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Title: Blood Pressure Classification

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Review Of Management Of Hypertension
By Professor Dr Intekhab Alam Department of
Medicine Lady Reading Hospital, Peshawar
Management of Hypertension
  • Lecture Objectives
  • Define Hypertension (HTN)
  • Learn how to measure blood pressure
  • Understand initial clinical evaluation
  • Identify causes of secondary HTN
  • Describe lifestyle modifications that lower
  • pressure
  • Select appropriate anti-HTN medications
  • Provide appropriate follow-up care

What is Blood Pressure?
  • The primary reason most of us are awake and
    breathing at this very moment in this lecture!
  • BP CO x TPR (CO HR x SV)
  • Stroke volume affected by contractility and
    venous return
  • TPR is regulated by
  • Norepinephrine, Epinephrine, Angiotensin II.

Hypertension Defined
  • Hypertension (HTN) is defined as sustained
    abnormal elevation of the arterial blood
  • (Brashers, 2006, p.1).

  • It is an abnormal and persistent elevation of
  • BP limits are different in children and
  • BP goal is different if you have diabetes or
    chronic kidney disease.
  • Primary (essential) 95 of cases.
  • Secondary 5 of cases.
  • Starting at 115/75 mmHg, CVD risk doubles with
    each increment of 20/10 mmHg throughout the BP

JNC-7 Classification
SBP (mmHg)
DBP (mmHg)
BP Classification
Normal Prehypertension Stage I hypertension Stage
II hypertension
lt 120 120-139 140-159 gt 160
lt 80 80-89 90-99 gt 100
and or or or
Diagnosis of HTN
  • Repeated abnormal elevation of BP using
  • proper technique/cuff on 3 separate occasions
    over at least 6 weeks
  • A single blood pressure gt200/120
  • Keep in mind
  • Risk factors
  • Evidence of end-organ disease

Epidemiology !
  • The most common primary diagnosis in the United
    States, 50 million American affected.
  • Only 70 are aware they have HTN
  • Of those aware of their HTN, only 50 are being
  • Only 25 of all hypertensive patients have their
    BP under control
  • In the year 2000, 167 million people died from
    cardiovascular disease, accounting for 303 of
    all deaths worldwide
  • HTN is a risk factor for coronary artery disease
    (CAD), congestive heart failure (CHF), stroke,
    and renal failure

Prevalence of Hypertension in South Asia
  • More than half of the cardiovascular deaths take
    place in developing countries.
  • South Asia (Pakistan, India, Bangladesh, Nepal,
    and Sri Lanka) represents more than a quarter of
    the developing world, and is likely to be
    strongly affected by the increase in
    cardiovascular disease, for several reasons.
  • First, people from south Asia are known to have a
    high coronary risk this tendency has been well
    recorded in studies of expatriate south Asians
    and has also been shown in native settings.

Prevalence of Hypertension in South Asia
Sex Pakistan 1 India 2,3 Bangladesh 4 Nepal 6 Sri Lanka 5
Men 15-30 Years 17 36.4 9.8 .. 17
Women 15-30 Years 37.5 15.6 .. ..
  • Hypertension classified according to WHO
  • References 1. Pakistan Medical Research Council.
    National Health Survey of Pakistan 1990-94
    health profile of the people of Pakistan.
    Islamabad Network publication service, 1998. 2.
    Gupta R, Gupta VP, Sarna M, et al. Prevalence of
    coronary heart disease and risk factors in an
    urban Indian population Jaipur Heart Watch-2.
     Indian Heart J  2002 54 59-66.  3.Fernandes
    VL, Kottke TE, Nicholas JJ. Tobacco consumption
    and coronary artery disease. In Rao GHR, Kakkar
    VV, eds. Coronary artery disease in South
    Asians., New Dehli Jaypee Brothers, 2001
    147-64. 4. Zaman MM, Yoshiike N, Rouf MA, et al.
    Cardiovascular risk factors distribution and
    prevalence in a rural population of Bangladesh.
     J Cardiovasc Risk  2001 5. 103-08. 5.Mendis S,
    Ekanayake EM. Prevalence of coronary heart
    disease and its risk factors in middle aged males
    in a defined population in central Sri Lanka.
     Int J Cardiol  1994 46 135-42. 6.Pandey MR,
    Neupane RP, Gautam A. Epidemiological study of
    tobacco smoking among adults in a rural community
    of the hill region of Nepal with special
    reference to attitudes and beliefs.  Int J
    Cardiol  1988 17 535-41.

The CVD Situation in Pakistan
  • Pakistan's Hypertension Statistics (NHS)
  • Hypertension is the most common cardiovascular
    disease in Pakistan.
  • There are an estimated 12 million hypertensives
    in the country.
  • Hypertension affects one in three individuals
    over the age of 45 years in Pakistan.
  • Only 3 of the hypertensive population in
    Pakistan is adequately controlled.
  • (The National Health Survey of Pakistan,
    jointly conducted by the Pakistan Medical
    Research Council in collaboration with the
    Federal Bureau of statistics, Pakistan and the
    Department of Health ad Human Services,
    Washington, USA )

Historical Trends in HTN
National Health and Nutrition Examination Survey
Trends in awareness, treatment, and control of
high blood pressure in adults ages 18-74
1991-1994 68 54 27
1976-1980 51 31 10
1988-1991 73 55 29
1994-2000 70 59 34
Awareness Treatment Control
SBP lt 140 mmHg and DBP lt 90 mmHg
Benefits of Lowering BP
  • Sustaining a 12 mmHg reduction in SBP over 10
    years will prevent one death for every 11
    patients treated with Stage I HTN with additional
    CVD risk factors
  • Why to treat HTN?
  • The relationship between BP and CVD is positive
    and continuous.
  • 35-40 ? in stroke morbidity and mortality
  • 20-25 ? CAD events
  • 21 ? vascular mortality
  • 52 ? in CHF
  • 35 ? in LVH

BP Measurement Techniques
Method Brief Description
In-office Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contra lateral arm.
Ambulatory BP monitoring Indicated for evaluation of white-coat HTN. Absence of 1020 BP decrease during sleep may indicate increased CVD risk.
Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate white-coat HTN.
Patient Evaluation
  • Evaluation of patients with documented HTN has
    three objectives
  • Assess lifestyle and identify other CV risk
    factors or concomitant disorders that affects
    prognosis and guides treatment.
  • Reveal identifiable causes of high BP.
  • Assess the presence or absence of target organ
    damage and CVD.

Patient Evaluation
Assess lifestyle and identify other CV risk
factors or concomitant disorders
  • Hypertension
  • Smoking
  • Obesity
  • Physical inactivity
  • Dyslipidemia
  • Diabetes
  • Microalbuminuria or est GFR lt 60 ml/min
  • Age
  • Males gt 55 yrs
  • Females gt 65 yrs
  • Family history of CVD
  • Males lt 55 yrs
  • Females lt 65 yrs

Identifiable Causes of Hypertension
  • Sleep apnea
  • Drug-induced or related causes
  • Chronic kidney disease
  • Primary aldosteronism
  • Renovascular disease
  • Chronic steroid therapy and Cushings syndrome
  • Pheochromocytoma
  • Coarctation of the aorta
  • Thyroid or parathyroid disease

Target Organ Damage
  • Heart
  • Left ventricular hypertrophy
  • Angina or prior myocardial infarction
  • Prior coronary revascularization
  • Heart failure
  • Brain
  • Stroke or transient ischemic attack
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy

Laboratory Tests
  • Routine Tests
  • Electrocardiogram (Look for LVH, CAD, arrhythmia)
  • Urinalysis (Look for protein/blood)
  • Blood glucose, and hematocrit
  • Serum potassium, creatinine, or the corresponding
  • estimated GFR, and calcium
  • Lipid profile, after 9- to 12-hour fast, that
  • high-density and low-density lipoprotein
    cholesterol, and
  • AlbCr ratio Look for microscopic albuminuria.
  • Optional tests
  • Measurement of urinary albumin excretion or
    albumin/creatinine ratio
  • Specialized investigations for secondary
    hypertension not generally indicated unless BP
    control is not achieved or clinically indicated.

Treatment Outline
  • Goals of Therapy
  • Lifestyle modification
  • Classification and management of BP for adults
  • Pharmacologic treatment
  • Compelling indications for individual drug
  • Follow-up and monitoring

Goals of Therapy
  • Reduce CVD and renal morbidity and mortality.
  • Treat to BP lt140/90 mmHg or BP lt130/80 mmHg in
    patients with diabetes or chronic kidney disease.
  • Achieve SBP goal especially in persons gt50 years
    of age.
  • Maintain QOL and Minimize side effects.

Lifestyle Modification
  • Works best in motivated individuals
  • Initiate at prehypertension classification
  • Obesity ? risk for HTN and DM
  • Sodium restriction and other diet aids
  • Usual salt intake 10 gm/d 4 gm Na
  • Reduce to 2.4 gm Na/day
  • Caution salt substitutes contain K
  • Discourage excessive consumption of coffee and
    other caffeine-rich products.
  • Stop smoking and Alcohol consumption.
  • Exercise/Activity
  • 30-40 minutes 3-4x/wk, optimal 5x/wk
  • Stress reduction

Lifestyle Modification
Modification Approximate SBP reduction(range)
Weight reduction 520 mmHg/10 kg weight loss
Adopt DASH eating plan 814 mmHg
Dietary sodium reduction 28 mmHg
Physical activity 49 mmHg
Stopping alcohol consumption 24 mmHg
Pharmacologic Treatment
  • Antihypertensive Drug Classes
  • Diuretics
  • Angiotensin Converting Enzyme Inhibitors (ACEI)
  • Angiotensin II Receptor Blockers (ARB)
  • Beta blockers
  • Calcium Channel Blockers (CCB)
  • Direct Vasodilators

JNC-7 Management of BP for Adults
No compelling indication No drug tx Thiazide
for most 2 drugs combination including thiazide
BP classification Normal Prehypertension Stage
Lifestyle ? Encourage Yes Yes Yes
Compelling indication Drugs targeted for the
compelling indications
lt 120/80
120-139 / 80-89
Drugs targeted for the compelling indications
140-159 / 90-99
Drugs targeted for the compelling indications
gt 160 / gt 100
National Institute for Health and Clinical
Excellence (NICE)
  • NICE is an independent UK based organisation
    responsible for providing national guidance on
    the promotion of good health and the prevention
    and treatment of ill health.

Pharmacological interventions
  • In hypertensive patients aged 55 or older or
    black patients of any age, the first choice for
    initial therapy should either be a
    calcium-channel blocker or a thiazide-type
    diuretic. For this recommendation, black patients
    are considered to be those of African or
    Caribbean descent, not mixed-race, Asian or
  • In hypertensive patients younger than 55, the
    first choice for initial therapy should be an
    angiotensin-converting enzyme (ACE) inhibitor (or
    an angiotensin-II receptor antagonist if an ACE
    inhibitor is not tolerated).

Pharmacological interventions
  • If initial therapy was with a calcium-channel
    blocker or a thiazide-type diuretic and a second
    drug is required, add an ACE inhibitor (or an
    angiotensin-II receptor antagonist if an ACE
    inhibitor is not tolerated). If therapy was
    initiated with an ACE inhibitor (or
    angiotensin-II receptor antagonist), add a
    calcium-channel blocker or a thiazide-type
  • If treatment with three drugs is required, the
    combination of ACE inhibitor (or angiotensin-II
    receptor antagonist), calcium-channel blocker and
    thiazide-type diuretic should be used.

Pharmacological interventions
  • If blood pressure remains uncontrolled on
    adequate doses of three drugs, consider adding a
    fourth and/or seeking expert advice.
  • If a fourth drug is required, one of the
    following should be considered
  • a higher dose of a thiazide-type diuretic or the
    addition of another diuretic (careful monitoring
    is recommended) or
  • beta-blockers or
  • selective alpha-blockers.

Pharmacological interventions
  • If blood pressure remains uncontrolled on
    adequate doses of four drugs, and expert advice
    has not yet been obtained, this should now be
  • Beta-blockers are not a preferred initial
    therapy for hypertension.
  • However, beta-blockers may be considered in
    younger people, particularly
  • those with an intolerance or contraindication to
    ACE inhibitors and angiotensin-II receptor
    antagonists or
  • women of child-bearing potential or
  • people with evidence of increased sympathetic
  • In these circumstances, if therapy is
    initiated with a beta-blocker and a second drug
    is required, add a calcium-channel blocker rather
    than a thiazide-type diuretic to reduce the
    patients risk of developing diabetes.

Pharmacological interventions
  • When a beta-blocker is withdrawn, the dose should
    be stepped down gradually. Beta-blockers should
    not be withdrawn in patients who have compelling
    indications for beta-blockade, for example those
    who have symptomatic angina or who have had a
    myocardial infarction.
  • Offer patients with isolated systolic
    hypertension (systolic BP 160 mmHg or more) the
    same treatment as patients with both raised
    systolic and diastolic blood pressure.
  • Offer patients over 80 years of age the same
    treatment as other patients over 55, taking
    account of any comorbidity and their existing
    burden of drug use.

The Atenolol Debate
  • Meta-analysis of 8 randomized, controlled,
    clinical studies involving atenolol
  • Atenolol vs. placebo (6825)
  • No outcome difference for all-cause mortality, CV
    mortality, or MI
  • Trend for lower risk of stroke (outlier HEP?)
  • Atenolol vs. other antihypertensive (17,671)
  • No major differences with respect to BP control
  • ? mortality, ? trend CV mortality, ? risk of

The Atenolol Debate
  • Authors suggestion for findings
  • Perhaps all B-blockers are not created equal?
  • Atenolol hydrophilic, lacks penetration into
  • Atenolol no benefit in remodeling, endothelial
  • More doom for Atenolol?
  • ASCOT Trial was halted early
  • gt 19,000 patients
  • Atenolol Thiazide vs. Amlodipine Perindopril
  • Results due in March implication thus far for
    greater CV mortality and stroke

Pharmacological interventions
  • Where possible, recommend treatment with drugs
    taken only once a day.
  • Prescribe non-proprietary drugs where these are
    appropriate and minimise cost.

Special Considerations
  • Compelling Indications
  • Compelling Populations
  • Blacks
  • Diabetics
  • Elderly
  • Renovascular disease
  • Pregnancy

Compelling Indications
Compelling Indication Initial Therapy Options
Clinical Trial Basis
Heart failure
Thiazide, BB, ACEI, ARB, ALDO-Ant
ACC/AHA HF Guidelines, Merit-HF, Copernicus,
ACC/AHA Guidelines, BHAT, SAVE, Capricorn, Ephesus
High CAD risk
Thiazide, BB, ACEI, CCB
NKF Guideline, Captopril trial, RENAAL, IDNT,
Recurrent Stroke Prevention
Thaizide, ACEI
Compelling Populations
  • High-Risk Hypertensives
  • Blacks
  • Diabetics
  • Elderly
  • Renovascular disease
  • Pregnancy

  • The single most at risk population with HTN
  • Disproportionately higher rate and more severe
  • Lower plasma renin activity, more Na and
    volume-dependent hypertension
  • Initial tx DIURETICS
  • Second line CCB gt ACEI ARB, B-blockers

  • Direct correlation between systolic BP and
    decline in GFR
  • As little as a 2 mmHg ? BP results in significant
    reductions in CVD (HOT study)
  • Preferred agents ACEI or ARBs

  • Population with the lowest BP control, yet the
    most to gain! Isolated systolic
    hypertension is common
  • Issues polypharmacy, altered drug metabolism,
    physiological changes
  • gt 50 of these patients will require combination
    therapy to achieve goal BP
  • Susceptible to volume depletion orthostatic
  • Cognitive impairment
  • Fixed incomes
  • Low-dose thiazide is drug of choice
  • Additional agent should include CCB or
  • Start low and go slow

Renal vascular Disease
  • ACEI and ARBs
  • In patients with RAS or RA hyperplasia
  • ACEI and ARBs particularly advantageous
  • ? plasma renin and angiotensin activity
  • Caution Rapid and profound drop in BP as well
    as renal failure
  • Avoid in bilateral RAS

  • Almost all cardiovascular drugs are either risk
    category C or D.
  • Chronic/transient hypertension vs. preeclampsia
  • Treatment warranted with DBP gt 100mmHg
  • Problem not much data from controlled clinical
  • Methyldopa, Hydralazine, Diuretics
  • Caution?
  • BB, CCB
  • Avoid

Causes of Resistant HTN
  • Improper BP measurement
  • Excess sodium intake
  • Inadequate diuretic therapy
  • Medication
  • Inadequate doses
  • Compliance
  • Drug interactions
  • OTC/herbals/dietary supplements
  • Excess alcohol intake
  • Identifiable causes of HTN

Public Health Challenges and Community Programs
  • Public health approaches (e.g. reducing calories,
    saturated fat, and salt in processed foods and
    increasing community/school opportunities for
    physical activity) can achieve a downward shift
    in the distribution of a populations BP, thus
    potentially reducing morbidity, mortality, and
    the lifetime risk of an individuals becoming
  • These public health approaches can provide an
    attractive opportunity to interrupt and prevent
    the continuing costly cycle of managing HTN and
    its complications.

Population-Based Strategy
SBP Distributions
Before Intervention
After Intervention
Reduction in BP
Reduction in SBP mmHg 2 3 5
Reduction in Mortality
Stroke CHD Total 6 4 3 8 5 4 14 9 7
Which is the Best StrategyPolypill vs. Polymeal
  • CVD Reduction by 80.
  • Wald et al. BMJ 2003
  • Enalapril 10 mg
  • Thiazide 25 mg
  • Atenolol 25 mg
  • Aspirin 75 mg
  • Atorvastatin 10 mg
  • Folic acid 5 mg
  • CVD Reduction by 75.
  • Franco et al. BMJ 2004
  • Fish 114 g.
  • Walk, 4 times/week
  • Dark chocolate 100 g
  • Fruits and vegetables 400 g
  • Garlic 2.7 g
  • Almonds 68 g

Follow-up and Monitoring
  • Patients should return for follow-up and
    adjustment of medications until the BP goal is
  • More frequent visits for stage 2 HTN or with
    complicating comorbid conditions.
  • Serum potassium and creatinine monitored 12
    times per year.
  • After BP at goal and stable, follow-up visits at
    3- to 6-month.
  • Comorbidities, such as heart failure, associated
    diseases, such as diabetes, and the need for
    laboratory tests influence the frequency of

Continuing treatment
  • The aim of medication is to reduce blood pressure
    to 140/90 mmHg or below. However, patients not
    achieving this target, or for whom further
    treatment is inappropriate or declined, will
    still receive worthwhile benefit from the drug(s)
    if these lower blood pressure.
  • Patients may become motivated to make lifestyle
    changes and want to reduce or stop using
    antihypertensive drugs. If at low cardiovascular
    risk and with well controlled blood pressure,
    these patients should be offered a trial
    reduction or withdrawal of therapy with
    appropriate lifestyle guidance and ongoing

Thankyou very much
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