Hypertension and Ramadan

By Dr.Abdelsalam Sherif

MD Cardiology

Introduction1 .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

Ezzati et al. Lancet 2002:360:1347-60.

Underweight

Unsafe water, sani & hygiene

Alcohol

Physical inactivity

High BMI

Low fruit &vegetables intake

Unsafe sex

High cholesterol

Tobacco

Raised Blood Pressure

0 1 2 3 4 5 6 7Millions of Deaths

7 million

Developing region

Developed region

Peripheral vascular disease

Morbidity Disability

Renal disease

CADCHFLVH

Stroke

Hypertension

Hypertension: A Significant CV and Renal Disease Risk Factor

National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186–208.

These diseases account for significant disability, loss of productivity, and decreased quality of life

Proportion of diseases attributable to hypertension

Disease % attributable to hypertension

Myocardial InfarctionsHeart failureA . F. StrokesRenal failure

30 – 40 %Up to 50 %Up to 50 %30 – 40 %25 – 30 %

Prevalence Of Hypertension

Hypertension classification in ESH/ESC 2003 guidelines

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 hypertension

140 <90

Classification of BP levels (mmHg) according to JNC VII

BP Classificatio

n

Systolic BP

Diastolic BP

Initial drug therapy

Normal <120 <80

Pre-hypertension

120-139 80-89 No antihypertensive drug 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

JNC III: Drug TreatmentThresholds and Goals

Age > 60 yrsSystolic:

Threshold > 150 mmHgGoal < 150 mmHgLOE: Grade A

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A

JNC VIII: Drug TreatmentThresholds and Goals

Age < 60 yrsSystolic:

Threshold > 140 mmHgGoal < 140 mmHgLOE: Grade E

Diastolic:Threshold > 90 mmHgGoal < 90 mmHgLOE: Grade A for ages 40-59; Grade E for ages 18-39

Questions Frequently Asked

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?

Effect of Ramadan On Normotensive Males

Factors Affecting Hemodynamics During Ramadan Fasting

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.

Tips 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.

Medical Education & Information – for all Media, all Disciplines, from all over the WorldPowered by

2013 ESH/ESC Guidelines for the management of arterial hypertension

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

Lifestyle changes for hypertensive patientsRecommendations to reduce BP and/or CV risk

factorsSalt intake Restrict 5-6

g/dayModerate alcohol intake Limit to 20-30 g/day

men,10-20 g/day women

Increase vegetable, fruit, low-fat dairy intakeBMI goal 25 kg/m2Waist 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

Precautions for antihypertensive agents

Circadian Variation In Pharmacokinetics and Pharmacodynamics of some drugs

Is there an absolute contraindication for Ramadan fasting among hypertensive

patients?

Home Message

Thanks