BLOOD PRESSURE

&
HYPERTENSION
By

Dr. Amir Riaz

(M.B.B.S, F.C.P.S)
Consultant Physician & Gastroenterologist

Acquisitions

Associate Professor
Lahore college of Pharmaceutical Sciences (LCPS), Lahore.
(www.lcps.edu.pk/)

Scientific Chair
Center of Research for Public Health (CRPH). (www.crph.org.pk/)

Editor-in-Chief, theHealth Journal. (www.thehealth.liphealth.pk/)

Research fellow in Viral Hepatitis

College of Physician & Surgeons Pakistan (CPSP)

Member Asia Pacific Association for Study of Liver (APASL)

Member European Association for Study of Liver (EASL)

Member Union of European Gastroenterologists (UEG)

Member American Academy of Family Medicine (AAFM)

Preamble

Significance of the Topic.

What is Blood Pressure (B.P)?

B.P is a misnomer.

Systemic Arterial Pressure.

Basic Facts about B.P.

Hypertension.

Prevention

Follow-up

Hypertension

Non Communicable disease

Common

Inevitable

Misconceptions

Preventable

Serious complication

Cost in Health System

Size of the problem

Hypertension causes one in every eight deaths, making

it the third leading killer in the world. (WHO estimated data)

Globally, there are one billion hypertensives & 4 million

people die annually as a direct result of hypertension.

Individuals normotensive at the age 55 years have a

90% lifetime risk for developing hypertension.
(EMR0 Technical Publications)

Blood pressure is under control in less than 20% of

patients with hypertension in many countries.
(A joint CINDI/EuroPharm Forum project WHO)

TOD in Hypertension
(Target Organ Damage)

Cardiovascular Mortality Risk

Doubles with Each 20/10 mmHg Increment in Systolic/Diastolic BP*

8X
risk

6
4

4X
risk

2
risk

Cardiovascular mortality

1X risk

2X
risk

115/75

135/85

155/95

175/105

Systolic BP/Diastolic BP (mmHg)

*Individuals aged 4069 years

Lewington et al. Lancet 2002;360:190313

Blood Pressure Reduction &

Risk of Cardiovascular Events

Meta-analysis of 61 prospective, observational studies

1 million adults
12.7 million person-years

2 mmHg
decrease in
mean SBP

7% reduction in
risk of ischemic
heart disease
mortality
10% reduction in
risk of stroke
mortality

Lewington et al. Lancet 2002;360:190313

Basic Concepts
Blood Pressure = pressure exerted by
circulating blood on blood vessel walls.
Pressure is the force per unit area, i.e.
P = F/A
Force = Work done by Heart
Area = Circulation

Basic Concepts

Work done by Heart = Cardiac Output (C.O)

C.O is volume of blood pumped by heart

per unit time, i.e.
Cardiac output = Heart rate x Stroke volume
(C.O = H.R x S.V)

Area = Circulation (Pulmonary & Systemic)

Blood

vessels in circulation produce resistance

to blood flow according to their cross sectional
areas

Circulation

Circulation

Circulation

Arterial Pulse & Pulse Pressure

HEART BEAT

Contraction
SYSTOLE

Systolic Pressure
SBP

Relaxation
DIASTOLE

Diastolic Pressure
DBP

SBP DBP = PP
Pulse Pressure

Circulation

Blood Pressure

Blood pressure is a product of Cardiac

Output & Total Peripheral Resistance
B.P = C.O x TPR

&

C.O = H.R x S.V

B.P = H.R x S.V x TPR

B.P = Blood pressure, H.R = Heart rate, S.V = Stroke volume, TPR = Total peripheral resistance

Circulation
Systemic Circulation

Pulmonary Circulation

Blood Pressure - Misnomer

Arterial side of Systemic Circulation

Systemic Arterial Blood Pressure

Hypertension Basic Facts

Various

factors effect both systolic & diastolic

pressures in each person & its is variable at times.

Therefore

no magic threshold of blood pressure can

be defined above which a person is labeled

hypertensive and below which one is safe.
Hence
Blood

hypertension is defined somewhat arbitrarily.

pressure should be measured at least twice

at two separate occasions under basal conditions

after initial screening.

Hypertension Basic Facts

It

varies with age, sex, race & screening value.

Prevalence

increases with age & when present

in young adults it tends to be more severe and
detrimental.

Female

more hypertensive than males but in

older age group in which disease is relatively
benign. Before 50 years hypertension is more
common in males.

Blacks

affected twice as compared to whites &

more vulnerable to complications.

Hypertension
Classification of Blood Pressure according to JNC 7th Report
BP classification

Systolic BP
mmHg

Diastolic BP
mmHg

< 120

< 80

Pre-hypertension

120 139

80 89

Stage 1
hypertension

140 159

90 99

Stage 2
hypertension

160

100

Normal

JNC Joint National Committee

(for prevention, detection, evaluation & treatment of high blood pressure)

Types of Hypertension

Primary hypertension
(90

- 95% of cases)

Secondary hypertension
(5

10 % of cases)

Renal
Drugs
Endocrine
Coarctation

of the aorta and aortitis

Pregnancy-induced

hypertension

Possibility of secondary hypertension

Young age
Family history of renal disease
Evidence of renal disease
Hypertension due to drugs
Episodes of sweating, headache, anxiety
(phaeochromocytoma)
Episodes of muscle weakness and
tetany. (hyperaldosteronism)

Risk Factors for Hypertension

Cigarette smoking & Alcohol

Obesity* (body mass index 30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 mL/min
Age ( > 55 for men, > 65 for women)
Family history of premature CVS disease
(men under age 55 or women under age 65)

*Metabolic syndrome,
(hypertension, obesity, dyslipidemia, diabetes mellitus)

Obesity
Physical Inactivity
Smoking & Alcohol
Diabetes Mellitus
Dyslipidemia

Renal disease - Low GFR

Microalbuminuria D.M
Drugs
CVS disease
Metabolic syndrome

B.P = H.R x S.V x TPR

Smoking
Stress & Anxiety
Endocrine disease
Hormones
Drugs

Normal Control of Blood Pressure

Blood volume
(Stroke
volume)
Sodium
Mineralocorticoids
ANP

Humoral Factors
Dilators
Prostaglandin
Kinins
NO & EDRF

Constrictors
Angiotensin
Cathecolamines
Thromboxane
Leukotrines
Endothelin

B.P = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Constrictors
Cardiac Factors
Heart Rate
Contractility

- adrenergic
Dilators

Autoregulation
Ionic (pH) &
Hypoxia

-adrenergic
Neural Factors

Local Factors

ANP= Atrial natriuretic peptide, NO= Nitric oxide, EDRF= Endothelium derived growth factor.

Clinical Features of Hypertension

Symptoms & Signs (S/S)

(related to type, cause, duration & TOD)

Asymptomatic, non-specific headache,

pulsating occipital or temporal headaches,
palpitation, giddiness, somnolence, confusion,
visual disturbance, tinnitis, vertigo, nausea &
vomiting.

S/S of target organ damage (TOD)

S/S of underlying disease in case of Sec. HTN

EVALUATION FOR HYPERTENSION

Measurement of Blood Pressure

Seated in a quiet room

Arm muscles relaxed

Cubital fossa at heart level

Avoid tight sleeves

Suitable size Cuff to be used

Repeat if BP > 140/90

Measurement on both arms

Mercury sphygmomanometers
are most reliable
Goodman and Gilman's1993

Measurement of Blood Pressure

The "white-coat" effect

Higher B.P recordings in

clinics or hospitals

Prevalence of white coat

hypertension was 3.6%
overall and 12.8% in
hypertensive patients
Marquez Contreras et al. 2006

Clinical assessment of people with

hypertension

Objectives

to confirm a persistent elevation of

blood pressure

to assess the overall cardiovascular risk

to evaluate existing organ damage or

concomitant disease

to search for possible causes of the

hypertension

PREVENTION OF HYPERTENSION

Prevention Of Hypertension

Physical activity, Regular exercise program

Control body weight & prevent Obesity
DASH eating plan

Dietary Advise to Stop Hypertension

Stop Smoking & Alcohol

Good control of Diabetes Mellitus
Good control of Dyslipidemia
Treatment of Renal disease
Treatment of Endocrine disease
Treatment of Secondary causes of HTN
Avoidance of Drugs & Hormones

Table 5.Lifestyle modifications for hypertension

Modification

Recommendation

Approximate SBP
Reduction (Range)

Weight reduction

Maintain normal body weight

(body mass index 18.5 24.9 kg/m 2 ).

5 20 mmHg/10 kg
Weight Loss 23,24

Adopt DASH eating

plan

Consume a diet rich in vegetables and fruits,

8 14 mmHg
low fat dairy products with a reduced content of 25,26
saturated and total fat.

Dietary sodium
reduction

Reduce dietary sodium intake to no more than

100 mmol per day
(2.4 g sodium or 6 g sodium chloride).

2 8 mmHg 25 27

Physical activity

Engage in regular aerobic physical activity

such as brisk walking (at least 30 min per
day, most days of the week).

4 9 mmHg 28,29

Moderation of alcohol
consumption

Limit consumption to no more than 2 drinks

(1 oz or 30 mL ethanol; e.g.,24 oz beer,10 oz
wine, or 3 oz 80-proof whiskey) per day in
most men and to no more than 1 drink per
day in women and lighter weight persons.

2 4 mmHg 30

Algorithm for Treatment of Hypertension

Lifestyle Modifications
Not at goal B.P ( < 140/90 mm Hg) or
(130/80 mm Hg with compelling indications
Initial Drug Therapy
Without Compelling
indications

With Compelling
indications

Stage 1 HTN

Stage 2 HTN

(SBP 140-149 DBP 90-99 mm Hg)

Thiazide type Diuretics for most
May consider ACE-I, ARB, BB, CCB
Or combination therapy

(SBP >150 DBP > 100 mm Hg)

2 drug combination for most
Thiazide type diuretic plus
ACE-I or ARB or BB or CCB

Drug(s) for compelling

Indications alone or
in combination for target
(B.P >130/80 mmHg)

Not at Goal B.P

Optimize dosage or add or change drug combination till target B.P
Consider consultation with Hypertension Specialist

FOLLOW-UP OF HYPERTENSION

Follow-up for HTN

Follow-up and adjustment of medications at

monthly intervals until the BP goal is reached.
More frequent visits for patients with stage 2 HTN
or with complicating co morbid conditions.
Serum potassium and creatinine should be
monitored at least 12 times/year.
After BP is at goal & stable, visits at 3-6-monthly.
Co morbidities, such as heart failure, diabetes, and
other needs for laboratory tests influence the
frequency of visits.
Other cardiovascular risk factors should be treated
to their respective goals.
Tobacco avoidance should be promoted vigorously.

Thank You & Good Bye

For Comments & Queries
email @
amir.riaz@crph.org.pk
amirriaz64@hotmail.com