Hypertension: The Whole Story Raven Voora, MD Hypertension Specialist UNC Kidney Center

Hypertension = elevated blood pressure Category Systolic Blood Pressure Diastolic Blood Pressure Normal < 120 <80 Pre-hypertension 120-139 80-89 Hypertension – Stage 1 140-159 90-99 Hypertension – Stage 2 >160 >100 In 2003, the JNC met and issued a report called JNC 7. This reports guides physicians with respect to the evaluation and treatment of hypertension. According to JNC7, a normal BP is < 120/80. Hypertension is >140/90. In between normal blood pressure and hypertension is a category called pre-hypertension. It is a designation that was created to help identify those patients who may be at greater risk of developing hypertension and in whom you would want to be more aggressive in monitoring/enforcing lifestyle changes. There are 2 stages to hypertension- stage 1 and stage depending on the severity of the reading. Patients with prehypetension should have their blood pressure checked at least yearly. Prehypertension is a warning. Classification of hypertension: JNC 7

Symptoms of Hypertension Hypertension is dangerous because it gives off no warning signs or symptoms Having your blood pressure checked regularly is the only way to tell if your blood pressure is high That’s why it’s called the silent killer

Diagnosis of Hypertension Based upon the average of two or more properly measured readings at each of two or more visits after an initial screen The diagnosis of hypertension should not be based on one office reading. That’s because BP changes from one visit to another. BP should be checked in both arms and the SBP should not vary by more than 15 mm Hg. Nor should your BP decrease too much when you stand (less than 20 mm Hg upright).

White Coat Hypertension Blood pressure is repeatedly normal when measured outside of the provider’s office (home, work) but persistently elevated in the office. This problem is more common in the elderly.

Study took patients with hypertension and found that a new doctor’s visit raised the systolic pressure by 22 mm hg within the first few minutes. When the nurse took the BP, the BP did not go up as much and returned to baseline within 10 minutes but remained elevated in the group who had their BP checked by the physician. BP measurement can create an alerting reaction in certain individuals especially when they are not familiar with the physician or office.

How to Measure Your Blood Pressure Use an automatic monitor Check the accuracy of your home monitor at the doctor’s office Use a monitor with an arm cuff Not a wrist or finger cuff Use a large cuff if you have a large arm After putting on the cuff, sit quietly for a few minutes before checking your pressure

Why do people get hypertension?

Essential vs Secondary Hypertension The majority of patients with hypertension have “essential hypertension” (≈90-95% of cases) Less frequently, there is an underlying condition that may lead to hypertension. This is called “secondary hypertension” (≈5-10% of cases)

Pathogenesis of Essential Hypertension Poorly understood Complex interaction between genetic and environmental factors These factors lead to narrowing of blood vessels If vessels wide open blood flows easily If vessel narrows pressure inside increases causing hypertension

Factors Influencing the Development of Hypertension Uncontrollable Factors Controllable Factors Family History of hypertension Reduced kidney mass at birth African-American ancestry Age Obesity and weight gain Physical inactivity Excess sodium intake Alcohol consumption Hypertension is about twice as common in subjects who have one or two hypertensive parents and multiple studies suggest that genetic factors account for approximately 30% of the variation in blood pressure in various populations. Reduced adult nephron mass may predispose to hypertension which may be related to genetic factors, intrauterine developmental disturbance and post-natal environment. African-Americans have a greater prevalence of hypertension (38% men; 39% of women) than non-Hispanic whites (33% of men; 25% women). The risk of developing elevated BP is 2-6 times higher in overweight than in normal-weight individuals. Physical inactivity increased the risk for hypertension, and exercise is an effective means of lowering blood pressure. Hypertension may be more common among those with certain personality traits such as hostile attitudes and time urgency/impatience as well as among those with depression.

Controllable Factors Influencing the Development of Hypertension Excess sodium intake Certain segments of the population are ‘salt sensitive’ because their blood pressure is affected by salt consumption

Controllable Factors Influencing the Development of Hypertension Alcohol consumption

How Can Hypertension Be Treated?

Treatment of Hypertension Engage in Lifestyle Modifications Avoid Medicines That Can Raise Blood Pressure Take Medications That Can Lower Blood Pressure

Treatment of Hypertension Engage in Lifestyle Modifications Avoid Medicines That Can Raise Blood Pressure Take Medications That Can Lower Blood Pressure

Lifestyle Modifications Maintain a healthy weight, lose weight if overweight. Be more physically active. Drink alcoholic beverages in moderation. Reduce the intake of sodium in the diet to approximately 2400 mg/day. The relationship between obesity and BP appears to be linear and exists throughout the non-obese range. But the strength of the association of obesity with hypertension varies among different racial and ethnic groups. Generally, risk estimates suggest that approximately 75 and 65 percent of the cases of hypertension in men and women, respectively, are directly attributable to an overweight condition and obesity. Most Americans consume about 4,000 - 6,000 mg sodium/day.

Lifestyle Modifications Approximate SBP Reduction Reduce Weight 5-20 mmHg for every 10 kg (22 lb) loss Limit ETOH consumption 2-4 mmHg Reduce Na intake to < 2.4 gm/day 2-8 mmHg Aerobic activity for 30-34 min/day 4-9 mmHg The things you do and the foods you eat have a big effect on your blood presure and overall health. Not only can these things lower your BP, but they can also prvent you from getting hypertension or reduce the need for blood pressure medications. The other benefits: can make certain blood pressure medications work better as well as decrease the risk of kidney, heart disease and stroke.

Not adding salt does not simply mean that you don’t add salt when you are the table or when you are cooking. This only helps a little. Almost all the sodium you get is in the food you buy at the grocery store or at restaurants.

Reading a Food Label for Sodium Content

Food Labels Claim Amount Low Sodium >140 mg/serving Very Low Sodium Sodium Free >5 mg/serving Reduced Sodium 25% less than original Convenience food must be >360 mg/serving individual food or >480 mg/serving meal

Reducing Sodium in the Diet Use fresh poultry, fish and lean meat, rather than canned or processed. Buy fresh, plain frozen or canned with “no salt added” vegetables. When available, buy low- or reduced-sodium or ‘no-salt-added’ versions of foods like: Canned soup, canned vegetables, vegetable juices cheeses, lower in fat condiments like soy sauce crackers and snack foods like nuts processed lean meats

The DASH Diet The Dietary Approaches to Stop Hypertension clinical trial (DASH) Hypothesis: Does a diet rich in fruits, vegetables, and low fat dairy foods lower blood pressure in individuals with hypertension and high normal blood pressure?

DASH Study Control: Fruits and Vegetables Combination: Ca, Mg, & K ~ 25% of US diet Macronutrients and fiber ~ US average Fruits and Vegetables Fruits and vegetables increased to 8.5 servings K and Mg to 75% Combination: Add 2-3 servings low-fat dairy to fruit & vegetable diet. Ca, K and Mg increased to 75%

DASH Study Outcomes Fruit and Vegetable Diet: Combination Diet: Decrease in systolic and diastolic blood pressure in entire study group and in the hypertensive subgroup. Combination Diet: Significant decrease in both systolic and diastolic blood pressure in both groups. Greatest drop was in systolic BP in hypertensive group (11.4 mmHg)

DASH Diet Implications Combination diet affects comparable to pharmacological trials in mild hypertension. Population wide reductions in blood pressure similar to DASH results would reduce CHD by ~ 15% and stroke by ~27% Great potential in susceptible groups: African Americans and elderly.

Treatment of Hypertension Engage in Lifestyle Modifications Avoid Medicines That Can Raise Blood Pressure Take Medications That Can Lower Blood Pressure

Medicines Can Raise Blood Pressure Analgesics NSAIDs, COX-2 inhibitors, Aspirin Decongestants/Allergy Medicines Diet pills Stimulants Methylphenidate Herbals (Ephedra or Ma Huang) Talk with your provider before you take OTC meds, supplments, herbal medicines as these can interact with prescription meds and can also cause hypertension

Treatment of Hypertension Engage in Lifestyle Modifications Avoid Medicines That Can Raise Blood Pressure Take Medications That Can Lower Blood Pressure

Antihypertensive Medications Most common types of medicines used to treat hypertension: “Diuretics” Rid the body of excess fluid and salt “Ace-inhibitors” or “Angiotensin Receptor Blockers” Block hormones that cause arteries to narrow “Calcium channel blockers” Reduce the heart rate and relax blood vessels “Beta blockers” Reduce the heart rate and work of the heart There are many medicines available to treat hypertension. It may take time for your provider to find the dosage or type of medication that is most effective and beneficial for you (and doesn’t cause side effects). Realize that most people need 3 different Blood pressure medications to control their blood pressure. You other health problems may help figure into why you are on a certain medication for your blood pressure rather than another type. The main point is to take your blood pressure medications as directed by your provider. If you are having side effects or can’t afford the medications, then talk with your provider. There are ways to address this but you have to tell your provider first.

Guidelines Have Established Treatment Goals Condition mm Hg Essential HTN < 140/90 Diabetes Mellitus < 130/80 Chronic Kidney Disease <130/80 Age > 65 ???? JNC 7

What new therapies are there?

Control of Hypertension is Not Adequate N = 73.6 million Hypertensive Aware (79%) Treated (69%) Controlled (45%) Uncontrolled (55%) Untreated (10%) Unaware (21%) Nearly 55% of US hypertensive patients do not achieve systolic pressure goal of less than 140/90 mmHg Despite the prevalence of hypertension and its associated complications, control of hypertension is far from adequate. Data from NHANES 2005-6 survey show that only 46 to 51 percent of persons with hypertension have their BP under control, defined as a level below 140/90. There are multiple reasons cited- including physician related reasons in addition to patient related reasons Based on Data from NHANES/NCHS 2005-6

Renal Denervation ABLATION OF RENAL SYMPATHETIC NERVES 35 35

Baroreflex Activation Therapy ELECTRICAL STIMULATION OF CAROTID SINUS BARORECEPTORS

Remember …. Hypertension is a lifelong disease. It can be controlled, not cured Know your blood pressure. Have it checked regularly Maintain a healthy lifestyle If you do have hypertension, take your medications as prescribed

Questions? From all the things I discussed today, what can you do to help control your blood pressure? What is most important for you and how can you make that part of your routine?