Lessons from Hypertension guidelines :Treatment Of Hypertension

BYPROF.DR.KAMAL

MAHMOUDAHMAD

HEADOF

THE CARDIOLGY UNITMEDICAL RESEARCH

INSTITUTEALEX. UNIVERSITY

Easy to diagnose OFTEN remains undetectedSimple to treat OFTEN remains untreated

Despite availability of potent drugs, treatment is too OFTEN ineffective

Hypertension even today is a triple paradox which is:

Guidelines

• European Society of Hypertension • European Society of Cardiology• JNC 7• Canadian Guidelines• Egyptian Guidelines

Relationship of Hypertensionto Its Comorbidities

Comorbidity Relationship to Hypertension

Coronary artery disease 50% of patients with coronary artery disease have hypertension

Left ventricular hypertrophy

15% to 20% of hypertensive adults have an increased left ventricular mass

Ischemic stroke 77% of patients who have a first stroke have a blood pressure >140/90 mm Hg

Chronic kidney disease 8% to 15% of hypertensive adults have decreased renal function

Diabetes75% of added cardiovascular risk in diabetic patients is attributable to hypertension

Peripheral artery disease 74% of patients with peripheral artery disease have hypertension

Rosamond W, et al. Circulation. 2007;115:69-171;

MAGNITUDE OF THE PROBLEM IN EGYPT

· Hypertension is a major health problem in Egypt with a prevalence rate of 26.3% among the adult population (>

25 years) .

Its prevalence increases with aging, pproximately 50% of Egyptians above the age of 60 years

suffer from hypertension.

.

21

79

never stopped

stopped

1940 patients

Egyptian HTN Physician & Patient Survey*

*M. Mohsen Ibrahim -

Causes of Discontinuation of The Drugs

• Poor understanding of the magnitude of the risk.• Poor communication (doctor-patient)• Patient forgetfulness.• Lack of motivation.• Logistic barrier ..Cost.• Side effects.• Complex regimen.• Poor follow up.

Blood Pressure Classification

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension

140–159 or 90–99

Stage 2 Hypertension

>160 or >100

BP Classification SBP mmHg DBP mmHg

BHS classification of blood pressure levels

Category Systolic blood

pressure (mmHg)

Diastolic blood

pressure

(mmHg) Optimal blood pressure <120 <80

Normal blood pressure <130 <85

High-normal blood pressure 130-139 85-89

Grade 1 Hypertension (mild) 140-159 90-99

Grade 2 Hypertension (moderate) 160-179 100-109

Grade 3 Hypertension (severe) >180 >110

Isolated Systolic Hypertension (Grade 1) 140-159 <90

Isolated Systolic Hypertension (Grade 2) >160 <90

Appropriate BP measurement 2008

o Allow the patients to relax for several minutes

o Take at least two measurements spaced by 1-2 min and additional measurements if the first two are quite different [use phase I and V (disappearance) Korotkoff sounds to identify SBP and DBP]

o Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and children

o Have the cuff at the heart level

o Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one

o Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients and in other conditions in which postural hypotension may be frequent or suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)

Home BP measurements

• Self-measurement of BP at home should be encouraged

• Response to antihypertensive therapy– Improving adherence with therapy – Evaluating white-coat HTN

• On the contrary, Self-measurement of BP should be discouraged when: it causes anxiety to the patient it induces self-modification of the treatment

regimen

Ambulatory BP Monitoring

ABPM is warranted for evaluation of “white-coat” HTN in the absence of target organ injury.

Ambulatory BP values are usually lower than clinic readings.

Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.

BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.

24-Hour Blood Pressure(n = 19)

Physical examination for secondary hypertension

Signs suggesting secondary hypertension

• Features of Cushing syndrome

• Skin stigmata of neurofibromatosis (phaeochromocytoma)

• Palpation of enlarged kidneys (polycystic kidneys)

• Auscultation of abdominal murmurs

(renovascular hypertension)

• Auscultation of precordial or chest murmurs; Diminished and delayed femoral pulses femoral BP

(aortic coarctation or aortic disease)

Laboratory TestsLaboratory Tests Routine Tests

• Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR, and calcium• Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density

lipoprotein cholesterol, and triglycerides

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

Blood pressure target values for treatment of hypertension

Condition Target

SBP and DBP mmHg

Isolated systolic hypertension <140

Systolic/Diastolic Hypertension• Systolic BP • Diastolic BP

<140<90

Diabetes or Chronic Kidney Disease• Systolic • Diastolic

<130<80

II. Goals of Therapy

Lifestyle Recommendations for Prevention and Treatment of Hypertension

To reduce the possibility of becoming hypertensive,Reduce sodium intake to less than 2300 mg / day 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 salt in accordance with Canada's Guide to Healthy Eating.

Regular physical activity: accumulation of 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7/week in addition to routine activities of daily living

Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)

Waist Circumference Men Women- Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm- South Asian, Chinese <90 cm <80 cm- Japanese <85 cm <90 cm

Smoke free environment