1 HYPERTENSION V.V.L.N.S.N.Gupta. 2 Risk stratification of patients with hypertension Blood pressure (mm Hg) StageOther risk factors and disease history.

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HYPERTENSION

V.V.L.N.S.N.Gupta

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Risk stratification of patients with hypertension

Blood pressure (mm Hg)

Stage Other risk factors and disease history

Stage 1 Stage 2 Stage 3

SBP 140-159 or DBP 90-99

SBP 160-179 or DBP 100-109

SBP 180 or DBP 110

I No other risk factors Low risk Medium risk High risk

II 1-2 risk factors Medium risk Medium risk Very high risk

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Risk stratification of patients with hypertension

Blood pressure (mm Hg)

Stage Other risk factors and disease history

Stage 1 Stage 2 Stage 3

SBP 140-159 or DBP 90-99

SBP 160-179 or DBP 100-109

SBP 180 or DBP 110

III 3 or more risk factor or TOD or Diabetes

High risk High risk Very high risk

IV ACC Very high risk Very high risk Very high risk

Risk strata (typical 10 year risk of stroke or myocardial infarction):Low risk = Less than 15%Medium risk = about 15-20%High risk = about 20-30%Very high risk – 30%TOD: Targe Organ DamageACC: Associated clinical condition, including clinical cardiovascular disease or renal disease

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Risk factors for HTN:

1. Non-modifiable

2. Modifiable

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Non-modifiable risks:

1. Age

2. Genetic factors

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Modifiable risks:

1. Obesity

2. Salt intake

• High salt intake (7-8 g/day) increases B.P proportionately

• Low sodium intake lowers B.P

(Due to genetic abnormality of Kidney which makes salt excretion difficult except at raised levels of arterial pressure)

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Modifiable risks:

3. Other minerals

• Potassium lowers B.P

• Calcium, Cadmium, Magnesium also lowers B.P

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Modifiable risks:

4. Saturated fats:

• Raise BP

5. Alcohol

• High alcohol intake is associated with increased risk of high B.P

• Alcohol consumption raises Systolic B.P more than Diastolic B.P

• Abstinence brings B.P back to previous level

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Modifiable risks:

6. Physical activity

• Leads to weight reduction and hence B.P

7. Environmental stress

• Over activity of sympathetic nervous system increase B.P

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Modifiable risks:

8. Other factors

• Oral contraceptive pills (due to oestrogens)

• Noise

• Vibration, Temperature, Humidity – consistent

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Modifiable risks:

Smoking: • Nicotine and Carbon monoxide are potent

vasoconstrictors

• Smoking of 2 cigarettes raises SBP & DBP by 16 mm Hg for 20 minutes

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HTN – 2 MAIN CATEGORIES:

I. Primary (essential) – causes unknown

II. Secondary – due to some cause e.g., Kidney disease, Adrenal gland tumors, Toxemia of pregnancy

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CAUSES OF HYPERTENSION

SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE

I. Decreased compliance of aorta (arteriosclerosis)

II. Increased stroke volume

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SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE

I. Aortic regurgitation

II. Thyrotoxicosis

III. Hyperkinetic heart syndrome

IV. Fever

V. Arteriovenous fistula

VI. Patent ductus arteriosus

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SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR

RESISTANCE

I. Renal

a. Chronic pyelonephritis

b. Acute and chronic glomerulonephritis

c. Polycystic renal disease

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d. Renovascular stenosis or renal infarction

e. Most other severe renal diseases (arteriolar nephrosclerosis, diabetic nephropathy etc.,)

f. Renin-producing tumors



RESISTANCE

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II. Endocrine

a. Oral contraceptives

b. Adrenocortical hyper function

1. Cushing’s disease and syndrome

2. Primary hyperaldosteronism

3. Congenital or hereditary adrenogenital syndromes (17-hydroxylase defects)



RESISTANCE

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c. Pheochromocytoma

d. Myxedema

e. Acromegaly



RESISTANCE

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III. Neurogenic

A. Psychogenic

B. Diencephalic syndrome

C. Familial dysautonomia (Riley-Day)



RESISTANCE

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D. Polyneuritis (acute poryphyria, lead poisoning)

E. Increased intracranial pressure (acute)

F. Spinal cord section (acute)



RESISTANCE

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IV. Miscellaneous

A. Coarctation of aorta

B. Increased intravascular volume (excessive transfusion, polycythemia vera)

C. Plyarteritis nodosa

D. Hypercalcemia

E. Medications, e.g., glucocorticoids, cyclosporine



RESISTANCE

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V. Unknown etiology

A. Essential hytypertension ( 90% of all cases of hypertension)

B. Toxemia of pregnancy

C. Acute intermittent prophyria



RESISTANCE

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V. Effects on Heart

1.1. Left Ventricular Hypertrophy

Deterioration of cardiac function

Dilatation & thinning of LV Cavity

Heart failure

EFFECTS OF HTN

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1. Angina pectoris (due to increased 02 demand of a hypertrophied heart)

2. Ischaemia or Infarction

3. Death due to 1, 2,3

EFFECTS OF HTN

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B. Neurological effects

Retinal changes

CNS dysfunction

EFFECTS OF HTN

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Occipital headache especially in morning

Dizziness

Light headache

Vertigo

Tinnitis

EFFECTS OF HTN

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Dimmed vision

Syncope

Cerebral infarction

Haemorrhage

Encephalopathy

EFFECTS OF HTN

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Effects on Kidney:

Arteriosclerosis of afferent & efferent glomerular arterioles

Decreased Glomerular filtration rate

Proteinemia

Haematuria (Microspic )

Renal failure

EFFECTS OF HTN

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EFFECTS OF HTN

D. Blood loss

I. from Kidneys

II. Epistaxis

III. Haemoptysis

IV. Metrorrhagia

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HTN-SOME FACTS

1) Anti hypertensive treatment is associated with decrease n incidence of

• Stroke by 35-40%

• MI by 20-25%

• Heart failure by 50%

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HTN-SOME FACTS

2) 5 mm of Hg reduction in DBP can reduce heart disease risk by 21%

3) For every fall of 20 mm Hg SBP & 10 mm Hg DBP, You need one intervention –

• Lifestyle modification or treatment with one drug

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Three sources of error in recording B.P

A. Observer errors e.g., hearing acuity interpretation of Korotkow sounds

B. Instrumental errors e.g., leaking valve Cuffs that do not encircle the arm

• Small cuff – higher reading

C. Subject errors: e.g., Circumstances of examination

• Physical environment

• Position of the subject

• External stimuli e.g., fear, anxiety

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Three sources of error in recording B.P

C. Subject errors: e.g., Circumstances of examination

• Physical environment

• Position of the subject

• External stimuli e.g., fear, anxiety

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WHO Recommendation:

• Sitting position

• Uniform policy – consistently use the same arm for B.P measurement

• Pressure at which the sounds are first heard (Phase I) Systolic pressure

• Near Diastolic B.P, sounds first become muffled (Phase-IV) & then disappear (Phase-V) Phase-V taken as DBP

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Rule of halves:

• ½ of the HTN patients, aware of this condition

• ½ of these being treated

• ½ of these being treated effectively

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Investigations:

• Urine for protein

• Blood glucose

• Microscopic urinalysis

• Haematocrit or ESR

• S.Potassium

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Investigations:

• S.Creatinine and/or BUN

• FBS

• Total Cholesterol

• ECG in all cases

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TREATMENT:

• General measures:

• Relief of stress

• Dietary management

• Regular aerobic exercise

• Weigh reduction

• Control of other risk factors contributing to development of arteriosclerosis

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Drug treatment:

1. ACE Inhibitors e.g., Encaplril, Lisinopril, Ramipril

2. Angiotensin I antagonists e.g., Losartan, temisartan, Valsartan

3. Calcium channel Blockers e.g., Nifedipine, Amlodepine

4. Diuretics e.g., Furosemide, Hydrochlorothiazide, Spironolactone

5. Beta Aderenergic Blockers e.g,Atenolol, Metoprolol

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Drug treatment:

6. Alpha Adrenergic Blockers e.g., Prazosin, Terazocin

7. Central Sympatholytics e.g., Methyldopa

8. Vasodilators

• Arteriolar e.g, Hydralazine, Minoxidil, Diazoxide

• Arteriolar + Venous – e.g., Sodium Nitrtoprusside

1 HYPERTENSION V.V.L.N.S.N.Gupta. 2 Risk stratification of patients with hypertension Blood pressure (mm Hg) StageOther risk factors and disease history.

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