Prof. Jamal Al Wakeel Consultant Nephrology Division Department of Medicine HYPERTENSION
Feb 22, 2016
Prof. Jamal Al WakeelConsultant Nephrology Division
Department of Medicine
HYPERTENSION
Case 47 year old man came to your clinic with headache for 3 weeks. The nurse measure his Blood Pressure and was found to be 150/95 mmHg:
1. Does he have Hypertension?2. What is the stage of Hypertension?3. What investigation should you perform?4. What could be your management on his
case?5. Is their any possible prevention to his
disease and its complication?
The Objectives of this Lecture are:
1. To be able to recognize the definition of hypertension
2. To be able to identify the Stages of Hypertension
3. To find out the complication of Hypertension
4. To learn how to measure blood pressure
5. To familiarize with the test done for Hypertension
6. To acquire knowledge on how to treat hypertension
The 4th most common cause of death world-wideDirectly and indirectly responsible for >20% of all deaths From 1999 to 2009 the death rate from high blood pressure increased 17.1%29-30% (about 77.9 million, 1 out of very 3) incidence of hypertension adult of the United States.9.1% and 8.7% the population of Saudi Arabia with hypertension 160/95 mmHg
HYPERTENSION
Onset stage 25-55 years mainly in 40-50y Occurs over 30%of persons older tha 65 y
Only 34%-52.5% of persons with hypertension have their blood pressure under control.
Prevalence of High Blood Pressure inAdults Age 20 and Older NHANES: 2007–2010
20-34 35-44 45-54 55-64 65-74 ≥750
10
20
30
40
50
60
70
80
90
9.1
24.4
37.7
52
63.9
72.1
6.7
17.6
34
52
70.8
80.1
MaleFemale
Age (years)
Perc
ent
of P
opul
atio
n
Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.
BP Control RatesTrends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
II
1976–80
II(Phase
1)1988–
91
II(Phase
2)1991–
94
1999–2000
2007 - 2010
Awareness
51 73 68 70 81.5%
Treatment
31 55 54 59 74.9%
Control 10 29 27 34 52.5%Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. and American Heart Association: Statistical Fact Sheet 2013 Update
In 90%-95% of cases no cause can be found primary hypertension (essential)
Secondary hypertension 5-10%
Hypertension
Essential HTN
Risk factorsObesity---metabolic syndromeExcessive salt intake---low potassium intakeExcessive alcohol intake PolycythemiaLack of exercise Non-steroid anti-inflammatory drugsFamily history of essential HTN
Caffeine and smoking increase the BP acutely but are not risk factors for the development of chronic essential HTN
Primary renal diseaseOral contraceptivesSleep apnea syndromePrimary hyperaldosteronismRenovascular diseaseCushing’s syndromePheochromocytomaOther endocrine disorders Coarctation of the aorta
Secondary Hypertension
National Heart, Lung, and Blood Institute
National High Blood Pressure Education Program
The Seventh Report of the Joint National Committee
Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC 7)
U.S. Department of
Health and Human Services
National Institutes of Health
National Heart, Lung, and Blood
Institute
Blood Pressure Classification
BP Classification
SBP mmHg
DBP mmHg
Normal 120 and
<80
Pre-hypertension
120-139 or 80-89
Stage 1 HTN 140-159 or 90-99Stage 2 HTN >160 or >100
European Society of Nephrology Classification of Blood Pressure
Levels Category Systolic blood
pressure (mmHg)Diastolic blood
pressure (mmHg)Optimal blood
pressure<120 <80
Normal blood pressure
<130 <85
High-normal blood pressure
130-139 85-89
Grade 1 hypertension (mild)
140-159 90-99
Grade 2 hypertension (moderate)
160-179 100-109
Grade 3 hypertension (severe)
>/= 180 >/= 110
Isolated systolic hypertension
>140 <90
Stage 1Clinical Blood Pressure – 140/90 mmHgAmbulatory Blood Pressure day time Monitoring (ABPM) – 135/85 mmHgHome Blood Pressure Monitoring (HBPM) - 135/85 mmHg
Stage 2 Clinical Blood Pressure – 160/100 mmHgAmbulatory Blood Pressure day time Monitoring (ABPM) – 150/95 mmHgHome Blood Pressure Monitoring (HBPM) - 150/95 mmHg
Severe hypertension (Stage 3)Clinical Blood Pressure – 180/110 mmHg
National Institute for Health and Clinic Excellence Hypertension
Guidelines 2011 (UK)
Type of Instrument of Blood Pressure Measurement
Sphygmomanometer
Type of Instrument of Blood Pressure Measurement
Home Blood Pressure Monitoring
Type of Instrument of Blood Pressure Measurement
Ambulatory Pressure Monitoring
Apply to adults on no antihypertensive medications and who are not acutely ill.
If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension.
Measure blood pressure to arm the high reading.
Blood Pressure
Patient should be seated with the back straight and the arm supported at heart level
The patient should rest for 5 minutes
The bladder of the pressure cuff should encircle at least 80% of the upper arm
If BP measure =more140/90 mmHg, perform second reading. If second reading is still high, take third reading.
Measurement
The diagnosis of mild hypertension should not be made until the blood pressure has been measured on at least three to six visits
Average of 10 to 15 mmHg decrease between visits 1 and three
Approximately 20 to 25% of patients with mild office hypertension
More common in elderly
Infrequent in patients with office diastolic pressures ≥105 mmHg
White Coat Hypertension
HypertensionCAD, ECG,
Arrthymia, Sudden Death
Renal Disease
Peripheral Vascular Disease
Hypertensive EmergencyAnd Increase Emergency Morbidity
CHFLVH
Aortic Dissection
COMPLICATIONS
24
Risk of Hypertension for each 2 mmHg increase in systolic blood pressure
Increase risk of cardiovascular mortality by 7%
Risk of stroke by 10%
This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.
The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The
myocardial fibers have undergone hypertrophy.
Marked hypertension with encephapapathy& retinal hemorrhages, exudates, or papilledema
Associated with a diastolic pressure above 120 mmHg
Malignant Hypertension
Grade Description Alternative Description
A:V Ratio
I Minimal narrowing of retinal arteries
50%
II Narrowing of retinal arteries in conjunction with regions of focal narrowing and arterio-venous nipping
33%
III Abnormalities seen in Grade 1 and II, as well as retinal hemorrhages, hard exudation and cotton wool spots.
25%
IV Abnormalities encountered in Grades I through III, as well as swelling of the optic nerve head and macular star
<20%
HYPERTENSIVE RETINOPATHY
Generalized arteriolar
constriction-seen as
`silver wiring` and Vascular tortuosities
Hypertensive Retinopathy Grade 1
Hypertensive Retinopathy Grade 2
Arteriovenous nicking in association with hypertension Grade
2 (yellow arrow)
Hypertensive Retinopathy Grade 3
Flame-shaped hemorrhage in association with
severe hypertension Grade 3 (yellow arrow)
Hypertensive Retinopathy Grade 4
Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow)
Hypertensive Emergency
Hypertensive UrgencySevere hypertension (diastolic blood pressure above 120 mmHg) in asymptomatic patients
There is no proven benefit from rapid reduction in BP in asymptomatic patients who have no evidence of acute end-organ and are little short-term risk
Severe hypertension (diastolic blood pressure above 120 mmHg) in end organ damage (MI,STROKE,AKI,CHF)
Clinical Presentations:AsymptomaticHeadacheEpistaxisChest discomfortSymptom of complications
Screening:Every two years for persons with systolic and diastolic pressures below 120 mmHg and 80 mmHgYearly for persons with a systolic pressure of 120 to 139 mmHg OR Diastolic pressure of 80-89 mmHg
Diagnosis Hypertension
Presence of precipitating or aggravating factorsNatural course of the blood pressureExtent of target organ damagePresence secondary HTN of other risk factors for cardiovascular disease
History
To evaluate for signs of end-organ damage
For evidence of a cause of secondary hypertension
Physical Examination
Laboratory TestsRoutine Tests
ElectrocardiogramUrinalysis Serum sodium, serum potassium, creatinine, or the corresponding estimated GFR, and calciumBlood glucose, and hematocrit Lipid profile, after 9- to 12-hour fast, that includes high density and low-density lipoprotein cholesterol, and triglycerides
Optional tests Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
TREATMENT OF HYPERTENSION
Lifestyle modifications High normal SBP >130 – 139 mmHg
DBP 85 – 89 mmHg in high risk patients
Drug therapy If BP is 140/90 mmHg
Blood Pressure Target: (UK)
Age < 80 yrs (high risk) <140/90 mmHg
Age < 80 yrs (no risk) 140/90 mmHg
Age > 80 yrs 150/90 mmHg
Blood Pressure Target: (European)
<140/90 mmHg
Benefits of Lowering BP
Average Percent ReductionStroke incidence 35–40%
Myocardial infarction
20–25%
Heart failure 50%
Renal Failure 35-50%
Lifestyle ModificationModification Approximate SBP
reduction (range) Weight reduction 5–20 mmHg/10 kg
weight loss Adopt DASH eating 8–14 mmHg
Dietary sodium 2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Diet high in fruits and vegetables and low-fat dairy products
Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish.
NEJM 1997; 366: 1117-24.
Dietary Approaches To Stop Hypertension (DASH)
Follow-up And Monitoring
Patients should return for follow-up after 4 weeks and adjustment of medications until the BP goal is reached
More frequent visits for stage 2 HTN or with complicating co-morbid conditions.
Serum potassium and creatinine monitored 1–2 times per year.
A low dose of initial drug should be used, slowly titrating upward.
Optimal formulation should provide 24-hour efficacy with once-daily dose.
Combination therapies may provide additional efficacy with fewer adverse effects.
Drug Therapy
Diuretics → Hypokalemia
β-Adrenergic Blocking Agents → Bradycardia +
Angiotensin-Converting Enzyme Inhibitors → Hyperkalemia + cough
Angiotensin II Receptor Blockers → Hyperkalemia
Calcium Channel Blocking Agents → Edema + Tachycardia + Bradycardia
α-Adrenoceptor Antagonists → 1st dose hypotension
Drugs with Central Sympatholytic Action → Drowsiness
Arteriolar Dilators → Tachycardia + Edema
Summary of antihypertensive drug treatment
Key
A – ACE inhibitor or angiotensin II receptor blocker (ARB)12 C – Calcium-channel blocker (CCB)13 D – Thiazide-like diuretic
Resistant hypertensionA + C + D + consider further diuretic14, 15 or
alpha- or beta-blocker16
Consider seeking expert advice
Aged over 55 years or
black person of African
Step 4
Step 3
Step 2
Step 1
A + C + D
A
Aged under
55 years
C
A + C12 Choose a low-cost ARB.13 A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has edema, evidence of heart failure or a high risk of heart failure.14 Consider a low dose of spironolactone15 or higher doses of a thiazide-like diuretic.15 At the time of publication (August 2011), spironolactone did not have a UK marketing authorization for this indication. Informed consent should be obtained and documented.16 Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective.
High Risk Group TherapyStart in pre-hypertension (130 – 139)/(85 – 89) mmHg
Lifestyle change
CHF – Thiazide, ACE-1, Aldosterone, BB
Post Myocardial Infarction – BB, ACEi
Diabetes Mellitus – ACEi, ARB, Thiazide, CCB
CKD – ACEi, ABB, Thiazide
Stroke – SSB +ACEi
ACE inhibitors and diuretics
Angiotensin II receptor antagonists and diuretics
Calcium antagonists and ACE inhibitors
Angiotensin II receptor antagonists &-adrenergic blockers or ACEI NOT RECOMMENDEDOther combinations (-adrenergic blockers and diuretics)
Combination Therapies
Who should be treated?
If the systolic pressure is persistently ≥140 mmHg and/or the diastolic pressure is persistently ≥90 mmHg after three to six visits.
Systolic pressure is persistently above 130 mmHg and/or the diastolic pressure is above 80 mmHg in patients with cardiovascular disease, post-myocardial infarction, heart failure, CKD & DM. Lifestyle changes – no medication