HYPERTENSIONHYPERTENSION AND ITSAND ITS MANAGEMENTMANAGEMENT
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI, FAPSC, FAPSIC, FAHA
Associate Professor of CardiologyNational Institute of Cardiovascular
DiseasesSher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malbagh branch.
HypertensionA World Wide Epidemic
Nearly 1 billion hypertensive in the worldHypertension is poorly controlled, with less than 25% controlled in developed countries and less than 10% in developing countries.Hypertension which is responsible for 3 million death annually.May 14th is World Hypertension Day
Prevalence of Prevalence of HypertensionHypertension
131 144
302
584
240
0
100
200
300
400
500
600
Prev
alen
ce R
ate/
1000
1
India (2000) Bangladesh (2002) Malaysia (2002)China (2002) USA (2002)
Hypertension is a hemodynamic disorder A well accepted definition of hypertension was
suggested by Evans and Rose: “Hypertension should be defined in the terms
of blood pressure level above which investigation and treatment do good more than harm”
A patient is said to be hypertensive when his SBP≥ 140 mm Hg & DBP ≥ 90 mm Hg provided that the patient is not on antihypertensive drugs.
Hypertension: Hypertension: DefinitionDefinition
Varieties OF HTNVarieties OF HTN Labile HTNIsolated diastolic hypertensionIsolated systolic hypertensionMalignant or accelerated HypertensionRefractory/ Resistant hypertensionHypertensive emergencies/ urgencies
Classification of BP for AdultsClassification of BP for AdultsJNC-VI;1997JNC-VI;1997
BP Classification Systolic BP Diastolic BPOptimal <120 and <80
Normal <130 and <85
High Normal 130-139 or 85-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT 160-179 or 100-109
Stage 3 HT ≥ 180 or ≥ 110
BP Classification Systolic BP Diastolic BP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HT 140-159 or 90-99
Stage 2 HT ≥ 160 or ≥ 100
JNC-VII;2003JNC-VII;2003
Classification of BP LevelsClassification of BP LevelsESH-ESC Guidelines, 2003
BP Classification
OptimalNormalHigh NormalGrade 1 HT (mild)Grade 2 HT (moderate)Grade 3 (severe)Isolated systolic HT
Systolic BP
<120120-129130-139140-159160-179>180>140
Diastolic BP
<8080-8485-8990-99100-109>110<90
Regulation of BPBP = CO X PVR
SV HR
Haemodynamic Pattern in Haemodynamic Pattern in HypertensionHypertension
Young : BP = CO X TPR
Middle Aged : BP = CO X TPR
Elderly : BP = CO X TPR
Aetiology of Systemic Aetiology of Systemic HypertensionHypertensionA) Essential or Primary HTN (95%)
A. Age
B. Genetic • Both parents (45%) • Single (25%)
C. Environment • Diet FatSaltalcohol
• Obesity
• Physical inactivity
• Stress
• Smoking
D. Hormonal
Aetiology of Systemic Aetiology of Systemic HypertensionHypertension
B) Secondary HTN (05%)
A. Renal (80%) • AGN• CGN,• CPN, • Polycyst. K.D
• Renal Artery stenosis
B. Endocrine • Adrenal • Primary aldosteronism• Cushing’s syndrome Pheochromocytoma
• Acromegaly
• Exogenous hormone • Oral contraceptive) • Glucosteroids
• Hypothyroidism &• Hyperparathyroidism
Continue…
C) Others
Coarctation of the aorta Pregnancy Induced HTN (Pre-eclampsia) Sleep Apnea Syndrome.
Aetiology of Systemic Aetiology of Systemic HypertensionHypertension
Clinical ManifestationClinical Manifestation
• Asymptomatic in the majority of patients. Can remain undetected for many years
• Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated.
Measuring Blood PressureMeasuring Blood Pressure
• Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level
•An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm)
•At least 2 measurements
Continue…
Measuring Blood PressureMeasuring Blood Pressure
• Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of disappearance of the sounds (Korotkoff 5th)
Continue…
Measuring Blood PressureMeasuring Blood Pressure
• Ambulatory BP Monitoring - information about BP during daily activities and sleep.
• Correlates better than office measurements with target-organ injury.
Continue…
Complication of Complication of HypertensionHypertension
1. Cardiac :
LVH LVF •Systolic•Diastolic IHD Arrhythmias
2. Vascular Peripheral arterial disease•Aortic dissection
3. Cerebral StrokeTIAEncephalopathy
4. Renal NephropathyRenal failure
5. Eye Retinopathy
The scope of the problemThe scope of the problem
– Heart Attack (MI) – Heart Failure– Stroke– Kidney Disease
THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO MINIMISE CARDIOVASCULAR RISK AND DAMAGE
TO TARGET ORGANS
Hypertension even today is aHypertension even today is atriple paradox which is :triple paradox which is :
Easy to diagnose OFTEN remains undetected
Simple to treat OFTEN remains untreated
Despite availability of potent drugs, treatment all too OFTEN is ineffective
The "Rule of Halves" inThe "Rule of Halves" inHypertension Hypertension
Only 1/2 have been diagnosedOnly 1/2 of those diagnosed have been treatedOnly 1/2 of those treated are adequately controlled
Only 12.5% overall are adequately controlled
Not diagnosed
Not treated
Not controlled
Controlled
Evaluation of hypertensive Evaluation of hypertensive patients patients
Objectives:To know accurate and representative measurement of BPTo identity any known cause of HypertensionTo assess presence or absence of TODTo assess response to therapy To identity cardiovascular risks factor To know concomitant disorders
Continue….
Evaluation of hypertensive Evaluation of hypertensive patients patients
Evaluation by Medical history
Physical Examination
Laboratory investigation Routine tests Optional tests.
Effects of Antihypertensive Drug Treatment Effects of Antihypertensive Drug Treatment on CV Mortality and Morbidityon CV Mortality and Morbidity
Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated compared to control
Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478
-52%
-38%-35%
-25%
-16%
-60%
-50%
-40%
-30%
-20%
-10%
0%
CHF Strokes(fatal/nonfatal)
LVF CVD Deaths CVD events(fatal/nonfatal
Management of HTN Management of HTN
140
120
100
80
60
40
20 0
50
40
30
20
10
0
Historical Lessons About HypertensionHistorical Lessons About Hypertension
Hypertension Increases Morbidity and Mortality
Men Women
CHD
Inc i d
ence
Ra t
e/
10
00 p
erso
ns p
er y
ear
THE FRAMINGHAM STUDY
Cum
ulat
ive
fat a
l &
Nonf
atal
End
poi n
ts
Treatment Decreases Morbidity and Mortality
Men Women
Placebo Active Treatment
THE VET.ADM. STUDY II
Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152
NormotensionHypertension
Implication of reduction in Diastolic BP Implication of reduction in Diastolic BP for Primary Preventionfor Primary Prevention
30
20
% R
e du c
tio n
Change in DBP
0
-10
-20
-30
-40
-50
7.5 mm Hg 5-6 mm Hg 2 mm Hg
-21
-46
-16
-38
-6
-15
CHD
Stroke
Cook, et al. Arch Int med. 1995; 155:711-109
Millimeters Matter…… Millimeters Matter……
“ A 2-mm Hg reduction in DBP would result in…
a 6% reduction in the risk of CHD and a 15% reduction
in the risk of stroke and TIAs”
Cook, et al. Arch Int med. 1995; 155:711-109
Impact of High Normal BP on CV Impact of High Normal BP on CV Disease Risk in MenDisease Risk in Men
High Normal130-139/ 85-89 mm Hg
Normal120-129/ 80-84 mm Hg
Optimal<120/ 80 mm Hg
Cum
u la t
ive
I nc i
denc
e (%
)
Time (Years) N Engl J Med. 2001;345:1291-97
Benefits of Lowering BPBenefits of Lowering BP
Average percentreduction
Stroke reduction 35-40%
Myocardial infarction 20-25%
Heart failure 50%
Goals of TherapyGoals of Therapy• Reduction of cardiovascular and renal
morbidity and mortality. 1
• The primary focus should be on achieving the systolic BP goal.
• Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease in CVD complications.
• In patients with hypertension with diabetes or renal disease, the BP goal is < 130/80 mmHg 1
1 JNC - VII Report, JAMA , 2003;289:2560-2572
JNC VII Algorithm for Treatment of Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle Modifications
Not at Goal BP(< 140/90 mmHg or < 130/80
mmHg for Those with Diabetes or Chronic Kidney Disease
Initial Drug Choices
Lifestyle Modification: 1Lifestyle Modification: 1 Socioeconomic condition in the world suggest that
prevention through Lifestyle Modifications is the universal “vaccine” against Hypertension
Weight Reduction– Maintain normal body weight
• BMI: 18.5 – 24.9• BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan– Dietary Approaches to Stop Hypertension
• Fruits, Vegetables, Low-fat dairy• Reduce saturated and total fat• 8-14 mmHg BP reduction
Lifestyle Modification: 2Lifestyle Modification: 2Dietary Sodium Reduction
• 2.4 grams Sodium or 6 grams Sodium Chloride• 2-8 mmHg BP reduction
Physical Activity –Regular aerobic physical activity
•4-9 mmHg BP reduction
Lifestyle Modification: 3Lifestyle Modification: 3
Smoking Cessation•Any independent chronic effect of smoking on BP is small•Smoking cessation does not decrease BP•BUT total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke should be counselled on smoking cessation
Antihypertensive Drugs
Continue….AT1 receptor
ARB
Antihypertensive Drugs
JNC VII Algorithm for Treatment of Hypertension
Hypertension without compelling indications
Hypertension with compelling indication
(Systolic Bp 140-159 mmHg or Diastolic BP 90-99 mmHg)
Thiazide-Type Diuretics for MostMay Consider ACE inhibitor, ARB, ß-blocker, CCB or combination
Systolic Bp >160 mmHg or Diastolic BP > 100 mmHg)
2- Drug Combination for Most(Usually Thiazide - Type Diuretic and ACE Inhibitor or ARB or ß-blocker, CCB)
Drug (s) for the Compelling Indications
Other Anithypertensive Drugs
(Diuretics, ACE inhibitor, ARB, ß-blocker, CCB) as needed
Initial Drug Choices
ChoiceChoice of antihypertensiveof antihypertensive
• Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors, angiotensin receptor antagonists) are suitable for the initiation and maintenance of therapy
• Choice: Previous experience of the patient Cost Risk profile, target organ damage, clinical cardiovascular or renal
disease or diabetes or lung disorder Patient’s preference
• Long acting preparations providing 24-h efficacy on a once daily basis(2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).
Special ConsiderationsSpecial ConsiderationsGuideline Basis for Compelling Indications for Individual Drug Classes
High Risk Conditions With Compelling Indication
Heart failure
Post-myocardial infarction
High coronary disease risk
Diabetes
Chronic Kidney Disease
Recurrent stroke prevention
Recommended Drugs
Diuretic -blocker ACE inhibitor ARB CCB Aldosterone Antagonist
JNC - VII Report, JAMA , 2003;289:2560-2572
Choice Between Choice Between Monotherapy and Monotherapy and
Combination therapyCombination therapy
Possible Combination of Possible Combination of Antihypertensive AgentsAntihypertensive Agents
Diuretics
Beta Blocker
-Blocker
ACE inhibitor
CCBs
ARBs
EHS-ESC Guidelines, 2003;
Indications and Contraindications Indications and Contraindications for the Major Classes of for the Major Classes of Antihypertensiue DrugsAntihypertensiue Drugs
Class Conditions favouringthe use
Compellingcontraindications
Possiblecontraindications
ACEIs CHFLV dysfunctionPost-MINondiabetic nephropathyType 1 diabetic nephropathyProtienuria
PregnancyHyperkalaemiaBilateral RAS
ARBs Type 2 diabetic nephropathyDiabetic microalbuminuriaProteinuriaLVHACE inhibitor cough
PregnancyHyperkalaemiaBilateral RAS
a-Blockers Prostatic hyperplasia (BPH)Hyperlipidaemia
Orthostatic hypotension
CHF
EHS-ESC Guidelines, 2003;
EVOLUTION OF HYPERTENSION EVOLUTION OF HYPERTENSION MANAGEMENTMANAGEMENT
JNC I 1977
JNC II 1980
JNC III 1984
JNC IV 1988
JNC V 1993
JNC VI 1997
JNC VII 2003
High Dose
diuretic
High Dose
diuretic
LowerDose
diureticOr
-blocker
LowerDose
diureticOr
-blockerOr
ACEIOr
CCB
LowerDose
diureticOr
-blockerOr
ACEIOr
CCB-blocker
Or / blocker
• Individulised
Therapy•Single-agent
titration preferred•Loe-dose
combo therapy as a secondary
option
•Focus on Systolic
BP Control•Thiazide-
type diuretics preferred as initial
drug treatment•Emphasis
on combination therapy
High-dose Monotherapy Low-dose Combination
Management of HTN in Special Management of HTN in Special SituationSituation
1. Hypertension CrisesHypertension EmergenciesHypertension Urgencies
2. Refractory/ Resistant hypertension
3. HTN in Pregnancy
4. HTN with coexisting Cardiovascular & other disorders
4. Management of Secondary HTN
Resistant Hypertension
• Not uncommon : 15-20%• Persistence of elevated systo-diastolic pressure in
spite of at 3 anti-hypertensive drugs ( including diuretics)
• Pre-requisites: Exclusion of pseudo-hypertension; white-coat hypertension,use of not-appropriate cuffs.
Resistant hypertension: Causes
• Insufficient patient compliance• Inability to follow prescribed life-style
modifications ( weight loss, increased alcohol consumption)
• Use of offending drugs: steroids,NSAID• Obstructive Sleep apnoea syndrome• Volume overload
Therapeutic intervention
• Exclude undiagnosed secondary hypertension
• Compliance of drugs• Adherence to life style changes• Consider use of 3 or more anti-hypertensive
drugs• Consider the use of drugs such as
spironolactone
Failure of reduction of DBP<90 mm Hg despite the use of three or more drugs which include a diuretic
Resistant hypertension
Braunwald’s Heart Disease, 2005
Volume overload & pseudotolerance“White coat”Pseudohypertension in the elderlyExcess sodium intakeInadequate diuretic therapyVolume retention
Drug relatedDosage too lowInappropriate combinationDrug interaction
Associated conditionsSmokingObesityExcess alcoholSleep apnea
Secondary hypertension
Resistant hypertensionCauses:
Braunwald’s Heart Disease, 2005
Current recommendations for primary prevention of hypertension involve:
a population based approach, and
an intensive targeted strategy focused on individuals at high risk for hypertension.
Primary Prevention of Hypertension
Hypertension Primer, AHA, 2004
Conclusion• Hypertension is easy to diagnose and easy to treat• Aim of the management is to save the target
organ from the deleterious effect• Pharmacological armament of antihypertensive
drugs so rich that we have wide range of options. And this makes the physicians comfortable in varied situations. Conversely one needs to be judicious regarding the choice of the drug
• Besides pharmacology we have other choices and one has to be acquainted with that choice
• Primary prevention of hypertension should be highlighted and it should get more priority than it is getting now.
Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in developing countries
Early diagnosis & management can prevent end organ damage from HTN
Target goal of BP in hypertensive patients:-< 140/90 mm Hg< 130/80 mm Hg for patients with DM & renal disease
Lifestyle modification is the universal “Vaccine” against Hypertension
ConclusionConclusion
Thank Thank you !you !