Hypertension

Hypertension is a sustained elevation of systemic arterial blood

pressure, most commonly defined as systolic blood pressure (SBP) 140 mm
Hg or diastolic blood pressure (DBP) 90 mm Hg.

Onset is generally at age 20-50 years, but prevalence increases with age.

Risk factors for hypertension include weight gain and obesity, alcohol use
(particularly for men), a family history of the condition, a high sodium diet, a
low-potassium diet, and a sedentary lifestyle. In the Philippines, 25% of
adults 21 years old and above have high blood pressure. Hypertension
prevalence in the Philippines has been steadily on the rise from 11% in 1992
to 28% in 2013 based on the Presyon 3 survey of the Philippine Heart
Association.

Most patients with hypertension have primary or essential hypertension, but

in 10%-15% of patients it may be due to secondary causes.

There is a directly proportional relationship between blood pressure and

cardiovascular disease (CVD). The relationship is also linear, continuous, and
independent of and additive to other risk factors. The risk for CVD is doubled
across the range of blood pressures from 115/75 to 185/115 mm Hg for
persons aged 40 to 70 years in each increment of 20 mm Hg in systolic blood
pressure or 10 mm Hg in diastolic blood pressure. The CVD risk associated
with hypertension is even higher if patient has Diabetes Mellitus or Chronic
Kidney Disease.

Complications of hypertension include retinopathy, cerebrovascular disease,

ischemic heart disease, left ventricular hypertrophy, atrial fibrillation, heart
failure, chronic kidney disease, and peripheral vascular disease.

Blood pressure levels starting at 115/75 mm Hg already increases

cardiovascular risk. It is recommended to screen all adults for hypertension at
intervals of 1 to 2 years. Patients with a steeper blood pressure trajectory will
probably reach a blood pressure of 140/90 mm Hg sooner, which may
increase risk for CVD.

In persons older than 50 years, systolic blood pressure greater than 140 mm
Hg is a more important CVD risk factor than diastolic hypertension.

Different types of Hypertension

essential hypertension - idiopathic or primary hypertension
resistant hypertension - elevated BP despite concurrent use of 3
antihypertensive drugs of different classes, including a diuretic
secondary hypertension - hypertension due to an identifiable,
potentially curable cause
masked hypertension - elevated BP at home or on ambulatory blood
pressure monitoring but normal office blood pressure
 white coat hypertension - normal BP at home or on ambulatory blood
pressure monitoring but elevated office blood pressure

Classification of Hypertension
The definition of high blood pressure is not redefined in Eighth Joint National
Committee (JNC 8) 2014 guidelines for management of high blood pressure in
adults, prior (JNC 7) classification of blood pressure measurements for adults
without acute end organ damage is shown below:
stage 1 hypertension if systolic blood pressure (SBP)
140-159 mm Hg or diastolic blood
pressure (DBP) 90-99 mm Hg
stage 2 hypertension if SBP 160 mm Hg or DBP
100 mm Hg
ambulatory blood pressure o > 135/85 mm Hg when
values consistent with awake
hypertension o > 120/75 mm Hg when
asleep

Complications
Hypertension is a risk factor for:
o coronary artery disease (CAD)
o heart failure
o chronic kidney disease
o stroke
o intracerebral hemorrhage
o transient ischemic attack (TIA)
o peripheral arterial disease (PAD)
o aortic regurgitation
o atrial flutter
o mild cognitive impairment (MCI)

Mortality and Incidence of Hypertension and its Risk Factors in the

Philippines
Worldwide, it is estimated that high blood pressure causes 51% of deaths due
to stroke and 45% due to heart disease. Hypertension is a major risk factor
for cardiovascular disease. Coronary artery Disease remains the number one
cause of mortality in the Philippines. The second cause of mortality is stroke.
Treating hypertension results in a 40% decrease in the risk of stroke and 15%
decrease in risk of MI.

According to the WHO data published in May 2014 Hypertension Deaths in

Philippines reached 20,986 or 4.03% of total deaths. The age adjusted Death
Rate is 38.20 per 100,000 of population and ranks Philippines #11 in the
world. Coronary Heart Disease Deaths in Philippines reached 87,881 or
16.86% of total deaths. Stroke Deaths in Philippines reached 63,261 or
12.14% of total deaths.

In Western Pacific region (WPR), 25.4% adults >20 are overweight. In the
Philippines, 27% adults >20 are overweight and obese. High levels of
physical inactivity is also reported among Filipino adults >20 at work (76%),
non-work (76%), travel (94%), and leisure (93%).

Prevalence of Hypertension
More than 50% of people aged 60-69 years and about 75% of people
70 years old are affected Hypertension worldwide. Global prevalence of
raised blood pressure 24% in men and 20% in women in 2015 (Lancet
2017 Jan 7;389(10064):37, accessed 3/31/17)

Global prevalence of elevated systolic blood pressure and elevated

blood pressure-related mortality in adults 25 years old increased
between 1990 and 2015. The most common SBP-related deaths were
caused by ischemic heart disease, hemorrhagic stroke, and ischemic
stroke (JAMA 2017 Jan 10;317(2):165, editorial can be found in JAMA
2017 Jan 10;317(2):142 accessed 3/31/17)

prevalence increases with age

o prevalence of hypertension was
27.3% among persons < 60 years old
63% among persons aged 60-79 years
74% among persons 80 years old (JAMA
2005 Jul 27;294(4):466)
90% residual lifetime risk for developing
hypertension in middle-aged and elderly persons (JAMA
2002 Feb 27;287(8):1003)

Complications

Hypertensive retinopathy
o classification
4-stage classification previously used but 3-grade system
proposed because
o early retinopathy grades are difficult to distinguish
o prognostic implications of early hypertensive
retinopathy grades are unclear
Grade 1: mild retinopathy (formerly stage 1
Narrowing in terminal branches of and 2) -
vessels and the presence of silver
wiring representing light reflecting
from the thickened arteriolar wall
Grade 2:
To the preceding signs add general
narrowing of vessels with severe local
constriction
Grade 3: moderate retinopathy (formerly
To the peceding signs add striate stage 3) -
hemorrhages and soft exudates:
additional findings of flame-shaped or
blot-shaped hemorrhages, cotton-wool
spots, hard exudates, microaneurysms,
or a combination of all of these
Grade 4: severe retinopathy (formerly stage
To the preceding signs add 4)
papilledema.

Left ventricular hypertrophy (LVH)

Principal ECG features associated with LVH include increase in QRS amplitude
and duration, and changes in instantaneous and mean QRS vectors.
Supportive but not diagnostic ECG features of LVH include
ST-T abnormalities
P-wave abnormalities (present frequently in patients with
hypertension and may be early sign of hypertensive hear but also present
without LVH)
left axis deviation (may be associated with LVH but also
occurs with left anterior fascicular block and other factors, such as
increasing age)

Cardiac findings of LVH or Structural Heart Disease

point of maximal intensity displaced Patients PMI at 6th intercostal space
laterally
S4 (one of earliest physical findings Patient has a fourth heart sound.
of hypertension)
S3 (from high left atrial pressure;
suggests heart failure, volume
overload, need for treatment)

right ventricular heave and murmur

in back (interscapular) with
coarctation of aorta
 valvular murmurs (aortic stenosis,
mitral regurgitation

Electrocardiography (ECG) and Echocardiography

Echocardiography is considered the gold standard for identification of left
ventricular hypertrophy. In patients with hypertension, meeting ECG criteria
for left ventricular hypertrophy (LVH) suggests high likelihood of LVH on
echocardiography, but absence of ECG criteria for LVH not sufficiently
sensitive to rule out LVH.

The American College of Cardiology/American Heart Association (ACC/AHA)

recommends ECG for patients who are suspected or at high risk of cardiac
disease or dysfunction due to presence of symptoms, abnormal physical
exam or lab findings, or family history consistent with increased risk of
cardiovascular disease.

Risk factors for total cardiovascular risk

Gender male
Age 55 years in men or 65 years in women
Smoking history Patient with significant smoking history
with 1 of
total cholesterol > 4.9 mmol/L (190 mg/dL)
low-density lipoprotein cholesterol > 3 mmol/L
Dyslipidemia (115 mg/dL)
high-density lipoprotein cholesterol < 1 mmol/L
(40 mg/dL) in men or < 1.2 mmol/L (46 mg/dL) in
women
High body mass obesity ( 30 kg/m2)
index
Abdominal waist circumference 102 cm (40.2 inches)
obesity
Family history of
premature men < 55 years old, women < 65 years old
cardiovascular
Fasting plasma 5.6-6.9 mmol/L (102-125 mg/dL)
glucose or a
history of
chronic kidney with estimated glomerular filtration rate < 30
disease mL/minute/1.73 m2

asymptomatic pulse pressure 60 mm Hg in elderly persons

organ damage left ventricular hypertrophy on electrocardiogram or
echocardiogram
 carotid wall thickening (intima-media thickness > 0.9
mm) or plaque

carotid-femoral pulse wave velocity > 10 meters/second

ankle-brachial index < 0.9

microalbuminuria (30-300 mg/24 hour), or albumin-

creatinine ratio (30-300 mg/g [3.4-34 mg/mmol])

DIAGNOSIS:
Left Ventricular Hypertrophy secondary to Uncontrolled Stage 2 Hypertension;
Mild Retinopathy