this slide was prepared for NCD programme June, 2012, the informations shown here were taken from both JN7 and NICE guideline.useful for family practitioners, community clinic doctors.Thanks

1. Hypertension
Dr. Mohammad Tanvir Islam
Assistant Professor (Medicine)
Bangabandhu Sheikh Mujib Medical University

4. •Strict sodium restriction (for example the rice diet
•Sympathectomy (surgical ablation of parts of the
sympathetic nervous system)
•Pyrogen therapy (injection of substances that caused a
fever, indirectly reducing blood pressure)

5. Sodium thiocyanate
1900 Not well tolerated
Hexamethonium, hydralazine and reserpine
2nd World War Popular and reasonably effective
Chlorothiazide, the first thiazide diuretic
Major breakthrough,1st well
1958
tolerated oral agent

6. Disease burden
• Globally 1 billion ( 25% of the adult population)
• 50 million people in USA
• In Asia, dramatic increase in last 30 years
• In China, prevalence has increased from 7.8% in 1980 to 27.2% in 2001
• For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is
a doubling of mortality from both IHD and stroke
• High BP, the second most important cause of disability adjusted life year
(DALY) loss in Asian countries.
• The Framingham Heart study suggests that individuals who are
normotensive at 50 years of age have a 90 % lifetime risk for developing
hypertension.

7. HTN in Bangladesh
Hypertension Deaths in Bangladesh reached
18,245 or 1.91% of total deaths
WHO data published in April 2011
•Prevalence rates of systolic and diastolic hypertension in
natives > 20 years of age are14.4% and 9.1% respectively
• Among the elder individuals, it is 65%
BMRC

8. Today's topic includes
• Understanding hypertension
• Basic knowledge on measurement of BP
• Common issues in management of hypertension
• Treatment of hypertension in community clinics or
hospitals
Topics not included
• Hypertensive emergencies
• Pregnancy related hypertension
• Secondary hypertension

9. What is Hypertension?
It is the level of blood pressure
above which treatment has
been shown to reduce the
development or progression of
disease There is no natural cut-point above
which "hypertension" definitively
exists and below which, it does not

10. Blood Pressure Classification
BP Classification SBP mmHg DBP mmHg
Normal <120 and <80
Prehypertension 120–139 or 80–89
Stage 1 Hypertension 140–159 or 90–99
Stage 2 Hypertension >160 or >100
According to JNC 7

11. Systolic 120-139 mmHg
Prehypertension
Diastolic 80-89 mmHg
Reduce BP
Decrease progression of BP to
hypertensive levels with age
Prevent hypertension entirely
According to JNC 7

12. BP Measurement Techniques
Clinic/office BP measurement
Home BP monitoring
Ambulatory BP monitoring

13. Office/ Clinic measurement
• With a properly calibrated and validated instrument
• Patient is seated quietly for at least 5 minutes in a
chair with feet on the floor and arms supported at
the heart level
• Appropriate sized cuff (Cuff – bladder encircling 80%
of the arm) is used.
• At least two measurements are made at separate
occasion at a reasonable interval

14. Diagnosis
If the clinic blood pressure is 140/90 mmHg or higher
Offer
Ambulatory blood pressure monitoring (ABPM) to confirm the
diagnosis of hypertension.
According to NICE guideline 2011

15. Diagnosis
When using the following to confirm diagnosis, ensure:
ABPM:
• at least two measurements per hour during the person’s usual waking
hours, average of at least 14 measurements to confirm diagnosis
HBPM:
• two consecutive seated measurements, at least 1 minute apart
• blood pressure is recorded twice a day for at least 4 days and
preferably for a week
• measurements on the first day are discarded –
average value of all remaining is used.
According to NICE guideline 2011

16. Hypertension should not be diagnosed nor treatment
offered on the basis of a single BP measurement

17. Types of hypertension
Essential – 95%
Secondary – 5%
• Sleep apnea
• Pregnancy
• Coarctation of aorta
• Renal diseases
• Endocrine diseases
• Drugs

18. Patient Evaluation
Identify CV risk factors Reveal secondary Asses TOD
causeds
• Hypertension • Sleep apnea • Heart
• Cigarette smoking • Drug-induced or related • Left ventricular
• Obesity causes hypertrophy
• Physical inactivity • Chronic kidney disease • Angina or prior
• Dyslipidemia • Primary aldosteronism myocardial infarction
• Diabetes mellitus • Renovascular disease • Prior coronary
• Microalbuminuria or • Chronic steroid therapy revascularization
estimated GFR <60 and Cushing’s syndrome • Heart failure
ml/min • Pheochromocytoma • Brain
• Age (older than 55 for • Coarctation of the aorta • Stroke or transient
men, 65 for women) • Thyroid or parathyroid ischemic attack
• Family history of disease • Chronic kidney disease
premature CVD • Peripheral arterial disease
• (men under age 55 or • Retinopathy
women under age 65)
TOD= target organ damage

19. Look for identifiable causes
Pheochromocytoma
• labile or paroxysms of hypertension accompanied by
• headache,palpitations, pallor, and perspiration
Aortic coarctation
• Decreased pressure in the lower extremities or delayed or
• absent femoral arterial pulses
Cushing’s syndrome
• truncal obesity, glucose intolerance,and purple striae

20. Look for identifiable causes
Chronic kidney disease
• Facial or leg swelling
• H/O oliguria or polyuria
Thyroid disorders
• Thyroid swelling
• Weight loss/gain
• Palpitaion/skin thickening etc
Renal artery stenosis
• sudden/severe/resistant HTN
• H/O flash pulmonary edema
Polycystic kidney disease
• Palpable kidney
• H/O hematuria

21. Target organ damage
CHD,LVH,Heart Stroke Chronic kidney
failure disease
Peripheral Hypertensive
vascular disease retinopathy

22. How shall we investigate this patient

23. Investigation
1.Investigations of
all patients
2. Investigation of
selected patients

24. Investigation of all patients
• Urinalysis for blood, protein and glucose
• Blood urea, electrolytes and creatinine
• Blood glucose
• Serum total and HDL cholesterol
• 12-lead ECG (left ventricular hypertrophy,
coronary artery disease)

25. Investigation for selected patients
• Chest X-ray: to detect cardiomegaly, heart failure, coarctation of the
aorta
• Echocardiogram: to detect or quantify left ventricular hypertrophy
• Renal ultrasound: to detect possible renal disease
• Renal angiography: to detect or confirm presence of renal artery
stenosis
• Urinary catecholamines: to detect possible phaeochromocytoma
• Urinary cortisol and dexamethasone suppression test: to detect
possible Cushing's syndrome
• Plasma renin activity and aldosterone: to detect possible primary
aldosteronism

26. Do we need
to treat ??

27. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%

28. Benefits of Lowering BP
In stage 1 HTN and additional CVD risk factors, achieving
a sustained 12 mmHg reduction in SBP over 10 years will
prevent 1 death for every 11 patients treated

29. Treating hypertension
Non pharmacologic
• Major life - style modification
• Decreases BP
• Increase a drug efficacy
• Decrease cardiovascular risks
Drug treatment
• Effective treatment reduces
• CVD – 30%
• CAD – 20%

30. Life style Modifications
Modification Recommendation Approximate SBP
Reduction
Weight Reduction BMI 18.5 – 24.9 5 – 20 mmHg/ 10 kg wt
loss
Adopt DASH eating plan ↑ fruits, vegetables, 8 – 14 mmHg
↓saturated and total fat
Dietary sodium reduction 2.4 gm Na+ or 6 gm NaCI 2 – 8 mmHg
Physical activity Brisk walking, 30 min/day 4 – 9 mmHg
Alcohol (moderate) 10 oz or 30 ml ethanol for 2 – 4 mmHg
men not more than 1 drink/
day.

31. DASH (Dietary Approaches to Stop Hypertension)
Type of food Number of servings for Servings on a 2000 Calorie
1600 - 3100 Calorie diets diet
Fruits 4-6 4-5
Vegetables 4-6 4-5
Low fat or non fat dairy 2-4 2-3
foods
Lean meat, fish, poultry 1.5-2.5 2 or less
Nuts, seeds, and legumes 3-6 per week 4-5 per week
Fats and sweets 2-4 limited
Grains and grain products 6-12 7-8
(include at least 3 whole
grain foods each day)

32. Initiating treatment
Drug should be given to -
Any age with stage 2 HTN
< 80 yr with stage 1 HTN who have target organ
damage (TOD) -
Established cardiovascular disease
Renal disease
Diabetes
10 yr cardiovascular risk ≥ 20%

33. Initiating treatment
General principles
• If possible, offer drugs taken only once a day
• Prescribe non-proprietary drugs if these are appropriate
and minimise cost
• Offer people with isolated systolic hypertension (systolic
blood pressure 160 mmHg or higher)the same treatment
as people with both raised systolic and diastolic blood
pressure
• Offer people aged over 80 years the same
antihypertensive drug treatment as people aged 55–80
years, taking into account any comorbidities.
• Do not combine an angiotensin-converting enzyme (ACE)
inhibitor with an angiotensin II receptor blocker (ARB)

34. Choosing antihypertensive
Step 1 treatment:
age< 55 yr
• ACE inhibitor 1st choice, If not tolerated , then ARB
age over 55 yr or black people of any age
• calcium-channel blocker is 1st choice for

35. Choosing antihypertensive
Thiazide-like diuretic (chlortalidone or
indapamide)
• If a CCB is not suitable, or
if heart failure
Who already having thiazide and BP is well
controlled, treatment should be continued

36. Choosing antihypertensive
Beta-blockers may be considered in younger
those with an intolerance to ACE inhibitors & ARB
or
women of child-bearing potential
or
people with increased sympathetic drive

37. Choosing antihypertensive
Step 2 treatment
• If BP is not controlled , a CCB is added with
either an ACE inhibitor or an ARB
• If a CCB is not tolerated, or there is heart failure
thiazide-like diuretic is the choice
• For black people, consider an ARB in preference
to an ACE inhibitor, in combination with a CCB

38. Choosing antihypertensive
Step 3 treatment
• Before considering step 3 , medication
should be reviewed to ensure step 2
treatment is at optimal or best tolerated
dose
• If treatment with three drugs is required,
thiazide-like diuretic should be used as
3rd drug

39. Choosing antihypertensive
Step 4 treatment
• If BP not controlled with 3 drugs
• A 4th drug is added and/or
• Expert advice is needed
• As a 4th drug, further diuretic with low-dose
spironolactone , if the blood K+ < 4.5 mmoll

40. Choosing antihypertensive
Higher-dose thiazide-like diuretic is considered if the
blood K+ level is higher than 4.5 mmol/l
Blood Na+ and K+ and renal function should be
monitored within 1 month and repeat as required
If further diuretic at step 4 is not tolerated, an alpha-
or beta-blocker should be used

41. Aged over 55 years or
black person of African
or Caribbean family
Aged under Summary of
origin of any age
55 years
antihypertensive
drug treatment
A C Step 1
Key
A +C Step 2 A – ACE inhibitor or low-cost
angiotensin II receptor blocker
(ARB)
A+C+D Step 3 C – Calcium-channel blocker
(CCB)
D – Thiazide-like diuretic
Resistant hypertension Step 4
A + C + D + consider further diuretic or
alpha- or
beta-blocker
Consider seeking expert advice

42. Additional recommendations
• Crucial part of patient management
Patient education
and adherence
• information about benefits of drugs and side
effects
• details of patient organisations
Provide:
• an annual review of care.

43. Follow-up visits

44. Useful links
www.nice.org.uk
www.nhlbi.nih.gov/guidelines/hypertension
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf

45. Thank you for being with us