HYPERTENSION

1. HYPERTENSION

2. Problem Magnitude • Hypertension( HTN) is the most common primary diagnosis in America. • 35 million office visits are as the primary diagnosis of HTN. • 50 million or more Americans have high BP. • Worldwide prevalence estimates for HTN may be as much as 1 billion. • 7.1 million deaths per year may be attributable to hypertension.

3. Definition • A systolic blood pressure ( SBP)>139 mmHg and/or • A diastolic (DBP)>89 mmHg. • Based on the average of two or more properly measured, seated BP readings. • On each of two or more office visits.

4. Accurate Blood Pressure Measurement • The equipment should be regularly inspected and validated. • The operator should be trained and regularly retrained. • The patient must be properly prepared and positioned and seated quietly for at least 5 minutes in a chair. • The auscultatory method should be used. • Caffeine, exercise, and smoking should be avoided for at least 30 minutes before BP measurement. • An appropriately sized cuff should be used.

5. BP Measurement • At least two measurements should be made and the average recorded. • Clinicians should provide to patients their specific BP numbers and the BP goal of their treatment.

6. Classification www.nhlbi.nih.gov

7. Prehypertension • SBP >120 mmHg and <139mmHg and/or • DBP >80 mmHg and <89 mmHg. • Prehypertension is not a disease category rather a designation for individuals at high risk of developing HTN.

8. Pre-HTN • Individuals who are prehypertensive are not candidates for drug therapy but • Should be firmly and unambiguously advised to practice lifestyle modification • Those with pre-HTN, who also have diabetes or kidney disease, drug therapy is indicated if a trial of lifestyle modification fails to reduce their BP to 130/80 mmHg or less.

9. Isolated Systolic Hypertension • Not distinguished as a separate entity as far as management is concerned. • Systolic BP is more important cardiovascular risk factor after age 50. • Diastolic BP is more important before age 50.

10. Hypertensive Crises • Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated Hypertension) • Hypertensive Emergencies: Progressive end-organ dysfunction. (Malignant Hypertension)

11. Hypertensive Urgencies • Severe elevated BP in the upper range of stage II hypertension. • Without progressive end-organ dysfunction. • Examples: Highly elevated BP without severe headache, shortness of breath or chest pain. • Usually due to under-controlled HTN.

12. Hypertensive Emergencies • Severely elevated BP (>180/120mmHg). • With progressive target organ dysfunction. • Require emergent lowering of BP. • Examples: Severely elevated BP with: Hypertensive encephalopathy Acute left ventricular failure with pulmonary edema Acute MI or unstable angina pectoris Dissecting aortic aneurysm

13. Primary HTN: also known as essential HTN. accounts for 95% cases of HTN. no universally established cause known. Secondary HTN: less common cause of HTN ( 5%). secondary to other potentially rectifiable causes. Types of Hypertension

14. Common Intrinsic renal disease Renovascular disease Mineralocorticoid excess Uncommon Pheochromocytoma Glucocorticoid excess Coarctation of Aorta Hyper/hypothyroidism Causes of Secondary HTN

15. Secondary HTN-Clues in Medical History • Onset: at age < 30 yrs ( Fibromuscular dysplasi) or > 55 (athelosclerotic renal artery stenosis), sudden onset (thrombus or cholesterol embolism). • Severity: Grade II, unresponsive to treatment. • Episodic, headache and chest pain/palpitation (pheochromocytoma, thyroid dysfunction). • Morbid obesity with history of snoring and daytime sleepiness (sleep disorders)

16. Secondary HTN-clues on Exam • Pallor, edema, other signs of renal disease. • Abdominal bruit especially with a diastolic component (renovascular) • Truncal obesity, purple striae, buffalo hump (hypercortisolism)

17. Secondary HTN-Clues on Routine Labs • Increased creatinine, abnormal urinalysis ( renovascular and renal parenchymal disease) • Unexplained hypokalemia (hyperaldosteronism) • Impaired blood glucose ( hypercortisolism) • Impaired TFT (Hypo-/hyper- thyroidism)

18. Secondary HTN-Screening Tests www.nhlbi.nih.gov

19. Renal Parenchymal Disease • Common cause of secondary HTN (2-5%) • HTN is both cause and consequence of renal disease • Multifactorial cause for HTN including disturbances in Na/water balance, vasodepressors/ prostaglandins imbalance • Renal disease from multiple etiologies.

20. Renovascular HTN • Atherosclerosis 75-90% ( more common in older patients) • Fibromuscular dysplasia 10-25% (more common in young patients, especially females) • Other • Aortic/renal dissection • Takayasu’s arteritis • Thrombotic/cholesterol emboli • CVD • Post transplantation stenosis • Post radiation

21. Complications of Prolonged Uncontrolled HTN • Changes in the vessel wall leading to vessel trauma and arteriosclerosis throughout the vasculature • Complications arise due to the “target organ” dysfunction and ultimately failure. • Damage to the blood vessels can be seen on fundoscopy.

22. Target Organs • CVS (Heart and Blood Vessels) • The kidneys • Nervous system • The Eyes

23. Effects On CVS • Ventricular hypertrophy, dysfunction and failure. • Arrhithymias • Coronary artery disease, Acute MI • Arterial aneurysm, dissection, and rupture.

24. Effects on The Kidneys • Glomerular sclerosis leading to impaired kidney function and finally end stage kidney disease. • Ischemic kidney disease especially when renal artery stenosis is the cause of HTN

25. Patient Evaluation Objectives • (1) To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment • (2) To reveal identifiable causes of high BP • (3) To assess the presence or absence of target organ damage and CVD

26. (1) Cardiovascular Risk factors • Hypertension • Cigarette smoking • Obesity (body mass index ≥30 kg/m2) • Physical inactivity • Dyslipidemia • Diabetes mellitus • Microalbuminuria or estimated GFR <60 mL/min • Age (older than 55 for men, 65 for women) • Family history of premature cardiovascular disease (men under age 55 or women under age 65)

27. (2) Identifiable Causes of HTN • Sleep apnea • Drug-induced or related causes • Chronic kidney disease • Primary aldosteronism • Renovascular disease • Chronic steroid therapy and Cushing’s syndrome • Pheochromocytoma • Coarctation of the aorta • Thyroid or parathyroid disease

28. (3) Target Organ Damage • Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure • Brain Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy

29. History • Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers • Asthma, COPD: Preclude the use of b-blockers • Heart failure: ACE inhibitors indication • DM: ACE preferred • Polyuria and nocturia: Suggest renal impairment

30. History-contd. • Claudication: May be aggravated by b-blockers, atheromatous RAS may be present • Gout: May be aggravated by diuretics • Use of NSAIDs: May cause or aggravate HTN • Family history of HTN: Important risk factor • Family history of premature death: May have been due to HTN

31. History-contd. • Family history of DM : Patient may also be Diabetic • Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and stroke • High alcohol: A cause of HTN • High salt intake: Advice low salt intake

32. Examination • Appropriate measurement of BP in both arms • Optic fundi • Calculation of BMI ( waist circumference also may be useful) • Auscultation for carotid, abdominal, and femoral bruits • Palpation of the thyroid gland.

33. Examination-contd. • Thorough examination of the heart and lungs • Abdomen for enlarged kidneys, masses, and abnormal aortic pulsation • Lower extremities for edema and pulses • Neurological assessment

34. Routine Labs • EKG. • Urinalysis. • Blood glucose and hematocrit; serum potassium, creatinine ( or estimated GFR), and calcium. • HDL cholesterol, LDL cholesterol, and triglycerides. • Optional tests urinary albumin excretion. albumin/creatinine ratio.

35. Goals of Treatment • Treating SBP and DBP to targets that are <140/90 mmHg • Patients with diabetes or renal disease, the BP goal is <130/80 mmHg • The primary focus should be on attaining the SBP goal. • To reduce cardiovascular and renal morbidity and mortality

36. Benefits of Treatment • Reductions in stroke incidence, averaging 35–40 percent • Reductions in MI, averaging 20–25 percent • Reductions in HF, averaging >50 percent.

37. Lifestyle modifications www.nhlbi.nih.gov

38. Lifestyle Changes Beneficial in Reducing Weight • Decrease time insedentary behaviors such as watching television, playing video games, or spending time online. • Increase physical activity such as walking, biking, aerobic dancing, tennis, soccer, basketball, etc. • Decrease portion sizes for meals and snacks. • Reduce portion sizes or frequency of consumption of calorie containing beverages.

39. DASH Diet • Dietary approaches to Stop Hypertension • As effective as one medication

40. JNC 7 Reference Card