2098 Franklin #12098 Franklin #1

HYPERTENSION

Dr Haider BaqaiAssistant Professor of Medicine

RMC & Allied Hospitals

2098 Franklin #2

Clinical Scenario

• A 57 year old gentleman presented in the emergency department with H/O sudden onset of headache, L sided weakness, fits followed by loss of consciousness for the last 2 hours.

2098 Franklin #3

• On examination the patient is in coma grade II. His vitals are pulse: 96/min, BP: 220/100

• He has L hemiplegia with L plantar up going

• Fundoscopy reveals Grade III hypertensive retinopathy with haemorrhages & exudates

2098 Franklin #4

• ECG shows evidence of LVH• RFTs: Urea: 57 Cretanine: 1.4 mg/dl• Urine R/E reveals ++ Albuminuria

2098 Franklin #5

• Diagnosis?

2098 Franklin #6

Defining Hypertension

• High blood pressure is a trait• As opposed to a specific disease

2098 Franklin #7

Defining Hypertension

• By the numbers?– ≥95 DBP– >120/80

“A number at which the benefits of intervention exceed those of inaction”

2098 Franklin #8

EPIDEMIOLOGY

2098 Franklin #9

Why is hypertension considered a major Public health problem?

Firstly, hypertension is very common In the adult population

50

65

0

20

40

60

80

100

1988-1994 1999-2000National Health and Nutrition Survey (NHANES)

Increased Prevalence of Hypertension in the Increased Prevalence of Hypertension in the United States from 1988-1994 (NHANES III) to United States from 1988-1994 (NHANES III) to

1999-2000 NHANES1999-2000 NHANES

Fields, et al. Hypertension. 2004;44:398f

Pop

ulat

ion

With

H

yper

tens

ion

(mill

ions

)

30% increase, p<.00130% increase, p<.001

Nearly 1 in 3 Adults (31%) in the US Has Hypertension

1976-98 Cumulative Incidence of HTN 1976-98 Cumulative Incidence of HTN in Women and Men Aged 65 Yearsin Women and Men Aged 65 Years

Vasan, et al. JAMA.2002;287:1003Vasan, et al. JAMA.2002;287:1003

0 2 4 6 8 10 12 14 16 18 200

20

40

60

80

100Risk of Hypertension Risk of Hypertension %%

Years of Follow-upYears of Follow-up

WomenWomenMenMen

Secondly, hypertension is associated with considerablecardiovascular risk.

2098 Franklin #13

Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors

Ezzati et al. Lancet. 2002;360:1347-1360.Ezzati et al. Lancet. 2002;360:1347-1360.Attributable Mortality Attributable Mortality (In thousands; total 55,861,000)(In thousands; total 55,861,000)

High mortality, developing regionHigh mortality, developing region

Lower mortality, developing regionLower mortality, developing region

Developed regionDeveloped region

00 8000800070007000600060005000500040004000300030002000200010001000

High blood pressureHigh blood pressure

TobaccoTobacco

High cholesterolHigh cholesterol

Unsafe sexUnsafe sex

High BMIHigh BMI

Physical inactivityPhysical inactivity

AlcoholAlcohol

Indoor smoke from solid fuelsIndoor smoke from solid fuels

Iron deficiencyIron deficiency

UnderweightUnderweight

2098 Franklin #14

CV Mortality Risk Doubles withEach 20/10 mm Hg BP Increment*

*Individuals aged 40-70 years, starting at BP 115/75 mm Hg.CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressureLewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.

CVmortalityrisk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105

2098 Franklin #15

Thirdly, there is considerablereduction in cardiovascular riskwith effective lowering of bloodpressure with therapy.

2098 Franklin #16

35%-40%

20%-25%

>50%

Average reduction in events (%)

–60

–50

–40

–30

–20

–10

0Stroke

Myocardialinfarction Heart failure

Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.

Long-Term Antihypertensive Therapy Significantly Reduces CV Events

2098 Franklin #17

Aetiology of Hypertension• Primary – 90-95% of cases – also termed

“essential” of “idiopathic”• Secondary – about 5% of cases

– Renal or renovascular disease– Endocrine disease

– Phaeochomocytoma– Cusings syndrome– Conn’s syndrome– Acromegaly and hypothyroidism

– Coarctation of the aorta– Iatrogenic

– Hormonal / oral contraceptive– NSAIDs

2098 Franklin #18

Clinical Features

• Hypertension is termed as the “SILENT KILLER”

• Headache is a common manifestation• Mostly patients present with complications

of hypertension

2098 Franklin #19

Retinopathy Renal failurePeripheral vascular

disease

Complications of Hypertension:

LVH, CHD, HF

TIA, stroke

Hypertension Hypertension is a risk factoris a risk factor

2098 Franklin #20

This left ventricle is very thickened (slightly over 2 cm in thickness)

2098 Franklin #21

2098 Franklin #22

2098 Franklin #23

MANAGING HYPERTENSION

2098 Franklin #24

JNC Reclassification of BP Based on Risk

Source for JNC VI: Arch Intern Med. 1997;157:2413-2446.Adapted with permission from Chobanian AV et al. Hypertension. 2003;42:1206-1252.

JNC VISBP(mm Hg)

DBP(mm Hg)

SBP(mm Hg)

DBP(mm Hg)

Optimal Normal80 <120<120 and 80andNormal

Hi-normalPrehypertension

120-129

130-139120-139

80-84

or 85-89

and80-89or

Stage 1

HypertensionStage 1140-159 140-15990-99or 90-99or

Stage 2

Stage 3Stage 2

160-179

≥ 180≥ 160

100-109or≥ 110or

≥ 100or

Category CategoryJNC 7

2098 Franklin #25

Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed

With Compelling Indications

Lifestyle Modifications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achievedConsider consultation with hypertension specialist

Stage 2 Hypertension (SBP >160 or DBP >100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB,

or combination

Without Compelling Indications

JNC 7 Algorithm for Treatment of Hypertension

Chobanian et al. JAMA. 2003;289:2560-2572.Chobanian et al. JAMA. 2003;289:2560-2572.

2098 Franklin #26

Compelling and possible indications for the major classes of antihypertensive drugs                                 INDICATIONS              

CLASSS OF DRUG COMPELLING POSSIBLE-blockers Prostatism Dyslipidaemia

ACEI HF, LV dysfunction DM

ARBs Cough induced by ACE inhibitor

blockers Myocardial infarction Angina  

Heart failure    

CCBs ISH in elderly patients Angina Elderly patients

Calcium antagonists (rate limiting) Angina Myocardial infarction

Thiazides ISH, HF  

2098 Franklin #27

Logical Combinations

Diuretic -blocker CCB ACE inhibitor -blocker

Diuretic          -          -

-blocker          - *          -

CCB          - *          -

ACE inhibitor          -          -

-blocker          -* Verapamil + beta-blocker = absolute contra-indication    

2098 Franklin #28

Yet another algorithm

2098 Franklin #29

Case #1Case #1

A 76 year old female comes to her family doctor complaining of constipation and epigastric pain as well as weakness and painful cramps (due to hypokalemia).

2098 Franklin #30

 Observation: Mild hypertension (BP 145/90);

History: She has a history of hypertension, for which she has been taking propranolol and hydrochlorothiazide for the past several months.

2098 Franklin #31

Treatment: Potassium rich foods (chickpeas, bananas, papaya), potassium supplement, or switch to potassium-sparing diuretics such as spironolactone or triamterene.

2098 Franklin #32

Case #2Case #2

A 62 year old female is referred to a pulmonary specialist by her family physician because of a chronic dry cough that has been unresponsive to medications.

2098 Franklin #33

History: On careful questioning the specialist discovers that she had been taking captopril for hypertension for six months.

Observation: Normal BP

2098 Franklin #34

Treatment: Consider alternate antihypertensive agents.

Losartan would be a good choice.

2098 Franklin #35

• Any questions

THANK YOU