Hypertension

• 20% of Canadians have this.

• Only 16% of hypertensives take
medication needed to control it.
• Sometimes called the “silent killer”.
• Hypertensive people lose about 16 years of
life on average.
• Death is from cardiovascular (e.g. strokes),
cardiac and renal diseases.
 Hypertension, objectives:
1. Primary causes
2. Secondary causes
3. Effects
4. Treatment issues.
 Hypertension
• Systolic pressure – caused by heart’s
contraction
• Diastolic pressure – between contractions
of heart due to resistance of capillaries.
• WHO: systolic 160 mm Hg
diastolic 95 mm Hg.
• 25% of adults exceed this – an example
that “normal” is not healthy.
 Blood pressure
systolic diastolic
Normal <130 <85 mm Hg
Mild 140-159 90-99
Moderate 160-179 100-109
Severe 180-209 110-119
Very severe >210 >120

On 2 occasions, 6 hours part.

[Note: white coat phenomenon]
 Hypertension, clinical:
• Blurred vision,
• Heart disease – cardiomegaly, ischaemic heart
disease (IHD)
• Stroke
• Renal failure
• Nocturia
• Epistaxis
• Headaches (occiput, throbbing, early morning).
Bp =cardiac out + peripheral vascular resistance
1. Left ventricular 1. Sympathetic nervous
pressure increased. system
2. Mineralo- 2. Hormones:
corticoids. angiotensin,
3. Fluid load increased. catecholamines
 Control of blood pressure:
• Aldosterone
• Renin-angiotensin
• Sodium pump
ATP
K Na
O
K Na
ADH volume

Renal blood flow

thirst

Hypothalamic osmolality Renin release

Angiotensin II

Plasma Na Aldosterone
 Of interest in hypertension:
• Alcohol,
• Stress,
• Polycythaemia,
• Oral contraceptives, pregnancy,
• Diabetes mellitus,
• Gout,
• Obesity,
• Family history,
• Coarctation of aorta.
Coarctation of aorta
Hypertension’s causes, theories:
1. Prolonged high stress – arterial walls
thicken – arteriosclerosis.
2. Sodium intake too high – inability of
kidney to eliminate sodium and water
load.
Note: Chimpanzees.
Preliterate societies.
Blood pressure and age.
 Take blood pressure properly
• Clinical examination:
2. Fundus
3. Pulse
4. Left ventricular hypertrophy
5. Heart sounds.
 Systolic hypertension only then
• Thyrotoxicosis,
• Aortic valve disease
• Psychogenic
• Anaemia
• Polycythaemia.

• Could lead to heart failure.

 Systolic and diastolic
hypertension
• “Essential”, primary 96%
• Renal – nephritis, diabetes mellitus, renovascular
• Endocrine – Cushing’s, Conn’s 1%,
Pheochromocytoma < 0.1%.
• Central nervous system – raised intracranial
pressure.
• Coarctation of aorta
• Toxaemia of pregnancy.
 Hypertension, be wary of:
• Obesity,
• Alcohol
May have role in development of “essential”
hypertension
• Oral contraceptives

• Hypertension could be benign or

malignant (accelerated)
 Secondary hypertension
1. Renal
2. Drugs – oral contraceptives
3. Aldosterone – Conn’s, Cushing’s,
congenital, liquorice
4. Pheochromocytoma
5. Acromegaly
6. Pregnancy - eclampsia
 Renal hypertension
• Football player
hit in lower
back.
• Headaches
• Plasma renin
increased
 Renal hypertension
10 year old girl with
headaches,
flank discomfort,
puffiness of face,
red urine,
2 weeks ago had sore throat, painful swallowing,
39.5oC, swollen tonsils,
Cervical lymph nodes enlarged,
 10 year old girl, now
• 37 C, blood pressure 140/100, pulse 100bpm
• Face puffy, ankle and sacral oedema
• Urine:
• tea coloured (clear yellow)
• Protein 1 g/L (0)
• Blood large (0)
• Microscopy: erythrocytes, casts (0)
• Volume 250 mL (1L)
 10 year old girl, now
• CBC: Haemoglobin 120 g/L (115-150)
• Leukocytes 9.6 x 109/L (4.5-13.5 x 109/L)
• Platelets 380 x 103/L (150-400)
• Serum creatinine 285 umo/L (53-97)
• Serum albumin 35 g/L (32-45)
 OC hypertension, 22 year old
student
• Occipital headache
• Fuzziness of vision for 5 days
• On oral contraceptives
• Pulse 68 bpm, regular
• Blood pressure 220/130
• Fundoscopic exam bilateral hemorrhages and
exudates
• 4th heart sound
• Peripheral pulses normal.
 22 year old student, continued:
Complete blood count normal
serum, sodium 140 mmol/L (135-147)
Serum potassium 2.8 mmol/L (3.5-5)
Serum chloride 102 mmol/L (95-108)
Serum bicarbonate 25 mmol/L (22-30)
Serum creatinine 110 umol/L (<110)
Urinalysis, abnormal result
Protein 1 g/L (0)
Aldosterone, 60 year old man, a
known hypertensive
• Serum K 2.0 mmol/L (3.5-5)
• Check for potassium loss
• Drugs
• Serum Na
• Give K supplements to normalize
• Put on Na 100 mmol/L diet
 60 year old, continued:
8 hours in bed then
• Blood for
• electrolytes,
• aldosterone,
• renin
30 minutes ambulatory then
• Blood for
• electrolytes,
• aldosterone,
• Renin.
Conn’s hyperaldosteronism
 Cushing’s, 30 year man, obese,
hypertensive
• Serum cortisol, no diurnal variation
• Insulin hypoglycaemia test – no change in
cortisol
• Dexamethasone suppression – no
suppression
• Plasma ACTH < 2 ng/L (7-51)
Cushing’s syndrome
 Pheochromocytoma:
• 50 year old man
• Headaches, palpitations, sweating,
irritable, nephritis, diabetes, angina in
family.
• Blood pressure 190/115 mm Hg
• Diuretics – no effect
• Beta-blocker – bad effect.
 Pheochromocytoma, continued
2, serum tests:
• Sodium 140 mmol/L (135 147)
• Potassium 3.5 mmol/L (3.5-5)
• Chloride 102 mmol/L (96-108)
• Bicarbonate 30 mmol/L (22-30)
• Urea 5 mmol/L (3-7)
• Creatinine 120 umol/L (<120)
• Creatinine clearance 1.5 mL/s/sq m (0.6-1.3)
• Protein 72 g/L (64-83)
• Albumin 42 g/L (34-48)
• Urate 510 umol/L (<450)
 Pheochromocytoma, continued
3, serum tests:
• Thyroxine 108 nmol/L (55-155)
• Cholesterol 8 mmol/L (<5.2)
• Triglyceride 4 mmol/L (<1.8)
• Urinalysis dipstick: glucose ++ (0), protein
negative (0).
• Haemoglobin 156 g/L(135-175)
• ECG normal
• chest X ray normal
• IVP normal
 Pheochromocytoma, continued
4, urine tests:
• Creatinine 12.2 umol/d (7-17)
• Aldosterone 40 nmol/L (14-66)
• Vanillyl mandelic acid VMA 60 umol/d (<35)
• Epinephrine 800 nmol/d (<110)
• Norepinephrine 1200 nmol/d (<500)
• Dopamine 2500 nmol/d (<2600)
• Renin 1.3ng/L/s(slight increase)
• Cortisol 160 nmol/d (55-250)
Pheochromocytoma
 Toxemia of pregnancy:
• 21 year old woman
• 31 weeks pregnant
• at 12 weeks blood pressure was 110/70
• now 180/110
• swollen.
 Preclampsia (toxemia)
• Multisystem disease
• Spectrum of symptoms
• Severe systolic bp >160 mmHg
• diastolic bp >110
• Proteinuria > 5g/d (0)
• Oliguria <400mL/d (>1.5)
• Central nervous system CNS irritability
• Pulmonary oedema, cyanosis, epigastric pain,
thrombocytopenia, haemolysis, severe liver
dysfunction.
 Pre-eclampsia, risk factors:

Increase in risk
Family history 7-11
First pregnancy 6-8
Multiple pregnancy 5
Molar pregnancy 10
Hypertensive before 5
Previous toxemia 1.2-1.5
Diabetes mellitus common
Black, Filipino increased
 Preclampsia tests:
• Urine protein
• Renal function tests
Sometimes:
• Serum urate
• Serum calcium
• Anticonvulsant used MgSO4
then monitor s-Mg.
* {Rarer CBC, LFT, LD in HELLP syndrome}
 HELLP, hemolysis, liver, low
platelets
Measure serum
• bilirubin
• Lactate dehydrogenase
• Aspartate amino transferase
• Blood platelets

• BP could be normal
• 50% are > 170/110.
 Hypertension’s effects:
1. Cardiovascular disease
2. Peripheral vascular disease
3. Cardiac failure
4. Renal failure
HT heart
 Hypertension laboratory
investigations:
• Look for secondary causes
• Renal damage
• Monitor therapy:
• Salt restriction
• Exercise
• Weight loss
• Drugs – thiazides, beta blockers.
 Antihypertensive drugs:
• Thiazides
• Loop diuretics
• Potassium sparing
• Beta-blockers
• Calcium channel blockers
• Angiotensin converting enzyme (ACE)
inhibitors.