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![Management of Hypertension in Pregnancy
▪ Mild hypertension: Drug treatment at persistent BP >150/95 mmHg in all women.
Drug treatment at persistent BP >140/90 mmHg in gestational hypertension,
preexisting hypertension with superimposed gestational hypertension; hypertension
with subclinical HMOD at any time during pregnancy.
▪ First choices: methyldopa, beta-blockers (labetalol), and dihydropyridine-calcium
channel blockers (DHP-CCBs) (nifedipine [not capsular], nicardipine).
▪ Severe hypertension: At BP >170 mmHg systolic and/ or >110 mmHg diastolic:
immediate hospitalization is indicated (emergency). Treatment with intravenous
labetalol (alternative intravenous nicardipine, esmolol, hydralazine, urapidil), oral
methyldopa or DHP-CCBs (nifedipine [not capsular] nicardipine). Add magnesium
(hypertensive crisis to prevent eclampsia). In pulmonary edema: nitroglycerin
intravenous infusion.](https://image.slidesharecdn.com/worldhtnday24-240520194252-4df77eab/75/World-Hypertension-Day-17th-may-2024-ppt-42-2048.jpg)
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World Hypertension Day 17th may 2024 ppt
- 1. Hypertension: Prevention and management of Complications DRSEEBAT MASRUR D-CARD STUDENT CARDIOLOGY SZRMCH
- 2. Global Burden OfHypertension Ref: https://www.who.int/news-room/fact- sheets/detail/hypertension#:~:text=An%20estimated%2046%25%20of%20adults,cause%20of%20premature%20death%20worldwide. ▪ An estimated 1.28 billion adults aged 30–79 years worldwide have hypertension, most (two-thirds) living in low- and middle-income countries ▪ An estimated 46% of adults with hypertension are unaware that they have the condition. ▪ Less than half of adults (42%) with hypertension are diagnosed and treated. ▪ Approximately 1 in 5 adults (21%) with hypertension have it under control. ▪ Hypertension is a major cause of premature death worldwide.
- 3. Hypertension in Bangladesh ▪Prevalence: Adults (18-69 years): 23.5% Men: 24.1% Women: 23.0% ▪ Elderly Population (>60 years): Overall: 49% Men: 42% Women: 56% ▪ Awareness and Treatment: 50% of hypertensive adults are unaware. Only 35% receive treatment. Blood pressure controlled in 14%. ▪ Based on this study, we estimate that 1 out of 5 Bangladeshi adults have hypertension. The risk of hypertension increases with older age and high BMI ▪ Ref-2018 May;32(5):334-348. doi: 10.1038/s41371-017-0018-x. Epub 2017 Dec 11
- 4. Epidemiology of hypertensionamong Bangladeshi adults Ref:https://www.nature.com/articles/s41371-018-0087-5
- 5. Impact of Hypertension ▪Hypertensive patients are prone to develop Atrial Fibrillation (AF), Premature Ventricular Contractions (PVC), and Ventricular Tachycardia (VT) ▪ The incidence of Sudden Cardiac Death (SCD) also increases in LVH caused by HTN. ▪ HTN is strongly, independently, and linearly associated with the risk of Stroke. ▪ Risk of Heart Failure (HF) increases 2-3 fold in HTN.
- 6. Impact of Hypertension ▪In-hospital mortality in Hypertensive Heart Failure (HHF) is 13-15% among Asians. ▪ HTN doubles CAD risk. ▪ Shear stress of HTN promotes atherosclerosis. ▪ Sexual dysfunction is a potential complication of hypertension
- 7. 50% The Seventh Reportof the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 20 mmHg SBP increase Mortality from IHD & Stroke Prospective Studies Collaboration. Lancet. 2002;360:1903-1913 SBP versus Mortality
- 8. The Seventh Reportof the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 10% 2 mmHg SBP decrease Mortality from IHD & Stroke Prospective Studies Collaboration. Lancet. 2002;360:1903-1913 Even a small decrease is beneficial
- 10. Definition ofHypertension Hypertension basedon Office-, Ambulatory (ABPM)- and Home Blood Pressure (HBPM) measurement
- 11. Validated equipment forblood pressure measurement
- 12. Office Blood PressureMeasurement ● 2-3 office visits at 1-4-week intervals. ● Whenever possible, the diagnosis should not be made on a single visit (unless BP ≥180/110 mmHg and CVD). ● If possible and available, the diagnosis of hypertension should be confirmed by out- of-office measurement. Blood Pressure Measurementand Diagnosis ofHypertension
- 13. Blood Pressure Measurementand Diagnosis ofHypertension
- 14. Home BP monitoring,before each visit to the health professional 2 X 2 = 4 2 measurements on each occasion 2 occasions in a day (morning and evening) 4 days in a week
- 15. Hypertension Risk Factors NonModifiable Modifiable Family history Gender Age Ethnicity Obesity Excess Salt intake High Saturated fat intake Low consumption of fruits and vegetables Alcohol Smoking Stress Physical inactivity Socio-economic status Drugs eg NSAIDs, STeroids
- 16. Emerging Risk factors SleepDuration and Quality: Conditions such as sleep apnea and insufficient sleep duration have been associated with an increased risk of hypertension. Air Pollution: Exposure to air pollutants, such as particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3), has been identified as a potential risk factor for hypertension. Chemicals found in common household products, plastics, and pesticides, known as endocrine disruptors, may interfere with hormone regulation and contribute to hypertension. Chronic exposure to heavy metals such as lead, cadmium, and mercury, often through environmental pollution or occupational hazards, may contribute to hypertension development by promoting oxidative stress and endothelial dysfunction. Imbalances in gut bacteria, known as dysbiosis, have been associated with hypertension and related metabolic disorders.
- 17. Emerging Risk factors ▪Vitamin D deficiency has also emerged as a potential risk factor for hypertension. ▪ Irregular work schedules and night shifts have been linked to hypertension risk, likely due to disruptions in sleep patterns, circadian rhythms. ▪ Conditions like depression, anxiety, and chronic stress have been linked to hypertension, potentially through mechanisms involving dysregulated stress hormones and unhealthy coping behaviors. ▪ C-reactive protein (CRP) is an emerging biomarker associated with hypertension. ▪ Elevated serum uric acid (s-UA) is common in patients with hypertension.
- 18. Silent Killer ▪ Mostof the patients with hypertension are asymptomatic. ▪ The high BP only noted during an incidental clinical examination. ▪ Small number will present with symptoms such as breathlessness and headache. ▪ A proportion of patients will present with a major preventable complications. ▪ That is why hypertension is called a Silent Killer.
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- 20. Hypertension Mediated OrganDamage Cardiac Complications ▪ Left Ventricular Hypertrophy ▪ Coronary Artery Disease ▪ Heart Failure ▪ Atrial Fibrillation Cerebrovascular Complications ▪ Transient Ischemic Attack ▪ Stroke Peripheral Vascular Complications ▪ Limb Ischemia
- 21. Hypertension Mediated OrganDamage Renal Complication ▪ GFR <60 ml/min/1.73 m2 ▪ Proteinuria (1+ or greater) ▪ Microalbuminuria (2 out of 3 positive tests over a period of 4-6 months) ▪ Dependent (leg) edema Retinopathy ▪ Hemorrhages or exudates, with or without papilledema
- 23. Healthy diet Dietary Approachesto stop hypertension(DASH) Emphasizes on: Whole grains, Fruits & vegetables, Polyunsaturated fats, Dairy products Increase intake of vegetables( leafy green, beetroot etc). Eat ≥ 5 servings of vegetables/fruit per day. Use healthy oils, such as soyabean, sunflower, olive, sesame (Til). Focus on food high in essential elements such as magnesium, calcium and potassium Moderate consumption of fish and poultry Limited intake of red meat Moderate consumption of coffee, green and black tea Limits: Foods high in sugar(sweets, cakes, cookies, fizzy drinks, sugar sweetened beverages, saturated fat, transfat, Alcohol
- 24. Salt reduction ▪ Thereis strong evidence for a relationship between high salt intake and increased blood pressure. ▪ Reduce salt added when preparing foods, and at the table. ▪ Avoid or limit consumption of high salt foods such as soy sauce, fast foods and processed food including breads and cereals high in salt. ▪ Reducing salt intake to the recommended level of <5 gm /day lowers BP in both hypertensive and normotensive individuals.
- 25. Weight reduction ▪ Bodyweight control is indicated to avoid obesity. Particularly abdominal obesity should be managed. ▪ A waist-to-height ratio. ▪ Approximately 60–70% of hypertension in adults is attributable to adiposity (excess body fat). Central body fat, linked to insulin resistance and dyslipidemia, has a more potent impact on blood pressure elevation than peripheral body fat. ▪ Every 1 kg (2.2 pounds) of weight loss, blood pressure decreases by approximately 1 mm Hg.
- 26. Regular physical activity ▪Adults should do at least 150–300 minutes of moderate- intensity aerobic physical activity; or at least 75–150 minutes of vigorous intensity aerobic physical activity; or an equivalent combination of moderate-and vigorous-intensity activity throughout the week, for substantial health benefits. Examples: Brisk walking, swimming, cycling, or yoga. ▪ Adults should also do muscle strengthening activities at moderate or greater intensity that involve all major muscle groups on 2 or more days a week. Examples: Weightlifting, resistance exercises, High-Intensity Interval Training (HIIT).
- 27. Stop Smoking Smoking isintricately linked to hypertension through various mechanisms ▪ Nicotine temporarily raises BP by causing vasoconstriction and increasing heart rate. ▪ Cardon monoxide causes hypoxia, increasing cardiac workload contributing to elevated BP. ▪ Smoking triggers inflammatory response leading to endothelial damage and arterial stiffness which are associated with increased BP. ▪ Studies have shown that quitting smoking leads to a significant reduction in BP, with some individuals experiencing normalization of BP levels within a few weeks to months after cessation.
- 28. Reduce stress andinduce mindfulness ▪ Chronic stress has been associated to high blood pressure later in life. ▪ Stress leads to the release of hormones that temporarily increase heart rate and narrow blood vessels, causing a rise in blood pressure. ▪ Stress Management Strategies: Adjust your schedule to reduce stress. Practice deep, slow breathing to relax. Regular exercise (3–5 times a week for 30 minutes) can lower stress and improve overall health.
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- 34. The Therapeutic approachin special situation Hypertensive urgencies may be treated in an outpatient facility with oral antihypertensives; treatment consists of a slow lowering of BP over 24 to 48 hours. A reduction in BP of no more than 25% within the first 24 hours has been suggested.
- 35. Hypertensive Emergency Hypertensive emergenciesrequire immediate medical attention, including admission to the intensive care unit. The primary goal would be to lower the mean arterial pressure by no more than 25% within the first hour, followed by BP reduction to 160/110-100 mmHg within the next 2 to 6 hours.
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- 38. High blood pressurein patients with diabetes mellitus/DKD Diabetic kidney disease (DKD) causes hypertension in 30-75% of cases of CKD. The presence of microalbuminuria and later frank proteinuria is the effect of DKD and responsible for developing hypertension later. Use of ACEi or ARB are the gold standard to prevent proteinuria and DKD. The BP target for hypertension in DKD is ≤120/80 mm Hg according to KDOQI, ESH and ASH. The management of blood pressure (BP) in patients with ESRD treated with dialysis is difficult. Up to 70-80% of dialysis patients carry a diagnosis of hypertension. According to the 2004 National Kidney Foundation Kidney Disease Outcome Quality Initiative guideline when pre-dialysis BP is>140/90 or when post dialysis BP is antihypertensives are required.
- 39. Hypertension in CoronaryArtery Diseases ▪ A strong epidemiological interaction exists between CAD and hypertension that accounts for 25%–30% of acute myocardial infarctions. ▪ A recent meta-analysis of RCTs of antihypertensive therapy showed that for every 10-mmHg reduction in SBP, CAD was reduced by 17%. ▪ Lifestyle changes are recommended (smoking cessation, diet and exercise). ▪ BP should be lowered if ≥140/90 mmHg and treated to a target <130/80 mmHg (<140/80 in elderly patients). ▪ In hypertensive patients with CAD, beta-blockers and RAS blockers may improve outcomes in post-myocardial infarction period and reduces the mortality in ACS. In patients with symptomatic angina, beta-blockers and rate limiting calcium antagonists are the preferred components of the drug treatment strategy.
- 40. Hypertension in HeartFailure ▪ Hypertension is the leading risk factor for the development of heart failure and most patients with heart failure will have an antecedent history of hypertension. ▪ Heart failure guideline-directed medications are recommended for the treatment of hypertension in patients with HFrEF. ACE inhibitors, ARBs, Angiotensin receptor-neprilysin inhibitor (ARNI) (i.e. sacubitril and valsartan),beta-blockers, and MRAs (e.g.spironolactone and epleronone) are all effective in improving clinical outcome in patients with established HFrEF.
- 41. Hypertension and ChronicObstructive Pulmonary Disease (COPD) ▪ Hypertension is the most frequent comorbidity in patients with COPD. ▪ BP should be lowered if ≥140/90 mm Hg and treated to a target <130/80 mm Hg (<140/80 in elderly patients). ▪ Environmental (air) pollution should be considered and avoided if possible. ▪ The treatment strategy should include an angiotensin AT1 -receptor blocker (ARB) and CCB and/or diuretic, while beta blockers (ß1 -receptor selective) may be used in selected patients (eg, CAD, HF).
- 42. Management of Hypertensionin Pregnancy ▪ Mild hypertension: Drug treatment at persistent BP >150/95 mmHg in all women. Drug treatment at persistent BP >140/90 mmHg in gestational hypertension, preexisting hypertension with superimposed gestational hypertension; hypertension with subclinical HMOD at any time during pregnancy. ▪ First choices: methyldopa, beta-blockers (labetalol), and dihydropyridine-calcium channel blockers (DHP-CCBs) (nifedipine [not capsular], nicardipine). ▪ Severe hypertension: At BP >170 mmHg systolic and/ or >110 mmHg diastolic: immediate hospitalization is indicated (emergency). Treatment with intravenous labetalol (alternative intravenous nicardipine, esmolol, hydralazine, urapidil), oral methyldopa or DHP-CCBs (nifedipine [not capsular] nicardipine). Add magnesium (hypertensive crisis to prevent eclampsia). In pulmonary edema: nitroglycerin intravenous infusion.
- 43. Resistant Hypertension ▪ Resistanthypertension is defined as seated office BP >140/90 mmHg in a patient treated with three or more antihypertensive medications at optimal (or maximally tolerated) doses including a diuretic. ▪ Resistant hypertension is defined as seated office BP >140/90 mmHg in a patient treated with three or more antihypertensive medications at optimal (or maximally tolerated) doses including a diuretic. ▪ Resistant hypertension affects around 10% of hypertensive individuals
- 44. Device-Based Therapies 2017 ESH/ESCguidelines state that various device-based therapies are available:- ▪ Carotid baroreceptor stimulation (pacemaker and stent). ▪ Renal denervation. ▪ Creation of an arteriovenous fistula (ie, ROX coupler)
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- 46. Take Home Message ▪Hypertension is a very common serious medical condition that increase the risk of heart, brain, kidney, blood vessel and eye damage. ▪ It is a major cause of preventable premature death. ▪ Adopting a Healthy lifestyle is the key to a healthy heart and mind. ▪ Awareness about risk factors of hypertension & Early intervention is the key to control hypertension effectively and reduce complication. ▪ Accurate measurement of blood pressure is imperative for the detection and diagnosis of hypertension.
- 47. Thank You IN TINYSTEPS WE FIND OUR WAY, TO KEEP HYPERTENSION AT BAY, WITH HEALTHY CHOICES COME WHAT MAY, WE MANAGE BLOOD PRESSURE DAY BY DAY
- 48. References ▪ 2020 InternationalSociety of Hypertension Global Hypertension Practice Guidelines ▪ National Guideline on Hypertension 2023 ▪ Hypertensive Crisis- (Maria Alexandra Rodriguez, Siva K. Kumar, Matthew De Caro)- Cardiology in Review 2010;18: 102–107
- 49. LIFESTYLE MODIFICATION ADVICEFOR ALL PATIENTS ▪ Stop all tobacco use, avoid secondhand tobacco smoke. ▪ Stop taking alcohol. ▪ Increase physical activity to equivalent of brisk walk 150 minutes per week. ▪ If overweight, lose weight. ▪ Eat heart-healthy diet: o Reduce dietary salt intake o Eat ≥ 5 servings of vegetables/fruit per day. o Use healthy oils, such as soyabean, sunflower, olive, sesame (Til). o Eat nuts, peas, whole grains and foods rich in potassium like spinach, watermelon, yogurt and banana. o Limit red meat to once or twice a week at most. o Eat fish or other food rich in omega 3 fa�y acids at least twice a week. o Avoid added sugar from sweets, cakes, cookies, fizzy drinks, sugar sweetened beverages
- 51. Conditions constituting evidenceof EOD ▪ Hypertensive encephalopathy ▪ Intracerebral heamorrhage ▪ Stroke ▪ Head trauma ▪ Ischemic heart disease (most common) ▪ AMI ▪ Acute LVF with P/oedema ▪ Unstable angina ▪ Aortic dissection ▪ Eclampsia ▪ Life threatening arterial bleed
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- 53. 2020 ISH HypertensionPractice Guidelines 53 ISH 2020 guidelines were developed To be used Globally To be fit for application low and high resource setting To be concise, simplified and easy to use
- 54. Average Percentage ofReduction Stroke Incidence 35-40% Myocardial Infraction 20-25% Heart Failure 50% Benefits of Lowering BP
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