Hypertension

Presenter : Dr. Anaas Alsamaani

Supervisor : Dr. andurahman Aldukhayel
Contents

► Definition & epidemiology

► Types
► Screening
► Classification
► Approach: History, physical examination, lab workup
► Treatment: non-pharmacological
What is Hypertension?

► Hypertension is a sustained elevation of systemic

arterial blood pressure.
Worldwide Prevalence

► Globally, an estimated 26% of the world’s population (972 million people) has
hypertension,
► expected to increase to 29% by 2025.
► -  Age: onset 20-25 increases with age
► -  Gender: men > women
► - Ethnicity: black>white
► - Socio-economic: low-middle
KSA Prevalence

► 2 out of 5 adults are affected by high blood pressure.

► 3.2% age: 15-24 years
► 51.2% age: 55-64 years
► 70% age: 65 years & older.
Types of Hypertension

► Essential hypertension ► Secondary Hypertension

► Also Called ► hypertension due to an
identifiable medical
► primary hypertension condition.
idiopathic hypertension
► Causes:
► systolic blood pressure
► OSA
(SBP) ≥ 140 mm Hg or
diastolic blood pressure ► Thyroid disease
(DBP) ≥ 90 mm Hg. ► Hypercortisolism “Cushing”
► Hyperaldosteronism
► Coarctation of aorta
► Renal artery stenosis
► Pheochromocytoma
Types of Hypertension

► White coat hypertension ► Masked hypertension

► blood pressure that is ► blood pressure that is
consistently elevated by consistently elevated by
office readings but does out-of-office
not meet diagnostic measurements but does
criteria for hypertension not meet the criteria for
based upon out-of-office hypertension based upon
readings. office readings.
Types of Hypertension

► Gestational hypertension refers to hypertension with

onset in the latter part of pregnancy (>20 weeks'
gestation) without any other features of
preeclampsia, and followed by normalization of the
blood pressure postpartum.
► Resistant hypertension: elevated blood pressure despite concurrent use of
3 antihypertensive drugs of different classes, including a diuretic

► Causes:
► undiagnosed secondary hypertension
factors related to lifestyle and diet suboptimal choice of antihypertensive
regimen chronic kidney disease
Urgency VS Emergency

► Hypertensive urgency ► Hypertensive emergency

► severely elevated ► severe blood pressure
blood pressure (180 elevation in the presence
mm Hg or more of acute target organ
systolic, or 110 mm Hg injury, such as
or more diastolic) encephalopathy,
without acute target cerebrovascular or
organ injury. cardiovascular events,
pulmonary edema,
renal injury, or aortic
dissection.
Screening

► all individuals 18 years or older should be screened for elevated blood pressure.

► Annual Screening is recommended for:

1. adults aged 40 years or older
2. increased risk of high blood pressure and those who are overweight or obese.

► Adults aged 18–39 years with normal blood pressure (<130/85 mm Hg) who do
not have other risk factors should be re-screened every 3–5 years.
Classification & Approach

► Clinical Evaluation Aims:

► Establish the diagnosis of HTN
► Identify secondary HTN
► Detect additional RFs
► Determine TOD
Classification
Diagnosis – Office BP Measurement

► Serial visit ► Single visit

► Measurements BP ► Hypertensive
over 3-5 visits. urgency or
emergency.
Diagnosis–Out Of
Office BP Monitoring

► Proper Out-of-office BPM has a better prognostic value than Office

Blood Pressure Monitoring (OBPM). It helps to rule out white coat
hypertension (WCH) and identifies Masked HTN.
Diagnosis–Out Of Office BP Monitoring
► Home Blood Pressure
Monitoring (HBPM)
► Two readings (one minute
apart) taken each morning and
evening for 7 days (28 total).
First-day home BP values
should not be considered.
► Ambulatory BP Monitoring
(ABPM)
► It is performed by a validated
automated device over a period of 24
hours.
► •BP is measured at repeated
intervals (every 15–30 mins while
awake, and every 30–60 mins during
sleep).
► •The patient is instructed to engage
in normal activities but at the time
of cuff inflation, to stop moving and
talking and keep the arm still with
the cuff at heart level.
Diagnostic Criteria for Hypertension Based on
Office, Ambulatory (ABPM), and Home Blood
Pressure (HBPM) Measurement
Approach

► HISTORY
► CLINICAL EVALUATION:
1. BP Measurement
2. PHYSICAL EXAMINATION
History
► Medical History ► Symptoms of target organ
damage
► New onset hypertension
► Chest pain
► Duration, previous BP levels
► Dyspnea
► Current and previous antihypertensive
medication ► Palpitations
► History of intolerance (side-effects) of ► Claudication
antihypertensive medications
► Peripheral edema
► Adherence to antihypertensive
treatment
History
► Risk Factors (STRONG)
► Obesity
► Aerobic exercise <3 times/week ► Risk Factors (WEAK)
► Moderate/high alcohol intake ► Sodium intake >1.5 g/day
► Metabolic syndrome ► Low fruit and vegetable intake
► Diabetes mellitus ► Dyslipidemia
► Black ancestry
► Age >60 years
► FHx of hypertension or coronary
artery disease
► Sleep apnoea
History

► Symptoms of secondary hypertension

► Onset young age (<30 years) or old age (>65 years)
► Severe or resistant HTN
► Muscle weakness, cramps, polyuria (primary
aldosteronism)
► Sweating, flushing, palpitations, headaches
(pheochromocytoma)
► Snoring, daytime sleepiness (obstructive sleep
apnea)
► Pregnant (pre-eclampsia)
History

► Drugs and substances that may cause elevated BP

► NSAIDs
► Oral contraceptives
► Antidepressants e.g., MAOIs, SNRIs, TCAs .
► Cocaine, amphetamines and other illicit drugs
► Systemic corticosteroids
► Decongestants e.g., pseudoephedrine
► Caffeine
► Nicotine (smoking)
Examination
Examination
BP MEASUREMENT
Methods of BPM
II. Oscillometric
I. Auscultatory (Automated / Electronic)

Mercury
Automated arm
Aneroid
Automated
unattended
office

Automated wrist
(Digital) Hybrid
What Blood Pressure Measurement
Device is better to use ?

● Canadian guidelines recommend electronic (oscillometric) upper arm devices instead of

using auscultation to measure blood pressure in the clinic setting.
● Automated devices may not measure blood pressure accurately in case of pulse
irregularity. Thus, palpation of the pulse before measuring blood pressure is required. In
that case, the auscultatory method is recommended.
● Upper arm devices are recommended. Wrist and finger monitors are less accurate.
Standards for BP
Measurement

1- Patient-Related
Standards
2-Equipment-RelatedStandards

1. Appropriate cuff 2.Correct cuff 3. Correct stethoscope

size position position
2.5 cm (2 fingers) The bell of the
between the lower end stethoscope placed
of the cuff and the above and medial to the
antecubital antecubital fossa but
below edge of the cuff.
Investigations

► Basic Investigations:
► 1 .Urinalysis (protein, glucose, blood, casts)
► 2. Blood chemistry: potassium, sodium, creatinine with e-GFR, fasting blood
glucose, and serum uric acid
► 3. Complete fasting lipid profile
► 4. Hemoglobin and hematocrit
► 5. Electrocardiography (ECG)
Investigations

► Additional Optional Investigations, if needed:

► 1.TSH, Free T4
2. Chest X-ray
3. Abdominal sonography
► 4. Echocardiography
► Cases with signs suggesting secondary HTN should be referred to the proper
specialty or to a clinical hypertension specialist.
Meanwhile, proper general management must be started
Treatment Goals

► To achieve the maximum reduction in total risk of cardiovascular and renal

morbidity and mortality. This requires two steps:
► 1. Reducing blood pressure to the target level
2 . Controlling all other reversible cardiovascular risk factors.
Diabetes Smoking Dyslipidemia Obesity
Alcoholism Physical inactivity Stressful life style Unhealthy diet
Treatment Goals

► The target BP should be <140/90 mm Hg for most patients with HTN.

Treatment Goals JNC8
Non-Pharmacological Approach
Dietary Approach to stop hypertension
(DASH) Diet

► Includes the intake of:

► - fruits and vegetables - Legumes
► - whole grains
low-fat dairy products
- moderate amounts of unprocessed meat
- Poultry
- Fish
- moderate amounts of polyunsaturated
and monounsaturated fats.
Weight Reduction

► On average, for each 10 kg increase over the

ideal bodyweight, SBP increases 2–3 mm Hg
and DBP rises 1–3 mm Hg.
► The healthiest way to lose weight and achieve
long-term success is to lose weight gradually,
not more than 0.5–1 kg per week through
a well-balanced diet and increased physical
activity.
Regular Physical Activity

► 1 - Regular Physical Activity of moderate

intensity for 30 minutes on most days of
the week is encouraged 2- brisk walking
3- low-speed swimming
► 4 -cycling
Smoking cessation

► Reduces overall cardiovascular risk factors.

Therefore, inquiries and advice to stop smoking should be given by healthcare
professionals.
Non-Pharmacological Approach

► Summary of Recommendations:
► Weight reduction to ideal body weight • Adopt DASH dietary plan
► Restrict sodium intake to <1500 micro gram/ day (1/2 to 3/4 teaspoon) •
Regular moderate-intensity physical activity
► Smoking cessation
Referral

► Resistant HTN
► Suspicion of secondary HTN
► Referral
► Sudden onset of HTN
► HTN diagnosed at young age ( 30 years old) •Worsening of HTN
► Malignant HTN
thanks