EPIDEMIOLOGY OF

HYPERTENSION

Mrs.Elavarasi.R
Professor,
Dept.of Community Health Nursing
IQ City Institute of Nursing sciences
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HYPERTENSION

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 A
SILENT
KILLER

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• Hypertension is a silent, invisible killer that
rarely causes symptoms.
• Increasing public awareness is key, as is
access to early detection.
• Raised blood pressure is a serious
warning sign that significant lifestyle
changes are urgently needed.
• People need to know why raised blood
pressure is dangerous, and how to take
steps to control it.
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 Hypertension is defined as a systolic
blood pressure equal to or above 140 mm
Hg and/or diastolic blood pressure equal
to or above 90 mm Hg

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 History of
History of
Hypertension

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 Historical of hypertension records as far
back as 2600 B.C. hold mention of “hard
pulse disease”
 First treatments: Leeching/phlebotomy,
acupuncture
 Hippocrates recommended phlebotomy
 120 AD – cupping of the spine to
draw animal spirits down and out
was recommended

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Lithograph showing the leeching of a patient. 9
No way to measure prior to
1700s

cupping of the spine 10

1733 – Reverend
Stephen Hales
measured the intra-
1733 – Reverend Stephen Hales measured the
arterial
intra-
BP of a
horse

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 1905 – N.C. Korotkoff reported on the
method of auscultation of brachial artery, the
method which is widely used today
 Allowed auscultation of diastolic BP as well

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 WHO/ISH CLASSIFICATION
OF BLOOD PRESSURE

CATEGORY SYSTOLIC DIASTOLIC

(mmHg) (mmHG)

Optimal <120 <80

Normal <130 <85
Grade 140-159 > 90-99
1 160-179 >100-109
Grade 2 >180 >110
Hyperte >140 <90
nsion
Grade 3
Hyperte
nsion
("severe
")
Isolated
Systolic 13
BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120–139 or 80–89

Stage 1 Hypertension 140–159 or 90–99

Stage 2 Hypertension >160 or >100

Isolated systolic >140 - <90
hypertension

*JNC-7 14
 Seated quietly for 5 minutes
 Appropriate size cuff
 Inflate 20-30 mmHg above loss of radial
pulse.Deflate at 2mmHg per second
 1st sound SBP ; Disappearance of Korotkoff
sound (phase 5) is DBP.
 – Confirm Elevated blood pressure within
2months(stage 1) –shorter for stage 2 if
new onset

*JNC-7
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 Globally cardiovascular disease
accounts for approximately 17
million deaths a year, nearly one
third of the total deaths. Of these,
complications of hypertension
account for 9.4 million deaths
worldwide every year .
 Hypertension is responsible for at
least 45% of deaths due to heart
disease and 51% of deaths due to
stroke .

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 In terms of attributable
deaths, hypertension is one
of the leading behavioral and
physiological risk factor to
which 13% of global deaths
are attributed.

Hypertension is reported
to be the fourth
contributorto
premature death in developed
countries and
seventh in the developing
countries.

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Recent reports indicate that nearly
1 billion adults (more than
a quarter of the world’s
population)
had hypertension in 2000,
and this is increase
predictedto
to
1.56 billion by 2025.

Today, mean blood pressure

remains very high in many African
and some European countries.
The prevalence of raised blood
pressure in 2008 was highest in
the WHO African Region at 36.8%
.
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 Global Burden of Hypertension
2025
Year 2000 Projection Year 2025
 26.4% of world adult • 29.2% of world adult
population had population will have
hypertension hypertension

 Total of 972 • Total of 1.56 billion adults

million 20 % in developed nations,
adults 80% in developing nations)


Highest prevalence is in• Highest prevalence will be in
established market developing continents
economies (eg, North (eg, Asia, Africa) will account
America, Europe) for 75% of world’s
Kearney PM et al. Lancet. 2005;365:217-223. hypertensive patients 19
 Recent studies from India have shown the
prevalence of HTN to be 25% in urban and 10% in
rural people in India .

 According to the WHO estimates , the prevalence of

raised BP in Indians is 32.5% (33.2% in men and
31.7% in women) .

 Andhra Pradesh (13.3%), Odisha (9%), Chhattisgarh

(8.4%) and Gujarat (6.7%) have highest prevalence
while Assam and Rajasthan (1.4%), Kerala (2.4%),
Bihar (2.7%), Madhya Pradesh (2.8%) and Uttar
Pradesh (3.6%) are low prevalence states.

Journal of Hypertension:June 2014 - Volume 32 - Issue 6 - p 1170–1177*

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 RULE OF HALVES

JAPI • VOL. 51 • FEBRUARY 2003 22

Primary (Essential) Hypertension
 - Elevated BP with unknown
cause - 90% to 95% of all
cases

Secondary Hypertension
 - Elevated BP with a specific
cause - 5% to 10% in
adults

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 NON-MODIFIABLE
 Age (> 55 for men; > 65 for women)
 Gender

 Family history

 Ethnicity (African Americans)

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a) Alcohol
b) Cigarette smoking
c) Diabetes mellitus
d) Elevated serum lipids
e) Excess dietary sodium
f) Obesity (BMI > 30)
g) Sedentary lifestyle
h) Socioeconomic status
i) Stress

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Frequently asymptomatic until severe and
target organ disease has occurred

 Fatigue, reduced activity tolerance

 Dizziness/Headache
 Palpitations,
 Angina
 Dyspnoea

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§ Sleepapnea
§ Drug-induced or related causes

§ Chronic kidney disease

§ Primary aldosteronism

§ Renovascular disease

§ Chronic steroid therapy and Cushing’s syndrome

§ Pheochromocytoma

§ Coarctation of the aorta

§ Thyroid or parathyroid disease

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The pathogenesis
of primary
hypertension is still
unclear.

There are many

factors associated
with
it.

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a. Genetic factors
b. Sodium intake
c. Renin- agiotensin
systems
d. Sympathetic nervous
system
e. Endothelial
dysfunction
f. Insulin resistance
g. Other factors

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 The off springs of the
hypertensive
parents are more
prone to suffer
from essential
hypertension
compared with that
without hypertensive
family.

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 The mechanisms
leading to
hypertension are
due to increased
blood volume and
the content of the
sodium in the
smooth muscle cells
enhance following
subsequent calcium
increase.

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 The activation
of Sympathetic
nervous can
augment periphery
resistant which

increase systemic
arterial pressure.

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 Obesity
Smoking
Intake alcohol
OSAS
Low calcium ,
magnesium and
potassium.

(Obstructive Sleep Apnea Syndrome)

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 Systemic atherosclerosis
develops with increased
intimal-medium
thickness leading to
ischemic alterations in
target organs such as
heart, brain, kidney and
peripheral artery.

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 In Aorta and large
arteries recurrent
pulsatile stress
produces
disruption uncoiling,
and
calcification of elastic
fibres. At the
same time, relatively
inelastic collagen
is also increased.

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This is a result of
ageing as well as
hypertension : both
processes
therefore cause
loss of the normal
elastic reservoir
funtion of arteries.

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 Hypertensive Heart Disease/ Coronary
artery disease
 Left ventricular hypertrophy/ Heart
failure
 Cerebro-vascular Disease/ Stroke
 Peripheral Vascular Disease
 Nephrosclerosis/nephropathies
 Retinal Damage
 Hypertensive emergencies
 Dissection of aorta
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§ Routine Tests
• Electrocardiogram
• Urinalysis / Blood glucose, and hematocrit
• Serum potassium, creatinine, or the
corresponding estimated GFR, and calcium
• Lipid profile, after 9- to 12-hour fast, that includes
high- density and low-density lipoprotein cholesterol,
and triglycerides
§ Optionaltests - Measurement of urinary albumin
excretion or albumin/creatinine ratio
§ Moreextensive testing for identifiable causes is not
generally indicated unless BP control is not being
achieved.

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40
JNC-8 :TREATMENT CHOICES

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PREVENTION
OF

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 Hypertension can be prevented by
complementary application of strategies
that target the general population and
individuals and groups at higher risk for
high blood pressure.
 However, prevention strategies applied
early in life provide the greatest long-term
potential for reducing the overall burden of
blood pressure related complications in the
community

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 A population-based approach
aimed at achieving a downward
shift in the distribution of blood
pressure in the general population
and is an important component for
any comprehensive plan to prevent
hypertension.

A small decrement in systolic blood

pressure is likely to result in a
substantial reduction in the burden
of blood pressure-related illness

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 Average Percent Reduction
 Stroke incidence
35–40%
 Myocardial infarction
20–25%
 Heart failure
50%

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 In an analysis based on Framingham
Heart Study experience, Cook et al.
concluded that a 2 mmHg reduction in
the population average of diastolic
blood pressure for white U.S.
residents 35 to 64 years of age would
result in a 17 percent decrease in the
prevalence of hypertension, a 14
percent reduction in the risk of stroke
and transient ischemic attacks, and a 6
percent reduction in the risk of CHD

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 BP Reductions as Small as 2 mmHg Reduces the Risk
of CV Events by Up to 10%
 ▶ Meta-analysis of 61 prospective, observational
studies
 ▶ 1 million adults
 ▶ 12.7 million person- 10% increase in
years stroke Mortality
risk

 2 mmHg
 increase in
 mean SBP
7% increase in risk
of IHD Mortality
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 Public health approaches,
such lowering sodium
as
content or caloric density in
the food supply and
providing ,
and convenient
attractive, safe,
opportunities for exercise
are ideal population-based
approaches for reduction of
average blood pressure in
the community

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 More intensive targeted approaches, aimed at
achieving a greater reduction in blood pressure in those
who are most likely to develop hypertension.

 Groups at high risk for hypertension include those with a

grade –I blood pressure, a family history of
hypertension, overweight or obesity, smokers,a
sedentary lifestyle, excess intake of dietary sodium
and/or insufficient intake of potassium, and/or excess
consumption of alcohol.

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54
The Connection

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 Sodium, through hypertension, is a major contributor to
death, disability, disparities, and costs attributable to
cardiovascular diseases (CVD)
 Globally, 8.5 million deaths could be averted over 10
years from 2006 to 2015 through a 15% reduction in
sodium intake
 An adults should consume less than 2000
milligrams of sodium, or 5 g of salt per day

 Sodium content is high in processed

foods, such as bread (approximately 250
mg/100 g), processed meats like bacon
(approximately 1500 mg/100 g), and
popcorn (approximately 1500 mg/100 g),
as well as in condiments such as soy
sauce (approximately 7000 mg/100 g), and
bouillon or stock cubes (approximately 20
000 mg/100 g).

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WHO recommends that adults
should consume at least 3,510
mg of potassium/day.

Potassium-rich foods include :

beans and peas (approximately
1,300 mg of potassium per 100
g), nuts (approximately 600
mg/100 g), vegetables such as
spinach, cabbage and parsley
(approximately 550 mg/100 g)
and fruit such as bananas,
(approximately 300 mg/100 g).

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How public health
stakeholders
can tackle
hypertension?

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There are six important components of any
country

 1|an integrated primary care programme

 2|the cost of implementing the
programme
 3|basic diagnostics and medicines

 4|reduction of risk factors in the

population
 5|workplace-based wellness programmes

 6|monitoring of progress.
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 Integrated programmes must be
established at the primary care
level for control of hypertension.
In most countries thisis the
weakest level the
of system. health

 Treatment should be targeted

particularly at people at medium
or high risk of developing heart
attack, stroke or kidney damage.

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 The cumulative cost of implementing an
integrated primary care programme to
prevent heart attack, stroke and kidney
failure, using blood pressure as an entry
point that address cardiovascular disease and
cervicalcancer in all low- and middle-
income countries is estimated to be US$ 9.4
billion a year

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 Availability of basic technologies to manage
people with hypertension .
 Availability and appropriate use of essential
medicines to prevent complications in people
with moderate to high cardiovascular risk .
 The links between different levels of the
health system so that people can be
managed appropriately based on heir level of
risk.

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 The basic diagnostic technologies required
for addressing hypertension include accurate
blood pressure measurement devices,
weighing scales, urine albumin strips, fasting
blood sugar tests and blood cholesterol
tests.

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 Not all patients diagnosed with hypertension
require medication but those at medium to
high risk will need one or more of eight essen-
tial medicines to lower their cardiovascular
risk.

A thiazide diuretic, an angiotensin converting

enzyme inhibitor, a long-acting calcium chan-
nel blocker, a beta blocker, metformin, insulin,
a statin and aspirin).

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 The cost of implementing such a programme
is low, at less than US$ 1 per head in low-
income countries, less than US$ 1.50 per
head in lower middle-income countries and
US$ 2.50 in up- per middle-income countries

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 Most cardiovascular disease in the population
occurs in people with an average risk level, because
they constitute the largest proportion of the
population.

 The population-based approach is thus based on

the observation that effective reduction of
cardiovascular disease rates in the population
usually calls for community-wide changes in
unhealthy behaviors or reduction in mean risk
factor levels.

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 Population-wide approaches to reduce high blood
pressure are similar to those that address other
major non communicable diseases.
 They require public policies to reduce the exposure
of the whole population to risk factors such as an
unhealthy diet, physical inactivity, harmful use of
alcohol and tobacco use , with a special focus on
children, adolescents and youth.

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 WHO considers work place health programmes to
be one of the most cost-effective

 Workplace wellness programmes should focus

on promoting worker health through the
reduction of individual risk-related behaviours,
e.g. tobacco use, unhealthy diet, harmful use of
alcohol, physical inactivity and other health risk
behaviors

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 National surveillance health information systems
must be strengthened to monitor the impact of
action to prevent and control hypertension and
other risk factors of non communicable diseases.

Monitoring systems must collect reliable

information on risk factors and their determinants,
non communicable disease mortality and illness.
This data is critical for policy and programme
development. However, some countries still lack
surveillance data for hypertension and other
risk factors

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 National
of Programme
Diabetes, for Prevention
Cardiovascular and and
Diseases Control
th
Stroke (NPDCS) was launched on 4 Jan 2008

 Objectives
1. Risk reduction for prevention of NCDs
(Diabetes, CVD and Stroke)
2. Early diagnosis and appropriate management of
Diabetes, Cardiovascular Diseases,cancer and
Stroke

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1. Health Promotion for the General Population
2. Disease Prevention for the High Risk
groups.

Community Based Interventions, Workplace

Interventions , Disease Prevention for the
High Risk, Setting up special clinics ,
Harnessing the Private Sector and Specific
interventions at the tertiary level to enhance
capacity to respond to the needs of NCD

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 Awareness generated on HEALTHY LIFE
STYLES.
 Decrease in the incidence of Non –
Communicable Diseases particularly,
Diabetes, Cardiovascular Diseases,cancer and
Stroke.


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A. At Sub centre

 1.Health promotion for behavior change

 2.‘Opportunistic’ Screening using B.P

measurement and blood glucose by strip
method

 3. Referral of suspected cases to CH

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 1. Prevention and health promotion including
counseling

 2.Early diagnosis through clinical and laboratory

investigations (Common lab investigations:
Blood Sugar, lipid profile, ECG, Ultrasound, X ray
etc.)

 3. Management of common CVD, diabetes and stroke

cases(out patient and in patients.)

 4. Home based care for bed ridden chronic cases

 5. Referral of difficult cases to District Hospital/higher

health care facilit

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 1. Investigations: Blood Sugar, lipid profile,
Kidney Function Test (KFT),Liver Function Test
( LFT), ECG, Ultrasound, X ray, colonscopy ,
mammography etc. (if not available, will be
outsourced)
 2. Medical management of cases ( out patient ,
inpatient and intensive Care )
 3.Follow up and care of bed ridden cases
 4.Day care facility

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 A combination increased
of physical
activity, moderation in
alcohol intake, and consumption of
an eating plan that is lower in
sodium content and higher in
fruits, vegetables and low fat dairy
products represents the best
approach for preventing high
blood pressure in the general
population and in high risk groups.

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a. For persons over age 50, SBP is a
more
important than DBP as CVD risk
factor.

b. Starting at 115/75 mmHg, CVD risk

doubles with each increment of 20/10
mmHg throughout the BP range.

c. Persons who are normotensive at age 55

have a 90% lifetime risk for developing
HTN.

d. Those with SBP 120–139 mmHg or DBP

80–89 mmHg should be considered
prehypertensive who require health-
promoting lifestyle modifications to
prevent CVD.
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1. WHO. A global brief on hypertension. World Health Day
2013.
2. Community Medicines with Recent Advances by A H
Suryakantha.Third Edition-2014.
3. The Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure. U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES , August 2004.
4. Primary Preventionof Hypertension: Clinical and
Public Health Advisory from the National High
Blood Pressure Education Program. NIH
PUBLICATION NO. 02-5076
NOVEMBER 2002.
79
5. A short history of blood pressure measurement.
Proc R Soc Med. Nov 1977; 70(11): 793–799.
http://www.ncbi. nlm.
nih.gov/pmc/articles/PMC1543468.
6. The Updated WHO/ISH Hypertension Guidelines.
Linda Brookes. Medscape Mar 16, 2004.
http://www.medscape. com/
viewarticle/471863.
7. 2014 Evidence-Based Guideline for the Management
of High Blood Pressure in AdultsReport From the
Panel Members Appointed to the Eighth Joint National
Committee (JNC 8) .
8. AMA. 2014;311(5):507-520. doi:10.1001/jama.
2013.284427.
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9. Kearney PM et al. Global burden of hypertension: analysis of
worldwide data. Lancet. 2005 Jan 15-21;365(9455):217-23.
10. Journal of Hypertension: June Volume 32 - Issue 6 - p 1170–
1177.
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- Issue 6 - p 1170–1177.
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13. NATIONAL PROGRAMME FOR PREVENTION AND
CONTROL OF CANCER,DIABETES,
ARDIOVASCULAR DISEASES & STROKE ,(NPCDCS),2004
14. R Deepa et al.Is the ‘Rule of Halves’ in Hypertension Still
Valid? -Evidence from the Chennai Urban Population Study.
JAPI • VOL. 51 • FEBRUARY 2003.
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National Academies Press; 2004.
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Dis. Author manuscript; available in PMC 2011 July 1.

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