Hypertension

• Chronic condition of concern due to its role in the

causation of CHD, stroke and other vascular
complications .
• It is one of the major risk factors for cardiovascular
mortality, which accounts for 20-50 per cent of all
deaths.
• Sir George Peckering: BP is distributed continuously as
a bell-shaped curve with no real separation
• The dividing line between normal and high blood
pressure can be defined only in an operational way.
 Classification of Blood Pressure
Measurements
Category Systolic B P mm of Hg Diastolic B P mm of Hg

Normal <120 <80

Pre 120- 139 80-90
Hypertension
Hypertension
Stage 1 140-159 90-99
Stage 2 > 160 >100
 Organ Damage
• Organ damage does not always correlates with
BP.
• Rate of progression varies from one individual
to another
• Therefore, blood pressure and organ
impairment should be evaluated separately.
• High pressures may be seen without organ
damage and vice versa
 Measurement of Blood Pressure

• A WHO Study Group recommended the sitting

position
• Uniform policy should be adopted, using either the
right or left arm consistently.
• The pressure at which the sounds are first heard
(phase I) is taken to indicate the systolic pressure and
disappearance (phase V) as diastolic
• Recorded 3 times over 3 minutes and the lowest
reading recorded.
 Sources of Errors
There are three sources of errors
a) Observer errors:
Such as hearing acuity, interpretation of Korotkow sounds.
b) Instrumental errors:
Leaking valve, cuffs that do not encircle the arm.
If the cuff is too small and fails to encircle the arm
properly then too high a reading will be obtained
c) Subject errors:
These include the physical environment, the position of
the subject, external stimuli such as fear, anxiety etc.
 Tracking of Blood pressure

Low blood pressures tend to be low and high

levels tend to be higher as individual groups
grow older
This knowledge can be applied in identifying
children and adolescents “ at risk” of
developing hypertension in future date
 Risk factors for hypertension

 Non -modifiable risk factors:

• Age :
Rises with age in both sexes and the rise is greater in those
with higher initial blood pressure.
Represents a mix of environment and genetics
• Sex :
Early in life there is little evidence of a difference in blood
pressure between the sexes.
At adolescence, men display a higher average level. This
difference is most evident in young and middle aged adults.
Late in life the difference narrows and the pattern may even
be reversed .
Post-menopausal changes in women may be the
contributory factor for this change.
• Genetic Factors :
Determined in part by genetic factors,
Inheritance is polygenic.
The evidence is based on twin and family studies.
Family study: Children of two normotensive parents: 3%,
45% in children of two hypertensive parents
• Ethnicity :
Black Americans of African origin have been
demonstrated to have higher blood pressure levels than
whites.
 Modifiable risk factors:
• Obesity :
The greater the weight gain, the greater the risk of high blood pressure.
Data also indicate that when people with high blood pressure lose weight,
their blood pressure generally decreases.
"Central obesity" indicated by an increased waist to hip ratio, has been
positively correlated with high blood pressure in several populations.

• Salt Intake :
There is an increasing body of evidence to the effect that a high salt intake
(i.e., 7-8 g per day) increases blood pressure proportionately.
Low sodium intake has been found to lower the blood pressure
Potassium antagonises the biological effects of sodium, and thereby
reduces blood pressure.

• Saturated Fats :
Recent evidence suggests that saturated fat raises blood pressure as well
as serum cholesterol
MAGNITUDE :
“Rule of Halves”
Only about half of the hypertensive subjects were
aware of the condition, only half of those aware of
the problem were being treated and only half of
those treated were considered adequately treated.
1. Whole community
2. Normotensive subjects
3. Hypertensive subjects
4. Undiagnosed hypertension
5. Diagnosed hypertension
6. Diagnosed but untreated
7. Diagnosed and treated
8. Inadequately treated
9. Adequately treated
• Dietary Fiber :
Risk of CHD and hypertension is inversely related to the
consumption of dietary fibre. Most fibres reduce plasma total and
LDL cholesterol .

• Alcohol :
High alcohol intake is associated with an increased risk of high
blood pressure
It appears that alcohol consumption raises systolic pressure more
than the diastolic
But do not necessarily lead to sustained blood pressure elevation

• Heart Rate :
Heart rate of the hypertensive group is invariably higher. This may
reflect a resetting of sympathetic activity at a higher level.
• Physical Activity :
Physical activity by reducing body weight may have an indirect effect on
blood pressure

• Environmental Stress :
The term hypertension itself implies a disorder initiated by tension or stress.
It is an accepted fact that psychosocial factors operate through mental
processes, consciously or unconsciously, to produce hypertension .
Significantly higher noradrenalin levels in hypertensives than in
normotensives.
This supports the contention that overactivity of the sympathetic nervous
system has an important part to play in the pathogenesis of hypertension

• Other Factors :
Causes of secondary hypertension. Oral Contraceptives. Vibrations, Noise .
 Prevention of Hypertension
1) Primary prevention
(a) Population strategy
(b) High-risk strategy
2) Secondary prevention
• Population Strategy
The concept of population approach is based on the
fact that even a small reduction in the average blood
pressure of a population would produce a large
reduction in the incidence of cardiovascular
complications such as stroke and CHD
The goal of the population approach is to shift the
community distribution of blood pressure towards
lower levels or "biological normality"
This involves a multifactorial approach,
 Interventions in Population Strategy
• Nutrition: Dietary changes are of paramount importance.
These comprise:
i) reduction of salt intake to an average of not more than 5
g per day
ii) moderate fat intake
iii) the avoidance of a high alcohol intake
iv) restriction of energy intake appropriate to body needs.
• Weight Education:
• Exercise Promotion:
• Behavioral Changes :
• Health Education:
• Self Care :
• High Risk Strategy :
The aim of this approach is "to prevent the
attainment of levels of blood pressure at which
the institution of treatment would be considered"
Since hypertension tends to cluster in families, the
family history of hypertension and "tracking" of
blood pressure from childhood may be used to
identify individuals at risk.
2) Secondary Prevention :
Goal: Detect and control HBP in affected
Early detection and treatment
Screening of the healthy (asymptomatic pt.)
Treatment
Aim: <140/90, close to 120/80
Treat smoking and elevated cholesterol
Patient compliance.
Health education
 Lifestyle modification to manage hypertension
Systolic
Modification Recommonded reduction decrease
5-20 mm
Weight reduction Maintain normal body weight (BMI, 18.5-24.9) Hg/10 kg
Consume a diet rich .in fruits, vegetables and
low-fat dairy products with a 8-14mmHg
Adopt DASH reduced content of saturated fat and total fat
Reduce dietary sodium intake to no more than
100 mEq/d 2-8mm Hg
Dietary sodium (2.4 g sodium or 6 g sod_ium chloride)
Engage in regular aerobic physical activity such
as brisk walking . 4-9mmHg
(at least 30 minutes. per day, most. days of the
Physical activity week) 2-4mmHg
Limit consumption to no more than two drinks
per day
Moderation of (1 oz or 30 ml ethanol eg, 24 oz beer, 10 oz
alcohol wine, or 3 oz 80- proof whisky)
in most men, and no more than one drink per
day in women