1. health and fitness
2. disease
3. heart disease

What is Blood Pressure?
Hypertension
The force of blood against the wall of the arteries.
Systolic means the pressure while the heart beats.
Dr Youssef Beaini
Clinical Lead in Cardiovascular Disease in
Bradford, Airedale, Wharfedale and Craven
GPwSI Cardiology
Diastolic pressure is measured as the heart relaxes.
Normal Blood pressure is less than 120 mm Hg systolic
and less than 80 mm Hg diastolic.
(We can have a debate about what’s normal!)
The Ridge Practice, Bradford
High Blood Pressure
A consistent blood pressure of 140/90 mm Hg or higher
is considered pathological.
Untreated Hypertension
Target Organs that are Damaged:
The heart – heart disease
It increases chance for multiple problems including heart
disease, kidney disease, and stroke.
The brain - cerebrovascular disease
Has no real warning signs or symptoms.
The kidneys - renal disease
Arteries - large vessel disease
How Does It Effect the Body?
The Brain
The Heart
High Blood Pressure is a major risk factor for heart
attack and Coronary Artery Disease
High blood pressure is the most important risk factor for
stroke – haemorrhagic (bleed) or thrombotic (clot).
Is the number one risk factor for Congestive Heart
Failure.
Indirect effects: AF
Image: www.washington.edu
1
The Kidneys
High blood pressure can cause
microvascular damage to the small blood
vessels in the kidneys.
The Eyes
Can eventually cause blood vessels to break and bleed
in the eye – hypertensive retinopathy
Can result in blurred vision or even blindness.
Worst case scenario: dialysis. Major
cause of CKD along with diabetes.
Image: www.diabetes.NIDDK.NIH.gov
Image: www.umich.edu
The Arteries
Hypertension can cause shear
stress and non-linear blood
flow, creating a vicious circle of
atheromatous damage to
arterial wall.
What causes High Blood
Pressure?
-Genetic factors (implicated in
majority)
-Being overweight or obese
-High salt intake
-Narrowing or stiffening of the
arteries (arteriosclerosis) / Aging
-Alcohol
-Secondary causes
renal – parenchymal disease,
renal artery stenosis,
endocrine
drugs
Image: http://www.nhlbi.nih.gov
Causes of years of life lost and
years of life with disability
“What’s all the fuss about? I feel fine”
Murray et al
Lancet 2013
UK Paper for 2010 Global Burden of
Disease Study.
2
In considering mortality data, it is
important to consider health risks
Years of Life Lost by Cause:
Top 5 causes of YLL
A = all ages
IHD
Lung Cancer
Stroke
COPD
Lower Resp Tract infection
Top 5:
Tobacco
BP
BMI
Activity
B = 20 to 54 yrs old
IHD
Self Harm
Cirrhosis
Breast Cancer
Lower Resp Tract infection
Alcohol
Outcomes attributable to HTN
Area
Bradford District
Bradford City
CCG
Bradford District
CCG
Airedale,
Wharfedale,
Craven CCG
Cases
cerebrovascular
disease
539
68
Cases ischaemic
heart disease
Risk Factors
CVD deaths,
preventable
727
102
294
31
355
441
193
121
190
73
•Most HTN is undiagnosed.
•Even in diagnosed still room for improvement.
•Scope for improvement in BP related outcomes
Hypertension is a major risk factor for:
•
•
•
•
•
•
ischaemic and haemorrhagic stroke
myocardial infarction
heart failure
chronic kidney disease
cognitive decline
premature death
Prevalence
At least one quarter of adults have high blood pressure.
and more than half of those older than 60
The prevalence of diagnosed hypertension in
Bradford is 12.2%
But:
About 62% of cerebrovascular disease and ~50% of
ischaemic heart disease are caused by suboptimal blood
pressure control (WHO, 2002).
Reducing mean population blood pressure levels by 5%
would result in discounted annual savings of
approximately £0.9 billion (NICE, 2011).
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Prevalence
Is it worth treating?
– local data
Estimate of true prevalence of hypertension in
Bradford:
Blood pressure:
Each 10mmHg systolic or 5mmHg diastolic (=10/5) drop
55,763 have undiagnosed hypertension
=
(estimated prevalence from the East of England
Public Health Observatory Prevalence Model)
22% reduction in cardiac events and
41% reduction in stroke
Benefits seen down to 110/70 mmHg
(Law et al, BMJ 2009;338:b1665)
Adherence
Potential Lives Saved
Nearly 10% of CVD events due to poor adherence
Patients can reduce risk of event by a quarter by
simply taking medicines as prescribed
(Choudhury et al. Eur Heart J (2013): 10.1093)
Cooney et al (2009) found that a 10% population
reduction in blood cholesterol, blood pressure and
smoking prevalence would save approximately
9120 lives per million population over 10 years
( e.g. = 4978 lives in Bradford over the next 10
years)
Definitions
So, what do I do about
hypertension?
Stage 1 hypertension:
• Clinic blood pressure (BP) is 140/90 mmHg or
higher and
• ABPM or HBPM average is 135/85 mmHg or higher.
Stage 2 hypertension:
• Clinic BP 160/100 mmHg is or higher and
• ABPM or HBPM daytime average is 150/95 mmHg
or higher.
Severe hypertension:
• Clinic BP is 180 mmHg or higher or
• Clinic diastolic BP is 110 mmHg or higher.
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Scope
Clinical management of
primary hypertension in
adults who may, or may
not, have pre-existing
cardiovascular disease.
Groups not included are people with secondary
causes of hypertension, accelerated hypertension
or acute hypertension, pregnant women, and
children and young people aged under 18.
Initiating drug treatment
Offer antihypertensive drug treatment to people:
• who have stage 1 hypertension, are aged under 80 and
meet identified criteria
• who have stage 2 hypertension at any age.
If aged under 40 with stage 1 hypertension and without
evidence of target organ damage, cardiovascular disease,
renal disease or diabetes, consider:
• specialist evaluation of secondary causes of
hypertension
Monitoring drug treatment (2)
For people identified as having a ‘white-coat effect’
consider ABPM or HBPM as an adjunct to clinic
blood pressure measurements to monitor response
to treatment.
Aim for ABPM/HBPM target average of:
• below 135/85 mmHg in people aged under 80
• below 145/85 mmHg in people aged 80 and over.
White-coat effect: a discrepancy of more than 20/10 mmHg between clinic
and average daytime ABPM or average HBPM blood pressure
measurements at the time of diagnosis.
Diagnosis (1)
If the clinic blood pressure is 140/90 mmHg or higher,
the GP should offer ambulatory blood pressure
monitoring (ABPM) to confirm the diagnosis of
hypertension.
Monitoring drug treatment (1)
Use clinic blood pressure measurements to monitor response
to treatment. Aim for target blood pressure below:
• 140/90 mmHg in people aged under 80
• 150/90 mmHg in people aged 80 and over
If diabetic, aim <140/80
or if end organ damage (stroke, eyes, CKD), then <130/80
CBPM ≥140/90 mmHg
& ABPM/HBPM
≥ 135/85 mmHg
CBPM ≥160/100 mmHg
& ABPM/HBPM
≥ 150/95 mmHg
Stage 1 hypertension
Stage 2 hypertension
Care pathway
If target organ damage present or
10-year cardiovascular risk > 20%
If younger than 40 years
Offer antihypertensive
drug treatment
Consider specialist
referral
Offer lifestyle interventions
Offer patient education and interventions to support adherence to treatment
Offer annual review of care to monitor blood pressure, provide support and
discuss lifestyle, symptoms and medication
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Aged over 55 years
or black person of
African or Caribbean
family origin of any
age
Aged under
55 years
C2
A
A+
C2
Summary of
antihypertensive
drug treatment
Drug treatment
Choosing antihypertensive drug treatment
Step 1
Step 2
A+C+D
Step 3
Resistant hypertension
Step 4
Key
A – ACE inhibitor or low-cost
angiotensin II receptor
blocker (ARB)1
C – Calcium-channel
blocker (CCB)
D – Thiazide-like diuretic
Offer people aged 80
and over the same
antihypertensive drug
treatment as people aged
over 55, taking into account
any comorbidities.
A + C + D + consider further
diuretic3, 4 or alpha- or
beta-blocker5
Consider seeking expert advice
See slide notes for details of
footnotes 1-5
Measuring blood pressure
(during diagnosis)
Measuring blood pressure
Standardise the environment and provide a relaxed,
temperate setting with the person quiet and seated.
• If
blood pressure measured in the clinic is 140/90
mmHg or higher:
When using an automated device:
Take a second measurement during the consultation.
• palpate the radial or brachial pulse before measuring
blood pressure. If pulse if irregular measure blood
pressure manually
• ensure that the device is
validated* and an appropriate
cuff size for the person’s arm
is used.
• If the second measurement is substantially different
from the first, take a third measurement.
• Record the lower of the last two measurements as the
clinic blood pressure.
* See notes
Additional recommendations
Lifestyle interventions
Lifestyle benefits in hypertension
Lifestyle
modification
Recommendation
Offer guidance and advice about:
Range of systolic blood
pressure reduction
(mm Hg)
– diet (including sodium and caffeine intake) and exercise
Weight loss
Maintain a normal body weight based
on BMI
5–20
– alcohol consumption
Dietary
Approaches
Diet high in fruits and vegetables, and
reduced fat
8–14
Low sodium
diet
Less than 6 grams
2–8
Exercise
30 min of aerobic activity at least 4
d/wk
4–9
Moderate
Alcohol
consumption
2 drinks or less per day for men, and 1
drink or less per day for women
2–4
– smoking.
Patient education and adherence
Provide:
– information about benefits of drugs and side effects
– details of patient organisations
– an annual review of care.
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Counseling Patients:
Dietary Changes
Diet and Hypertension
Non-pharmacologic way of treating hypertension
Losing 10-12 lbs or 4-5kg lowers
BP by 10/5 mmHg. This is often
more than one medication!
DASH diet
Reduce daily salt: average 10 to 6
grams
•
•
•
•
•
Teach patients to read food labels
DASH Diet
•
www.nhlbi.nih.gov/health/public/heart/dash
Dietary Approaches to Stop Hypertension
High in whole grains, fruits, vegetables, and low-fat dairy
Adequate Calcium, Potassium, Magnesium
Low in red meat, sweets and sugar beverages
Low in saturated and trans fat, cholesterol
3
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DASH Diet Pattern
Exercise
based on a 2,000 calorie diet
Food Group
Grains
Vegetables
Fruits
Low-fat or fat free dairy
Meats, poultry, fish
Nuts, seeds, dry beans and peas
Fats and oils
Sweets
Sodium
Servings*
6-8
4-5
4-5
2-3
less than 6
4-5/week
2-3
5/ week
2300 mg
* Per day unless indicated
Physical Activity
• 30 minutes at least 5 days a week
• Can divide into 10-15 minute periods
• Work up gradually
• Do something that you enjoy
• Use stairs instead of lift, get off bus 2 stops early, park
your car at the far end of the car park and walk!
Ways to Cut Sodium
 Remove salt shaker
 Add little if any salt to
cooking
 Buy more fresh or plain
frozen “no added salt”
veggies
 Use more herbs and
spices
 Make soups and stews
ahead without salt and
let flavors blend
 Use fresh poultry, lean
meat, and fish
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Adherence
1.
Simply explain what medicine is for and why treat
hypertension. Most patients respond to “risk of stroke
and heart attack”.
10% of CV events due to poor adherence.
2.
Titrating medical therapy based on home readings
3.
Once daily dosing
4.
Pill boxes, dosette etc. You will be experts in this!
Useful links
www.bloodpressureuk.org
www.Patient.co.uk
www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_da
sh.pdf (google search for DASH Diet)
Thank you
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