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By

Dr. James C. Ekwensi, Dr. Thomas Gray,

Dr. Abdulhalim Khan, and Khadijat B. Momoh

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Introduction & general overview of hypertension

Burden of hypertension

Strategies for intervention in Memphis

Policies & Recommendations

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Definition: Persistently high arterial blood pressure,defined as systolic blood pressure above 140 mm Hgand / or diastolic blood pressure above 90 mm Hg.

Hypertension is the most common public health problemin developed countries.

Called Silent Killer

No cure is available, but prevention and managementdecrease the incidence of hypertension and itscomplications

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Origins dates back to 2600 BC Suspect hypertension by the quality of one’s pulse Hard pulse that could not be compressed was often treated with

bleeding and leeches.

1733, Reverend Stephen Hales First published measurement of blood pressure.

Description of hypertension as a disease did not happen until 1808 byThomas Young and Richard Bright in 1836.

1896, Riva-Rocci developed the first Cuff Based Sphygmomanometer

that allow BP measurement in the clinic settings.

1905, Korotkoff improve the technique with the discovery of Korotkoff sounds, heard when the artery is osculated with stethoscope whilesphygmomanometer cuff is deflated.

Source: A Historical Look at Hypertension. Southern Medical Journal • Volume 99, Number 12,

December 2006

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Essential (Primary)Hypertension 90-95%

No obvious underlying medical cause

Secondary hypertension 5-10%

There are underlying causes such as conditions that affectthe kidneys, arteries, heart, and endocrine system.

Source: 7th report of JNC: Joint National committee on prevention,detection, evaluation and treatment of hypertension (JNC 7)

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Hypertension is most often asymptomatic

Commonly, the only sign is consistent elevation of the bloodpressure.

The following signs and symptoms may occur with severehypertension:

Headaches

Blurred Vision

Target organ damage

31% of people with Blood Pressure exceeding 140/90 wereasymptomatic and unaware of having hypertension.


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Essential (Primary) Hypertension

◦ No underlying cause

Secondary Hypertension

◦ Sleep apnea

◦ Drug-induced or related causes

◦ Chronic kidney disease

◦ Primary aldosteronism

◦ Reno-vascular disease

◦ Chronic steroid therapy and cushings’s syndrome

◦ Pheochromocytoma

◦ Thyroid or parathyroid disease

Source: JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

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Diagnosis of primary hypertension depends on

repeated demonstration of higher than normalsystolic and / or diastolic blood Pressure(BP) andexcluding secondary hypertension.

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Classification (JNC7)Systolic Pressure Diastolic pressure

mmHg mmHg

Normal 90 –119 60 –79

Prehypertension 120 –139 80 –89

Stage 1 hypertension 140 –159 90 –99

Stage 2 hypertension ≥160 ≥100

Isolated systolic

hypertension

≥140 <90


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Moderate elevation of arterial blood pressure isassociated with a shortened life expectancy.

Dietary and lifestyle changes can improve bloodpressure control and decrease the risk of associated health complications, although drugtreatment is often necessary in people for whom

lifestyle changes prove ineffective or insufficient

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Historically, treatment of what is called “hard pulse disease” mainlyconsist of reducing the quantity of blood using blood letting or application of leeches.

Advocated by Emperor of China

Cornelius Celsius

Hippocrates

1900, the first chemical for hypertension, Sodium Thiocyanate

In 1950 Chlorothiazide, a diuretic, became available.

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Lifestyle modifications For prevention and management

Lose weight

Limit alcohol intake

Increase physical activities Reduce sodium intake

Maintain adequate intake of potassium.

For overall and cardiovascular health

Maintain adequate intake of calcium and magnesium

Stop smoking

Reduce dietary saturated fat and cholesterol.

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Source: 7th

report of JNC: Joint National committee on prevention,detection, evaluation and treatment of hypertension (JNC 7)

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There is no known cure for hypertension.

Reduction of morbidity and mortality is theultimate goal.

Target BP <140/90 <130/80 (diabetes, renal disease)

Source: 7th

report of JNC: Joint National committee on prevention,detection, evaluation and treatment of hypertension (JNC 7)

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http://www.thevisualmd.com/videos/result/what_is_hypertension





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1 out of every 3 adult persons 25 years and older havehypertension (2012 WH0)

Higher prevalence in low and moderate economicregions

Africa highest prevalence of hypertension (36.8% for both sexes in 2008)

America’s region Lowest with about 35%, men having39%, and women 32%.

It is projected that by 2025, ¾ of adult population wouldhave hypertension probably because of urbanization.

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Population: 1Billion persons worldwide havehypertension as of 2008

Trend: The prevalence rate of uncontrolled hypertensionhas reduced from the 80s till the 2008

Men: from 33% to 29% Women: from 29%-25%

The prevalence of hypertension worldwide is also said tohave reduced but the population growth has led to an

increase in the total persons with hypertension (from605M to 978M).

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Hypertension is directly related to 62% of cerebrovascular disease (Stroke)

49% of Ischemic heart disease

It is also the most prevalent PREVENTABLEdisease worldwide

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7.5M death or 12.8% of total death are related tohypertension

WHO 2008

Also, 57M Disability adjusted Life Years (DALYs)which is 3.7% of total DALY

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Prevalence: 68M: approximately 31% (CDC 2008;age adjusted for 18years and older)

Another 1/3 has prehypertension

70% receiving pharmacologic treatment

55.7% of diagnosed hypertensive are uncontrolled 86% of uncontrolled had medical insurance;

◦ The prevalence of uncontrolled hypertension was higher in those who did not have a usual source of medical care

irrespective of insurance type◦ The uninsured with hypertension had higher proportion of

uncontrolled.

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70%

59 55.7

8

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Framingham study shows that there is a 90%chance of developing hypertension in those non-hypertensives aged 55-65 years by age of 80-85years.

Men: 34.1%

Women: 32.7%

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69% of people who have a first heart attack have highblood pressure

77% of people who first have a stroke

74% of people with chronic heart failure

Major risk factor for kidney disease, eye disease andother complications/comorbidities.

579,000 people diagnosed with high blood pressurewere discharged from short-stay hospitals in 2009.

Discharges include people both living and deceasedi.

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348,000 primary or contributing cause of death

Proportion from total registered deaths in 2008:14%

The 2007 overall death rate from high bloodpressure was 18.3 per 100,000

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Directly attributable to hypertension in direct medicalexpenses: $131B annually

Indirect (lost productivity): $25B

(http://www.cdc.gov/bloodpressure/facts.htm)

http://www.cdc.gov/bloodpressure/facts.htm



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The prevalence of Hypertension in TN is 32% inpopulation above 20 years* (2005-2009 average)

TN spends 15.6% of gross state product on

healthcare compare to national average of 13.3%!

Despite that, health care ranks as 48 nationally

The prevalence of hypertension in Memphis is:37.3% in all population above 20years

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49%

35%

0%

10%

20%

30%

40%

50%

60%

Black White

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Shelby County:

Hospitalization:

3X more African American men than white for 65+years(Medicare patients) 2005-07

Mortality◦ 2.5 X more mortality rate in African American men than white men

◦ Mortality in African American women was slightly lower than the African American men (2007-09).

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Why is prevention so important?

Prevention can prevent disease and complications of thedisease.

As mentioned earlier hypertension is one of the mostexpensive health conditions and one of the mostpreventable.

Preventative measures can also be considered earlytreatment.

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Why is prevention so important?

A meta-analysis of four trials showed that reducing bloodpressure led to a 15% reduction in cardiovascular events,

a 20% reduction in strokes, and a 10% reduction incoronary heart disease events (Goetzel,2003).

Framingham study with white men and women aged from

35- 64 years old showed a reduction in just 2 mm Hg fromthe DBP results in a reduction of 17% in the prevalence of hypertension (Cook, 1995).

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Prevention includes screening.

In 1984 Johnson showed that door-to-door screening with junior high students was effective in Orange Mound.

Being revisited currently. Healthy Shelby –barbershop screening, church

congregations with CHC.

Church Health Center and Christ Community

Neighborhood clinics Health fairs

Pharmacy screenings

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Prevention-Effects of lowering systolic portion of blood

pressure:

Appel L J et al. Hypertension 2006;47:296-308

Copyright © American Heart Association

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Based on reducing these modifiable risk factors:

Excessive body weight

Diet

High sodium intake

Low potassium intake

Sedentary lifestyle

Excessive alcohol intake

Smoking is a risk factor for CAD but does not cause highblood pressure.

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Mild Weight Loss- As little as 5% weight loss results in 52%resolution of mild hypertension (Fogari, 2010)

Moderate Weight Loss- 18 lb weight loss results in decrease of blood pressure of SBP of 8.5 mm Hg and DBP of 6.5 mm Hg

(Bacon, 2004). Percentages of incidence reduction vary up to 77%(He, 2000)

Severe Weight Loss- Pure weight loss without changing diet(surgery) showed 46 lb loss showed 54% resolution of hypertension

plus additional 15% improved for total of 69% resolved or improved(Carson, 1994)

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Dietary Approach to Stop Hypertension (DASH)- rich infruits, vegetables, potassium, low sodium, and low fat.

DASH diet alone reduced SBP 5.5 mm Hg and DBP 3.0

mm Hg (Bacon, 2004).

He (2000) showed a 35% risk reduction with diet.

Other dietary components still being studied are theeffects of coffee, calcium supplementation, and fish oil.

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Aerobic, endurance exercise (as opposed to power exercise) alone resulted in reductions of both SBP (3.35mm Hg) and DBP (2.58 mm Hg). This was found in bothnormotensive, hypertensive, overweight, and normal-

weight people (Hernelahti, 2002).

Weight loss combined with exercise resulted in reducingSBP 12.5 mm Hg and DBP 7.9 mm Hg (Bacon, 2004).

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1 drink = 14 grams alcohol= 1.5 oz 80-proof liquor=5 ozwine=12 oz beer.

The association between hypertension and alcohol is alittle more confusing but appears that moderate to severe

consumption (>210 grams/ week,15 drinks) increases therisk of hypertension in all groups to the result of SBP 3.31mm Hg and DBP 2.04 mm Hg. (Fuchs, 1997)

Low to moderate consumption (<210 g/week) was a risk toonly African American men. (Fuchs, 1997)

Moderate consumption is defined as 1 drink/ day for women and 2 drinks / for men.

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Interventions-

Education

Let’s Move! is a comprehensive initiative, launched bythe First Lady, to address the problem of obesity.

30 minutes of exercise most days of the week

(4 days/week).

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Interventions- Education

Underage alcohol

Alcohol commercials

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Goals of treatment- The goal is simple and that is to reduce the BP to normal

or near normal levels adjusted for age and existingcomorbidity.

Normal is 120/80 but goals are to get it less than 140/90in patients without comorbidities or less than 130/80 indiabetes or chronic kidney disease.

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Once hypertension is diagnosed, all cases should betreated.

Lifestyle changes (same as preventive measures)-

Excessive body weight Diet

Sedentary lifestyle

Excessive alcohol intake

Drugs

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Source: 7th report of JNC: Joint National committee on prevention,

detection, evaluation and treatment of hypertension (JNC 7)

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Social- 28.6% African Americans in Memphis live under the poverty level

( Hispanics 38.6% and White 9.6%).

Education and understanding are essential interventions in preventing andtreating hypertension and poverty limits choice in education (Many state tie

school budgets to property taxes). Poverty limits choice in housing and environment.

Limited access to transportation to provider visits.

Limited ability to leave work for provider visits.

Less family support structure (Martins, 2004).

Peer pressure for unhealthy lifestyles. Stress “When things don't go the way I want them to, that just makes me

work even harder“ (John Henryism).

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Medical- Poor areas are also underserved areas

Limited access to providers

Higher poverty limits health insurance and drug plans.

Cultural food preferences of higher salt and fat content. Low calcium intake with high prevalence of lactose intolerance.

Low adherence to treatment plan with some medication side effectsmore common in African Americans.

Distrust of medical establishment (Tuskegee syphilis study from 1932-

1972, penicillin recognized as effective in the 1940s). Birth in 1972 isonly 40 year old.

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Disparities- Well established significant racial disparities. Penner (2007) and

Kaucchi (2005) both divide the reasons for the health caredisparity as:

Genetic/biologic- May not be as significant as once thought.

Social/economic- This is significant as much higher percentage African Americans are under the poverty level, but even if corrected disparities exist. Race is not a proxy for socioeconomicclass.

Prejudice, related processes. Penner (2007)calls it more of anunconscious racism of the healthcare system and Kaucchi (2005)refers more to an unmentioned “caste- like” attitude against

African Americans.

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System-based initiative to improvecontrol

Hypertension and Sodium

Community and Population based

changes to promote prevention

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PQRS Measure #317: Preventive Care and Screening:Screening for High Blood Pressure

◦ Percentage of patients aged 18 and older who are screened forhigh blood pressure.

PQRS Measure #236 (NQF 0018 ): Hypertension:Controlling High Blood Pressure

◦ Percentage of patients aged 18 through 85 years of age who

had a diagnosis of hypertension and whose blood pressure wasadequately controlled (<140/<90) during the measurementyear.

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Patients may be able to lower the required dose of blood pressuremedicines through reduced sodium intake

Patients with normotension or prehypertension may reduce or prolongtheir risk for developing hypertensionthrough sodium reduction

Referral to a Registered Dietitian for Counseling

Education during BP screenings Downloadable CDC resource: Reducing Sodium in Your Diet to HelpControl Your Blood Pressure

Advise consumption of fresh fruits and vegetables, frozen fruits and vegetables without sauce, and no salt added canned vegetables

Advise limiting processed foods high in sodium

http://www.cdc.gov/salt/pdfs/Reducing_Sodium_Diet_BP_Control.pdf





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The Asheville Project is a community-based, pharmacist-directed,medication therapy management (MTM) program provided for severalemployers in the Asheville, NC area

Patients with hypertension receiving education and long-term

medication therapy management services achieved significant clinicalimprovements that were sustained for as long as 6 years

◦ ↓ cardiovascular events

◦ ↑ adherence to medications

Bunting BA, et al. The Asheville Project: Clinical and economic outcomes of a community-basedlong-term medication therapymanagement program for hypertension and dyslipidemia. J Am Pharm Assoc . 2008;48:23–31.

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RWJF Aligning Forces for Quality

◦ Public reporting – Wisconsin Collaborative for Healthcare Quality

http://www.wchq.org/reporting/results.php?category_id=0&topic_id=17&source_id =0&providerType=0&region=0&measure_id=78

http://www.wchq.org/reporting/results.php?category_id=0&topic_id=17&source_id



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Community health workers and Promotores de Salud

◦ A liaison between health and social services and the community facilitating access to care

◦ Provides a trusted liaison through a shared culture with the

people they serve

Barbershop- and beauty shop-based interventions to

improve hypertension control

Faith-based support programs

Ferdinand KC, et al. Community-based approaches to prevention and management of hypertension andcardiovascular disease. Journal of Clinical Hypertension. 2012. Online ahead of print. DOI:10.1111/j.1751-7176.2012.00622.x

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Community Transformation Grants

Sodium Reduction in Communities

WISEWOMAN program

State Health Departments

Million Hearts™ Initiative

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Public health approaches such as increasing physicalactivity and reducing trans-fats and salt in processedfoods can achieve a downward shift in the distributionof a population’s blood pressure.

In addition to CDC activities on the previous slide,CDC funds many other programs to promote healthy

lifestyles.

http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

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CDC Vital Signs: Hypertension and Cholesterol◦ http://www.cdc.gov/vitalsigns/CardiovascularDisease/index.

html

CDC Vital Signs: Where’s the Sodium?

◦ http://www.cdc.gov/vitalsigns/Sodium/index.html

CDC Vital Signs: Prevalence, Treatment, and Controlof Hypertension

◦ http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.

htm?s_cid=mm6004a4_w

A Historical Look at Hypertension. Southern Medical Journal • Volume 99, Number 12, December 2006

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a4.htm?s_cid=mm6004a4_w





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CDC Grand Rounds: “Sodium Reduction: Time for

Choice” ◦ http://www.cdc.gov/about/grand-

rounds/archives/2011/April2011.htm

CDC Blood Pressure Information

◦

http://www.cdc.gov/bloodpressure/ DASH Diet

◦ http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

7th report of JNC: Joint National committee onprevention, detection, evaluation and treatment of hypertension (JNC 7 )

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