2. Lessons from Hypertension guidelines :
Treatment Of Hypertension

3. BY
PROF.DR.
KAMAL
MAHMOUD
AHMAD

4. MEDICAL RESEARCH INSTITUTE
HEAD OF
THE CARDIOLGY UNIT
MEDICAL RESEARCH INSTITUTE
ALEX. UNIVERSITY

5. Hypertension even today is a triple
paradox which is:
Easy to diagnose OFTEN remains undetected
Simple to treat OFTEN remains untreated
Despite availability of potent drugs, treatment is too OFTEN ineffective

6. Guidelines European Society of Hypertension
European Society of Cardiology
JNC 7
Canadian Guidelines
Egyptian Guidelines

8. Relationship of Hypertension to Its Comorbidities
Comorbidity
Relationship to Hypertension
Coronary artery disease
50% of patients with coronary artery disease have hypertension
Left ventricular hypertrophy
15% to 20% of hypertensive adults have an increased left ventricular mass
Ischemic stroke
77% of patients who have a first stroke have a blood pressure >140/90 mm Hg
Chronic kidney disease
8% to 15% of hypertensive adults have decreased renal function
Diabetes
75% of added cardiovascular risk in diabetic patients is attributable to hypertension
Peripheral artery disease
74% of patients with peripheral artery disease have hypertension
Relationship of Hypertension to Its Comorbidities
Most studies that have examined the relationship between hypertension and its comorbidities have compared outcomes between hypertensive and normotensive subjects. Determining how many individuals with primary hypertension will develop each of the comorbidities or will have identifiable precursors for them has been difficult and limited. This table summarizes some relevant findings.
Note: Hypertension occurs less than 20% of the time without one or more of the following risk factors: high levels of triglycerides and low-density lipoprotein cholesterol; reduced levels of high-density lipoprotein cholesterol; glucose intolerance; hyperinsulinemia; obesity; metabolic syndrome; and left ventricular hypertrophy.
References:
Diamond JA, Phillips RA. Hypertensive heart disease. Hypertens Res. 2005;28:
El-Atat F, McFarlane SI, Sowers JR. Diabetes, hypertension, and cardiovascular derangements: pathophysiology and management. Curr Hypertens Rep. 2004;6:
Kannel WB. Risk stratification in hypertension: new insights from the Framingham study. Am J Hypertens. 2000;13(Pt 2):3S-10S.
Pepine CJ. Systemic hypertension and coronary artery disease. Am J Cardiol. 1998;82:21H-24H.
Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:
Segura J, Campo C, Garcia-Donaire JA, Ruilope LM. Development of chronic kidney disease in essential hypertension during long-term therapy. Curr Opin Nephrol Hypertens. 2004;13:
Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation. 2004;110:
Rosamond W, et al. Circulation. 2007;115:69-171;

9. MAGNITUDE OF THE PROBLEM IN EGYPT
· Hypertension is a major health problem in Egypt with a prevalence rate of 26.3% among the adult population (> 25 years) .
Its prevalence increases with aging, pproximately 50% of Egyptians above the age of 60 years
suffer from hypertension. .

10. 1940 patients Egyptian HTN Physician & Patient Survey*
*M. Mohsen Ibrahim -

11. Causes of Discontinuation of The Drugs
Poor understanding of the magnitude of the risk.
Poor communication (doctor-patient)
Patient forgetfulness.
Lack of motivation.
Logistic barrier ..Cost.
Side effects.
Complex regimen.
Poor follow up.

12. Blood Pressure Classification
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139 or
80–89
Stage 1 Hypertension
140–159 or
90–99
Stage 2 Hypertension
>160 or
>100

13. BHS classification of blood pressure levels
bhs guidelines 2004.boeh-ingel
BHS classification of blood pressure levels 13

14. Appropriate BP measurement 2008
Allow the patients to relax for several minutes
Take at least two measurements spaced by 1-2 min and additional measurements if the first two are quite different [use phase I and V (disappearance) Korotkoff sounds to identify SBP and DBP]
Use a standard bladder but have a larger for fat arms and a smaller one for thin arms and children
Have the cuff at the heart level
Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease. In this instance, take the higher value as the reference one
Measure BP 1 and 5 min after assumption of the standing position in elderly subjects, diabetic patients and in other conditions in which postural hypotension may be frequent or suspected (e.g. heart, renal failure, SNS dysfunction, use of vasodilative agents)

16. Self-measurement of BP at home should be encouraged
Home BP measurements
Self-measurement of BP at home should be encouraged
Response to antihypertensive therapy
Improving adherence with therapy
Evaluating white-coat HTN
On the contrary, Self-measurement of BP should be discouraged when:
it causes anxiety to the patient
it induces self-modification of the treatment regimen

17. Ambulatory BP Monitoring
ABPM is warranted for evaluation of “white-coat” HTN in the absence of target organ injury.
Ambulatory BP values are usually lower than clinic readings.
Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.
BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.

18. 24-Hour Blood Pressure
(n = 19)

20. Physical examination for secondary hypertension
Signs suggesting secondary hypertension
Features of Cushing syndrome
Skin stigmata of neurofibromatosis (phaeochromocytoma)
Palpation of enlarged kidneys (polycystic kidneys)
Auscultation of abdominal murmurs
(renovascular hypertension)
Auscultation of precordial or chest murmurs; Diminished and delayed femoral pulses femoral BP
(aortic coarctation or aortic disease)

22. Laboratory Tests Routine Tests Electrocardiogram Urinalysis
Blood glucose, and hematocrit
Serum potassium, creatinine, or the corresponding estimated GFR, and calcium
Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides
Optional tests
Measurement of urinary albumin excretion or albumin/creatinine ratio
More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

24. Blood pressure target values for treatment of hypertension
II. Goals of Therapy
Blood pressure target values for treatment of hypertension
Condition
Target
SBP and DBP mmHg
Isolated systolic hypertension
<140
Systolic/Diastolic Hypertension
• Systolic BP
• Diastolic BP
<90
Diabetes or Chronic Kidney Disease
• Systolic
• Diastolic
<130
<80 24

25. Lifestyle Recommendations for Prevention and Treatment of Hypertension

26. To reduce the possibility of becoming hypertensive,
Reduce sodium intake to less than 2300 mg / day
Healthy diet: high in fresh fruits, vegetables, low fat dairy products, dietary and soluble fiber, whole grains and protein from plant sources, low in saturated fat, cholesterol and salt in accordance with Canada's Guide to Healthy Eating.
Regular physical activity: accumulation of minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk) 4-7/week in addition to routine activities of daily living
Maintenance of ideal body weight (BMI kg/m2)
Waist Circumference Men Women
- Europid, Sub-Saharan African, Middle Eastern <94 cm <80 cm
- South Asian, Chinese <90 cm <80 cm
- Japanese <85 cm <90 cm
Smoke free environment 26