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HYPERTENSION

AWARENESS, DETECTION, EVALUATION


AND INTERVENTION

DR. ABDUL RASHID KHAN

M.B.B.S., F.C.P.S., OJT CARDIOLOGY


ASST. PROFESSOR WAH MEDICAL COLLEGE
MEDICAL SPECIALIST/ CARDIOLOGIST
POF HOSPITAL WAH CANTT.

High blood pressurea silent killer

Problem Magnitude

Hypertension (HTN) is one of the most common


primary diagnosis in Pakistan..
According to Pakistan National Health Survey (PNHS)
33% of the population above the age of 45 years is
hypertensive.
Only 50% of people who have hypertension are
diagnosed and half of those who are diagnosed seek
treatment.
Worldwide prevalence estimates for HTN may be as
much as 1 billion.
7.1 million deaths per year may be attributable to
hypertension.

Definition
A systolic blood pressure ( SBP) >139
mmHg and/or
A diastolic (DBP) >89 mmHg.
Based on the average of two or more
properly
measured, seated BP
readings.
On each of two or more office visits.

UNDERSTANDING THE JARGON


SYSTOLIC BLOOD PRESSURE: BLOOD
PRESSURE WHEN VENTRICLES ARE
CONTRACTING.
DIASTOLIC BLOOD PRESSURE:
BLOOD PRESSURE WHEN
VENTRICLES ARE IN RELAXED STATE.

WHY IS HYPERTENSION SO
DANGEROUS?
KNOWN AS THE SILENT KILLER OF
DISEASES BECAUSE MOST OF THE
TIMES IT DOES NOT HAVE ANY
SYMPTOMS
USUALLY INCIDENTAL FINDING

IT SILENTLY DAMAGES OTHER


ORGANS LIKE HEART, BRAIN AND
KIDNEYS.
SYMPTOMS OCCUR AS END STAGE
ORGAN DAMAGE OCCURS, BY THEN
IT IS TOO LATE TO SAVE THE PATIENT.

BP Measurement
At least two measurements should be
made and the average recorded.
Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.

Confirmation of diagnosis
Home ambulatory monitoring is done in
patients in whom blood pressure of >140/90
mmhg is measured in 2 or more clinic visits
At home 2 readings are taken, one in
morning the other at night for at least 4 days
(7 days preferably)
Patient is said to hypertensive is BP
>135/85mmhg on the average

Accurate Blood Pressure Measurement

The equipment should be regularly inspected and


validated.
The operator should be trained and regularly retrained.
The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.

Caffeine, exercise, and smoking should be avoided


for at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.

Follow-up based on initial BP


measurements for adults*

www.nhlbi.nih.gov

*Without acute end-organ

Classification

www.nhlbi.nih
.gov

Prehypertension

SBP >120 mmHg and <139mmHg and/or

DBP >80 mmHg and <89 mmHg.

Prehypertension is not a disease category


rather a designation for individuals at high risk
of developing HTN.

Pre-HTN

Individuals who are prehypertensive are not


candidates for drug therapy but
Should be firmly and unambiguously advised to
practice lifestyle modification
Those with pre-HTN, who also have diabetes or
kidney disease, drug therapy is indicated if a
trial of lifestyle modification fails to reduce their
BP to 130/80 mmHg or less.

Isolated Systolic Hypertension


Not distinguished as a separate entity as
far as management is concerned.
SBP should be primarily considered
during treatment and not just diastolic BP.
Systolic BP is more important
cardiovascular risk factor after age 50.
Diastolic BP is more important before age
50.

White coat hypertension

the patients bp is persistently recorded to be


higher than 140/90 mmhg but upon home
ambulatory monitoring does not exceed
135/85mmhg.
It is though to be anxiety
induced and more
common in older people

Pregnancy induced
hypertension

A blood pressure of >140/90 mmhg in a


pregnant female after 20 weeks of
gestation without proteinuria or other
signs of preeclampsia is called pregnancy
induced hypertension.

Frequency Distribution of Untreated HTN by Age


Isolated
Systolic
HTN

Systolic Diastolic
HTN

Isolated
Diastolic
HTN

Hypertensive Crises

Hypertensive Urgencies: No progressive


target-organ dysfunction. (Accelerated
Hypertension)
Hypertensive Emergencies: Progressive
end-organ dysfunction. (Malignant
Hypertension)

Hypertensive Urgencies
Severe elevated BP in the upper range of
stage II hypertension.
Without progressive end-organ
dysfunction.
Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
Usually due to under-controlled HTN.

Hypertensive Emergencies

Severely elevated BP (>180/120mmHg).


With progressive target organ dysfunction.
Require emergent lowering of BP 25% of mean
arterial pressure within 2 hours.
Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary
edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

Types of Hypertension

Primary HTN:
also known as
essential HTN.
accounts for 95%
cases of HTN.
no universally
established cause
known.

Secondary HTN:
less common cause
of HTN ( 5%).
secondary to other
potentially rectifiable
causes.

Causes of Secondary HTN

Common

Intrinsic renal disease


Renovascular disease
Mineralocorticoid
excess
Sleep Breathing
disorder

Uncommon

Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism

Secondary HTN-Clues in Medical


History

Onset: at age < 30 yrs ( Fibromuscular dysplasi)


or > 55 (athelosclerotic renal artery stenosis),
sudden onset (thrombus or cholesterol
embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)

Secondary HTN-clues on Exam


Pallor, edema, other signs of renal
disease.
Abdominal bruit especially with a diastolic
component (renovascular)
Truncal obesity, purple striae, buffalo
hump (hypercortisolism)

Secondary HTN-Clues on Routine


Labs
Increased creatinine, abnormal urinalysis
( renovascular and renal
parenchymal disease)
Unexplained hypokalemia
(hyperaldosteronism)
Impaired blood glucose
( hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)

Secondary HTN-Screening
Tests

www.nhlbi.nih.gov

Renal Parenchymal Disease


Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of
renal disease
Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
Renal disease from multiple etiologies.

Renovascular HTN

Atherosclerosis 75-90% ( more common in


older patients)
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Other

Aortic/renal dissection
Takayasus arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation

Complications of Prolonged
Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
Complications arise due to the target
organ dysfunction and ultimately failure.
Damage to the blood vessels can be seen
on fundoscopy.

Target Organs
CVS (Heart and Blood Vessels)
The kidneys
Nervous system
The Eyes

COMPLICATIONS OF
UNCONTROLLED HYPERTENSION

Effects On CVS
Ventricular hypertrophy, dysfunction and
failure.
Arrhithymias
Coronary artery
disease, Acute MI
Arterial aneurysm,
dissection, and rupture.

Effects on The Kidneys


Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN

Nervous System
Stroke, intracerebral and subaracnoid
hemorrhage.
Cerebral atrophy and dementia

The Eyes
Retinopathy, retinal hemorrhages and
impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction

Retina Normal and Hypertensive


Retinopathy
A
B

Normal Retina

Hypertensive
Retinopathy

A: Hemorrhages
B: Exudates (Fatty
Deposits)
C: Cotton Wool Spots
(Micro Strokes)

Stage I- Arteriolar Narrowing


Arteriolar
Narrowing

AV Nicking

Stage II- AV Nicking


AV
AVNicking
Nicking
AV Nicking

Stage III- Hemorrhages (H), Cotton


Wool Spots and Exudats (E)
H

Stage IV- Stage III+Papilledema

Patient Evaluation Objectives

(1) To assess lifestyle and identify other


cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD

(1) Cardiovascular Risk factors

Hypertension
Cigarette smoking
Obesity (body mass index 30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)

(2) Identifiable Causes of HTN

Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

History

Angina/MI Stroke: Complications of HTN,


Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia: Suggest renal
impairment

History-contd.

Claudication: May be aggravated by bblockers, atheromatous RAS may be present


Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have
been due to HTN

History-contd.
Family history of DM : Patient may also
be Diabetic
Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake

Examination

Appropriate measurement of BP in both arms


Optic fundi
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
bruits
Palpation of the thyroid gland.

Examination-contd.
Thorough examination of the heart and
lungs
Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment

Routine Labs

EKG.
Urinalysis.
Blood glucose and hematocrit; serum potassium,
creatinine ( or estimated GFR), and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.

Goals of Treatment

Treating SBP and DBP to targets that are


<140/90 mmHg
Patients with diabetes or renal disease, the BP
goal is <130/80 mmHg
The primary focus should be on attaining the
SBP goal.
To reduce cardiovascular and renal morbidity
and mortality

Benefits of Treatment
Reductions in stroke incidence,
averaging 3540 percent
Reductions in MI, averaging 2025
percent
Reductions in HF, averaging >50 percent.

NON PHARMACOLOGICAL
TREATMENT

Lifestyle modifications

www.nhlbi.nih.gov

Lifestyle Changes Beneficial in Reducing Weight

Decrease time in sedentary behaviors such


as watching television, playing video games, or
spending time online.
Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.

DASH Diet
Dietary Approaches to Stop Hypertension
Low sodium diet
DASH diet include lots of whole grains, fruits,
vegetables and low-fat dairy products, fish,
poultry and legumes, small amount of nuts
and seeds a few times a week. You can eat
red meat, sweets and fats in small amount
As effective as one medication

Mediterranean diet

Traditional Mediterranean diet reduces the


risk of heart disease. The diet has been
associated with a lower level of oxidized
low-density lipoprotein (LDL) cholesterol
the "bad" cholesterol that's more likely
to build up deposits in your arteries.

obesity
The WHO now considers obesity to
be a global epidemic and a public
health problem as more nations
become "Westernized.
Globally, an estimated 250 million
adults are now obese, and many
more are overweight.

Facts and figures


Pakistan is ranked 9th out of 188 in terms
of obesity
Up to 56% men and 67% women in urban
areas are obese according to a survey
conducted by WHO
Childhood obesity is also on the rise
according to WHO

You are still Obese

When waist size in


males is over 40
inches

When waist size in


females is 35 inches

Body Mass Index (BMI)


BMI =
Body wt in Kg / (Ht in
m)2

Basics of Caloric Calculation in Foods

1 gram of Carbohydrate
contains
6 Calories
1 gram of Protein contains
6 Calories
1 gram of Fat contains
9 Calories

Ideal Body Weight


Men

Height

Standard Weight

5 ft 1 inch

49 to 54 Kg

5 ft 2 inch

55 to 60 Kg

5 ft 3 inch

56 to 62 Kg

5 ft 4 inch

57 to 63 Kg

5 ft 5 inch

59 to 65 Kg

5 ft 6 inch

61 to 67 Kg

5 ft 7 inch

63 to 69 Kg

5 ft 8 inch

64 to 71 Kg

5 ft 9 inch

66 to 73 Kg

5 ft 10 inch

68 to 75 Kg

5 ft 11 inch

70 to 77 Kg

6 ft

72 to 79 Kg

6 ft 1 inch

77 to 82 Kg

6 ft 2 inch

76 to 84 Kg

6 ft 3 inch

78 to 86 Kg

Ideal Body Weight


Women

Height

Standard Weight

4 ft 8 inch

44 to 49 Kg

4 ft 9 inch

45 to 50 Kg

4 ft 10 inch

46 to 51 Kg

4 ft 11 inch

47 to 53 Kg

5 ft

49 to 54 Kg

5 ft 1 inch

50 Kg

5 ft 2 inch

51 to 52 Kg

5 ft 3 inch

53 to 59 Kg

5 ft 4 inch

54 to 61 Kg

5 ft 5 inch

56 to 63 Kg

5 ft 6 inch

58 to 65 Kg

5 ft 7 inch

60 to 67 Kg

5 ft 8 inch

62 to 68 Kg

5 ft 9 inch

63 to 70 Kg

5 ft 10 inch

65 to 72 Kg

Calories Contents in
Common Soups
Serving Size: 1Cup
Type of Soup

No. of Calories

Chicken Corn Soup

100

Chicken Cream Soup

200

Chicken Yakhni

75

Mushroom Soup

117

Tomato Soup

175

Noodles Soup

117

Daal Soups

130

Calories Contents in
Products/Breakfast
Servings
TypeDairy
of Food
and their serving Size
No. of Calories
Boiled Egg One

75

Fried Egg One

100

Omelet made of 2 Eggs

175

Buffalo Milk One Cup


Cow Milk One Cup

45
100

Skimmed Milk

19

Bread One Slice

65

Butter 100 grams

210

Cream 100 grams

910

Cheese One Cup

750

Boiled Potato One Cup

125

Potato Chips One Cup

100

Soft Curd Plain One Cup

140

Chapati One Medium Size

40

Paratha One Medium Size

304

Puri One Small Size

68

Calories Content
in Fast Foods
Type of Food and their serving
Size

No. of Calories

Pizza 12 Inch Size

360

French Fries Regular Size

372

McDonalds Beef Burger Medium

229

McDonalds Beef Burger with


Cheese Medium

317

KFC Chicken Burger Medium

207

KFC Chicken Burger Large

482

KFC Fried Chicken 2 Pieces

344

Chicken Nuggets 6 Pieces

280

Chicken Drum Sticks 100 grams

291

Pop Corn One Cup

50

Noodles One Cup

125

Calories Contents in
Chaat/Namkeen Foods
Type of Food and their
serving Size

No. of Calories

Chaat 100 grams

474

Bhel Puri 100 grams

182

Samosa One

103

Kachori One with Bhujia

190

Dahi Bara One Big Size

82

Calories Contents in Routine Foods


Fried Foods/BarBQs
Type of Food and their serving
Size

No. of Calories

Chicken Tikka One normal Sized

200

BarBQ Beef 100 grams

300

BarBQ Chicken 100 grams

350

Seikh Kebabs serving of 6

350

Fried Fish 100 grams

200

Prawn Fried 10 in a serving

200

Chicken Fried Half

325

Beef Roast 100 grams

275

Mutton Roast 100 grams

200

Chicken Roast 100 grams

200

Calories Contents in Chinese


Foods
Type of Food and their serving Size

No. of Calories

Chicken Chowman One normal


plate

125

Beef Chowman One normal plate

150

Beef Stick One normal Plate

315

Chicken Fried Rice One normal plate

200

Calories Contents in Eastern Foods


Type of Food and their serving Size

No. of Calories

Daal Chawal One normal plate

188

Plain Rice One normal plate

100

Daal One normal plate

105

Fish Curry One normal plate

225

Vegetable Biryani One normal plate

457

Chicken Bryani

520

Mutton Biryani

644

Nehari

500

Beef Curry One normal plate

400

Chicken Curry One normal plate

325

Mutton Curry One normal plate

252

Egg Gravy One normal plate

250

Calories Contents in
Fresh Fruits
Type of Fruit and their serving
Size
Mango One Medium Size

No. of Calories
125

Apple One Small Size

75

Peach One Medium Size

75

Orange One Normal Size

75

Pear One Medium Size

75

Grapes 125 grams

75

Pine Apple One Medium Size

75

Papaya Half Cup

35

Guava One Medium size

75

Water Malone One Quarter of a


normal size

65

Grape Fruit Half

50

Sweet Potato 125grams


Cherry 25 in numbers

140
75

Calories Contents in Vegetables


Type of Vegetable (100
grams)

No. of Calories

Potato

97

Tomato

21

Peas

97

Cabbage

45

Carrot

48

Spinach

26

Onion

50

Cauliflower

30

French Beans

26

Calories Contents in
Dry Fruits

Type of Dry Fruit and serving


Size

No. of Calories

Almonds Roasted Half Cup

425

Almond Plain 12s serving

100

Peanuts 10s serving

100

Dates 6s serving

100

Pistachio 16s serving

50

Cashew nuts 7s serving

75

Wall nut one

50

Calories Contents
in Mithaian/Sweet Dishes
Type of
Mithai

Serving Size

No. of Calories

387

Jaleebi

100 grams

494

Laddoo

100 grams

421

Sohan Halwa

100 grams

399

Qalaqand

100 grams

421

Suji ka Halwa

100 grams

263

Gajar ka
Halwa

100 grams

561

Gajar Kheer

100 grams

226

Rice Kheer

100 grams

141

Siwayan

One Cup

125

Custard

One Cup

140

Ice Cream

One Cup

150

Gulab Jaman

Calories Contents in
Soft Drinks
Type of Drink

Serving Size

Calories

Soft Drinks

250 ml Bottle

70-100

Diet Soft Drink

250 ml Bottle

Apple Juice

One Cup

150

Pomegranate Juice

One Cup

125

Grape Juice

One Cup

141

Pine Apple Juice

One Cup

226

Orange Juice

One Cup

35

One Glass 250 ml

75

Milk with Cream

One Cup

140

Milk without Cream

One Cup

50

Milk Shake

Calories Contents in Hot Drinks


Type

Serving Size

No. of Calories

Tea with
cream and
Sugar

One Cup

130

Tea without
cream and
Sugar

One Cup

Black Coffee
without sugar

One Cup

Black Coffee
with sugar

One Cup

60

Cream Coffee
with sugar

One Cup

140

Calories Contents in

Sweeteners/Cereals
Sweeteners
Type

Serving Size

Sugar
(Cheeni)

One table
spoon

90

Gurr

One table
spoon

56

Honey

Cereals
One table

No. of
Calories

25

Type

spoon
Serving Size

Rice

100 grams

325

Maize

100 grams

355

Wheat

100 grams

341

No. of
Calories

Calories Contents in Bakery Products


Type
Biscuits
Chocolate/Almond
Cake
Plain Cake
Fruit Bun

Serving Size

No. of
Calories

387

One Slice

494

One medium

561

One

263

Calories Consumption
in Daily Routine works
Consumption of Calories in Daily Routine Activities

Per Hour
Type of Work

Calories
Consumed

Type of Work

Calories
Consumed

Office Work

130

Swimming

300

Car Driving

165

Playing Golf

300

Cycling

410

Playing Lawn
Tennis

350

Eating

80

Fast Running

900

Standing a
place

135

Walking

216

Gardening

215

Pressing

250

Sleeping

60

Cooking

195

Calories Consumption
in Daily Routine Activities
At 10 Minutes
Type of Work

Walking downstairs
Walking upstairs

Calories
Consume
d

Type of Work

Calories
Consumed

75

Playing Squash

105

200

Playing
Badminton

65

Walking with brisk


pace

72

Playing
Volleyball

65

Walking with
moderate pace

40

Standing at
one place

15

Swimming

50

Dancing with
moderate
speed

75

Cleaning
House

40

Health Club

65

Running
Horse Riding

125
75

PHARMACOLOGICAL
TREATMENT

JNC 8 Summary
Joint National Commission 8th Report
PDF File on website
50 page document

NOVEL TREATMENT OPTIONS

Carotid baroreceptor activation

An implantable baroreceptor pacemaker


system is in trials in US and holds
promising results in controlling blood
pressure

Renal denervation
Percutaneous catheter based
radiofrequency ablation of renal nerve
Entered trials in Europe and Asia in 2014
Initial tests have revealed promising
results

Other Resources

Chronic Kidney Disease Information


GFR Calculator
www.nephron.com

Hyperlipedemia Information

Adult Treatment Panel 3 Guidelines

www.nhlbi.nih.gov/guidelines/cholesterol/index.htm

Questions???

THANK YOU