EPIDEMIOLOGY OF

HYPERTENSION (HT)
 HYPERTENSION
It is commonest CVD
It is a major RF for CV mortality, CHD, CVA,
CHF, and RF
The relationship between BP and risk of CVD
events is continuous, consistent, and
independent of other RFs. The higher the BP
the greater the chance of heart attack, HF,
stroke, and kidney diseases.
 In EMR it affects about 25% of adult
population
About 75% of hypertensive individuals are
unaware of being diseased
About 50% of hypertensive patients who knew
they are diseased are either not on treatment
or taking treatment but not controlled.
 HYPERTENSION
Definition of hypertension is arbitrary
BP follows normal distribution curve
BP has a high intra-individual variation

CV risk associated with HT is strongly

correlated with both SBP and DBP, correlation
is higher with SBP
 Population with HT constituted a risk
pyramid:

No. of individuals with mild HT at the base of

the pyramid is high, but the RR is small
No. of individuals with sever HT at the tip of
the pyramid is small, but the RR is high
Absolute no. of complications attributable to
HT is more at base than the tip of the pyramid
 To achieve community control of HT
related CV complications it is important to
control mild HT

A 2mm decrease in the entire distribution will

decrease mortality from
stroke by 6%,
CHD by 4% and
all causes by 3%
 Beginning at 115/75mmHg,
CVD risk (IHD and Stroke) doubles for each
increment of 20/10mmHg

BP values between
130-139/85-89mmHg
are associated with a more than twofold
increase in relative risk from CVD
as compared with those with BP levels below
120/80 mmHg
 DHT predominates before age 50, either alone
or in combination with SBP elevation
The prevalence of SHT increases with age and
above 50 SHT represents the most common
form of HT
DBP is a more potent
CV RF than SBP until the age 50,
thereafter SBP is more important.
 CLASSIFICATION OF HT

The severity of HT depends on:

BP level
Concomitant CV RFs
End-organ damage
 For practical reasons, HT can be classified
into
1.HT with NO other CV RFs and NO target organ
damage
2.HT with other CV RFs
3.HT with evidence of target organ damage
4.HT with other CV RFs AND evidence of other
organ damage
 Classification of HT by BP level:

TYPE SBP (mmHg) DBP (mmHg)

Normotensive <140 and <90

Mild HT 140-180 or 90-105
Subgroup, Borderline HT 140-160 or 90-95
Mod. And Severe HT >180 or >105
Isolated SHT >140 and <90
Borderline SHT 140-160 and <90
 Classification of HT
by Target Organ Damage:
Stage I: No Manifestation
Stage II: At least one of the following:
1.LVH
2.Gen. or Focal narrowing of retinal arteries
3.Microalbuminuria; proteinuria: and /or slight
increase in serum creatinin level (1.2-2 mg/dl)
4.U/S or radiology evidence of plaque in aorta,
carotid, iliac, or femoral arteries
Stage III: Appearance of symptoms or signs
Heart: Optic fundi
AP Retinal Hmg. And exudates
MI +/- papilloedema
HF Kidney:
Brain: S.creatinin level > 2 mg/dl
Stroke RF
TIA Vessels:
HT encephalopathy Dissecting aneurysm
Vascular dementia Symptomatic occlusive
disease
 Classification of HT
by Causes
I.Primary (essential) HT

II.Secondary HT:
Renal: renal parenchyma dis., Reno vascular dis. , rennin
producing tumor
Drugs: OC, Corticosteroids , Liquorices< carbenoxolone,
sympathomometics , NSAIDs
Endocrin:Acromegaly, Cushing Syndrome, Primary
hyperaldosteronism, Congenital adrenal hyperplasia,
Pheochromocytoma, Carcinoid tumors
Coarctation of Aorta and Aoartitis
Pregnancy induced HT
 RECLASSIFICATION OF BP

New data of lifetime risk of HT and the increase of CV

complications associated with levels of BP previously
considered to be normal
JNC 7 introduced prehypertension
The aim is to identify those in whom early
intervention by adoption of healthy lifestyle could
reduce BP, decrease the rate of progression of BP to
hypertensive levels with age, or prevent
hypertension entirely.
JNC6 category SBP/DBP JNC7 category

Optimal <120/80 Normal

Normal 120-129/80-84 Prehypertension

Borderline 130-139/85-89

Hypertension 140/90 Hypertension

Stage 1 140-159/90-99 Stage 1

Stage 2 160-179/100-109 Stage 2
180/110
Stage 3 Stage 2
 CLASSIFICATION OF BP FOR ADULTS
BP SBP DBP
classification mmHg mmHg
NORMAL <120 And <80

PREHYPERTE 120-139 Or 80-89

NSION
STAGE 1 HT 140-159 Or 90-99

STAGE 2 HT 160 Or 100

 Prehypertension is not a disease category. They are
not intended to have drug therapy, but should be
advised to practice lifestyle modification to reduce
risk of developing HT
Individuals with prehypertension who also have DM
or kidney diseases should be considered candidates
for appropriate drug therapy if a trial of lifestyle
modification fails to reduce their BP to 130/80mmHg
or less.
 This classification does not classify HT patients by the
presence or absence of RFs or target organ damage
in order to make different treatment
recommendations, should either or both be present.

All patients with stage 1 or 2 should be treated and

the goal is to reduce BP in HT patients with no other
compelling conditions <140/90
 The goal for individuals with prehypertension
with no compelling conditions is to lower BP
to normal levels with lifestyle changes, and
prevent the progressive rise in BP using the
recommended lifestyle modifications.
 Factors influencing BP level:
@ Age: appositive association between BP level and
age in most populations of different geographical,
cultural, and SE characteristics. The rise in SBP
continue throughout life in contrast to DBP which
rises until the age 50, tends to level off over the next
decade, and may remain the same or fall later in life.
@Sex: early in life, there is no difference between
males and females in BP level, but after puberty
males tend to have higher BP level than females.
After menopause the difference gets narrower.
@Ethnicity: Blacks have higher BP level than others
@SE status: in post-transitional populations
inverse relation In pre and transitional populations
positive association
 Risk Factors of HT
1.Hereditary factors : positive family history
2.Genetic factors: certain genes as ACE gene
3.Early life exposure to certain events: as LBW
4.Certain childhood predictors: as BP response to
exercise, weight gain, LV mass
 Risk Factors of HT(Cont)
5.Body weight: overweight individual has 2-6 times
higher risk having HT compared to a normal weight
individual.
6.Central Obesity and Metabolic Syndrome: high
waist/hip ratio is positively associated with HT
7.Nutritional factors: positive association between Nacl
intake and HT, negative association between
potassium intake and HT, and no relation with
other nutrients.
 Risk Factors of HT (CONT)
8.Alcohol intake : causes acute and chronic
increase in BP level
9.Physical Inactivity : Sedentary unfit individual
has 20-50% excess risk to have HT
10.Heart rate : Ht patients have HR than
normotensive individuals
11.Psychological factors: acute mental stress
causes increase in BP level
12.Environmental factors: noise, air pollution
 Organ Damage Associated With HT

The incidence depends

on level of other RFs(risk factors)
as DM, HCH, Smoking
 Organ Damage Associated With HT
1. LVH:
Powerful predictor of CV complications
Higher risk with strain pattern than with
voltage pattern
Best diagnosed by Echo.
Reversible by anti-HT , and causes
improvement of diastolic function with no
impairment of systolic function
 Organ Damage Associated With HT
2.Atherosclerosis:
Higher in presence of other RFs
3.CHF :
Progressive LV dilatation
LVH+ Coronary Atherosclerosis mark the
development of CHF
Anti-HT can decrease incidence of CHF by 50%
4.Stroke:
HT is the most important and the most modifiable Rf
of all types of stroke
5-6 mmHg reduction in DBP can decrease incidence
of stroke by 40%
 Organ Damage Associated With HT
5.Carotid Stenosis
Frequent cause of stroke
Ulcerated plaques can be a source of emboli
causing TIA
6.Kidney:
Severe accelerated HT causes fibrinoid necrosis of
small blood vessels leading to renal insufficiency
Renal damage in HT is heralded by proteinuria
Microalbuminurea and proteinurea are
independent RF of all CV mortality.
Effective BP reduction can decrease risk of
proteinurea
 Prevention of HT
Community Approach
Primary prevention of HT in the whole
population
High risk Approach
( individual case management)
Identification of individuals with high BP who
are at increased of complications
 Needs of HT control Strategy
1.Data collection: prevalence of HT, RFs of HT, and other CVDs
2.Early Detection: in the health setting and increased self
referral through increased public awareness
3.Health Care Services: responding to the needs of HT
patients, and providing adequate diagnostic and
treatment facilities
4.Coordination of the government and NGOs concerned in
primary prevention of HT and integrate it NCDs
Prevention Program, concentrating on life style measures
5.Community Participation: health education
6.Medical Audit: to monitor the process and quality of care
to patients with HT
 Community Approach
Aim: Primary Prevention of HT through:

1.Elimination of modifiable RFs

2.Promotion of protective factors maintaining

reasonable BP

3.Reduction of risks of complications by altering

the norms and behavior of population
 It is useful to:
Avoid risky life-style that increase BP

Adoption of healthy life-style

Encourage industrial and agricultural activities to

provide healthier food
 Goals:
Increase population awareness that HT is a
major PH problem
Help in detection of HT patients or those at
risk
Advocate life style that eliminate
controllable RFs
 Components Health Education :
1. Public Education:
Nature, causes, complications, prevalence and treatable
nature of HT.
Life style measures for prevention, management, and
contributory role of other CV RFs.
2. Professional Education:
Training in detection, management, and prevention of HT.
Adoption of advocacy role in the community to adopt
healthy life-style.
3. Patient Education:
The need for effective management
Benefits of life-style changes
The need to adhere to health care advice
Regular monitoring and periodic visits
 Population approach is highly effective in
decreasing HT and its complications in the
community,
but it offers little direct individual effect,
making it of less motivation to people and
physicians.
Life style modification at population level requires:
1.Inter-sectoral collaboration
2.Multidisciplinary approach
3.Community involvement and participation
particularly through NGOs
 Individual Approach
Aim: Prevention of complications among HT patients

Components:
Identification of HT patients at risk of complications
Effective management of HT through life-style modification
with or without pharmacologic intervention.

This approach is associated with high motivation for patients and

physicians, but it is costly.
The two approaches are complementary to each other
 Lifestyle measures for prevention of HT
In the whole population (primary prevention) :
they help in
Decrease risk of development of HT
Decrease risk of development of other life-
style related disorders (DM, CHDs,)
In individual patient
they help in:
Decrease BP
Avoid or decrease need for anti-HT treatment
Control associated RFs
 FOYR life-style
measures proved effective in clinical trials:
1.Weight Reduction
2.Reduction of alcohol intake
3.Increased physical activity
4.Reduction of Sodium intake
Life style measures to control other CV RF
CV RF control life-style
1.Tobacco smoking
2.Dyslipidemia
3.Diabetes Mellitus
 1.Weight Reduction
Decreases BP in HT patients with >10% overweight
Decreases insulin resistance
Improves lipid profile
Obese patients with mild or borderline HT should try
weight reduction for 3-6 months before starting
anti-HT treatment
2.Reduction of alcohol intake
Decreases SBP/DBP by 4.8/3.3 mmHg
When combined with 10 Kg weight loss , BP will
decrease by 10.2/7.5 mmHg
 3.Increased physical activity
Effective for prevention and treatment of HT
Dynamic , isotonic exercises ( walking) is more
effective than static , isometric exercises (
weight lifting)
Brisk walking for 30-60 minutes /day for 5
times / week is better than strenuous
exercises.
4.Reduction of Sodium intake
Recommended intake is < 6 gm /day
Elderly people and blacks demonstrate more
sensitivity to sodium restriction
 Life style measures to control other CV RF
1.Tobacco smoking
Smoker 2-3 folds excess risk of stroke and CHD.
Cessation of smoking is the most effective ve.
2.Dyslipidemia
Increased physical activity is most appropriate in
HT patients with dyslipidemia
3.Diabetes Mellitus
Regular exercise, weight reduction, and low fat
high fiber diet can improve insulin sensitivity, and
decrease contribution of insulin resistance to
high BP.