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Hypertension
- 1. HYPERTENSION Dr Haider Baqai Assistant Professor of Medicine RMC & Allied Hospitals 2098 2098 Franklin #1 Franklin #1
- 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 #2
- 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 #3
- 4. • ECG shows evidence of LVH • RFTs: Urea: 57 Cretanine: 1.4 mg/dl • Urine R/E reveals ++ Albuminuria 2098 Franklin #4
- 6. Defining Hypertension • High blood pressure is a trait • As opposed to a specific disease 2098 Franklin #6
- 7. Defining Hypertension • By the numbers? – ≥95 DBP – >120/80 “A number at which the benefits of intervention exceed those of inaction” 2098 Franklin #7
- 9. Why is hypertension considered a major Public health problem? Firstly, hypertension is very common In the adult population 2098 Franklin #9
- 10. Increased Prevalence of Hypertension in the United States from 1988-1994 (NHANES III) to 1999-2000 NHANES 100 30% increase, p<.001 Population With Hypertension (millions) 80 60 65 50 40 20 0 1988-1994 1999-2000 Nat ional Healt h and Nut rit ion Survey ( NHANES) Nearly 1 in 3 Adults (31%) in the US Has Hypertension Fields, et al. Hypertension. 2004;44:398f
- 11. 1976-98 Cumulative Incidence of HTN in Women and Men Aged 65 Years Risk of Hypertension % 100 80 Men Women 60 40 20 0 0 2 4 6 8 10 12 14 16 18 20 Years of Follow-up Vasan, et al. JAMA.2002;287:1003
- 12. Secondly, hypertension is associated with considerable cardiovascular risk.
- 13. Global Mortality 2000: Impact of Hypertension and Other Health Risk Factors High blood pressure Tobacco High cholesterol Underweight Unsafe sex High BMI Physical inactivity High mortality, developing region Alcohol Lower mortality, developing region Indoor smoke from solid fuels Developed region Iron deficiency 0 1000 2000 3000 4000 5000 6000 7000 8000 Attributable Mortality Ezzati et al. Lancet. 2002;360:1347-1360. (In thousands; total 55,861,000) 2098 Franklin #13
- 14. CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment* 8 7 6 CV mortality risk 5 4 3 2 1 0 115/75 135/85 155/95 175/105 SBP/DBP (mm Hg) *Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet. 2002; 60:1903-1913. JNC 7. JAMA. 2003;289:2560-2572. 2098 Franklin #14
- 15. Thirdly, there is considerable reduction in cardiovascular risk with effective lowering of blood pressure with therapy. 2098 Franklin #15
- 16. Long-Term Antihypertensive Therapy Significantly Reduces CV Events Stroke Myocardial infarction Heart failure 0 –10 –20 Average reduction in events (%) –30 20%-25% –40 –50 –60 35%-40% >50% Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964. 2098 Franklin #16
- 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 #17
- 18. Clinical Features • Hypertension is termed as the “SILENT KILLER” • Headache is a common manifestation • Mostly patients present with complications of hypertension 2098 Franklin #18
- 19. Complications of Hypertension: Hypertension is a risk factor TIA, stroke LVH, CHD, HF Retinopathy Peripheral vascular disease Renal failure 2098 Franklin #19
- 20. This left ventricle is very thickened (slightly over 2 cm in thickness) 2098 Franklin #20
- 24. JNC Reclassification of BP Based on Risk JNC VI Category SBP (mm Hg) Optimal <120 JNC 7 DBP (mm Hg) and Normal 120-129 and Hi-normal 130-139 80 80-84 or 85-89 90-99 Category SBP (mm Hg) Normal <120 DBP (mm Hg) and Prehypertension 120-139 or 80 80-89 Hypertension Stage 1 140-159 or Stage 2 160-179 or 100-109 Stage 3 ≥ 180 or ≥ 110 Stage 1 140-159 or 90-99 or ≥ 100 Stage 2 Source for JNC VI: Arch Intern Med. 1997;157:2413-2446. Adapted with permission from Chobanian AV et al. Hypertension. 2003;42:12061252. ≥ 160 2098 Franklin #24
- 25. JNC 7 Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling Indications Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB, 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) With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed or combination Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved Consider consultation with hypertension specialist Chobanian et al. JAMA. 2003;289:2560-2572. 2098 Franklin #25
- 26. Compelling and possible indications for the major classes of antihypertensive drugs INDICATIONS α-blockers COMPELLING Prostatism POSSIBLE ACEI HF, LV dysfunction DM ARBs Cough induced by ACE inhibitor CLASSS OF DRUG Dyslipidaemia Myocardial infarction Angina Heart failure CCBs ISH in elderly patients Calcium antagonists (rate limiting) Angina Elderly patients Angina Myocardial infarction β−blockers Thiazides ISH, HF 2098 Franklin #26
- 27. Logical Combinations Diuretic Diuretic β-blocker β-blocker CCB ACE inhibitor α-blocker - - - * - CCB - - * ACE inhibitor - - α-blocker - * Verapamil + beta-blocker = absolute contra-indication 2098 Franklin #27
- 28. Yet another algorithm 2098 Franklin #28
- 29. Case #1 A 76 year old female comes to her family doctor complaining of constipation and pigastric pain as well as weakness and painful cramps (due to hypokalemia). 2098 Franklin #29
- 30. History: She has a history of hypertensio or which she has been taking propranolo nd hydrochlorothiazide for the past everal months. Observation: Mild hypertension (BP 145/90); 2098 Franklin #30
- 31. Treatment: Potassium rich foods (chickpeas, bananas, papaya), potassium supplement, or switch to potassium-sparing diuretics such as spironolactone or triamterene. 2098 Franklin #31
- 32. Case #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 #32
- 33. History: On careful questioning the specialist discovers that she had been taking captopril for hypertension for six months. Observation: Normal BP 2098 Franklin #33
- 34. Treatment: Consider alternate antihypertensive agents. Losartan would be a good choice. 2098 Franklin #34
- 35. • Any questions 2098 Franklin #35
- 36. THANK YOU
Notes de l'éditeur
- The Comparative Risk Assessment module of the World Health Organization (WHO)’s Global Burden of Disease 2000 study performed a systematic assessment of changes in population health that would result from modifying exposure to environmental and physiological health risk factors. The methodology used to determine the attributable mortality and attributable burden of disease due to each risk factor was a counterfactual analysis in which the contribution of 1 or a group of risk factors is estimated by comparing the current disease burden with the magnitude that would be expected in an alternative scenario characterized by a theoretical minimal exposure. In the case of high BP and cholesterol, the theoretical minimal exposures were levels of 115 mm Hg and 3.8 mmol/L, respectively. This analysis of the contribution of 26 selected risk factors to global disease burden found that high BP was the leading cause of mortality in both developing regions and developed regions of the world. The study looked at the impact of risk factors on mortality. High mortality, developing regions such as many countries in Africa and Southeast Asia. Lower mortality, developing regions such as Latin America and countries in the Western Pacific. Developed regions including Europe, Japan, and North America. In high mortality, developing regions, the leading causes of death were reported to be childhood and maternal undernutrition, including being underweight. However, despite the large contribution of communicable, maternal, perinatal, and nutritional conditions and their underlying risk factors to disease burden in the high mortality, developing regions, the “industrialized” risks of high BP, tobacco, and blood cholesterol levels also resulted in significant loss of life in these regions. Across developed regions, high BP, tobacco use, alcohol, high cholesterol, and high body mass index (BMI) were reported to be consistently the leading causes of loss of life.
- Slide Summary According to a meta-analysis of over 60 prospective studies, the risk of cardiovascular mortality doubles with each rise of 20 mm Hg in systolic blood pressure (BP) and 10 mm Hg in diastolic BP. Background In a meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline, the researchers found that between the ages of 40-69 years, each incremental rise of 20 mm Hg systolic BP and 10 mm Hg diastolic BP was associated with a twofold increase in death rates from ischemic heart disease and other vascular disease. The researchers also noted that when attempting to predict vascular mortality risk from a single BP measurement, the average of systolic and diastolic BP was “slightly more informative” than either alone, and that pulse pressure was “much less informative.” The seventh report Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) notes this study result as yet more information linking hypertension to high risk for cardiovascular events. Lewington S, Clarke R, Qizilbash H, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2003;361:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.
- Hypertension is an important contributing risk factor for end-organ damage and subsequent increases in morbidity and mortality. The goal in treating hypertension is to prevent cardiovascular and renal complications. Even small elevations above optimal blood pressure (BP) values (<120/80 mm Hg) increase the likelihood of developing hypertension (BP ≥140/90 mm Hg) and incurring target-organ damage. Chronic elevations of BP lead to target-organ damage and the development of cardiovascular and renal diseases, including retinopathy, peripheral vascular disease, stroke, coronary heart disease, heart failure, left-ventricular hypertrophy, and renal failure. Signs of target-organ damage herald a poorer prognosis and may present in the heart, blood vessels, kidneys, brain, or eyes. Later consequences include cardiac, cerebrovascular, vascular, and renal morbidities and death. Because of the complex nature of hypertension, it is not surprising that single antihypertensive agents normalize BP for less than a majority of hypertensive patients. Reference Cushman WC. J Clin Hypertens. 2003;5(suppl):14-22.
- This slide shows the changes in classification of blood pressure from JNC VI to JNC 7.1,2 “Optimal” blood pressure in JNC VI became “normal” in JNC 7, while “normal” and “borderline” blood pressures in JNC VI were combined as “prehypertension” in JNC 7.1,2 Stage 1 hypertension remained constant from JNC VI to JNC 7.1,2 However, JNC 7 grouped JNC VI Stage 2 and Stage 3 hypertension into one stage (Stage 2).1,2 This change reflected the fact that the approach to patient management for both former categories is similar.1
- As recommended by JNC 7, hypertension treatment should start with lifestyle modifications. If the patient is not at goal BP of <140/90 mm Hg (<130/80 mm Hg for those with diabetes or chronic kidney disease), pharmacologic therapy should be initiated. Initial drug choices for patients without compelling indications should be a thiazide diuretic for most patients with stage 1 hypertension. Typically, combination therapy with 2 drugs is required for stage 2 hypertension. When use of a single drug fails to achieve the BP goal, addition of a second drug from a different class should be initiated. A 2-drug combination usually consists of a thiazide-type diuretic plus an ACEI, an ARB, a -blocker, or a CCB. Specific antihypertensives are designated for compelling indications (ie, HF, post-MI, high coronary artery disease [CAD] risk, diabetes, etc.). If a patient is still not at goal BP following the treatment algorithm, optimize the patient’s dosages or add additional drugs until goal BP is achieved. Also consider consulting with a hypertension specialist.