Hypertension

Hypertension is one of the most important preventable causes of premature morbidity and mortality. Hypertension is a major risk factor for

• ischaemic and haemorrhagic stroke• myocardial infarction,• heart failure, • chronic kidney disease, • cognitive decline• premature death.

Untreated hypertension is usually associated with a progressive rise in blood pressure.

The vascular and renal damage that this may cause can culminate in a treatment-resistant state.

Know the prevalence of hypertension in the Saudi society

Recognize the risk factors for developing HTN Understand the recent guidelines for the diagnosis of

hypertension Measure blood pressure following recommended steps. Understand the recent guidelines for the management

of hypertension Understand the best practice approach to patients with

hypertension in the clinic Understand and list the complications of untreated

hypertension

By the end of this session the learner should be able to:

• There are 972 million persons worldwide with hypertension

• It is the fourth leading cause of the global burden of disease.

Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension?

From Science to Clinical Practice J Clin Hypertens (Greenwich). 2009; 11:66–73.

Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension?

From Science to Clinical Practice J Clin Hypertens (Greenwich). 2009; 11:66–73.

Hypertension in Saudi Arabia.Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, Al-Maatouq MA, Al-Marzouki K, Al-Khadra A, Nouh MS, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A.

OBJECTIVE:

To determine the prevalence of hypertension among Saudis of both gender, between the ages of 30-70 years in rural as well as urban communities. This work is part of a major national study on Coronary Artery Disease in Saudis Study (CADISS).

METHODS: This is a community-based study conducted by examining subjects in the age group of 30-70 years of selected households during a 5-year period between 1995 and 2000 in Saudi Arabia. ……….

Saudi Med J. 2007 Jan;28(1):77-84.

RESULTS:

The total number of subjects included in the study was

17,230. The prevalence of hypertension was 26.1% in crude

terms. For males, the prevalence of hypertension was 28.6%,

while for females; the prevalence was significantly lower at

23.9% (p<0.001). The urban population showed significantly

higher prevalence of hypertension of 27.9%, compared to

rural population's prevalence of 22.4% (p<0.001). The

prevalence of CAD among hypertensive patients was 8.2%,

and 4.5% among normotensive subjects (p<0.001).

Increasing weight showed significant increase in prevalence

of hypertension in a linear relationship. Saudi Med J. 2007 Jan;28(1):77-84.

CONCLUSION:

Hypertension is increasing in prevalence in KSA affecting

more than one fourth of the adult Saudi population. We

recommend aggressive management of hypertension as

well as screening of adults for hypertension early to

prevent its damaging consequences if left untreated.

Public health awareness of simple measures, such as low

salt diet, exercise, and avoiding obesity, to maintain normal

arterial blood pressure need to be implemented by health

care providers.

Saudi Med J. 2007 Jan;28(1):77-84

World Health Organization - NCD Country Profiles , 2011.

Saudi Arabia2010 total population: 27 448 086

Diagnosis

Definitions

• Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM)average blood pressure is 135/85 mmHg or higher.

• Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher.

• Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher, or clinic diastolic blood pressure is 110 mmHg or higher.

NICE clinical guideline 127

Measuring blood pressure

Measuring blood pressure

provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported.

palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery

If using an automated blood pressure monitoring device, ensurethat the device is validated and an appropriate cuff size for theperson’s arm is used.

When considering a diagnosis of hypertension, measure bloodpressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements

Measu

ring

Blo

od P

ress

ure

Historically, hypertension was often treated as anisolated symptom, with 1 or 2 drugs such as diuretics and⁄ or b-blockers as first-step treatment ( to decrease the blood pressure level)

Actually :The goal of antihypertensive treatment is to decrease the total cardiovascular risk, which results from the coexistence of different risk factors, organ damage, and disease such as type 2 diabetes.

Pt approach and Management

Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension?

From Science to Clinical Practice J Clin Hypertens (Greenwich). 2009; 11:66–73.

Patient factors contribute to uncontrolled BP in at least 50% of the population with treated hypertension.

It is also well known that some suboptimal results have a great deal to do with physician inertia, the act of not increasing therapy (dose or number of antihypertensive drugs) or not starting therapy in patients with increased BP.

Pt approach and Management

Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension?

From Science to Clinical Practice J Clin Hypertens (Greenwich). 2009; 11:66–73.

For all people with hypertension offer to:

-Test for the presence of protein in the urine by sending a urine

sample for estimation of the albumin:creatinine ratio and test for

haematuria using a reagent strip

-Take a blood sample to measure plasma glucose, electrolytes,

creatinine, estimated glomerular filtration rate, serum total

cholesterol and HDL cholesterol

-Examine the fundi for the presence of hypertensive retinopathy

-Arrange for a 12-lead electrocardiograph to be performed.

Treatment algorithm for patients with newly diagnosed hypertension

NICE hypertension guideline,2011

BP classific

ation

Systolic BP

mmHg*  

Diastolic BP

mmHg*

Management*

Lifestyle

modification

Initial drug therapy

Without compelling indication

With compelling indications•

Normal <120 and <80 Encourage

   

Prehypertension

120-139 or 80-89 Yes No antihypertensive drug indicated

Drug(s) for the compelling indications

Classification and management of blood pressure for adults aged 18 years or older

Stage 1 hypertension

140-159 or 90-99 Yes Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, beta blocker, CCB, or combination

Drug(s) for the compelling indications; other anti-hypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed

Stage 2 hypertension

≥160 or ≥100 Yes 2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta blocker or CCB)◊

Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed

Modification Recommendation Approx systolic BP reduction, range*

Weight reduction

Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2)

5-20 mmHg per 10-kg weight loss

Adopt DASH eating plan

Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat

8 to 14 mmHg

Dietary sodium reduction

Reduce dietary sodium intake to no more than 100 meq/day (2.4 g sodium or 6 g sodium chloride)

2 to 8 mmHg

Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)

4 to 9 mmHg

Moderation of alcohol consumption

Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in women and lighter-weight persons

2 to 4 mmHg

Lifestyle modifications in the management of hypertension

JNC 8- 2014Recommendation 1In the general population aged 60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP)150 mmHg or diastolic blood pressure (DBP)90mmHg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation –Grade A)

Recommendation 2In the general population <60 years, initiate pharmacologic treatment to lower BPatDBP90mmHg and treat to a goal DBP<90mmHg. (For ages30-59 years, Strong Recommendation – Grade A; For ages 18-29 years,Expert Opinion – Grade E)

Recommendation 3In the general population <60 years, initiate pharmacologic treatment to lowerBPatSBP140mmHg and treat to a goal SBP <140mmHg. (ExpertOpinion – Grade E)

Recommendation 4In the population aged 18 years with chronic kidney disease (CKD), initiatepharmacologic treatment to lowerBPatSBP140mmHgorDBP90mmHg and treat to goal SBP<140mmHgandgoalDBP<90mmHg. (ExpertOpinion – Grade E)

Recommendation 5In the populationaged18years with diabetes, initiate pharmacologic treatment to lower BP at SBP140mmHgorDBP90mmHgandtreat to a goalSBP <140mmHg and goal DBP <90mmHg. (Expert Opinion –Grade E)

Recommendation 6In the general nonblack population, including those with diabetes, initialantihypertensive treatment should include a thiazide-type diuretic, calciumchannel blocker (CCB), angiotensin-converting enzyme inhibitor(ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation– Grade B)

Recommendation 7In the general black population, including those with diabetes, initial antihypertensivetreatment should include a thiazide-type diuretic or CCB. (Forgeneral black population: Moderate Recommendation –Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

Recommendation 8In the population aged18 years with CKD, initial (or add-on) antihypertensivetreatment should include an ACEI or ARB to improve kidney outcomes.This applies to all CKDpatientswith hypertension regardless of raceor diabetes status. (Moderate Recommendation – Grade B)

If goal BPis not reached within amonth of treatment, increase the doseof the initial drug or add a second drug from one of the classes in recommendation6(thiazide-type diuretic,CCB,ACEI, or ARB).

Hypertension is quantitatively the major risk factor

for premature cardiovascular disease

Hypertension increases the risk of heart failure at all

ages with the hazard increasing with the degree of

blood pressure elevation

Left ventricular hypertrophy is a common problem in

patients with hypertension

Complication of untreated hypertension

Hypertension is the most common and most

important risk factor for stroke

Hypertension is the most important risk factor for the

development of intra-cerebral hemorrhage

Hypertension is a risk factor for chronic kidney

disease and end-stage renal disease

Complication of untreated hypertension

Hypertension Prevention

Hypertension Prevention include:

• Maintaining a healthy weight; • Being physically active; • Following a healthy eating plan, that emphasizes fruits,

vegetables, and low fat dairy foods; • Choosing and preparing foods with less salt and sodium; • Stop alcoholic beverages, • Stop smoking

Clinical cases

Case 1Hamad is a 48-year-old clerk who sees you occasionally for a recurrent cough and upper respiratory tract infections. He has no significant past medical history, is taking no medicineshas no known allergies, he is a regular smoker and has been since his teens.He has come to see you for another cold that has gone to my chest . Vital observations are:

temperature 37°CPulse rate 78, regularblood pressure (BP) 148/94 mmHgrepeat BP 144/92 mmHg..

Does he have hypertension?

He may have hypertension, because his BP measurements are in the abnormal hypertensionrange. However, the diagnosis of hypertension should be based on multiple BP measurements taken on separate occasions.

Does he need BP-lowering medicine?

Before deciding whether or not to prescribe BP-lowering medicine, confirm that he has hypertension. BP should be measured on a subsequent visit, by the nurse to minimize the white coat effect.

If hypertension is confirmed from multiple BP measurements, medical history should be recorded and he should be examined for, and investigations done to see if he has,cardiovascular disease (CVD) or target organ damage.

In the absence of CVD or target organ damage, you should formally calculate Bill s absolute risk score.

Does he need BP-lowering medicine?

Regardless of whether the absolute risk is low, medium or high:you should recommend:

Behavioral modification as the basis of his hypertension management (e.g. life style changes) and to reduce his risk of CVD (smoking cessation).

What should be the first choice hypertension drugtreatment?

Choice of first line medicine is driven by relative and absolute indications or contraindications, according to co-morbidity.Consider the possibility that he has chronic obstructive pulmonary disease (COPD) and avoid prescribing a beta-blocker. An appropriate medicine is a low-dose ACE-inhibitor, Angiotensin II receptor blocker (ARB) or calcium channel blocker (CCB).

What BP should I aim to get Bill to?

Diagnostic and therapeutic BP goals vary according to a patient s risk status. This is becausethe greater the risk, the greater the benefit of lowering BP and the greater the residual risk if goals are not met.

If he had evident CVD, diabetes and/or significant renal disease, his target would be lower (130/80).

Case 2A 55-year old female schoolteacher with BP of 170⁄105 mm Hg Had type 2 diabetes diagnosed 5 years ago, treated with diet and an OHA. She exhibits diabetic nephropathy with microalbuminuria and a slight decrease in glomerular filtration rate, a low level HDL, Abdominal obesity, sedentary lifestyle, HBA1C >7.5%.

she exhibits at least 3 risk factors, including type 2 diabetes and Established renal disease in addition to hypertension, she is considered at very high risk for CVD.

The target is to decrease her BP to <130⁄80 mm Hgto manage the diabetes

Recommendations for this patient include:

A change in lifestyle, with exercise, weight loss,reduced salt consumption, and reduced saturatedfat intake.

Treatment options include antidiabetic agents (OHA) together with antihypertensive drugs.

According to the results of the trials, it would appear that an ACEI or an ARB should be part of the treatment regimen, and theaddition of a CCB may be the best choice.

Diuretics or b-blockers may not be appropriate in patients with type 2 diabetes and associated renal disease.

Recommendations for this patient

In ALLHAT, however, diabetic patients had a favorable outcome with a diuretic as well as with an ACEI or CB. Thus, an RAAS inhibitor and a diuretic may also be appropriate.

Due to her very high–risk profile, this patient should firstreceive the minimum dose of each drug, but dosescould rapidly be titrated higher if the BP target isnot adequately reached within a few weeks oftreatment, and then possibly a third drug couldbe added.

References1- Overview of hypertension in adults, UpToDate® www.uptodate.com

2- Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J Clin Hypertens (Greenwich). 2009; 11:66–73.

3- Woolf K J, Bisognano J D; Nondrug Interventions for Treatment of Hypertension J Clin Hypertens (Greenwich). 2011;13:829–835. (interesting)

4- Garcia-Touza M, Sowers J R; Evidence-Based Hypertension Treatment in Patients With Diabetes, J Clin Hypertens (Greenwich). 2012;14:97–102 (conclusion part)