1. HYPERTENSION: AN OVERVIEW Prof Ahmed Mandil, Dr Hafsa Raheel KSU Dept of Family & Community Medicine

2. Objectives By the end of this session, students should be able to: Understand the basic concepts of hypertension Explain the magnitude of the problem Identify important risk factors for hypertension Identify the important complications of hypertension Explain important concepts of prevention and control of hypertension 11 October 2014Hypertension2

3. Headlines Magnitude of the problem Risk factors Assessment & diagnosis Complications Prevention and control 11 October 20143Hypertension

4. Magnitude ■ In developed and developing countries alike, essential hypertension affects 25-35% of the adult population. Up to 60-70% of those beyond the seventh decade of life ■ Each increment of 20 mm Hg in systolic blood pressure or 10 mm Hg in diastolic blood pressure doubles the risk of cardiovascular disease events independent of other factors. 11 October 20144Hypertension

5. Prevalence of Hypertension in Obese and non-Obese Saudis The study group: 14.805 males: 6225 females: 8580 The age: 14 – 70 years Non-obese prevalence: 4.8 % males 2.8 % females Obese prevalence: 8 % males 8 % females El-Hazmi M. Saudi Medical Journal 2001; 22 (1): 44-48 11 October 20145Hypertension

6. Hypertension among attendants of primary health care centers in Al-Qassim region, Saudi Arabia. Study sample: 1114 Prevalence: 30 % Higher among: ● Age > 40 years ● Overweight and obese people ● illiteracy Awareness: 20 % of hypertensive women 25 % of hypertensive men Khalid A et al. Saudi Med J 2001; 22 (11) 960-963 11 October 20146Hypertension

7. Blood Pressure Measurement and Hypertension Diagnosis 1 in 5 adult Canadians have hypertension Over 40% of Canadians at aged 56-65 have hypertension 90% of normotensive persons aged 55-65 developed hypertension in the next 20 years in the Framingham study 2010 Canadian Hyprtension Education Program 11 October 20147Hypertension

8. Hypertension in the community- Rule of halves 11 October 2014Hypertension8

9. Risk Factors Smoking Dyslipidaemia Diabetes Mellitus Obesity Age ( older than 55 for men, 65 for women) Gender (men or postmenopausal women) Family History of cardiovascular disease (men under age 55 or women under age 65) 11 October 20149Hypertension

10. Modifiable Risk Factors for Developing Hypertension Obesity Poor dietary habits High sodium intake Sedentary lifestyle High alcohol consumption 11 October 201410Hypertension

11. Colors of Salt White Black Red Yellow Green Brown Clear Table salt Soy sauce Catsup Mustard Pickles Soups & gravies Saline 11 October 201411Hypertension

12. High Risk Subjects ► ABP ≥ 180 systolic and/or ≥ 110 diastolic ► Systolic BP > 160 with low diastolic <70 ► Diabetes mellitus ► Metabolic syndrome ► ≥ 2 cardiovascular risk factors (smoking, dyslipidaemia, obesity, …..) 11 October 201412Hypertension

13. Life time Risk of Hypertension in normotensive women and men aged 65 years Risk of Hypertension % 0 2 4681012 14161820 Years to Follow-up Women Risk of Hypertension % Years to Follow-up 0 2 4681012 14161820 Men JAMA 2002:297:1003-10. Framingham data. 100 80 60 40 20 0 100 80 60 40 20 0 11 October 201413Hypertension

14. Types & Complications of Hypertension

15. Types of hypertention, 2007, USA Essential * 92.0-95.0 % Secondary Chronic kidney disease 3.0-6.0 % Renovascular disease 0.2-1.0 % Pheochromocytoma 0.1-0.2 % Aldosteronism 0.1-0.3 % Cushing’s syndrome 0.1-0.2 % Coarctation 0.1-0.2 % Oral contraceptives 0.2-1.0 % * Onset in 30s and 40s, gradual onset, family history, obesity 11 October 201415Hypertension

16. TIA = transient ischemic attack; LVH = left ventricular hypertrophy; CHD = coronary heart disease; MI = myocardial infarction; HF = heart failure. Cushman WC. J Clin Hypertens. 2003;5(Suppl):14-22. Retinopathy Renal failure Peripheral vascular disease Complications of Hypertension: LVH, IHD, MI, HF TIA, stroke Hypertension is a risk factor 11 October 201416Hypertension

17. Assessment & Diagnosis

18. Nokolai Korotkoff, 1905 Auscultatory method of blood pressure measurement 11 October 201418Hypertension

19. Noninvasive Blood Pressure Measurement Methodologies - Auscultatory (K sound) - Mercury - Aneroid - Oscillometric Locations Situations  - Upper arm - Clinic - Wrist - Home - Finger - Ambulatory

20. The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC), 2007 Systolic Diastolic Optimal <120 and <80 Normal 120–129 and/or 80–84 High normal 130–139 and/or 85–89 Grade 1 HTN 140–159 and/or 90–99 Grade 2 HTN 160–179 and/or 100–109 Grade 3 HTN 180 and/or 110 Isolated Systolic HTN ≥140 and <90 Definitions and Classification of blood pressure

21. Prevention & Control

22. ◘ Reduce sodium intake ◘ 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 sodium. ◘ Regular physical activity: 30-60 minutes of moderate intensity cardiorespiratory activity (e.g. a brisk walk); 5-7 days/week in addition to routine activities of daily living ◘ Low risk alcohol consumption (≤2 standard drinks/day and less than 14/week for men and less than 9/week for women) Primary Prevention – Population Strategies 1 11 October 201422Hypertension

23. Primary Prevention – Population Strategies 2 ◘ Maintenance of ideal body weight (BMI 18.5-24.9 kg/m 2 ) Waist Circumference Men Women - EMR, Europe, Sub-Saharan African <94 cm <80 cm - South Asian, Chinese <90 cm <80 cm ◘ Prevention / cessation of tobacco use Health Education Behavioral change 11 October 2014Hypertension23

24. Primary Prevention- High Risk approach Tracking of blood pressure from childhood, in high risk families 11 October 2014Hypertension24

25. 11 October 201425Hypertension

26. Secondary prevention 11 October 2014Hypertension26  Timely diagnosis and adequate control of BP  Compliance with treatment

27. Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension * ConditionInitiation SBP or DBP mmHg Systolic or Diastolic hypertension 140/90 Diabetes Chronic Kidney Disease 130/80 Indications for Pharmacotherapy 11 October 201427Hypertension * Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) EXPRESS

28. BENEFITS OF LOWERING BLOOD PRESSURE The Clinical Trials had shown: Reduction in STROKE 35 – 40 % MI 20 – 25 % HEART FAILURE > 50% 11 October 201428Hypertension

29. Conclusion ASSESS AND MANAGE CV RISK IN HYPERTENSIVES High dietary sodium intake, smoking, dyslipidemia, dysglycemia, abdominal obesity, unhealthy eating, and physical inactivity. LIFESTYLE MODIFICATION Sustained lifestyle modification is the cornerstone for the prevention and control of hypertension and the management of cardiovascular disease. Encourage patients to reduce their sodium intake. TREATING TO TARGET BP Treat blood pressure to less than <140/90 mmHg. In people with diabetes or chronic kidney disease target to <130/80 mmHg and more than one drug is usually required including diuretics to achieve BP targets. 11 October 201429Hypertension

30. Global initiativesGlobal initiatives: World Health Day 2013 11 October 2014Hypertension30

31. Local hypertension initiatives Saudi societies working in the hypertension field: Saudi hypertension management society Saudi heart association Related databases: HEARTS database: http://www.hearts- ksa.com/home.html HEARTS database:http://www.hearts- ksa.com/home.html SPACE registry project in Saudi Arabia: http://www.space-ksa.com/ http://www.space-ksa.com/ Saudi Hypertension management guidelines 11 October 2014Hypertension31

32. References 1 1. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 2003 2. Saudi Hypertension Management Guidelines 3. The British Hypertension Society. NICE Guidelines 4. Franklin S. Epidemiology of hypertension. UC Irvine 5. The Canadian Hypertension Education Program: Recommendations for management of hypertension, 2006 11 October 201432Hypertension

33. References 2 6. Treatment of hypertension in the prevention and management of Ischemic Heart Disease. American Heart Association, 2007 7. European guidelines for management of arterial hypertension 2007 8. Saad H. Hypertension updates, 2010 9. International societies: American Heart Association; Heart & Stroke Foundation of Canada; British Heart Foundation; European Society of Cardiology, World Health Organization (www.who.int); Centers for disease control and prevention. www.cdc.govwww.who.intwww.cdc.gov 11 October 201433Hypertension