HT is worldwide epidemic

In many countries 50% population >60yrs have ht

Major MODIFIABLE risk factor for stroke ,MI,CKD

BACKGROUND 20% world adults have hypertension

75% are aware of hypertension

68% are treated with drugs

64% have controlled hypertension

Benefits of treatment of hypertension

40% reduction in stroke incidence

25% reduction in myocardial infarction

>50% reduction in heart failure

DEFINITION Systolic BP >140mmhg or Diastolic BP>90mmhg

Normal SBP<120mmhg:DBP<80mmhg

Prehypertension- SBP 120-139mmhg

DBP 80-89mmhg

Stage 1 SBP 140-159mmhg

DBP 90-99mmhg

Stage 2 SBP 160mmhg and above

DBP 100mmhg and above

Average of 2 or more readings taken at each of 2 or more visits

Prehypertension [jnc 7] –risk of progression to Ht and LSM is necessary

Hypertensive urgency >180/110–without TOD

Hypertensive emergency –with TOD

Malignant HT ->200/130 with grade 3 or 4 retinal changes – untreated 90% die in 1 yr ;even treated 30% die in 5 yrs

Ht emergency-reduce BP by25% in an hour and from there slowly upto 160/100

I S H Elderly

SBP >160

>50% over age 60

Stiffening of arteries

*2 MI

*3 Stroke

HYPERTENSION AND PREGNANCY CHRONIC HT

PREECLAMPSIA –ECLAMPSIA

PREECLAMPSIA ON CHRONIC HT

GESTATIONAL HT [>20 WKS GEST WITHOUT PREECLAMPTIC FEATURES]

SBP >160 –MATERNAL ICH ;DBP >110 PLACENTAL ABRUPTION

ETIOLOGY :PRIMARY [95%] -

environmental[multiple genes ,DM ;Obesity and heart disease]

genetic [DNA methylation is implicated in stress HT and preeclampsic HT ]

SECONDARY:[5%]

RENAL :Parenchymal /renovascular

VASCULAR: COA;Collagen vascular

ENDOCRINE: Conn;Cushing;pheo;CAH;thyroid;PTH

NEUROGENIC :Tumor; ICT;GBS

DRUGS :Ethanol;nsaids;etc

MISS: PIH ;OSA

Nonpharmacologic therapy Weight loss:SBP 5-20mmhg per 10kg

Limit alcohol :SBP-2-8mmhg

Stop smoking

Reduce sodium<6gm:SBP-2-8mmhg

Aerobic exercise -30minutes per day:SBP-4-9mmhg

Adequate intake of potassium,calcium and magnesium

Reduce intake of saturated fat and cholesterol

JNC 8

Recommendation 1

ELDERLY

In the general population aged ≥60 years:

Start drug treatment to reduce BP of ≥150 /90 mmHg

AND

Treat patients for blood pressure goal of <150/90 mmHg

Recommendation 2DBP

In general individuals aged <60 years:

Initiate drug treatment to reduce diastolic BP of ≥90 mmHg

AND

Treat patients for diastolic BP goal of <90 mmHg

Recommendation 3SBP

In general individuals aged <60 years:

Initiate drug treatment to reduce systolic BP of ≥140 mmHg

AND

Treat patients for systolic BP goal of <140 mmHg

Recommendation 4CKD

In the population aged ≥18 years with chronic kidneydisease :

Initiate drug treatment to reduce BP of ≥140/90 mmHg

AND

Treat patients for BP goal of <140/90 mmHg

Recommendation 5DM

In the population aged ≥18years with diabetes:

Initiate drug treatment to reduce BP of ≥140/90 mmHg

AND

Treat patients for BP goal of <140/90 mmHg

Recommendation 6NON BLACK -FIRST LINE

In the non-black individuals, including patients with

diabetes:

Recommend antihypertensive treatment with the following: Thiazide-type diuretic,

Calcium channel blocker (CCB),

Angiotensin-converting enzyme inhibitor (ACEI), or

Angiotensin receptor blocker (ARB).

Recommendation 7BLACK –FIRST LINE

In the black individuals, including patients with

diabetes:

Recommend antihypertensive treatment with: Thiazide-type diuretic

OR Calcium channel blocker (CCB)

Recommendation 8CKD –FIRST LINE OR ADDON

In adults aged ≥18 years with chronic kidney disease and

hypertension:

Initial or add-on antihypertensive treatment to improve kidney outcomes with: An ACEI

OR An ARB

Recommendation 9 Donot combine ACEI and ARB

If BP goal is not reached within 1 month of treatment increase the dose of the drug or add 2nd drug and if not reached with 2 drugs, add and titrate a third drug from the above mentioned class.

If goal BP cannot be reached using only the drugs from class of thiazide-type diuretic, CCB, ACEI, or ARB due to some contraindication or the need to use more than 3 drugs to reach goal BP, antihypertensive drugs from other classes can be added.

HF :BB;DIU;ACEI ;ARB;ALD ANT [CCB :less indicated]

POST MI:BB;ACEI;ARB

CAD RISK:BB;ACEI;CCB;DIU

DM:ACEI;ARB;CCB;[DIU;BB:less indicated]

CKD:ACEI;ARB;CCB;DIU;[ BB :less indicated ]

RECURRENT STROKE PREVENTION:ACEI;DIURETIC [BB:less indicated]

COMPELLING INDICATION

SOME INTERESTING CASES OF SECONDARY HT

FROM OUR HOSPITAL

IN THE RECENT PAST

1.YOUNG MALE WITH SHT AND DM 30 YEAR OLD K/C/O DM/SHT FOR > 1 YR ;3 DAYS

PRIOR TO ADMISSION HAD AN EPISODE OF LOC FOLLOWED BY BACK PAIN

WAS FOUND TO HAVE ELEVATED BP AND INCREASED RFT WITH RBC AND PUS IN URINE

USG DONE SHOWED MASS IN THE ADRENAL REGION

CT ABDOMEN MASS CONFIRMED

PROBABLES ?

24 HR URINARY METANEPHRINE /SPOT

MIBG SCAN

LAP ADRENELECTOMY

WHAT ANTIHYPERTENSIVES –MUST

WHAT IS THE CAUSE FOR LOC AT PRESENTATION

2.YOUNG PREGNANT FEMALE WITH HT 28 YR OLD WITH 2 MA REFERRED FOR HT

G2P1; PREECLAMPSIA IN FIRST DELIVERY ?/BABY DELIVERED IN THE 7 TH MONTH 750 GM IN APOLLO CHENNAI

NOW BP RT UL 210/120 LT UL 170/100

ASYMPTOMATIC BEFORE AND NOW

ANY DD

ECHO NORMAL ;NO E/O COA

USG :KIDNEYS NORMAL

UREA CREAT AND ELECTROLYTES NORMAL

WHAT NEXT

ABDOMINAL AORTA VERY TORTOUS AND DILATED

3.A NEW UNUSUAL CAUSE 30 YR OLD 86 KG /168 CM /BMI 32

CAME FOR HEADACHE AND TIREDNESS

BP 180/130 RT ; 190/130 LT /CONJUNCTIVAL INJECTION +

BASIC INVEST :RFT NORMAL ; SUGAR FBS 127 PPBS 210

DX GUESS

OSA SLEEP STUDY DONE CONFIRMED [EVEN

PULSEOXIMETRY AND VIDEO IS ALL THAT REQUIRED FOR DX]

ADV CPAP

BP REDUCTION AND GENERALISED WELL BEING BETTER WITH CPAP

IS AN INDEPENDENT RISK FACTOR FOR HT

4.HT IN +2 EXAM GOING STUDENT 17 YR OLD

REFERRED AT 11.00 PM FOR CHEST DISCOMFORT AND PALPITATION

WAS FOUND TO HAVE INC BP LOCALLY

BP ON ARRIVAL 170/110 RT 160/110 LT

?EXAM ANXIETY

EXAM REVEALED SCAR IN THE LOIN LEFT SIDE

GUESS ?

SX FOR CONG PUJ OBSTRUCTION 3 YRS BACK

KIDNEY SMALL LT

5.OLD MAN WITH HT WITH ABDOMINAL MASS 90 YR OLD CLOSE MATERNAL RELATION OF MINE

PRESENTED WITH HYPERTENSION WITH BILATERAL HYPOCHONDRIAL MASS PROMPTED ME TO ASK FOR AN USG ON MYSELF

GUESS WHAT AND WHY ?

ADPKD

TAKE HOME MESSAGE FIRST : YOUNG HT ALWAYS SEARCH FOR

SECONDARY CAUSE WHICH MAY BE CURABLE ;ALSO APPROPRIATE ANTI HT BY CORRECT DIAGNAOSIS [ALPHA BLOCKADE]

SECOND : NOT ALL INC BP IN PREG IS PRECLAMPSIA ;NEEDS STRICT F/U OF ANY HT OR DM OF PREGNANCY LATER ;DIFFERENTIAL BP :COA AND AORTOARTERITIS

THIRD :OVERWEIGHT WITH SHT ;OSA ; POTENTIALLY CURABLE

TAKE HOME MESSAGE FOURTH :FUNCTIONALITY OF THE KIDNEY AND

REGULAR F/U IS A MUST BEFORE ENDING UP WITH TOD

FIFTH : IN ADPKD; GENETIC SIDE ;F/U OF FAMILY MEMBERS AND EARLY INITIATION OF TREATMENT

THANK YOU