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A brief overview of hypertension and its management based on the JNC 7 report and protocol. Ideal for Final year MBBS Undergraduates.
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- Dr.Mohammed Sadiq Azam M.D.
Assistant Professor,
Department of Medicine,
Prof Siraj’s Unit (M – 1)
Deccan College of Medical Sciences
HYPERTENSIONApproach & Management
PROBLEM MAGNITUDE
Hypertension( HTN) is the most common primary
diagnosis.
35 million office visits are as the primary
diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be
as much as 1 billion.
7.1 million deaths per year may be attributable
to hypertension.
Definition
A systolic blood pressure (SBP)
≥140mmHg and/or
A diastolic (DBP) ≥90 mmHg.
Based on the average of two or more
properly measured, seated BP readings.
On each of two or more office visits.
Accurate Blood Pressure Measurement
The equipment should be regularly inspected and
validated.
The operator should be trained and regularly
retrained.
The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.
Caffeine, exercise, and smoking should be avoided for
at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.
BP Measurement
At least two measurements should be
made and the average recorded.
Clinicians should provide to
patients their specific BP numbers
and the BP goal of their treatment.
JNC 7 Classification of HTN
Follow-up based on initial BP measurements for adults*
*Without acute end-organ damage
Prehypertension SBP >120 mmHg and <139mmHg and/or
DBP >80 mmHg and <89 mmHg.
Prehypertension is not a disease
category rather a designation for
individuals at high risk of developing
HTN.
Pre-HTN
Individuals who are prehypertensive are not
candidates for drug therapy, BUT,
Should be firmly and unambiguously advised
to practice lifestyle modification
Those with pre-HTN, who also have diabetes
or kidney disease, drug therapy is indicated
IF a trial of lifestyle modification fails
to reduce their BP to 130/80 mmHg or less.
Isolated Systolic Hypertension
Not distinguished as a separate entity as
far as management is concerned.
SBP should be primarily considered during
treatment and not just diastolic BP.
Systolic BP is more important cardiovascular
risk factor after age 50.
Diastolic BP is more important before age
50.
Hypertensive Crises
Hypertensive Urgencies: No progressive target-
organ dysfunction. (Accelerated Hypertension)
Hypertensive Emergencies: Progressive end-organ
dysfunction. (Malignant Hypertension)
Hypertensive Urgencies
Severe elevated BP in the upper range of
stage II hypertension.
Without progressive end-organ dysfunction.
Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
Usually due to under-controlled HTN.
Hypertensive Emergencies
Severely elevated BP (>180/120mmHg).
With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm
Types of Hypertension
Primary HTN:
Also known as
essential HTN.
Accounts for 95%
cases of HTN.
No universally
established cause
known.
Secondary HTN:
Less common cause
of HTN ( 5%).
Secondary to other
potentially
rectifiable causes.
Causes of Secondary HTN
Common
Intrinsic renal
disease
Renovascular disease
Mineralocorticoid
excess
Sleep Breathing
disorder
Uncommon
Pheochromocytoma
Glucocorticoid
excess
Coarctation of
Aorta
Hyper/
hypothyroidism
Secondary HTN - Clues in Medical History
Onset: at age < 30 yrs ( Fibromuscular
dysplasia) or > 55 (athelosclerotic renal
artery stenosis), sudden onset (thrombus or
cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)
Secondary HTN - clues on Exam
Pallor, edema, other signs of renal
disease.
Abdominal bruit especially with a
diastolic component (renovascular)
Truncal obesity, purple striae,
buffalo hump (hypercortisolism)
Secondary HTN - Clues on Routine Labs
Increased creatinine, abnormal urinalysis
(renovascular and renal parenchymal
disease)
Unexplained hypokalemia (hyperaldosteronism)
Impaired blood glucose
(hypercortisolism)
Impaired TFT (Hypo/hyperthyroidism)
Secondary HTN - Screening Tests
Renal Parenchymal Disease
Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of
renal disease
Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins imbalance
Renal disease from multiple etiologies.
Renovascular HTN Atherosclerosis 75-90% ( more common in older patients)
Fibromuscular dysplasia 10-25% (more common in young patients, especially females)
Other• Aortic/renal dissection• Takayasu’s arteritis• Thrombotic/cholesterol emboli• CVD• Post transplantation stenosis• Post radiation
Complications of Prolonged Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
Complications arise due to the “target
organ” dysfunction and ultimately
failure.
Damage to the blood vessels can be seen
on fundoscopy.
Target Organs CVS (Heart and Blood Vessels) The kidneys Nervous system The Eyes
Effects On CVS Ventricular hypertrophy, dysfunction and failure.
Arrhithymias Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and rupture.
Effects on The Kidneys
Glomerular sclerosis leading to
impaired kidney function and
finally end stage kidney disease.
Ischemic kidney disease especially
when renal artery stenosis is the
cause of HTN
Nervous System Stroke, intracerebral and subaracnoid hemorrhage.
Cerebral atrophy and dementia
The Eyes Retinopathy, retinal hemorrhages and impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to extraoccular muscle paralysis and dysfunction
Retina Normal and Hypertensive Retinopathy
Normal Retina Hypertensive Retinopathy
A: HemorrhagesB: Exudates (Fatty Deposits)C: Cotton Wool Spots (Micro Strokes)
A B
C
Stage I- Arteriolar Narrowing
Arteriolar Narrowing
Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking
AV Nicking
Stage III- Hemorrhages (H), Cotton Wool Spots and Exudates (E)
H
E
Stage IV- Stage III+Papilledema
Patient Evaluation Objectives
(1) To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of target organ damage and CVD
(1) Cardiovascular Risk factors Hypertension Cigarette smoking Obesity (body mass index ≥30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women) Family history of premature cardiovascular disease (men under age 55 or women under age 65)
(2) Identifiable Causes of HTN
Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome
Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
(3) Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction
Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy
History Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred Polyuria and nocturia: Suggest renal impairment
History-contd. Claudication: May be aggravated by b-blockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have been due to HTN
History-contd. Family history of DM : Patient may also be Diabetic
Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and stroke
High alcohol: A cause of HTN High salt intake: Advice low salt intake
Examination Appropriate measurement of BP in both arms
Optic fundi Calculation of BMI ( waist circumference also may be useful)
Auscultation for carotid, abdominal, and femoral bruits
Palpation of the thyroid gland.
Examination-contd. Thorough examination of the heart and lungs
Abdomen for enlarged kidneys, masses, and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment
Routine Labs ECG.
Urinalysis.
Blood glucose (FPG/PPG) and hematocrit;
serum potassium, creatinine ( or estimated
GFR), and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Urinary albumin excretion or Spot
Albumin/creatinine ratio.
Goals of Treatment Treating SBP and DBP to targets that are
<140/90 mmHg
Patients with diabetes or renal disease,
the BP goal is <130/80 mmHg
The primary focus should be on attaining
the SBP goal.
To reduce cardiovascular and renal
morbidity and mortality
Benefits of Treatment
Reductions in stroke incidence,
averaging 35–40 percent
Reductions in MI, averaging 20–25
percent
Reductions in HF, averaging >50
percent.
Lifestyle modifications
Lifestyle Changes Beneficial in Reducing Weight
Decrease time in sedentary behaviors such as
watching television, playing video games, or
spending time online.
Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.
DASH Diet
Dietary Approach to Stop
Hypertension
As effective as one
medication
Management of HTN
THANK YOU