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  1. Hypertension

  2. Hypertension is one of the most important preventable causes of premature morbidity and mortality. • Hypertension is a major risk factor for • ischaemicand haemorrhagicstroke • myocardial infarction, • heart failure, • chronic kidney disease, • cognitive decline • premature death. • Untreated hypertension is usually associated with a progressive rise in blood pressure. • The vascular and renal damage that this may cause can culminate in a treatment-resistant state.

  3. By the end of this session the learner should be able to: • Know the prevalence of hypertension in the Saudi society • Recognize the risk factors for developing HTN • Understand the recent guidelines for the diagnosis of hypertension • Measure blood pressure following recommended steps. • Understand the recent guidelines for the management of hypertension • Understand the best practice approach to patients with hypertension in the clinic • Understand and list the complications of untreated hypertension

  4. There are 972 million persons worldwide with hypertension • It is the fourth leading cause of the global • burden of disease. Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J ClinHypertens (Greenwich). 2009; 11:66–73.

  5. Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J ClinHypertens (Greenwich). 2009; 11:66–73.

  6. Hypertension in Saudi Arabia. Al-Nozha MM, Abdullah M, Arafah MR, Khalil MZ, Khan NB, Al-Mazrou YY, Al-Maatouq MA, Al-Marzouki K, Al-Khadra A, Nouh MS, Al-Harthi SS, Al-Shahid MS, Al-Mobeireek A. OBJECTIVE: To determine the prevalence of hypertension among Saudis of both gender, between the ages of 30-70 years in rural as well as urban communities. This work is part of a major national study on Coronary Artery Disease in Saudis Study (CADISS). METHODS: This is a community-based study conducted by examining subjects in the age group of 30-70 years of selected households during a 5-year period between 1995 and 2000 in Saudi Arabia. ………. Saudi Med J. 2007 Jan;28(1):77-84.

  7. RESULTS: The total number of subjects included in the study was 17,230. The prevalence of hypertension was 26.1% in crude terms. For males, the prevalence of hypertension was 28.6%, while for females; the prevalence was significantly lower at 23.9% (p<0.001). The urban population showed significantly higher prevalence of hypertension of 27.9%, compared to rural population's prevalence of 22.4% (p<0.001). The prevalence of CAD among hypertensive patients was 8.2%, and 4.5% among normotensive subjects (p<0.001). Increasing weight showed significant increase in prevalence of hypertension in a linear relationship. Saudi Med J. 2007 Jan;28(1):77-84.

  8. CONCLUSION: Hypertension is increasing in prevalence in KSA affecting more than one fourth of the adult Saudi population. We recommend aggressive management of hypertension as well as screening of adults for hypertension early to prevent its damaging consequences if left untreated. Public health awareness of simple measures, such as low salt diet, exercise, and avoiding obesity, to maintain normal arterial blood pressure need to be implemented by health care providers. Saudi Med J. 2007 Jan;28(1):77-84

  9. Saudi Arabia 2010 total population: 27 448 086 World Health Organization - NCD Country Profiles , 2011.

  10. Diagnosis

  11. Definitions • Stage 1 hypertension Clinic blood pressure is 140/90 mmHg or higher and subsequent ambulatory blood pressure monitoring (ABPM) daytime average or home blood pressure monitoring (HBPM)average blood pressure is 135/85 mmHg or higher. • Stage 2 hypertension Clinic blood pressure is 160/100 mmHg or higher and subsequent ABPM daytime average or HBPM average blood pressure is 150/95 mmHg or higher. • Severe hypertension Clinic systolic blood pressure is 180 mmHg or higher, or clinic diastolic blood pressure is 110 mmHg or higher. NICE clinical guideline 127

  12. Measuring blood pressure

  13. Measuring blood pressure provide a relaxed, temperate setting, with the person quiet and seated, and their arm outstretched and supported. palpate the radial or brachial pulse before measuring blood pressure. If pulse irregularity is present, measure blood pressure manually using direct auscultation over the brachial artery If using an automated blood pressure monitoring device, ensure that the device is validated and an appropriate cuff size for the person’s arm is used. When considering a diagnosis of hypertension, measure blood pressure in both arms. If the difference in readings between arms is more than 20 mmHg, repeat the measurements

  14. Measuring Blood Pressure

  15. Pt approach and Management Historically, hypertension was often treated as an isolated symptom, with 1 or 2 drugs such as diuretics and⁄ or b-blockers as first-step treatment( to decrease the blood pressure level) Actually : The goal of antihypertensive treatment is to decreasethe total cardiovascular risk, which results from the coexistence of different risk factors, organ damage, and disease such as type 2 diabetes. Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J ClinHypertens (Greenwich). 2009; 11:66–73.

  16. Pt approach and Management Patient factors contribute to uncontrolled BP in at least 50% of the population with treated hypertension. It is also well known that some suboptimal results have a great deal to do with physician inertia, the act of not increasing therapy (dose or number of antihypertensive drugs) or not starting therapy in patients with increased BP. Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J ClinHypertens (Greenwich). 2009; 11:66–73.

  17. For all people with hypertension offer to: -Test for the presence of protein in the urine by sending a urine sample for estimation of the albumin:creatinine ratio and test for haematuria using a reagent strip -Take a blood sample to measure plasma glucose, electrolytes, creatinine, estimated glomerular filtration rate, serum total cholesterol and HDL cholesterol -Examine the fundi for the presence of hypertensive retinopathy -Arrange for a 12-lead electrocardiograph to be performed.

  18. Treatment algorithm for patients with newly diagnosed hypertension NICE hypertension guideline,2011

  19. Classification and management of blood pressure for adults aged 18 years or older

  20. Lifestyle modifications in the management of hypertension

  21. JNC 8- 2014 Recommendation 1 In the general population aged 60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP)150 mmHg or diastolic blood pressure (DBP)90mmHg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A)

  22. Recommendation 2 In the general population <60 years, initiate pharmacologic treatment to lower BPatDBP90mmHg and treat to a goal DBP<90mmHg. (For ages 30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Expert Opinion – Grade E)

  23. Recommendation 3 In the general population <60 years, initiate pharmacologic treatment to lowerBPatSBP140mmHg and treat to a goal SBP <140mmHg. (Expert Opinion – Grade E)

  24. Recommendation 4 In the population aged 18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lowerBPatSBP140mmHgorDBP90 mmHg and treat to goal SBP<140mmHgandgoalDBP<90mmHg. (Expert Opinion – Grade E)

  25. Recommendation 5 In the populationaged18years with diabetes, initiate pharmacologic treatment to lower BP at SBP 140mmHgorDBP90mmHgandtreat to a goal SBP <140mmHg and goal DBP <90mmHg. (Expert Opinion –Grade E)

  26. Recommendation 6 In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommendation – Grade B)

  27. Recommendation 7 In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation –Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

  28. Recommendation 8 In the population aged18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKDpatientswith hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)

  29. If goal BPis not reached within amonth of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation6( thiazide-type diuretic,CCB,ACEI, or ARB).

  30. Complication of untreated hypertension • Hypertension is quantitatively the major risk factor for premature cardiovascular disease • Hypertension increases the risk of heart failure at all ages with the hazard increasing with the degree of blood pressure elevation • Left ventricular hypertrophy is a common problem in patients with hypertension

  31. Complication of untreated hypertension • Hypertension is the most common and most important risk factor for stroke • Hypertension is the most important risk factor for the development of intra-cerebral hemorrhage • Hypertension is a risk factor for chronic kidney disease and end-stage renal disease

  32. Hypertension Prevention • Hypertension Prevention include: • Maintaining a healthy weight; • Being physically active; • Following a healthy eating plan, that emphasizes fruits, vegetables, and low fat dairy foods; • Choosing and preparing foods with less salt and sodium; • Stop alcoholic beverages, • Stop smoking

  33. Clinical cases

  34. Case 1 • Hamadis a 48-year-old clerk who sees you occasionally for a recurrent cough and upper respiratory tract infections. • He has no significant past medical history, is taking no medicines • has no known allergies, he is a regular smoker and has been since his teens. • He has come to see you for another cold that has gone to my chest . Vital observations are: • temperature 37°C • Pulse rate 78, regular • blood pressure (BP) 148/94 mmHg • repeat BP 144/92 mmHg..

  35. Does he have hypertension? He may have hypertension, because his BP measurements are in the abnormal hypertension range. However, the diagnosis of hypertension should be based on multiple BP measurements taken on separate occasions.

  36. Does he need BP-lowering medicine? Before deciding whether or not to prescribe BP-lowering medicine, confirm that he has hypertension. BP should be measured on a subsequent visit, by the nurse to minimize the white coat effect. If hypertension is confirmed from multiple BP measurements, medical history should be recorded and he should be examined for, and investigations done to see if he has, cardiovascular disease (CVD) or target organ damage. In the absence of CVD or target organ damage, you should formally calculate Bill s absolute risk score.

  37. Does he need BP-lowering medicine? Regardless of whether the absolute risk is low, medium or high: you should recommend: Behavioral modification as the basis of his hypertension management (e.g. life style changes) and to reduce his risk of CVD (smoking cessation).

  38. What should be the first choice hypertension drug treatment? Choice of first line medicine is driven by relative and absolute indications or contraindications, according to co-morbidity. Consider the possibility that he has chronic obstructive pulmonary disease (COPD) and avoid prescribing a beta-blocker. An appropriate medicine is a low-dose ACE-inhibitor, Angiotensin II receptor blocker (ARB) or calcium channel blocker (CCB).

  39. What BP should I aim to get Bill to? Diagnostic and therapeutic BP goals vary according to a patient s risk status. This is because the greater the risk, the greater the benefit of lowering BP and the greater the residual risk if goals are not met. If he had evident CVD, diabetes and/or significant renal disease, his target would be lower (130/80).

  40. Case 2 A 55-year old female schoolteacher with BP of 170⁄105 mm Hg Had type 2 diabetes diagnosed 5 years ago, treated with diet and an OHA. She exhibits diabetic nephropathy with microalbuminuria and a slight decrease in glomerular filtration rate, a low level HDL, Abdominal obesity, sedentary lifestyle, HBA1C >7.5%.

  41. she exhibits at least 3 risk factors, including type 2 diabetes and Established renal disease in addition to hypertension, she is considered at very high risk for CVD. The target is to decrease her BP to <130⁄80 mm Hg to manage the diabetes

  42. Recommendations for this patient include: A change in lifestyle, with exercise, weight loss, reduced salt consumption, and reduced saturated fat intake. Treatment options include antidiabetic agents (OHA) together with antihypertensive drugs. According to the results of the trials, it would appear that an ACEI or an ARB should be part of the treatment regimen, and the addition of a CCB may be the best choice. Diureticsor b-blockers may not be appropriate in patients with type 2 diabetes and associated renal disease.

  43. Recommendations for this patient In ALLHAT, however, diabetic patients had a favorable outcome with a diuretic as well as with an ACEI or CB. Thus, an RAAS inhibitor and a diuretic may also be appropriate. Due to her very high–risk profile, this patient should first receive the minimum dose of each drug, but doses could rapidly be titrated higher if the BP target is not adequately reached within a few weeks of treatment, and then possibly a third drug could be added.

  44. References 1- Overview of hypertension in adults, UpToDate®www.uptodate.com 2- Farsang C; Naditch-Brule L; Avogaro A; Where Are We With the Management of Hypertension? From Science to Clinical Practice J ClinHypertens (Greenwich). 2009; 11:66–73. 3- Woolf K J, Bisognano J D; Nondrug Interventions for Treatment of HypertensionJ ClinHypertens (Greenwich). 2011;13:829–835. (interesting) 4- Garcia-Touza M, Sowers J R; Evidence-Based Hypertension Treatment in Patients With Diabetes, J ClinHypertens(Greenwich). 2012;14:97–102 (conclusion part)