Hypertension Prevention and Control

DR ISAH ABIODUN
DEPT OF FAMILY MEDICINE
FMC KEFFI
*
1

*
*Introduction
*Definition
*Epidemiology
*Classification
*Types
*Risk factors
*Management
* History
* Physical Examination
* Investigations
* Treatment
*Complications
*Prevention.
*Conclusion
*References.
2

*
* Hypertension is a global health challenge and its prevalence is
increasing rapidly amongst adults in many African countries
*Hypertension and other non-communicable diseases are currently
responsible for at least 20% of all deaths in Nigeria.
*Although it rarely causes symptoms on its own, its complications can
lead to suffering, avoidable death and financial burdens.
*Hypertension is arguably the most important modifiable risk factor
for coronary heart disease and stroke
3

*
* Hypertension is a global health challenge and its prevalence is
increasing rapidly amongst adults in many African countries
*Hypertension and other non-communicable diseases are currently
responsible for at least 20% of all deaths in Nigeria.
*Although it rarely causes symptoms on its own, its complications can
lead to suffering, avoidable death and financial burdens.
*Hypertension is arguably the most important modifiable risk factor
for coronary heart disease and stroke
4

Hypertension is a silent, invisible killer that
rarely causes symptoms. Increasing public
awareness is key, as is access to early
detection. Raised blood pressure is a serious
warning sign that significant lifestyle changes
are urgently needed. People need to know why
raised blood pressure is dangerous, and how to
take steps to control it
Dr Margaret Chan
DG WHO5

*
*Systolic blood pressure greater than 140 mm Hg and
a diastolic pressure greater than 90 mm Hg based on
the average of two or more accurate blood pressure
measurements taken during two or more contacts
with a health care provider.
JNC 7
6

*
According to CDC , 1 in 3 Americans are hypertensive.
Globally, 1 billion people grapple with the condition
The prevalence rates of hypertension vary around worldwide with the lowest
prevalence in rural India (3.4% in men and 6.8% in women) and the highest
prevalence in Poland (68.9% in men and 72.5% in women)
*In 2000,972 million people had hypertension with a prevalence rate of
26.4%,333 million developed countries and 639 million in developing
countries.
* It is projected that by 2025 a total of 1.54 billion people accounting for
30% of the World population would be hypertensive with 75% of these from
the developing countries and regions.
7

Global Burden of Hypertension
2025 Projection
*26.4% of world adult
population had
hypertension
*Total of 972 million
adults
*Highest prevalence is in
established market
economies (eg, North
America, Europe)
• 29.2% of world adult
population will have
hypertension
• Total of 1.56 billion adults
20 % in developed nations,
80% in developing nations)
• Highest prevalence will be in
developing continents (eg,
Asia, Africa) will account for
75% of world’s hypertensive
patients
Year 2000 Year 2025
8

*
*In 2008, among all WHO regions, the prevalence of high blood
pressure was highest in the African Region (46%) and lowest in the
Region of the Americas (35%).
* From 1990 to 1999, the pooled prevalence of hypertension was
15.0%; with a significant increase to 22.5% from 2000 to 2009.
*Adedoyin et al. Recorded a prevalence of 30.4% in southwestern
Nigeria.[
*Onwubere et al. in 2011 in a study carried out inEzeagu Community,
Enugu State found a prevalence rate of 46.4% in a population aged
40– 70 years.
9

*Classification
*
Blood pressure(mmhg)
Classsification Systolic Diastolic
Normal 119 or lower 79 or lower
Prehypertension 120-139 80-89
Stage1 hypertenson 140-159 90-99
Stage2 hypertension 160 0r higher 100 or higher
10

*
*Prehypertension is not a disease category rather a designation
for individuals at high risk of developing HTN
*Should be firmly and unambiguously advised to practice
lifestyle modification
*Prehypertensive Clients are not candidates for drug therapy
however if co-morbidity exist then, drug therapy is indicated if
a trial of lifestyle modification fails to reduce their BP to
130/80 mmHg or less
11

Renal Parenchymal diseases, renal cysts(PKD),
renal tumors, obstructive uropathy.
Endocrine causes 1o aldosteronism, Cushin syndrome,
pheochromocytma, hyper/hypothyroidism,
hypercalcemia.
Neurogenic Acute raised ICP,psychogenic, acute soinal
cord section, famillial dysautonomia. Lead
poisoning, Gullian- Barre syndrome.
Drugs Oral contraceptives, adrenal steroids,
antidepressants, cyclosporine, nasal
decongestants, NSAIDS, MAOI,
erythropoetin, cocaine
Pregnancy induced hypertension
Obstructive Sleep apnoea
Co-arctation of the aorta
* 12

*
*Primary HTN:
*Also known as essential HTN.
*Accounts for 95% cases of HTN.
*Gradual in onset
*Age of onset: 4th decade
*S/S occur years after onset of
HTN.
*Strong Family history
*No universally established cause
known, risk factors however
exist.
*Secondary HTN:
*Less common cause of HTN
(5%).
*Dramatic in onset
*Age of onset: 1st- 2nd / 5th -6th
decades
*S/S occur at the start of HTN
*F.H: May/may not be present.
*Secondary to other potentially
rectifiable cause.
13

*Alcohol
*Cigarette smoking
*Diabetes mellitus
*Elevated serum lipids
*Excess dietary sodium
*Obesity (BMI > 30)
*Sedentary lifestyle
*Socioeconomic status
*Stress
*Age (> 55 for men; > 65 for women
*Gender
*Family history
*Ethnicity (African Americans)
*
14

*
*Onset: at age < 20 yrs or > 40 sudden onset (thrombus or
cholesterol embolism).
*Episodic, headache and chest pain/palpitation.
*Nosebleeds - Difficulty in breathing
*Tinnitus (ringing or buzzing in the ears)
*Blurred Vision
*History of snoring and daytime sleepiness (sleep disorders)
*Positive family history of HTN
*Personal habits (cardiac risk factors): nutrition, smoking, alcohol,
exercise, drugs ( Prescribed / recreational)
*Co-morbidities : Diabetes, AGN, CGN, Hyperthyroidism
16

*
Item
General appearance Look for signs of metabolic syndrome (overweight,
truncal obesity), skin chances (striae in cushing
syndrome)
Fundoscopy Retinal changes reflect severity of HTN.
Examination of the neck. Assess for thyroid enlargement, carotid bruits
Cardiopulmonary
Examination
Take blood pressure .Gallops may indicate heart
failure,
Neurological Examination Look for evidence of previous stroke, evaluate
cognition
Peripheral Pulses Reduced leg pulses can indicate coarctation of the
aorta or systemic atherosclerosis. Thickened brachial
artery is indicative of artherosclerosis.
17

*
INITIAL INVESTIGATIONS
1. Urine for: Protein, blood, glucose
2. FBC
3. FBS
4. Serum electrolyte urea and Creatinine
5. ECG
6. Serum – Total cholesterol, HDL, LDL, Triglycerides
7. X-ray chest P/A view
ADDITIONAL INVESTIGATIONS
1. Ambulatory BP recording
2. Renal ultrasonography
3. Renal angiography
4. 24 hours urine assay for creatinine meta morphines and
catacholamines or plasma catacolamines if pheochromocytoma
suspected.
5. Plasma renin activity & aldesterone
18

*Management
*Non- Pharmacological
*Pharmacological
19

*
*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
20

*
*Reductions in stroke incidence, averaging 35–40 percent
*Reductions in MI, averaging 20–25 percent
*Reductions in HF, averaging >50 percent.
21

*
*Having assessed the patient and determined the overall risk profile,
management of hypertension should proceed as follows:
*In low risk patients, it is suggested to institute life style
modifications and observe BP for a period of 2-3 months, before
deciding whether to initiate drug therapy.
*In medium risk patients, institute life style modifications and initiate
drug therapy after 2-4 weeks, in case BP remains above 140/90.
*In high and very high-risk groups, initiate immediate drug treatment
for hypertension and other risk factors in addition to instituting life-
style modification
22

*Renin inhibitors, a newer type of medicine for treating high
blood pressure, act by relaxing your blood vessels
*Renin inhibitors work, as the name would suggest, by
inhibiting the activity of renin, the enzyme largely
responsible for angiotensin II levels. In clinical trials, renin
inhibitors have proven effective in not only lowering blood
pressure, but also keeping blood pressure levels steadier
throughout the day.One renin inhibitor, aliskiren (Tekturna),
was approved by the FDA in 2007. Other drugs in this class are
in development
23

*
*Primodal prevention
*Primary Prevention
*Secondary Prevention
*Tertiary Prevention.
*Quartinary Prevention
28

*
*THE RATIONALE
1. Importance: Hypertension is a very prevalent condition that
contributes to significant adverse health outcomes, including
premature death, heart attack, renal insufficiency, and stroke.
2. Detection: The USPSTF found good evidence that blood pressure
measurement can identify adults at increased risk of
cardiovascular disease from high blood pressure.
3. Benefits of detection and early treatment: The USPSTF found
good evidence that treatment of high blood pressure in adults
substantially decreases the incidence of cardiovascular events
29

*
1. Patient population: This recommendation applies to adults
without known hypertension.
2. Screening tests: Office measurement of blood pressure is most
commonly performed with a sphygmomanometer. Diagnosis is only
after two or more elevated readings are obtained on at least two
visits over a period of one to several weeks.
3. Assessment of risk: The actual level of blood pressure elevation
should not be the only factor in determining treatment. When
making treatment decisions, physicians should consider the
patient's overall cardiovascular risk profile, including smoking,
diabetes, abnormal blood lipid values, age, sex, sedentary
lifestyle, and obesity.
4. Screening interval: The JNC 7 recommends screening every two
years in persons with blood pressure less than 120/80 mm Hg, and
every year in persons with systolic blood pressure of 120 to 139
mm Hg or diastolic blood pressure of 80 to 90 mm Hg.
30

31
*
*Themed: HEALTHY HEART BEAT/HEALTHY BLOOD PRESSURE
*OBJECTIVES
*Raise awareness of the causes and consequence of HTN
*Provide information on how to prevent HTN and related complications.
*Encourage self care to prevent HTN
*Make blood pressure checks affordable for all.
*Incite national and local authority to create a healthy environment for
healthy behaviour
*World

How public health
stakeholders
can tackle hypertension
32

There are six important components of any country
1|an integrated primary care programme
2|the cost of implementing the programme
3|basic diagnostics and medicines
4|reduction of risk factors in the population
5|workplace-based wellness programmes
6|monitoring of progress.
*Initiative To Address Hypertension
33

* Integrated programmes must be established
at the primary care level for control of
hypertension. In most countries this is the
weakest level of the health system.
*Treatment should be targeted particularly at
people at medium or high risk of developing
heart attack, stroke or kidney damage.
The features of an integrated primary
care programme34

*The cumulative cost of implementing an integrated primary
care programme to prevent heart attack, stroke and kidney
failure, using blood pressure as an entry point that address
cardiovascular disease and cervical cancer in all low- and
middle-income countries is estimated to be US$ 9.4 billion a
year
1. Cost of implementing an integrated
primary care programme
35

* Availability of basic technologies to manage people with
hypertension .
*Availability and appropriate use of essential medicines to prevent
complications in people with moderate to high cardiovascular risk .
*The links between different levels of the health system so that
people can be managed appropriately based on heir level of risk.
* 2. A WHO costing tool to estimate
the cost of establishing such a
programme in any country36

*The cost of implementing such a programme is low, at less
than US$ 1 per head in low-income countries, less than US$
1.50 per head in lower middle-income countries and US$ 2.50
in up- per middle-income countries
*
37

*Most cardiovascular disease in the population occurs in
people with an average risk level, because they
constitute the largest proportion of the population.
*The population-based approach is thus based on the
observation that effective reduction of cardiovascular
disease rates in the population usually calls for
community-wide changes in unhealthy behaviors or
reduction in mean risk factor levels.
4 . Reduction of risk
factors in the population
38

*Population-wide approaches to reduce high blood
pressure are similar to those that address other major
non communicable diseases.
*They require public policies to reduce the exposure of
the whole population to risk factors such as an
unhealthy diet, physical inactivity, harmful use of
alcohol and tobacco use , with a special focus on
children, adolescents and youth.
*
39

*WHO considers work place health programmes to be one
of the most cost-effective
* Workplace wellness programmes should focus on
promoting worker health through the reduction of
individual risk-related behaviours, e.g. tobacco use,
unhealthy diet, harmful use of alcohol, physical
inactivity and other health risk behaviors
*
5 Workplace wellness
programmes
and high blood pressure
control 40

*National surveillance health information systems must be
strengthened to monitor the impact of action to prevent and
control hypertension and other risk factors of non
communicable diseases.
*Monitoring systems must collect reliable information on risk
factors and their determinants, non communicable disease
mortality and illness. This data is critical for policy and
programme development. However, some countries still lack
surveillance data for hypertension and other risk factors
*
6. Monitoring the impact of action
to tackle hypertension
41

1. Health Promotion for the General Population
2. Disease Prevention for the High Risk groups.
Community Based Interventions, Workplace Interventions ,
Disease Prevention for the High Risk, Setting up special clinics
, Harnessing the Private Sector and Specific interventions at
the tertiary level to enhance capacity to respond to the
needs of NCD
*Strategies
42

*Awareness generated on HEALTHY LIFE STYLES.
*Decrease in the incidence of Non –Communicable Diseases
particularly, Diabetes, Cardiovascular Diseases,cancer and
Stroke.
*
* Expected outcomes
43

*
* The following non pharmacologic therapies are associated with
reductions in blood pressure:
* Reduction of dietary sodium intake
* Potassium supplementation
* Increased physical activity and weight loss
* Stress management
* Reduction of alcohol intake
*Pharmacological Therapy
*Other Recommendations
*Adults with hypertension should be screened for diabetes.
*Adults should be screened for hyperlipidemia (depending on age, sex, risk
factors) and smoking.
*Physicians should discuss aspirin chemoprophylaxis with patients at increased
risk of cardiovascular disease.
44

*
*1. Patient Based
*2.Physician Based
*3. Societal Based
45

*
IMPEDIMENTS INTERVENTION
Attitudes about hypertension Education at the community and
individual level concerning consequences
of hypertension
Medication Side Effects Use of medications with fewer side
effects.
Medication cost & Availability Use of diuretics and other generically
available medication
Medication Adherence
Less frequent dosing of medications,
combination medications
Methods to increase ease of medication
renewal (i.e, telephone or computer-
linked)
46

*
Knowledge Conferences, academic detailing,
computer-based algorithms, publication of
clinical trials
Access Use of physician extenders, group visits,
work site care, expansion of health
coverage
Awareness Computer based reminders
Motivation Incentives for health providers and
managers
47

*
Awareness Public education campaigns
Community-screening
programs
Work-based programs
Access to care Expansion of health coverage
(private and government
financed)
48

*
*“We stand at a critical crossroads in history when our actions – or
inaction – can shape the future of life on Earth as we know
it…………..
This is a global challenge, one requiring global cooperation among all
sectors of society. In the coming year, my hope is that governments,
working with the business community, civic organizations, foundations,
academic and faith based groups, will continue to work with the United
Nations to help forge a more sustainable path to the future. Working
together, we can bring hope and opportunity to all. The future is truly in
our hands.”
-UN Secretary-General, Ban Ki moon
51

*
*Guidelines Sub-Committee. 1999 World Health Organization –
International Society of Hypertension guidelines for the
management of hypertension. J Hypertens. 1999;17: 151-183.
*Okosun IS, Sooper RS, Rotimi CN, Osotimehin B, Forrester T.
Association of waist circumference with risk of hypertension and
Type 2 diabetes in Nigerians, Jamaicans and African-Americans.
Diabetes Care 1998;21:1836-42.
*World Health Organization, International Society of Hypertension
Writing Group. 2003 World Health Organization (WHO)/International
Society of Hypertension (ISH) statement on management of
hypertension. J Hypertens. 2003;21:1983-1992
*Hay JH. A British Medical Association Lecture on THE SIGNIFICANCE
OF A RAISED BLOOD PRESSURE. Br. Med. J. 1931; 2 (3679): 43–47
*Appel LJ et al. A clinical trial of the effects of dietary patterns on
blood pressure:DASH Collaborative Research Group. N Engl J Med.
1997; 336:1117–1124.
52

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