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Hypertension

Physiology, Pathophysiology and ClinicalManagements

Jun Tao


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Stro e an Isc emic Heart Disease IHD Morta ityRate in Each Decade of Age, Versus Usual Systolic

BP at the Start of that Decade

Mortality

*

Usual SBP (mmHg)

5059 y

6069 y

7079 y

8089 y

Stroke

Age at risk

256

128

64

32

16

8

4

21

0 120 140 160 180

IHD

Usual SBP (mmHg)

5059 y

6069 y

7079 y

8089 yAge at risk

4049 y

256

128

64

32

16

8

4

2

1

0 120 140 160 180

*Floating absolute risk and 95% CI Reproduced from The Lancet, 360, Lewington et al. pp. 190313Copyright 2002, with permission from Elsevier


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Introduction

Primary hypertension is a clinical

syndrome characterized by theincrease in systemic arterial pressure.


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95% 0f the patients with hypertension areprimary hypertension with unknowncauses and 5% secondary hypertension

with definitive causes.


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Hypertension affects approximately 1billion individual worldwide. In China theincidence of hypertension is about 180

million individuals.


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Primary hypertension


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Etiology and pathogenesis

Thepathogenesis of primaryhypertension is still unclear. There aremany factors associate with it.


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Genetic factors

Sodium intake

Renin agiotensin systems Sympathetic nervous system

Endothelial dysfunction

Insulin resistance Other factors


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Genetic factors

The offsprings of the hypertensiveparents are prone to suffering fromessential hypertension compared with thatwithout hypertensive family.


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Sodium intake

The mechanisms leading tohypertension are due to increased bloodvolume and the content of the sodium inthe smooth muscle cells enhance followingsubsequent calcium increase.


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Sympathetic nervous activation

The activation of Sympathetic nervouscan augment periphery resistant which

increase systemicarterialpressure.


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Insulin resistance

Increased absorbability to sodium

Increased sympathetic nervous activationIncreased cellular contents in sodium andcalcium

Caused vascular wall hypertrophy


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This is a result of ageing as well ashypertension : both processes thereforecause loss of the normal elastic reservoir

funtion of the aorta and large arteries.


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This explains one curious feature ofelderly hypertensive patients. Diastolicblood pressure in patients with isolated

systolic hypertension is inversely related toprognosis.


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Hpertrophy of left ventricle


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Central nervous system

Cerebral infarction in a hypertensivepatient is usually attributable to atheromaof one of the larger cerebral arteries(usually the middle cerebral artery) andaccounts for about 80 percent of the

strokes which these patients suffer.


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The kidney

The long-term renal damageproduced by glomerular hypertensionprobably accountd for progressiveglomerulosclerosis in essentialhypertension.


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X


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Malignant hypertension:Fibrinoid necrosis of damaged arteriole of kidney


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Nocturia

this is one of the most frequent clinicallyapparent consequences of blood pressureelevation resulting from reduction in urine-concentrating capacity.


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Symptoms associated with target organ damage

Cardiovascular system

Effort dyspnoea and orthopnoeasuggest cardiac failure. Increased leftventricular mass is associated withdecreased compliance and impairedcardiac output response to exercise.


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Retinopathy

Scotomas suggest fundal haemorrhagesor exudates, whilst blurring of vision isassociated with papilloedema.


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CategorySystolic blood

pressure (mmHg)

Diastolic blood

pressureOptimal blood pressure


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CVD Risk Factors

Hypertension* Cigarette smoking

Obesity* (BMI >30 kg/m2)

Physical inactivity

Dyslipidemia*

Diabetes mellitus*

Microalbuminuria or estimated GFR


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Lifestyle Modification

Weight reduction:

the trial of hypertension preventionproduced an average weight loss of 3.8

kg at 18 months, reduction of SBP andDBP by 2.9 and 2.3 mm Hg.


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Exercise:

Following increased physical activity,BP falls up 6-7 mm Hg for both SBP and

DBP.


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Algorithm for Treatment of


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Algorithm for Treatment ofHypertension

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usuallythiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.May consider ACEI, ARB, BB, CCB,

or combination.

Without CompellingIndications

Not at GoalBlood Pressure

Optimize dosages or add additional drugsuntil goal blood pressure is achieved.

Consider consultation with hypertension specialist.


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Diuretics

Indications : cardiac failure

elderly patients

systolic hypertension in elderly


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-Adrenergic blockers

Indications: prostatism

Contraindications: urinary incontience


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Compelling and possible indications, contraindications, and cautions forthe major classes of antihypertensive drugs

Class of

drug

Compelling

indications

Possible

indications Caution

Compellingcontra-

indications

Alpha-blockers

Benign prostatichypertrophy

Posturalhypotension,heart failure

Urinaryincontinence

ACE-inhibitors

Heart failure,LV dysfunction, post

MI or established CVD,Type I diabeticnephropathy, 2o strokeprevention

Chronic renaldisease,

Type II diabeticnephropathy,proteinuric renaldisease

Renal impairment

PVDPregnancy,renovascular

disease

ARBs ACE inhibitor-intolerance,Type II diabeticnephropathy,hypertension with LVH,heart failure in ACE-intolerant patients, postMI

LV dysfunctionpost MI, intol-erance of otherantihypertensivedrugs, proteinuricrenal disease,chronic renaldisease,

heartfailure

Renal impairmentPVD

Pregnancy,renovasculardisease


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Other medications for hypertensive patients


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Other medications for hypertensive patients

Primary prevention(1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressurecontrolled to


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Lipid targets


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Targets for lipid lowering

Ideal - TC


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Some key points of the 2007 ESHand ESC guidelines


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CVD Risk Factors

There are some new risk factors :

fasting blood glucose 5.66.9mmol/L ;

pulse pressure (in the elderly)


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f


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ESH - ESC Guidelines, J Hypertens 2008

-BP < 140/90 mmHg in all hypertensive

patients

< 130/80 mmHg in hypertensive patients

with diabetes or renal disease

-Control of all cardiovascular risk factors

Goals of treatment

b d


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About drug treatment

Diuretics, Blockers, Calcium channel blockers,ACE inhibitors and Angiotensin II receptorblockers can be used in onset and maintenanetherapy.

Diuretics combined with Blockers is notsuitable for metabolic syndrome or high-riskdiabetes patients.

Low-dose combination therapy as first linetreatment of mild-to-moderatehypertension


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