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Control 10 29 27 34 52.5%Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.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