Hypertension
From Standard of Care
Normal blood pressure less than 120/80 mm Hg.
Pre-hypertension-systolic blood pressure between 120 and 139 mm Hg and diastolic between 80 and 89 mm Hg.
Defined as a systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure 90 mm Hg or higher.
Most common problem for which patients visit physicians.
About 20-30% of adults have hypertension.
Lifetime incidence is 90%.
Approximately 73 million adults in the U.S, and approximately 1 billion adults worldwide suffer with this entity.
Framingham study: 90% of individuals with normal blood pressure at age 55 years eventually developed hypertension.
Prevalence of hypertension increased from 25% in 1988 to 27.7% among those 18 years of age or older with increased body mass index responsible for most of the increase.
People who are normotensive at age 55 have a 90% chance of developing hypertension in their lifetime.
More than 50% of all adults older than age 65 have hypertension.
The risk of cardiovascular death doubles with each 20/10 mm Hg increment beginning with a BP 115/75 mmHg.
There is a continuous linear increase in systolic blood pressure with advancing age.
There are four stages blood pressure classification-normal, prehypertension, stage 1, and stage 2 hypertension.
Hypertension single most common risk factor for the development of atrial fibrillation..
Stroke, heart failure are common complications of AF, are both related to hypertension.
Contributes to more excess deaths in women than any other preventable factor.
The higher and individual's systolic or diastolic pressure, the higher their risk of cardiovascular morbidity and mortality ( National High Blood Pressure Education Program Working Group).
Excessive alcohol intake and alcohol abstinence, use of nonnarcotic analgesics and low folic acid intake are independent and modifiable risk factors in women for the development of high blood pressure.
Blood pressure level related to risk of stroke, coronary artery disease, congestive heart failure, and death from cardiovascular disease in a continuous manner for values as low as 115/75 mm Hg.
Multiple Risk Factor Interventional trial involving 347,978 men, the risk of fatal stroke for systolic blood pressure over 180 mm Hg was nearly 15 times as high and the risk of fatal ischemic heart disease 7 times as high as the rates among individuals with optimal blood pressure.
60% of Caucasians over the age of 60 years have hypertension.
Most common disease in industrialized nations, with a prevalence greater than 20% in the general population.
Essential hypertension account for 90% of cases.
Pattern changes with age: before age 50 most cases related to diastolic hypertension, after age 50 as systolic pressure rises, and diastolic pressure tends to fall, isolated systolic hypertension predominates.
Pronounded elevation of systolic BP during stress, such as during a treadmill test associated with adverse long-term prognosis (Mundal R).
Secondary hypertension resulting from an underlying, identifiable, often correctable cause make up 5-10% of cases of hypertension.
Estimated prevalence of hypertension in children 2-5%.
Hypertension in children may be due to secondary factors or essential.
Majority of children and adolescents with mild to moderate hypertension have primary disease without a known cause.
Hypertension in children correlate with family history of hypertension, low birth weight and excessive weight.
Blood pressure in children and adolescents is increasing in parallel with weight gain.
Hypertension in children more commonly due to secondary factors such as renal disease, endocrine abnormalities and coarctation of the aorta.
Associated with increased CV disease related morbidity, mortality, blindness, chronic kidney disease and ESRD.
One of the most important preventable causes of premature morbidity and motality.
During childhood reflects an independent risk factor for hypertension in adulthood and is a marker for risk development of left ventricular hypertrophy, intima and media thickness atherosclerosis, diastolic dysfunction and arterial compliance changes.
White coat hypertension accounts for 20% of the patients with elevated readings.
Cushing's and primary aldosteronism account for less than 10% of cases.
Prevalence of hypertension 1.5-2.0 times greater in African Americans than in white population.
Blacks have the highest morbidity and mortality from hypertension than any group in the U.S. and is among the highest in the world.
Obstructive sleep apnea is an independent risk factor for hypertension.
Medications associated with HT: acetaminophen, NSAIDs, antidepressants, birth control pills, decongestants, corticosteroids, bevacizumab, tamoxifen, sorafenib,and aromatase inhibitors.
Treatment reduces the incidence of stroke, myocardial infarction, heart failure and cardiovascular disease and total mortality in men and women age 65 and older.
Modest reduction in blood pressure is associated with significant reductions in the risk of adverse cardiovascular events such as stroke, coronary heart disease, and death.
Fewer than 1/3 of patients with hypertension achievevrecommended levels of blood pressure control.
Estimated that as many as two-thirds of the very old have hypertension.
Prevalent in the elderly, with 64% of men and 68% of men having hypertension.
High prevalence in the elderly is related to age associated increase in arterial stiffness from media arterial structural change in collagen, interstitial fibrosis and calcifications.
Increased stiffness and tortuosity of the aorta and large arteries is reflected in increased systolic blood pressure and widened pulse pressure.
Elevated blood pressure causes vascular damage and accelerated conduit arterial stiffening.
Aortic and vascular stiffness increases pressure pulsatility and may increase systolic BP.
Elderly individuals with hypertension are more likely to have increased left ventricle mass, peripheral resistance, characteristic aortic impedance at rest, left atrial enlargement, reduced baroreceptor sensitivity, let ventricular early diastolic filling volume and cardiovascular response to catecholamines.
Baroreflex sensitivity reduction occurs when the age and with hypertension and leads to impaired baroreflex mediated increase in systemic vascular resistance and inability to increase heart rate, so that elderly hypertensives are more likely to develop orthostatic and postprandial hypotension.
Hypertension in the elderly person accelerates renal function impairment.
Increased systolic blood pressure and pulse pressure in the elderly are stronger risk factors for cardiovascular morbidity and mortality then increased diastolic blood pressure.
Increased pulse pressure in older persons with isolated systolic hypertension indicates reduced vascular compliance in large arteries and is a better risk marker in systolic or diastolic blood pressure.
The Cardiovascular Health Study indicated that a brachial systolic blood pressure higher than 169 mmHg increased mortality rate 2.4 times in older men and women (Fried LP et al).
In men age 85 and older higher systolic blood pressure is associated with better survival.
In pregnancy BP 140/90 or higher.
Poorly controlled BP patients have increased BP with varying kinds of stress due to the association of increased sensitivity to BP elevating hormones due to thickened vascular smooth muscles in arterioles (Folkow B).
White coat elevations in BP only weakly associated with long-term prognosis compared to ambulatory BP measurements (Boggia J).
Nocturnal BP profile in the absence of physical activity, emotional stress, and environmental factors that are usually present during the day, is more representative of the true blood pressure status, and a stronger predictor of cardiovascular outcomes.
Altered circadian pattern of BP is associated with higher levels of proteinuria.
Ambulatory blood pressure monitoring is the only method to identify white coat hypertension and nighttime hypertension simultaneously.
Ambulatory bilood pressure measurement is superior to clinic blood pressnure measurements in predicting end stage renal disease and/or all cause mortality and cardiovascular events.
Ambulatory blood pressure measurement is a better predictor of renal and cardiovascular end points compared with office blood pressure measurement in patients with chronic kidney disease (Minutolo R et al).
Systolic ambulatory blood pressure measurement in the above study was a better predictor of adverse outcomes then was ambulatory diastolic blood pressure values.
Ambulatory blood pressure measurement of nighttime systolic blood pressure in the above study was a stronger predictor than daytime systolic blood pressure for cardiovascular endpoints.
Home blood pressure monitoring correlates better with end-organ damage than measurements in the clinic.
Physical fitness decreases blood pressure in both lean and obese subjects.
Only about 25% of patients with hypertension in the U.S. are being treated with a blood pressure level below 140/90.
Goal for BP management 140/90 or less, for diabetics less than 130/80 mmHg, for diabetics with chronic kidney disease 125/75 mmHg.
In young men, blood pressure above normal is significantly related to increased long-term mortality due to cardiovascular disease, coronary artery disease and all causes.
Increases the risk of renal cell cancer.
Goal of management should be set at <140/85 mm Hg.
Treatment results in reduction of strokes by 36%, coronary artery disease by 27% and all cardiovascular disease by 32%.
Treatment results in a 20% reduction in total mortality (Ford ES et al).
Most common risk factor for CHF.
Comparison trials of antihypertension medicines with placebo have consistently shown lowering of blood pressure reduces the incidence of coronary events, strokes and congestive heart failure, irrespective of age sex, severity of disease, presence of comorbid factors or type of antihypertensive agent utilized
At all ages, systolic blood pressure should be lowered to below 140 mm Hg.
For patients at any age with a diastolic blood pressure greater than 90 mm Hg, a reduction to below 90 mm Hg is appropriate.
For people older than 65 years with hypertension and diastolic blood pressure less than 90 mm Hg, caution is needed not to inadvertently lower than levels below 65 mm Hg when treating hypertension.
In the U.S. only 70% of hypertensive patients are aware of their problem, 59% are on treatment and only 34% are adequately controlled.
The initiation of antihypertensive drugs in the elderly is associated with an immediate increase in the risk of falls.
Orthostatic hypotension with uncontrolled hypertension is a risk factor for falls.
Risk of cardiovascular disease increases with progressive and continuous elevations of systolic or diastolic blood pressure, with an approximate doubling for every 20 mm Hg in systolic and 10 mm Hg in diastolic increases within the range of 115/75 to 185/115 mm Hg.
Increase in cardiovascular disease risk occurs independently of other risk factors.
Elevated systolic blood pressure is more important than increased diastolic pressure as a risk factor for both cardiovascular and renal disease.
Premenopausal females with isolated hypertension have a relatively low absolute short term risk of cardiovascular disease compared with males.
Only 25% of African Americans have their blood pressure under control compared the 34% if whites.
In a randomized trial of 1094 black patients with hypertensive chronic kidney disease to receive either intensive with standard blood pressure control: primary clinical outcome was the progression of chronic kidney disease defined as a doubling of the serum creatinine or death with a follow-up from 8.8-12.2 years: intensive blood pressure control had no effect on kidney disease progression (Appel LJ et al).
In the African-American Study of Kidney Disease and Hypertension (AASK): intensive blood pressure control had no effect on the progression of kidney disease, although lowering blood pressure may retard progressive renal disease in patients with a protein-to-creatinine ratio of more than 0.22 at baseline (Appel LJ et al).
Prevalence of chronic kidney disease, stages 1-4, among adults in the United States increased from 10% from 1988-1994 to 13% from 1999-2004.
Average decline in GFR among black patients with hypertensive chronic kidney disease is approximately 2 mL per minute per 1.73 m² of body surface area or year, which is about twice the usual age associated decline in the general population (Wright JT et al Lindeman RD et al).
BP control worlwide is poor, below 10%.
Determination of serum creatinine is needed in all patients as a determination of target organ damage.
Frankly elevated creatinine is a poor prognosis factor.
Treatment reduces both ischemic and hemorrhagic strokes.
The Hypertension in the Very Elderly Trial (HYVET) 3845 patients 80 years or older wewre randomized to indapamide, with or without perindopril or placebo: Treated patients had a reduced sitting mean systolic and diastolic blood pressures of 15.0 and 6.1 mm Hg and had a 64% reduction in the rate of heart failure, 23% reeduction in rate of cardiovascular death, and a 21% reduction in death of any cause, but no benefit to reducing stroke (Beckett NS et al).
Higher systolic blood pressure is associated with increased risk of mortality among elderly adults who have a medium to fast walking speed: In contrast among slow walking older adults there is not an association between elevated systolic blood dialogue diastolic blood pressure and mortality (Odden MC et al).
Blood pressure control in the elderly is suggested at 140/90 mm HG.
Nearly a three-fold increase is the risk for developing hypercreatinemia in patients with diastolic blood pressure of 115 mm Hg or greater compared with those with a diastolic blood pressure between 90 and 104 mm Hg.
Sodium intake should be no more than 6 gm of sodium chloride per day.
Individuals with higher sodium or lower potassium intake have increased risk for hypertension.
Insulin resistance and hyperinsulism predispose individuals to develop hypertension via cellular abnormalities of insulin signaling and associated hemodynamic and metabolic abnormalities.
Insulin resistance abnormalities that predispose to hypertension include cellular cation imbalance, increased sympathetic nervous system activity, enhanced renin-angiotensin activity, increased inflammatory changes and oxidative stress.
Should maintain and adequate dietary intake of potassium, approximately 90 mmol/day.
Only 24% of patients with hypertension and on treatment have blood pressures of <140/90 mm Hg.
Treatment can reduce heart failure by 55%.
Initial evaluation includes assessment for other cardiovascular risk factors, end-organ damage analysis, assessment of concomitant diseases, identifying causes of hypertension, identifying lifestyle factors contributing to the process.
Systolic blood pressure and pulse pressure correlate more strongly with cardiovascular disease risk than does diastolic blood pressure.
Elevated diastolic pressures of greater than 120 mm Hg not associated with progressive or new end-organ damage can be managed over hours to days as an outpatient.
Marked elevation of diastolic blood pressures requires emergency management in an intensive care unit with parental medication treatment.
Reduction in systolic blood pressure of a little as 5 mm Hg reduces incidence of stroke by approximately 40% and myocardial infarction by 20%.
Weight reduction to a body mass index <24.9 kg/ m2 can decrease systolic pressure ranging from 5-20 mmHg with a 10 kg weight loss.
The DASH. diet should be implemented.
Exercise of 30 minutes of aerobic activity most days of the week encouraged.
Among women with hypertension diuretic monotherapy, ACE inhibitors plus diuretics and B-blockers plus diuretics are superior to calcium channel blockers plus diuretics in preventing cardiovascular complications associated demonstrated in the Women's Health Initiative Observational Study.
Diuretics, particularly thiazide type, or B-blockers recommended as initial therapy for stage I hypertension (systolic blood pressure of 140-59 mm Hg or diastolic blood pressure of 90-99 mm Hg.
Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial-a randomized double blind study involving hypertension compared an angiotensin converting enzyme (ACE) inhibitor benazepril (Lotensin) combined with the calcium channel blocking agent amlopidine (Norvasc) or the diuretic hydrochlorthiazide.
ACCOMPLISH results: the combination of benazepril and amlopidine compared to benazepril and hydrochlorthiazide revealed a 20% relative risk reduction and an absolute risk reduction of 2.2% of composite illness and death from cardiovascular causes, and a similar reduction from death due to cardiovascular reasons and nonfatal myocardial infarction.
ACCOMPLISH study patients was at high risk of cardiovascular disease with average age at entry was 68 years, a history of ischemic heart disease, peripheral vascular disease, left ventricular hypertrophy and diabetes were included.
In the second Nurses’ Health Study 83,882 adult women aged 27-44 yeas without hypertension were followed for 14 years for incident hypertension: low risk combinations of modifiable lifestyle factors such as maintaining a normal BMI, consuming a diet high in fruits, vegetables, low fat dairy products and low sodium , participating in vigorous daily physical activity, drinking a moderate amount of alcohol, avoidance of nonnarcotic and consuming folic acid were associated with a dramatic decrease in the incidence of hypertension (Forman JP).
Aggressive control of hypertension compared to standard treatment does not reduce all cause mortality and rates of myocardial infarction, stroke, congestive heart failure major cardiovascular events and end-stage renal disease (Arguedas).
In a review of 22,000 participants with hypertension and comparing standard therapy with target treatment goals of lowering blood pressure to 140-160 mm Hg systolic and 90-100 mm Hg diastolic, while reducing systolic and diastolic blood pressure levels about 4 mm Hg and 3 mm Hg, respectively: benefits were found to be limited (Cochrane Database).
European society of hypertension recommending threshold blood pressure levels of about 120 mm Hg systolic and 70 mm Hg diastolic for patients at high risk of cardiovascular complications from hypertension and suggest that further lowering of blood pressure is harmful (Sleight).
For stage 2 hypertension (systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 100 mm Hg) ACE inhibitors, angiotensin receptor blockers, B-blockers, or calcium channel blockers and combined therapy with thiazide diuretics plus another drug class are recommended agents.
Reduction of left ventricular mass with antihypertensive treatment can improve patients prognoses.
Persistence of LVH with antihypertensive drugs is associated with a poor prognosis.
Inhibition of the renin-angiotensin system with angiotensin-converting enzyme inhibitors, or angiotensin-II receptor blockers, should be the first line treatment in patients with nephropathy, with or without diabetes, to decrease proteinuria and slow progression of renal disease.
Hypertension Optimal Treatment (HOT) trial suggested reduced cardiovascular outcomes for diabetic patients assigned to diastolic treatment goal of less than 80 mm Hg compared to treatment with higher goals (Hannson L).
United Kingdom Prospective Diabetes Study group data indicated tight control of blood pressure reduced macrovascular and microvascular outcomes.
Tight control of systolic blood pressure among patients with diabetes and coronary artery disease is not associated with improved cardiovascular outcomes compared with usual control (Cooper-DeHoff, RM).
In the above study during 16893 patient-years of follow-up the same degree of cardiovascular outcomes was noted among the tight controlled group and the usual treatment control group (Cooper-DeHoff, RM).
Decreasing systolic blood pressure to lower than 130 mm Hg in patients with diabetes and coronary artery disease is not associated with further reduction in morbidity beyond that associated with systolic blood pressure lower than 140 mm Hg, and is associated with an increase in all-cause mortality (Cooper-DeHoff, RM).
Induction of left ventricular hypertrophy results in excess fibrous tissue deposition throughout the myocardium increasing the likelihood of ventricular arrhythmias than patients without LVH or with normal blood pressure.
