Dr. Anil Ballani M.D.

Consultant PhysicianHinduja Hospital

HYPERTENSION

Hypertension – Silent Killer

• Silent killer because it produces no symptoms till late stages

• Major misconception that with hypertension patient should have headache, giddiness, etc.,

• Most of these symptoms come up only when the B.P. reaches above 180 mm Hg

• The incidence of Hypertension in community is almost 30-40%

• As age increases the incidence of hypertension also increases exponentially

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HYPERTENSION

The Truth is

It is only a marker of the bigger problem

Hypertension is a multi-organ systemic disease

What we record as B.P.

The Problem is

Hypertension is asymptomatic in 85% of cases

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How to be wise in HT?

The Truth is

To consider Hypertension as an isolated disease

Hypertension, DM, Dyslipidemia, Obesity often coexist

They are the 4 pallbearers to the grave of CHD, CVD

For all of them

Primary and secondary prevention by TLC is the answer

Afflicted with one, must be screened for all other thieves

It is wrong

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Treatment Goal

The Truth is

Keep B.P. < 140/90 mm Hg in each patient

This may be revised to 120/80 may be ? 110/70

MRFIT’s cut off values are 115/75 mm Hg

It is essential to keep the B.P at or below the goal

But, It also matters how the goal B.P. is achieved !

Goal BP

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Definitions

As per JNC VII and ISH (WHO) 2004

1. What is normal B.P ?

Normal SBP < 120 and DBP < 80

2. What is pre hypertension ?

Pre HT SBP 120 to 139 mm HgDBP 80 to 99 mm Hg

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Definitions

1. What is stage 1 HT ?

2. What is stage 2 HT ?

Stage 1 SBP 140 to 159 DBP 90 to 99

Stage 2 SBP 160 and moreDBP 100 and more

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JNC VII Classification

CategoryCategory SBP (mm Hg)SBP (mm Hg) DBP (mm Hg)DBP (mm Hg)

Normal < 120 < 80

Pre – hypertension 120-139 80-90

Hypertension

Stage 1 140 – 159 90 – 99

Stage 2 160 and above 100 and above

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Definitions

Are the values same for Diabetics , CKD?

No, for DM, IHD and CKD the criteria are more stringent

The cut off values are 10 mm lower

Stage 1 SBP 130 to 149 DBP 80 to 89

Stage 2 SBP 150 and moreDBP 90 and more

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Rule of Halves

What is this rule of halves in HT ?

• For every 800 adults in the community• 400 are HT (either ↑ SBP or ↑ DBP or both)• Of them only 200 are diagnosed HT• Of them only 100 are started on treatment• Of them only 50 are on correct drug• Of them in only 25 the goal B.P. is attained• Means 25 ÷ 400 = 6% only have goal BP

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Normotensives (78%)Normotensives (78%)

Hypertensives (22%)

Under control (40%)

(7.5% of the total hypertensives)

Uncontrolled hypertension

(60%)

Diagnosed HT

Diagnosed HT Under

treatment (50%)

Under treatment

(50%)

Undiagnosed HT

How many are really Dx. and Rx.ed ??

37%

63%

Un Rx. HT

A study from Europe on 23,339 patients

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Isolated Systolic Hypertension

1. What is ISH ? –

2. What percentage of 65+ aged have ISH ?

3. Which is more harmful – ↑ SBP or DBP ?

4. Why is ISH important ?

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Isolated Systolic Hypertension

1. What is ISH ? – SBP 140+ , DBP < 90

2. What percentage of 65+ aged have ISH ?More than 90%

3. Which is more harmful – ↑ SBP or DBP ?Of course ↑ SBP

4. Why is ISH important ? Because of ↑↑ CVA and CHD mortality

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For adequate control of B.P.

Do you think we can control most of thepatients of hypertension with –

One drugTwo drugsThree drugsCan’t control

In most of the patients of hypertension Two drugs are required for adequate controlMore so if the initial BP is 20/10 above the goal

TODAY’S PARADIGM

Gone are the days of monotherapy

It is the era of combination therapy

Why is it so?

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Dr.Sarma@works 16

Global Risk Profile and HT

25)

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Diseases Attributable to Hypertension

Hypertension

Heart failureStroke

Coronary heart disease

Myocardial infarction

Left ventricular hypertrophy

Aortic aneurysm

Retinopathy

Peripheral vascular disease

Hypertensive encephalopathy

Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.

AllVascular

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Target Organ Damage (TOD)

• Heart Left ventricular hypertrophy (LVH)Angina or prior myocardial infarction (CHD)Prior Coronary revascularization PTCA or

CABGHeart failure (Systolic / Diastolic dysfunction)

• Brain CVA Stroke or Transient Ischemic Attack (TIA)

• Kidney : Chronic kidney disease and CRF• Vessels : Peripheral arterial disease PVD• Eyes : Hypertensive Retinopathy

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Target Organ Damage - Assessment

Routine Tests• Electrocardiogram, Echocardiography (desirable) • Urinalysis for proteinuria, Microalbuminuria• Blood glucose (F and PP), and Hematocrit • Serum Na and K, Creatinine or GFR, Calcium• Lipid Profile complete, Eye examination, ABIOptional tests • X-Ray Chest PA• 24 hr. urine albumin excretion or ACR• More extensive testing is not generally indicated

Ambulatory Blood Pressure Monitoring - ABPM

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1. 24 hour B.P monitoring (every 15 minutes)2. Today - 24 hour B.P. control is essential3. Identifies dippers and non-dippers4. Excludes white coat hypertension

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What is MOST essential ??

Not that ‘my drug is superior to yours’

Not that ‘this trial is better than that’

Nor ‘this combination is better than that’

But to get AS MANY PEOPLE as we can to goal SBP < 140 & DBP < 90

And prevent or halt TOD. Of course, tailor the treatment as per

individual patient’s co-morbidities.

So, What is new in Hypertension ?

1. High B.P recorded is only a clinical marker disease

2. HT is a multi-organ disease, often asymptomatic

3. Not to consider in isolation- Must look for ‘Co-Thieves’

4. Today’s goal BP is 140/90 – It will sure be less tomorrow

5. It matters to attain goal; matters more how it is attained

6. In DM, CKD, IHD the cut off values are 10 mm less

7. Remember rule of ½ in HT– Adequate control only in 7%22

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Lifestyle Modification

Modification Approximate BP reduction(range)

Weight reduction 5–20 mm/10 kg wt loss

Adopt DASH eating plan 8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Abstinence from alcohol 2–4 mmHg

All put together reduce BP by 20 to 55 mmHg

DASH

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Dietary Approach to Stop Hypertension

1.Eating more fruits, vegetables, high fiber diet and low fat dairy foods

2.Reduce fried food, red meat, organ meat, sweets, direct sugars and bakery products

3.More whole grain products, fruits, nuts (almonds & walnuts)

4.Approximately 1 tsp. of salt/ day, which is 6gms or 2400mg of salt/ day

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Hypertension – Why Combinations ?

If goal BP is not achieved by a single drug in full dose

Then adding another agent will help achieve the goal BP

Two agents sometimes nullify each others side effects

Fixed dose combinations will reduce the no. of tablets

Once daily formulations are good for compliance

Sustained release or LA formulations for 24 h BP control

If three drugs can’t achieve goal BP – Resistant HT

Thank You!!

For any query, write us on- info@hindujahospital.com