Dr Manish Ruhela HYPERTENSION IN INDIA
Hypertension in India Dr Manish Ruhela
Jul 08, 2015
Seminar on hypertension in India
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Transcript
Dr Manish Ruhela
HYPERTENSION IN INDIA
Introduction
Hypertension is the most common important preventable condition
seen in primary care and leads to Myocardial infarction Stroke Renal
failure and death if not detected early and treated appropriately
Epidemiology of Hypertension
As per the World Health Statistics 2012 of the estimated57million global deaths in 2008 36 million (63) weredue to non communicable diseases (NCDs)
The largest proportion of NCD deaths is caused bycardiovascular diseases (48)
In terms of attributable deaths raised blood pressure isone of the leading behavioral and physiological riskfactor to which 13 of global deaths are attributed
Hypertension is reported to be the fourth contributor topremature death in developed countries and the seventhin developing countries
Recent reports indicate that nearly 1 billion adults (morethan a quarter of the worldrsquos population) had hypertension in2000 and this is predicted to increase to 156 billion by 2025
Earlier reports also suggest that the prevalence ofhypertension is rapidly increasing in developing countriesand is one of the leading causes of death and disability
While mean blood pressure has decreased in nearly all high-income countries it has been stable or increasing in mostAfrican countries
Today mean blood pressure remains very high in manyAfrican and some European countries The prevalence ofraised blood pressure in 2008 was highest in the WHOAfrican Region at 368
The Global Burden of Diseases Chronic Disease RiskFactors Collaborating Group has reported 35-year (1980-2005) trends in mean levels of body mass index (BMI)systolic BP and cholesterol in 199 high-income middle-income and low-income countries
Mean systolic BP declined in high and middle-incomecountries but increased in low-income countries and isnow more than in high-income countries
The India specific data are similar to the overall trends inlow-income countries
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Introduction
Hypertension is the most common important preventable condition
seen in primary care and leads to Myocardial infarction Stroke Renal
failure and death if not detected early and treated appropriately
Epidemiology of Hypertension
As per the World Health Statistics 2012 of the estimated57million global deaths in 2008 36 million (63) weredue to non communicable diseases (NCDs)
The largest proportion of NCD deaths is caused bycardiovascular diseases (48)
In terms of attributable deaths raised blood pressure isone of the leading behavioral and physiological riskfactor to which 13 of global deaths are attributed
Hypertension is reported to be the fourth contributor topremature death in developed countries and the seventhin developing countries
Recent reports indicate that nearly 1 billion adults (morethan a quarter of the worldrsquos population) had hypertension in2000 and this is predicted to increase to 156 billion by 2025
Earlier reports also suggest that the prevalence ofhypertension is rapidly increasing in developing countriesand is one of the leading causes of death and disability
While mean blood pressure has decreased in nearly all high-income countries it has been stable or increasing in mostAfrican countries
Today mean blood pressure remains very high in manyAfrican and some European countries The prevalence ofraised blood pressure in 2008 was highest in the WHOAfrican Region at 368
The Global Burden of Diseases Chronic Disease RiskFactors Collaborating Group has reported 35-year (1980-2005) trends in mean levels of body mass index (BMI)systolic BP and cholesterol in 199 high-income middle-income and low-income countries
Mean systolic BP declined in high and middle-incomecountries but increased in low-income countries and isnow more than in high-income countries
The India specific data are similar to the overall trends inlow-income countries
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Epidemiology of Hypertension
As per the World Health Statistics 2012 of the estimated57million global deaths in 2008 36 million (63) weredue to non communicable diseases (NCDs)
The largest proportion of NCD deaths is caused bycardiovascular diseases (48)
In terms of attributable deaths raised blood pressure isone of the leading behavioral and physiological riskfactor to which 13 of global deaths are attributed
Hypertension is reported to be the fourth contributor topremature death in developed countries and the seventhin developing countries
Recent reports indicate that nearly 1 billion adults (morethan a quarter of the worldrsquos population) had hypertension in2000 and this is predicted to increase to 156 billion by 2025
Earlier reports also suggest that the prevalence ofhypertension is rapidly increasing in developing countriesand is one of the leading causes of death and disability
While mean blood pressure has decreased in nearly all high-income countries it has been stable or increasing in mostAfrican countries
Today mean blood pressure remains very high in manyAfrican and some European countries The prevalence ofraised blood pressure in 2008 was highest in the WHOAfrican Region at 368
The Global Burden of Diseases Chronic Disease RiskFactors Collaborating Group has reported 35-year (1980-2005) trends in mean levels of body mass index (BMI)systolic BP and cholesterol in 199 high-income middle-income and low-income countries
Mean systolic BP declined in high and middle-incomecountries but increased in low-income countries and isnow more than in high-income countries
The India specific data are similar to the overall trends inlow-income countries
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Recent reports indicate that nearly 1 billion adults (morethan a quarter of the worldrsquos population) had hypertension in2000 and this is predicted to increase to 156 billion by 2025
Earlier reports also suggest that the prevalence ofhypertension is rapidly increasing in developing countriesand is one of the leading causes of death and disability
While mean blood pressure has decreased in nearly all high-income countries it has been stable or increasing in mostAfrican countries
Today mean blood pressure remains very high in manyAfrican and some European countries The prevalence ofraised blood pressure in 2008 was highest in the WHOAfrican Region at 368
The Global Burden of Diseases Chronic Disease RiskFactors Collaborating Group has reported 35-year (1980-2005) trends in mean levels of body mass index (BMI)systolic BP and cholesterol in 199 high-income middle-income and low-income countries
Mean systolic BP declined in high and middle-incomecountries but increased in low-income countries and isnow more than in high-income countries
The India specific data are similar to the overall trends inlow-income countries
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The Global Burden of Diseases Chronic Disease RiskFactors Collaborating Group has reported 35-year (1980-2005) trends in mean levels of body mass index (BMI)systolic BP and cholesterol in 199 high-income middle-income and low-income countries
Mean systolic BP declined in high and middle-incomecountries but increased in low-income countries and isnow more than in high-income countries
The India specific data are similar to the overall trends inlow-income countries
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Global Burden of Hypertension2025 Projection
264 of world adult
population had hypertension
Total of 972 million adults
Highest prevalence is in
established market economies (eg North
America Europe)
bull 292 of world adult population will
have hypertension
bull Total of 156 billion adults
(60 overall 24 in
developed nations 80 in developing nations)
bull Highest prevalence will be in
economically developing continents (eg Asia Africa)
ndash will account for 75 of worldrsquos hypertensive patients
Year 2000 Year 2025
Kearney PM et al Lancet 2005365217-223
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The Natural History of UntreatedHypertension
Untreated hypertension is a self-accelerating conditionEvolving arteriolar hypertrophy and endothelial dysfunctionfacilitate the later increase of BP transition to higher stage
A summary of nearly all placebo- controlled early outcomestrials in hypertension indicated that
1493 of 13342 (112) subjects in the placebo groupsprogressed in stages of hypertension
Compared with only 95 of 13389 ( 07) in the drug-treatedgroups
Hansen TW Staessen JA Zhang H et al Cardiovascular outcome in relation to progression to hypertension in the Copenhagen MONICA cohort Am J Hypertens 200720 483-491
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Attributable Risk
Only half of the burden seen in people with hypertension
(BP gt 140 mmHg) remainder in prehypertensives (BP gt 115mmHg)
gt 80 of the burden seen in low-income and middle-income regions
Over half occurred in people aged 45-69 yrs
54 stroke
47 IHD
25 other CVD
135 Total mortality
Study by Int Society of hypertension Lancet May 20083711513-8
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Global Leading Risks for Death
Systolic blood
pressure gt 115
mmHg
Global Burden of Disease Study 2010 Lancet 2012 380 2224ndash60
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
National The prevalence of hypertension in the late nineties and early
twentieth century varied among different studies in India rangingfrom 2-15 in Urban India and 2-8 in Rural India
Review of epidemiological studies suggests that the prevalence ofhypertension has increased in both urban and rural subjects andpresently is 25 in urban adults and 10-15 among rural adults
In a meta-analysis of multiple cardiovascular epidemiologicalstudies it was reported that prevalence rates of coronary arterydisease and stroke have more than trebled in the Indianpopulation In the INTERHEART and INTERSTROKE studyhypertension accounted for 179 and 346 of populationattributable risk of various cardiovascular risk factors for coronaryartery disease and stroke respectively
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
As per the Registrar General of India and Million Death Studyinvestigators (2001-2003) CVD was the largest cause ofdeaths in males (203) as well as females (169) and led toabout 2 million deaths annually
The Global Status on Non- Communicable Diseases Report(2011) has reported that there were more than 25 milliondeaths from CVD in India in 2008 two-thirds due to coronaryartery disease and one-third to stroke
These estimates are significantly greater than thosereported by the Registrar General of India and shows thatCVD mortality is increasing rapidly in the country CVD is thelargest cause of mortality in all regions of the country
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
There are large regional differences in cardiovascularmortality in India among both men and women Themortality is highest in south Indian states eastern andnorth eastern states and Punjab in both men andwomen while mortality is the lowest in the central Indianstates of Rajasthan Uttar Pradesh and Bihar
The prospective phase of the ongoing Million DeathsStudy from 2004-2013 shall provide robust data onregional variations and trends in CVD mortality in India
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The prevalence of hypertension in the last six decades hasincreased from 2 to 25 among urban residents and from2 to 15 among the rural residents in India
According to Directorate General of Health Government ofIndia the overall prevalence of hypertension in India by 2020will be 159461000 population
Factors responsible for this rising trend
increased life expectancy
urbanization
lifestyle changes sedantry habits
increasing salt intake
overall epidemiologic transition India is experiencing
increased awareness of HTN and its detection
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
India- Soon Heading Towards Being Hypertension Capital
604
1073
578
1062
0
20
40
60
80
100
120
2000 2025No
o
f p
eo
ple
wit
h h
yp
ert
en
sio
n
in In
dia
(m
illio
ns
)
Men Women
Lancet 2005365217-23 JHH 20041873-8J Assoc Physicians India 200755323-4
At least 1 out of every 5 adult Indians has hypertension
Age gt 20 yrs
Hypertension is responsible for 57 of all stroke deaths
and 24 of all CHD deaths in India
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The prevalence of high normal blood pressure (alsocalled pre hypertension in JNC-VII) has been seen inmany recent studies and was found to be around 32 ina recent urban study from Central India
In some studies from South India (Chennai) and fromDelhi prevalence of high normal blood pressure has beeneven higher upto 36 and 44 respectively in theseregions The prevalence of hypertension increases withage in all populations In a recent urban study it increasedfrom 137 in the 3rd decade to 64 in the 6th decade
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
In last 2 decades the prevalence of hypertension has beenseen to be static in some urban areas The prevalence ofsmoking has declined while that of diabetes metabolicsyndrome hypercholesterolemia and obesity has beenincreasing
Hypertension awareness treatment and control status islow with only half of the urban and a quarter of the ruralhypertensive individuals being aware of its presence
It has been seen that only one in five persons is ontreatment and less than 5 are controlled
Rural location is an important determinant of poorhypertension awareness treatment and control
It has been said that in India the rule- of-halves is not validand only a quarter to a third of subjects are aware ofhypertension
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The Rule of Halvesbull Only 12 have been diagnosed
bull Only 12 of those diagnosed have been treated
bull Only 12 of those treated are adequately controlled
bull Thus only 125 overall are adequately controlled
19
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Preventive measures are required so as to reduce obesityincreasing physical activity decreasing the salt intake ofthe population and a concerted effort to promoteawareness about hypertension and related risk behaviors
Two upcoming studies for identification of regionaldifferences of CVD risk factors in India are the India HeartWatch and PURE studies
PURE is a prospective study localized to five urban and fiverural locations while India Heart Watch has centres all overthe country
These studies shall further highlight the prevalence andregional variations of hypertension as a CVD risk factor
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
In conclusion this review shows that there are wide regionalvariations in cardiovascular disease mortality and burden in IndiaApart from the well known gender based differences there arevariations in mortality in different states and in urban and ruralregions and among different socioeconomic groups within statesAlthough no nationwide study of risk factors exists review suggests thatthere are significant state-level and rural-urban differences in majorcardiovascular risk factors of smoking obesity central obesityhypertension hypercholesterolemia and diabetes However there isneed to perform nationwide studies for determining cardiovascularrisk factors using uniform protocols to assess regional differencesThere is also a need to determine the ldquocauses of the causesrdquo orprimordial determinants of these risk factors The India Heart Watchstudy shall be able to provide some of these answers
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
THE PURE STUDYAN OVERVIEW FROM INDIA
Prospective Urban Rural Epidemiology ( PURE )
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
To asses hypertension prevalenceawareness treatment and control in urban and rural communities in multiple countries
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Overall Prevalence of Hypertension by
Location Smoking status Gender Cooking Fuel
Variable Category Adjusted rate P Values
Smoking Status Not Smoker 99 0062
Smoker 81
Gender Female 84 0283
Male 95
Location Rural 63 lt0001
Urban 127
Cooking Fuel Other 117 lt0001
Solid Fuel 68
Female smoking status Not smoker 101 0086
Smoker 70
Male smoking status Not smoker 98 0450
Smoker 92
Adjusted for age smoking cooking fuel location amp gender
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Conclusion Hypertension in PURE Highly prevalent in all communities
Awareness is low
Once aware substantial proportion are treated but control of BP is poor
Few people with HTN are on 2 or more drugs
Alternative strategies to detect ( systematic screening) by simplified algorithm algorithms and early use of combination therapies (polypill) are critical to controlling this epidemic
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
PREVALENCE OF HYPERTENSION IN INDIA
2001 - 118 million 2025 - 214 million Till early 1980s ndash prevalence 3 - 4 Mid 1990s urban areas 25 ndash 29 rural areas 10 -13
(ICMR 1994) Sentinel Surveillance Project documented 28
prevalence of hypertension (criteria =JNC VI) from 10 regions of the country in the age group 20-69 years
Gupta (1994 2001 2003) through 3 serial epidemiological studies (Criteriagt=14090 mm of Hg) demonstrated rising prevalence of hypertension (30 36 and 51 respectively among males and 34 38 and 51 among females)
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
PREVALENCE VARIES ACCORDING TO
AGE
SEX
BP CUT OFF VALUE
DEVELOPING vs DEVELOPED COUNTRIES
ETHNIC
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
CHANGING HEALTH SCENARIO - MAJOR
FACTORS OF MORTALITY
MALNUTRITION
INFECTION
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
CHANGING HEALTH SCENARIO - COMMON CAUSES OF MORTALITY
CARDIO - VASCULAR DISEASES
CEREBRO - VASCULAR DISEASES
RENAL DISEASES
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
COMMON DENOMINATOR
UNDERLYING HYPERTENSION
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
WHY THIS SHIFT
IMPROVING HYGEINE
INFECTION CONTROL STEPS
BETTER DRUGS amp VACCINES
BASIC MEDICAL FACILITY AVAILABLE
TO COMMON MAN
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
THE URBAN LIFE
INCREASE STRESS LEVELS
SMOKING
ALCOHOLISM
CHANGING FOOD HABITS
SEDENTARY JOBS
NO PHYSICAL EXCERCISE
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
THE PRICE WE PAY
10 - 20 PREVALENCE OF HYPERTENSION
ALL OVER THE WORLD
APPLY TO INDIAN SCENARIO
THE HYPERTENSIVE POPULATION IS
APPROXIMATELY 12CRORES
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
ldquoWHOrdquo - ON HYPERTENSION
A MAJOR HEALTH PROBLEM
COMPLEX AND MULTI DIMENSIONAL
APPROACH
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
GOOD NEWS
PERSISTANT REDUCTION OF BP
CVD CORONARY DEATH
5mmHg 34 21
75mmHg 46 29
10mm Hg 56 37
Hypertension 20032892560-2572
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
35-40
20-25
gt50
Average reduction
in events ()
ndash60
ndash50
ndash40
ndash30
ndash20
ndash10
0
StrokeMyocardialinfarction Heart failure
Blood Pressure Lowering Treatment Trialistsrsquo Collaboration Lancet 20003551955-1964
Long-Term Antihypertensive Therapy Significantly Reduces CV Events
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
BAD NEWS
Patients with DBP gt 105mmHg - 10 fold
in stroke 5 fold in Cardio vascular
disease
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
THE INDIAN SCENARIO
MYTHS amp FACTS
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
MYTH - HYPERTENSIVES ARE
SYMPTOMATIC
FACT - 90 ARE ASYMPTOMATIC
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
MYTH - HYPERTENSION IS
DISEASE OF ELDERLY
FACT - NO AGE FOR HYPERTENSION
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
MYTH - ONCE DIAGNOSED START
DRUGS
FACT - EVALUATE FOR SECONDARY HTN STRESS ON LIFE STYLE
MODIFICATION
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
MYTH - STOP DRUGS ONCE BP IS
NORMAL
FACT - HTN IS CONTROLLABLE
NOT CURABLE
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
MYTH - REGULAR INTAKE OF DRUGS
CAN PRODUCE SIDE EFFECTS
FACT - UNCONTROLLED HTN PRODUCES
ENDORGAN DAMAGES
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
2013
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Hypertension is a major contributor to cardiovascularmorbidity and mortality in India and worldwide In viewof our special geographical and climatic conditionsethnic background dietary habits literacy levels andsocio- economic variables there could be some areaswhere significant differences need to be addressed Withthis in mind the Association of Physicians of India (API)Cardiological Society of India (CSI) the Indian College ofPhysicians (ICP) and the Hypertension Society of India(HSI) developed the ldquoFIRST INDIAN GUIDELINES FORTHE MANAGEMENT OF HYPERTENSION - 2001rdquo
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The second Indian guidelines were published in 2007 Ever sincesignificant new data on epidemiology of hypertension hasemerged globally and so also from India
It was therefore felt necessary to update the Indian guidelines toalign them with the current best evidence
Hence the third Indian Guidelines on Hypertension (IGH)-III
are being published now in 2013 under the aegis of API
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The primary aim of these guidelines is to offer balancedinformation to guide clinicians rather than rigid rulesthat would constrain their judgment about themanagement of individual adult patients who will differin their personal medical social economic ethnic and
clinical characteristics
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Methodology
In consonance with the first and second guidelines arevised format was evolved by the Core committeewhich was then reviewed by 300 physicians andspecialists from across the country whose inputshave been incorporated Like the previousguidelines this document has also been studiedreviewed and endorsed by the CSI HypertensionSociety of India (HSI) Indian College of Physicians(ICP) Indian Society of Nephrology (ISN) ResearchSociety for Study of Diabetes in India (RSSDI) andIndian Academy of Diabetes (IAD)
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Definition and classification There is a continuous relationship between the level of
blood pressure and the risk of complications Starting at11575 mmHg CVD risk doubles with each increment of2010 mmHg throughout the blood pressure range
All definitions of hypertension issued by variousinternational authorities are arbitrary There is someevidence that the risk of cardiovascular events in AsianIndians is higher at relatively lower levels of blood pressure(BP)
Hypertension in adults age 18 years and older is defined assystolic blood pressure (SBP) of 140 mmHg or greaterandor diastolic blood pressure (DBP) of 90 mmHg orgreater or any level of blood pressure in patients takingantihypertensive medication
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Classification
The positive linear relationship between SBP and DBP and cardiovascular risk has long been recognized
This relationship is strong continuous graded consistent independent predictive and etiologically significant for those with and without CAD
For persons over age 50 SBP is more important than DBP as a CVD risk factor SBP is more difficult to control than DBP SBP needs to be as aggressively controlled as DBP
Therefore although classification of adult blood pressure is somewhat arbitrary it is useful for clinicians who make treatment decisions based on a constellation of factors along with the actual level of blood pressure
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
This classification is for individuals who are not takingantihypertensive medication and who have no acute illness and isbased on the average of two or more blood pressure readings takenat least on two subsequent occasions one to three weeks apartafter the initial screening
When SBP and DBP fall into different categories the highercategory should be selected to classify the individualrsquos bloodpressure
The term lsquoPrehypertensionrsquo introduced in the JNC VII guidelinesincludes a wide range of BP from normal to high normal It is feltthat the term ldquoprehypertensionrdquo is more likely to create anxiety in alarge subset of population Hence they do not recommend the useof the term ldquopre- hypertensionrdquo
There is emerging evidence that the high normal group needs to betreated sometimes in the presence of family history of hypertensionand concomitant diseases like diabetes and (TOD)
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Prehypertension
SBP 120ndash139 or DBP 80ndash89
CV risk increases progressively from levels as low as 115mmHg SBP
54 of stroke and 46 of ischemic heart disease eventsoccurring in persons with blood pressures in this range
Lawes CM Vander Hoorn S Rodgers A International Society of Hypertension Global burden of blood pressure- related disease 2001 Lancet 2008
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Progress to HTN
Among patients gt 35 yr or more than 17 of those with normal BP
and 37 of those with BP in the prehypertensive range progress to
overt hypertension within 4 years without changes in lifestyle or
pharmacological intervention
Vasan RS Larson MG Leip EP Kannel WB Levy D Assessment of frequency of progression to hypertension in non-hypertensive participants in the Framingham Heart Study a cohort study Lancet 2001 358(9294)1682-1686
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Acta Cardiol 2011 Feb66(1)29-37
Prevalence and risk factors for prehypertension and hypertension in five Indian cities
Singh RB1 Fedacko J Pella D Macejova Z Ghosh S de Amit K Begom R Tumbis ZA Haque M Vajpeyee SK de Meester F Sergey C Agarwalo RMuthusamy VV Five City Study Group Gupta AK
BACKGROUND
There are few studies detailing the prevalence of prehypertension and hypertension in India
RESULTS
Prevalence of prehypertension and hypertension respectively was significantly greater in South India (TrivandrumW 315 319 M 351 355) and West India (Mumbai W 300 291 M 347 356) compared to North India (Moradabad W 246 245 M 267 270) and East India (Kolkata W 209 224 M 235 240) Subjects with prehypertension and hypertension were older had a higher BMI central obesity and a sedentary lifestyle They had a higher salt and alcohol intake with greater oral contraceptive usage (W) Multivariable logistic regression analysis revealed strong positive associations of hypertension with age central obesity BMI sedentary lifestyle salt and alcohol intake and oral contraceptive usage (W) Fruit vegetable and legume intake showed inverse associations tobacco intake showed none One in four with hypertension was aware of their diagnosis and of those receiving treatment one in three had well-controlled hypertension
CONCLUSIONS
There is little awareness that prehypertension and hypertension are public health issues in India Ageing population central obesity sedentary lifestyle excessive salt and alcohol lower fruit vegetable and legumes intake increase risk for blood pressure elevation
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Evaluation
Evaluation of patients with documentedhypertension has three objectives
bull To identify known causes of high blood pressure
bull To assess the presence or absence of target organdamage
bullTo identify other cardiovascular risk factors orconcomitant disorders that may define prognosisand guide treatment
Data for evaluation is acquired through medicalhistory physical examination laboratory tests andother special diagnostic procedure
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Medical History Duration and level of elevated blood pressure if known
Symptoms of CAD CHF CVD PAD and CKD
DM dyslipidaemia obesity gout sexual dysfunction and other co-morbid conditions
Family history of HTN obesity premature CAD and strokedyslipidaemia and diabetes
Symptoms suggesting secondary causes of hypertension
History of smoking or tobacco use physical activity dietary assessmentincluding intake of sodium alcohol saturated fat and caffeine
Socioeconomic status professional and educational levels
History of use intake of all prescribed and over-the-countermedications herbal remediesThese may raise blood pressure or interferewith the effectiveness of antihypertensive drugs
History of OCPs use and hypertension during pregnancy
History of previous antihypertensive therapy including adverse effectsexperienced if any
bull Psychosocial and environmental factors
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Most Common Causes of Secondary Hypertension by Age
Am Fam Physician 2010 Dec 1582(12)1471-8
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Physical Examination Record three blood pressure readings separated by 2
minutes with the patient either supine or sitting positionand after standing for at least 2 minutes
Record height weight and waist circumference
Examine the pulse and the extremities for delayed or absentfemoral and peripheral arterial pulsations bruits and pedaledema
Examine the abdomen for bruits enlarged kidneys massesand abnormal aortic pulsation
Examine the optic fundus and do a neurological assessment
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The cost of investigations in the context of the needs ofan individual patient and resources available is animportant consideration
In patients with essential hypertension where there is aresource crunch one may be required to initiate therapywithout carrying out any laboratory investigations
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Laboratory Investigations
Routine
Urine examination for protein and glucose and microscopic examination for RBCs and other sediments
Haemoglobin fasting blood glucose serum creatinine potassium and total cholesterol ECG
Investigations in special circumstances can include ndash
Echocardiogram
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Management of hypertension
Goals of therapy
The primary goal of therapy of hypertension shouldbe effective control of BP in order to preventreverse or delay the progression of complicationsand thus reduce the overall risk of an individualwithout adversely affecting the quality of life
Patients should be explained that the lifestylemodifications and drug treatment is generallylifelong and regular drug compliance is important
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Initiation of therapy
Having assessed the patient and determined the overall risk profile management of hypertension should proceed as follows
In low risk patients it is suggested to institute life style modifications and observe BP for a period of 2-3 months before deciding whether to initiate drug therapy
In medium risk patients institute life style modifications and initiate drug therapy after 2-4 weeks in case BP remains above 14090
In high and very high-risk groups initiate immediate drug treatment for hypertension and other risk factors in addition to instituting life-style modification
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Management Strategy
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Non-Pharmacological therapy
Life style measures should be instituted in all patients including those who require immediate drug treatment These include
Patient education Patients need to be educated about the various aspects of the disease adherence to life style changes on long term basis and need for regular monitoring and therapy
Weight reduction Weight reduction of even as little as 45 kg has been found to reduce blood pressure in a large proportion of overweight persons with hypertension
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Physical activity
Regular aerobic physical activity can promote weight lossincrease functional status and decrease the risk ofcardiovascular disease and all cause mortality
A program of 30ndash45 minutes of brisk walking or swimmingat least 3ndash4 times a week could lower SBP by 7ndash8 mmHg
Alcohol intake
Excess alcohol intake causes a rise in blood pressureinduces resistance to antihypertensive therapy and alsoincreases the risk of stroke
Alcohol consumption should be limited to no more than 2drinks per day (24oz beer 10 oz wine 30 oz 80- proofwhiskey) for most men and no more than 1 drink 2 per dayfor women and lighter weight people
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Salt intake
Epidemiological evidence suggests an associationbetween dietary salt intake and elevated blood pressureThe total daily intake of salt should be restricted to 6 gms(amounting to 3ndash4 gms of sodium) however in hotsummer this may be relaxed
Patients should be advised to avoid added saltprocessed foods and salt-containing foods such aspickles papads chips chutneys and preparationscontaining baking powder
In the Indian context salt restriction is more importantas Indian cooking involves a high usage of salt
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The Salt Controversy and Hypertension
The WHO recommends a sodium intake of less than 2 gper day based on projections made from small clinicaltrials in primary prevention populations
Recent studies suggest that both low and high sodiumintake are harmful and salt intake should be limited to 4 gfrasld to 5 gfrasld
Stolarz-Skrzypek K Kuznetsova T Thijs L et al European Project on Genes in Hypertension (EPOGH) Investigators Fatal and nonfatal outcomes incidence of hypertension and blood pressure changes in relation to urinary sodium excretion JAMA 2011
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
OPTIMAL SODIUM INTAKE IN HIGH RISK PATIENTS
A recent publication in high CV risk patientsdemonstrated the association between urinary sodiumexcretion and CV events may be J-shaped based on datafrom ONTARGET and TRANSCEND studies
OrsquoDonnell MJ Yusuf S Mente A et al Urinary sodium and potassium excretion and risk of cardiovascular events JAMA 20113062229ndash2238
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Salt reduction is associated with a small physiological
increase in plasma renin activity aldosterone and
noradrenaline and no significant change in lipid
concentrations
Their results showed larger reductions in salt intake will
lead to larger falls in systolic blood pressure
Further Reduction to 3 gday will have a greater effect and
should become the long term target for population salt
intake
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Slow reduction in salt intake as currently recommended
has a significant effect on blood pressure both in
individuals with raised blood pressure and in those with
normal blood pressure
Measurement error in assessing daily salt intake Sudden
reduction in salt intake with neuro harmonal activation
and Reverse causality may be responsible for J curve
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Smoking
Smoking or consumption of tobacco in any formis the single most powerful modifiable lifestylefactor for prevention of major cardiovascular andnon- cardiovascular disease in hypertensives
Cardiovascular benefits of cessation of smokingcan be seen within one year in all age groups
Yoga and Meditation
Yoga meditation and biofeedback have beenshown to reduce blood pressure
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Diet- Vegetarians have a lower blood pressure compared to non-veg This is due to a
higher intake of fruit vegetables fibers coupled with a low intake of saturatedfats and not due to an absence of intake of meat protein
- Intake of saturated fats is to be reduced since concomitant hyperlipidemia isoften present in hypertensives
- Regular fish consumption may enhance blood pressure reduction in obesehypertensives
- Adequate potassium intake from fresh fruits and vegetables may improve bloodpressure control in hypertensives
- Caffeine intake increases blood pressure acutely but there is rapid developmentof tolerance to its pressor effect Epidemiological studies have notdemonstrated a direct link between caffeine intake and high blood pressure
Thus the diet in hypertensives should be low calorie lowfat and low sodium with normal protein intake
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Pharmacologic therapy Principles of drug treatment Over the past decade the goals of treatment have
gradually shifted from optimal lowering of bloodpressure which is taken for granted to patientrsquosoverall well-being control of associated risk factorsand protection from future target organ damage
Achieve gradual reduction of blood pressure Uselow doses of antihypertensive drugs to initiatetherapy
Five classes of drugs can be recommended as firstline treatment for stage 1ndash2 hypertension Theseinclude 1) ACE inhibitors 2) angiotensin II receptorblockers 3) calcium channel blockers 4) diureticsand 5) b-blockers
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
The Blood Pressure LoweringTreatmenTrialists Collaboration concluded that treatment with any commonly used regimen reduces the risk of total major cardiovascular events and larger reductions in blood pressure produce larger reductions in risk
Choice of an antihypertensive agent is influenced by age concomitant risk factors presence of target organ damage other co-existing diseases socioeconomic considerations availability of the drug and past experience of the physician
Combining low doses of two or more drugs having synergistic effect is likely to produce lesser side effects In 60ndash70 of patients goal blood pressure will be achieved with two or more agents only
Use of fixe dose formulations should be considered to improve compliance
Drugs with synergistic effects should be combined pertinently to enhance BP lowering effect so as to achieve target BP
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Use of long acting drugs that provide 24-hour efficacy withonce daily administration ensures smooth and sustainedcontrol of blood pressure which in turn is expected toprovide greater protection against the risk of majorcardiovascular events and target organ damage Once dailyadministration also improves patient compliance
Although antihypertensive therapy is generally lifelong aneffort to decrease the dosage and number ofantihypertensive drugs should be considered after effectivecontrol of hypertension (step-down therapy)
Due to a greater seasonal variation of temperatures inIndia marginal alterations in dosages of drugs may beneeded from time to time
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Consensus Target BP Levels Since JNC 7 in the Prevention and Management of
Ischemic Heart DiseaseAmerican Heart Association (AHA) Scientific Statement
Area of Concern BP Target (mmHg)
General CAD prevention lt14090
High CAD risk lt13080
Stable Angina lt13080
Unstable AnginaNSTEMI lt13080
STEMI lt13080
LV Dysfunction lt12080
High CAD risk = diabetes mellitus chronic kidney disease known CAD CAD equivalent (carotid artery disease peripheral artery disease abdominal aortic aneurysm) or 10-year Framingham risk score gt10
Rosendorff et al Circulation2007115 2761-2788
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Conclusion
Hypertension is a major public health problem inIndia and its prevalence is rapidly increasingamong both urban and rural populations In facthypertension is the most prevalent chronicdisease in India
The prevalence of hypertension ranges from 20-40 in urban adults and 12-17 among ruraladults
The number of people with hypertension isprojected to increase from 118 million in 2000 to214 million in 2025 with nearly equal numbers ofmen and women
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Reducing blood pressure can decreasecardiovascular risk and this can be achievedby lifestyle measures in mild cases and shouldbe the initial approach to hypertensionmanagement in all cases
But unlike in Western countries stressmanagement is often given greater emphasisin India
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Because of the heightened risk therecommended targets are lower for allIndianslt13085 and lt12080 for those withdiabetes or heart failure
Comprehensive hypertension managementshould focus not only on reducing the bloodpressure but reducing the cardiovascular riskby lifestyle measures lipid managementsmoking cessation and regular exercise
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
Balance your life when possiblehellip
hellipand make time for funhellip
And help others to achieve
well-beinghelliphellip
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