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Case 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. Men BMI <25 BMI 25-<27 BMI 27-<30 BMI >30 100 Percent 75 46.2 50 25 24.6 10.4 3.5 7.4 16.3 23.3 51.7 53.6 49.1 30.2 0 20-39 40-59 *Defined as mean systolic blood pressure 140mm Hg, mean diastolic 90 mm Hg, or currently taking antihypertensive medication. Brown C et al. Body Mass Index and the Prevalence of Hypertension and Dyslipidemia. Obes Res. 2000; 8:605-619. 60+ 61.6 The overall prevalence of hypertension was ( 15.2% and 40.6% of Saudis were hypertensive or borderline hypertensive) only 44.7% of hypertensives were aware Risk of hypertension increased among men, with age, obesity, diabetes, and hypercholesterolemia. 57.8% of hypertensive Saudis were undiagnosed 71.8% of them received pharmacotherapy only 37.0% were controlled. . Source: International Journal of Hypertension Abdalla A. Saeed, Nasser A. Al-Hamdan Volume 2011 (2011), Article ID 174135, 8 pages Hypertension In 90%-95% of cases no cause can be found primary hypertension (essential) Secondary hypertension 5-10% Mechanism of Blood Pressure: Blood Pressure = Cardiac output X Systemic Vascular Resistance = CO X SVR = Stroke volume X HR X SVR 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 CHD Rates by SBP, DBP and Age Hypertension Update 2016 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 The Seventh Report of the Joint National Committee Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 & 8) U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute BP Classification SBP mmHg Normal 120 and <80 Prehypertension 120-139 or 80-89 Stage 1 HTN ≥140-159 or ≥90-99 Stage 2 HTN >160 or >100 DBP mmHg Category Systolic BP (mmHg) Diastolic (mmHg) Office BP ≥140 and/or ≥90 Daytime (or awake) ≥135 and/or ≥85 Nighttime (or sleep) ≥120 and/or ≥70 24 h ≥ 130 and/or ≥80 Home BP ≥135 and/or ≥85 Ambulatory BP Out-of-Office BP 2013 ESH and ESC Guidelines Type of Instrument of Blood Pressure Measurement Sphygmomanometer Type of Instrument of Blood Pressure Measurement Home Blood Pressure Monitoring 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. To allow the patients to sit for 3–5 minutes before beginning BP measurements Back straight and arm supported at heart level Take at least two BP measurements, spaced 1–2 min apart, and additional measurements if the first two are quite different. Consider the average BP if deemed appropriate. To use a standard bladder (12–13 cm wide and 35 cm long) A larger bladder for larger arm (circumference >32 cm) The bladder of the pressure cuff should encircle at least 80% of the upper arm Place the cuff at the heart level, whatever the position of the patient. Measure BP in both arms at first visit to detect possible differences. In this instance, take the arm with the higher value as the reference. Measure BP in sitting and standing position in elderly subjects and diabetic patients Use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively. 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 Stroke, Ischemia, Hemorrhage, Alzheimer’s Disease, Cognitive, retinal hemorrhage CAD, ECG, Arrthymia, Sudden Death CHF LVH Aortic Dissection Renal Disease Peripheral Vascular Disease Hypertensive Emergency And Increase Emergency Morbidity Hypertension 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 I Minimal narrowing of retinal arteries II Narrowing of retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping III Abnormalities seen in Grade 1 and II, as well as retinal hemorrhages, hard exudation and cotton wool spots. IV Abnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star 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 1. Confirm the diagnosis of hypertension 2. Detect causes of secondary hypertension 3. Assess CV risk 4. Organ damage 5. Concomitant clinical conditions. 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 mmHg 7% reduction in risk of IHD mortality 2 mmHg decrease in mean SBP 10% reduction in risk of stroke mortality Meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline mmHg | 43 Who should be treated Low risk ? If the systolic pressure is persistently ≥140 mmHg and/or the diastolic pressure is persistently ≥90 mmHg after three to six visits. Usual Office BP Threshold Values for Initiation of Pharmacological Treatment Population SBP Hypertension Update 2016 DBP High Risk (SPRINT population) >130 NA Diabetes >130 >80 Moderate-to-high risk (TOD or CV risk factors)* >140 >90 Low risk (no TOD or CV risk factors) >160 >100 TOD = target organ damage *AOBP threshold >135/85 In patients with chronic kidney disease, antihypertensive therapy should be started in those with systolic blood pressures consistently >140/90 mmHg and treated to a target of <140/90 mmHg For patients at moderate absolute CVD risk (<10% 5-year risk) with persistent blood pressure ≥140 mmHg systolic and/or ≥90 mmHg diastolic, antihypertensive therapy should be started For patients at low absolute CVD risk (<10% 5-year risk) with persistent blood pressure ≥160/100 mmHg, antihypertensive therapy should be started. Average Percent Reduction Stroke incidence 35–40% Myocardial infarction Heart failure 20–25% Renal Failure 35-50% 50% Lifestyle modifications High normal SBP >130 – 139 mmHg DBP 85 – 89 mmHg in high risk patients Drug therapy Lifestyle changes: Salt restriction to 4-5 gm/day. Increased consumption of vegetables, fruits and low-fat dairy products. 7-8 servings/day of grain/grain products, 45 vegetable, 4-5 fruit Reduction of weight to BMI of 25 kg/m2. Waist circumference Men < 102 cm Women < 88 cm Regular exercise (≥30 min of moderate dynamic exercise on 5-7 days per week) Smoking cessation Potassium supplementation Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg SBP or >10 mmHg DBP above target Thiazide Diuretic CONSIDER •Non-adherence •Secondary HTN •Interfering drugs or lifestyle •White coat effect Dual Combination Triple or Quadruple Therapy Lifestyle Modification Initial Therapy ACEI ARB Longacting CCB Dual Combination Beta-blocker* *Not indicated as first line therapy over 60 y Triple or Quadruple Therapy Hypertension Update 2016 Aged under 55 years Aged over 55 years or black person of African 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 C &D A&B A(B) + C or A(B)+D Step 3 A+C+D B+ C+D Step 4 Resistant hypertension Consider a low dose of spironolactone15 or higher doses of a thiazide-like diuretic. 14 15 16 Consider 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 13 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. A – ACE inhibitor B-angiotensin II receptor blocker (ARB)12 A + C + D + consider further diuretic14, 15 or alpha- or beta-blocker16 Consider seeking expert advice High Risk Group Therapy Start in pre-hypertension (130 – 139)/(85 – 89) mmHg Lifestyle change Drug therapy (If BP is 130/80 mmHg) CHF – Thiazide, ACE-1, Aldosterone, BB Post Myocardial Infarction – BB, ACEi Diabetes Mellitus – ACEi, ARB, Thiazide, CCB CKD – ACEi, ABB, Thiazide Stroke – CCB +ACEi Anti-hypertensive Medications and Complications 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+constipation α-Adrenoceptor Antagonists → 1st dose hypotension Drugs with Central Sympatholytic Action → Drowsiness Arteriolar Dilators → Tachycardia + Edema 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. Patients should return for follow-up after 2- 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. Recommended Office BP Treatment Targets Treatment consists of health behaviour ± pharmacological management Population SBP DBP High Risk ≤120 NA Diabetes < 130 < 80 All others* < 140 < 90 * Target BP with AOBP < 135/85 Hypertension Update 2016 A Controlled Trial of Renal Denervation for Resistant Hypertension. This blinded trial did not show a significant reduction of systolic blood pressure in patients with resistant hypertension 6 months after renalartery denervation as compared with a sham control Source: The New England Journal of Medicine April 10, 2014 An implantable device designed to activate baroreceptors to reduce blood pressure does not appear to reduce blood pressure