Hypertension: The Whole Story

Raven Voora, MDHypertension Specialist

UNC Kidney Center

Hypertension = elevated blood pressure

Category Systolic Blood Pressure

Diastolic Blood Pressure

Normal < 120 <80

Pre-hypertension 120-139 80-89

Hypertension – Stage 1

140-159 90-99

Hypertension – Stage 2

>160 >100

Classification of hypertension: JNC 7

Symptoms of Hypertension

• Hypertension is dangerous because it gives off no warning signs or symptoms

• Having your blood pressure checked regularly is the only way to tell if your blood pressure is high

Diagnosis of Hypertension

• Based upon the average of two or more properly measured readings at each of two or more visits after an initial screen

White Coat Hypertension

• Blood pressure is repeatedly normal when measured outside of the provider’s office (home, work) but persistently elevated in the office.

How to Measure Your Blood Pressure

• Use an automatic monitor– Check the accuracy of your home monitor at the

doctor’s office• Use a monitor with an arm cuff

– Not a wrist or finger cuff– Use a large cuff if you have a large arm

• After putting on the cuff, sit quietly for a few minutes before checking your pressure

Why do people get hypertension?

Essential vs Secondary Hypertension

• The majority of patients with hypertension have “essential hypertension” (≈90-95% of cases)

• Less frequently, there is an underlying condition that may lead to hypertension. This is called “secondary hypertension” (≈5-10% of cases)

Pathogenesis of Essential Hypertension

• Poorly understood– Complex interaction between genetic and

environmental factors• These factors lead to narrowing of blood

vessels – If vessels wide open blood flows

easily– If vessel narrows pressure inside

increases causing hypertension

Factors Influencing the Development of Hypertension

Uncontrollable Factors• Family History of

hypertension• Reduced kidney mass at

birth• African-American ancestry• Age

Controllable Factors• Obesity and weight gain• Physical inactivity• Excess sodium intake• Alcohol consumption

Controllable Factors Influencing the Development of Hypertension

• Excess sodium intake

• Certain segments of the population are ‘salt sensitive’ because their blood pressure is affected by salt consumption

Controllable Factors Influencing the Development of Hypertension

• Alcohol consumption

How Can Hypertension Be Treated?

Treatment of Hypertension

• Engage in Lifestyle Modifications

• Avoid Medicines That Can Raise Blood Pressure

• Take Medications That Can Lower Blood Pressure

Treatment of Hypertension

• Engage in Lifestyle Modifications

• Avoid Medicines That Can Raise Blood Pressure

• Take Medications That Can Lower Blood Pressure

Lifestyle Modifications

• Maintain a healthy weight, lose weight if overweight.

• Be more physically active.• Drink alcoholic beverages in moderation.• Reduce the intake of sodium in the diet to

approximately 2400 mg/day.

Lifestyle Modifications

Modification Approximate SBP Reduction

Reduce Weight 5-20 mmHg for every 10 kg (22 lb) loss

Limit ETOH consumption 2-4 mmHg

Reduce Na intake to < 2.4 gm/day 2-8 mmHg

Aerobic activity for 30-34 min/day 4-9 mmHg

Reading a Food Label for Sodium Content

Food LabelsClaim Amount

Low Sodium >140 mg/serving

Very Low Sodium >35 mg/serving

Sodium Free >5 mg/serving

Reduced Sodium 25% less than original

Reducing Sodium in the Diet

• Use fresh poultry, fish and lean meat, rather than canned or processed.

• Buy fresh, plain frozen or canned with “no salt added” vegetables.

• When available, buy low- or reduced-sodium or ‘no-salt-added’ versions of foods like:– Canned soup, canned vegetables, vegetable juices– cheeses, lower in fat– condiments like soy sauce– crackers and snack foods like nuts– processed lean meats

The DASH Diet

• The Dietary Approaches to Stop Hypertension clinical trial (DASH)

• Hypothesis: Does a diet rich in fruits, vegetables, and low fat dairy foods lower blood pressure in individuals with hypertension and high normal blood pressure?

DASH Study

• Control:– Ca, Mg, & K ~ 25% of US diet– Macronutrients and fiber ~ US average

• Fruits and Vegetables– Fruits and vegetables increased to 8.5 servings– K and Mg to 75%

• Combination:– Add 2-3 servings low-fat dairy to fruit & vegetable diet.– Ca, K and Mg increased to 75%

DASH Study Outcomes

• Fruit and Vegetable Diet:– Decrease in systolic and diastolic blood pressure in entire

study group and in the hypertensive subgroup.

• Combination Diet:– Significant decrease in both systolic and diastolic blood

pressure in both groups.– Greatest drop was in systolic BP in hypertensive group

(11.4 mmHg)

DASH Diet Implications

• Combination diet affects comparable to pharmacological trials in mild hypertension.

• Population wide reductions in blood pressure similar to DASH results would reduce CHD by ~ 15% and stroke by ~27%

• Great potential in susceptible groups: African Americans and elderly.

Treatment of Hypertension

• Engage in Lifestyle Modifications

• Avoid Medicines That Can Raise Blood Pressure

• Take Medications That Can Lower Blood Pressure

Medicines Can Raise Blood Pressure

• Analgesics– NSAIDs, COX-2 inhibitors, Aspirin

• Decongestants/Allergy Medicines• Diet pills• Stimulants

– Methylphenidate• Herbals (Ephedra or Ma Huang)

Treatment of Hypertension

• Engage in Lifestyle Modifications

• Avoid Medicines That Can Raise Blood Pressure

• Take Medications That Can Lower Blood Pressure

Antihypertensive Medications

• Most common types of medicines used to treat hypertension:– “Diuretics”

• Rid the body of excess fluid and salt

– “Ace-inhibitors” or “Angiotensin Receptor Blockers”• Block hormones that cause arteries to narrow

– “Calcium channel blockers”• Reduce the heart rate and relax blood vessels

– “Beta blockers”• Reduce the heart rate and work of the heart

Guidelines Have Established Treatment Goals

Condition mm Hg

Essential HTN < 140/90

Diabetes Mellitus < 130/80

Chronic Kidney Disease <130/80

Age > 65 ????

JNC 7

What new therapies are there?

HypertensiveN = 73.6 million

Aware (79%)

Treated (69%)

Controlled (45%)

Uncontrolled (55%)

Untreated (10%)

Unaware (21%)

Control of Hypertension is Not Adequate

• Nearly 55% of US hypertensive patients do not achieve systolic pressure goal of less than 140/90 mmHg

Based on Data from NHANES/NCHS 2005-6

Renal Denervation

ABLATION OF RENAL SYMPATHETIC NERVES

Baroreflex Activation Therapy

ELECTRICAL STIMULATION OF CAROTID SINUS BARORECEPTORS

Remember ….

• Hypertension is a lifelong disease. It can be controlled, not cured

• Know your blood pressure. Have it checked regularly

• Maintain a healthy lifestyle• If you do have hypertension, take your

medications as prescribed

Questions?

• From all the things I discussed today, what can you do to help control your blood pressure?

• What is most important for you and how can you make that part of your routine?