drinks/day)
• Modest weight loss (3% to 9% of total body weight)
• Na restriction
It is more effective in blacks
In whites: SBP decreases by 4.2 mmHg
DBP decreases by 2.0 mmHg
In blacks: SBP decreases by 6.4 mmHg
DBP decreases by 2.0 mmHg
Limit of sodium intake daily: 2-4 g/day (stage 1 and
prehypertension)
DASH DIET: dietary approach
to stop hypertension
• Low in saturated fat
• High in fruits and vegetables (8-10
servings
• High in low fat dairy products
Results in:
↓ SBP:>11 mmHg
↓DBP: >5 mmHg
+ Na restriction (<2g daily)
↑Fiber intake, ↑K intake
Pharmacologic Treatment of
Hypertension
Thiazide Diuretic Plus:
• ACE inhibitor
• Aldosterone antagonist
• Angiotensin receptor blocker
• Β-blocker
• Calcium channel blocker
Pharmacologic Treatment of
Hypertension
Calcium Channel Blocker Plus:
ACE inhibitor
Angiotensin receptor blocker
Β-blocker
•THANKS YOU FOR
YOUR ATTENTION