Hypertension -A Global burden

“Hypertension - A global burden”

Professor Dr. Md. Zakir Hossain

President (Honorary)

Hypertension and Research Centre, Rangpur 

Professor & Head of Medicine

Shaheed Ziaur Rahman Medical College, Bogra

Ex-Principal, Rangpur Medical College, Rangpur

 

Global Burden of Hypertension

• More than 25% of the world adult population is already hypertensive

• The number is projected to increase to 29%  (1.56 billion) by 2025

• Almost 75% of the worldwide population with HTN will be in developing countries

• In Bangladesh, prevalence of raised blood pressure among adults aged ≥ 18 years in 2014 was 25.1% & 26.1% in male & female respectively

• is most prevalent risk factor for cardiovascular and renal diseases worldwide, contributing to -

  • one half of the IHD, and

  • ≈ two thirds of stroke

• Worldwide,1 million deaths occurs from hypertension per year

• In 2002, it was named 'the number one killer' by WHO in The World Health Report

Why Hypertension is so important?

A term, triple paradox is helpful to understand the importance of it. It is-

• Easy to diagnose but often remains undetected

• Simple to treat but often remains untreated

• Despite availability of potent drugs, treatment often is ineffective

 

How Hypertension is defined?

Any definition of HTN is arbitrary. According to JNC 7, a most acceptable guidelines for hypertension noted Hypertension as-

A systolic blood pressure ( SBP) ≥140 mmHg  and/or a diastolic (DBP) ≥90 mmHg based on the average of two or more properly measured, seated BP readings on each of two or more office visits.

Blood Pressure Categories:

According to JNC VII, level of Hypertension is classified as below:

Stage	SBP mm Hg	DBP mmHg
Normal	<120	and <80
Prehypertension	120-139	or 80-89
Stage 1 hypertension	140-159	or 90-99
Stage 2 hypertension	>_ 160	>_100

 

Types of Hypertension

• Primary Hypertension:
  • also known as essential HTN
  • accounts for about 95% of cases of HTN
  • no universally established cause known
• Secondary Hypertension:
  • less common cause of HTN (5%)
  • secondary to other potentially rectifiable causes
  • Causes of Secondary HTN:
• Common
  • Renal disorder
  • Drug induced
  • Thyroid disorder
  • Sleep apnea
• Uncommon
  • Pheochromocytoma
  • Cushing’s Syndrome
  • Coarctation of Aorta
  • Primary Aldosteronism

Risk factor:

• Family and personal H/o HTN, CVD, dyslipidemia and diabetes
• Smoking habits
• Dietary habits
• Recent weight change; obesity
• sedentary lifestyle (lack of physical activity)
• Snoring, sleep apnea
• Low birth weight

 

Diagnostic Procedures

• Positive presentation with risk factor
• History and Physical examination including BP measurements
• Laboratory investigations
• Further diagnostic tests

Presentation:

A patient with Hypertension is frequently Asymptomatic until the development of complication. Many patients may be incidentally found as hypertensive during their visit with the doctor for another health related problem. But some patient may present with symptoms as:

• Headache
• Breathlessness
• Bleeding from nose
• Fatigue
• Sleepiness
• Profuse sweating
• Blurred vision.

Investigations:

Laboratory investigations is not mandatory for diagnosis of Primary hypertension. But limited investigations may be necessary for evaluation of patients status during initial visit.

Occationally extensive investigations may be required when secondary cause of hypertension is sustected. Routine investigations includes:

• Urine  for blood, protein and glucose
• Urea,electrolyte and creatinine
• Blood glucose
• Lipid profile
• Thyroid function test
• ECG

Treatment:

Treatment is based on Non-Pharmacological and pharmacological approach.

• Non-Pharmacological:

        By Life style modification. It includes:

• Physical activity.
• Weight reduction.
• Moderation of alcohol
• Smoking ceasation
• DASH diet: DASH diet includes plenty of fruits and vegetables, low fat dairy product, whole grain, fish, lean poultry, and nuts, diet low in saturated fat low sodium and adequate potassium.
• Pharmacological:
• Choice of pharmacological treatment depends on variety of factor which includes

Age, Race, pregnancy, stage of HTN, therapeutic target, drug cost, dosing side effect and contraindication, associated  co-morbid condition needed to be treated-compelling indication.

• Initial drugs for control of Hypertension are:
  • ACE inhibitor
  • Angiotensin receptor blocker
  • Thiazide diuretics
  • Calcium Channel blocker

Target BP:

Eligible population	Target BP
General population upto age 79	BP < 140/90 mmHg
General population aging 80 or above	BP < 150/90 mmHg
Any age with: DM, CKD, PVD, CAD, Cardiac failure, aortic aneurysm, secondary prevention of stroke and TIA	BP < 130/85 mmHg

Target organ:

Epidemiological data suggests that hypertension remains a major modifiable risk factor for cardiovascular disease through target organ damage. Major target organ that involves are -Heart, Brain, Kidney, Peripheral arteries, Retina.

Complications:

• Blood vessels:

• Smooth muscles hypertrophy
• Hyaline arterio-sclerosis
• Aortic aneurysm
• Aortic dissection
• Wide spread atheroma develops may lead to coronary artery disease and or / CVD
• Increased peripheral resistance that aggravate hypertension
• Central nervous system:
• CVD
• TIA is more common
• Hypertensive encephalopathy
• Eye:
• Hypertensive retinopathy
• Heart:
  • Excess cardiac mortality and morbidity
  • Left ventricular hypertrophy
  • AF Common due to left ventricular diastolic dysfunction.
  • LVF
• Kidneys:
  • Protenuria
  • Progressive renal failure by damaging renal vasculature

 

Benefits of lowering BP: Average percent reduction-
o    Stroke reduction	35-40%
o    Myocardial infarction	20-25%
o    Heart failure	50%

Follow up:

Patients taking antihypertensive therapy require follow up at 3 monthly intervals to maintain BP, minimize side effects & reinforce lifestyle advice. Patients with target organ damage require more frequent follow up.

Conclusion:

Hypertension is the most recognised treatable risk factor for cardiovascular mortality and morbidity. The asymptomatic nature of hypertension and the inherent variability in blood pressure can delay the diagnosis and treatment. Effective management requires continuity of care by a physician, awareness of the patient and active involvement of educated person of the society. As well as, institutional care is very much important to establish a regular follow up & extensive care as per need. Hypertension & Research Centre, Rangpur is such an institution that provide all the facilities that is needed for a hypertensive patient with or without target organ damage.

Hypertension and Research Centre, Rangpur

An Overview

 

             Hypertension and Research Centre, Rangpur is a sister-concern of Dr. Wasim-Waleda

Foundation.

Milestones:

• Established on 14^th November 2008, Rangpur, Bangladesh.
• Registered by ministry of social affairs, Bangladesh.
• Started lab facilities as a part of expansion of activities.
• Research work started from July, 2011
• Hypertension detection center started from 2011.

Necessities for HTN care centre:

• High burden of hypertensive patients
• Low resource community
• Least awareness of HTN
• Silent killer disease
• Social responsibility

Prerequisite of registration of patient

 Only Hypertensive patients can be registered this centre. Besides, any disease accompanied with hypertension as like as stroke, ischaemic heart diseases, paralysis etc are treated here.   

Registration subscription fee

• Registration (including a guideline & prescribing book): 50tk.
• Subsequent follow-up fee: 40tk.

 

Flow chart of treatment:

• Registration & Personal Data fill-up
• Providing a guideline & prescribing book
• Counseling
• Treatment by a Senior Medical officer
• If needed or as per patients wish consult with a consultant
• If needed or as per patients wish consult with chief consultant
• If needed medical board is formed for better management

All the above mentioned process need no additional free.

Patient profile:

• Total patient: 20073 (up to 27.10.17)
• Daily patients: 40-50

• New patient: 5-10 Daily
• Follow up patients: 30-40 daily.

Activities of HTNCRp:

• At very beginning only treatment of hypertensive patients in low cost
• Create awareness for HTN & its consequences
• Detection of HTN
• Preserve the data of hypertensive patients
• Research activities about HTN
• Provide comprehensive service to the hypertensive patients; including quality investigation facility, target organ care facilities

Activities performed yet:

• Arrangement of free medical camp: 31
• Awareness generation program: 218
• Free blood pressure check up camp: 73
• Scientific seminars: 26
• Publications of health magazine yearly: 03
• Observation of various remarkable day like world hypertension day

Achievement:

Within about 9 years of establishment-

• Over 20,073 (upto 27 October 2017) hypertensive patients have registered in the center from northern zone of Rangpur division.
• Research done: 06
• Research ongoing: 06
• Thesis done: 07
• Publications: 09
• Scientific paper presentation-15
  • Home 11
  • Abroad 04.

Visions of HTNCRp:

• Development of guideline in management of hypertension & its complication.
• Establishment of complete laboratory facilities.
• Establish branches throughout the country
• Act as a partner organization in collaboration with Gov and NGO’s in NCD study & control program
• Establishment of target organ damage management centre
• Stroke care corner
• Kidney care centre
• Heart care corner