Hypertension Dr. Indranil Das PGT(Final year)Department of Community Medicine Burdwan Medical College

Hypertension is the commonest cardiovascular disorder posing a major public health challenge. Sir George Pickering first formulated a concept that blood pressure is distributed continuously in a bell shaped curve with no real separation between normotension and hypertension

Prevalence: Prevalence is increasing day by day. Tracking of Blood pressure: Those individuals whose BP was initially high would probably continue the same track as adults. This phenomenon of persistence of rank order of BP has been described as “tracking”

Hypertension is an iceberg disease. Rule of halves: Only about half of the hypertensive subjects are aware of the condition, only about half of those aware were being treated & only about half of those treated were adequately treated.

Risk factors of hypertension 1.Non-modifiable risk factors: a)Age: DBP is a more potent cardiovascular risk factor than SBP until age 50;thereafter, SBP is more important. b)Sex: In early life little difference Higher level in men during adolescence and adulthood Late in life the difference narrows and situation may even be reversed.

c)Genetic Factors: Twin studies have confirmed the importance BP levels among first degree relatives have also been noted to be statistically significant. d)Ethnicity: Black Americans of African origin have been found to have high BP.

2. Modifiable risk factors: a)Obesity: greater the weight gain greater the risk of high BP. Central obesity has been positively correlated with high BP in several population. b)Salt intake: High salt intake(7-8gm/day) increases BP proportionately Potassium antagonizes the biological effect of sodium and there by reduces BP. c)Saturated fat: raises both BP and cholesterol d)Dietary fibre: Risk of CHD and hypertension is inversely related to the consumption of dietary fibre. e)Alcohol: High alcohol intake is associated with increased risk of BP.

f)Heart rate: Heart rate of hypertensive group were higher. g)Physical Activity: Reducing body weight, hypertension can be reduced. h)Environmental stress: Over activity of the sympathetic system increases risk of hypertension i)Socio-economic factor: Both in upper & lower S E group.

Measurement of BP The auscultatory method of BP measurement should be used. Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level. Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. An appropriately sized cuff (cuff bladder encircling at least 80 percent of the arm) should be used to ensure accuracy. At least two measurements should be made and the average recorded. For manual determinations, palpated radial pulse obliteration pressure should be used to estimate SBP—the cuff should then be inflated 20–30 mmHg above this level for the auscultatory determinations; the cuff deflation rate for auscultatory readings should be 2 mmHg per second. SBP is the point at which the first of two or more Korotkoff sounds is heard (onset of phase 1), and the disappearance of Korotkoff sound (onset of phase 5) is used to define DBP.

Classification of BP measurement (WHO Guideline) CATEGORYSBP(mmHg)DBP(mmHg) Normal<130<85 High Normal Hypertension Stage Stage Stage

Classification of hypertension: (Based on JNC - 7 criteria) Normal- Systolic and diastolic < 120/80 Prehypertension: systolic or diastolic mm of Hg Stage-1 hypertension: systolic or diastolic mm of Hg Stage-2 hypertension: systolic ≥ 160 or diastolic ≥ 100 mm of Hg

Various forms of Hypertension: Essential Hypertension/Primary Hypertension/Idiopathic Hypertension: No definable causes are present. Secondary Hypertension: Individuals in whom a specific structural organ or gene defect is responsible for hypertension Isolated Systolic Hypertension: Defined by systolic BP≥140mmHg together with a normal diastolic BP. White Coat Hypertension: Persistently higher BP when measured by a professional in the office than when measured at home. Accelerated Hypertension: Significant recent increase in BP over previous hypertensive levels associated with evidence of vascular damage on fundoscopic examination but without papilledema.

Organ Damage Left ventricular hypertrophy Genralised and focal narrowing of retinal arteries Micro-albuminuria,protienuria and/or slight elevation of plasma creatinine When BP range is more than >180/110 symptoms and signs have appeared as signs of organ damage. Heart: Angina pectoris Myocardial infarction Heart failure Brain: Stroke Transient Ischaemic attack Hypertensive Encephalopathy Vascular Dementia Optic Fundi: Retinal haemorrhages and exudates with or without papilloedema Kidney: CKD Vessel: Dissecting aneurysm Peripheral vascular disease

PREVENTION OF HYPERTENSION A.Primary prevention: a)Population Strategy: BP towards the lower level of biological normality. 1.Nutrition: Reduction of salt intake to an average of not more than 5gm/day Moderate fat intake Avoidance of high alcohol intake Restriction of energy intake appropriate to body needs Fruit and vegetable intake

2.Weight reduction: Keeping the BMI within normal range; ideal is to maintain normal body weight. 3.Exercise promotion: Regular physical exercise of at least 30mins/day for 5 days in a week. 4.Behavioural changes: Reduction of smoking, stress. 5.Health Education : Preventive advice on all risk factors 6.Self-care: Maintaining log book of his readings of BP

b)High-risk strategy: The family history of hypertension and tracking of BP from childhood helps to detect the individual at risk.

B.Secondary prevention: a)Early case detection : Early case detection is problem---- High BP rarely causes symptoms until organ damage has already occurred. The only effective method is screening.

b)Treatment: Goals of Therapy The ultimate public health goal of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality. Since most persons with hypertension, especially those >50 years of age, will reach the DBP goal once the SBP goal is achieved, the primary focus should be on attaining the SBP goal. Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications. In patients with hypertension and diabetes or renal disease,the BP goal is <130/80 mmHg

Treatment Algorithm Life Style Modification Not controlled Stage 1 Stage 2 Thiazides Two drug combination (one of which should be thiazide)

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