OBJECTIVES :

• To discuss Hypertension and its criteria

• To discuss the pathophysiology of Hypertension
• To discuss its etiology and risk factors
• To enumerate types of hypertension and
complications
• To discuss pharmacological and non-
pharmacological management and treatment of
patient with hypertension
 HYPERTENSION
• “Two or more elevated blood pressure
readings on at least two (2) outpatient visits
over a period of one to several weeks.

-Harrison’s Principles of Internal Medicine

 HYPERTENSION
• Sustained systolic BP elevation of 140 mmHg
or more, or sustained diastolic BP elevation of
90 mmHg or more, based on measurements
done during at least 2 visits taken at least 1
week apart or hypertension in one visit but
with evidence of target organ damage

-Philippine Society of Hypertension

 Etiology of Hypertension
A. Primary Hypertension

1. Abnormal cardiac & peripheral hemodynamics

2. Impaired pressure natriuresis
3. Baroreceptor resetting
4. Abnormalities in the renin-angiotensin-aldosterone
system
5. Abnormalities in other vasoregulatory systems
a. Endothelin
b. Atrial Natriuresis Peptide (ANP)
c. Endothelium-derived relaxation factor (EDRF)
 Etiology of Hypertension
B. Secondary Hypertension

1. Renovascular hypertension
2. Renal parenchymal diseases
a. Altered excretory function
b. Altered renin-angiotenism-aldosterone activity
3. Endocrinologic causes
a. Oral contraceptives
b. Mineralcorticosteroid excess syndrome
c. Pheochromocytoma
d. Miscellaneous causes (Acromegaly, Hyperparathyroidism,
Hyperthyroidism, Coarctation of the aorta )
3rd Leading Cause of Morbidity
in the Philippines (WHO)
EPIDEMIOLOGY

• Prevalence
increases with age

• Men > Women

until 55yo

• More in women
after that
 RISK FACTORS
• Obesity and weight gain 60% of patients
• >20% overweight
• High NaCl intake
• Low calcium and potassium intake
• Alcohol consumption
• Smoking
• Psychosocial stress
• Physical inactivity
PATHOPHYSIOLOGY
 VARIATIONS OF BP
• White coat hypertension
– 3 clinic-based measurement of >140/90 and 2 non-
cinic-based measurement of <140/90
• Masked hypertension
– Normal or low BP in a patient with advanced
atherosclerotic dse or evident target-organ damage
• Orthostatic hypotension
– Fall of BP in response to assumption of upright
posture from supine position within 3 mins. Systolic
fall >20mmHg, diastolic fall >10mmHg.
– Postural light-headedness and syncope
 Variations of BP
• Prior to labeling a person with hypertension, it is
important to use an average based on ≥2
readings obtained on ≥2 occasions to estimate
the individual’s level of BP.
• Out-of-office and self-monitoring of BP
measurements are recommended to confirm the
diagnosis of hypertension and for titration of BP-
lowering medication, in conjunction with clinical
interventions and health counseling.
 Hypertensive Crisis
• Severe rapid increase in blood pressure with the
systolic of 180mm Hg or higher or a diastolic of
120 mm Hg or higher. This can lead to damaged
blood vessels. The blood vessels become
inflamed and can leak fluid or blood.

• Hypertensive crisis is uncommon in children but if

a sudden severe increase in a child’s blood
pressure occurs they will require immediate
intervention to prevent harmful consequences.
Hypertensive crisis is divided into two
categories:
• Urgent
– Extremely high blood pressure. The patient is not
suspected to have any damage to organs.

• Emergency
– Extremely high blood pressure which has caused
damage to organs.
 HYPERTENSIVE WORK-UP
• RENAL:
– urinalysis (albumin excretion), serum bun and/or
creatinine
• ENDOCRINE:
– serum sodium, potassium, chloride, or TSH (optional)
• METABOLIC:
– FBS, total cholesterol, HDL, LDL, cholesterol,
triglycerides
• CBC, SGPT/SGOT
• Chest X-ray, Electrocardiogram
PHARMACOLOGIC MANAGEMENT
CLASS MECHANISM OF ACTION ADVERSE EFFECTS DRUGS
THIAZIDE •Inhibit NaCl transport (DCT) •K wasting •Hydrochlorothiazide
DIURETICS •Slow onset of action • Hyperuricemia •Chlorthalidone
•Long duration of action (6- •Impaired glucose
12hrs) tolerance
•Mild or moderated HPN • Hyponatremia
• Impotence
• Allergic reactions

LOOP •Thick ascending loop of •Hypokalemia •Furosemide

DIURETICS Henle w/c reabsorbs •Ototoxicity • Bumetanide
•20-30% of filtered load of •Hyperuricemia •Torsemide
NaCl •Hypocalcemia •Ethacrynic acid
• Most potent diuretics •Hypomagnesemia
(SEVERE EDEMA & •Allergic reactions
AZOTEMIA) •hyperglycemia
•Severe HPN

POTASSIUM •↓Na absorption in CT & •BPH •Triamterene

SPARING ducts •Impotence •Spironolactone
DIURETICS •Gynecomastia • Amiloride
Menstrual
irregularities
CLASS MECHANISM OF ADVERSE EFFECTS DRUGS
ACTION

CARDIO •Selectively inhibits B1 •Bronchospasm •Atenolol

SELECTIVE receptors (less •Bradycardia •Metoprolol
BB (B1) pulmonary effects) •AV block •Bisoprolol
•Metabolic syndrome •Esmolol
•Glucose intolerance
•Sleep disturbance
•Depression
NON- •Inhibits both B1 and •“” •Propanolol
SELECTIVE B2 receptors •Pindolol
BB •Timolol
(B1/B2) •Nadilol

VASODILATING •Combined A1 and B- •“” •Carvedilol

BB adrenergic receptor •Nebivolol
(A1/B) blockade •Labetalol
CLASS MECHANISM OF ADVERSE EFFECTS DRUGS
ACTION

DIHYDROPYRIDINE •Blocks L-type calcium •Tachyarrythmia Amlodipine

channels •Edema Felodipine
•Vascular effect > AV •Headache Nifedipine
node effect

NON- •Blocks L-type calcium •2nd and 3rd AV Block Diltiazem

DIHYDROPYRIDINE •AV node •Trifascicular block Verapamil
effect>Vascular effect •Severe LV
dysfunction
•Heart failure
CLASS MECHANISM OF ADVERSE EFFECTS DRUGS
ACTION

ACE Inhibits ACE Cough Captopril

INHIBITORS Result : Ang I not Angioedema Enalapril
converted to Ang II Hyperkalemia Lisinopril
Renal agenesis Perindopril
Ramipril

ANGIOTENSIN Competitive Hyperkalemia Candesartan

RECEPTOR antagonism with Ang Renal agenesis Irbesartan
BLOCKERS II Less cough Losartan
Less angioedema Olmesartan
Telmisartan
Valsartan

DIRECT Directly inhibits Angioedema Aliskiren

RENIN INHIBITOR renin,the first enzyme Hyperkalema
in the RAAS Cough
Hyperuricemia
CLASS MECHANISM OF ADVERSE EFFECTS DRUGS
ACTION

ALPHA Blocks the Postural hypotension Prazosin

BLOCKERS postsynaptic A1 Reflex tachycardia Terazosin
receptors found in Doxazosin
capacitance and
resistance vessels

CENTRAL Activation of A2 Sedation Clonidine

SYMPATHOLYTICS receptors in the CNS Xerostamia Methyldopa
Impotence
CNS side effects

DIRECT Release of nitric oxide Reflex tachycardia Hydralazine

VASODILATORS leading to arterial Headache Minoxidil
vasodilation Hypotension
Lupus-like syndrome
Hypertrichosis
NON-PHARMACOLOGIC
MANAGEMENT
 COMPLICATIONS
• Hypertension is an independent predisposing
factor for:
– Heart Failure
– Coronary Artery Disease
– Stroke
– Renal Disease
– Peripheral Arterial Disease
– Sexual Dysfunction
Thank You!