DR.

ZOHRA ALMUKHAR CONSULTANT CARDIOLOGIST TAJOURA NATIONAL HEART CENTER

 Hypertension

is high blood pressure in the systemic arterial circulation, which can damage the walls of arteries, arterioles and the left ventricle of the heart Large and medium-sized arteries respond to high BP by thickening of the media and disruption of the elastic tissue within their walls

ESSENTIAL HYPERTENSION Sustained rise of B.P>140/90 mmhg no recognizable cause Occures in 95% of all hypertensives Classically raised systolic & diastolic B.P Diagnosd in young & middle aged

 Define

as systolic B.P >160 mmhg & diastolic <90 mmhg . Commenst in the elderly over the 60 yr . Hypertension is the most important risk factor for M.I, heart faliure & stroke. Drug of choice low dose thiazide or C.C.B. Target B.P. similar to that for younger patients .

Renal artary stenosis Ranel parenchymal disease Polycystic disease Phaeochromocytoma Cushing syndrome Thyroid disease Acromeglay Primary hyperaldosteronism (conns syndrome) Drugs Coarctation of the aorta

When to suspect Secondary Hypertension

HTN refractory to multiple medications Unexplained hypokalemia Symptoms consistent with: Pheochromocytoma Cushings syndrome Hyper/Hypothyroidism Hyperparathyroidism Sleep apnea

 Support

the arm at level of the heart Use a cuff of appropriate size Lower the mercury slowly (2 mmhg per second) Use phase V to measure distolic B.P Take 2 measurements at each visit Use a machine that has been validated Take 2 recording of B.P on 3 seprat occasions about 1 month a part

BHS CLASSIFICATION OF BLOOD PRESSURE LEVELS

Category Systolic blood pressure (mmHg) Diastolic blood pressure

Optimal blood pressure Normal blood pressure High-normal blood pressure Grade 1 Hypertension (mild) Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension (Grade 1) Isolated Systolic Hypertension (Grade 2)

<120 <130 130-139 140-159 160-179 >180 140-159 >160

<80 (mmHg) <85 85-89 90-99 100-109 >110 <90 <90

 TO

obtain accurate measurement of BP Identify contributing factors and underlying cause (secondary causes) To asses risk factors and quantify CVS risks To detect complications(target organ damage that already presents) To identify comorbidity that may influence the choice of antihypertensive therapy

HISTORY

-no symptoms, headache, symptoms of secondary causes. -Duration & progress of hypertension -Family history -Life style i.e. high salt intake, lake of physical activity, Smoking, Excess alcohol -Drug history

 BMI (overwt->25, obese->30) Waist circum (increased risk >94cm

males, >80cm females : high risk >102cm, >88cm females) CVS-, Pulses, radiofemoral delay Lungs for failure and evidence of bronchospasm Abd- renal size, masses, bruits Fundus- HPT, DM retinopathy CNS- CNS ds Endo-cushing, acromegaly

ROUTINE INVESTIGATIONS

Urine strip test for protein and blood

Serum creatinine and electrolytes Blood glucose - ideally fasted

Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) ideally fasted for consideration of triglycerides
Electrocardiogram

 Chest

X ray Ambulatory B.P recording Echo cardio graphy Renal ultra sound Renal angiography 24 hour urine V.M.A. Plazma renin & aldosterone level

Potential indications for the use of ambulatory blood pressure monitoring

Unusual variability Possible white coat hypertension Informing equivocal treatment decisions Evaluation of nocturnal hypertension Evaluation of drug-resistant hypertension Determining the efficacy of drug treatment over 24 hours Diagnoses and treatment of hypertension in pregnancy Evaluation of symptomatic hypotension

ISOLATED OFFICE (WHITE-COAT) HYPERTENSION

-The clinic BP is persistently above140/90 but the home or ambulatory BP measurements are 125/80mmHg or lower Its accounts for 10-15% of hypertensive patient The decision to initiate treatment should be based on the individual patients overall risk factor and the presence of target organ damage If a decision is made not to treat then close f/up is necessary

 Risk

factor organ damage cardio vascular disease

Target

Clinical

 Smoking Obesity-

BMI = or greater than 30 Lack of physical activity Hyperlipidemia D.M Age >55 yr for men or over 65 for women Microalbuminuria

Heart

disease i.e. LVH, angina, CAD,

CHF Stroke or TIA Nephropathy PVD Retinopathy

LIFESTYLE MEASURES
Maintain normal weight for adults (body mass index 20-25 kg/m2)

Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day)

Limit alcohol consumption to 3 units/day for men and 2 units/day for women Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for 30 minutes per day, ideally on most of days of the week but at least on three days of the week

Consume at least five portions/day of fresh fruit and vegetables

Reduce the intake of total and saturated fat

THRESHOLDS FOR INTERVENTION Initial blood pressure (mmHg)

>180/110

160179 100109

140159 9099

130139 8589

<130/85

* 160/100

** 140159 9099

*** <140/90

No target organ damage Target organ damage and or cardiovascular complications no cardiovascular complications and or no diabetes diabetes and or 20% 10 year CVD risk <20% 10 year CVD risk

Treat
* ** ***

Treat

Treat

Observe, reassess CVD risk yearly

Reassess yearly

Reassess in 5 years

Unless malignant phase of hypertensive emergency confirm over 12 weeks then treat If cardiovascular complications, target organ damage or diabetes is present, confirm over 34 weeks then treat; if absent re-measure weekly and treat if blood pressure persists at these levels over 412 If cardiovascular complications, target organ damage, or diabetes is present, confirm over 12 weeks then treat: if absent re-measure monthly and treat if these levels are maintained and if estimated 10 year CVD risk is 20% Assessed with CVD risk chart

OPTIMAL TARGET B.P DURING ANTI HYPERTENSIVE TREATMENT BRITISH HYPERTENSION SOCIETY GUIDELINES

NO DM

DM

Clinic measurements

<140/85

<140/80

A.B.P.M. or home measurement

<130/80

<130/75

accepted

<150/90

<140/85

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
Class of drug Alphablockers Compelling indications Benign prostatic hypertrophy Chronic renal disease, Type II diabetic nephropathy, proteinuric renal disease LV dysfunction post MI, intolerance of other antihypertensive drugs, proteinuric renal disease, chronic renal disease, heart failure Possible indications Compelling contraindications Urinary incontinence Pregnancy, renovascular disease

Caution Postural hypotension, heart failure Renal impairment PVD

ACEHeart failure, inhibitors LV dysfunction, post MI or established CVD, Type I diabetic nephropathy, 2o stroke prevention ARBs ACE inhibitorintolerance, Type II diabetic nephropathy, hypertension with LVH, heart failure in ACEintolerant patients, post MI

Renal impairment PVD

Pregnancy, renovascular disease

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
Class of drug Beta-blockers Compelling indications MI, Angina Possible indications Heart failure Caution Heart failure, PVD, Diabetes (except with CHD) Combination with betablockade Compelling contraindications Asthma/COPD, Heart block

CCBs (dihydropyridine) CCBs (rate limiting)

Elderly, ISH Angina

Angina Elderly

Heart block Heart failure Gout

Thiazide/thiazide- Elderly like diuretics ISH Heart failure 2 o stroke prevention

OTHER MEDICATIONS FOR HYPERTANSIVE PATIENTS

Primary prevention (1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies cardiovascular disease risk chart) (2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l (3) Vitamins: no benefit shown, do not prescribe

The Joint National Committee on High Blood Pressure has published a series of recommendations for appropriate follow-up, assuming no end-organ damage. -For a systolic BP 140-159 mm Hg/diastolic 90-99 mm Hg, confirm BP within 2 months. -For systolic BP 160-179 mm Hg/diastolic 100-109 mm Hg, evaluate within a month. - For systolic BP 180-209 mm Hg/diastolic 110-119 mm Hg, evaluate within a week. -For systolic BP greater than 210 mm Hg/diastolic greater than 120 mm Hg, evaluate immediately.

 Insufficient

drug dosage Weight gain Use of contraceptives Use of steroids Administration of sympathomimetics Undiagnosed secondary hypertension Renal artery stenosis Poor adherence to treatment

o Hypertensive emergency

(encephalopathy)
o Malignant hypertension o Hypertension in young <30 yr o Suspected secondary hypertension o Renal impairment o resistant hypertension o Multiple drug intolerance o Pregnancy

THANK YOU