Hypertension: The Whole Story

1. Hypertension: The Whole Story Raven Voora, MD Hypertension Specialist UNC Kidney Center

2. Hypertension = elevated blood pressure Classification of hypertension: JNC 7

3. Symptoms of Hypertension • Hypertension is dangerous because it gives off no warning signs or symptoms • Having your blood pressure checked regularly is the only way to tell if your blood pressure is high

4. Diagnosis of Hypertension • Based upon the average of two or more properly measured readings at each of two or more visits after an initial screen

5. White Coat Hypertension • Blood pressure is repeatedly normal when measured outside of the provider’s office (home, work) but persistently elevated in the office.

7. How to Measure Your Blood Pressure • Use an automatic monitor • Check the accuracy of your home monitor at the doctor’s office • Use a monitor with an arm cuff • Not a wrist or finger cuff • Use a large cuff if you have a large arm • After putting on the cuff, sit quietly for a few minutes before checking your pressure

8. Why do people get hypertension?

9. Essential vs Secondary Hypertension • The majority of patients with hypertension have “essential hypertension” (≈90-95% of cases) • Less frequently, there is an underlying condition that may lead to hypertension. This is called “secondary hypertension” (≈5-10% of cases)

10. Pathogenesis of Essential Hypertension • Poorly understood • Complex interaction between genetic and environmental factors • These factors lead to narrowing of blood vessels • If vessels wide open blood flows easily • If vessel narrows pressure inside increases causing hypertension

12. Factors Influencing the Development of Hypertension Uncontrollable Factors Controllable Factors Obesity and weight gain Physical inactivity Excess sodium intake Alcohol consumption • Family History of hypertension • Reduced kidney mass at birth • African-American ancestry • Age

13. Controllable Factors Influencing the Development of Hypertension • Excess sodium intake • Certain segments of the population are ‘salt sensitive’because their blood pressure is affected by salt consumption

14. Controllable Factors Influencing the Development of Hypertension • Alcohol consumption

15. How Can Hypertension Be Treated?

16. Treatment of Hypertension • Engage in Lifestyle Modifications • Avoid Medicines That Can Raise Blood Pressure • Take Medications That Can Lower Blood Pressure

17. Treatment of Hypertension • Engage in Lifestyle Modifications • Avoid Medicines That Can Raise Blood Pressure • Take Medications That Can Lower Blood Pressure

18. Lifestyle Modifications • Maintain a healthy weight, lose weight if overweight. • Be more physically active. • Drink alcoholic beverages in moderation. • Reduce the intake of sodium in the diet to approximately 2400 mg/day.

19. Lifestyle Modifications

21. Reading a Food Label for Sodium Content

22. Food Labels

23. Reducing Sodium in the Diet • Use fresh poultry, fish and lean meat, rather than canned or processed. • Buy fresh, plain frozen or canned with “no salt added” vegetables. • When available, buy low- or reduced-sodium or ‘no-salt-added’ versions of foods like: • Canned soup, canned vegetables, vegetable juices • cheeses, lower in fat • condiments like soy sauce • crackers and snack foods like nuts • processed lean meats

24. The DASH Diet • The Dietary Approaches to Stop Hypertension clinical trial (DASH) • Hypothesis: Does a diet rich in fruits, vegetables, and low fat dairy foods lower blood pressure in individuals with hypertension and high normal blood pressure?

25. DASH Study • Control: • Ca, Mg, & K ~ 25% of US diet • Macronutrients and fiber ~ US average • Fruits and Vegetables • Fruits and vegetables increased to 8.5 servings • K and Mg to 75% • Combination: • Add 2-3 servings low-fat dairy to fruit & vegetable diet. • Ca, K and Mg increased to 75%

26. DASH Study Outcomes • Fruit and Vegetable Diet: • Decrease in systolic and diastolic blood pressure in entire study group and in the hypertensive subgroup. • Combination Diet: • Significant decrease in both systolic and diastolic blood pressure in both groups. • Greatest drop was in systolic BP in hypertensive group (11.4 mmHg)

27. DASH Diet Implications • Combination diet affects comparable to pharmacological trials in mild hypertension. • Population wide reductions in blood pressure similar to DASH results would reduce CHD by ~ 15% and stroke by ~27% • Great potential in susceptible groups: African Americans and elderly.

28. Treatment of Hypertension • Engage in Lifestyle Modifications • Avoid Medicines That Can Raise Blood Pressure • Take Medications That Can Lower Blood Pressure

29. Medicines Can Raise Blood Pressure • Analgesics • NSAIDs, COX-2 inhibitors, Aspirin • Decongestants/Allergy Medicines • Diet pills • Stimulants • Methylphenidate • Herbals (Ephedra or Ma Huang)

30. Treatment of Hypertension • Engage in Lifestyle Modifications • Avoid Medicines That Can Raise Blood Pressure • Take Medications That Can Lower Blood Pressure

31. Antihypertensive Medications • Most common types of medicines used to treat hypertension: • “Diuretics” • Rid the body of excess fluid and salt • “Ace-inhibitors” or “Angiotensin Receptor Blockers” • Block hormones that cause arteries to narrow • “Calcium channel blockers” • Reduce the heart rate and relax blood vessels • “Beta blockers” • Reduce the heart rate and work of the heart

32. Guidelines Have Established Treatment Goals JNC 7

33. What new therapies are there?

34. Control of Hypertension is Not Adequate • Nearly 55% of US hypertensive patients do not achieve systolic pressure goal of less than 140/90 mmHg Based on Data from NHANES/NCHS 2005-6

35. Renal Denervation ABLATION OF RENAL SYMPATHETIC NERVES

36. Baroreflex Activation Therapy ELECTRICAL STIMULATION OF CAROTID SINUS BARORECEPTORS

37. Remember …. • Hypertension is a lifelong disease. It can be controlled, not cured • Know your blood pressure. Have it checked regularly • Maintain a healthy lifestyle • If you do have hypertension, take your medications as prescribed

38. Questions? • From all the things I discussed today, what can you do to help control your blood pressure? • What is most important for you and how can you make that part of your routine?