HYPERTENSION

1. HYPERTENSION Dr. MOhammed Batais Assistant professor & Consultant Family Medicine, Diabetes & Chronic Disease Management College of Medicine King Saud University

2. EPIDEMIOLOGY ■In developed and developing countries alike, Essential Hypertension affects 25-35% of the adult population. Up to 60-70% of those beyond the seventh decade of life. ■ Each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors.

3. Prevalence of Hypertension in Obese and non-Obese Saudis The study group: 14.805 males: 6225 females: 8580 The age: 14 – 70 years Non-obese prevalence: 4.8 % males 2.8 % females Obese prevalence: 8 % males 8 % females Mohsen A El-Hazmi, Saudi Medical Journal 2001; vol 22 (1): 44-48

4. Hypertension among attendants of primary health care centers in Al-Qassim region Saudi Arabia. Khalid A,et al Saudi Med J 2001; Vol. 22 (11) 960-963 The study sample: 1114 The prevalence: 30 % Higher in: ● Age > 40 years ● Overweight and obese people ● illiteracy Awareness: 20 % 0f hypertensive women 25 % of hypertensive men

5. EPIDEMIOLOGY In the Framingham Heart Study: ◊Those belowAge of 55 diastolic Bp is the strongest predictor of cardiovascular risk ◊Above 55 years, diastolic Bp was negatively related to the risk of coronary events, so the pulse pressure became superior predictor to the systolic Bp.

6. Systolic Diastolic 95 90 85 80 75 70 65 175 165 155 145 135 125 115 105 4 3 2 1 Systolic pressure (mm Hg) Diastolic pressure (mm Hg) 30-34 40-44 80-84 50-54 60-64 75-79 70-74 30-34 40-44 50-54 60-64 70-74 75-79 80-84 35-39 45-49 55-59 35-39 45-49 55-59 65-69 65-69 Age (y) Age (y) What happens to blood pressure with aging? •Systolic pressure increases with age • Diastolic pressure increases with age but peaks between 55 and 60 years then starts to decrease. • Arterial stiffness: cause of elevated systolic and lower diastolic pressure with aging •Entirecohort study •Studycohortwithdeaths, myocardialinfarctions and congestive heartfailuresexcluded BP values over lifetime period in population studies Franklin SS, Fustin W 4th, Wong ND, et al. Circulation. 1997;96:308-315.

7. Pulse Pressure and Total Mortality P<0.00001 event rate % < 25 50 60 > 65 30 40 pulse pressure (mm Hg) Mitchell, G.F. & Pfeffer, M.A., Curr Opin Cardiol 1999; 14: 361-9

8. Are we achieving adequate control Up to 65% of Americans with hypertension do not achieve adequate blood pressure control. The World Health Organization now projects that by 2030, ischemic heart disease and stroke will become the second and third leading causes of death worldwide.

9. Trends in awareness, treatment, and control of high BP in adults ages 18 -74 National Health and Nutrition Examination Survey, Percent II (1976- 80) III (Phase 1 1988- 91) III (Phase 2 1991- 94) 1999- 00

10. Classification for adults (18 yr or more) The average of two or more properly measured, seated, BP readings on each of two or more office visits.

11. Accurate Blood Pressure Measurement in the Office • Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level. • Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. • Measurement of BP in the standing position is indicated periodically, especially in those at risk for postural hypotension, prior to necessary drug dose or adding a drug, and in those who report symptoms consistent with reduced BP upon standing.

12. Diagnosis (NICE 2011) • Measure blood pressure in both arms. • If the difference between arms is >20 mmHg: repeat the measurements. • Remains >20 mmHg on the second measurement: measure subsequent blood pressures in the arm with the higher reading. • If blood pressure measured in the clinic is 140/90 mmHg or higher: • Take a second measurement during the consultation. • If the second measurement is substantially different from the first, take a third measurement. • Record the lower of the last two measurements as the clinic blood pressure.

13. Cont. • If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension (home blood pressure monitoring (HBPM)>>alternative). • When using ABPM to confirm a diagnosis of hypertension, ensure that at least two measurements per hour are taken during the person's usual waking hours (for example, between 08:00 and 22:00).Use the average value of at least14 measurements taken during the person's usual waking hours to confirm a diagnosis of hypertension.

14. JNC7

15. Definition of hypertension (ABPM report) Dipping:The average nocturnal blood pressure is approximately 15 percent lower than daytime values in both normotensive and hypertensive patients. Failure of the blood pressure to fall by at least 10 percent during sleep is called nondipping. Up to Date

16. ABPM report

17. Home measurement of blood pressure Morning and Evening, for an initial 7-day period. Which patients? • For the diagnosis of hypertension • Suspected non adherence • White coat hypertension • Masked hypertension Average BP equal to or over 135/85 mmHg should be considered elevated

18. When using HBPM to confirm a diagnosis of hypertension, ensure that: • For each blood pressure recording, two consecutive measurements are taken, at least 1 minute apart and with the person seated. • Blood pressure is recorded twice daily, ideally in the morning and evening. • Blood pressure recording continues for at least 4 days, ideally for 7 days. • Discard the measurements taken on the first day and use the average value of all the remaining measurements to confirm a diagnosis of hypertension.

19. Evaluation

20. How to approach a patient with Hypertension ? • Medical History • Physical Examination • Routine Laboratory Tests • Optional Tests • Non-Pharmacological Treatment • Drug Treatment

21. Patient Evaluation Evaluation of patients with documented HTN has three objectives: • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. • Reveal identifiable Causes of high BP. • Assess the presence or absence of Target Organ Damage and CVD.

22. Risk Factors • Smoking • Dyslipidaemia • Diabetes Mellitus • Obesity • Age older than 60 years • Sex (men or postmenopausal women) • F.H. of cardiovascular disease

23. MEDICAL HISTORY • Patient History of Cardiovascular Disease • Current and Previous Medications • Smoking • Lifestyle Factors • Family History

24. PHYSICAL EXAMINATION • Blood Pressure (Readings ?) • Height, Weight and Pulse • Exam. Of Neck, Heart, Lungs, Abdomen and Extremities • Funduscopic Examination (Arterial narrowing “copper wiring”, A-V nipping, Flame shaped haemorrhages, Soft exudates, Papilloedema)

25. ROUTINE LAPORATORY TESTS • CBC • Urine Analysis and Microalbuminuria • Urea , Creatinine, Electrolytes, Uric Acid and Calcium • Fasting Plasma Glucose • Lipid Profile (T.ch, Trig, LDL and HDL) • ECG • Chest X-ray ??

26. Who should be screened for causes of secondary hypertension?

27. Target Organ Damage • Heart • Left ventricular hypertrophy • Angina or prior myocardial infarction • Heart failure • Brain • Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy

28. High/Very high risk subjects ► BP 180 mmHg systolic and/or 110 mmHg diastolic ► Systolic BP > 160 mmHg with low diastolic BP (<70 mmHg) ► Diabetes mellitus ► Metabolic syndrome ►≥ 3 cardiovascular risk factors

29. High/Very high risk subjects One or more of the following subclinical organ damages: ►ECG with LVH and strain ►Echo. of concentric LVH ►U/S evidence of carotid artery wall thickening or plaque ► Moderate increase in serum creatinine ►Reduced creatinine clearance ►Microalbuminuria or proteinuria ►Established cardiovascular or renal disease

30. OPTIONAL TESTS • 24-hour Urinary Protein • Creatinine Clearance • Echocardiography • Ultrasonography • Thyroid Stimulating Hormone • 24-hour Urinary Vanyl Mandelic Acid • 24-hour Urinary Catechleamines • 24-hour Urinary Free Hydrocortisol

32. BENEFITS OF LOWERING BLOOD PRESSURE • The Clinical Trials had shown: Reduction in • STROKE35 – 40 % • MI 20 – 25 % • HEART FAILURE > 50%

33. CLASSES OF ANTIHYPERTENSIVE DRUGS ■BETA BLOCKERS • Atenolol • Bisoprolol • Carvedilol ■ACE Inhibitors • Captopril • Lisinopril • Enalapril

34. Angiotensin-receptor blocker ARB therapy may cut the risk of Alzheimer's disease (AD) by reducing amyloid deposition in the brain. 890 hypertensive patients with available brain autopsy data. The risk for AD was 24% lower in those prescribed ACE inhibitor. Ihab Hajjar, MD, and colleagues from University of Southern California Archives of Neurology, September 13, 2012

35. CLASSES OF ANTIHYPERTENSIVE DRUGS Angiotensin II Receptor Blockers •Losartan • Candesartan • Valsartan • Irbesartan ■Calcium Channel Blockers ( Long Acting) • Nifedipine Retard • Amlodipine • Felodipine ■Diuretics ( Thiazides, Indapamide SR) ■Vasodilators

36. NICE 2011 Aged over 55 years or black person of any age Aged under55 years C2 A Step 1 Key A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic A + C2 Step 2 A + C + D Step 3 Resistant hypertension A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice Step 4

37. Updated Guideline issued by NICE 2011 In hypertensive patients aged 55 or older or black patients of any age: • The first choice for initial therapy should be either a calcium-channel blocker or a Thiazide-type diuretic. • If a third drug is needed an ACE inhibitor or ARB is a choice. NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

38. Updated Guideline issued by NICE 2011 In hypertensive patients younger than 55, the first choice for initial therapy should be: • An ACE inhibitor (or an ARB if an ACE inhibitor is not tolerated). • Adding an ACE inhibitor to a calcium-channel blocker or a diuretic (or vice versa are logical combinations). NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

39. Updated Guideline issued by NICE 2011 Beta-blockers may be considered in younger people, particularly: • Those with an intolerance or contraindication to ACE inhibitors and ARB or • Child-bearing potential or • People with evidence of increased sympathetic drive. NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

40. Updated Guideline issued by NICE 2011 If therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a Thiazide-type diuretic to reduce the patient’s risk of developing Diabetes. • NICE clinical guideline 34, Hypertension: management of hypertension in adults in primary care, 2011. www.nice.org.uk

41. A meta-analysis of 94,492 patients with hypertension treated with beta blockers to determine the risk of new-onset diabetes mellitus. S. Bangalore et. Al. American journal of cardiology, may 2007. ■ Β blockers are associated with an increased risk for new-onset DM by 22%. ■ No benefit for the end point of death or mi. ■ Increased risk for stroke by 15%. ■ This risk was greater in patients with higher baseline BMI and higher baseline FPG. Dr. HUSSEIN SAAD

42. Evidence of use of B Blockers Source: Cardiosource , 2008 American College of Cardiology

43. There is a paucity of data or an absence of evidence to support the use of beta-blockers as Monotherapyor as First-line agents in uncomplicated HTN. ► Given the risk of stroke. ► Lack of cardiovascular morbidity and mortality benefit. ► Numerous adverse effects. ► Lack of regression of target end-organ effects of hypertension (e.g., left ventricular hypertrophy and endothelial dysfunction).

44. INITIAL DRUG CHOICES ■ Isolated Systolic Hypertension: ●Thiazides ● Calcium Channel Blockers ( Long Acting ) ■Peripheral Arterial Disease ●Calcium Channel Blockers ( Long Acting )

45. INITIAL DRUG CHOICES ■ Heart Failure: •ACE Inhibitors •Angiotensin II Receptor Blockers • Diuretics • B-Blockers ■ IHD and MI: • B-Blockers •ACE Inhibitors / Angiotensin II Receptor Blockers • Calcium Antagonists ( Diltiazem )

46. B.P. and DIABETES MELLITUS • Diabetic patients with BP ≥ 140/90 are candidate for antihypertensive treatment. • Patients should be checked to confirm the presence of hypertension. • Proceed to: ● Behavioral Approach / Lifestyle Modific. ● Drug Treatment

47. Table 9. Lifestyle modifications to prevent and manage hypertension* Weight reduction Maintain normal body weight 5–20 mmHg/10kg92,93 (body mass index 18.5–24.9 kg/m2). Adopt DASH eating plan Consume a diet rich in fruits, 8–14 mmHg94,95 vegetables, and lowfat dairy products with a reduced content of saturated and total fat. Dietary sodium reduction Reduce dietary sodium intake to no 2–8 mmHg94-96 more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). Physical activity Engage in regular aerobic physical 4–9 mmHg97-98 activity such as brisk walking (at least 30 min per day, most days of the week). Moderation of alcohol Limit consumption to no more than 2–4 mmHg99 consumption 2 drinks (e.g., 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons. Modification Recommendation Approximate SBP Reduction (Range)† DASH, Dietary Approaches to Stop Hypertension; SBP, systolic blood pressure DASH, Dietary Approaches to Stop Hypertension; SBP, systolic blood pressure For overall cardiovascular risk reduction, stop smoking.

48. WCH • White coat hypertension is defined when a patient has a persistently elevated clinic BP ≥ 140/90 and a normal HBPM or ABPM day time average, i.e. <135/85 • White coat hypertension is present in as many as 25% of patients, possibly leading to: • Incorrect diagnosis of hypertension. • Diagnosis of uncontrolled hypertension (receive inappropriate dose titrations or additional antihypertensive agents) • Resistant hypertension, with a reported prevalence of 37 to 44 %in some studies.

50. Pharmacologic Treatment (JNC8)