HYPERTENSIONHYPERTENSION AND ITSAND ITS MANAGEMENTMANAGEMENT

Dr. Md.Toufiqur Rahman

MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI, FAPSC, FAPSIC, FAHA

Associate Professor of CardiologyNational Institute of Cardiovascular

DiseasesSher-e-Bangla Nagar, Dhaka-1207

Consultant, Medinova, Malbagh branch.

HypertensionA World Wide Epidemic

Nearly 1 billion hypertensive in the worldHypertension is poorly controlled, with less than 25% controlled in developed countries and less than 10% in developing countries.Hypertension which is responsible for 3 million death annually.May 14th is World Hypertension Day

Prevalence of Prevalence of HypertensionHypertension

131 144

302

584

240

0

100

200

300

400

500

600

Prev

alen

ce R

ate/

1000

1

India (2000) Bangladesh (2002) Malaysia (2002)China (2002) USA (2002)

Hypertension is a hemodynamic disorder A well accepted definition of hypertension was

suggested by Evans and Rose: “Hypertension should be defined in the terms

of blood pressure level above which investigation and treatment do good more than harm”

A patient is said to be hypertensive when his SBP≥ 140 mm Hg & DBP ≥ 90 mm Hg provided that the patient is not on antihypertensive drugs.

Hypertension: Hypertension: DefinitionDefinition

Varieties OF HTNVarieties OF HTN Labile HTNIsolated diastolic hypertensionIsolated systolic hypertensionMalignant or accelerated HypertensionRefractory/ Resistant hypertensionHypertensive emergencies/ urgencies

Classification of BP for AdultsClassification of BP for AdultsJNC-VI;1997JNC-VI;1997

BP Classification Systolic BP Diastolic BPOptimal <120 and <80

Normal <130 and <85

High Normal 130-139 or 85-89

Stage 1 HT 140-159 or 90-99

Stage 2 HT 160-179 or 100-109

Stage 3 HT ≥ 180 or ≥ 110

BP Classification Systolic BP Diastolic BP

Normal <120 and <80

Prehypertension 120-139 or 80-89

Stage 1 HT 140-159 or 90-99

Stage 2 HT ≥ 160 or ≥ 100

JNC-VII;2003JNC-VII;2003

Classification of BP LevelsClassification of BP LevelsESH-ESC Guidelines, 2003

BP Classification

OptimalNormalHigh NormalGrade 1 HT (mild)Grade 2 HT (moderate)Grade 3 (severe)Isolated systolic HT

Systolic BP

<120120-129130-139140-159160-179>180>140

Diastolic BP

<8080-8485-8990-99100-109>110<90

Regulation of BPBP = CO X PVR

SV HR

Haemodynamic Pattern in Haemodynamic Pattern in HypertensionHypertension

Young : BP = CO X TPR

Middle Aged : BP = CO X TPR

Elderly : BP = CO X TPR

Aetiology of Systemic Aetiology of Systemic HypertensionHypertensionA) Essential or Primary HTN (95%)

A. Age

B. Genetic • Both parents (45%) • Single (25%)

C. Environment • Diet FatSaltalcohol

• Obesity

• Physical inactivity

• Stress

• Smoking

D. Hormonal

Aetiology of Systemic Aetiology of Systemic HypertensionHypertension

B) Secondary HTN (05%)

A. Renal (80%) • AGN• CGN,• CPN, • Polycyst. K.D

• Renal Artery stenosis

B. Endocrine • Adrenal • Primary aldosteronism• Cushing’s syndrome Pheochromocytoma

• Acromegaly

• Exogenous hormone • Oral contraceptive) • Glucosteroids

• Hypothyroidism &• Hyperparathyroidism

Continue…

C) Others

Coarctation of the aorta Pregnancy Induced HTN (Pre-eclampsia) Sleep Apnea Syndrome.

Aetiology of Systemic Aetiology of Systemic HypertensionHypertension

Clinical ManifestationClinical Manifestation

• Asymptomatic in the majority of patients. Can remain undetected for many years

• Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated.

Measuring Blood PressureMeasuring Blood Pressure

• Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level

•An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm)

•At least 2 measurements

Continue…

Measuring Blood PressureMeasuring Blood Pressure

• Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard

• Diastolic Blood Pressure is the point of disappearance of the sounds (Korotkoff 5th)

Continue…

Measuring Blood PressureMeasuring Blood Pressure

• Ambulatory BP Monitoring - information about BP during daily activities and sleep.

• Correlates better than office measurements with target-organ injury.

Continue…

Complication of Complication of HypertensionHypertension

1. Cardiac :

LVH LVF •Systolic•Diastolic IHD Arrhythmias

2. Vascular Peripheral arterial disease•Aortic dissection

3. Cerebral StrokeTIAEncephalopathy

4. Renal NephropathyRenal failure

5. Eye Retinopathy

The scope of the problemThe scope of the problem

– Heart Attack (MI) – Heart Failure– Stroke– Kidney Disease

THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO MINIMISE CARDIOVASCULAR RISK AND DAMAGE

TO TARGET ORGANS

Hypertension even today is aHypertension even today is atriple paradox which is :triple paradox which is :

Easy to diagnose OFTEN remains undetected

Simple to treat OFTEN remains untreated

Despite availability of potent drugs, treatment all too OFTEN is ineffective

The "Rule of Halves" inThe "Rule of Halves" inHypertension Hypertension

Only 1/2 have been diagnosedOnly 1/2 of those diagnosed have been treatedOnly 1/2 of those treated are adequately controlled

Only 12.5% overall are adequately controlled

Not diagnosed

Not treated

Not controlled

Controlled

Evaluation of hypertensive Evaluation of hypertensive patients patients

Objectives:To know accurate and representative measurement of BPTo identity any known cause of HypertensionTo assess presence or absence of TODTo assess response to therapy To identity cardiovascular risks factor To know concomitant disorders

Continue….

Evaluation of hypertensive Evaluation of hypertensive patients patients

Evaluation by Medical history

Physical Examination

Laboratory investigation Routine tests Optional tests.

Effects of Antihypertensive Drug Treatment Effects of Antihypertensive Drug Treatment on CV Mortality and Morbidityon CV Mortality and Morbidity

Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated compared to control

Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478

-52%

-38%-35%

-25%

-16%

-60%

-50%

-40%

-30%

-20%

-10%

0%

CHF Strokes(fatal/nonfatal)

LVF CVD Deaths CVD events(fatal/nonfatal

Management of HTN Management of HTN

140

120

100

80

60

40

20 0

50

40

30

20

10

0

Historical Lessons About HypertensionHistorical Lessons About Hypertension

Hypertension Increases Morbidity and Mortality

Men Women

CHD

Inc i d

ence

Ra t

e/

10

00 p

erso

ns p

er y

ear

THE FRAMINGHAM STUDY

Cum

ulat

ive

fat a

l &

Nonf

atal

End

poi n

ts

Treatment Decreases Morbidity and Mortality

Men Women

Placebo Active Treatment

THE VET.ADM. STUDY II

Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152

NormotensionHypertension

Implication of reduction in Diastolic BP Implication of reduction in Diastolic BP for Primary Preventionfor Primary Prevention

30

20

% R

e du c

tio n

Change in DBP

0

-10

-20

-30

-40

-50

7.5 mm Hg 5-6 mm Hg 2 mm Hg

-21

-46

-16

-38

-6

-15

CHD

Stroke

Cook, et al. Arch Int med. 1995; 155:711-109

Millimeters Matter…… Millimeters Matter……

“ A 2-mm Hg reduction in DBP would result in…

a 6% reduction in the risk of CHD and a 15% reduction

in the risk of stroke and TIAs”

Cook, et al. Arch Int med. 1995; 155:711-109

Impact of High Normal BP on CV Impact of High Normal BP on CV Disease Risk in MenDisease Risk in Men

High Normal130-139/ 85-89 mm Hg

Normal120-129/ 80-84 mm Hg

Optimal<120/ 80 mm Hg

Cum

u la t

ive

I nc i

denc

e (%

)

Time (Years) N Engl J Med. 2001;345:1291-97

Benefits of Lowering BPBenefits of Lowering BP

Average percentreduction

Stroke reduction 35-40%

Myocardial infarction 20-25%

Heart failure 50%

Goals of TherapyGoals of Therapy• Reduction of cardiovascular and renal

morbidity and mortality. 1

• The primary focus should be on achieving the systolic BP goal.

• Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease in CVD complications.

• In patients with hypertension with diabetes or renal disease, the BP goal is < 130/80 mmHg 1

1 JNC - VII Report, JAMA , 2003;289:2560-2572

JNC VII Algorithm for Treatment of Hypertension

JNC - VII Report, JAMA , 2003;289:2560-2572

Lifestyle Modifications

Not at Goal BP(< 140/90 mmHg or < 130/80

mmHg for Those with Diabetes or Chronic Kidney Disease

Initial Drug Choices

Lifestyle Modification: 1Lifestyle Modification: 1 Socioeconomic condition in the world suggest that

prevention through Lifestyle Modifications is the universal “vaccine” against Hypertension

Weight Reduction– Maintain normal body weight

• BMI: 18.5 – 24.9• BP reduction: 5-20 mmHg/10 kg loss

DASH Eating Plan– Dietary Approaches to Stop Hypertension

• Fruits, Vegetables, Low-fat dairy• Reduce saturated and total fat• 8-14 mmHg BP reduction

Lifestyle Modification: 2Lifestyle Modification: 2Dietary Sodium Reduction

• 2.4 grams Sodium or 6 grams Sodium Chloride• 2-8 mmHg BP reduction

Physical Activity –Regular aerobic physical activity

•4-9 mmHg BP reduction

Lifestyle Modification: 3Lifestyle Modification: 3

Smoking Cessation•Any independent chronic effect of smoking on BP is small•Smoking cessation does not decrease BP•BUT total cardiovascular risk is increased by smoking.

Therefore hypertensives who smoke should be counselled on smoking cessation

Antihypertensive Drugs

Continue….AT1 receptor

ARB

Antihypertensive Drugs

JNC VII Algorithm for Treatment of Hypertension

Hypertension without compelling indications

Hypertension with compelling indication

(Systolic Bp 140-159 mmHg or Diastolic BP 90-99 mmHg)

Thiazide-Type Diuretics for MostMay Consider ACE inhibitor, ARB, ß-blocker, CCB or combination

Systolic Bp >160 mmHg or Diastolic BP > 100 mmHg)

2- Drug Combination for Most(Usually Thiazide - Type Diuretic and ACE Inhibitor or ARB or ß-blocker, CCB)

Drug (s) for the Compelling Indications

Other Anithypertensive Drugs

(Diuretics, ACE inhibitor, ARB, ß-blocker, CCB) as needed

Initial Drug Choices

ChoiceChoice of antihypertensiveof antihypertensive

• Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors, angiotensin receptor antagonists) are suitable for the initiation and maintenance of therapy

• Choice: Previous experience of the patient Cost Risk profile, target organ damage, clinical cardiovascular or renal

disease or diabetes or lung disorder Patient’s preference

• Long acting preparations providing 24-h efficacy on a once daily basis(2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).

Special ConsiderationsSpecial ConsiderationsGuideline Basis for Compelling Indications for Individual Drug Classes

High Risk Conditions With Compelling Indication

Heart failure

Post-myocardial infarction

High coronary disease risk

Diabetes

Chronic Kidney Disease

Recurrent stroke prevention

Recommended Drugs

Diuretic -blocker ACE inhibitor ARB CCB Aldosterone Antagonist

JNC - VII Report, JAMA , 2003;289:2560-2572

Choice Between Choice Between Monotherapy and Monotherapy and

Combination therapyCombination therapy

Possible Combination of Possible Combination of Antihypertensive AgentsAntihypertensive Agents

Diuretics

Beta Blocker

-Blocker

ACE inhibitor

CCBs

ARBs

EHS-ESC Guidelines, 2003;

Indications and Contraindications Indications and Contraindications for the Major Classes of for the Major Classes of Antihypertensiue DrugsAntihypertensiue Drugs

Class Conditions favouringthe use

Compellingcontraindications

Possiblecontraindications

ACEIs CHFLV dysfunctionPost-MINondiabetic nephropathyType 1 diabetic nephropathyProtienuria

PregnancyHyperkalaemiaBilateral RAS

 

ARBs Type 2 diabetic nephropathyDiabetic microalbuminuriaProteinuriaLVHACE inhibitor cough

PregnancyHyperkalaemiaBilateral RAS

 

a-Blockers Prostatic hyperplasia (BPH)Hyperlipidaemia

Orthostatic hypotension

CHF

EHS-ESC Guidelines, 2003;

EVOLUTION OF HYPERTENSION EVOLUTION OF HYPERTENSION MANAGEMENTMANAGEMENT

JNC I 1977

JNC II 1980

JNC III 1984

JNC IV 1988

JNC V 1993

JNC VI 1997

JNC VII 2003

High Dose

diuretic

High Dose

diuretic

LowerDose

diureticOr

-blocker

LowerDose

diureticOr

-blockerOr

ACEIOr

CCB

LowerDose

diureticOr

-blockerOr

ACEIOr

CCB-blocker

Or / blocker

• Individulised

Therapy•Single-agent

titration preferred•Loe-dose

combo therapy as a secondary

option

•Focus on Systolic

BP Control•Thiazide-

type diuretics preferred as initial

drug treatment•Emphasis

on combination therapy

High-dose Monotherapy Low-dose Combination

Management of HTN in Special Management of HTN in Special SituationSituation

1. Hypertension CrisesHypertension EmergenciesHypertension Urgencies

2. Refractory/ Resistant hypertension

3. HTN in Pregnancy

4. HTN with coexisting Cardiovascular & other disorders

4. Management of Secondary HTN

Resistant Hypertension

• Not uncommon : 15-20%• Persistence of elevated systo-diastolic pressure in

spite of at 3 anti-hypertensive drugs ( including diuretics)

• Pre-requisites: Exclusion of pseudo-hypertension; white-coat hypertension,use of not-appropriate cuffs.

Resistant hypertension: Causes

• Insufficient patient compliance• Inability to follow prescribed life-style

modifications ( weight loss, increased alcohol consumption)

• Use of offending drugs: steroids,NSAID• Obstructive Sleep apnoea syndrome• Volume overload

Therapeutic intervention

• Exclude undiagnosed secondary hypertension

• Compliance of drugs• Adherence to life style changes• Consider use of 3 or more anti-hypertensive

drugs• Consider the use of drugs such as

spironolactone

Failure of reduction of DBP<90 mm Hg despite the use of three or more drugs which include a diuretic

Resistant hypertension

Braunwald’s Heart Disease, 2005

Volume overload & pseudotolerance“White coat”Pseudohypertension in the elderlyExcess sodium intakeInadequate diuretic therapyVolume retention

Drug relatedDosage too lowInappropriate combinationDrug interaction

Associated conditionsSmokingObesityExcess alcoholSleep apnea

Secondary hypertension

Resistant hypertensionCauses:

Braunwald’s Heart Disease, 2005

Current recommendations for primary prevention of hypertension involve:

a population based approach, and

an intensive targeted strategy focused on individuals at high risk for hypertension.

Primary Prevention of Hypertension

Hypertension Primer, AHA, 2004

Conclusion• Hypertension is easy to diagnose and easy to treat• Aim of the management is to save the target

organ from the deleterious effect• Pharmacological armament of antihypertensive

drugs so rich that we have wide range of options. And this makes the physicians comfortable in varied situations. Conversely one needs to be judicious regarding the choice of the drug

• Besides pharmacology we have other choices and one has to be acquainted with that choice

• Primary prevention of hypertension should be highlighted and it should get more priority than it is getting now.

Hypertension - a worldwide epidemic

It’s a disease which is responsible for 3 million death annually

About 15-20% of Bangladeshi population is suffering from Hypertension

HTN is very poorly controlled - < 25% in developed & < 10% in developing countries

Early diagnosis & management can prevent end organ damage from HTN

Target goal of BP in hypertensive patients:-< 140/90 mm Hg< 130/80 mm Hg for patients with DM & renal disease

Lifestyle modification is the universal “Vaccine” against Hypertension

ConclusionConclusion

Thank Thank you !you !