By

Dr.Abdelsalam Sherif
MD Cardiology
1. HPN is a major risk factor for cardiovascular disease.

2. The relationship of BP to the probability of

developing IHD and stroke is continuous and
graded.

3. Each 20/10 mmHg in systolic and diastolic blood

pressure, the risk for cardiovascular disease doubles.
 Major Underlying Factors causing Death - Worldwide
Raised Blood Pressure 7 million

Tobacco

High cholesterol

Underweight

Unsafe sex

Low fruit &

vegetables intake

High BMI
Developed region
Physical inactivity
Developing region
Alcohol

Unsafe water, sani & hygiene

0 1 2 3 4 5 6 7
Ezzati et al. Lancet 2002:360:1347-60. Millions of Deaths
 CAD
Stroke CHF
LVH

Hypertension
Renal  Morbidity
disease
 Disability
Peripheral
vascular disease

These diseases account for significant disability, loss of

productivity, and decreased quality of life
National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186–208.
Disease % attributable to
hypertension
Myocardial Infarctions 30 – 40 %
Heart failure Up to 50 %
A . F. Up to 50 %
Strokes 30 – 40 %
Renal failure 25 – 30 %
 Category Systolic BP Diastolic BP
Optimal <120 <80
Normal <130 <85
High-normal 130-139 85-89
Grade 1 (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) 180 110
Isolated systolic 140 <90
hypertension
 BP Systolic Diastolic Initial drug therapy
Classification BP BP
Normal <120 <80
Pre- 120-139 80-89 No antihypertensive drug
hypertension indicated

Stage 1 140-159 90-99 Thiazide diuretics for

most of the cases but
others may be considered

Stage 2  160  100 Drug combination for

most (usually thiazide type
& ACEI or AIIRA or BBs
or CCBs
JAMA may 21, 2003 vol 289
Age > 60 yrs
Systolic:
Threshold > 150 mmHg
Goal < 150 mmHg
LOE: Grade A

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A
Age < 60 yrs
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E

Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages 18-39
1.Hypertensive patients can fast Ramadan?

2.What about schedule of medications during

Ramadan?

3.What are the precautions for hypertensive patients

during Ramadan?

4.Is there an absolute contraindication for Ramadan

fasting among hypertensive patients?
1.Life style changes : food , sleep and physical
activities.
2.Effectiveness of long acting medications.
3.Energy Restriction has substantial impact
on ANS leading to ↑ vagal and ↓ in
sympathetic tone.
4. Augmented cardiac baroreflex sensitivity ,
loss of plasma volume and reduced venous
return.
 The following recommendations can reasonably be made :

• Physician’s advice and management should be individualized.

• Patient education should emphasize the need to maintain compliance
with non-pharmacological and pharmacological measures.
• Diuretics are better avoided, especially in hot climates, or should be
administered in the early evening.
• Patients are encouraged to seek medical advice before fasting in order
to adjust their medications if needed.
• A once-daily dosage schedule with long-acting preparations is
recommended.
• Patients with HTN should be advised to eat a low-salt, low-fat diet.
• Patients with difficult-to-control HTN should be advised not to fast
until their BP is reasonably controlled.
• Patients with hypertensive emergencies should be treated
appropriately regardless of fasting, including intravenous medications.
 For people who suffer from high blood pressure on how to fast during
the month of Ramadan without causing any harm to their health:

Lifestyle during Ramadan:

• Stay hydrated: Drink plenty of fluids from Iftar until Suhoor to prevent
complications that may occur.
• Salt: Reduce salt consumption
• Diet: Control food quality and quantity
• Physical activity: A while after iftar, go for a walk (4km at least), several
times a week
• Fat: Avoid any food that contains high percentage of fat.
Medication during Ramadan:
• Most medication prescribed for people with high blood pressure need to
be taken once or twice a day. Typically these medications will have a 12 –
16 hour effect. The tablets can be taken at Suhoor, and during the
evening at iftar.
• Patients who have tablets prescribed three times daily are likely to have
short acting drugs. For these patients, it would be prudent to ask their
physicians about the afternoon dose and if it can be adjusted to best help
the fasting month. Usually most doctors are more than willing to help
with adjustments.
 2013 ESH/ESC Guidelines for the management of arterial hypertension

Lifestyle changes for hypertensive

patients
Recommendations to reduce BP and/or CV risk factors
Salt intake Restrict 5-6 g/day
Moderate alcohol intake Limit to 20-30 g/day men,
10-20 g/day women

Increase vegetable, fruit, low-fat dairy intake

BMI goal 25 kg/m2
Waist circumference goal Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*

Exercise goals ≥30 min/day, 5-7

days/week
(moderate, dynamic
exercise)
Quit smoking
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281-1357
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Is there an absolute contraindication for
Ramadan fasting among hypertensive
patients?