Management of Hypertension

Professor Datin Dr Chia Yook Chin MBBS FRCP

Dept of Primary Care Medicine, UM Unscheduled Universities Lecture IKU, KL 20 August 2009

History of Hypertension: th century 19

19th century, knowledge about blood

pressure regulation had grown significantly

Claude Bernard, a French scientist, discovered the existence of vascular nerves and reasoned out their role in controlling the diameter of the blood vessels.

History of Hypertension: th century 19

Richard Bright:established a co-relation between high blood pressure and kidney disease.
Sir William Gowers highlighted the link between contractions of the arterioles of the retina and increased arterial blood pressure

History of Hypertension: 20th century:

McLeod described the main factors controlling blood pressure. In 1950s, life insurance companies observed that persons suffering from high blood pressure died earlier than those with lower blood pressure levels.
Thus, a link was established between high blood pressure and mortality rate.

Definition of Hypertension

BP 140/90 mm Hg

Systolic BP 140 and/ or

Diastolic 90 mm Hg

Differences with JNC VII

*JAMA 2003;289:2560-2572

Category
Optimal

Systolic
<120
and

Diastolic
<80

JNC VII*
Normal

Normal
High Normal Hypertension Stage 1 Stage 2 Stage 3

<130
130-139

and
and/or

<85
85-89

Prehypertension+

120-139/8089

Hypertension 140-159 160-179 >180

and/or and/or and/or

90-99 100-109 >110

Stage 1 Stage 2 >160/100

+ Pre-hypertensives patients twice as likely to develop hypertension compared to normal group Lancet 2001;358:1682-1686

Prognosis of Prehypertension

Pre HT associated with

increased risk of CVD RR 1.79 (95% CI 1.4-2.24) cf normotensive HT vs NT for CVD RR 2.64 (CI 2.18-3.19)

Associated with increase of

27% in all cause mortality, 66 % in CVD mortality cf normotensive

Isolated Systolic Hypertension (ISH)

Systolic 140 mm Hg and Diastolic < 80 mm Hg

ISH: 160/82 mm Hg

Complications of Hypertension

Cardiovascular Disease
Entire vascular tree
Heart,

(Cardiomegaly, Heart Failure)

Brain,

(cerebral infarction, intracerebral haemorrahge -> Strokes CVA, TIA),

(renal failure) blood vessels (claudication LL) (blindness,)

Kidneys, Eyes,

peripheral

How to Diagnose Hypertension?

Definition: BP 140/90 mm Hg Measure Blood Pressure

Measurement of Blood Pressure

Mercury column sphygmomanometer

Anaeroid sphygmomanometer

Electronic devices (oscillatory method)

Automated ambulatory BP devices

Measurement of BP

Correct cuff size

Bladder length must cover at least 80% of the circumference of arm

Width should be 40% of the circumference of the arm

Standard size: 13cmX 24 cm

Too small -> higher reading

Too big -> lower reading

Measurement of BP

Patient seated and adequately rested

Arm supported

should not smoke or drink caffeine within 30 mins of measurement

Measurement of BP

Systolic BP estimated by palpation

Pulse disappears, inflate by a further 20 mm Hg Deflate and feel pulse, when felt this is estimate of Systolic BP Reinflate till 20 mm Hg estimated Systolic BP Deflate slowly, 1-2 mm Hg per second while ascultating Important to palpate because of silent gap
Korotkoff sounds disappears and reappears later

Measurement of Blood Pressure

Mercury sphagnomanometer
Korotkoff 1=SBP Korotkoff 5=DBP

Measure both arms, take higher reading (<20/10 mmHg difference)

Standing BP; postural drop if >20mmHg difference

Sitting, average of at least 2 readings

Confirm on at least 2 separate occasions

Measurement of Blood Pressure

White coat hypertension

BP at home is less than office readings

Confirm by home blood pressure

monitoring or ambulatory BP measurement

Assessment of Patients with Hypertension

Look for a cause (look for secondary causes)

Ascertain presence or absence of target organ damage

Identify other risk factors eg smoking, diabetes, dyslipidaemia, f/h CHD

Assessment of Patients with Hypertension

Look for a cause (look for secondary causes)

Ascertain presence or absence of target organ damage

Identify other risk factors eg smoking, diabetes, dyslipidaemia, f/h CHD

Causes of Hypertension

Primary/Essential (80%)
Secondary (20%)

Causes of Hypertension

Primary/Essential (80%)
No identifiable cause Family history later age of onset

Causes of Hypertension

Secondary causes (20%) Renal Chronic kidney disease/failure Glomerulonephritis eg post strep GN
Endocrine Cushings Disease, phaechromocytoma Primary aldosteronism, acromegaly Thyroid or parathyroid disease

Causes of Hypertension

Secondary causes (20%) Cardiac causes Coarctation of Aorta Primary arteritis (Takayasus Disease) Renal stenosis (reno-vascular disease) Drug induced Steriods NSAIDs OCP Others Sleep apnoea

Assessment of Patients with Hypertension

Look for a cause (look for secondary causes)

Ascertain presence or absence of target organ damage

Identify other risk factors eg smoking, diabetes, dyslipidaemia, f/h CHD

Target Organ Damage

Heart Left ventricular hypertrophy (Cardiomegaly, ECG) Angina, old MI Prior coronary revascularisation Brain Stroke or TIA Kidney Microalbuminuria Chronic kidney failure Eye Retinopathy Peripheral vascular Disease

Assessment of Patients with Hypertension

Look for a cause (look for secondary causes)

Ascertain presence or absence of target organ damage

Identify other risk factors eg smoking, diabetes, dyslipidaemia, f/h CHD

Major CVD Risk Factors

Smoking
Diabetes Central obesity

Dyslipidaemia
Physical inactivity Microalbuminuria Age Men> 55 , women >65 yrs Family history of premature CVD (men <55 women <65 yrs)

Assessment of Patients with Hypertension

History

Identify cause, Risk factors Target organ damage

Physical examination
20 causes eg Cushings, Heart size, Pulses, coarctation, PAD Renal bruit: renal stenosis Eyes: retinopathy

Assessment of Patients with Hypertension

Ix:
FBC urinalysis (microalbuminuria) renal function FBS Lipids ECG CXR

Magnitude of Hypertension
National Health and Morbidity Survey II, 1996: Prevalence: 32% High normal: 17% Stage 1: 20 % Stage 2: 8 % Stage 3: 4 % -Rule of halves -half not diagnosed -half not treated -half not controlled

Aims and Targets of Hypertension Management

Reduce CV morbidity and mortality Reduce BP levels

Effect of Antihypertensive Therapy

0 10 % Reduction 20 30 40 50% Heart Failure Cerebrovascular Coronary Heart Disease Disease 16%

48%

50
60

12 mmHg reduction

MacMahon SW et al. Prog Cardiovasc Dis. 1986;29(suppl 1):99118.

Treatment of Hypertension

Non-phramacological Pharmacological

Treatment of Hypertension

Non-pharmacological
Lose weight Regular exercise 30 mins three times per week Low salt diet Avoid alcohol Healthy eating

Drugs for Treatment of Hypertension

Pharmacological
ACE inhibitors eg lisnopril Calcium channel blockers eg amlodipine Diuretics eg hydrochlorothiazide AIIA ( ARBs: angitensin receptor blocker) eg lorsartan

blockers eg atenolol
(alpha) blockers eg prazosin blockers eg labetalol

Drugs for Treatment of Hypertension

Pharmacological
Centrally acting eg methldopa Direct vasodilators eg minoxidil Aldosterone anatgonist: eg aldosterone Renin inhibitors eg aliskerin

Hypertension in Other Groups

Elderly Pregnant Women Children

Hypertension in the Elderly

Definition: same as adults 140/90 mm Hg Assessment and management is the same Drugs: start low go slow Postural hypotension

Hypertension in the Pregnant Women

Pregnancy induced hypertension Definition: 140/90 mm Hg Korotkoff V as cutoff for Diastolic BP If korotkoff V does not end, then use korotkoff IV Pre-eclampsia and eclampsia

Hypertension in Children

Increasing in prevalence Def: based on age, gender and height Defined as BP >95% for age, gender and height Normative tables for BP for children based on age, sex and height (NCHS: Nat Health Statistics for Growth Chart) Appropriate cuff size Refer to paediatrician

Summary: Hypertension Management

Definition: 140/90 mm Hg adults Associated with increased CVD risk and mortality Proper measurement of BP Assessment of Hypertension:
Cause Target organ damage Associated CVD risk factors

Summary: Hypertension Management

Definition: 140/90 mm Hg adults BP is a continumum Associated with increased CVD risk and mortality Proper measurement of BP Assessment of Hypertension:
Cause Target organ damage Associated CVD risk factors

Primary Aim of Hypertension Management

Reduce CV morbidity and mortality

Reduce BP levels

Case Discussion
Encik Ahmad, 56 retired clerk Comes for running nose BP 148/86 mmHg

Case Discussion

Has he got hypertension?

Measure it twice at one sitting

Rested

Not smoked, no coffee, coke,

Arm supported

Cuff size correct

BP 148/88 mm Hg Need to reconfirm on another occasion

Case Discussion

Come back in a month

BP 146/86 mm Hg (2X) 148/84 mm Hg Has he got hypertension

What next?
1. 2. 3.

Cause
Target organ damage Associated CVD risk factors

How to do that?
1. 2. 3.

History
Physical examination Investigations

What exactly?
1.

History
Cause

p/h of HT f/h HT p/h of kidney disease, haematuria, kidney stones, ankle oedema, puffiness Drugs eg NSAIDs, steroids Thyroid disease eg thyrotoxicosis

What exactly
1.

History
Target organ damage

Cardiac complications eg chest pain, difficulty in breathing, orthopnoea TIA, strokes, intermittent claudication Kidneys: facial puffiness, ankle oedema, polyuria, nocturia Eyes: visual problems PAD: intermittent claudication

What exactly
1.

History
Associated CVD risk Factors

f/h premature cardiac problems Smoke Dyslipidaemia Diabetes Physical inactivity

Physical Examination: What to examine?

Cause:
Endocrine disease eg Cushings Kidney disease: facial puffiness, ankle oedema, anaemai, acidotic, sallow Renal Artery stenosis; renal bruit
Primary aretritis

Coarcatation of aorta

Physical Examination: What to examine?

Target organ damage:

Heart size (LVH) Heart failure Eyes: retinopathy Evidence of kidney disease Peripheral pulses

Physical Examination: What to examine?

Associated CVD Risk factors:

Obesity, BMI, waist circumference Nicotine stains Xanthomas Evidence of diabetes mellitus

Investigations: What to order?

Cause, target organ damage, assoc CVD RF
Hb (anaemia: renal failure) Urine FEME (caused and target organ damage) Renal functions (cause and target organ damage) Lipids (associated risk factors) FBG: assocaited risk factors ECG ( Target organ damage) CXR (cause and target organ damage)

Investigations: What to order?

Cause, target organ damage, assoc CVD RF
Hb (anaemia: renal failure) Urine FEME (caused and target organ damage) Renal functions (cause and target organ damage) Lipids (associated risk factors) FBG: assocaited risk factors ECG ( Target organ damage) CXR (cause and target organ damage)

Case Discussion

Encik Ahmad, 56 yr man Non-smoker, no significant p/h otherwise well Not on any drugs no premature CVD Father and one older brother HT

Case Discussion

BMI 25, waist 96 cm Not Cushingnoid No cardiomegaly, no retinopathy, pulses all felt, equal and normal

No renal bruit
No retinopathy

Case Discussion

Tg 1.7 mmol/l total chol 6.2 mmol ldl chol 4.5 mmol

hdl 0.9 mmol/l

FBS 6.1 mmol/l Renal functions: normal Urine: proteinuria 1+ no cells CXR: no cardiomegaly ECG: No LVH

Summary of Encik Ahmad

Essential hypertension Target organ damage: proteinuria Assoc CVD risk: hypercholesterolaemia