SYSTEMIC HYPERTENSION

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SYSTEMIC HYPERTENSION

• RANDA M. AL-HARIZY
• Prof. of Internal Medicine

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SYSTEMIC HYPERTENSION

• Definitions of hypertension
• Elevated arterial blood pressure is a major
  cause of premature vascular disease leading to
  cerebrovascular events, ischaemic heart disease
  and peripheral vascular disease.

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Hypertension - Introduction

• Silent Killer painless complications
• It is the leading risk factor MI, HF, CRF Stroke
• Responsible for the majority of office visits,
• Number one reason for drug prescription.
• 25 of population
• Complications bring to diagnosis but late

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Regulation of BP

• BP Cardiac Output x Peripheral Resistance
• Endocrine Factors
• Renin, Angiotensin, ANP, ADH, Aldosterone.
• Neural Factors
• Sympathetic Parasympathetic
• Blood Volume
• Sodium, Mineralocorticoids, ANP
• Cardiac Factors
• Heart rate Contractility.

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Control of Blood Pressure
Humoral Factors
Vasoconstrictors Angiotensin II Catecholamines
Vasodilators Pg Kinins
Blood Volume Na, Aldosterone
Cardiac Factors Rate Contract..
Local Factors pH, Hypoxia

• Neural Factors
• Adrenergic Cons
• ß Adrenergic - Dil

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Etiology

• 1- Essential
• In more than 95 of cases, an underlying
• cause cannot be found. Proposed mechanisms
• include
• Excess renal sodium retention
• Over activity of sympathetic nervous system
• Renin angiotensin excess
• Hyperinsulinemia
• Alterations in vascular endothelium

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Factors contributing to the development of
Essential hypertension

• Genetic Factors hypertension is more common in
  some families and in some ethnic groups like
  African Americans
• Environmental factors include obesity, alcohol,
  lack of exercise and excess salt intake

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2- Secondary hypertension

• Renal These account for over 80 of the cases of
  secondary hypertension. The common causes are
  diabetic nephropathy, chronic glomerulonephritis,
  adult polycystic disease, chronic
  tubulointerstitial nephritis, and renovascular
  disease.
• Endocrinal These include
• Conn's syndrome, adrenal hyperplasia,
  acromegaly,
• Phaeochromocytoma, Cushing's syndrome.
• Drugs and toxins
• Pregnancy-induced hypertension
• Vascular coarctation of aorta, vasculitis

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Complications

• Cerebrovascular disease and coronary artery
  disease are the most common causes of death,
  although hypertensive patients are also prone to
  renal failure and peripheral vascular disease.

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HYPERTENSION

• Classification of blood pressure levels
• (according to the British Hypertension Society)
• Category Systolic blood pressure
  Diastolic blood pressure
• Optimal lt 120
  lt 80
• Normal lt 130
  lt 85
• High normal 130-139
  85-89
• Hypertension
• Grade I (mild) 140-159
  90-99
• Grade 2 (moderate) 160-179
  100-109
• Grade 3 (severe) 180
  110
• Isolated systolic hypertension
• Grade 1 140-149
  lt 90
• Grade 2 160
  lt 90

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Malignant Hypertension

• Malignant or accelerated hypertension occurs when
  blood pressure rises rapidly and is considered
  with severe hypertension (diastolic blood
  pressure gt 120 mmHg).
• Unless treated, it may lead to death from
  progressive renal failure, heart failure, aortic
  dissection or stroke.
• The changes in the renal circulation result in
  rapidly progressive renal failure, proteinuria
  and haematuria. There is also a high risk of
  cerebral oedema and haemorrhage with resultant
  encephalopathy, and in the retina there may be
  flame-shaped haemorrhages, cotton wool spots,
  hard exudates and papilloedema

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HISTORY

• The patient with mild hypertension is usually
  asymptomatic.
• Attacks of sweating, headaches and palpitations
  may point towards the diagnosis of
  phaeochromocytoma.
• Higher levels of blood pressure may be associated
  with headaches, epistaxis or nocturia.
• Breathlessness may be present owing to left
  ventricular hypertrophy or cardiac failure.
• Malignant hypertension may present with severe
  headaches, visual disturbances, fits, transient
  loss of consciousness or symptoms of heart
  failure.

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EXAMINATION

• Elevated blood pressure is usually the only
  abnormal sign.
• Signs of an underlying cause should be sought,
  such as renal artery bruits in renovascular
  hypertension, or radiofemoral delay in
  coarctation of the aorta.
• The cardiac examination may also reveal features
  of left ventricular hypertrophy and a loud aortic
  second sound. If cardiac failure develops, there
  may be a sinus tachycardia and a third heart
  sound.

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Hypertensive Retinopathy

• Grade I Thickening of arterioles.
• Grade II Focal Arteriolar spasms. Vein
  constriction.
• Grade III Hemorrhages (Flame shape), dot-blot
  and Cotton wool and hard waxy exudates.
• Grade IV - Papilloedema

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INVESTIGATIONS

• Routine investigation of the hypertensive
• patient should include
• ECG
• Urine stix test for protein and blood
• Fasting blood for lipids (total and high-density
  lipoprotein cholesterol) and glucose
• Serum urea, creatinine and electrolytes.

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Investigation of selected cases

• Chest X-ray
• Ambulatory BP recording
• Echocardiogram
• Renal ultrasound
• Renal angiography
• Urinary catecholamines
• Urinary cortisol and dexamethasone suppression
  test
• Plasma renin activity and aldosterone

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Non-pharmcological treatment

• Weight reduction - BMI should be lt 25 kg/m2
• Low-fat and saturated fat diet
• Low-sodium diet - lt 6 g sodium chloride per day
• Limited alcohol consumption - 21 units/week for
  men and 14 units/week for women
• Dynamic exercise - at least 30 minutes' brisk
  walk per day
• Increased fruit and vegetable consumption
• Reduce cardiovascular risk by stopping smoking
  and increasing oily fish consumption.

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Pharmcological treatment should be based on the
following

• The initiation of antihypertensive therapy in
  subjects with sustained systolic blood pressure
  (BP) 160 mmHg, or sustained diastolic BP 100
  mmHg.
• In patients with diabetes mellitus, the
  initiation of antihypertensive drug therapy if
  systolic BP is sustained 140 mmHg, or diastolic
  BP is sustained 90 mmHg.
• In non-diabetic hypertensive subjects, treatment
  goals BP lt 140/85 mmHg. In some hypertensive
  subjects these levels may be difficult to
  achieve.
• Most hypertensive patients will require a
  combination of antihypertensive drugs to achieve
  the recommended targets.
• In most hypertensive patients, therapy with
  statins and aspirin to reduce the overall
  cardiovascular risk burden. Glycaemic control
  should be optimized in diabetics (HbA1c lt 7).

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Pharmacological Treatment

• Several classes of drugs are available to treat
• hypertension. The usual are
• ACE inhibitors or Angiotensin receptor
  antagonists
• Beta-blockers
• Calcium-channel blockers
• Diuretics
• Other drugs as a-blocker, direct vasodilator, or
  centrally acting drugs

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• Choice of antihypertensive therapy
• The choice of antihypertensive therapy is usually
  dictated by
• cost, convenience, the response to treatment and
  freedom of
• side effects
• Comorbid conditions may have an important
  infleunce on
• initial drug selection e.g.
• ?-blocker in angina
• Thiazide diuretics and calcium antagonists in
  elderly people
• ACE in heart failure, post MI, type 1 diabetic
  nephropathy
• ARBs in type 2 diabetic nephropathy, intolerance
  to ACE
• a-blocker in benign prostatic hypertrophy

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• Management of severe or malignant hypertension
• Patients with severe hypertension (diastolic
  pressure gt 140 mmHg), malignant hypertension
  (grades 3 or 4 retinopathy), hypertensive
  encephalopathy or with severe hypertensive
  complications, such as cardiac failure, should be
  admitted to hospital for immediate initiation of
  treatment.
• In most cases, the aim is to reduce the
  diastolic blood pressure to 100-110 mmHg over
  24-48 hours. This is usually achieved with oral
  medication, e.g. atenolol or amlodipine. Blood
  pressure can then be normalized over the next 2-3
  days.
• When rapid control of blood pressure is required
  (eg. in aortic dissection), the agent of choice
  is IV sodium nitroprusside. Alternatively,
  infusion of labetalol can be used. The infusion
  dosage must be titrated against blood pressure
  response.

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Management of hypertension in pregnancy

• Mild hypertension can be treated with methyldopa,
  which has been established as being safe in
  pregnancy, or labetalol. Pre-eclamptic
  hypertension can be treated with the same agents,
  or nifedipine, although the only method for
  reversal of overt pre-eclampsia is delivery. More
  severe hypertension or eclampsia requires
  treatment with intravenous hydralazine and may
  even require termination of the pregnancy.

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PROGNOSIS

• The prognosis from hypertension depends on a
  number of features
• Level of blood pressure
• Presence of target-organ changes (retinal, renal,
  cardiac or vascular)
• Coexisting risk factors for cardiovascular
  disease, such as hyperlipidaemia, diabetes,
  smoking, obesity, male sex
• Age at presentation.
• Several studies have confirmed that the treatment
  of hypertension, even mild hypertension, will
  reduce the risk not only of stroke but of
  coronary artery disease as well.

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Summary

• Hypertension is the commonest cause of major
  morbidity, but less than a quarter of patients
  are adequately treated.
• A reduction in cardiovascular disease mortality
  and morbidity can be achieved through improved
  treatment and control of hypertension.
• A greater choice of drugs are available for
  hypertension than for other chronic diseases.
• Rational choice of single and combination drugs
  facilitated by understanding their effects on the
  renin system, but systematic trial and error may
  still be necessary.

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