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A Cllnlcosoclal Case resenLaLlon
resent|ng Comp|a|nt
uurgappa a 36 year old male paLlenL from
uavengere wlLh llLeracy sLaLus upLo 8
Lh
sLandard currenLly noL worklng comes wlLh Lhe
chlef complalnLs of
lefL slded weakness and dlfflculLy ln walklng
slnce 20 days
Lhree eplsodes of vomlLlng 6 days back
n|story of resent|ng I||ness
aLlenL wlLh comorbld lllness of hyperLenslon
slnce 3 years and ulabeLes MelllLus slnce 2 years
comes wlLh lefL slded weakness of upper and
lower llmb
Slnce 20 days
Sudden onseL
Crade 4
nonprogresslve
WlLh gradual lmprovemenL
Pe was Laken Lo a hosplLal ln Shlmoga where
he had 3 eplsodes of vomlLlng
Small ln quanLlLy
WhlLlsh ln colour wlLh food parLlcles
non foul smelllng
non blood Llnged
lollowlng Lhls he complalned of generallzed
weakness and was broughL Lo kasLurba
PosplLal
negaLlve PlsLory
no hlsLory of Lrauma
no sensory deflclL
no memory loss
no headache
no syncope
no selzures
ast n|story
PyperLenslve slnce 3 yearson Amlodlplne
ulabeLlc slnce 2 yearson lnsulln LreaLmenL
no hlsLory of 1uberculosls or 8ronchlal
AsLhma
ersona| n|story
8owel/8ladder hablLs normal
Sleep lncreased
AppeLlLe ls reduced
aLlenL complalns of welghL loss whlch he
could noL quanLlfy
no rlsk facLors such as smoklng or alcohol
consumpLlon
Iam||y n|story noL ellclLed
LkAMINA1ICN
enera| Lxam|nat|on
no pallor lcLerus cyanosls clubblng
lymphadenopaLhy or edema
!v noL ralsed
ulse 81/mlnuLe
8lood ressure 160/100 mmPg
Afebrlle
8Ml 26
8esplraLory 8aLe 22/mlnuLe
ystem|c Lxam|nat|onCN
Plgher menLal funcLlons aLlenL was drowsy
Speech was normal lnformanL had noL
noLlced any memory loss
Cranlal nerve LxamlnaLlon normal
MoLor sysLem no muscle wasLlng 1one was
normal LefL slde showed grade 3 weakness ln
boLh upper and lower llmb
ronaLor drlfL Lo lefL
8eflexes normal
ystem|c Lxam|nat|on
kesp|ratory ystem nv8S
Card|ovascu|ar ystem S1 S2 heard no
murmurs
Abdomen SofL no organomegaly
Cphtha|mo|og|c Consu|tat|on grade lll
reLlnopaLhy
C||n|ca| |mpress|on
36yr old male wlLh comorbld lllness of
PyperLenslon and ulabeLes MelllLus presenLs
wlLh lefL slded hemlparesls due Lo sLroke
resulLlng from unconLrolled P1
Level of leslon rlghL lnLernal capsule
lnvLS1lCA1lCnS
|p|d prof||e
1rlglycerldes 101 (73130mg/dl)
PuL cholesLerol 28 (3060mg/dl)
LuL cholesLerol 81 (80130mg/dl)
ugar rof||e
lasLlng 8lood Clucose
141mg/dl (110126 mg/dl)
kena| Iunct|on 1est
urea 43 (13130mg/dl)
CreaLlnlne 11 (0313mg/dl)
C1 can
Well deflned hypodenslLy ls seen ln Lhe lefL
occlplLal reglon s/o acuLe lnfarcL ln Lhe lefL CA
LerrlLory
venLrlcles sulcl and clsLerns are normal
8ralnsLem ls normal
Invest|gat|ons recommended
1hyrold luncLlon 1esL
uSC Abdomen
Lo look for renal paLhology
Lo rule ouL any adrenal mass
Iam||y art|cu|ars
lL ls a nuclear famlly
Pead (paLlenL)
Wlfe housewlfe
2 sons aged 21yrs and 23yrs are earnlng
l daughLer 8 years old
nous|ng and Lnv|ronment
1ype of house ucca
Source of waLer 1ap waLer
MeLhod of wasLe dlsposal Munlclpal dlsposal
ersonal Pyglene Cood
CusLoms and hablLs none
now|edge re|ated to d|sease
AC1ICN
%
Time For Some
Ind|v|dua| eve|
We|ght contro|
CenLral CbeslLy has a poslLlve assoclaLlon wlLh
hlgh blood pressure
Average welghL reducLlon
of 92 kg leads Lo 8 reducLlon
of 63/31 mmPg
a|t kestr|ct|on
ually salL lnLake of 6gms ls recommended
Lowerlng ually naCl lnLake Lo 4474gms resulLs
ln 8 reducLlon by 4/2 mmPg
uleL deflclenL ln Ca k Mg ls seen Lo be
assoclaLed wlLh hlgh 8
An 1r|a|
(uleLary Approach Lo SLop PyperLenslon)
uleL rlch ln frulL vegeLable conLenL and low faL
dalry producLs(low faL and hlgh flbre) ls
recommended
Iam||y eve|
8ecognlLlon of uanger Slgns
PyperLenslve headache
alplLaLlons
ulzzlness
lncreased laLlgablllLy
Loss of Consclousness
Lnsure paLlenL Lakes regular medlcaLlon and
monlLorlng of 8
1rack|ng
1he paLlenLs chlldren should be encouraged
Lo adopL healLhy llfesLyle and
geL Lhelr 8 checked Lo ldenLlfy lf Lhey are aL
rlsk
Commun|ty eve|
Ceneral populaLlon
Plgh 8lsk groups
ln18CuuC1lCn Anu LluLMlCLCC?
uLllnl1lCn
nypertens|on (n1N) or h|gh b|ood pressure ls a cardlac chronlc medlcal
condlLlon ln whlch Lhe sysLemlc arLerlal blood pressure ls elevaLed
ClasslflcaLlon
SysLollc pressure ulasLollc pressure
mmPg ka mmPg ka
normal 90119 12139 6079 80103
rehyperLen
slon
120139 160183 8089 107119
SLage 1 140139 187212 9099 120132
SLage 2 160 213 100 133
lsolaLed
sysLollc
hyperLenslon
140 187 90 120
CLASSlllCA1lCn
Cn Lhe basls of eLlology
Lssent|a| hypertens|on
2econdaryhypertens|on
Cn Lhe basls of organ damage
rade I
rade II
rade III
MACnl1uuL Cl 1PL 8C8LLM
kLVALNCL
WC8Lu
4 264 of Lhe adulL populaLlon ln 2000 had
hyperLenslon 266 of men
26 of women
4 1he esLlmaLed LoLal number of adulLs wlLh
hyperLenslon ln 2000 was 2 m||||on
333 mllllon ln developed counLrles
63 mllllon ln developlng counLrles
lnulA
4 ln lndla
399 and 699 per 1000 urban males and
females
333 and 339 per 1000 rural males and
females
8uLL Cl PALvLS
Cnly abouL half of Lhe hyperLenslve sub[ecLs ln Lhe general populaLlon of
developed counLrles were aware of Lhe condlLlon only abouL half of Lhose
aware of Lhe problem were belng LreaLed and only abouL half of Lhose
LreaLed were consldered adequaLely LreaLed
1WPCLL CCMMunl1?
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3P?L81LnSlvL Su8!LC1S
4unulACnCSLu P?L81LnSlCn
3ulACnCSLu P?L81LnSlCn
6ulACnCSLu 8u1 un18LA1Lu
7ulACnCSLu Anu 18LA1Lu
8lnAuLCuA1LL? 18LA1Lu
9AuLCuA1LL? 18LA1Lu
MC81ALl1?
PyperLenslon ls a ma[or rlsk facLor for
SLroke
Coronary hearL dlsease
PearL and kldney fallure
Maxlmum morLallLy assoclaLed wlLh hyperLenslon ls due Lo
cardlovascular dlsease
(PyperLenslon ls one of Lhe chronlc dlseases whlch has shown Lhe largesL
decllne ln morLallLy ln some counLrles durlng Lhe lasL four decades due Lo Lhe
avallablllLy and usage of very effecLlve drugs Lo conLrol P1n)
Cvu uLA1P 8A1LS/lCCCCC MALLS
Cvu uLA1P 8A1LS/100000 lLMALLS
8lSk lAC1C8S lC8 P?L81LnSlCn
nCn MCulllA8LL
ACL 8 lncreases wlLh age ln boLh sexes
SLx Larly llfe llLLle or no dlfference
Adolescence hlgher ln men
?oung adulLs
mlddle age hlgher ln men
Cld age nearly equal (hlgher ln posL
menopausal women)
CLnL1lC lAC1C8S blood pressure levels are
deLermlned ln parL by geneLlc facLors and Lhe
lnherlLance ls polygenlc
L1PnlCl1? hlgher blood pressure levels are
commonly seen ln black communlLles
8lSk lAC1C8S lC8 P?L81LnSlCn
MCulllA8LL
C8LSl1? Lhe greaLer Lhe welghL galn Lhe greaLer
Lhe rlsk of hyperLenslon
SAL1 ln1AkL hlgh salL lnLake (78gms per day)
lncreases Lhe blood pressure
proporLlonaLely
SA1u8A1Lu lA1 ralses blood pressure and serum
cholesLerol
ulL1A8? ll88L P1n ls lnversely relaLed Lo Lhe
consumpLlon of dleLary flbre
ALCCPCL hlgh alcohol lnLake hlgh 8
P?SlCAL AC1lvl1? lnverse relaLlonshlp wlLh
blood pressure
Lnvl8CnMLn1AL S18LSS psychosoclal facLors
also conLrlbuLe Lo P1n
SCClC LCCnCMlC S1A1uS
ueveloped counLrlesmore ln lower socloeconomlc
groups
ueveloplng counLrlesmore ln hlgher soclo
economlc groups
C1PL8 lAC1C8S oral conLracepLlon
drugs causlng salL and
waLer reLenLlon
underlylng sysLemlc
dlseases
Cllnlcal leaLures
SympLoms
MosL of Lhe people are generally asympLomaLlc
SympLoms relaLed Lo lncreased blood pressure
Peadache mosL commonly ln Lhe occlplLal
reglon (ln severe cases)
ulzzlness
alplLaLlons
LplsLaxls
SympLoms relaLed Lo vascular dlsease
PemaLurla
8lurrlng of vlslon dude Lo reLlnal damage
ulzzlness followlng LranslenL cerebal lschemla
SympLoms suggesLlve of secondary hyperLenslon
olyurla olydypsla rlmary AldosLeronlsm
Lplsodlc headaches alplLaLlons ulaphoresls
and osLural ulzzlness heochromocyLoma
SlCnS
Cn Ceneral LxamlnaLlon a 8ound lace and
1runcal CbeslLy Cushlng's Syndrome
apllledema seen on lundoscoplc
LxamlnaLlon
1hlrd PearL Sound and ulmonary 8ales on
examlnaLlon of Lhe chesL and hearL are
suggesLlve of aorLlc coarcLaLlon
revenLlon
1he degree Lo whlch hyperLenslon can be prevenLed
depends on a number of facLors
currenL blood pressure level
sodlum/poLasslum balance
deLecLlon and omlsslon of envlronmenLal Loxlns
changes ln end/LargeL organs (reLlna kldney hearL)
rlsk facLors for cardlovascular dlseases
age aL dlagnosls of prehyperLenslon or Lhe rlsk of
hyperLenslon
3 ma[or approaches as per WPC
rlmary prevenLlon
opulaLlon sLraLegy
Plgh rlsk sLraLegy
Secondary prevenLlon
1erLlary prevenLlon
rlmary prevenLlon
deflned as 'all measures Lo reduce Lhe lncldence of dlsease ln
a populaLlon by reduclng Lhe rlsk of onseL'
2 esLabllshed Lerms populaLlon sLraLegy hlgh rlsk sLraLegy
8oLh Lhe approaches are complemenLary
opulaLlon SLraLegy
1hls ls a mulLlfacLorlal approach dlrecLed aL Lhe whole
populaLlon lrrespecLlve of lndlvldual rlsk levels
ConcepL ls based on Lhe facL LhaL even a small reducLlon ln
Lhe average blood pressure of a populaLlon would brlng abouL
a large reducLlon ln Lhe lncldence of compllcaLlons such as
CPu or sLroke
oa| Lo shlfL Lhe communlLy dlsLrlbuLlon of blood pressure
Lowards lower levels or blologlcal normallLy
a nuLrlLlon dleLary changes
8educLlon of salL lnLake Lo an average of noL 3g/day
lncreaslng poLasslum lnLake Lo rld Lhe renal sysLem of dleLary
sodlum usage of poLasslum chlorlde as a salL subsLlLuLe ls
adopLed by many ln Lhe wesLern world as lL helps lower body
sodlum levels oLasslum lnLake should be aL a level LhaL wlll
keep Lhe sodlum Lo poLasslum raLlo close Lo 10 le dally
poLasslum lnLake level of 7080 mmol
uASP dleL (dleLary approaches Lo sLop hyperLenslon) whlch ls
rlch ln frulLs and vegeLables and lowfaL or faLfree dalry
producLs lrulLs vegeLables and whole graln cereal have hlgh
flbre conLenL whlch reduces Lhe rlsk of CPu
ulsconLlnuaLlon of alcohol and Lobacco consumpLlon
lncreaslng omega3 faLLy aclds ln Lhe dleL lor example flsh oll
whlch has been shown Lo lower hyperLenslon
b romoLlon of physlcal acLlvlLy
Lhere ls slgnlflcanL evldence LhaL regular physlcal acLlvlLy leads Lo
fall ln body welghL blood llplds and blood pressure
1hls ls especlally lmporLanL conslderlng presenL day llfesLyle
changes
Larly mornlng [ogs brlsk walklng playlng ouLdoor games
swlmmlng worklng ouL aL Lhe gym eLc are a few examples
c WelghL reducLlon
prevenLlon and correcLlon of overwelghL obeslLy (8Ml 23) ls a
prudenL way of reduclng Lhe rlsk of hyperLenslon and hence CPu
1hls can be achleved Lhrough Lhe above menLloned polnLs dleLary
modlflcaLlon and physlcal acLlvlLy
d 8ehavloural changes
8educLlon of sLress by pracLlce of yoga medlLaLlon eLc whlch have
been shown Lo be good sLressbusLers
CulL smoklng
Modlfy llfesLyle
e PealLh LducaLlon whole communlLy musL be moblllzed and made
aware of Lhe posslblllLy of prlmary prevenLlon
f aLlenL parLlclpaLlon Lhe paLlenL ls LaughL selfcare le Lo Lake hls
own blood pressure and keep a log book of Lhe readlngs Pereby Lhe
burden on offlclal healLh servlces ls reduced conslderably 1hese log
books also serve ln Lhe long Lerm followup of cases
Plgh 8lsk SLraLegy
Alm 'Lo prevenL Lhe aLLalnmenL of levels of blood pressure aL
whlch Lhe lnsLlLuLlon of LreaLmenL would be consldered'
1hls approach ls approprlaLe lf Lhe rlsk facLors occur wlLh very
low prevalence ln Lhe communlLy
CpLlmum use of cllnlcal meLhods should be encouraged for
Lhe deLecLlon of hlgh rlsk sub[ecLs lor example ldenLlfylng
famllles wlLh a hlsLory of hyperLenslon and 'Lracklng' of blood
pressure form chlldhood Lo ldenLlfy lndlvlduals aL rlsk
Secondary hyperLenslon
oa| Lo deLecL and conLrol hlgh blood pressure ln affecLed
lndlvlduals
1he conLrol measures comprlse Lhe followlng
Larly Case deLecLlon
1reaLmenL
aLlenL compllance
a) Lar|y Case detect|on
1hls ls a ma[or problem because hlgh blood pressure rarely
causes slgnlflcanL sympLoms unLll organ damage has occurred
1herefore Lhe maln alm ls Lo conLrol lL before Lhls happens
1he meLhod proven Lo be mosL effecLlve ls screenlng of Lhe
populaLlon coupled wlLh followup and susLalned care
SelfexamlnaLlon of blood pressure makes Lhe screenlng
process easler
b) 1reatment baslc alm ls Lo brlng Lhe blood pressure below
140/90 mmPg and ldeally Lo around 120/80 mmPg 1here are
varlous anLlhyperLenslve drugs ln use presenLly
ACL lnhlblLors capLoprll enalaprll llslnoprll
A88s losarLan candesarLan valsarLan
CC8s nlfedlplne amlodlplne nlcardlplne
ulureLlcs hydrochloroLhlazlde furosemlde splronolacLone
.blockers propranolol meLoprolol
-blockers prazosln Lerazosln phenoxybenzamlne
CenLrally acLlng sympaLholyLlc clonldlne meLhyl dopa
vasodllaLors Pydralazlne mlnoxldll sodlum nlLroprusslde
c) at|ent Comp||ance
ueflned as 'Lhe exLenL Lo whlch paLlenL behavlour colncldes
wlLh cllnlcal prescrlpLlon'
aLlenL behavlour baslcally refers Lo Lhe paLlenLs' regularlLy
wlLh Lhelr medlcaLlon dleL modlflcaLlon and llfesLyle changes
eLc
1hls ls a slgnlflcanL problem as Lhe LreaLmenL for hyperLenslon
ls llfelong
Compllance raLes can be lmproved Lhrough educaLlon dlrecLed
aL paLlenLs famllles and communlLles as a whole
1erLlary prevenLlon
lL means Lo llmlL Lhe dlsablllLy ln paLlenLs who have developed
compllcaLlons due Lo hyperLenslon by LreaLlng Lhose
compllcaLlons
PosplLal and famlly based rehablllLaLlon are advlsable along wlLh
LherapeuLlc and supporLlve care
naLlonal rogramme for revenLlon and ConLrol of ulabeLes
Cardlovascular ulseases and SLroke (nuCS)
ueveloped under Lhe CovernmenL of lndlaWPC collaboraLlve
programme 20082009
118 mllllon people esLlmaLed Lo have hlgh blood pressure ln lndla
ln Lhe year 2000 expecLed Lo go up Lo 213 mllllon by Lhe year
2023
lndlans succumb Lo dlabeLes hlgh 8 and hearL aLLacks 310 years
earller Lhan Lhelr wesLern counLerparLs durlng Lhelr mosL
producLlve years
LsLlmaLed LhaL by Lhe year 2030 lndla wlll lose around 179 mllllon
poLenLlally producLlve years whlch ls hlgher Lhan Lhe expecLed
comblned loss ln Chlna 8ussla uSA orLugal and 8razll
Cb[ect|ves
revenLlon and conLrol of noncommunlcable dlseases (nCus)
CeneraLlon of awareness on llfesLyle changes
Larly deLecLlon of nCus
CapaclLy bulldlng of healLh sysLems Lo Lackle nCus
lloL phase launched ln 10 sLaLes (!an 2008) focused on healLh
promoLlon and educaLlon advocacy aL varlous seLLlngs
Intervent|ons
PealLh promoLlon for Lhe general populaLlon
ulsease prevenLlon for Lhe hlgh rlsk group
AssessmenL of prevalence of rlsk facLors
lan Lo lmplemenL Lhe programme ln 626 dlsLrlcLs ln all sLaLes 34
medlcal colleges dlsLrlcL hosplLals CPCs PCs subcenLres eLc
toJoys tlsky bebovloots ote tomottows tlsk foctots
toJoys tlsk foctots ote tomottows Jlseose