1. HYPERTENSION Detection, Evaluation and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA

2. Problem Magnitude
Hypertension( HTN) is the most common primary diagnosis in America.
35 million office visits are as the primary diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be as much as 1 billion.
7.1 million deaths per year may be attributable to hypertension.

3. Definition A systolic blood pressure ( SBP) >139 mmHg and/or
A diastolic (DBP) >89 mmHg.
Based on the average of two or more properly measured, seated BP readings.
On each of two or more office visits.

4. Accurate Blood Pressure Measurement
The equipment should be regularly inspected and validated.
The operator should be trained and regularly retrained.
The patient must be properly prepared and positioned and seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.
Caffeine, exercise, and smoking should be avoided for at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.

5. BP Measurement
At least two measurements should be made and the average recorded.
Clinicians should provide to patients their specific BP numbers and the BP goal of their treatment.

6. Follow-up based on initial BP measurements for adults*
*Without acute end-organ damage

7. Classification
Acute end-organ damage

8. Prehypertension SBP >120 mmHg and <139mmHg and/or
DBP >80 mmHg and <89 mmHg.
Prehypertension is not a disease category rather a designation for individuals at high risk of developing HTN.

9. Pre-HTN
Individuals who are prehypertensive are not candidates for drug therapy but
Should be firmly and unambiguously advised to practice lifestyle modification
Those with pre-HTN, who also have diabetes or kidney disease, drug therapy is indicated if a trial of lifestyle modification fails to reduce their BP to 130/80 mmHg or less.

10. Isolated Systolic Hypertension
Not distinguished as a separate entity as far as management is concerned.
SBP should be primarily considered during treatment and not just diastolic BP.
Systolic BP is more important cardiovascular risk factor after age 50.
Diastolic BP is more important before age 50.

11. Frequency Distribution of Untreated HTN by Age
Isolated Systolic
HTN
Systolic Diastolic
HTN
Isolated Diastolic
HTN

12. Hypertensive Crises
Hypertensive Urgencies: No progressive target-organ dysfunction. (Accelerated Hypertension)
Hypertensive Emergencies: Progressive end-organ dysfunction. (Malignant Hypertension)

13. Hypertensive Urgencies
Severe elevated BP in the upper range of stage II hypertension.
Without progressive end-organ dysfunction.
Examples: Highly elevated BP without severe headache, shortness of breath or chest pain.
Usually due to under-controlled HTN.

14. Hypertensive Emergencies
Severely elevated BP (>180/120mmHg).
With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

15. Types of Hypertension Primary HTN: also known as essential HTN.
accounts for 95% cases of HTN.
no universally established cause known.
Secondary HTN:
less common cause of HTN ( 5%).
secondary to other potentially rectifiable causes.

16. Causes of Secondary HTN
Common
Intrinsic renal disease
Renovascular disease
Mineralocorticoid excess
Sleep Breathing disorder
Uncommon
Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism

17. Secondary HTN-Clues in Medical History
Onset: at age < 30 yrs ( Fibromuscular dysplasi) or > 55 (athelosclerotic renal artery stenosis), sudden onset (thrombus or cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation (pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and daytime sleepiness (sleep disorders)

18. Secondary HTN-clues on Exam
Pallor, edema, other signs of renal disease.
Abdominal bruit especially with a diastolic component (renovascular)
Truncal obesity, purple striae, buffalo hump (hypercortisolism)

19. Secondary HTN-Clues on Routine Labs
Increased creatinine, abnormal urinalysis ( renovascular and renal parenchymal disease)
Unexplained hypokalemia (hyperaldosteronism)
Impaired blood glucose
( hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)

20. Secondary HTN-Screening Tests

21. Renal Parenchymal Disease
Common cause of secondary HTN (2-5%)
HTN is both cause and consequence of renal disease
Multifactorial cause for HTN including disturbances in Na/water balance, vasodepressors/ prostaglandins imbalance
Renal disease from multiple etiologies.

22. Renovascular HTN
Atherosclerosis 75-90% ( more common in older patients)
Fibromuscular dysplasia 10-25% (more common in young patients, especially females)
Other
Aortic/renal dissection
Takayasu’s arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation

23. Complications of Prolonged Uncontrolled HTN
Changes in the vessel wall leading to vessel trauma and arteriosclerosis throughout the vasculature
Complications arise due to the “target organ” dysfunction and ultimately failure.
Damage to the blood vessels can be seen on fundoscopy.

24. Target Organs CVS (Heart and Blood Vessels) The kidneys Nervous system
The Eyes

25. Effects On CVS Ventricular hypertrophy, dysfunction and failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and rupture.

26. Effects on The Kidneys
Glomerular sclerosis leading to impaired kidney function and finally end stage kidney disease.
Ischemic kidney disease especially when renal artery stenosis is the cause of HTN

27. Nervous System Stroke, intracerebral and subaracnoid hemorrhage.
Cerebral atrophy and dementia

28. The Eyes Retinopathy, retinal hemorrhages and impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to extraoccular muscle paralysis and dysfunction

29. Retina Normal and Hypertensive RetinopathyB C B
Normal Retina
Hypertensive Retinopathy
A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro Strokes)

30. Stage I- Arteriolar Narrowing

31. Stage II- AV Nicking
AV Nicking
AV Nicking
AV Nicking
AV Nicking

32. AV Nicking

33. Stage III- Hemorrhages (H), Cotton Wool Spots and Exudats (E)

34. Stage IV- Stage III+Papilledema

35. Patient Evaluation Objectives
(1) To assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that may affect prognosis and guide treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of target organ damage and CVD

36. (1) Cardiovascular Risk factors
Hypertension
Cigarette smoking
Obesity (body mass index ≥30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men under age 55 or women under age 65)

37. (2) Identifiable Causes of HTN
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease

38. (3) 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

39. History
Angina/MI Stroke: Complications of HTN, Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia: Suggest renal impairment

40. History-contd.
Claudication: May be aggravated by b-blockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have been due to HTN

41. History-contd. Family history of DM : Patient may also be Diabetic
Cigarette smoker: Aggravate HTN, independently a risk factor for CAD and stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake

42. Examination Appropriate measurement of BP in both arms Optic fundi
Calculation of BMI ( waist circumference also may be useful)
Auscultation for carotid, abdominal, and femoral bruits
Palpation of the thyroid gland.

43. Examination-contd. Thorough examination of the heart and lungs
Abdomen for enlarged kidneys, masses, and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment

44. Routine Labs EKG. Urinalysis.
Blood glucose and hematocrit; serum potassium, creatinine ( or estimated GFR), and calcium.
HDL cholesterol, LDL cholesterol, and triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.

45. Goals of Treatment
Treating SBP and DBP to targets that are <140/90 mmHg
Patients with diabetes or renal disease, the BP goal is <130/80 mmHg
The primary focus should be on attaining the SBP goal.
To reduce cardiovascular and renal morbidity and mortality

46. Benefits of Treatment
Reductions in stroke incidence, averaging 35–40 percent
Reductions in MI, averaging 20–25 percent
Reductions in HF, averaging >50 percent.

47. Lifestyle modifications

48. Lifestyle Changes Beneficial in Reducing Weight
Decrease time in sedentary behaviors such as watching television, playing video games, or spending time online.
Increase physical activity such as walking, biking, aerobic dancing, tennis, soccer, basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of consumption of calorie containing beverages.

49. DASH Diet Dietary approaches to Stop Hypertension
As effective as one medication

51. JNC 7 Summary Joint National Commission 7th Report PDF File on website
50 page document

52. Other JNC 7 Resources
Software for use with Palm and Pocket PC

53. JNC 7 Reference Card

54. Other Resources Chronic Kidney Disease Information
GFR Calculator
Hyperlipedemia Information
Adult Treatment Panel 3 Guidelines

55. Questions