High Blood Pressure

1
High Blood Pressure
2
Definition of high blood pressure
What is high blood pressure? High blood pressure,
or hypertension, is defined as a consistent
recording of systolic blood pressure of 140 mm Hg
or greater, diastolic blood pressure of 90 mm Hg
or greater, or taking antihypertensive medication.
Source NHBPEP, Fifth Report of the Joint
National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC V), 1993.
3

• Systolic blood pressure is the pressure when the
  heart contracts
• Diastolic blood pressure is the pressure when the
  heart is between beats (at rest)

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Classification of blood pressure for adults
Systolic(mm Hg)
Diastolic(mm Hg)
Optimal Normal High-normal Hypertension Stage 1
(mild) Stage 2 (moderate) Stage 3
(severe) Stage 4 (very severe) Isolated systolic

• 120-129
• 130-139
• 140-159
• 160-179
• 180-209
• 210
• 140

• 80-84
• 85-89
• 90-99
• 100-109
• 110-119
• 120
• 90

Source NHBPEP, Fifth Report of the Joint
National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC V), 1993.
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Age Related (not age caused)

• Blood pressure increases by decade
• By old age 2/3rds of Americans will be
  hypertensive, but it may not be a direct cause of
  aging

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Prevalence

• 50 million Americans or 28 of the adult
  population is hypertensive, 30 million are high
  normal
• Greater among Blacks
• Greater for low-SES groups
• Greater in Southeastern States
• Greater in men than in women (in young and
  middle age thereafter reverse is true)
• In the past two decades prevalence in the US had
  deceased in every age, sex, and race subgroup
  except black men age 50 or older

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Prevalence of hypertension by race and sex, age
18 and older United States, 1988-91
Age-adjustedpercentage
Estimated population(in thousands)
Black Male Female White Male Female Mexican
American Male Female
32.4 34.0 31.0 23.3 25.4 21.0 22.4 23.2 21.6
5,672 2,664 3,008 34,697 17,259 17,438 1,143 604 5
39
Sources NCHS, 1988-91 National Health and
Nutrition Examination Survey (phase I).
8
Distribution of blood pressure levels among
adults by race United States, 1988-91
Source NCHS, 1988-91 National Health and
Nutrition Examination Survey (phase I).
9
Hypertension awareness, treatment, and control
rates among adults by race United States,
1976-91
Sources NCHS, 1976-80 National Health and
Nutrition Examination Survey 1988-91 NHANES
(phase I).
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Health Problems Caused by Hypertension

• Silent Killer of 37,000 Americans each year
• Contributes to 700,000 deaths per year
• Stroke
• Coronary events
• Cardiovascular diseases
• Kidney failure
• All-cause mortality

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• Causes an enlarged heart
• Causes aneurysms to form in the brain which may
  cause strokes
• Causes blood vessels in the kidneys to narrow
  which leads to kidney failure
• Arteries in the heart, brain, and kidneys harden
  and caused disease

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Systolic Pressure and Cardiovascular Mortality
5
4
Percent of men
3
Relative risk
2
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Systolic Blood Pressure and Stroke
Relative risk
Systolic Blood Pressure
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Age-adjusted stroke mortality among adults by
State United States, 1989-91
23.0
25.8
23.1
25.1
26.9
28.9
30.2
27.1
26.8
29.6
29.1
25.1
24.3
24.3
30.2
24.3
27.4
24.2
28.6
28.9
28.1
29.0
27.0
31.3
24.5
33.6
23.9
23.0
27.3
31.1
23.6
34.0
28.6
30.4
33.2
40.2 Dist. of Col.
40.4
24.2
39.2
30.9
22.6
40.1
47.2
42.3
41.1
39.3
39.4
Stroke Belt States
31.2
27.0
25.6
32.0
Deaths per 100,000 population Source NCHS,
U.S. Vital Statistics, 1989 to 1991.
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Treatment algorithm
1
Lifestyle modifications
Inadequate response
Continue lifestyle modifications Initiate
pharmacological selection (diuretics or
beta-blockers preferred)
2
Inadequate response
Increase drug dose
Substitute another drug
Add a second agent from a different class
3
Inadequate response
Add a second or third agent and/or diuretic if
not already prescribed
4
Source NHBPEP, Fifth Report of the Joint
National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC V), 1993.
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Start with Lifestyle Change

• A 2 mmHG drop in systolic BP can cause a 6
  reduction in stroke risk and a 4 reduction in
  coronary heart disease
• 1 mmhg decrease in diastolic can cause a 2-3
  decrease in heart attack (MI) risk

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Hypertension Risk Factors

• Overweight
• Increased salt intake
• Alcohol (more than two drinks per day)
• Physical inactivity
• Tobacco use
• Reduce consumption of saturated fat and
  cholesterol

Source NHBPEP, Fifth Report of the Joint
National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC V), 1993.
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Effects of Weight Loss

• For every kg (2.2 pounds) of lost weight there is
  a 1.6/1.1 mm HG loss in systolic and diastolic
  blood pressure

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Weight loss and effect on blood pressure
Reduction in blood pressure mmHg
Arch Intern Med 153849-858, 1993
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Whats up with Sodium?

• We eat between 2,500 and 5,000 mg of sodium/day
• 1 teaspoon of salt 2,000 mg
• We only need 2,400 mg
• Is there such a thing as sodium sensitivity?

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Review of the Sodium Literature

• Intensive diet modification programs are the most
  effective
• People how lower sodium consumption can usually
  go off BP medication
• After 5 years systolic was still down 1.1 mmHg
  and diastolic .6 mmHg

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The DASH diet

• Dietary Approaches to Stop Hypertension (DASH)
• fruits, vegetables, and low-fat dairy foods,
  whole grains, poultry, fish, nuts and small
  amounts of red meat, some sweets and soda
• 412 participants, 30 days

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Results

• 7.1 mm Hg drop in systolic for normal BP
• 11.5 mmHg drop in systolic for hypertensives

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To eat less sodium

• Learn to read labels, avoid foods high in sodium
• Chose more fruits and vegetables
• Reduce use of salt when cooking, use other spices
• Avoid using the salt shaker
• Limit use of foods with visible salt on them
  (chips, nuts, pretzels, etc)

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Sodium Content of Common Foods (1 cup)
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What about Alcohol Consumption?
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Alcohol Consumption

• This data comes from cohort studies, no
  randomized trials have been completed
• Evidence suggests moderate amounts of alcohol
  (1-2 drinks/day) can increase HDL cholesterol
• Can reduce platelet clotting (thins the blood)
• Men who drink moderate amounts are 30-40 less
  likely to have heart attacks compared to non
  drinkers

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Alcohol CVD Mortality Curve
Cardiovascular mortality
Alcohol Consumption
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Now the bad news

• For women 2 drinks a day increases the risk of
  breast cancer by 20-25
• It can disturb sleep
• Causes 1/3 of all traffic deaths
• Impares judgement
• Is addictive, and interacts with medications
• Much is still unknown

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Physical Activity
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Summary of Physical Activity and Reductions in BP
for Normotensives
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Summary of Physical Activity and Reductions in BP
for Hypertensives
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Strength Training and Reductions in BP for
Normotensives
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Physical Activity Mechanisms

• Lower peripheral vascular resistance
• Reduced serum catecholamines and reduced plasma
  renin activity (control of blood volume)
• Decreased visceral (abdominal) fat

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Medications

• Diuretics- prompt kidneys to excrete sodium,
  which reduces blood volume and thus blood
  pressure
• Beta-blockers- Slows heart beat and lessens force
  of hearts contractions
• Calcium Channel Blockers- prevents calcium from
  enabling muscles cells to constrict around the
  blood vessels, thus dilating the vessels
• ACE inhibitors- Dilates blood vessels by
  blocking enzymes which cause artery walls to
  constrict

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Lifestyle and Lifestyle with Drugs
Change in blood pressure mmHg
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Recommendations for followup based on initial set
of blood pressure measurements for adults
Initial BP (mm Hg)
Systolic
Diastolic
Follow-up
210
120
Recheck in 2 years Recheck in 1 year Confirm
within 2 months Evaluate or refer within 1
month Evaluate or refer within 1 week Evaluate or
refer immediately
Source NHBPEP, Fifth Report of the Joint
National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure (JNC V), 1993.