HYPERTENSION AN OVERVIEW Prof Ahmed Mandil Dr Hafsa

HYPERTENSION: AN OVERVIEW Prof Ahmed Mandil, Dr Hafsa Raheel KSU Dept of Family & Community Medicine

Objectives By the end of this session, students should be able to: n Understand the basic concepts of hypertension n Explain the magnitude of the problem n Identify important risk factors for hypertension n Identify the important complications of hypertension n Explain important concepts of prevention and control of hypertension 5/24/2021 Hypertension 2

Headlines Magnitude of the problem n Risk factors n Assessment & diagnosis n Complications n Prevention and control n 5/24/2021 Hypertension 3

Magnitude ■ In developed and developing countries alike, essential hypertension affects 25 -35% of the adult population. Up to 60 -70% of those beyond the seventh decade of life ■ Each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors. 5/24/2021 Hypertension 4

Prevalence of Hypertension in Obese and non-Obese Saudis The study group: 14. 805 males: 6225 females: 8580 The age: 14 – 70 years Non-obese prevalence: 4. 8 % 2. 8 % Obese prevalence: 8% 8% males females El-Hazmi M. Saudi Medical Journal 2001; 22 (1): 44 -48 5/24/2021 Hypertension 5

Hypertension among attendants of primary health care centers in Al-Qassim region, Saudi Arabia. Study sample: 1114 Prevalence: 30 % Higher among: ● Age > 40 years ● Overweight and obese people ● illiteracy Awareness: 20 % of hypertensive women 25 % of hypertensive men Khalid A et al. Saudi Med J 2001; 22 (11) 960 -963 5/24/2021 Hypertension 6

Blood Pressure Measurement and Hypertension Diagnosis n n n 1 in 5 adult Canadians have hypertension Over 40% of Canadians at aged 56 -65 have hypertension 90% of normotensive persons aged 55 -65 developed hypertension in the next 20 years in the Framingham study 2010 Canadian Hyprtension Education Program 5/24/2021 Hypertension 7

Hypertension in the community. Rule of halves 5/24/2021 Hypertension 8

Risk Factors Smoking n Dyslipidaemia n Diabetes Mellitus n Obesity n Age (older than 55 for men, 65 for women) n Gender (men or postmenopausal women) n Family History of cardiovascular disease (men under age 55 or women under age 65) n 5/24/2021 Hypertension 9

Modifiable Risk Factors for Developing Hypertension n n Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption 5/24/2021 Hypertension 10

Colors of Salt n n n n 5/24/2021 White Black Red Yellow Green Brown Clear n n n n Table salt Soy sauce Catsup Mustard Pickles Soups & gravies Saline Hypertension 11

High Risk Subjects ► ABP ≥ 180 systolic and/or ≥ 110 diastolic ► Systolic BP > 160 with low diastolic <70 ► Diabetes mellitus ► Metabolic syndrome ► ≥ 2 cardiovascular risk factors (smoking, dyslipidaemia, obesity, …. . ) 5/24/2021 Hypertension 12

Life time Risk of Hypertension in normotensive women and men aged 65 years Risk of Hypertension % 100 Women 80 80 60 60 40 40 20 20 0 0 2 4 6 8 10 12 14 16 18 20 0 Men 0 2 Years to Follow-up 4 6 8 10 12 14 16 18 20 Years to Follow-up JAMA 2002: 297: 1003 -10. Framingham data. 5/24/2021 Hypertension 13

Types & Complications of Hypertension

Types of hypertention, 2007, USA Essential * 92. 0 -95. 0 % Secondary Chronic kidney disease 3. 0 -6. 0 % Renovascular disease 0. 2 -1. 0 % Pheochromocytoma 0. 1 -0. 2 % Aldosteronism 0. 1 -0. 3 % Cushing’s syndrome 0. 1 -0. 2 % Coarctation 0. 1 -0. 2 % Oral contraceptives 0. 2 -1. 0 % * Onset in 30 s and 40 s, gradual onset, family history, obesity 5/24/2021 Hypertension 15

Complications of Hypertension: Hypertension is a risk factor TIA, stroke Retinopathy LVH, IHD, MI, HF Peripheral vascular disease Renal failure TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; MI = myocardial infarction; HF = heart failure. Cushman WC. J Clin Hypertens. 2003; 5(Suppl): 14 -22. 5/24/2021 Hypertension 16

Assessment & Diagnosis

Auscultatory method of blood pressure measurement 5/24/2021 Nokolai Korotkoff, 1905 Hypertension 18

Noninvasive Blood Pressure Measurement Methodologies - Auscultatory (K sound) - Mercury Aneroid - Oscillometric Locations Situations - Upper arm - Wrist - Finger - Clinic - Home - Ambulatory

Definitions and Classification of blood pressure The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC), 2007 Systolic Optimal Normal High normal Grade 1 HTN Grade 2 HTN Grade 3 HTN Isolated Systolic HTN <120 120– 129 130– 139 140– 159 160– 179 180 ≥ 140 Diastolic and <80 and/or 80– 84 and/or 85– 89 and/or 90– 99 and/or 100– 109 and/or 110 and <90

Prevention & Control

Primary Prevention – Population Strategies 1 ◘ Reduce sodium intake ◘ Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and sodium. ◘ Regular physical activity: 30 -60 minutes of moderate intensity cardiorespiratory activity (e. g. a brisk walk); 5 -7 days/week in addition to routine activities of daily living ◘ Low risk alcohol consumption (≤ 2 standard drinks/day and less than 14/week for men and less than 9/week for women) 5/24/2021 Hypertension 22

Primary Prevention – Population Strategies 2 ◘ Maintenance of ideal body weight (BMI 18. 5 -24. 9 kg/m 2) n n n Waist Circumference - EMR, Europe, Sub-Saharan African - South Asian, Chinese Men <94 cm <90 cm Women <80 cm ◘ Prevention / cessation of tobacco use Health Education Behavioral change 5/24/2021 Hypertension 23

Primary Prevention- High Risk approach n Tracking of blood pressure from childhood, in high risk families 5/24/2021 Hypertension 24

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Secondary prevention q. Timely diagnosis and adequate control of BP q. Compliance with treatment 5/24/2021 Hypertension 26

Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension * Condition Initiation SBP or DBP mm. Hg • Systolic or Diastolic hypertension 140/90 • Diabetes • Chronic Kidney Disease 130/80 * Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS 5/24/2021 Hypertension 27

BENEFITS OF LOWERING BLOOD PRESSURE n The Clinical Trials had shown: Reduction in • STROKE • MI 35 – 40 % 20 – 25 % • HEART FAILURE > 50% 5/24/2021 Hypertension 28

Conclusion n ASSESS AND MANAGE CV RISK IN HYPERTENSIVES n High dietary sodium intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating, and physical inactivity. LIFESTYLE MODIFICATION n Sustained lifestyle modification is the cornerstone for the prevention and control of hypertension and the management of cardiovascular disease. Encourage patients to reduce their sodium intake. TREATING TO TARGET BP n Treat blood pressure to less than <140/90 mm. Hg. n In people with diabetes or chronic kidney disease target to <130/80 mm. Hg and more than one drug is usually required including diuretics to achieve BP targets. 5/24/2021 Hypertension 29

Global initiatives: World Health Day 2013 5/24/2021 Hypertension 30

Local hypertension initiatives n n Saudi societies working in the hypertension field: n Saudi hypertension management society n Saudi heart association Related databases: n HEARTS database: http: //www. heartsksa. com/home. html n SPACE registry project in Saudi Arabia: http: //www. space-ksa. com/ n Saudi Hypertension management guidelines 5/24/2021 Hypertension 31

References 1 1. 2. 3. 4. 5. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003 Saudi Hypertension Management Guidelines The British Hypertension Society. NICE Guidelines Franklin S. Epidemiology of hypertension. UC Irvine The Canadian Hypertension Education Program: Recommendations for management of hypertension, 2006 5/24/2021 Hypertension 32

References 2 6. 7. 8. 9. Treatment of hypertension in the prevention and management of Ischemic Heart Disease. American Heart Association, 2007 European guidelines for management of arterial hypertension 2007 Saad H. Hypertension updates, 2010 International societies: American Heart Association; Heart & Stroke Foundation of Canada; British Heart Foundation; European Society of Cardiology, World Health Organization (www. who. int); Centers for disease control and prevention. www. cdc. gov 5/24/2021 Hypertension 33