UNIT 2:
CLASSIFICATION OF BLOOD PRESSURE
MEASUREMENTS AND
TYPES OF HYPERTENSION
Objectives:
By the end of this session the participants will be able to:
1. Classify BP measurements
2. Identify causes and risk factors for Hypertension
3. Identify Factors which increases cardiovascular events in
hypertensive patients.
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I. Grading of Raised Blood Pressure
Classification SBP (mmHg) DBP (mmHg)
Normal <120 <80
Pre-hypertension 120-139 80-89
Grade 1 HTN 140-159 90-99
Grade 2 HTN 160-179 100-109
Grade 3 HTN(Severe) >180 >110
Isolated Systolic Hypertension >140 <90
age >60
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Special Groups of hypertension
Isolated systolic hypertension: elevated systolic BP with
normal diastolic BP, mostly seen in elderly patients.
White coat hypertension : Consistently elevated BP in the clinic
setting, but reverts to normal BP out of the clinic.
Masked Hypertension: This is the opposite of white coat
hypertension where patients report to have persistently high
blood pressure at home while their clinic measurements are in
the normal range. Despite having normal/target blood pressure
at clinics they present with evidence of end-organ damages.
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Factors influencing the cardiovascular
risk related to hypertension
•Blood pressure must be seen as a component of a
cardiovascular risk profile. The following four factors
influence the occurrence of complications related to
hypertension:
1. The level of blood pressure
2. The presence of classical CV risk factors
3. Asymptomatic Target Organ Damage
4. Associated Clinical Conditions
1. The level of blood pressure
•Hypertension is the most commonly identified modifiable CV
risk factor in patients presenting with cardiovascular events.
•The higher the blood pressure the higher the risk.
•Pre-hypertension was previously found to be common (up to
40%) in a study population and was associated with increased
risk of myocardial infarction, stroke, heart failure and CV death.
These patients need to be followed up and lifestyle modification
advised.
2. Cardiovascular risk factors
Any factor which significantly increases the likelihood of developing cardiovascular
event is called cardiovascular (CV) risk factor. They are classified as modifiable and
non modifiable risk factors(age,sex ,genetics).
Majority of people with hypertension have multiple other CV risk factors. Presence
of these risk factors in hypertensive patients significantly increases the likelihood of
developing cardiovascular events and therefore should be identified and treated.
These risk factors include:
• Diabetes mellitus
• Smoking
• Low fruit Intake
• Excess alcohol consumption
• Physical inactivity
• Dyslipidemia
• Psychosocial stress
• Obesity
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• Family history of Premature cardiovascular death( Male<55 and Female <65
3. Asymptomatic Target Organ Damage
•Left Ventricular hypertrophy on ECG or echocardiography
•Proteinuria ( excretion of 30-300mg of albumin/24 hr)
•Chronic Kidney Disease with estimated GFR between 30-
60ml/min/1.73msq. body surface area)
•Asymptomatic Peripheral vascular disease
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4. Associated clinical Conditions(ACC)
Current or Past history of cardiovascular diseases or
other diseases which increase the risk of future
cardiovascular events are called Associated Clinical
Conditions(ACC) .
ACCs include:
• Chronic kidney disease(GFR<30ml/min/1.73msq.
body surface )
• Stroke/Transient Ischemic Attack
• Myocardial infarction/Angina
• Heart Failure
• Peripheral arterial disease
• Retinopathy(exudates , papiledema)
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Major Risk factors for CVD
The 9 risk factors account for more than 90% of
10 ischaemic heart disease.
Table 2:Factors-other than BP-influencing prognosis; used
for stratification of total CV risk
Risk Factors Diabetes TOD ACC
Age (>55 male and Fasting plasma Left Ventricular Chronic kidney
>65 female) glucose 126 hypertrophy on disease(GFR<30ml/mi
Male Sex mg/dL on two ECG or n/1.73msq body
Smoking repeated echocardiography surface )
Dyslipidemia measurements, Proteinuria Stroke/TIA
Prediabetes and/or ( excretion of 30- Myocardial
Obesity: abdominal HbA1c >7% 300mg of infarction/Angina
waist circumference: and/or albumin/24 hr) Heart Failure
men ≥94 cm; women Random CKD with eGFR Peripheral artery
≥80 cm or BMI>30. plasma glucose between 30- disease
Family history of >200 mg/dL 60ml/min/1.73ms Retinopathy
Premature q body surface (exudates ,
cardiovascular death area) papiledema)
(Male<55 and Female Asymptomatic
<65 yrs) Peripheral vascular
disease
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Total CV Risk Prediction Chart based on BP levels and presence
of other Risk factors
Figure 3 :CV risk Prediction Chart based on BP levels and presence of other Risk factors . Adapted From ESC/ESH 2013 guideline.
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Case Study 2
Ato Mulatu is 52 year old male person presented to a
clinic for cough , fever and chest pain over the last three
days. He is known to have diabetes for the last five years
but never told to have hypertension . His father died
suddenly while walking to work place with suspected
heart problem at age 50 . On physical he had PR of
112/min, temperature of 37.9o C. His blood pressure
was 150/95 on right arm and 155/95 mmHg on his left
arm. His calculated BMI was 32. No positive findings in
other system examination.
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Case Study 2
Questions
1. How do you interpret the BP values of this patient?
2. Classify the BP reading of this patient.
3. What other CV risk factors is the patient having?
4. Outline your next steps for a patient with these BP
values.
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Case Study 2
Answers
1. How do you interpret the BP values of this patient?
He has raised BP
2. Classify the BP reading of this patient.
If confirmed on different occasions ,he has stage 1 hypertension
3. What other CV risk factors is the patient having?
Diabetes, family history of premature death and obesity.
4. Outline your next steps for a patient with these BP values.Such patties with
raised BP and multiple risk factors ( more than two) should be referred to
higher health facility for evaluation of end organ damages and imitation of
antihypertensive. Once diagnosis is established the patient can be followed at
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health center
