Dr.M.N.RamakrishnDr.M.N.Ramakrishn B.Sc., M.B.B.S., M.D.,AFIH., PGDHSc.(Diab)B.Sc., M.B.B.S., M.D.,AFIH., PGDHSc.(Diab)

Dy. Chief Medical OfficerDy. Chief Medical OfficerMain HospitalMain HospitalKothagudemKothagudem

HYPERTENSIOHYPERTENSIONN

What is HypertensionWhat is Hypertension??

Hypertension Hypertension is a condition in which the patient is a condition in which the patient has a higher blood pressure than that judged as has a higher blood pressure than that judged as normal.normal.

It is the pressure exerted by the flow of blood on It is the pressure exerted by the flow of blood on the walls of blood vessels.the walls of blood vessels.

Arterial pressure, like most physiological Arterial pressure, like most physiological measures, is a variable, but a blood pressure measures, is a variable, but a blood pressure above 140/90mm of Hg.is considered as above 140/90mm of Hg.is considered as Abnormal.Abnormal.

Normal Blood PressureNormal Blood Pressure

Normal blood pressure is different in different Normal blood pressure is different in different age groupsage groups

Systolic BP of < 140mm of Hg. and Diastolic BP Systolic BP of < 140mm of Hg. and Diastolic BP of <90 mm of Hg. are considered of <90 mm of Hg. are considered Normal Normal in an in an adult.adult.

In adults normal average BP isIn adults normal average BP is

Systolic BP 120 mm of Hg.Systolic BP 120 mm of Hg.

Diastolic BP 80 mm of Hg.Diastolic BP 80 mm of Hg.

GRADING OF HYPERTENSIONGRADING OF HYPERTENSION

Systolic DiastolicSystolic Diastolic

Normal Blood Pressure: 120 mm of Hg 80 mm of Hg.Normal Blood Pressure: 120 mm of Hg 80 mm of Hg.

Pre-Hypertension : 120-139 mm of Hg 80-89 mm of Hg Pre-Hypertension : 120-139 mm of Hg 80-89 mm of Hg

Stage I HTN : 140-159 mm of Hg 90-99 mm of Hg Stage I HTN : 140-159 mm of Hg 90-99 mm of Hg

Stage II HTN : >160 mm of Hg >100 mm of Hg Stage II HTN : >160 mm of Hg >100 mm of Hg

Isolated Systolic HTN : >140 mm of Hg <90 mm of Hg Isolated Systolic HTN : >140 mm of Hg <90 mm of Hg

HOW TO MEASURE BLOOD PRESSURE?HOW TO MEASURE BLOOD PRESSURE?

Blood pressure is measured with an instrument called Blood pressure is measured with an instrument called Sphygmo-manometer.Sphygmo-manometer.

Accurate measurements are essential under standardised Accurate measurements are essential under standardised conditionsconditions

Three sources of errors have been identified in recording BP:Three sources of errors have been identified in recording BP:

a).a).Observer errorsObserver errors: Eg.,Hearing acuity, Interpretation of : Eg.,Hearing acuity, Interpretation of KorotkowKorotkow

sounds.sounds. b).b).Instrumental errors:Instrumental errors: Eg., Valve leakage, Cuff that do Eg., Valve leakage, Cuff that do

notnot encircle the arm.encircle the arm. c).c).Subject errors:Subject errors: Eg., Physical environment, Position of Eg., Physical environment, Position of subject, Fever Anxiety etc.subject, Fever Anxiety etc. Contd.Contd.

HOW TO MEASURE BLOOD PRESSURE?HOW TO MEASURE BLOOD PRESSURE?

WHO study group recommended the sitting position than WHO study group recommended the sitting position than the supine position for routine BP check up.the supine position for routine BP check up.

There should be uniform policy for checking BP either There should be uniform policy for checking BP either the left arm or right arm consistently.the left arm or right arm consistently.

The pressure at which the sounds are heard (phase I) is The pressure at which the sounds are heard (phase I) is taken as Systolic BP.taken as Systolic BP.

Near the Diastolic pressure the sounds first become Near the Diastolic pressure the sounds first become muffled (phase IV) and then disappear (phase V).muffled (phase IV) and then disappear (phase V).

Most of the studies have used phase V to measure Most of the studies have used phase V to measure Diastolic BP.Diastolic BP.

The Systolic and Diastolic pressures should be measured The Systolic and Diastolic pressures should be measured at least 3 times over a period of 3mts and the lowest at least 3 times over a period of 3mts and the lowest reading recorded.reading recorded.

CLASSIFICATION OFCLASSIFICATION OF HYPERTENSIONHYPERTENSION

Hypertension is classified into:Hypertension is classified into:

- Primary (Essential) - Primary (Essential) HTNHTN

- Secondary HTN- Secondary HTN

Primary HTN:Primary HTN: The cause is unknown. The cause is unknown.

It is most common form (90-95%).It is most common form (90-95%).

Secondary HTN: Secondary HTN: Some other disease process orSome other disease process or

abnormality is involved in its causation.abnormality is involved in its causation.

(Eg.Kidney disease, tumors of Adrenal(Eg.Kidney disease, tumors of Adrenal

glands, Congenital narrowing of Aorta,glands, Congenital narrowing of Aorta,

Toxemias of Pregnancy etc.)Toxemias of Pregnancy etc.)

Signs & SymptomsSigns & Symptoms Mild to Moderate Essential HTN–Mild to Moderate Essential HTN– Usually asymptomatic Usually asymptomatic

Accelerated HTN (Hypertensive Encephalopathy):Accelerated HTN (Hypertensive Encephalopathy):

* Headache* Headache * Dizziness* Dizziness * Confusion* Confusion * Vision disorders* Vision disorders * Nausea* Nausea * Vomiting* Vomiting * Epistaxis* Epistaxis * Fainting* Fainting * Chest pain* Chest pain * Breathlessness* Breathlessness * Palpitation * Palpitation

Secondary HTN:Secondary HTN: Signs& Symptoms depend on under lying cause. Signs& Symptoms depend on under lying cause.

Risk Factors for HTN

Non-Modifiable risk factors of HTN Age Family History Genetic Factors

Modifiable Risk Factors Elevated Serum cholesterol Diabetes mellitus Obesity Smoking Sedentary habits Environmental Stress Lack of exercise Salt Intake Alcohol Oral Contraceptives Vitamin D deficiency Noise & Vibration

Genetic Factors

There is evidence that BP levels are determined in part by genetic factors

Twin studies have confirmed the importance of genetic factors in HTN

Probably the genetic factors are most important determinants of an individual’s “Total Cholesterol and HDL levels”.

contd…

Genetic FactorsGenetic Factors

Family studies have shown that Family studies have shown that possibility of HTN in children ofpossibility of HTN in children of

Two Normo-tensive Parents is 3%Two Normo-tensive Parents is 3%

Two Hypertensive Parents is 45%Two Hypertensive Parents is 45%

SATURATED FAT Animal fats (Meat, Milk Products, Egg etc.)

except fish, contain saturated fatty acids which contain low density lipids ,will increase the thickness of blood vessel walls resulting in Hypertension and Coronary Artery Disease.

Vegetable oils(except palm oil & coconut oil) contain poly unsaturated fatty acids, have more ‘high density lipids’ which protect the heart. The HDL fat acts as a ‘scavenger’ in removing the LDL attached inside the blood vessel walls.

In typical Indian diet, which is cereal based, about 20gms of fat is obtained as ‘invisible fat’. Therefore a daily in take of 20gms or 4 tea spoons of visible fat is sufficient. The ratio of saturated to PUFA should be roughly 0.8-1.0

Diabetes Mellitus

In Diabetes the blood lipids are increased and these contribute to premature or accelerated process of ‘Atherosclerosis’ and Hypertension.

Obesity

The higher the body weight the greater is the risk of HTN

For every extra KG of fat, one tends to produce 20mg more cholesterol per day.

It is hence necessary to maintain ideal body weight.

The simple formula to know the ideal body weight in KGs is height in centimeters minus 100.

The tendency for obesity seems to be inherited and over eating. Also it is clearly an important cause with low physical activity.

Sedentary life style

With increasing industrialization, modernization and mechanization, sedentary habits have become a part and parcel of our life styles.

Sedentary habits decrease the energy expenditure and therefore contribute to over weight and rise in blood lipids

Lack of Physical Exercise

Incidence of HTN is more in those who lack physical exercise.

Regular physical exercise increases the concentration of HDL and decreases the body weight, blood glucose, blood lipids and blood pressure.

Walking briskly for 45 minutes a day can bring down the risk of HTN.

Stress It is well established that ambitious and aggressive

personalities are more prone for HTN.

Stress can be physical, social or emotional. Stress causes heart to beat faster, the blood pressure to go up, the muscles to become tense and the arteries to go into spasms. All these occur through release of a substance called “Adrenaline”

Practice Yoga

Yoga, the age-old Indian practice of mind and body control can play prominent role in the reduction of stress and indirectly prevents HTN. Yogic practices are ancient in India, systematized by Pathanjali in 300 BC.

Salt (Sodium Chloride)

Excess salt is bad for the heart.

Indians are in the habit of consuming 10-15 gm of salt/day in the form of added salt.

Probably 3gms of salt/day is both safe and adequate for healthy adults.

Reduction in salt will reduce blood pressure

POTASSIUMPOTASSIUM

Potassium antagonises the Potassium antagonises the biological effects of Sodium and biological effects of Sodium and there by reduces Blood Pressure.there by reduces Blood Pressure.

Potassium supplements have Potassium supplements have been found to lower Blood been found to lower Blood Pressure of mild to moderate Pressure of mild to moderate Hypertensives.Hypertensives.

All fruits contain large amounts All fruits contain large amounts of Potassium.of Potassium.

Take 2 Bananas a day and keep Take 2 Bananas a day and keep away HTN is the slogan of away HTN is the slogan of Nutritionists.Nutritionists.

Alcohol

High alcohol intake defined as 75gms or more per day is an independent risk factor for HTN

Alcohol stimulates heart,and increase blood pressure transiently.

Alcohol consumption raises Systolic BP more than the Diastolic BP.

Alcohol also stimulates ‘FAT’ metabolism, increases obesity and results in Arteriosclerosis and Hypertension.

Onion & Garlic

In scientific studies large doses of onion & garlic are noted to be beneficial causing a decrease in blood lipids and Hypertension.

The garlic and onions that are regularly included in Indians diets may also have beneficial effect.

One may as well eat garlic as part of daily diet rather than resort to garlic capsules.

Oral Contraceptive pills

‘Oral contraceptive pills’ can raise

blood pressure

COMPLICATIONS OF COMPLICATIONS OF HYPERTENSIONHYPERTENSION

Coronary Artery Disease.Coronary Artery Disease. Heart Failure.Heart Failure. Cerebro -Vascular Accident.Cerebro -Vascular Accident. Aortic Dissection.Aortic Dissection. Hypertensive Encephalopathy.Hypertensive Encephalopathy. Malignant Hypertension.Malignant Hypertension. Renal Failure.Renal Failure. HaemorrhageHaemorrhage..

ADVANTAGES OF LIFE STYLE ADVANTAGES OF LIFE STYLE MODIFICATIONSMODIFICATIONS

Modification Modification Recommendation Recommendation Reduction in Reduction in SystolicSystolic

Blood Blood PressurePressure

Weight reduction BMI 18.5-24.9 5-20mm of Hg/10 Weight reduction BMI 18.5-24.9 5-20mm of Hg/10 kgkg

reductionreduction DASH eating plan Fruits, vegetables, low fat etc. 8-14mm of Hg.DASH eating plan Fruits, vegetables, low fat etc. 8-14mm of Hg. Reduction in Na. 5-6 gms of sodium 2-8 mm of Hg.Reduction in Na. 5-6 gms of sodium 2-8 mm of Hg. Physical Activity Regular aerobic physical activity 4-9 mm of Hg. Physical Activity Regular aerobic physical activity 4-9 mm of Hg.

30 mts /day30 mts /day Limitation of Alcohol < 2drinks/day(30ml ethanal) 2-4 mm of Hg.Limitation of Alcohol < 2drinks/day(30ml ethanal) 2-4 mm of Hg.

Strategy of Prevention of HTN

Population strategy

High risk strategy

Secondary prevention

Population StrategyPopulation Strategy

The concept of this approach is that even a small The concept of this approach is that even a small reduction in the average BP would reduce the incidence of reduction in the average BP would reduce the incidence of complications to a large extent. This involves a multi-complications to a large extent. This involves a multi-factorial approach based on the following non-factorial approach based on the following non-pharmacotherapeutic interventions:pharmacotherapeutic interventions:

a).Nutrition(Reduction in salt, fat & alcohol)a).Nutrition(Reduction in salt, fat & alcohol)

b).Weight reductionb).Weight reduction

c).Exercise promotionc).Exercise promotion

d).Behavioural change (Reduction in stress, d).Behavioural change (Reduction in stress,

smoking etc.)smoking etc.)

e).Health education ( On all risk factors)e).Health education ( On all risk factors)

f). Self care ( Self examination of BP etc.)f). Self care ( Self examination of BP etc.)

HIGH RISK STRATEGYHIGH RISK STRATEGY

Identification of high risk groups i.e., persons Identification of high risk groups i.e., persons with family history of HTN, Obesity, Diabetes, with family history of HTN, Obesity, Diabetes, lack of physical exercise, Alcoholics, Smokers lack of physical exercise, Alcoholics, Smokers etc.etc.

Educating them on risk factors, life style Educating them on risk factors, life style modifications etc.modifications etc.

SECONDARY PREVENTIONSECONDARY PREVENTION

The goal is to detect and control high BP in affected The goal is to detect and control high BP in affected individuals and prevent complications. The control measures individuals and prevent complications. The control measures comprise:comprise:

1) 1) Early case detectionEarly case detection through screening of through screening of populations and follow-up of detected cases.populations and follow-up of detected cases.

2) 2) Treatment: Treatment: Should aim at keeping BP < 140/90 mmShould aim at keeping BP < 140/90 mm of Hg and ideally at 120/80 mm of Hg.of Hg and ideally at 120/80 mm of Hg.

3) 3) Patient compliance: Patient compliance: It is defined as ‘the extent to which It is defined as ‘the extent to which thethe

patient behaviour coincides with clinical prescription’. This patient behaviour coincides with clinical prescription’. This can becan be

improved by educating patients families, community etc.improved by educating patients families, community etc.