Workshop Hypertension

Classification, Epidemiology,
Pathophysiology of
Hypertension

Stella Palar
CLASSIFICATION
 Classification of Hypertension JNC
VII
BP classification on people age > 18 y.o
Adults on no antihypertensive medications & who are not
acutely ill.
Systolic Diastolic
Category (mm Hg) (mm Hg)
Normal < 120 and <80
Prehypertension 120-139 or 80-89
Hypertension
Stage 1 140-159 or 90-99
Stage 2 > 160 or 100

Isolated hypertension age>55 yo, SBP 140 & DBP <90 mmHg
 ESH/ESC Definition & Classification
of Blood Pressure Levels (mm Hg)
Category Systolic Diastolic

Optimal 120 and 80

Normal 120-129 and/or 80-84
High Normal 130-139 and/or 85-89
Grade 1 Hypertension 140-159 and/or 90-99
Grade 2 Hypertension 160-179 and/or 100-109
Grade 3 Hypertension 180 and/or 110

Isolated Systolic
140 and 90
Hypertension
Mancia G, et al. J Hypertens 2007;25:1105-1187
Classification of Hypertension
JNC 6 Category JNC 7 Category ESH

SBP/DBP SBP DBP (mmHg)

(mmHg)
Optimal < 120/80 Normal < 120 < 80

Normal 120-129/80-84 < 130 < 85

Pre-hypertension
Borderline 130-139/85-89 130-139(High Normal)85-89
Hypertension 140/90 Hypertension
Stage 1 140-159/90-99 Stage 1 140-159 90-99
Stage 2 160-179/100-109 160-179 100-109
Stage 2
Stage 3 180/110 180 110
Isolated St. 1 140-159 < 90
Isolated St. 2 160 < 90
Kaplans Clinical Hypertension, 2009
Classification of hypertension InaSH

Tekanan darah (mm Hg) Kategori

Sistolik Diastolik

<120 and <80 Normal

120-139 or 80-89 Prehipertensi

140-159 or 90-99 Hipertensi tingkat 1

160 or 100 Hipertensi tingkat 2
EPIDEMIOLOGY
Epidemiology

In world : 1 billion hypertension,

mortality 7,1 million / year
Increase elderly population increase
prevalence of hypertension
In population age >65 >50% have
systolic and /or diastolic hypertension
Controlling of hypertension only about
45% of all hypertension cases
 In developed country prevalence of
hypertension 30-40% of adult
population
In Indonesia 6-31.7%
The National Health and Nutrition
Examination Survey (NHANES) 1999-
2000:
Incidence hypertension 29-31% (58-65
million adult has hypertension
There an increasing 15 million compared
 Prevalence of hypertension*:
North America and Europe

80
Men
70 Women
60
Prevalence (%)

Total
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* BP 140/90 mmHg or treatment with antihypertensive medication Wolf-Maier K, et al. JAMA 2003;289:2363-2369
 Prevalence of hypertension: Asia

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Men
70
Women
Prevalence (%)

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Total
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Gu DF, et al. Hypertension 2002;40:920-927; Singh RB, et al. J Hum Hypertens 2000;14:749-763; Janus ED. Clin Exp Pharmacol Physiol 1997;24:987-
988; National Health Survey 1998, Singapore. Epidemiology and Disease Department, Ministry of Health, Singapore.; Lim TO, et al. Singapore Med J
2004;45:20-27; Tatsanavivat P, et al. Int J Epidemiol 1998;27:405-409; Muhilal H. Asia Pacific J Clin Nutr 1996;5:132-134;
Gupta R. J Hum Hypertens 2004;18:73-78; Asai Y, et al. Nippon Koshu Eisei Zasshi 2001;48:827-836 [in Japanese]
 Prevalence of Hypertension
in Indonesia
Age group Prevalence
(year) (%)
18 24 12.2
25 34 19.0
35 44 29.9
45 54 42.4
55 - 64 53.7
65 74 63.5
> 75 67.3
Total 31.7

National Basic Health Survey, 2007

 Prevalence of Hypertension
Hypertension is often founded in practical clinic

70
65
prevalence of hypertension (%)

SBP > 140 mm Hg 64

60 DBP > 90 mm Hg
54
50
44
40

30
21
20 4 11
10

0
age (yrs) 18-29 30-39 40-49 50-59 60-69 70-79 80+

Franklin, S.S., J Hypertens 1999; 17 (suppl 5): S29-S36

 Prevalence of high blood pressure, 140/90 mm Hg,
rises with age
% Non-hispanic black
Percentage of hypertension Non-hispanic white
80 Mexican American

60

40

20

0 Age, years
18-29 30-39 40-49 50-59 60-69 70-79 80
US 1988-91 Men NHANES3, Burt et al 1995
 Prevalence of high blood pressure, 140/90 mm Hg,
rises with age
% Non-hispanic black
Percentage of hypertension Non-hispanic white
80 Mexican American

60

40

20

0 Age, years
18-29 30-39 40-49 50-59 60-69 70-79 80
US 1988-91 Women NHANES3, Burt et al 1995
 Percent of Population 50
41,8 41,4 42,0
39,0 38,2
37,5
40
29,9
28,5 28,0 26,7
30 25,6
26,9 26,2
25,0
27,0
24,3
22,9
21,0
20

10

0
NH White NH White NH Black NH Black Mexican Mexican
Only Men Only Women Men Women American American
Men Women

1988-94 1999-04 2005-06

Age adjusted prevalence trends for HBP in adults more than 20 years of age by race/ ethnicity, sex, and surveys
(NHANES: 1988 to 1994, 1999 to 2004, and 2005 to 2006). (From Lloyd-Jones D, Adams R, Carnethon M, et al.
Heart disease and stroke statistics-2009 update: A report from the American Heart Association statistics
commintee and stroke statistic subcommittee. Circulation 2009;119:e21-e181, with permission

Kaplans Clinical Hypertension, 2010

 90
76,4
80
Percent of Population

69,6
70 64,7 64,1
55,8
60 53,7

50
36,2 35,9
40
30 23,2
16,5
20 13,4

10 6,2

0
20-34 35-44 45-44 55-64 65-74 75+

Men Women

Prevalence of HBP in adults more than 20 years by age and sex (NHANES: 2005 to 2006). Adapted from NCHS and
NHLBI. Hypertension is defines as SBP 140 mmHg or DBP 90 mmHg, taking antihypertensive medication, or
being told twice by a physician or other professional that one has hypertension. (From Lloyd-Jones D, Adam R.
Carnethon M, et al. Heart disease and stroke statistics-2009 update: A report from the American Heart Association
statistics committee and stroke statistics subcommitee. Circulation 2009; 119:e21-e181, with permission)

Kaplans Clinical Hypertension, 2010

RULE OF HALF
Hypertensive patients
Patients who are aware
who are treated
but remain untreated
but uncontrolled
and uncontrolled

25% 12.5%
12.5%

50%

Hypertensive patients Hypertensive patients

who are unaware who are treated
and controlled

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

Awareness, Treatment and Control of Blood Pressure
(1976-2004)

National Health and Nutrition Examination Survey (%)

1976-1980 1988-1991 1991-1994 2000-2004 2005-2006

Awarenes
51 73 68 70 79
s
Treatment 31 55 54 59 61
Control 10 29 27 34 45

Kaplans Clinical Hypertension, 2010

 < 140/90 mmHg < 160/95 mmHg
USA Canada Finland Spain Australia
16 20.5 20 19
27

England France Germany Scotland India

6 9
24 22.5 17.5

> 65 years

USA: JNC VI. Arch Intern Med 1997 Marques-Vidal P et al. J Hum Hypertens 1997
Canada: Joffres et al. Am J Hypertens 1997
England: Colhoun et al. J Hypertens 1998
France: Chamontin et al. Am J Hypertens 1998
Adapted from G. Mancia / L. Ruilope
 Hypertension Prevalence & Treatment:
North America and Europe
Patients on Therapy
US
55 Canada
100 Italy
50
90 Sweden
45 England
80 Spain
40
70 Finland
% 35 % Germany
60
30
50
25
40
20
30
15
20
10
10
5
0
0
Country Country
Wolf-Maier K et al. JAMA. 2003;289:2363-2369.
 Cardiovascular Mortality Risk
Increases as Blood Pressure Rises*
8x
8
Cardiovascular

7
Mortality Risk

6
5
4x
4
3
2x
2
1
0
115/75 135/85 155/95 175/105
Systolic/Diastolic Blood Pressure (mm Hg)
*Measurements taken in individuals aged 4069 years, beginning with a blood
pressure of 115/75 mm Hg.
Slide Source
Lewington S, et al. Lancet. 2002;360:1903-1913; Hypertension Online
www.hypertensiononline.org
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
PATHOPHYSIOLOGY
 Pathophysiology of hypertension

INAPPROPRIATELY HIGH
SYMPATHETIC OUTFLOW

Increased large
arterial stiffness

Abnormal venoconstriction
and high venous return Inappropriately high Increased
cardiac output systemic
resistance

INAPPROPRIATELY HIGH ABNORMAL RENAL

RENIN RELEASE SALT/WATER HANDLING

Courtesy of JL Izzo Jr, MD.

 Sympathetic nervous system up-regulation

Increased Beta blocker

Norepinephrine levels

Activation of the Decreased Direct

RAA system Renal blood Myocardial toxicity
flow
LV dysfunction
Increased
Angiotensin II & Increased HR, PVR & Myocyte
Aldosteron arteriolar vasoconstriction necrosis

Increased myocardial Intracellular

Na+ & water oxygen demand Ca2+ overload/
retention Energy depletion

Vasoconstriction Cardiac remodeling Apoptosis

Cesario et.al; Reviews in cardiovascular medicine, vol 3, no.1, 2002

Increase BP
 Proteinuria

Apoptosis Tubular transport

Glomerular Growth of glomerular

hemodynamics and tubular cells

Induction of reactive Inhibition of NO

oxigen species Angiotensin II synthesis

Induction of Metabolic effects

chemokines

Increase in tubular HDL and

Upregulation of Toll- Albumin uptake
like % receptors
Stimullation of extracellular matrix
sythesis, inhibition of extracellular
matrix turnover

Ang II is a cytokine with many effects on the kidney

clearly beyond the classical function as a hemodynamic mediator.

J Am Soc Nephrol 17: 2985-2991, 2006