Dr.

Yoga Nathan
Public Health
UL
 160/95 mm Hg?

140/90 mm Hg?
How can we define `Hypertension or `High blood
pressure?

BY DEFINING THE BP LEVEL ABOVE WHICH IT

IS BENEFICIAL TO REDUCE BP

This the definition generally used

Arbitrary definition, changing over time
1950s DBP 120
1960s DBP 110
1980s DBP 100 SBP 160
Now DBP 90 SBP 140
A small proportion of individuals with high
blood pressure have a specific medical cause
(secondary hypertension):

<1% in general population

<5% in medical clinics

The rest have no specific medical cause (primary

or essential hypertension)
a) -Coarctation of aorta
b) -Renal and renal vascular disease
c) -Adrenal disease
d) cortical 1 hyperaldosteronism,
e) Cushings syndrome
f) medulla phaeochromocytoma
g) -Pregnancy
h) -Drugs esp OCP, HRT
 Rural communities in less developed settings
Hunter gatherer, subsistence diet
low in fat, salt, alcohol
Low mean body mass index
High physical activity
Low stress levels (?)
-Generally show that blood pressure patterns
change (increase) to those of the host population:

* Change generally occurs within 6 months

* Strong evidence for ENVIRONMENTAL
influence on population BP
* May be exceptions high BP in African-
Caribbeans may have genetic basis
 SBP higher by:-
-High body mass index 15 mmHg
-High alcohol intake 8 mmHg
-High salt intake 5 mmHg
-Low potassium intake 5 mmHg
-Low fibre/high fat 2-3 mmHg
-Physical inactivity 2-3 mmHg
-Stress ????
 Age being older
Ethnicity African-Caribbean
Family history positive
Body mass Overweight/obese
Alcohol intake high
Which is more strongly related to
risk, systolic or diastolic?

-Both are important, systolic slightly more so

-In older people, `high systolic BP can occur

with `normal diastolic pressure (isolated
systolic hypertension), is associated with
increased CV risk
How strong are the relative risks of
high blood pressure (60-69 years)?

-Usual systolic BP 20 mmHg higher:-

relative risk of stroke 2.32
relative risk of CHD 1.85
-Usual diastolic BP 10 mmHg higher:-
relative risk of stroke 2.50
relative risk of CHD 1.79

Applies above SBP 115, DBP 75 mmHg

Prospective Studies Collaboration, Lancet 2002

 25
Percent of Population

20

15 90th percentile

10
95th percentile
5

0
80 100 120 140 160 180 200
Systolic Blood Pressure (mm Hg)
Source: NHANES II
 12
Stroke Rate per 1,000

10
Population

6
4

2
0
<120 120-139 140-159 160-179 180+
Systolic Blood Pressure (mm Hg)

Source: Framingham Heart Study, 1980

 140 United States
130 Northern Europe
(No./10,000 Person Years)

120
Mortality From CHD

110 Mediterranean southern Europe

100 Inland southern Europe
90 Serbia
80
70 Japan
60
50
40
30
20
10
0
110 120 130 140 150 160 170
Systolic Blood Pressure (mm Hg)

(Adjusted for age, serum TC, current smoking status for each quartile)
Van den Hoogen PCW, et al, for the Seven Countries Study Research Group. N Engl J Med.
2000;342:1-7.
 DIES

16 yr Lost
150/100

9 yrs
140/95

130/90 4

120/80

0 10 20 30 40 50
Build/Bp Study: 1935-1954;Metropolitan Life
 Hypertension

Angina TIA Renovascular Claudication

pectoris Ischemic disease Aneurysm
Unstable stroke Renal failure Critical limb
angina Hemorrhagic ischemia
Myocardial stroke
infarction
Sudden death
Heart failure
 -Coronary (ischaemic) heart disease
-Stroke (all types)
-Ischaemic stroke
-Haemorrhagic stroke
-Subarachnoid haemorrhage
-Heart failure
-Hypertensive heart disease
-Sudden death
-Renal failure
-(All-cause mortality) How do we know this?
 Population-Based Strategy
SBP Distributions

After Before
Intervention Intervention

Reduction in
BP

Reduction in SBP % Reduction in Mortality

mmHg Stroke CHD Total
2 -6 -4 -3
3 -8 -5 -4
5 -14 -9 -7
Hypertension 1991;17:I-16I-20.
 SOURCES OF DIETARY SALT

Other
Sodium Table Salt
Water
1% 3% 9%
Cooking Salt
6%

Processed Food
81%

Source: James et al. The dominance of salt in manufactured food in the sodium intake
of affluent societies. Lancet 1987;8530:426-428.
 Raised blood pressure is the biggest single cause
of cardiovascular disease accounting for 62% of
strokes and 49% of heart disease.
Strokes and coronary heart disease kill more
people around the world than any other cause of
death around 12.7 million people each year.
It is estimated that reducing salt intake by 6g a
day could lead to a 24% reduction in deaths from
strokes and an 18% reduction in deaths from
coronary heart disease, thus preventing
approximately 2.6 million stroke and heart
attack deaths each year worldwide.
 Preventable

Treatable

Controllable

Why is so Difficult to Do?

Sustained reduction in blood pressure over about
5 years effectively reverses the risks of the higher
pressure

-If usual diastolic BP 10 mmHg lower:-

relative risk of stroke reduced by about 60%
relative risk of CHD reduced by about 44%
Greater BP reduction gives greater CV risk
reduction
-Similar BP reduction (e.g. 10 mmHg) will
reduce
relative risk of CVD by similar amount, whatever
the starting blood pressure
Because the relations of BP and CVD risk are
continuous there is no rational target for BP
reduction (pragmatic targets for patients on
treatment)

Br Hyp Soc SBP <140 DBP < 85 mmHg

Who should have their BP lowered?
-The traditional view:
The reason for lowering blood pressure is that it is high.
`People who need their blood pressure lowered are those
who have a high blood pressure

-The new view

The reason to lower blood pressure is to reduce the risk of
cardiovascular disease
`People who need their blood pressure lowered are those
who are at high risk of cardiovascular disease (almost
irrespective of their blood pressure)

-The third (middle) way

`Blood pressure should be treated on its merits but should
take account of overall CV risk
Lifestyle Modifications
Approximate SBP
Modification Reduction
(range)

Weight Reduction 5-10 mmHg/10kg

Adopt DASH eating plan 8-14 mmHg

Dietary sodium reduction 2-8 mmHg

Physical activity 4-9 mmHg

Moderation of alcohol
24 mmHg
consumption
 Responsibility for a Problem
(Who is to blame?)

Self Other

Moral Model Compensatory Model

Person feels lazy Person feels deprived
Responsibility Self
Person needs motivation Person needs power
for a Solution (skill)
(Who will control
the future?)
Enlightenment Model Medical Model
Other Person feels guilty Person feels ill
Person needs discipline Person needs treatment

* Brickman, American Psychologist 37(4):368384, April 1982.

 Patient believes
His diagnosis Patient cooperates Patient doesnt
Hypertension is serious with doctor, and BP want to think of
In the efficacy of medicine is controlled. himself as sick.
He can control HBP with Patient told, Its
doctors help. okay now.

Patient believes
Patient doesnt doctor meant
Patient receives Patient stops
understand the Stop taking the
no re-education medicine and
difference between medicine when
about the visits.
control and cure. he said, Youre
lifelong need for
He thinks hes under control.
treatment.
cured.

Belief that hes

Patient receives
cured and told to Drops
no call from
stop medicine is out
doctor.
reinforced.
Patient believes Patient Patient believes he can
His diagnosis believes control HBP with self-
In medicine and its hypertension discipline or by
efficacy to lower blood is nervous accepting life.
pressure tension.
In the need for lifelong
treatment Patient takes
In the hazard of HBP if medicine when he
left uncontrolled feels tense and
believes this
Patient believes he adequately lowers
can tell when BP is BP.
Patient believes
medicine is needed high since he
only to lower blood knows when he is
pressure, not to keep tense. Patient feels no need to Drops
it low. see doctor and keep out
appointments because
he knows when to take
medicine.

Medical system Patient believes hes adequately

Patient has no
does not follow up controlledreinforced by lack of
symptoms to tell him
to recall patient for professional intervention.
that blood pressure is
appointments.
uncontrolled.

Remains Uncontrolled
 Public health approaches, (e.g. reducing calories,
saturated fat, and salt in processed foods) can
achieve a downward shift in a populations BP.
Reducing overall BP by only a few mm Hg could
affect overall CVD morbidity and mortality by as
much or more than treatment alone.
Public Health approaches provide an attractive
opportunity to interrupt and prevent the costly
cycle of managing hypertension and its
complications.