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RT. students.
Introduction • HTN. is silent killer , an asymptomatic chronic disorder, that undetected and undertreated ,silently damages the blood vessels , heart , brain and kidneys. (Brounwald 2012 )
Bp.
Major risk factors • Hypertension • Age • Diabetes mellitus • Dyslipidemia • Estimated GFR <60 ml/min • Family history • Microalbuminuria • Obesity • Physical inactivity • Tobacco usage Target organ damage • Heart  Left ventricular hypertrophy  Angina/prior myocardial infarction  Prior coronary revascularization  Heart failure • Brain  Stroke or transient ischemic attack  Dementia • Chronic kidney disease • Peripheral arterial disease • Retinopathy JNC 7 Cardiovascular Risk Factors
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
Prevalence of Hypertension by Age  Age  18-29  30-39  40-49  50-59  60-69  70-79  80+  % Hypertensive  4  11  21  44  54  64  65
Hypertension GULF-RACE 53 50 49 60 56 34 0 20 40 60 80 100 Oman UAE Qatar Bahrain Kuwait Yemen %
Messerli N Engl J Med 1995;3321038.
Messerli N Engl J Med 1995;3321038.
TOMHS VA MONORx CONVINCE ALLHAT ANBP2 LIFE HAPPHY MAPHY INSIGHT NORDIL CAPPP STOP-2 VALUE ASCOT ACCOMPLISH Clinical Trials in Hypertension HR Black, 2003. 1960s 1970s 1980s 1990-1995 1996-1999 2000 2001-2003 2004-2009 Should we treat diastolic HBP? What is the best way to treat HBP? Should we treat DBP in older persons? What is the goal of treatment? Should we treat ISH in older persons? Can we prevent hypertension? VA Cooperative Studies MRC-1 ANHBP-1 EWPHE MRC-2 STOP-1 SCOPE HDFP HOT UKPDS Syst-Eur Syst-China SHEP TROPHY
11 Globally Renowned HT Societies 1. JNC VIII – Joint National Committee on HT, USA 2. ISH – WHO International Society on HT 3. AHA – American Heart Association, USA 4. ACC – American College of Cardiologist 5. BHS – British Hypertension Society 6. NIHLB – National Inst. Heart Lung & Blood vessels 7. EHS – European Hypertension Society 8. CHS – Canadian Hypertension Society 9. NKF – National Kidney Foundation, USA 10.AKA – American Kidney Association, USA 11.GHA- Gulf heart association 12.SHA –Saudi Heart Association 13.EHS- Egyptian hypertension society 14.Etc.
Physicians’ Bias in HT 12  Isolated SHT is often dubbed as ‘aging factor’  To consider HT is only in the ‘ARM’ and not in the body  No concept of ‘pulse pressure’ – Not seeing the whole  Worry about side effects – Need to watch, not to worry  OK, some control is achieved – why attain goal BP ?  Not insisting on compliance with drugs & assessments  Pressure from patients – B.P. How much ? How much ?  Concentrating on the pill & not on the ill –TLC forgotten
13 HYPERTENSION The Truth is It is only a marker of the bigger problem Hypertension is a multi-organ systemic disease What we record as B.P. The Problem is Hypertension is asymptomatic in 85% of cases
14 How to be wise in HT? The Truth is To consider Hypertension as an isolated disease Hypertension, DM, Dyslipidemia, Obesity often coexist They are the 4 pallbearers to the grave of CHD, CVD For all of them Primary and secondary prevention by TLC is the answer Afflicted with one, must be screened for all other thieves It is wrong
Systemic Arterial Hypertension JNC VII / WHO - IHS BP > 140/90 mmHg  BP Continuous biological variable  No cut-off point of separation N vs H  High BP doubling the long term risk
16 Progression of HT to LVH to HF
SURVIVAL RATE HT + LVH V/S NT + LVH 17 1.00 0.99 0.98 0.97 0.96 0.95 0.94 0.93 2 0 4 6 8 10 12 14 16 18 Survival Time (Years) Hypertensive-LVH Normotensive-LVH Hypertensive-No LVH Nomotensive-No LVH Portion Surviving Source : Am Hear J, 2000; 140 (6) : 848-856.
Management of hypertension: the issues
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
a. Office measurement b. Home measurement c. Monitoring BP To establish the diagnosis, measure BP accurately
To confirm hypertension & determine its level  Home readings correlate better with TOD  < office readings by 12/7 mmHg  Epidemiology is based on office readings  Not more than twice weekly  Periodical calibration at home
 Careful & frequent measurements.  3 sets of 3 readings at intervals of 2 or more.  Average of multiple readings taken  Over 1-2 months Office Measurement
Accurate blood pressure measurement I. Patient II. Equipment III. Technique
I. Patient - Posture  Patient seated , back supported, arm bared at heart level  Five minutes rest Blood pressure measurement 
I. Patient - Circumstances  Quiet , warm room  No caffeine, smoking, alcohol 30 min. p  No talking Blood pressure measurement
II. Equipements • Cuff size : 12-13 cm x 35 cm • Manometer : types/calibration Blood pressure measurement
• Non - invasive • Semi - automatic • Automatic II. Equipment - Devices Blood pressure measurement
III. Technique  Korotkoff Sound no 5 (disap of sound=DBP)  Both arms: (if peripheral arterial dis)  Standing BP: in elderly & diabetic(orthostatic HTN.)  Cuff at heart level (whatever patient’s position) Blood pressure measurement
I. Patient - Posture
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
I. Patient - Posture
I. Patient - Arm
I. Patient - Arm
Popliteal BP +20 mmHg
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
• Non - invasive
Sphygmomanometer or Devices
II. Equipment • Cuffs size Blood pressure measurement
II. Equipment • Cuff size Blood pressure measurement
II. Equipment Blood pressure measurement
• Cuff size
• Cuff size
• Cuff size
II. Equipment Blood pressure measurement
II. Equipment Blood pressure measurement
II. Equipment Calibration
II. Equipment Calibration
Stethoscope
BP measurement devices  Manual sphygmomanometers : - Mercury and aneroid sphygmomanometer  Automated sphygmomanometers : - Use in hospitals - Self measurement - AMBP measurement - Measurement in community settings
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
7- HssssssssssssssssssTN-2020ثثثثثث.pptx
200 180 160 140 120 100 80 60 40 20 0 No sound Clear sound Clear sound Muffled sound No sound Phase 1 Phase 3 Phase 4 Phase 5 Muffling Phase 2 Auscultatory gap No sound mmHg Korotkoff sounds Systolic BP Phase 3 Phase 4 Diastolic BP
BP Measurement Definitions BP Measurement Definition SBP First Korotkoff sound* DBP Fifth Korotkoff sound* Pulse pressure SBP minus DBP Mean arterial pressure DBP plus one third pulse pressure† Mid-BP Sum of SBP and DBP, divided by 2 *See Section 4 for a description of Korotkoff sounds. †Calculation assumes normal heart rate . BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.
To confirm hypertension & determine its level To establish the diagnosis measure BP accurately : a. Office measurement b. Home measurement c. Ambulatory Monitoring BP
The ambulatory blood pressure monitoring (ABPM)
The ambulatory blood pressure monitoring (ABPM)

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7- HssssssssssssssssssTN-2020ثثثثثث.pptx

  • 2. Introduction • HTN. is silent killer , an asymptomatic chronic disorder, that undetected and undertreated ,silently damages the blood vessels , heart , brain and kidneys. (Brounwald 2012 )
  • 3. Bp.
  • 4. Major risk factors • Hypertension • Age • Diabetes mellitus • Dyslipidemia • Estimated GFR <60 ml/min • Family history • Microalbuminuria • Obesity • Physical inactivity • Tobacco usage Target organ damage • Heart  Left ventricular hypertrophy  Angina/prior myocardial infarction  Prior coronary revascularization  Heart failure • Brain  Stroke or transient ischemic attack  Dementia • Chronic kidney disease • Peripheral arterial disease • Retinopathy JNC 7 Cardiovascular Risk Factors
  • 6. Prevalence of Hypertension by Age  Age  18-29  30-39  40-49  50-59  60-69  70-79  80+  % Hypertensive  4  11  21  44  54  64  65
  • 8. Messerli N Engl J Med 1995;3321038.
  • 9. Messerli N Engl J Med 1995;3321038.
  • 10. TOMHS VA MONORx CONVINCE ALLHAT ANBP2 LIFE HAPPHY MAPHY INSIGHT NORDIL CAPPP STOP-2 VALUE ASCOT ACCOMPLISH Clinical Trials in Hypertension HR Black, 2003. 1960s 1970s 1980s 1990-1995 1996-1999 2000 2001-2003 2004-2009 Should we treat diastolic HBP? What is the best way to treat HBP? Should we treat DBP in older persons? What is the goal of treatment? Should we treat ISH in older persons? Can we prevent hypertension? VA Cooperative Studies MRC-1 ANHBP-1 EWPHE MRC-2 STOP-1 SCOPE HDFP HOT UKPDS Syst-Eur Syst-China SHEP TROPHY
  • 11. 11 Globally Renowned HT Societies 1. JNC VIII – Joint National Committee on HT, USA 2. ISH – WHO International Society on HT 3. AHA – American Heart Association, USA 4. ACC – American College of Cardiologist 5. BHS – British Hypertension Society 6. NIHLB – National Inst. Heart Lung & Blood vessels 7. EHS – European Hypertension Society 8. CHS – Canadian Hypertension Society 9. NKF – National Kidney Foundation, USA 10.AKA – American Kidney Association, USA 11.GHA- Gulf heart association 12.SHA –Saudi Heart Association 13.EHS- Egyptian hypertension society 14.Etc.
  • 12. Physicians’ Bias in HT 12  Isolated SHT is often dubbed as ‘aging factor’  To consider HT is only in the ‘ARM’ and not in the body  No concept of ‘pulse pressure’ – Not seeing the whole  Worry about side effects – Need to watch, not to worry  OK, some control is achieved – why attain goal BP ?  Not insisting on compliance with drugs & assessments  Pressure from patients – B.P. How much ? How much ?  Concentrating on the pill & not on the ill –TLC forgotten
  • 13. 13 HYPERTENSION The Truth is It is only a marker of the bigger problem Hypertension is a multi-organ systemic disease What we record as B.P. The Problem is Hypertension is asymptomatic in 85% of cases
  • 14. 14 How to be wise in HT? The Truth is To consider Hypertension as an isolated disease Hypertension, DM, Dyslipidemia, Obesity often coexist They are the 4 pallbearers to the grave of CHD, CVD For all of them Primary and secondary prevention by TLC is the answer Afflicted with one, must be screened for all other thieves It is wrong
  • 15. Systemic Arterial Hypertension JNC VII / WHO - IHS BP > 140/90 mmHg  BP Continuous biological variable  No cut-off point of separation N vs H  High BP doubling the long term risk
  • 16. 16 Progression of HT to LVH to HF
  • 17. SURVIVAL RATE HT + LVH V/S NT + LVH 17 1.00 0.99 0.98 0.97 0.96 0.95 0.94 0.93 2 0 4 6 8 10 12 14 16 18 Survival Time (Years) Hypertensive-LVH Normotensive-LVH Hypertensive-No LVH Nomotensive-No LVH Portion Surviving Source : Am Hear J, 2000; 140 (6) : 848-856.
  • 21. a. Office measurement b. Home measurement c. Monitoring BP To establish the diagnosis, measure BP accurately
  • 22. To confirm hypertension & determine its level  Home readings correlate better with TOD  < office readings by 12/7 mmHg  Epidemiology is based on office readings  Not more than twice weekly  Periodical calibration at home
  • 23.  Careful & frequent measurements.  3 sets of 3 readings at intervals of 2 or more.  Average of multiple readings taken  Over 1-2 months Office Measurement
  • 24. Accurate blood pressure measurement I. Patient II. Equipment III. Technique
  • 25. I. Patient - Posture  Patient seated , back supported, arm bared at heart level  Five minutes rest Blood pressure measurement 
  • 26. I. Patient - Circumstances  Quiet , warm room  No caffeine, smoking, alcohol 30 min. p  No talking Blood pressure measurement
  • 27. II. Equipements • Cuff size : 12-13 cm x 35 cm • Manometer : types/calibration Blood pressure measurement
  • 28. • Non - invasive • Semi - automatic • Automatic II. Equipment - Devices Blood pressure measurement
  • 29. III. Technique  Korotkoff Sound no 5 (disap of sound=DBP)  Both arms: (if peripheral arterial dis)  Standing BP: in elderly & diabetic(orthostatic HTN.)  Cuff at heart level (whatever patient’s position) Blood pressure measurement
  • 30. I. Patient - Posture
  • 32. I. Patient - Posture
  • 37. • Non - invasive
  • 39. II. Equipment • Cuffs size Blood pressure measurement
  • 40. II. Equipment • Cuff size Blood pressure measurement
  • 50. BP measurement devices  Manual sphygmomanometers : - Mercury and aneroid sphygmomanometer  Automated sphygmomanometers : - Use in hospitals - Self measurement - AMBP measurement - Measurement in community settings
  • 53. 200 180 160 140 120 100 80 60 40 20 0 No sound Clear sound Clear sound Muffled sound No sound Phase 1 Phase 3 Phase 4 Phase 5 Muffling Phase 2 Auscultatory gap No sound mmHg Korotkoff sounds Systolic BP Phase 3 Phase 4 Diastolic BP
  • 54. BP Measurement Definitions BP Measurement Definition SBP First Korotkoff sound* DBP Fifth Korotkoff sound* Pulse pressure SBP minus DBP Mean arterial pressure DBP plus one third pulse pressure† Mid-BP Sum of SBP and DBP, divided by 2 *See Section 4 for a description of Korotkoff sounds. †Calculation assumes normal heart rate . BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.
  • 55. To confirm hypertension & determine its level To establish the diagnosis measure BP accurately : a. Office measurement b. Home measurement c. Ambulatory Monitoring BP
  • 56. The ambulatory blood pressure monitoring (ABPM)
  • 57. The ambulatory blood pressure monitoring (ABPM)