HYPERTENSION

INTRODUCTION
Hypertension( HTN) is the most common primary
diagnosis in America.
50 million or more Americans have high BP.
Worldwide prevalence estimates for HTN may be as
much as 1 billion.
7.1 million deaths per year may be attributable to
hypertension.
HYPERTENSION
Blood pressure levels are a function of cardiac output multiplied by
peripheral resistance (the resistance in the blood vessels to the flow of
blood)
 Patophysiology
Autoregulation

BLOOD PRESSURE = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Hypertension = Increased CO and/or Increaced PR

Preload Contractility Functional Structural

Constriction hypertrophy
Fluid Volume
Volume Redistribution
Sympathetic Renin- Cell Hyper
nervous over- Angiostensin Membran Insulinemia
Renal Decreased activity Excess Alteration
Sodium filtration
Retension surface

Stress Obesity

Excess Genetic Genetic Endothelium

Sodium Alteration Alteration derived
Intake factors
 CLASSIFICATION AND MANAGEMENT OF BLOOD
PRESSURE FOR ADULTS (JNC VII)
INITIAL DRUG THERAPY

DBp*
BP SBp* mmH Lifestyle Without Compelling With Compelling
Classification mmHg g MODIFICATION Indication indication
Normal 120 And Encourage
80
Prehypertension 120- Or 80- Yes No Antihypertension Drug(s) for comppelling
139 89 Drug indicated indication
Stage 1 140- Or 90- Yes Thiazide-type Drug(s) for the
Hypertension 159 99 diuretics for most. compelling indications
May consider Other antihypertensive
ACEI,ARB,BB, CCB drugs (diuratics, ACEI,
or combination ARB, BB, CCB) as
needed
Stage 160 Or Yes Two drug
Hypertension 100 combination for most
(usually Thiazide-type
diuretics an ACEI or
ARB or BB or CCB)

DBP* diagnostic blood pressure, SBP* systotic blood pressure

Drug abbreviations :ACEL, angiotension converting enxyme inhibitor. ARBN, Angiotension receptor blocker. BB beta-blocker.
CCB, calcium chanel blocker.
HYPERTENSIVE CRISES

Hypertensive Urgencies: No progressive target-organ

dysfunction. (Accelerated Hypertension)

Hypertensive Emergencies: Progressive end-organ dysfunction.

(Malignant Hypertension)
 TYPES OF HYPERTENSION
Primary HTN:
Also known as essential HTN. Accounts for 95% cases of HTN.
No universally established cause known.

Secondary HTN:
Less common cause of HTN (5%). Secondary to other
potentially rectifiable causes.
 CAUSES OF SECONDARY HTN
Common Uncommon
Intrinsic renal disease Pheochromocytoma
Renovascular disease Glucocorticoid excess
Mineralocorticoid excess Coarctation of Aorta
Sleep Breathing disorder Hyper/hypothyroidism
 SECONDARY HTN-CLUES IN MEDICAL HISTORY
Onset: at age < 30 yrs (Fibromuscular dysplasia) or >
55 (athelosclerotic renal artery stenosis), sudden onset
(thrombus or cholesterol embolism).
Severity: Grade II, unresponsive to treatment.
Episodic, headache and chest pain/palpitation (thyroid
dysfunction).
Morbid obesity with history of snoring and day time
sleepiness (sleep disorders)
SECONDARY HTN-CLUES ON EXAM
Pallor, edema, other signs of renal disease.
Abdominal bruit especially with a diastolic
component (renovascular)
SECONDARY HTN-CLUES ON ROUTINE LABS

Increased creatinine, abnormal urinalysis

(renovascular and renal parenchymal disease)
Unexplained hypokalemia (hyperaldosteronism)
Impaired blood glucose (hypercortisolism)
Impaired TFT (Hypo-/hyper- thyroidism)
EVALUATION OBJECTIVES

To identify know causes

To assess presence or absence of target
organ damage and cardiovascular
disease
To identify other risk factors or disorders
that might guide treatment
EVALUATION COMPONENTS

Medical history
Physical examination
Routine laboratory tests
Optional tests
MEDICAL HISTORY

Duration and classification of hypertension

Patient history of cardiovascular disease
Family history
Symptoms suggesting causes of hypertension
Lifestyle factors
Current and previous medications
PHYSICAL EXAMINATION

Blood pressure readings (two or more)

Verification in contralateral arm.
Height, weight, and waist circumference
Funduscopic examination
Examination of the neck, heart, lungs, abdomen, and extremities
Neurological assessment
LABORATORY TESTS AND OTHER DIAGNOSTIC
PROCEDURE

Determine presence of target organ damage and other risk factors

Seek specific causes of hypertension
LABORATORY TESTS RECOMMENDED
BEFORE INITIATING THERAPY

Urinalysis
Complete blood count
Blood chemistry: potassium, sodium, creatinine, and fasting glucose
Lipid profile: total cholesterol and HDL cholesterol
12-lead electrocardiogram
STRATIFICATION OF RISK FACTORS
ON PATIENTS WITH HYPERTENSION

Major Risk Factors: Clinical Risk Factors

Smoking ( Target Organ Damage):

Dyslipidemia * Heart diseases (HHD or CAD )

Diabetes mellitus * Stroke or TIA
Age older than 60 years * Nephropathy ( CKD )
Sex (men or * Peripheral arterial disease
postmenopausal women) * Retinopathy
Family history of
cardiovascular disease
 RISK STRATIFICATION
Risk Group A ( Low ) No risk factors
No target organ disease/clinical
cardiovascular disease
Risk Group B ( Moderate ) At least one risk factor, not including
diabetes
No target organ disease/clinical
cardiovascular disease

Risk Group C ( High ) Target organ disease /clinical cardiovascular

disease and/or diabetes.
With or without other risk factors
 Target Organs Damage

Untreated hypertension can result in:

Arteriosclerosis --Kidney damage
Heart Attack --Stroke
Enlarged heart --Blindness
EFFECTS ON CVS
Ventricular hypertrophy, dysfunction and failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and rupture.

Effects on The Kidneys

Glomerular sclerosis leading to impaired kidney function and
finally end stage kidney disease.
Ischemic kidney disease especially when renal artery stenosis is
the cause of HTN
EFFECTS ON NERVOUS SYSTEM
Stroke, intracerebral and subaracnoid hemorrhage.
Cerebral atrophy and dementia

Effects on The Eyes

Retinopathy, retinal hemorrhages and impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to extraoccular muscle
paralysis and dysfunction
TREATMENT FOR HYPERTENSION
LIFESTYLE MODIFICATION

Maintain a healthy weight, lose weight if overweight.

Be more physically active.
Moderation of alcohol consumption.
Reduce the intake of salt and sodium in the diet to
approximately 2400 mg/day.
Maintain adequate intake of Potassium, calcium and
magnesium.
Stop smoking.
Reduce dietary saturated fat and cholesterol.
 TREATMENT STRATEGIES AND
RISK STRATIFICATION
Blood Pressure
Stages (mmHg) Risk Group A Risk Group B Risk Group C
High-normal Lifestyle modification Lifestyle modification Drug therapy
(130-139/85-89) Lifestyle modification

Stage 1 Lifestyle modification Lifestyle modification Drug therapy

(140-159/90-99) (up to 12 months) (up to 6 months)** Lifestyle modification

Stages 2 and 3 Drug therapy Drug therapy Drug therapy

(160/ 100) Lifestyle modification Lifestyle modification Lifestyle modification

Or those with heart failure, renal insufficiency, or diabetes

For those with multiple risk factors, clinicians should consider drugs as initial Therapy plus lifestyle
modification
GOALS OF TREATMENT
Treating SBP and DBP to targets that are <140/90 mmHg
Patients with diabetes or renal disease, the BP goal is <130/80
mmHg
The primary focus should be on attaining the SBP goal.
To reduce cardiovascular and renal morbidity and mortality

Benefits of Treatment
Reductions in stroke incidence, averaging 3540 percent
Reductions in MI, averaging 2025 percent
Reductions in HF, averaging >50 percent.24
 LIFESTYLE MODIFICATIONS

www.nhlbi.nih.gov
PHARMACOLOGIC TREATMENT

Decreases cardiovascular morbidity and

mortality based on randomised controlled
trials
Protects against stroke, coronary events,
heart failure, progression of renal disease,
progression to more severe hypertension,
and all-cause mortality
DRUG THERAPY

A low dose of initial drug should be used

slowly titrating upward.
Optimal formulation should provide 24-hour
efficacy with once-daily dose with at least
50% of peak effect remaining at end of 24
hours
Combination therapies may provide additional
efficacy with fewer adverse effects
 CLASSES OF
ANTIHYPERTENSIVE DRUGS

ACE inhibitors ( e.g captopril )

Adrenergic inhibitors ( e.g bisoprolol )
Angiotensin II receptor blockers ( e.g valsartan )
Calcium antagonists ( e.g amlodipine , diltiazem )
Direct vasodilators ( e.g nitrate )
Diuretics ( e.g hydrochlorothiazide, furosemide )
COMBINATION THERAPIES

adrenergic blockers and diuretics

ACE inhibitors and diuretics
Angiotensin II receptor antagonists and diuiretics
Calcium antagonists and ACE inhibitors
Other combinations
FOLLOW UP
Follow up within 1 to 2 months after initiating therapy
Recognize that high-risk patients often require high
dose or combination therapies and shorter intervals
between changes in medications
Consider reasons for lack of responsiveness if blood
pressure is uncontrolled after reaching full dose
Consider reducing dose and number of agents after 1
year at or below goal.
HYPERTENSIVE EMERGENCIES AND URGENCIES

Emergencies require immediate blood pressure

reduction to prevent or limit target organ damage
Urgencies benefit from reducing blood pressure within
a few hours
Elevated blood pressure alone rarely requires
emergency therapy
Fast-acting drugs are available.
DRUGS AVAIBLABLE FOR
HYPERTENSIVE EMERGENCIES

Vasodilators : Adrenergic Inhibitors :

Nitroprusside Labetalol
Nicardipine Esmolol
Fenoldopam Phentolamine
Nitroglycerin
Enalaprilat
Hydralazine
ALGORITHM FOR TREATMENT OF HYPERTENSION

Begin or Continue Lifestyle Modification

Not at Goal Blood Pressure

Initial Drug Choices

Not at Goal Blood Pressure

Not response or Inadequate response

Trouble some side effect But well tolerated

Subtitute drug, from Add agent from

Different class Different class

Not at Goal Blood Pressure

Continue adding agents from other classes

Consider referral to a hypertension specialist
ALGORITHM FOR TREATMENT OF
HYPERTENSION
Initial Drug Choices *
Compelling Indications
* Heart failure
- ACE inhibitors
- Diuretics
* Mycardial infarction
- -blockrs (non-ISA)
- ACE inhibitors (with systolic dysfunction)
* Diabetes Mellitus (Type 1) with proteinuria
- ACE inhibitors
* Isolated systolic hypertension (older persons)
- Diuretics preffered
- Long-acting dihydropyridine calcium antagonists

* Based on randomized controlled trials

THANK YOU