1. Sunday 23 October 2011
421 Primary Health Care Course
Under the supervision of
Dr. Hussein Saad

2.  Definition of BP
 Epidemiology of HT
 Diagnosis of HT
 Measuring & confirming of HT
 Approach to hypertensive patients
 Risk factors of HT
 Complications of HT
 Lowering & prevention of HT
 Investigation
 Management
 Highlights
 Cases

3. The pressure of blood flowing through your blood vessels
against the vessel walls
Systolic BP: during heart
beat “written on top”
Diastolic BP: during heart
relaxation “written on
bottom”

4.  It is a sustained elevated blood pressure more
than 140 mmHg systolic and more than 90 mmHg
diastolic

5.  World epidemiology:
Based on data collected in the 1999 to 2000 National Health
and Nutrition Examination Survey (NHANES), the estimated
overall prevalence of hypertension in 2000 was 28.7%. Among
1565 participants with hypertension, 68.9% were aware of the
problem, and 58.4% were under pharmacological treatment.
Overall, only 31.0% of individuals had hypertension controlled
to a blood pressure of <140 mm Hg systolic and 90 mm Hg
diastolic. This figures implies that >40 million adults have
uncontrolled hypertension in the United States.
Us epidemiology: Hajjar I, Kotchen TA. Trends in prevalence, awareness, treatment, and control of hypertension in the United
States, 1988–2000. JAMA. 2003; 290: 199–206 .

6.  KSA epidemiology :
In Saudi Arabia at a recent study
it was found that the prevalence
of hypertension was found to be 26.1% in general in subjects
between 30 to 70.
prevalence in males was at 28.6 %.
In females it was at 23.9 %.
Prevalence of CAD between hypertensive subjects was 8.2 %.
In normotensive patients it was 4.5 %.
ksa epidemiology : Al-Nozha MM, Abdullah M, Arafah MR, et al. Hypertension in Saudi Arabia. Saudi Med J. 2007
Jan;28(1):77-84.

7.  4758 subjects participated in recent study.
 51% was female.
 The prevalence was 25.5%.
 27.1% males, 23.9% females.
 55.3% of the patients were unaware of their
disease.(5)
 Abdalla A. Saeed, Nasser A. Al-Hamdan, Ahmed A. Bahnassy, et al. Prevalence, Awareness, Treatment, and
Control of Hypertension among Saudi Adult Population: A National Survey. International Journal of Hypertension.
Volume 2011 (2011): 8.

8. The American Heart Association has
recommended guidelines to define
normal and high blood pressure.
 Normal blood pressure less than
120/80
 Pre-hypertension 120-139 / 80-89
 High blood pressure (stage 1) 140-
159 / 90-99
 High blood pressure (stage 2)
higher than 160/100

10. Blood pressure is measured with a blood pressure
cuff (sphygmomanometer). This may be done
using a stethoscope and a cuff and gauge or by
an automatic machine
IMPORTANT : measuring alone is
not completely enough, it has
to go hand in hand with a proper
history regarding ….??

11. To measure the blood pressure correctly the
patient has to be :
1) sitting
2) has not smoked or
consumed caffeine products
in the last 30 min
3) rest for 5 minutes prior to
measuring
4) if it is elevated recheck the other arm
* use a cuff of a proper size for the particular
patient, place it 3 cm over the elbow crease.

12. Patient has a reading of 145/95 mmHg is he
hypertensive?
145
95

13. BE WARE !!!
WCH ??
What’s the opposite?

14. 1) Medical History
 Age, sex & race
 Family Hx (1st degree relatives)
 Chronic dis.
(CV, diabetes, renal, vascular, …)
 Diet, smoking, alcohol
 Medications (like OCP) previous and current
 feeling tired, dizzy, blurred vision, headache at the
back of the head,…
 Activity and lifestyle

15. 2) Examination
 Measuring BP correctly
 CV examination (HR & pulse)
 Height & weight (BMI < 26)
 Chest, neck, abdomen and lungs
 Fundoscpoic examination of eyes

16. 3) Routine & optional lab tests
4) Treatment with and without drugs
Canadian Guidelines of Hypertension 2011 updated
• www.hypertension.ca CHEP 2011 guidelines
• JNC 7 May 2003

17.  Family history
 Age > 60 (after menopause)
 Sex (M>F)
 Race (black > white)
 Diabetes
 Pregnant and OCP
 Renal diseases
 Vascular ,,
 Obesity
 Inactivity (lack of physical activities)
 Smoking
 Alcohol
 Stress
 Diet: salt & fat (indirectly)
------------------------------------------
• Canadian guidelines of HT 2011
• JNC7

18.  Cardiac events (HF, angina and strokes)
 Vascular (Heart, brain and peripheral vascular
disease)
 Eye (including blindness)
Angina Retinopathy

19.  Renal (kidney damage)
 Role of kidney in keeping healthy BP
 HT  CKD
 HT  heart work harder  damage blood vessels
including renal  ↓ removing wastes & extra fluids
 increase fluids in blood vessels  HT
Dangerous cycle
 HT one of the leading causes of KF (ESRD)
Canadian guidelines of Hypertension 2011
• JNC7
• www.medicinenet.com

20.  Physical exercise
 Weight reduction
 Alcohol consumption
 Dietary recommendations
 Sodium intake and caffeine
 Stop smoking

21. Benefits
 In Clinical Trials, lowering of BP is associated with
 ↓ in:
Stroke incidence 35-40%
MI 20-25%
Heart Failure > 50%

22. Routine laboratory tests :
 CBC
 Urine analysis & Microalbuminuria
 Urea, electrolytes and calcium
 Fasting plasma glucose
 Lipid profile
 ECG
 Chest X-Ray

23. Optional laboratory tests :
 Serum uric acid
 24 Hrs urinary protein
 Creatinine clearance
 Echocardiography
 Ultrasonography
 Thyroid stimulating hormone
 24 Hrs urinary vanyl mandelic acid
 24 Hrs urinary free hydrocortisol
 JNC 7
&
European Association of Hypertension

24. The ultimate public health goal of
antihypertensive therapy is the reduction
of cardiovascular and renal morbidity and
mortality.

25.  BP targets are (systolic/diastolic):
 ≤140/90 mmHg in all patients with
hypertension.
 ≤130/80 mmHg in patients with diabetes and
in high-risk.
 It may be difficult to achieve BP
targets, especially in elderly and diabetic
patients, and in patients with CV damage.

26. Non-
pharmacological
pharmacological

27. Life style :
* Weight Reduction
* Dietary sodium reduction
* Physical Activity
* Avoid alcohol consumption
* Type of food

28. Modification Recommendation Approximate SBP
Reduction (Range)
Weight reduction Maintain normal body 5–20 mmHg/10 kg
weight weight loss
23,24
Adopt DASH eating plan Consume a diet rich in 8–14 mmHg
fruits, vegetables, and 25,26
low fat dairy products
with a reduced content
of saturated and total
fat.
Dietary sodium Reduce dietary sodium 2–8 mmHg
reduction intake to no more than 25–27
100 m mol per day
(2.4 g sodium or 6 g
sodium chloride).
Physical activity Engage in regular 4–9 mmHg
aerobic physical 28,29
activity such as brisk
walking
(at least 30 min per
day, most
days of the week).
Moderation of alcohol Limit consumption to 2–4 mmHg
consumption no more than 2 drinks s 30

29. There are five major classes of such agents
licensed for initiation or maintenance of
hypertension, alone or in combination:
 Angiotensin converting enzyme inhibitors
(ACEIs)
 Angiotensin receptor blockers (ARBs)
 Beta-blockers (BBs)
 Calcium channel blockers (CCBs)
 Thiazide-type diuretics

30. Without
Compelling
indication
With compelling
Indication

31.  Initial therapy should be monotherapy with a
thiazide diuretics.
Hypokalemia??
 if target BP not achieved with standard dose of
monotherapy?
combination : thiazide diuretic - CCB
CCB + ACEI
Other combination
ACEI –ARB – not recommended

32. # Ischemic Heart Disease
 most common form of target organ damage
associated with hypertension.
 Pt. with hypertension and coronary artery
disease , an ACE inhibitor or ARB is
recommended
 Pt. with stable angina → B blocker
 Pt. had a recent MI → B blocker and ACEI

33.  Combinations of two or more drugs are
usually needed to achieve the target
goal of <130/80 mmHg.
Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs
are beneficial in reducing CVD and stroke
incidence in patients with diabetes.
 ACEI- or ARB-based treatments favorably
affect the progression of diabetic
nephropathy and reduce albuminuria have
been shown to reduce progression to
macroalbuminuria.

34.  target BP <130/80 mmHg
 Initial therapy should be an ACEI or ARB if
there is intolerance to ACEI
 Thizide diuretic are recommended as
additive therapy

35. Gestational hypertension: pregnant woman
developing high blood pressure after 20
weeks of pregnancy

36. Who is at more risk
1) Obese women
2) Women who have chronic hypertension
3) Pregnant women under the age of 20 or over
the age of 40.
4) Women who are pregnant with more than one
baby
5) Women with diabetes, kidney disease,
rheumatoid arthritis, lupus or scleroderma

37. Resistant hypertension
Blood hypertension in despite of use of 3
Concurrent antihypertensive of different classes.
One of the agents is diuretics and all of the
agents should be used at optimal doses.

39. A 55 year old man, who is known case of
diabetes on insulin.
 BP: 160 ∕ 100 P: 92 ∕ min.
 Wt: 86 kg Ht: 1.68 cm.
 How are you going to manage this patient ?

40. A 63 year old man who is a known case of
hypertension, came for follow up. He is
regular on lisinopril 10 mg daily.
 His BP is 156 ∕ 104 .
 How are you going to manage this patient ?

41. A 22 year young patient present to your clinic
with high blood pressure after 2 documented
reading.
 BP:160 ∕ 110
 How are you going to manage this patient ?

42. MCQs

43. 1) American Heart Association
http://circ.ahajournals.org/content/112/11/1651.full
2)
http://www.medicinenet.com/pregnancy_induced_hypertensio
n/page2.htm
3) Canadian Hypertension Guidelines
4) European Association of Hypertension
5) JNC 7