Dr.M.N.

Ramakrishn
B.Sc., M.B.B.S., M.D.,AFIH., PGDHSc.(Diab)

Dy. Chief Medical Officer Main Hospital Kothagudem

HYPERTENSION

What is Hypertension?
Hypertension is a condition in which the patient has a higher blood pressure than that judged as normal. It is the pressure exerted by the flow of blood on the walls of blood vessels. Arterial pressure, like most physiological measures, is a variable, but a blood pressure above 140/90mm of Hg.is considered as Abnormal.

Normal Blood Pressure

Normal blood pressure is different in different age groups Systolic BP of < 140mm of Hg. and Diastolic BP of <90 mm of Hg. are considered Normal in an adult. In adults normal average BP is Systolic BP 120 mm of Hg. Diastolic BP 80 mm of Hg.

GRADING OF HYPERTENSION
Systolic

Diastolic 80 mm of Hg.

Normal Blood Pressure: 120 mm of Hg

Pre-Hypertension
Stage I HTN

: 120-139 mm of Hg
: 140-159 mm of Hg

80-89 mm of Hg
90-99 mm of Hg

Stage II HTN

: >160 mm of Hg

>100 mm of Hg
<90 mm of Hg

Isolated Systolic HTN : >140 mm of Hg

HOW TO MEASURE BLOOD PRESSURE?

Blood pressure is measured with an instrument called Sphygmo-manometer. Accurate measurements are essential under standardised conditions Three sources of errors have been identified in recording BP: a).Observer errors: Eg.,Hearing acuity, Interpretation of Korotkow sounds. b).Instrumental errors: Eg., Valve leakage, Cuff that do not encircle the arm. c).Subject errors: Eg., Physical environment, Position of subject, Fever Anxiety etc. Contd.

HOW TO MEASURE BLOOD PRESSURE?

WHO study group recommended the sitting position than the supine position for routine BP check up. There should be uniform policy for checking BP either the left arm or right arm consistently. The pressure at which the sounds are heard (phase I) is taken as Systolic BP. Near the Diastolic pressure the sounds first become muffled (phase IV) and then disappear (phase V). Most of the studies have used phase V to measure Diastolic BP. The Systolic and Diastolic pressures should be measured at least 3 times over a period of 3mts and the lowest reading recorded.

CLASSIFICATION OF HYPERTENSION

Hypertension is classified into: - Primary (Essential) HTN - Secondary HTN Primary HTN: The cause is unknown. It is most common form (90-95%). Secondary HTN: Some other disease process or abnormality is involved in its causation. (Eg.Kidney disease, tumors of Adrenal glands, Congenital narrowing of Aorta, Toxemias of Pregnancy etc.)

Signs & Symptoms

Mild to Moderate Essential HTN Usually asymptomatic Accelerated HTN (Hypertensive Encephalopathy): * Headache * Dizziness * Confusion * Vision disorders * Nausea * Vomiting * Epistaxis * Fainting * Chest pain * Breathlessness * Palpitation Secondary HTN: Signs& Symptoms depend on under lying cause.

Risk Factors for HTN

Non-Modifiable risk factors of HTN Age Family History Genetic Factors Modifiable Risk Factors Elevated Serum cholesterol Diabetes mellitus Obesity Smoking Sedentary habits Environmental Stress Lack of exercise Salt Intake Alcohol Oral Contraceptives Vitamin D deficiency Noise & Vibration

Genetic Factors
There is evidence that BP levels are determined in part by genetic factors Twin studies have confirmed the importance of genetic factors in HTN Probably the genetic factors are most important determinants of an individuals Total Cholesterol and HDL levels.
contd

Genetic Factors

Family studies have shown that possibility of HTN in children of Two Normo-tensive Parents is 3% Two Hypertensive Parents is 45%

SATURATED FAT
Animal fats (Meat, Milk Products, Egg etc.) except fish, contain saturated fatty acids which contain low density lipids ,will increase the thickness of blood vessel walls resulting in Hypertension and Coronary Artery Disease.
Vegetable oils(except palm oil & coconut oil) contain poly unsaturated fatty acids, have more high density lipids which protect the heart. The HDL fat acts as a scavenger in removing the LDL attached inside the blood vessel walls.

In typical Indian diet, which is cereal based, about 20gms of fat is obtained as invisible fat. Therefore a daily in take of 20gms or 4 tea spoons of visible fat is sufficient. The ratio of saturated to PUFA should be roughly 0.8-1.0

Diabetes Mellitus

In Diabetes the blood lipids are increased and these contribute to premature or accelerated process of Atherosclerosis and Hypertension.

Obesity
The higher the body weight the greater is the risk of HTN

For every extra KG of fat, one tends to produce 20mg more cholesterol per day.
It is hence necessary to maintain ideal body weight. The simple formula to know the ideal body weight in KGs is height in centimeters minus 100. The tendency for obesity seems to be inherited and over eating. Also it is clearly an important cause with low physical activity.

Sedentary life style

With increasing industrialization, modernization and mechanization, sedentary habits have become a part and parcel of our life styles. Sedentary habits decrease the energy expenditure and therefore contribute to over weight and rise in blood lipids

Lack of Physical Exercise

Incidence of HTN is more in those who lack physical exercise. Regular physical exercise increases the concentration of HDL and decreases the body weight, blood glucose, blood lipids and blood pressure. Walking briskly for 45 minutes a day can bring down the risk of HTN.

Stress
It is well established that ambitious and aggressive personalities are more prone for HTN.

Stress can be physical, social or emotional. Stress causes heart to beat faster, the blood pressure to go up, the muscles to become tense and the arteries to go into spasms. All these occur through release of a substance called Adrenaline
Practice Yoga Yoga, the age-old Indian practice of mind and body control can play prominent role in the reduction of stress and indirectly prevents HTN. Yogic practices are ancient in India, systematized by Pathanjali in 300 BC.

Salt (Sodium Chloride)

Excess salt is bad for the heart. Indians are in the habit of consuming 10-15 gm of salt/day in the form of added salt. Probably 3gms of salt/day is both safe and adequate for healthy adults. Reduction in salt will reduce blood pressure

POTASSIUM

Potassium antagonises the biological effects of Sodium and there by reduces Blood Pressure. Potassium supplements have been found to lower Blood Pressure of mild to moderate Hypertensives. All fruits contain large amounts of Potassium. Take 2 Bananas a day and keep away HTN is the slogan of Nutritionists.

Alcohol
High alcohol intake defined as 75gms or more per day is an independent risk factor for HTN
Alcohol stimulates heart,and increase blood pressure transiently. Alcohol consumption raises Systolic BP more than the Diastolic BP. Alcohol also stimulates FAT metabolism, increases obesity and results in Arteriosclerosis and Hypertension.

Onion & Garlic

In scientific studies large doses of onion & garlic are noted to be beneficial causing a decrease in blood lipids and Hypertension. The garlic and onions that are regularly included in Indians diets may also have beneficial effect. One may as well eat garlic as part of daily diet rather than resort to garlic capsules.

Oral Contraceptive pills

Oral contraceptive pills can raise blood pressure

COMPLICATIONS OF HYPERTENSION

Coronary Artery Disease. Heart Failure. Cerebro -Vascular Accident. Aortic Dissection. Hypertensive Encephalopathy. Malignant Hypertension. Renal Failure. Haemorrhage.

ADVANTAGES OF LIFE STYLE MODIFICATIONS

Modification Recommendation Reduction in Systolic Blood Pressure
5-20mm of Hg/10 kg reduction 8-14mm of Hg. 2-8 mm of Hg. 4-9 mm of Hg. 2-4 mm of Hg.

Weight reduction DASH eating plan Reduction in Na. Physical Activity

BMI 18.5-24.9

Fruits, vegetables, low fat etc. 5-6 gms of sodium Regular aerobic physical activity 30 mts /day Limitation of Alcohol < 2drinks/day(30ml ethanal)

Strategy of Prevention of HTN

Population strategy
High risk strategy Secondary prevention

Population Strategy
The concept of this approach is that even a small reduction in the average BP would reduce the incidence of complications to a large extent. This involves a multi-factorial approach based on the following nonpharmacotherapeutic interventions: a).Nutrition(Reduction in salt, fat & alcohol) b).Weight reduction c).Exercise promotion d).Behavioural change (Reduction in stress, smoking etc.) e).Health education ( On all risk factors) f). Self care ( Self examination of BP etc.)

HIGH RISK STRATEGY

Identification of high risk groups i.e., persons with family history of HTN, Obesity, Diabetes, lack of physical exercise, Alcoholics, Smokers etc. Educating them on risk factors, life style modifications etc.

SECONDARY PREVENTION
The goal is to detect and control high BP in affected individuals and prevent complications. The control measures comprise: 1) Early case detection through screening of populations and follow-up of detected cases. 2) Treatment: Should aim at keeping BP < 140/90 mm of Hg and ideally at 120/80 mm of Hg. 3) Patient compliance: It is defined as the extent to which the patient behaviour coincides with clinical prescription. This can be improved by educating patients families, community etc.