2. Prevention of Hypertension

7. شیوع پرفشاری خون در اصفهانبر اساس آمار پروژه قلب سالم اصفهان :
شیوع پرفشاری خون در اصفهانبر اساس آمار پروژه قلب سالم اصفهان :
بین افراد 35 تا 65 سال 23%

8. tertiary
primary
secondary

9. Effects of dietary sodium on blood pressure
tertiary
primary
Randomised
double-blind crossover
secondary
Usual Salt
4 wks
Reduced Salt
4 wks
168
166
Supine SBP
(mmHg)
164
162
Mean fall = 9.5 mmHg
160
P=0.001
158
156
154
152 92 91
Supine DBP
(mmHg) 90 89
P=0.004
Mean fall = 5.3 mmHg 88 87 86
175
Urinary
Sodium
(mmol/24h)
150
125
P=0.001
Mean fall = 4.5 g/day of salt
100 75 50 25
Lancet. 1982;1:

10. Salt 4.6 g/d ↓ Benefits of Reducing Population Salt Intake
tertiary
primary
secondary
Benefits of Reducing Population Salt Intake
Salt 4.6 g/d ↓
Hypertension prevalence 30% ↓
Forrester etal. J Human Hypertens 2005: 19:

11. Finland Salt intake (g/day) Diastolic BP (mmHg) Stroke mortality
tertiary
primary
secondary
Salt intake
(g/day)
Diastolic BP
(mmHg)
Stroke mortality
(1/100000)
Men
Men
Women
Women
Year
Year
Year
Karppanen & Mervaala. Prog Cardiovasc Dis 2006;49:59-75.

12. Potassium :supplements reduced mean blood pressures (systolic/diastolic) by 1.8/1.0 mmHg in normotensive subjects and 4.4/2.5 mmHg in hypertensive subjects
2 g/d is associated with 5.0/2.5 mmHg¹
Safe dose: 3.5 g/d
This may be achieved through adequate daily consumption of fruits and vegetables.
Concerns in renal failure

13. tertiary
primary
secondary

14. Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
life style modification To reduce the possibility of becoming hypertensive
Maintenance of ideal body weight (BMI kg/m2)

15. Waist Circumference < 102 cm for men < 88 cm for women
tertiary
life style modification To reduce the possibility of becoming hypertensive
primary
secondary
Waist Circumference
< 102 cm for men
< 88 cm for women

16. Population-Based Strategy
SBP Distributions
After
Intervention
Before
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

17. We are not doing a good job…
secondary
primary
We are not doing a good job…
tertiary
70% of those with HTN are aware of their diagnosis
59% of those with HTN are treated
34% of those with HTN are treated to a SBP < 140

18. Secendery prevention Screening :
The U.S. Preventive Services Task Force
(USPSTF) recommends screening for high blood
pressure in adults aged 18 and older.
screening every 2 years in persons with blood
pressure less than 120/80 mmHg and every year with systolic blood pressure of 120 to 139 mmHg or diastolic blood pressure of 80 to 90 mmHg.

19. CLASSIFICATION JNC VII Category Systolic BP Diastolic BP
secondary
primary
tertiary
Category Systolic BP Diastolic BP
Normal <120 and <80
PREHTN or
Hypertension
-Stage or Stage >160 or >100
JNC VII

20. Objective of the clinical evaluation:
secondary
primary
tertiary
Objective of the clinical evaluation:
1) Identify other CV risk factors
- assess lifestyle and concomitant disorders that may affect prognosis and guide treatment
2) Reveal identifiable causes of high BP
3) Assess the presence/absence of target organ damage (TOD) and CVD

21. SECONDARY HYPERTENSION
Sleep apnea
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy / Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

22. secondary
primary
tertiary

23. Ambulatory BP Monitoring: Specific Role in Selected Patients
Which patients?
Those with suspected office-induced BP elevation
Untreated
Mild to moderate clinic BP elevation and without target organ damage
Treated patients
Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy
Symptoms suggestive of hypotension
Fluctuating office blood pressure readings

24. Ambulatory BP Monitoring Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
Average daytime ambulatory blood pressure >135/85 mmHg is considered elevated
A drop in nocturnal BP of <10% is associated
with increased risk of CV events

25. Secendery prevention Treatment: Effective treatment can decrease:
secondary
primary
tertiary
Treatment:
Effective treatment can decrease:
Heart failure by 50%
CVA by 35-40%
MI by 25%

26. Younger than 60 Older than 60 Benefits of Treating Hypertension
secondary
primary
tertiary
Benefits of Treating Hypertension
Younger than 60
reduces the risk of stroke by 42%
reduces the risk of coronary event by 14%
Older than 60
reduces overall mortality by 20%
reduces cardiovascular mortality by 33%
reduces incidence of stroke by 40%
reduces coronary artery disease by 15%

28. نمک افزایش شانس سرطان معده پوکی استخوان فشار خون آترواسکلروز
میزان به گرم
میزان مصرف به زبان ساده و کاربردی مناسب جامعه

29. میانگین دریافت نمک مواد خام سر سفره نان در پختن غذا کل دریافتی
مقدار نمک
نوع غذا
2 گرم
مواد خام
سر سفره
احتمالا 2 گرم
نان
6 گرم
در پختن غذا
12 گرم
کل دریافتی

30. نحوه توضیح میزان مناسب نمک غذا به زبان ساده؟
Tehran Arrhythmia Center

31. Treatment of Hypertension in Patients with Ischemic Heart Disease
Stable angina
1. Beta-blocker
2. Long-acting CCB
ACE-I are recommended in ALL patients with established CAD
• Caution should be exercised when combining a non DHP-CCB and a beta-blocker
• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem)
Short-acting
nifedipine

32. Treatment of Hypertension for Patients with Cerebrovascular Disease
Strongly consider blood pressure reduction
in all patients after the acute phase of non disabling stroke or TIA .
An ACE-I / diuretic combination may be preferred
Stroke
TIA

33. Hydralazine, Minoxidil Can Increase LVH
Treatment of Hypertension in Patients with Left Ventricular Hypertrophy
Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events.
Vasodilators:
Hydralazine, Minoxidil Can Increase LVH
Left ventricular
hypertrophy
ACE-I
ARB,
CCB
Diuretic
- BB (below age 60)*
ARB
- BB (below age 60)

34. Treatment of Hypertension in Patients with chronic kidney disease
Target BP: < 130 mmHg systolic and
< 80 mmHg diastolic
Renal disease
ACE-I/ARB: Bilateral renal artery stenosis
1. ACE-I
2. Alternate if ACE-I not tolerated: ARB
Combination with other agents
Additive therapy: Diuretic.
Usually a loop diuretic

35. Follow-up and Monitoring
Patients should return for follow-up and adjustment of medications until the BP goal is reached, usually monthly.
More frequent visits for stage 2 HTN or with complicating comorbid conditions.
Serum potassium and creatinine monitored 1–2 times per year.

36. میزان مطلوب فشارخون با درمان
در افراد زیر فشار دیاستول باید به کمتر از 80 برسد:
مبتلایان به بیماری ایسکمیک (اگر سیستول باشد بهتر است)
مبتلایان به دیابت
شروع به طرف نارسایی کلیه (دفع رزوانه پروتئین 1-2 گرم) 125/75
در سیاه پوستان با توجه به ریسک بالای عوارض

37. میزان مطلوب فشارخون با درمان
فشارخون سیستولی ایزوله
در افراد سالمند فشارخون سیستول کمتر از 150 برسد ولی احتیاط شود که دیاستول به کمتر از 65 نرسد
کاهش بیشتر به دلیل عوارض دارویی توصیه نمی شود

38. ورزش و فشارخون
ریسک ورزش هایی مثل شنا، گلف و بولینگ برای فشارخون stage 1 کم است
این افراد در صورتی که LVH و آسیب های ارگان ندارند (با کنترل فشار) محدودیتی در ورزش ندارند
Stage 2 فشارخون تا کنترل شدن آن باید محدودیت ورزش داشته باشد
فشارخون به تنهایی باعث مرگ ناگهانی نمی شود

39. غربال گری برای ورزش
شرح حال خانوادگی مرگ ناگهانی و بیماری قلبی زیر 50 سال
وجود ضعف، سنکوپ یا Faint) ( ، نفس تنگی و درد سینه
معاینه: سوفل قلبی، نبض فمورال، هلائم مارفان، میزان فشارخون
ورزشکاران مبتلا باید اکوکاردیوگرافی شوند بهتر است Maximal exc. test شوند
ریسک بالا: بروز ایسکمی در حین وزرش ، EF< 50%
(در صورت آنژیوگرافی) Coronary obstruction > 50%

40. Follow-up and Monitoring (continued)
After BP at goal and stable, follow-up visits at 3- to 6-month intervals.
Co-morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits