Blood Pressure Classification

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Review Of Management Of Hypertension
By Professor Dr Intekhab Alam Department of
Medicine Lady Reading Hospital, Peshawar
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Management of Hypertension

• Lecture Objectives
• Define Hypertension (HTN)
• Learn how to measure blood pressure
• Understand initial clinical evaluation
• Identify causes of secondary HTN
• Describe lifestyle modifications that lower
  blood
• pressure
• Select appropriate anti-HTN medications
• Provide appropriate follow-up care

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What is Blood Pressure?

• The primary reason most of us are awake and
  breathing at this very moment in this lecture!
• BP CO x TPR (CO HR x SV)
• Stroke volume affected by contractility and
  venous return
• TPR is regulated by
• Norepinephrine, Epinephrine, Angiotensin II.

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Hypertension Defined

• Hypertension (HTN) is defined as sustained
  abnormal elevation of the arterial blood
  pressure.
• (Brashers, 2006, p.1).

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Hypertension

• It is an abnormal and persistent elevation of
  BP.
• BP limits are different in children and
  pregnancy.
• BP goal is different if you have diabetes or
  chronic kidney disease.
• Primary (essential) 95 of cases.
• Secondary 5 of cases.
• Starting at 115/75 mmHg, CVD risk doubles with
  each increment of 20/10 mmHg throughout the BP
  range.

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JNC-7 Classification
SBP (mmHg)
DBP (mmHg)
BP Classification
Normal Prehypertension Stage I hypertension Stage
II hypertension
lt 120 120-139 140-159 gt 160
lt 80 80-89 90-99 gt 100
and or or or
http//hin.nhlbi.nih.gov/nhbpep_slds/menu.htm
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Diagnosis of HTN

• Repeated abnormal elevation of BP using
• proper technique/cuff on 3 separate occasions
  over at least 6 weeks
• A single blood pressure gt200/120
• Keep in mind
• Risk factors
• Evidence of end-organ disease

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Epidemiology !

• The most common primary diagnosis in the United
  States, 50 million American affected.
• Only 70 are aware they have HTN
• Of those aware of their HTN, only 50 are being
  treated.
• Only 25 of all hypertensive patients have their
  BP under control
• In the year 2000, 167 million people died from
  cardiovascular disease, accounting for 303 of
  all deaths worldwide
• HTN is a risk factor for coronary artery disease
  (CAD), congestive heart failure (CHF), stroke,
  and renal failure

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Prevalence of Hypertension in South Asia

• More than half of the cardiovascular deaths take
  place in developing countries.
• South Asia (Pakistan, India, Bangladesh, Nepal,
  and Sri Lanka) represents more than a quarter of
  the developing world, and is likely to be
  strongly affected by the increase in
  cardiovascular disease, for several reasons.
• First, people from south Asia are known to have a
  high coronary risk this tendency has been well
  recorded in studies of expatriate south Asians
  and has also been shown in native settings.

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Prevalence of Hypertension in South Asia
Sex Pakistan 1 India 2,3 Bangladesh 4 Nepal 6 Sri Lanka 5
Men 15-30 Years 17 36.4 9.8 .. 17
Women 15-30 Years 37.5 15.6 .. ..

• Hypertension classified according to WHO
  Criteria
• References 1. Pakistan Medical Research Council.
  National Health Survey of Pakistan 1990-94
  health profile of the people of Pakistan.
  Islamabad Network publication service, 1998. 2.
  Gupta R, Gupta VP, Sarna M, et al. Prevalence of
  coronary heart disease and risk factors in an
  urban Indian population Jaipur Heart Watch-2.
   Indian Heart J  2002 54 59-66.  3.Fernandes
  VL, Kottke TE, Nicholas JJ. Tobacco consumption
  and coronary artery disease. In Rao GHR, Kakkar
  VV, eds. Coronary artery disease in South
  Asians., New Dehli Jaypee Brothers, 2001
  147-64. 4. Zaman MM, Yoshiike N, Rouf MA, et al.
  Cardiovascular risk factors distribution and
  prevalence in a rural population of Bangladesh.
   J Cardiovasc Risk  2001 5. 103-08. 5.Mendis S,
  Ekanayake EM. Prevalence of coronary heart
  disease and its risk factors in middle aged males
  in a defined population in central Sri Lanka.
   Int J Cardiol  1994 46 135-42. 6.Pandey MR,
  Neupane RP, Gautam A. Epidemiological study of
  tobacco smoking among adults in a rural community
  of the hill region of Nepal with special
  reference to attitudes and beliefs.  Int J
  Cardiol  1988 17 535-41.

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The CVD Situation in Pakistan

• Pakistan's Hypertension Statistics (NHS)
• Hypertension is the most common cardiovascular
  disease in Pakistan.
• There are an estimated 12 million hypertensives
  in the country.
• Hypertension affects one in three individuals
  over the age of 45 years in Pakistan.
• Only 3 of the hypertensive population in
  Pakistan is adequately controlled.
• (The National Health Survey of Pakistan,
  jointly conducted by the Pakistan Medical
  Research Council in collaboration with the
  Federal Bureau of statistics, Pakistan and the
  Department of Health ad Human Services,
  Washington, USA )

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Historical Trends in HTN
National Health and Nutrition Examination Survey
Trends in awareness, treatment, and control of
high blood pressure in adults ages 18-74
1991-1994 68 54 27
1976-1980 51 31 10
1988-1991 73 55 29
1994-2000 70 59 34
Awareness Treatment Control
SBP lt 140 mmHg and DBP lt 90 mmHg
http//hin.nhlbi.nih.gov/nhbpep_slds/menu.htm
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Benefits of Lowering BP

• Sustaining a 12 mmHg reduction in SBP over 10
  years will prevent one death for every 11
  patients treated with Stage I HTN with additional
  CVD risk factors
• Why to treat HTN?
• The relationship between BP and CVD is positive
  and continuous.
• 35-40 ? in stroke morbidity and mortality
• 20-25 ? CAD events
• 21 ? vascular mortality
• 52 ? in CHF
• 35 ? in LVH

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BP Measurement Techniques
Method Brief Description
In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contra lateral arm.
Ambulatory BP monitoring Indicated for evaluation of white-coat HTN. Absence of 1020 BP decrease during sleep may indicate increased CVD risk.
Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.
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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.

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Patient Evaluation
Assess lifestyle and identify other CV risk
factors or concomitant disorders

• Hypertension
• Smoking
• Obesity
• Physical inactivity
• Dyslipidemia
• Diabetes

• Microalbuminuria or est GFR lt 60 ml/min
• Age
• Males gt 55 yrs
• Females gt 65 yrs
• Family history of CVD
• Males lt 55 yrs
• Females lt 65 yrs

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Identifiable Causes of Hypertension

• Sleep apnea
• Drug-induced or related causes
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushings syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

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Target Organ Damage

• Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
• Brain
• Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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Laboratory Tests

• Routine Tests
• Electrocardiogram (Look for LVH, CAD, arrhythmia)
• Urinalysis (Look for protein/blood)
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding
  
• estimated GFR, and calcium
• Lipid profile, after 9- to 12-hour fast, that
  includes
• high-density and low-density lipoprotein
  cholesterol, and
  triglycerides.
• AlbCr ratio Look for microscopic albuminuria.
• Optional tests
• Measurement of urinary albumin excretion or
  albumin/creatinine ratio
• Specialized investigations for secondary
  hypertension not generally indicated unless BP
  control is not achieved or clinically indicated.

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Treatment Outline

• Goals of Therapy
• Lifestyle modification
• Classification and management of BP for adults
• Pharmacologic treatment
• Compelling indications for individual drug
  classes
• Follow-up and monitoring

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Goals of Therapy

• Reduce CVD and renal morbidity and mortality.
• Treat to BP lt140/90 mmHg or BP lt130/80 mmHg in
  patients with diabetes or chronic kidney disease.
  
• Achieve SBP goal especially in persons gt50 years
  of age.
• Maintain QOL and Minimize side effects.

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Lifestyle Modification

• Works best in motivated individuals
• Initiate at prehypertension classification
• Obesity ? risk for HTN and DM
• Sodium restriction and other diet aids
• Usual salt intake 10 gm/d 4 gm Na
• Reduce to 2.4 gm Na/day
• Caution salt substitutes contain K
• Discourage excessive consumption of coffee and
  other caffeine-rich products.
• Stop smoking and Alcohol consumption.
• Exercise/Activity
• 30-40 minutes 3-4x/wk, optimal 5x/wk
• Stress reduction

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Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 520 mmHg/10 kg weight loss
Adopt DASH eating plan 814 mmHg
Dietary sodium reduction 28 mmHg
Physical activity 49 mmHg
Stopping alcohol consumption 24 mmHg
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Pharmacologic Treatment

• Antihypertensive Drug Classes
• Diuretics
• Angiotensin Converting Enzyme Inhibitors (ACEI)
• Angiotensin II Receptor Blockers (ARB)
• Beta blockers
• Calcium Channel Blockers (CCB)
• Direct Vasodilators

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JNC-7 Management of BP for Adults
No compelling indication No drug tx Thiazide
for most 2 drugs combination including thiazide
BP classification Normal Prehypertension Stage
I HTN Stage II HTN
Lifestyle ? Encourage Yes Yes Yes
Compelling indication Drugs targeted for the
compelling indications
lt 120/80
120-139 / 80-89
Drugs targeted for the compelling indications
140-159 / 90-99
Drugs targeted for the compelling indications
gt 160 / gt 100
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National Institute for Health and Clinical
Excellence (NICE)

• NICE is an independent UK based organisation
  responsible for providing national guidance on
  the promotion of good health and the prevention
  and treatment of ill health.

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Pharmacological interventions

• In hypertensive patients aged 55 or older or
  black patients of any age, the first choice for
  initial therapy should either be a
  calcium-channel blocker or a thiazide-type
  diuretic. For this recommendation, black patients
  are considered to be those of African or
  Caribbean descent, not mixed-race, Asian or
  Chinese.
• In hypertensive patients younger than 55, the
  first choice for initial therapy should be an
  angiotensin-converting enzyme (ACE) inhibitor (or
  an angiotensin-II receptor antagonist if an ACE
  inhibitor is not tolerated).

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Pharmacological interventions

• If initial therapy was with a calcium-channel
  blocker or a thiazide-type diuretic and a second
  drug is required, add an ACE inhibitor (or an
  angiotensin-II receptor antagonist if an ACE
  inhibitor is not tolerated). If therapy was
  initiated with an ACE inhibitor (or
  angiotensin-II receptor antagonist), add a
  calcium-channel blocker or a thiazide-type
  diuretic.
• If treatment with three drugs is required, the
  combination of ACE inhibitor (or angiotensin-II
  receptor antagonist), calcium-channel blocker and
  thiazide-type diuretic should be used.

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Pharmacological interventions

• If blood pressure remains uncontrolled on
  adequate doses of three drugs, consider adding a
  fourth and/or seeking expert advice.
• If a fourth drug is required, one of the
  following should be considered
• a higher dose of a thiazide-type diuretic or the
  addition of another diuretic (careful monitoring
  is recommended) or
• beta-blockers or
• selective alpha-blockers.

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Pharmacological interventions

• If blood pressure remains uncontrolled on
  adequate doses of four drugs, and expert advice
  has not yet been obtained, this should now be
  sought.
• Beta-blockers are not a preferred initial
  therapy for hypertension.
• However, beta-blockers may be considered in
  younger people, particularly
• those with an intolerance or contraindication to
  ACE inhibitors and angiotensin-II receptor
  antagonists or
• women of child-bearing potential or
• people with evidence of increased sympathetic
  drive.
• In these circumstances, 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
  patients risk of developing diabetes.

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Pharmacological interventions

• When a beta-blocker is withdrawn, the dose should
  be stepped down gradually. Beta-blockers should
  not be withdrawn in patients who have compelling
  indications for beta-blockade, for example those
  who have symptomatic angina or who have had a
  myocardial infarction.
• Offer patients with isolated systolic
  hypertension (systolic BP 160 mmHg or more) the
  same treatment as patients with both raised
  systolic and diastolic blood pressure.
• Offer patients over 80 years of age the same
  treatment as other patients over 55, taking
  account of any comorbidity and their existing
  burden of drug use.

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The Atenolol Debate

• Meta-analysis of 8 randomized, controlled,
  clinical studies involving atenolol
• Atenolol vs. placebo (6825)
• No outcome difference for all-cause mortality, CV
  mortality, or MI
• Trend for lower risk of stroke (outlier HEP?)
• Atenolol vs. other antihypertensive (17,671)
• No major differences with respect to BP control
• ? mortality, ? trend CV mortality, ? risk of
  stroke

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The Atenolol Debate

• Authors suggestion for findings
• Perhaps all B-blockers are not created equal?
• Atenolol hydrophilic, lacks penetration into
  CNS
• Atenolol no benefit in remodeling, endothelial
  dysfunction
• More doom for Atenolol?
• ASCOT Trial was halted early
• gt 19,000 patients
• Atenolol Thiazide vs. Amlodipine Perindopril
• Results due in March implication thus far for
  greater CV mortality and stroke

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Pharmacological interventions

• Where possible, recommend treatment with drugs
  taken only once a day.
• Prescribe non-proprietary drugs where these are
  appropriate and minimise cost.

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Special Considerations

• Compelling Indications
• Compelling Populations
• Blacks
• Diabetics
• Elderly
• Renovascular disease
• Pregnancy

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Compelling Indications
Compelling Indication Initial Therapy Options
Clinical Trial Basis
Heart failure
Thiazide, BB, ACEI, ARB, ALDO-Ant
ACC/AHA HF Guidelines, Merit-HF, Copernicus,
CIBIS, SOLVD, AIRE, TRACE, ValHeft, Rales
MI
ACC/AHA Guidelines, BHAT, SAVE, Capricorn, Ephesus
BB, ACEI, ALDO-Ant
High CAD risk
Thiazide, BB, ACEI, CCB
ALLHAT, HOPE, LIFE, Convince
Diabetes
BB, ACE, ARB, CCB
NKF-ADA Guideline, UKPDS, ALLHAT
ACE, ARB
NKF Guideline, Captopril trial, RENAAL, IDNT,
REIN, AASK
CRF
Recurrent Stroke Prevention
Thaizide, ACEI
PROGRESS
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Compelling Populations

• High-Risk Hypertensives
• Blacks
• Diabetics
• Elderly
• Renovascular disease
• Pregnancy

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Blacks

• The single most at risk population with HTN
• Disproportionately higher rate and more severe
• Lower plasma renin activity, more Na and
  volume-dependent hypertension
• Initial tx DIURETICS
• Second line CCB gt ACEI ARB, B-blockers

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Diabetics

• Direct correlation between systolic BP and
  decline in GFR
• As little as a 2 mmHg ? BP results in significant
  reductions in CVD (HOT study)
• Preferred agents ACEI or ARBs

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Elderly

• Population with the lowest BP control, yet the
  most to gain! Isolated systolic
  hypertension is common
• Issues polypharmacy, altered drug metabolism,
  physiological changes
• gt 50 of these patients will require combination
  therapy to achieve goal BP
• Susceptible to volume depletion orthostatic
  hypotension
• Cognitive impairment
• Fixed incomes
• Low-dose thiazide is drug of choice
• Additional agent should include CCB or
  B-blocker
• Start low and go slow

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Renal vascular Disease

• ACEI and ARBs
• In patients with RAS or RA hyperplasia
• ACEI and ARBs particularly advantageous
• ? plasma renin and angiotensin activity
• Caution Rapid and profound drop in BP as well
  as renal failure
• Avoid in bilateral RAS

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Pregnancy

• Almost all cardiovascular drugs are either risk
  category C or D.
• Chronic/transient hypertension vs. preeclampsia
• Treatment warranted with DBP gt 100mmHg
• Problem not much data from controlled clinical
  studies
• Methyldopa, Hydralazine, Diuretics
• Caution?
• BB, CCB
• Avoid
• ACEI, ARB

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Causes of Resistant HTN

• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Inadequate doses
• Compliance
• Drug interactions
• OTC/herbals/dietary supplements
• Excess alcohol intake
• Identifiable causes of HTN

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Public Health Challenges and Community Programs

• Public health approaches (e.g. reducing calories,
  saturated fat, and salt in processed foods and
  increasing community/school opportunities for
  physical activity) can achieve a downward shift
  in the distribution of a populations BP, thus
  potentially reducing morbidity, mortality, and
  the lifetime risk of an individuals becoming
  hypertensive.
• These public health approaches can provide an
  attractive opportunity to interrupt and prevent
  the continuing costly cycle of managing HTN and
  its complications.

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Population-Based Strategy
SBP Distributions
Before Intervention
After Intervention
Reduction in BP
Reduction in SBP mmHg 2 3 5
Reduction in Mortality
Stroke CHD Total 6 4 3 8 5 4 14 9 7
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Which is the Best StrategyPolypill vs. Polymeal

• CVD Reduction by 80.
• Wald et al. BMJ 2003
• Enalapril 10 mg
• Thiazide 25 mg
• Atenolol 25 mg
• Aspirin 75 mg
• Atorvastatin 10 mg
• Folic acid 5 mg

• CVD Reduction by 75.
• Franco et al. BMJ 2004
• Fish 114 g.
• Walk, 4 times/week
• Dark chocolate 100 g
• Fruits and vegetables 400 g
• Garlic 2.7 g
• Almonds 68 g

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Follow-up and Monitoring

• Patients should return for follow-up and
  adjustment of medications until the BP goal is
  reached.
• More frequent visits for stage 2 HTN or with
  complicating comorbid conditions.
• Serum potassium and creatinine monitored 12
  times per year.
• After BP at goal and stable, follow-up visits at
  3- to 6-month.
• Comorbidities, such as heart failure, associated
  diseases, such as diabetes, and the need for
  laboratory tests influence the frequency of
  visits.

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Continuing treatment

• The aim of medication is to reduce blood pressure
  to 140/90 mmHg or below. However, patients not
  achieving this target, or for whom further
  treatment is inappropriate or declined, will
  still receive worthwhile benefit from the drug(s)
  if these lower blood pressure.
• Patients may become motivated to make lifestyle
  changes and want to reduce or stop using
  antihypertensive drugs. If at low cardiovascular
  risk and with well controlled blood pressure,
  these patients should be offered a trial
  reduction or withdrawal of therapy with
  appropriate lifestyle guidance and ongoing
  review.

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Thankyou very much
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Questions?