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

2. Hypertension = elevated blood pressure
Category
Systolic Blood Pressure
Diastolic Blood Pressure
Normal
< 120
<80
Pre-hypertension
80-89
Hypertension – Stage 1
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

3. 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

4. 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).

5. 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.

6. 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.

7. 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

8. Why do people get hypertension?

9. 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)

10. 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

12. 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.

13. 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

14. Controllable Factors Influencing the Development of Hypertension
Alcohol consumption

15. How Can Hypertension Be Treated?

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

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

18. 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 mg sodium/day.

19. 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 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.

20. 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.

21. Reading a Food Label for Sodium Content

22. 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

23. 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

24. 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?

25. 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%

26. 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)

27. 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.

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

29. 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

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

31. 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.

32. 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

33. What new therapies are there?

34. 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 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

35. Renal Denervation
ABLATION OF RENAL SYMPATHETIC NERVES 35 35

36. Baroreflex Activation Therapy
ELECTRICAL STIMULATION OF CAROTID SINUS BARORECEPTORS

37. 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

38. 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?