Hypertension (HT) High Blood Pressure (HBP)

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Hypertension (HT) High Blood Pressure (HBP)
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Introduction

• Definition Hypertension is defined as elevated
  arterial blood pressure.
• Hypertension is one of the most common disease in
  the world
• In our country, 160 million people over the age
  of 15 have established or borderline HP
• HP Essential HP (95) Secondary HP (5)

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Etiology

• Genetic
• Environment
• Dietary Salt intake
• Alcohol intake
• Obesity
• Infant dysnutrition

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Pathogenesis

• High activity of the SNS (Sympathetic Nervous
  System)
• RAAS (Renin-Angiotension Aldosterone System)
• Renal Sodium Handling
• Vascular Remodelling
• Endothelial Cell Dysfunction
• Insulin Resistance

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Pathological consequences

• target organs
  hemorrhage
• the CNS
  stroke thrombosis
• 
  
• 
  LVH HF
• HBP the Heart
  CHD AP MI HF arrhythmia
• the Kidney
  progressive renal nephrosclerosis
• 
  progressive scarring of the glomerula
• 
  renal failure
• the Arteriosclerosis
  stenosis thrombosis occlusion
• 
  dilatation rapture
  hemorrhage

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The pathological changes of small artery
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The pathological change of the Heart

• Left ventricular hypertrophy (LVH)
• Heart failure
• Coronary artery atherosclerosis
• Myocardial infarction

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Pathological change of the Brain

• Stroke
• Ischemic stroke
• Hemorrhagic stoke

Arterial Aneurysm
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Pathological change of Renal

• Hypertension induced nephrosclerosis, atrophy of
  renal cortex

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Clinical Features

• The blood pressure varies widely over time,
  depending on many variables, including SNS
  activity, posture, state of hydration, and
  skeletal muscle tone.
• Symptoms
• Always asymptomatic
• Symptoms often attributed to hypertension
• headache, tinnitus, dizziness, fainting

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Clinical Features

• Complications of Hypertension
• Heart LVH, CHD,HF
• Brain TIA, Stroke
• Renal Microalbuminuria, renal dysfunction
• Ratinopathy

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Laboratory Examination

• Blood pressure measurement
• Clinic Blood Pressure
• Home Blood Pressure
• Ambulatory monitoring

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Ambulatory Measurement

• Ambulatory monitoring can provide
• readings throughout day during usual activities
• readings during sleep to assess nocturnal changes
• measures of SBP and DBP load
• Exclude white coat or office hypertension
• Ambulatory readings are usually lower than in
  clinic (hypertension is defined as gt 135/85 mm Hg)

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Laboratory Examination

• Urinalysis
• Blood examination
• Chest X Ray
• EKG
• UCG (Ultrasound cardiography)
• Retina examination

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The Keith-Wagner Criteria (change in retina)

• KW I Minimal arteriolar narrowing,
  irregularity
• of the lumen, and increased light
  reflex
• KW II More marked narrowing and irregularity
• with arteriovenous nicking (crossing
  defects)
• KW III Flame-shaped hemorrhages and exudates in
• addition to above arteriolar changes
• KW IV Any of the above with addition of
  papilledema

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Pepilledema
Flame shaped hemorrhage
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Diagnosis Differential Diagnosis
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Classification of blood pressure for adult

• Category SBP (mmHg) DBP (mmHg)
• Normal lt 120
  lt 80
• High normal 120-139
  80-89
• Hypertension 140 90
• Stage 1 140-159
  90-99
• Stage 2 160-179
  100-109
• Stage 3 180
  110
• Systolic HBP 140 lt 90
• When the SBP and DBP fall into different
  categories, use the higher category

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Evaluation Objectives

• To identify cardiovascular risk factors
• To assess presence or absence of target organ
  damage
• To identify other causes of hypertension
• These evaluation may used in stratification of
  the hypertension patients

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Cardiovascular Risk Factors

• Blood pressure
• Age
• Gender
• Dyslipidemia
• Abdomen Obesity
• Family History of cardiovascular disease
• CRP 1mg/dl

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Target Organ Damage

• Left ventricular hypertrophy
• Echo shows IMT of carotid artery
• Plasma creatinine slight elevation
• Microalbuminuria

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Associated Clinical Condition

• Cerebrovascular diseases Stroke, TIA
• Heart diseases MI, AP, CHF, Coronary artery
  revasculation
• Kidney diseases DN, Dysfunction of the kidney,
  Proteinuria, CRF
• Diabetes
• Peripheral artery disease
• Retinopathy

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Evaluation Components

• Medical history
• Physical examination
• Routine laboratory tests

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Stratification of Hypertension patients
Blood Pressure Blood Pressure Blood Pressure
risk factors Disease History Grade I Grade II Grade III
I . No risk factors Low risk Med risk High risk
II. 1-2 risk factors Med risk Med risk Very high risk
III. 3 or more risk factors or TOD or diabetes High risk High risk Very high risk
IV. ACC Very high risk Very high risk Very high risk
TOD-Target Organ Damage ACC-Associated Clinical
Conditions
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Differential Diagnosis

• Should exclude Secondary Hypertension

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Secondary Hypertension Common Causes

• Renal
• Glomerulonephritis
  Pyelonephritis Obstructive nephropathy
  Collagen diseases, Congenital diseases
  Diabetes nephropathy Renal tumor---- renin
  secreting tumor
• Pheochromocytoma
• Primary aldosteronism

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Phenochromocytoma

• Ganglion-neurotomas and neuroblastomas
• Excretion of large amounts of catecholamines
• 90 arise in the adrenal medulla
• 10 are malignant.
• Paroxymal or persist HT
• Clinic features Headache, sweating,
  palpitations, nervousness, weight loss,
  hypermetabolism, orthostatic hypotension, severe
  presser response

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Primary Aldosteronism

• Mild or moderate hypertension
• Hypokalemia, muscle weakness, paralysis
• Polyuria, nocturia and polydipsia,
• Hypochloremic alkalosis
• Urine aldosterone elevation
• Plasma renin active decrease

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Secondary Hypertension

• Obstructive Sleep Apnea (OSA)
• Renal artery stenosis
• Cushings syndrome
• Coarctation of the aorta
• Drug-induced
• NSAIDs Sympathomimetic
  medications
• Prophylactic Monoamine oxidase
  inhibitors
• Mineralocorticoids Immuno-inhibitors
• Epogen

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Therapy
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Goal of Hypertension Management

• lt 140/90 mm Hg
• With Diabetes or kidney dysfunction
  lt130/80mmHg
• To reduce morbidity and mortality of cerebral and
  cardiovascular complications.
• Controlling other cardiovascular risk factors

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Lifestyle Modifications

• Stop smoking
• Limit alcohol intake
• Lose weight or keep fit
• Suitable diet
• Increase aerobic physical activity
• Decrease psychological stress

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Principle of Drug Therapy

• Drug therapy should be individually
• A low dose of initial drug therapy
• Combination therapies may provide additional
  efficacy with fewer adverse effects.
• Optimal formulation should provide 24-hour
  efficacy with once-daily dose.

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Antihypertensive Drugs

• Diuretics
• ß-Adrenergic receptor blockers (BB)
• Calcium channel blockers (CCB)
• ACE inhibitors (ACEI)
• Angiotensin II receptor blockers (ARB)

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Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure
Initial Drug Choices
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Algorithm for Treatment of Hypertension
(continued)
Initial Drug Choices
No associated clinical condition
Associated clinical condition
I stage hypertension Diuretics, BB,CCB,ACEI,ARB
II stage hypertension Two drugs combination
therapy
Choice the drugs according to ACC
Not at Goal Blood Pressure
Increase dosage or add another agent from
different class
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Drug choices in hypertension patient associated
with clinical condition
ACC Drug Drug Drug Drug Drug Drug
ACC Diuretics BB ACEI ARB CCB Antialdosterone
HF v v v v
MI v v v
CAD v v v v
DM v v v v v
CRF v v
Stroke v v
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Combination Therapies

• May provide additional efficacy with fewer
  adverse effects.
• Diuretics as the basement drug in combination
  therapy.
• Diuretics ---- ACEI / ARB
• Diuretics ---- BB
• Diuretics ---- CCB
• CCB as the basement drug in combination therapy
• CCB ---- ACEI
• CCB ---- BB
• Others Three drugs combination

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Causes for InadequateResponse to Drug Therapy

• Incorrect measurement of the BP
• Volume overload or Pseudo-resistance
• Drug-related causes
• Associated conditions

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Hypertensive crisis

• Hypertensive Emergencies and Urgencies
• Emergencies The blood pressure is elevated
  severely and associated with target organ damage,
  such as hypertensive encephalopathy, AMI,
  pulmonary edema, require immediate blood pressure
  reduction.
• Urgencies The blood pressure is elevated
  severely but no target organ damage has acute
  target organ damage.
• Fast-acting drugs are available.

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Drugs Available forHypertensive Crisis

• Vasodilators
• Nitroprusside
• Nicardipine
• Nitroglycerin
• Hydralazine

• Adrenergic Inhibitors
• Labetalol
• Esmolol
• Phentolamine

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Case 1

• Male 29 years old
• Blood pressure elevated for two years
• With paroxysmal dizziness, blurred vision,
  sweating and palpitation
• BP 160-180/90-100mmHg
• HR 100-120 bpm
• When the patient with symptoms, the BP would
  elevate to 240-260/120-130mmHg, and HR increase
  to 130-150 bpm.

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• Physical examination
• BP 165/100mmHg HR 112 bpm
• No positive sign in chest examination
• Can find a mass at right abdomen, if press on it
  the BP of the patient elevated to 250/120mmHg,
  and the HR increased to 145 bpm.

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• Laboratory test
• Blood routine, Urinalysis, Blood biochemistry are
  normal
• Plasma renine activation   0.93ng/ml.h
  (0.93-6.56)  
• AT II   51.5pg/ml ? (55.3-115.3) 
• Aldosterone  129.4pd/ml (63-239.6)
• NE 33.40pmol/ml ??  (0.51-3.26)
• 12-lead electrocardiogram High voltage of LV
• Chest X ray Normal

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• CT scan of abdomen
• Found a mass at right adrenal

Diagnosis as Phenochromocytoma
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Case 2

• Male, 65 years old
• Hypertension history for 30 years
• Headache, blurred vision, vomiting for 2 hours
• Paralysis of left side body
• BP 220/130mmHg
• HR 106 bpm
• CT scan of the head Normal

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• Diagnosis Hypertensive crisis
• Therapy Controlled the BP, using fast-acting
  drug,such as Nitroprusside, Labetalol
• The reduction of BP should less than 25 in 24
  hours
• BP 160/100mmHg in 48 hours

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Summary

• Specific therapy for patients with LVF, CAD, and
  HF. ACEI can be used for all type patients.
• In older persons, diuretics and CCB are
  preferred.
• Many patients need combination therapy.
• Goal of the patients with renal insufficiency
  with proteinuria (gt1 g/day) 125/75 mmHg
• (lt 1 g/day) 130/80 mmHg.
• Patients with diabetes should be treated to a
  therapy goal of below 130/80 mm Hg.