Prof. Jamal Al Wakeel Consultant Nephrology Division Department of Medicine

1. HYPERTENSION Prof. Jamal Al Wakeel Consultant Nephrology Division Department of Medicine

2. Case • 47 year old man came to your clinic with headache for 3 weeks. The nurse measure his Blood Pressure and was found to be 150/95 mmHg: • Does he have Hypertension? • What is the stage of Hypertension? • What investigation should you perform? • What could be your management on his case? • Is their any possible prevention to his disease and its complication?

3. The Objectives of this Lecture are: To be able to recognize the definition of hypertension To be able to identify the Stages of Hypertension To find out the complication of Hypertension To learn how to measure blood pressure To familiarize with the test done for Hypertension To acquire knowledge on how to treat hypertension

4. HYPERTENSION • The 4th most common cause of death world-wide • Directly and indirectly responsible for >20% of all deaths • From 1999 to 2009 the death rate from high blood pressure increased 17.1% • 29-30% (about 77.9 million, 1 out of very 3) incidence of hypertension adult of the United States. • 9.1% and 8.7% the population of Saudi Arabia with hypertension 160/95 mmHg

5. Onset stage 25-55 years mainly in 40-50y • Occurs over 30%of persons older tha 65 y • Only 34%-52.5% of persons with hypertension have their blood pressure under control.

6. Prevalence of High Blood Pressure inAdults Age 20 and Older NHANES: 2007–2010 Source: NCHS and NHLBI. Hypertension is defined as SBP 140 mm Hg or DBP 90 mmHg, taking antihypertensive medication, or being told twice by a physician or other professional that one has hypertension.

7. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. and American Heart Association: Statistical Fact Sheet 2013 Update

8. In 90%-95% of cases no cause can be found primary hypertension (essential) • Secondary hypertension 5-10% Hypertension

9. Essential HTN • Risk factors • Obesity---metabolic syndrome • Excessive salt intake---low potassium intake • Excessive alcohol intake • Polycythemia • Lack of exercise • Non-steroid anti-inflammatory drugs • Family history of essential HTN • Caffeine and smoking increase the BP acutely but are not risk factors for the development of chronic essential HTN

10. Secondary Hypertension • Primary renal disease • Oral contraceptives • Sleep apnea syndrome • Primary hyperaldosteronism • Renovascular disease • Cushing’s syndrome • Pheochromocytoma • Other endocrine disorders • Coarctation of the aorta

11. National Heart, Lung, and Blood Institute National High Blood Pressure Education Program U.S. Department of Health and Human Services The Seventh Report of the Joint National Committee Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) National Institutes of Health National Heart, Lung, and Blood Institute

12. Blood Pressure Classification

13. European Society of Nephrology Classification of Blood Pressure Levels

14. National Institute for Health and Clinic Excellence Hypertension Guidelines 2011 (UK) • Stage 1 • Clinical Blood Pressure – 140/90 mmHg • Ambulatory Blood Pressure day time Monitoring (ABPM) – 135/85 mmHg • Home Blood Pressure Monitoring (HBPM) - 135/85 mmHg • Stage 2 • Clinical Blood Pressure – 160/100 mmHg • Ambulatory Blood Pressure day time Monitoring (ABPM) – 150/95 mmHg • Home Blood Pressure Monitoring (HBPM) - 150/95 mmHg • Severe hypertension (Stage 3) • Clinical Blood Pressure – 180/110 mmHg

15. Type of Instrument of Blood Pressure Measurement Sphygmomanometer

16. Type of Instrument of Blood Pressure Measurement Home Blood Pressure Monitoring

17. Type of Instrument of Blood Pressure Measurement Ambulatory Pressure Monitoring

18. Blood Pressure • Apply to adults on no antihypertensive medications and who are not acutely ill. • If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension. • Measure blood pressure to arm the high reading.

19. Measurement • Patient should be seated with the back straight and the arm supported at heart level • The patient should rest for 5 minutes • The bladder of the pressure cuff should encircle at least 80% of the upper arm • If BP measure =more140/90 mmHg, perform second reading. If second reading is still high, take third reading.

21. The diagnosis of mild hypertension should not be made until the blood pressure has been measured on at least three to six visits • Average of 10 to 15 mmHg decrease between visits 1 and three

22. White Coat Hypertension • Approximately 20 to 25% of patients with mild office hypertension • More common in elderly • Infrequent in patients with office diastolic pressures ≥105 mmHg

23. COMPLICATIONS

25. Risk of Hypertension for each 2 mmHg increase in systolic blood pressure Increase risk of cardiovascular mortality by 7% Risk of stroke by 10%

26. This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.

27. The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.

28. Malignant Hypertension • Marked hypertension with encephapapathy& retinal hemorrhages, exudates, or papilledema • Associated with a diastolic pressure above 120 mmHg

29. HYPERTENSIVE RETINOPATHY

30. Hypertensive RetinopathyGrade 1 • Generalized arteriolar constriction-seen as `silver wiring` and Vascular tortuosities

31. Hypertensive Retinopathy Grade 2 Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow)

32. Hypertensive Retinopathy Grade 3 Flame-shaped hemorrhage in association with severe hypertension Grade 3 (yellow arrow)

33. Hypertensive Retinopathy Grade 4 Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow)

34. Hypertensive Urgency Severe hypertension (diastolic blood pressure above 120 mmHg) in asymptomatic patients There is no proven benefit from rapid reduction in BP in asymptomatic patients who have no evidence of acute end-organ and are little short-term risk Hypertensive Emergency Severe hypertension (diastolic blood pressure above 120 mmHg) in end organ damage (MI,STROKE,AKI,CHF)

35. Diagnosis Hypertension Clinical Presentations: • Asymptomatic • Headache • Epistaxis • Chest discomfort • Symptom of complications Screening: • Every two years for persons with systolic and diastolic pressures below 120 mmHg and 80 mmHg • Yearly for persons with a systolic pressure of 120 to 139 mmHg OR Diastolic pressure of 80-89 mmHg

36. History • Presence of precipitating or aggravating factors • Natural course of the blood pressure • Extent of target organ damage • Presence secondary HTN of other risk factors for cardiovascular disease

38. Physical Examination • To evaluate for signs of end-organ damage • For evidence of a cause of secondary hypertension

40. Laboratory Tests • Routine Tests • Electrocardiogram • Urinalysis • Serum sodium, serum potassium, creatinine, or the corresponding estimated GFR, and calcium • Blood glucose, and hematocrit • 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

41. TREATMENT OF HYPERTENSION • Lifestyle modifications • High normal SBP >130 – 139 mmHg DBP 85 – 89 mmHg in high risk patients • Drug therapy • If BP is 140/90 mmHg

42. Blood Pressure Target: (UK) • Age < 80 yrs (high risk) <140/90 mmHg • Age < 80 yrs (no risk) 140/90 mmHg • Age > 80 yrs 150/90 mmHg • Blood Pressure Target: (European) • <140/90 mmHg

43. Benefits of Lowering BP

44. Lifestyle Modification

45. Dietary Approaches To Stop Hypertension (DASH) • Diet high in fruits and vegetables and low-fat dairy products • Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. NEJM 1997; 366: 1117-24.

46. Follow-up And Monitoring • Patients should return for follow-up after 4 weeks and adjustment of medications until the BP goal is reached • More frequent visits for stage 2 HTN or with complicating co-morbid conditions. • Serum potassium and creatinine monitored 1–2 times per year.

47. Drug Therapy • A low dose of initial drug should be used, slowly titrating upward. • Optimal formulation should provide 24-hour efficacy with once-daily dose. • Combination therapies may provide additional efficacy with fewer adverse effects.

48. Diuretics → Hypokalemia β-Adrenergic Blocking Agents →Bradycardia+ Angiotensin-Converting Enzyme Inhibitors → Hyperkalemia + cough AngiotensinII Receptor Blockers → Hyperkalemia Calcium Channel Blocking Agents → Edema + Tachycardia + Bradycardia α-Adrenoceptor Antagonists → 1st dose hypotension Drugs with Central SympatholyticAction → Drowsiness Arteriolar Dilators → Tachycardia + Edema

49. Aged under55 years Aged over 55 years or black person of African Summary of antihypertensive drug treatment Key A –ACE inhibitor or angiotensin II receptor blocker (ARB)12 C – Calcium-channel blocker (CCB)13 D – Thiazide-like diuretic C Step 1 A 12 Choose a low-cost ARB. 13 A CCB is preferred but consider a thiazide-like diuretic if a CCB is not tolerated or the person has edema, evidence of heart failure or a high risk of heart failure. 14 Consider a low dose of spironolactone15 or higher doses of a thiazide-like diuretic. 15 At the time of publication (August 2011), spironolactone did not have a UK marketing authorization for this indication. Informed consent should be obtained and documented. 16 Consider an alpha- or beta-blocker if further diuretic therapy is not tolerated, or is contraindicated or ineffective. Step 2 A + C A + C + D Step 3 Step 4 Resistant hypertension A + C + D + consider further diuretic14, 15 or alpha- or beta-blocker16 Consider seeking expert advice

50. High Risk Group Therapy • Start in pre-hypertension (130 – 139)/(85 – 89) mmHg • Lifestyle change • CHF – Thiazide, ACE-1, Aldosterone, BB • Post Myocardial Infarction – BB, ACEi • Diabetes Mellitus – ACEi, ARB, Thiazide, CCB • CKD – ACEi, ABB, Thiazide • Stroke – SSB +ACEi