HYPERTENSION

Silent killer
 DEFINITION
• Hypertension is defined as persistent elevation
of systolic BP of 140 mmHg or greater and/or
diastolic BP of 90 mmHg or greater
• Measurement based on average of two or
more readings taken at two or more visits to
the doctor.
 CAUSES
• Primary
• Secondary
– Sleep apnoea
– Drug-induced or drug-related
– Chronic kidney disease
– Primary aldosteronism
– Renovascular disease
– Chronic steroid therapy and Cushing syndrome
– Phaeochromocytoma
– Acromegaly
– Thyroid or parathyroid disease
– Coarctation of the aorta
– Takayasu Arteritis
 SYMPTOMS
• Most of the time hypertension is assymptomatic.
• Symptoms occur in extremely high blood pressure :
– Severe headache
– Fatigue or confusion
– Vision problems
– Chest pain
– Difficulty breathing
– Irregular heartbeat
– Blood in the urine
– Pounding in your chest, neck, or ears
 Classification hypertension
category systolic diastolic prevalence
Optimal <120 <80 32

Prehypertension 120-139 80-89 37

Hypertension
Stage 1 140-159 90-99 20

Stage 2 160-179 100-109 8

Stage 3 >180 >110 4

 PREHYPERTENSION
• PreHPT : systolic BP (SBP) 120 to 139 or diastolic BP (DBP)
80 to 89 mmHg, based on 2 @> properly measured
seated BP on 2 or more visits
• Patients with preHPT at increased risk for progression to
HPT
• All patients should be mx with non-pharmacologic
interventions/therapeutic lifestyle modifications to lower
BP
• Need yearly follow up
• pharmacological tx should be based on the individual
patient’s global CVD risk. In DM or CKD, medical tx is
required if BP is above 130/80 mmHg
CARDIOVASCULAR RISK FACTORS: Major risk factors

• Hypertension
• Cigarette smoking
• Central obesity (waist circumference >90 cm for men,
• >80 cm for women)
• Physical inactivity
• Dyslipidaemia
• Diabetes mellitus
• Microalbuminuria
• Estimated GFR* <60 mL/min
• Age (>55 years for men, >65 years for women)
• Family history of premature cardiovascular disease
• (men <55 years or women <65 years)
 TARGET ORGAN DAMAGE
• Heart
– Left ventricular hypertrophy
– Angina or prior myocardial infarction
– Prior coronary revascularisation
– Heart failure
• Brain
– Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy
 HPT vs OTHER MEDICAL ILLNESS
• High blood pressure is the most important
modifiable cause of stroke.
• Hypertensive patients are more prone to silent
myocardial ischaemia, MI and sudden death.
• It’s also one of the causes of progression of
renal impairment especially in diabetic patient.
• In pregnancy, early diagnosis oh hypertension
and proper management may prevent
progression to eclampsia which is one of the
cause of maternal mortality.
 Cont…
• Hypertension is one of the major risk factors
for atherosclerosis and cardiovascular disease
• The early effects of hypertension on the
myocardium are stiffness and subsequently
left ventricular hypertrophy, later cause both
diastolic and systolic left ventricular
dysfunction which leading to CCF and death.
 Management of hypertension
1. NON-PHARMACOLOGICAL
MANAGEMENT
2. PHARMACOLOGICAL
MANAGEMENT
NON-PHARMACOLOGICAL MANAGEMENT

• Therapeutic lifestyle modification

• It may be the only treatment necessary in
Stage 1 hypertension
• However it needed high degree of motivation
to be success without pharmacological
treatment.
 NON-PHARMACOLOGICAL MANAGEMENT

1. Weight reduction
2. Sodium intake – low sodioum intake
3. Avoidance of alcohol intake
4. Regular physical exercise
5. Healthy eating
6. Cessation of smoking
7. Others
• stress management
• micronutrient alterations and dietary supplementation
with fish oil, K+, ca,mg and fibre. (However, they have limited or
unproven efficacy)
 1. Weight reduction
• Weight reduction is most beneficial in patients who are
>10% overweight ( Normal for asian : 18.5 to 23.5 kg/m2)
• A practical target for overweight patients is a minimum
reduction of 5% in body weight.
• However a weight loss as little as 4.5 kg significantly
reduces BP
• Overweight patients on monotherapy receiving lifestyle
intervention have significantly lower BP than those
without such intervention.
 2. Sodium intake
• The effect of Na restriction in HPT can be
variable.
• Elderly subjects are more sensitive to sodium
intake.
• On average, a reduction of 4 mmHg systolic
and 2 mmHg diastolic is achievable with
sodium restriction
• High potassium intake
– High potassium intake is assoc with reduced BP
– can be achieved through diet rather than pills
– potassium has a greater BP-lowering effect in the
context of a higher salt intake and lesser BP
reduction in the setting of a lower salt intake.
– however, the combination of both sodium
reduction and increased potassium did not further
lower BP
 3. Avoidance of alcohol intake
• Alcohol has an acute effect in elevating BP
• The standard advice is to restrict intake to no
more than 21 units for men and 14 units for
women per week (1 unit equivalent to 1/2 a pint
of beer or 100ml of wine or 20ml of proof whisky)
• Hypertensives who are heavy drinkers are
more likely to have hypertension resistant to
drug treatment
 4. Regular physical exercise
• Aerobic type exercise is more effective than
exercise which involves resistance training, (e.g.
weightlifting).
• The effect of at least 6 months of exercise on BP
reduction amongst patients with HPT is
however very modest.
• General advice on cardiovascular health would
be for “milder” exercise, such as brisk walking
for 30 – 60 minutes at least 3 times a week.
 5. Healthy eating
• A diet rich in fruits, vegetables and dairy
products with reduced saturated and total fat
can substantially lower BP (11/6 mmHg in HPT
patients and 4/2 mmHg in patients with high
normal BP).
• This type of diet also has a beneficial effect on
overall cardiovascular health.
 6. Cessation of smoking

• This is important in the overall management

of the patients with HPT in reducing
cardiovascular risk
• Smoking can also acutely increase BP.
• The effect of chronic smoking per se on BP is
not clear.
 PHARMACOLOGICAL MANAGEMENT
• Various groups of antihypertension are
available.
• The ideal drug should be free from side-effects,
able to prevent all the complications of
hypertension, easy to use and affordable.
• The choice of drug use depends on the co-
morbid ilness of patient;
– In CV dis, preferable is Beta blocker and ACE group
– In diabetic/renal impairment – ACE or ARB
 GROUP EXAMPLE
α blocker Prazosin, doxazosin
β blocker Atenolol, metaprolol,bisoprolol
ACE inhibitor Perindopril, enalapril,ramipril
Calcium channel blocker Amlodipine,nifedipine
Diuretics Chlorothiazide, indapamide
Angiotensin receptor blocker Losartan,irbesatan
Centrally acting Methyldopa
α and β blocker Labetolol, carvedilol
Direct vasodilator minoxidil
 Hypertension and diabetes mellitus
• HPT is a common in patients with DM. Its
increases the risk of morbidity & mortality.
• HPT should be detected & treated early in DM to
prevent CV disease and to delay the progression
of renal disease and diabetic retinopathy
• Dietary counselling should target at optimal body
weight & glycaemic control & the mx of
concomitant dyslipidaemia.
– Moderate dietary Na restriction is advisable. It
enhances the effects of BP lowering drugs especially
ACEIs and the ARBs.
– Further Na restriction, with or without a diuretic, may
be necessary in the presence of nephropathy or
when the BP is difficult to control.
 SUMMARY
• Hypertension is one of common illness in
population.
• HPT is assoc w risk for many other systemic illness.
• Management consist of pharmalogical and non
pharmalogical component.
• Nonpharmalogical is important especially in
prehypertensive and as adjunct to pharmacological
treatment
• Proper mx of HPT can help reduce complication ,
morbidity and mortality
Thank You