FAME HTN Mohsen. Epidemiology and stuff About 1/3 of middle aged patients have hypertension About ½ of elderly patients have hypertension. Responsible.

FAME HTNFAME HTN

MohsenMohsen

Epidemiology and stuffEpidemiology and stuff

About 1/3 of middle aged patients have About 1/3 of middle aged patients have hypertensionhypertension

About ½ of elderly patients have hypertension.About ½ of elderly patients have hypertension. Responsible for 12% of deaths worldwide.Responsible for 12% of deaths worldwide. 5-6% reduction in diastolic blood pressure over 5 5-6% reduction in diastolic blood pressure over 5

years reduces risk of CVA by 35-40% and IHD by years reduces risk of CVA by 35-40% and IHD by 20-25%20-25%

Proportion of deaths attributable to leading risk Proportion of deaths attributable to leading risk factors worldwide (2000)factors worldwide (2000)

Attributable Mortality (In millions; total 55,861,000)

High mortality, developing region

Lower mortality, developing region

Developed region

0 87654321

High blood pressure

Tobacco

High cholesterol

Unsafe sex

High BMI

Physical inactivity

Alcohol

Indoor smoke from solid fuels

Iron deficiency

Underweight

Classification:Classification:

Important Points:Important Points: Hypertension is the most common treatable risk factor Hypertension is the most common treatable risk factor

for cardiovascular disease in patients over 50 ys.for cardiovascular disease in patients over 50 ys. Only 70% are aware they have HTNOnly 70% are aware they have HTN Of those aware of their HTN, only 50% are being Of those aware of their HTN, only 50% are being

treated.treated. Only 25% of all hypertensive patients have their BP Only 25% of all hypertensive patients have their BP

under control.under control. HTN is a risk factor for coronary artery disease (CAD), HTN is a risk factor for coronary artery disease (CAD),

congestive heart failure (CHF), stroke, and renal congestive heart failure (CHF), stroke, and renal failure.failure.

Important Points:Important Points: For persons over age 50, SBP is a more important For persons over age 50, SBP is a more important

than DBP as CVD risk factor.than DBP as CVD risk factor.

Persons who are normotensive at age 55 have a Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.90% lifetime risk for developing HTN.

Those with SBP 120–139 mmHg or DBP 80–89 Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to require health-promoting lifestyle modifications to prevent CVD.prevent CVD.

ESSENTIAL HYPERTENSIONESSENTIAL HYPERTENSION

> 90% of all cases> 90% of all cases

multifactorialmultifactorial

interplay of genetics and environmentinterplay of genetics and environment

genes - polygenicgenes - polygenic

environment - obesity, salt, smokingenvironment - obesity, salt, smoking

environment - intrauterine growthenvironment - intrauterine growth

MAJORITY OF CASES ASSOCIATED WITH HIGH MAJORITY OF CASES ASSOCIATED WITH HIGH

CIRCULATING RENINCIRCULATING RENIN

Secondary hypertensionSecondary hypertension

Coarctation of the aortaCoarctation of the aorta Renal artery stenosisRenal artery stenosis Polyarteritis nodosaPolyarteritis nodosa PhaeochromocytomaPhaeochromocytoma Conn’s syndromeConn’s syndrome Polycystic kidneyPolycystic kidney Fibromuscular hyperplasiaFibromuscular hyperplasia

Effects of HypertensionEffects of Hypertension Left ventricular hypertrophyLeft ventricular hypertrophy Coronary atheromaCoronary atheroma Other atheroma (all medium/large blood vessels)Other atheroma (all medium/large blood vessels) Acute myocardial infarctionAcute myocardial infarction Cerebral infarctCerebral infarct Cerebral haemorrhageCerebral haemorrhage Hypertensive retinopathyHypertensive retinopathy Renal impairmentRenal impairment Aortic dissectionAortic dissection

Target Organ DamageTarget Organ Damage

Cerebrovascular diseaseCerebrovascular disease- transient ischemic attacks- transient ischemic attacks- ischemic or hemorrhagic stroke- ischemic or hemorrhagic stroke

Hypertensive retinopathyHypertensive retinopathy

Left ventricular dysfunction/LVHLeft ventricular dysfunction/LVHCoronary artery diseaseCoronary artery disease

- myocardial infarction- myocardial infarction- angina pectoris- angina pectoris- congestive heart failure- congestive heart failure

Chronic kidney diseaseChronic kidney diseasePeripheral artery diseasePeripheral artery disease

- intermittent claudication- intermittent claudication

Accurate BP MeasurementAccurate BP Measurement

““Persons should be seated quietly for 5 minutes Persons should be seated quietly for 5 minutes with feet on the floor and the arm supported at with feet on the floor and the arm supported at heart level”heart level”

Cuff must be appropriately sized (cuff bladder Cuff must be appropriately sized (cuff bladder must encircle 80% of the arm)must encircle 80% of the arm)

Check both arms and a leg (or palpate pulses Check both arms and a leg (or palpate pulses carefully)carefully)

Caffeine and Tobacco can transiently raise BP Caffeine and Tobacco can transiently raise BP substantiallysubstantially

White Coat HypertensionWhite Coat Hypertension

20-30% of Apparently Resistant Hypertension May 20-30% of Apparently Resistant Hypertension May be due to “White-Coat Hypertension”be due to “White-Coat Hypertension”

Patients with WCH have an increased risk of CV Patients with WCH have an increased risk of CV events and often have some degree of end organ events and often have some degree of end organ damagedamage

Use home or ambulatory monitoring to sort outUse home or ambulatory monitoring to sort out

Home and Ambulatory BP Home and Ambulatory BP Monitoring (ABPM)Monitoring (ABPM)

Often lower than office readingsOften lower than office readings Useful to “calibrate” home monitorsUseful to “calibrate” home monitors Nocturnal Dip (10-20% fall during the night) Nocturnal Dip (10-20% fall during the night)

is physiologically important (Dippers vs. is physiologically important (Dippers vs. Non-Dippers)Non-Dippers)

Can identify “windows of poor control” or Can identify “windows of poor control” or windows of low BP and correlate with windows of low BP and correlate with perceived symptomsperceived symptoms

The assessment of the new The assessment of the new hypertensivehypertensive

What do you do and why?What do you do and why?

What to ask?What to ask?

Height and weight.Height and weight. AlcoholAlcohol SmokingSmoking Diet, fats and saltDiet, fats and salt Exercise.Exercise. Stress.Stress.

Assess for secondary causesAssess for secondary causes

When might you suspect this?When might you suspect this? What might they be?What might they be? How would for check for them?How would for check for them?

Other medical conditions to take into Other medical conditions to take into account.account.

Ischaemic heart disease.Ischaemic heart disease. Cerebrovascular disease.Cerebrovascular disease. Renal disease.Renal disease. Peripheral vascular diseasePeripheral vascular disease Other conditions that might have a bearing on the Other conditions that might have a bearing on the

treatment chosen.treatment chosen.

Checking blood pressure at homeChecking blood pressure at home

Some monitors are inaccurate and are not Some monitors are inaccurate and are not calibrated.calibrated.

Wrist monitors are not usually accurate.Wrist monitors are not usually accurate. Can give multiple recordings and help in Can give multiple recordings and help in

management of white coat hypertension.management of white coat hypertension. Involves patient in the management.Involves patient in the management. Results should be factored up by 10/5.Results should be factored up by 10/5.

White coat hypertensionWhite coat hypertension

Prevalence of 10-30%Prevalence of 10-30% Increases with age.Increases with age. White coat hypertension maybe the White coat hypertension maybe the

precursor for hypertension.precursor for hypertension. There maybe an increased risk of CVDThere maybe an increased risk of CVD

Routine Laboratory TestsRoutine Laboratory Tests

1. Urinalysis

2. Complete blood count

3. Blood chemistry (potassium, sodium and creatinine)

4. Fasting glucose

5. Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides

6. Standard 12-leads ECG

Investigation of all patients with hypertension

Optional Laboratory TestsOptional Laboratory Tests

Investigation for specific patient subgroups

• For those with diabetes or renal disease:assess urinary protein excretion, since lower blood pressure targets are appropriate if proteinuria is present.

• For those suspected of having an endocrine cause for the high blood pressure, or renovascular hypertension, see following slides.

• Other secondary forms of hypertension require specific testing.

1

To reduce the possibility of becoming hypertensive,

1. Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt in accordance with Canada's Guide to Healthy Eating

2. Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 3-5/week at least 4/week

3. Low risk alcohol consumption (≤2 drinks/day or less than 14/week for men and less than 9/week for women)

4. Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

5. Waist Circumference< 102 cm for men< 88 cm for women

5. Restriction of salt intake to less than 100 mmol/day in individuals considered salt-sensitive, such as: Canadians of African descent, age over 45, individuals with impaired renal function or with diabetes.

6. Smoke free environment

Lifestyle Recommendations for Prevention of Lifestyle Recommendations for Prevention of

Hypertension for NON-Hypertensive Individuals.Hypertension for NON-Hypertensive Individuals.

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