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By Dr. James C. Ekwensi, Dr. Thomas Gray, Dr. Abdulhalim Khan, and Khadijat B.

Momoh

Introduction & general overview of hypertension


Burden of hypertension

Strategies for intervention in Memphis


Policies & Recommendations

Definition: Persistently high arterial blood pressure, defined as systolic blood pressure above 140 mm Hg and / or diastolic blood pressure above 90 mm Hg. Hypertension is the most common public health problem in developed countries. Called Silent Killer

No cure is available, but prevention and management decrease the incidence of hypertension and its complications

Origins dates back to 2600 BC


Suspect hypertension by the quality of ones 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 by Thomas 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 while sphygmomanometer cuff is deflated.
Source: A Historical Look at Hypertension. Southern Medical Journal Volume 99, Number 12, December 2006

Essential (Primary)Hypertension
90-95% No obvious underlying medical cause

Secondary hypertension
5-10% There are underlying causes such as conditions that affect the kidneys, arteries, heart, and endocrine system.

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

Hypertension is most often asymptomatic Commonly, the only sign is consistent elevation of the blood pressure. The following signs and symptoms may occur with severe hypertension: Headaches Blurred Vision Target organ damage 31% of people with Blood Pressure exceeding 140/90 were asymptomatic and unaware of having hypertension.
Source: 7th report of JNC: Joint National committee on prevention, detection, evaluation and treatment of hypertension (JNC 7)

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 cushingss syndrome Pheochromocytoma Thyroid or parathyroid disease
Source: JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

Diagnosis of primary hypertension depends on repeated demonstration of higher than normal systolic and / or diastolic blood Pressure(BP) and excluding secondary hypertension.

Classification (JNC7) Normal

Systolic Pressure
mmHg 90119

Diastolic pressure
mmHg 6079

Prehypertension Stage 1 hypertension


Stage 2 hypertension Isolated systolic hypertension

120139 140159
160 140

8089 9099
100 <90

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

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

Moderate elevation of arterial blood pressure is associated with a shortened life expectancy. Dietary and lifestyle changes can improve blood pressure control and decrease the risk of associated health complications, although drug treatment is often necessary in people for whom lifestyle changes prove ineffective or insufficient

Historically, treatment of what is called hard pulse disease mainly consist 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.

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.

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

There is no known cure for hypertension.


Reduction of morbidity and mortality is the ultimate 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)

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

1 out of every 3 adult persons 25 years and older have hypertension (2012 WH0) Higher prevalence in low and moderate economic regions Africa highest prevalence of hypertension (36.8% for both sexes in 2008) Americas region Lowest with about 35%, men having 39%, and women 32%. It is projected that by 2025, of adult population would have hypertension probably because of urbanization.

Population: 1Billion persons worldwide have hypertension as of 2008 Trend: The prevalence rate of uncontrolled hypertension has reduced from the 80s till the 2008 Men: from 33% to 29% Women: from 29%-25% The prevalence of hypertension worldwide is also said to have reduced but the population growth has led to an increase in the total persons with hypertension (from 605M to 978M).

Hypertension is directly related to 62% of cerebrovascular disease (Stroke) 49% of Ischemic heart disease It is also the most prevalent PREVENTABLE disease worldwide

7.5M death or 12.8% of total death are related to hypertension WHO 2008 Also, 57M Disability adjusted Life Years (DALYs) which is 3.7% of total DALY

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.

1999 to 2000 National Health and Nutrition Examination Survey (NHANES)

Aware
Treatment Uncontrolled

70%
59 55.7

Unaware but hypertensive

Framingham study shows that there is a 90% chance of developing hypertension in those nonhypertensives aged 55-65 years by age of 80-85 years. Men: 34.1% Women: 32.7%

69% of people who have a first heart attack have high blood pressure 77% of people who first have a stroke 74% of people with chronic heart failure Major risk factor for kidney disease, eye disease and other complications/comorbidities. 579,000 people diagnosed with high blood pressure were discharged from short-stay hospitals in 2009. Discharges include people both living and deceasedi.

348,000 primary or contributing cause of death Proportion from total registered deaths in 2008: 14%

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

Directly attributable to hypertension in direct medical expenses: $131B annually Indirect (lost productivity): $25B

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

The prevalence of Hypertension in TN is 32% in population 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

Prevalence of hypertension Memphis


60% 50% 40% 30% 49%

35%

20%
10% 0% Black White

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).

Why is prevention so important?

Prevention can prevent disease and complications of the disease.

As mentioned earlier hypertension is one of the most expensive health conditions and one of the most preventable.
Preventative measures can also be considered early treatment.

Why is prevention so important?

A meta-analysis of four trials showed that reducing blood pressure led to a 15% reduction in cardiovascular events, a 20% reduction in strokes, and a 10% reduction in coronary 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 from the DBP results in a reduction of 17% in the prevalence of hypertension (Cook, 1995).

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 Shelbybarbershop screening, church congregations with CHC. Church Health Center and Christ Community Neighborhood clinics Health fairs Pharmacy screenings

PreventionEffects of lowering systolic portion of blood pressure: .

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

Copyright American Heart Association

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 high blood pressure.

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)

Dietary Approach to Stop Hypertension (DASH)- rich in fruits, 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 the effects of coffee, calcium supplementation, and fish oil.

Aerobic, endurance exercise (as opposed to power exercise) alone resulted in reductions of both SBP (3.35 mm Hg) and DBP (2.58 mm Hg). This was found in both normotensive, hypertensive, overweight, and normalweight people (Hernelahti, 2002). Weight loss combined with exercise resulted in reducing SBP 12.5 mm Hg and DBP 7.9 mm Hg (Bacon, 2004).

1 drink = 14 grams alcohol= 1.5 oz 80-proof liquor=5 oz wine=12 oz beer. The association between hypertension and alcohol is a little more confusing but appears that moderate to severe consumption (>210 grams/ week,15 drinks) increases the risk of hypertension in all groups to the result of SBP 3.31 mm Hg and DBP 2.04 mm Hg. (Fuchs, 1997) Low to moderate consumption (<210 g/week) was a risk to only African American men. (Fuchs, 1997) Moderate consumption is defined as 1 drink/ day for women and 2 drinks / for men.

Interventions

Education Lets Move! is a comprehensive initiative, launched by the First Lady, to address the problem of obesity. 30 minutes of exercise most days of the week (4 days/week).

Interventions Education Underage alcohol Alcohol commercials

Goals of treatment The goal is simple and that is to reduce the BP to normal or near normal levels adjusted for age and existing comorbidity.

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

Once hypertension is diagnosed, all cases should be treated.

Lifestyle changes (same as preventive measures) Excessive body weight Diet Sedentary lifestyle Excessive alcohol intake Drugs

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

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 and treating 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).

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 effects more common in African Americans. Distrust of medical establishment (Tuskegee syphilis study from 19321972, penicillin recognized as effective in the 1940s). Birth in 1972 is only 40 year old.

Disparities

Well established significant racial disparities. Penner (2007) and Kaucchi (2005) both divide the reasons for the health care disparity 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 socioeconomic class. Prejudice, related processes. Penner (2007)calls it more of an unconscious racism of the healthcare system and Kaucchi (2005) refers more to an unmentioned caste- like attitude against African Americans.

System-based initiative to improve control Hypertension and Sodium Community and Population based changes to promote prevention

PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure
Percentage of patients aged 18 and older who are screened for high 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 was adequately controlled (<140/<90) during the measurement year.

Patients may be able to lower the required dose of blood pressure medicines through reduced sodium intake Patients with normotension or prehypertension may reduce or prolong their risk for developing hypertension through sodium reduction Referral to a Registered Dietitian for Counseling Education during BP screenings Downloadable CDC resource: Reducing Sodium in Your Diet to Help Control 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

The Asheville Project is a community-based, pharmacist-directed, medication therapy management (MTM) program provided for several employers in the Asheville, NC area Patients with hypertension receiving education and long-term medication therapy management services achieved significant clinical improvements 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-based long-term medication therapy management program for hypertension and dyslipidemia. J Am Pharm Assoc. 2008;48:2331.

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

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 and cardiovascular disease. Journal of Clinical Hypertension. 2012. Online ahead of print. DOI:10.1111/j.1751-7176.2012.00622.x

Community Transformation Grants Sodium Reduction in Communities WISEWOMAN program State Health Departments Million Hearts Initiative

Public health approaches such as increasing physical activity and reducing trans-fats and salt in processed foods can achieve a downward shift in the distribution of a populations 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

CDC Vital Signs: Hypertension and Cholesterol


http://www.cdc.gov/vitalsigns/CardiovascularDisease/index. html

CDC Vital Signs: Wheres the Sodium?


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

CDC Vital Signs: Prevalence, Treatment, and Control of 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

CDC Grand Rounds: Sodium Reduction: Time for Choice


http://www.cdc.gov/about/grandrounds/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_das h.pdf

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