HYPERTENSION
Detection, Evaluation
and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA
Problem Magnitude
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Hypertension( HTN) is the most common
primary diagnosis in America.
35 million office visits are as the primary
diagnosis of HTN.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may
be as much as 1 billion.
7.1 million deaths per year may be attributable
to hypertension.
Definition
A systolic blood pressure ( SBP) >139
mmHg and/or
 A diastolic (DBP) >89 mmHg.
 Based on the average of two or more
properly
measured, seated BP
readings.
 On each of two or more office visits.
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Accurate Blood Pressure Measurement
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The equipment should be regularly inspected and
validated.
The operator should be trained and regularly retrained.
The patient must be properly prepared and positioned
and seated quietly for at least 5 minutes in a chair.
The auscultatory method should be used.
Caffeine, exercise, and smoking should be avoided
for at least 30 minutes before BP measurement.
An appropriately sized cuff should be used.
BP Measurement
At least two measurements should be
made and the average recorded.
 Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.
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Follow-up based on initial BP
measurements for adults*
www.nhlbi.nih.gov
*Without acute end-organ damage
Classification
www.nhlbi.nih.gov
Prehypertension
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SBP >120 mmHg and <139mmHg and/or
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DBP >80 mmHg and <89 mmHg.
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Prehypertension is not a disease category
rather a designation for individuals at high risk
of developing HTN.
Pre-HTN
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Individuals who are prehypertensive are not
candidates for drug therapy but
Should be firmly and unambiguously advised to
practice lifestyle modification
Those with pre-HTN, who also have diabetes or
kidney disease, drug therapy is indicated if a
trial of lifestyle modification fails to reduce their
BP to 130/80 mmHg or less.
Isolated Systolic Hypertension
Not distinguished as a separate entity as
far as management is concerned.
 SBP should be primarily considered
during treatment and not just diastolic BP.
 Systolic BP is more important
cardiovascular risk factor after age 50.
 Diastolic BP is more important before age
50.
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Frequency Distribution of Untreated HTN by Age
Isolated Systolic
HTN
Systolic Diastolic
HTN
Isolated Diastolic
HTN
Hypertensive Crises
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Hypertensive Urgencies: No progressive
target-organ dysfunction. (Accelerated
Hypertension)
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Hypertensive Emergencies: Progressive
end-organ dysfunction. (Malignant
Hypertension)
Hypertensive Urgencies
Severe elevated BP in the upper range
of stage II hypertension.
 Without progressive end-organ
dysfunction.
 Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
 Usually due to under-controlled HTN.
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Hypertensive Emergencies
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Severely elevated BP (>180/120mmHg).
With progressive target organ dysfunction.
Require emergent lowering of BP.
Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure with pulmonary
edema
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm
Types of Hypertension
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Primary HTN:
also known as
essential HTN.
accounts for 95%
cases of HTN.
no universally
established cause
known.
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Secondary HTN:
less common cause
of HTN ( 5%).
secondary to other
potentially rectifiable
causes.
Causes of Secondary HTN
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Common
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Intrinsic renal disease
Renovascular disease
Mineralocorticoid
excess
Sleep Breathing
disorder
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Uncommon
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Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism
Secondary HTN-Clues in Medical
History
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Onset: at age < 30 yrs ( Fibromuscular
dysplasi) or > 55 (athelosclerotic renal artery
stenosis), sudden onset (thrombus or
cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation
(pheochromocytoma, thyroid dysfunction).
Morbid obesity with history of snoring and
daytime sleepiness (sleep disorders)
Secondary HTN-clues on Exam
Pallor, edema, other signs of renal
disease.
 Abdominal bruit especially with a diastolic
component (renovascular)
 Truncal obesity, purple striae, buffalo
hump (hypercortisolism)
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Secondary HTN-Clues on Routine
Labs
Increased creatinine, abnormal urinalysis
( renovascular and renal parenchymal
disease)
 Unexplained hypokalemia
(hyperaldosteronism)
 Impaired blood glucose
( hypercortisolism)
 Impaired TFT (Hypo-/hyper- thyroidism)
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Secondary HTN-Screening
Tests
www.nhlbi.nih.gov
Renal Parenchymal Disease
Common cause of secondary HTN (2-5%)
 HTN is both cause and consequence of
renal disease
 Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins
imbalance
 Renal disease from multiple etiologies.
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Renovascular HTN
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Atherosclerosis 75-90% ( more common in
older patients)
Fibromuscular dysplasia 10-25% (more
common in young patients, especially females)
Other
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Aortic/renal dissection
Takayasu’s arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation
Complications of Prolonged
Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
 Complications arise due to the “target
organ” dysfunction and ultimately failure.
 Damage to the blood vessels can be seen
on fundoscopy.
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Target Organs
CVS (Heart and Blood Vessels)
 The kidneys
 Nervous system
 The Eyes
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Effects On CVS
Ventricular hypertrophy, dysfunction and
failure.
 Arrhithymias
 Coronary artery disease, Acute MI
 Arterial aneurysm, dissection, and
rupture.
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Effects on The Kidneys
Glomerular sclerosis leading to impaired
kidney function and finally end stage
kidney disease.
 Ischemic kidney disease especially when
renal artery stenosis is the cause of HTN
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Nervous System
Stroke, intracerebral and subaracnoid
hemorrhage.
 Cerebral atrophy and dementia
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The Eyes
Retinopathy, retinal hemorrhages and
impaired vision.
 Vitreous hemorrhage, retinal detachment
 Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction
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Retina Normal and Hypertensive
Retinopathy
A
B
C
Normal Retina
Hypertensive Retinopathy
A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots (Micro
Strokes)
Stage I- Arteriolar Narrowing
Arteriolar Narrowing
Stage II- AV Nicking
AV
AVNicking
Nicking
AV Nicking
AV Nicking
Stage III- Hemorrhages (H), Cotton
Wool Spots and Exudats (E)
H
E
Stage IV- Stage III+Papilledema
Patient Evaluation Objectives
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(1) To assess lifestyle and identify other
cardiovascular risk factors or concomitant
disorders that may affect prognosis and guide
treatment
(2) To reveal identifiable causes of high BP
(3) To assess the presence or absence of
target organ damage and CVD
(1) Cardiovascular Risk factors
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Hypertension
Cigarette smoking
Obesity (body mass index ≥30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)
(2) Identifiable Causes of HTN
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Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushing’s
syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
(3) Target Organ Damage
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Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
History
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Angina/MI Stroke: Complications of HTN,
Angina may improve with b-blokers
Asthma, COPD: Preclude the use of b-blockers
Heart failure: ACE inhibitors indication
DM: ACE preferred
Polyuria and nocturia: Suggest renal
impairment
History-contd.
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Claudication: May be aggravated by bblockers, atheromatous RAS may be present
Gout: May be aggravated by diuretics
Use of NSAIDs: May cause or aggravate HTN
Family history of HTN: Important risk factor
Family history of premature death: May have
been due to HTN
History-contd.
Family history of DM : Patient may also
be Diabetic
 Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
 High alcohol: A cause of HTN
 High salt intake: Advice low salt intake
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Examination
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Appropriate measurement of BP in both arms
Optic fundi
Calculation of BMI ( waist circumference also
may be useful)
Auscultation for carotid, abdominal, and femoral
bruits
Palpation of the thyroid gland.
Examination-contd.
Thorough examination of the heart and
lungs
 Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
 Lower extremities for edema and pulses
 Neurological assessment
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Routine Labs
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EKG.
Urinalysis.
Blood glucose and hematocrit; serum
potassium, creatinine ( or estimated GFR),
and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.
Goals of Treatment
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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
Benefits of Treatment
Reductions in stroke incidence,
averaging 35–40 percent
 Reductions in MI, averaging 20–25
percent
 Reductions in HF, averaging >50 percent.
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Lifestyle modifications
www.nhlbi.nih.gov
Lifestyle Changes Beneficial in Reducing Weight
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Decrease time in sedentary behaviors such
as watching television, playing video games, or
spending time online.
Increase physical activity such as walking,
biking, aerobic dancing, tennis, soccer,
basketball, etc.
Decrease portion sizes for meals and snacks.
Reduce portion sizes or frequency of
consumption of calorie containing beverages.
DASH Diet
Dietary approaches to Stop Hypertension
 As effective as one medication
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JNC 7 Summary
Joint National Commission 7th Report
 PDF File on website
 50 page document
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Other JNC 7 Resources
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Software for use with Palm and Pocket
PC
JNC 7 Reference Card
Other Resources
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Chronic Kidney Disease Information
GFR Calculator
 www.nephron.com
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Hyperlipedemia Information
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Adult Treatment Panel 3 Guidelines
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www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Questions
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mkeen@fammed.washington.edu