1 Hypertension Hypertension Cardiology Department, Shanghai Sixth Cardiology Department, Shanghai Sixth People’s Hospital, Shanghai JiaoTong People’s Hospital, Shanghai JiaoTong University University Qing Zhao Qing Zhao
Jan 07, 2016
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HypertensionHypertension
Cardiology Department, Shanghai Sixth People’s Cardiology Department, Shanghai Sixth People’s
Hospital, Shanghai JiaoTong UniversityHospital, Shanghai JiaoTong University
Qing ZhaoQing Zhao
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HypertensionHypertension
Clinical syndrome characterized as Clinical syndrome characterized as increased systemic arterial pressureincreased systemic arterial pressure
Primary Hypertension Primary Hypertension 90%-95%90%-95%
Secondary HypertensionSecondary Hypertension 5%-10%5%-10%
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Diagnostic criteria of hypertension
Chinese Guidelines for Preventive and Chinese Guidelines for Preventive and Treatment of HypertensionTreatment of Hypertension (2004) (2004)
CategoryCategory SBP(mmHg)SBP(mmHg) DBP(mmHg)DBP(mmHg)
NormalNormal << 120(≥90)120(≥90) << 80(≥60)80(≥60)
High High normalnormal 120-139120-139 80-8980-89
HypertensiHypertensionon ≥≥140140 ≥≥9090
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DefinitionDefinition Without any anti-hypertensive medicationWithout any anti-hypertensive medication ,,
SBPSBP≥140mmHg≥140mmHg and/or DBP≥90mmHgand/or DBP≥90mmHg
Blood pressure <140/90mmHg, but having Blood pressure <140/90mmHg, but having
a hypertensive history and currently a hypertensive history and currently
taking an anti-hypertesive medicationtaking an anti-hypertesive medication
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Classification of Classification of Hypertension(2004)Hypertension(2004)
CategoryCategory SBP(mmHg)SBP(mmHg) DBP(mmHg)DBP(mmHg)
Grade Grade 11(mild(mild)) 140-159140-159 90-9990-99
Grade 2 Grade 2 (moderate(moderate)) 160-179160-179 100-109100-109
Grade Grade 33(severe(severe)) ≥≥180180 ≥≥110110
Isolated Isolated systolic systolic
hypertensionhypertension≥≥140140 << 9090
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NoticeNotice
SBPSBP and and DBPDBPfall separately fall separately into different categories, the into different categories, the higher category should be higher category should be takentaken
Isolated systolic hypertension Isolated systolic hypertension can also be graded according can also be graded according to systolic blood pressure to systolic blood pressure values in the ranges indicatedvalues in the ranges indicated
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EpidemilologyEpidemilology
MobidityMobidity
In 2002, In 2002, 18.8%18.8%
In 1991, 11.88% In 1991, 11.88%
In 1979, 7.73%In 1979, 7.73%
In 1959, In 1959, 5.11%5.11%
Most common cardiovascular Most common cardiovascular
diseasesdiseases
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Hypertension PrevalenceHypertension Prevalence
MobidiMobidityty
AwarenAwareness Rateess Rate
TreatmeTreatment Ratent Rate
Control Control Rate Rate
2000 USA
70% 59% 34%
2002 China
18.8% 30.2% 24.7% 6.1%
19911991 11.11.88%88% 26.3%26.3% 1212.1%.1% 2.8%2.8%1991 1991 UrbanUrban 35.6%35.6% 17.1%17.1% 4.1%4.1%1991 1991 RuralRural 13.9%13.9% 5.4%5.4% 1.2%1.2%
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EpidemilologyEpidemilology
Three highThree high High High
mobiditymobidity High High
motalitymotality High High
disable rate disable rate Three lowThree low
Low awareness Low awareness raterate
Low treatment Low treatment raterate
Low control rateLow control rate
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General features and General features and patterns of hypertension patterns of hypertension
epidimiologyepidimiology1. Age1. Age
2. Sex differences2. Sex differences
3. Geographical differences3. Geographical differences
4. Seasonal variation exists4. Seasonal variation exists
5. Differences in region, 5. Differences in region, city and city and countrysidecountryside, races and , races and ethnicitiesethnicities
6. Diet, Genetics, etc.6. Diet, Genetics, etc.
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EtiololgyEtiololgy
Multiple factorMultiple factor
genetic predispositiongenetic predisposition (40%) (40%)
++ environmental factorenvironmental factor (60%)(60%)
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Genetic predispositionGenetic predisposition
Familial Familial aggregationaggregation
60%60%, familial , familial history history
Genetic inheritanceGenetic inheritance Black men more Black men more
white menwhite men
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Diet factorsDiet factors
High dietary saltHigh dietary salt Heavy alcohol drinkingHeavy alcohol drinking Long-term over Long-term over coffee intake Low calcium, low potassium, low Low calcium, low potassium, low
magnesium High proteinHigh protein High saturated fatty acid
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Psychological factorPsychological factor
Mental status
Psychological diposition
More in More in Brainworker Brainworker
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Other factorsOther factors
Overweight or Overweight or obesityobesity
BMI=body BMI=body weightweight (( kgkg )/)/body height (m)body height (m)2 (( 20 20 ~~ 24 24 ) )
Contraceptives Obstructive sleep
apnea syndrome (OSAS)
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Pathogenesy
mean blood pressure( MBP )
= cardiac output(CO)×peripheral vascular
resistance (PR)
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Mechanisms of hypertension
Sympathetic nervous systemSympathetic nervous system Renin-angiotensin systemRenin-angiotensin system Renal functionRenal function Insulin resistanceInsulin resistance Decreased ralaxed factors and Decreased ralaxed factors and
increased systolic factorsincreased systolic factors resistance vessel remodlingresistance vessel remodling OthersOthers :: arterial elasticityarterial elasticity
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Sympathetic nervous Sympathetic nervous systemsystem
Sympathetic nervous Sympathetic nervous hyperactivity-----catecholamine hyperactivity-----catecholamine ↑----resistance arterioles ↑----resistance arterioles contracted contracted ↑↑ ---- hypertension---- hypertension
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Renin-angiotensin system
AngiotensinogenAngiotensinogenLiver
Kid-ney
Lung
Angiotensin ⅠAngiotensin Ⅰ
Angiotensin ⅡAngiotensin Ⅱ
Vascular contractionVascular contraction
Angiotension IIReceptor antangonists
ACEInhibitors
ACEInhibitors
Angiotensin converting enzyme
(ACE)
ReninRenin ingibitors
etc.
etc.
etc.
Receptor
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Circulating RAS
Function of ATⅡ :
① vasoconstriction
② increased myocardial contractility
③ Sodium retention
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Tissue RAS
1. RAS in vessel wall
2. Cardiac RAS
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• High renin hypertension correlates with
circulating RAS activity
• Normal renin and low renin hypertension
correlates with tissue RAS activity
Circulating RAS and tissue RAS
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Insulin resistance, IR
Tissue cells are resistant to insulin,
thereby producing the
hyperinsulinemia.
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PathologyPathology
ArteryArtery Arteriolosclerosis hyalinization Smooth muscle cell proliferation
and fibrosis Vessel wall Vessel wall
thickningthickning ,, luminal stenoses Vessel wall remodlingVessel wall remodling Macro- and medium-sized artery
atherosclerosisatherosclerosis
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PathologyPathology
HeartHeart Left ventricular Left ventricular
hypertropghyhypertropghy Heart failureHeart failure Hypertensive heart Hypertensive heart
diseasedisease
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PathologyPathology
KidneyKidney Renal arteriolar Renal arteriolar
sclerosissclerosis Glomerulus fibrosis, Glomerulus fibrosis,
atrophyatrophy Renal failureRenal failure
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PathologyPathology
BrainBrain
microaneurysm 、、 rupturerupture 、、 hemorrhage:
cerebral hemorrhagecerebral hemorrhage
Cerebral atherosclerosis,,thrombokinesis:
cerebral infarctioncerebral infarction ,, lacunar lacunar
infarctioninfarction
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PathologyPathology RetinaRetina
arteriola spasm , exudation,
hemorrhage
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Clinical manifestation
SymptomSymptom No specific symptomsNo specific symptoms Dizziness, headache, palpitations, Dizziness, headache, palpitations,
easy fitigability,blurring of vision, easy fitigability,blurring of vision, etcetc
Symptoms not related to the level Symptoms not related to the level of blood pressureof blood pressure
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Clinical manifestation
First onset as complicationFirst onset as complication heartheart :: ACFACF 、、 APAP 、、 AMIAMI (( ACSACS )) bbrainrain :: cerebral hemorrhage, cerebral cerebral hemorrhage, cerebral
infarction,TIAinfarction,TIA
kkidneyidney :: rrenal dysfunctionenal dysfunction
vvesselessel :: aotic dissectionaotic dissection oothersthers :: nnasal hemorrhageasal hemorrhage 、、 rretinal etinal
hemmorrhagehemmorrhage
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SignsSigns A2 louderA2 louder S4S4 Systolic murmur Systolic murmur 、、 systolic early systolic early
clickclick Sign of LVHSign of LVH
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Target organ Target organ damage(TOD)damage(TOD)
LVHLVH ECGECG UCGUCG Chest X-rayChest X-ray
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Target organ Target organ damage(TOD)damage(TOD)
Arterial wall Arterial wall thickeningthickening
IMT IMT ≥0.9≥0.9mmmm
Atherosclerotic plaqueAtherosclerotic plaque
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Target organ Target organ damage(TOD)damage(TOD)
Slight increase in serum Slight increase in serum creatininecreatinine
MaleMale 115-133115-133µµmol/Lmol/L((1.3-1.5mg/dl1.3-1.5mg/dl))
FemaleFemale 107-124107-124µµmol/Lmol/L((1.2-1.4mg/dl1.2-1.4mg/dl))
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Target organ Target organ damage(TOD)damage(TOD)
MicroalbuminuriaMicroalbuminuria 30-30030-300mg/24hmg/24h
Albunim-creatinine ratioAlbunim-creatinine ratio Male Male ≥22mg/g≥22mg/g((2.5mg/ 2.5mg/ mmol/Lmmol/L)) Female Female ≥31mg/g≥31mg/g((3.5mg/ 3.5mg/ mmol/Lmmol/L))
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Associated clinical condition(ACC)Associated clinical condition(ACC)
Cerebrovascular Cerebrovascular diseasedisease①①ischemic strokeischemic stroke
②②cerebral hemorrhagecerebral hemorrhage
③③transient ischemic transient ischemic attack(attack(TIATIA) )
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Associated clinical condition(ACC)Associated clinical condition(ACC)
Heart disease:Heart disease:①①history of myocardial history of myocardial
infarctioninfarction
②②angina pectorisangina pectoris
③③coronary coronary revascularization(revascularization(PCIPCI ,, CACABGBG))
④④congestive heart failurecongestive heart failure
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Associated clinical condition(ACC)Associated clinical condition(ACC)
Renal disease:Renal disease:① ① diabetic nephropathydiabetic nephropathy② ② renal impairrmentrenal impairrment Male Male >133 >133 µµmol/Lmol/L Female Female >124 >124 µµmol/Lmol/L proteinurea proteinurea >300mg/24h>300mg/24h③ ③ renal failurerenal failure creatinine creatinine >> 177µ177µmol/Lmol/L
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Associated clinical condition(ACC)Associated clinical condition(ACC)
Peripheral vascular Peripheral vascular diseasedisease①①aotic dissectionaotic dissection
②②symptomatic symptomatic peripheral arterial peripheral arterial diseasedisease
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Associated clinical condition(ACC)Associated clinical condition(ACC)
Advanced Advanced retinopathyretinopathy①①hemorrhages of hemorrhages of
exudatesexudates
②②papilloedemapapilloedema
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Special type of Special type of hypertensionhypertension
Hypertension in the elderlyHypertension in the elderly ≥≥60(65)60(65) 岁岁 Isolated systolic hypertensionIsolated systolic hypertension Sensitivity of vessel baroreceptor Sensitivity of vessel baroreceptor
↓↓
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Hypertensive crisisHypertensive crisis Hypertensive emergencyHypertensive emergency
Hypertensive urgency Hypertensive urgency
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Hypertensive crisisHypertensive crisis
Progress quicklyProgress quickly Marked blood pressure Marked blood pressure
elevationelevation ,, usually usually DBPDBP≥130≥130mmHgmmHg Severe target organ damage in short Severe target organ damage in short
term, especially renal impairment, term, especially renal impairment, retinal hemorrhages and exudates, retinal hemorrhages and exudates, papilloedemapapilloedema
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Hypertension in pregnancyHypertension in pregnancy
Pregnancy-Induced Pregnancy-Induced Hypertension(PIH)Hypertension(PIH)
Gestational hypertensionGestational hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia
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Diagnosis and Differential Diagnosis and Differential diagnosisdiagnosis
DiagnosisDiagnosis
⒈ ⒈ to define blood pressure is highto define blood pressure is high
⒉ ⒉ to exclude secondary to exclude secondary hypertensionhypertension
⒊ ⒊ to classify hypertension and to to classify hypertension and to stratify risk to quantify prognosisstratify risk to quantify prognosis
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Clinical history and familial Clinical history and familial historyhistory
To collect a history of hypertension, To collect a history of hypertension, diabetes, dyslipidemia, coronary heart diabetes, dyslipidemia, coronary heart disease, renal disease, stroke, heart disease, renal disease, stroke, heart failure, etcfailure, etc
To identify risk factors, target organ To identify risk factors, target organ damage, associated clinical conditiondamage, associated clinical condition
Previous anti-hypertensive regimenPrevious anti-hypertensive regimen
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Physical examinationPhysical examination
Measure blood pressure, upper Measure blood pressure, upper limbs, lower limbslimbs, lower limbs
BMI, WCBMI, WC Optic funduscopy examination Optic funduscopy examination
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Routine examinationsRoutine examinations
Blood sugar, serum lipid, serum Blood sugar, serum lipid, serum potassium, serum uric acid, serum potassium, serum uric acid, serum creatininecreatinine
Hemoglobin and hematocritHemoglobin and hematocrit UrinalysisUrinalysis ElectrocardiogramElectrocardiogram
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Recommended Recommended examinationsexaminations
24hABPM24hABPM EchocardiogramEchocardiogram Echograms of carotid arteries and femoral Echograms of carotid arteries and femoral
arteriesarteries C-reactive proteinC-reactive protein Microproteinuria analysisMicroproteinuria analysis Quantitative assessment of urine proteinQuantitative assessment of urine protein Chest X-ray filmChest X-ray film
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Risk factorsRisk factors
①①Levels of systolic Levels of systolic and diastolic blood and diastolic blood pressurepressure
②②Male Male > > 55 55 yearsyears ,, FemaleFemale > > 6655yearsyears
③③smokingsmoking
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Risk factorsRisk factors
④④DyslipidemiaDyslipidemia TC TC ≥≥ 5.7mmol/L 5.7mmol/L ((220mg/dl220mg/dl)) Or LDL-C Or LDL-C > > 3.3mmol/L 3.3mmol/L ((130mg/dl130mg/dl)) Or HDL-C Or HDL-C < < 1.0mmol/L 1.0mmol/L ((40mg/dl40mg/dl))
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Risk factorsRisk factors
⑤⑤Family history of premature Family history of premature cardiovascular disease at age <50 cardiovascular disease at age <50 yearsyears
⑥⑥Abdominal obesity or obesityAbdominal obesity or obesity WCWC Male Male ≥85cm≥85cm ,, Female Female ≥80cm≥80cm
⑦⑦Obesity BMIObesity BMI≥28≥28kg/mkg/m22
⑧⑧C-reactive protein C-reactive protein ≥1.0mg/dl≥1.0mg/dl
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Diabetes mellitusDiabetes mellitus Fasting plasma glucoseFasting plasma glucose≥ ≥
7.0mmol/L 7.0mmol/L ((126mg/dl126mg/dl)) Postprandial plasma glucose Postprandial plasma glucose ≥ ≥
11.1mmol/L 11.1mmol/L ((200mg/dl200mg/dl))
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Stratification of risk to quantify Stratification of risk to quantify prognosisprognosis
Grade 1Grade 1 Grade 2Grade 2 Grade 3Grade 3
ⅠⅠ No other risk No other risk factorsfactors
Low added Low added riskrisk
Moderate Moderate added riskadded risk
High added High added riskrisk
ⅡⅡ1-2 1-2 risk factors risk factors Moderate Moderate added riskadded risk
Moderate Moderate added riskadded risk
Very High Very High added riskadded risk
Ⅲ ≥Ⅲ ≥33 个个 risk factors,risk factors, TOD or diabetesTOD or diabetes
High added High added riskrisk
High added High added riskrisk
Very High Very High added riskadded risk
ⅣⅣ ACCACCVery High Very High added riskadded risk
Very High Very High added riskadded risk
Very High Very High added riskadded risk
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Incidence of cardiovascular Incidence of cardiovascular diseases in ten yearsdiseases in ten years
Low added risk, Low added risk, << 15%15% Moderate added risk, Moderate added risk, 1515
%-20%%-20% High added risk, High added risk, 20%-3020%-30
%% Very high added risk, Very high added risk,
>> 30%30%
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Differential DiagnosisDifferential Diagnosis
To exclude secondary hypertensionTo exclude secondary hypertension Incidence rate, 5-10%Incidence rate, 5-10% Blood pressure could be controlled Blood pressure could be controlled
by treatment of primary diseasesby treatment of primary diseases
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⒈⒈Renal parenchymal Renal parenchymal hypertensionhypertension
Acute or chronic glomerulonephritisAcute or chronic glomerulonephritis Diabetic nephropathyDiabetic nephropathy nephritisnephritis Polycystic kidney Polycystic kidney After renal transplantationAfter renal transplantation
Renal dysfunction before the Renal dysfunction before the course of hypertensioncourse of hypertension
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⒉⒉Renovascular Renovascular hypertensionhypertension
Unilateral or bilateral renal artery stenosis Unilateral or bilateral renal artery stenosis Renal artery fibromuscular dysplasia Renal artery fibromuscular dysplasia arteritisarteritis Renal atherosclerosisRenal atherosclerosis
Radionuclide renal scanRadionuclide renal scan Renal artery angiogramRenal artery angiogram Measurements of renin in renal Measurements of renin in renal venousvenous
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⒊⒊PheochromocytomaPheochromocytoma Fluctution sin blood pressureFluctution sin blood pressure Sign of Sympathetic nervous Sign of Sympathetic nervous
hyperactivity hyperactivity 24h urine catecholamines and their 24h urine catecholamines and their
metabolitesmetabolites↑↑ Serum MN, NMN Serum MN, NMN ↑↑ EchocardiogramEchocardiogram , , nuclide nuclide
imagingsimagings ,, CTCT ,, MRIMRI
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⒋⒋Primary AldosteronismPrimary Aldosteronism Hypertension accompanied by Hypertension accompanied by
hypokalemiahypokalemia Renin activity decreased, Renin activity decreased,
aldosterone level increasedaldosterone level increased ARR ARR CTCT ,, echocardigramechocardigram
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5. Cushing’s Syndrome5. Cushing’s Syndrome
6. Aortic coarctation6. Aortic coarctation
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Further investigationsFurther investigations
Renin activityRenin activity AldosteroneAldosterone CatecholamineCatecholamine AteriogramAteriogram Echogram of Echogram of
kidney and adrenal kidney and adrenal glandsglands
CT or MRICT or MRI
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TreatmentTreatment
Goals of treatmentGoals of treatment
Uncomplicated hypertensionUncomplicated hypertension <<
140/90140/90mmHgmmHg
Elderly, SBPElderly, SBP << 150150mmHgmmHg
Combined with diabetes and renal Combined with diabetes and renal
disease, disease, << 130/80130/80mmHgmmHg
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Main purposeMain purpose
To achieve a maximum reduction in To achieve a maximum reduction in
the long-term total risk of the long-term total risk of
cardiovascular morbidity and mortalitycardiovascular morbidity and mortality
To treat all the reversible risk factorsTo treat all the reversible risk factors
To treat ACCTo treat ACC
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Patients with high and very Patients with high and very high riskhigh risk
Drug therapy on Drug therapy on elevated blood elevated blood pressurepressure
Drug therapy on risk Drug therapy on risk factorsfactors
Drug therapy on Drug therapy on clinical conditionsclinical conditions
Improvement of Improvement of lifestylelifestyle
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Patients with moderate Patients with moderate riskrisk
Observe the blood Observe the blood pressure for several pressure for several weeksweeks
Drug therapy targeted Drug therapy targeted on risk factorson risk factors
Improvement of lifestyleImprovement of lifestyle
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Patients with low riskPatients with low risk
Observed for a period of Observed for a period of timetime
Improvement of lifestyleImprovement of lifestyle
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Non-pharmacological Non-pharmacological therapytherapy
Improving lifestyleImproving lifestyle Giving up smokingGiving up smoking Losing body weightLosing body weight Reducing excessive alcohol Reducing excessive alcohol
intakeintake Appropriate physical exerciseAppropriate physical exercise Cutting down salt intakeCutting down salt intake Eating more fruit and Eating more fruit and
vegetable and cutting down vegetable and cutting down saturated fatty acid and total saturated fatty acid and total fat in food fat in food
Reducing stress and Reducing stress and maintaining mental maintaining mental equilibriumequilibrium
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Pharmacological therapy of Pharmacological therapy of hypertensionhypertension
DiureticsDiuretics Β-blockersΒ-blockers Calcium antagonistsCalcium antagonists Angiotensin-converting enzyme Angiotensin-converting enzyme
inhibitor (ACEI)inhibitor (ACEI) Angiotensin II receptor Angiotensin II receptor
blocker(ARB)blocker(ARB) -blockers-blockers
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Principles of durg Principles of durg treatmenttreatment
To start with a small To start with a small and efficacious doseand efficacious dose
The blood pressure The blood pressure within 24 hours within 24 hours should be kept stably should be kept stably under the target under the target levellevel
Combination therapyCombination therapy
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DiureticsDiuretics
Drug: Thiazides: hydrocholorothiazideDrug: Thiazides: hydrocholorothiazide Loop-acting: fursemideLoop-acting: fursemide Potassium-sparing: spironolactone, Potassium-sparing: spironolactone,
amilorideamiloride Indications: Mild hypertension, Indications: Mild hypertension, Isolated systolic hypertension in elderly Isolated systolic hypertension in elderly acompanied by heart failureacompanied by heart failure Contraindications: GoutContraindications: Gout
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ββ-blockers-blockers
Drugs dosageDrugs dosage acting course acting course selectivityselectivity
MetoprololMetoprolol 25mg bid short 25mg bid short ββ11
AtenololAtenolol 25mg bid short 25mg bid short ββ11
BisololBisolol 5mg qd long 5mg qd long ββ11
CarvediolCarvediol 25mg bid short 25mg bid short ,,ββ
LabetalolLabetalol 100mg tid short 100mg tid short ,,ββ
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ββ-blockers-blockers IndicationsIndications: :
Moderate to severe hypertension Moderate to severe hypertension
ContraindicationsContraindications: :
Congestive heart failure Congestive heart failure
Asthma Asthma
Diabetes mellitus (on hypoglycemic Diabetes mellitus (on hypoglycemic
therapy) therapy)
During MAO inhibitor During MAO inhibitor
administrationadministration
COPD COPD
Sick sinus syndrome Sick sinus syndrome
II degree or III degree heart block II degree or III degree heart block
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Calcium Channel AntagonistsCalcium Channel Antagonists Dihydropyridines Dihydropyridines
Nifedipine 10mg tidNifedipine 10mg tid
Nitrendipine 10mg tid Nitrendipine 10mg tid
Felodipine XL 5mg qd Felodipine XL 5mg qd
Amlodipine 5mg qd Amlodipine 5mg qd
Nifedipine XL 30mg qd Nifedipine XL 30mg qd
Lacidipine 4mg qd Lacidipine 4mg qd
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Calcium Channel AntagonistsCalcium Channel Antagonists Benzothiazepines: Benzothiazepines: Diltiazem Diltiazem short-acting : 30mg tidshort-acting : 30mg tid long-acting: 90mg qd long-acting: 90mg qd
Phenylalkylamine:Phenylalkylamine: Verapamil Verapamil short-acting: 40mg tidshort-acting: 40mg tid long-acting: 240mg long-acting: 240mg or 120mg or 120mg qdqd
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Calcium Channel Calcium Channel
AntagonistsAntagonistsIndications:Indications:
Mild to Moderate hypertensionMild to Moderate hypertension
Contraindications:Contraindications:
Heart failureHeart failure
II degree or III degree heart block II degree or III degree heart block
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Side effectsSide effects
1.Dihydropyridines: 1.Dihydropyridines:
tachycardia, flushing, dizziness, tachycardia, flushing, dizziness,
weakness, fluid weakness, fluid
retention retention
2. 2. Non-dihydropyridines:Non-dihydropyridines:
heart blockheart block
constipation constipation
liver dysfuction liver dysfuction
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ACEIACEI 1.Drugs : Captopril 1.Drugs : Captopril Benazepril Benazepril Enalapril Enalapril FosinoprilFosinopril Lisinopril Lisinopril Peridopril Peridopril Ramipril Ramipril
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ACEIACEI
Indications:Indications:
Mild to severe hypertensionMild to severe hypertension
renal artery stenosis renal artery stenosis
Contraindications:Contraindications:
Renal failure Renal failure
Bilateral renal artery stenosis Bilateral renal artery stenosis
Pregnancy Pregnancy
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Side effects of ACEISide effects of ACEI1.dry cough 1.dry cough
2.angioedema2.angioedema
3.leukopenia, pancytopenia3.leukopenia, pancytopenia
4. hyperkalemia 4. hyperkalemia
5. acute renal failure5. acute renal failure
6. hypotension6. hypotension
7. urticarial rash7. urticarial rash
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ARBARB Drugs : LosartanDrugs : Losartan Valsartan Valsartan Irbesartan Irbesartan
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ARBARB
Indications:Indications:
Mild to severe hypertensionMild to severe hypertension
renal artery stenosis renal artery stenosis
Contraindications:Contraindications:
Renal failure Renal failure
Bilateral renal artery stenosis Bilateral renal artery stenosis
Pregnancy Pregnancy
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Side effects of ARBSide effects of ARB1. hyperkalemia 1. hyperkalemia
2. acute renal failure in bilateral renal 2. acute renal failure in bilateral renal
artery stenosisartery stenosis
3. hypotension3. hypotension
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11-blockers-blockersDrugsDrugs:: PhentolaminePhentolamine IV 1-5mg bolus IV 1-5mg bolus PrazosinPrazosin 2-30mg bid,tid 2-30mg bid,tid DoxazosinDoxazosin 1-16mg qd 1-16mg qd TerazosinTerazosin 1-20mg qd 1-20mg qdIndications:Indications:
1. Suspected or proved 1. Suspected or proved pheochromocytomapheochromocytoma
2.Mild or moderate hypertension2.Mild or moderate hypertension Contraindications and Cautions:Contraindications and Cautions: Severe coronary artery disease Severe coronary artery disease Use with caution in the elderly Use with caution in the elderly
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11-blockers-blockers
Side effectsSide effects:: tachycardiatachycardia weakness weakness dizziness dizziness flushing flushing postural hypotension postural hypotension tachycardia tachycardia miosis miosis headache headache
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Combination therapyCombination therapy diuretic and β-blocker
diuretic and ACE inhibitor or angiotensin
receptor antagonist
calcium antagonist and diuretic
calcium antagonist (dihydropyridine) and β-
blocker
calcium antagonist and diuretic
-blocker and β-blocker
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Anti-hypertensive treatment in special Anti-hypertensive treatment in special populationspopulations
Angina pectorisAngina pectoris β-blocker, Calcium channel antagonistβ-blocker, Calcium channel antagonist
MIMI β-blocker, ACEIβ-blocker, ACEI ,, AldosteroneAldosterone
Heart failureHeart failure Diuretic, ACEI, ARBsDiuretic, ACEI, ARBs β-blockerβ-blocker (( stable in cardiac functiostable in cardiac functio
nn )) pregnancypregnancy
Labetalol , Methyldopa, Calcium Labetalol , Methyldopa, Calcium channel antagonistchannel antagonist
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Cerebral vascular diseaseCerebral vascular disease Calcium channel antagonistCalcium channel antagonist DiureticDiuretic , ACEI, ACEI
Renal dysfunctionRenal dysfunction Calcium channel antagonist, Calcium channel antagonist,
DiureticDiuretic ACEISACEIS ,, ARBsARBs Not indicated :β-blockerNot indicated :β-blocker
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Diabetes mellitusDiabetes mellitus ACEIACEI or ARBsor ARBs Calcium channel antagonistCalcium channel antagonist ,, ββ--
blocker, Direticsblocker, Diretics
DyslipidemiaDyslipidemia Calcium channel antagonistCalcium channel antagonist , ACEI, ACEI Not indicated: βNot indicated: β--blockerblocker, , DireticsDiretics
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Treatment of associated risk factorsTreatment of associated risk factors
Lipid loweringLipid lowering Anti-platelet therapyAnti-platelet therapy Glycolic controlGlycolic control
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Refractory hypertensionRefractory hypertension
Definition : Lifestyle modifications and the
administration of at least 3 anti-hypertensive
drugs including diuretics, the systolic or diastolic
blood pressure still cannot be controlled at the
target level.
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unidentified secondary causesunidentified secondary causespoor patient compliancepoor patient compliancecurrent using of pressor agentscurrent using of pressor agentsfailure of lifestyle modificationsfailure of lifestyle modificationsblood volume overloadblood volume overload
Causes of Refractory hypertensionCauses of Refractory hypertension
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To refer the refractory To refer the refractory hypertensive patients to hypertensive patients to specialized hypertension clinicsspecialized hypertension clinicsTo take effective treatmentTo take effective treatmentTo re-start a new simple anti-To re-start a new simple anti-hypertensive regimenhypertensive regimen
Therapeutic principles of Refractory Therapeutic principles of Refractory hypertensionhypertension
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Thanks for attention