slide 1 Hypertension (HT) High Blood Pressure (HBP)
Dec 22, 2015
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Hypertension (HT)
High Blood Pressure (HBP)
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Introduction
• Definition: Hypertension is defined as elevated arterial blood pressure.
• Hypertension is one of the most common disease in the world
• In our country, 160 million people over the age of 15 have established or borderline HP
• HP Essential HP (95%) Secondary HP (5%)
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Etiology
• Genetic
• Environment
Dietary: Salt intake
Alcohol intake
Obesity
Infant dysnutrition
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Pathogenesis1. High activity of the SNS (Sympathetic
Nervous System)2. RAAS (Renin-Angiotension Aldosterone
System)3. Renal Sodium Handling4. Vascular Remodelling5. Endothelial Cell Dysfunction6. Insulin Resistance
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The pathological changes of small artery
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The pathological change of the Heart
Left ventricular hypertrophy (LVH)
Heart failure
Coronary artery atherosclerosis
Myocardial infarction
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Pathological change of the Brain
Stroke:
Ischemic stroke
Hemorrhagic stoke
Arterial Aneurysm
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Pathological change of Renal
Hypertension induced nephrosclerosis, atrophy of renal cortex
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Clinical Features
• The blood pressure varies widely over time, depending on many variables, including SNS activity, posture, state of hydration, and skeletal muscle tone.
• Symptoms: Always asymptomatic Symptoms often attributed to hypertension: headache, tinnitus, dizziness, fainting
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Clinical Features
• Complications of Hypertension
Heart: LVH, CHD,HF
Brain: TIA, Stroke
Renal: Microalbuminuria, renal dysfunction
Ratinopathy
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Laboratory Examination
• Blood pressure measurement: Clinic Blood Pressure Home Blood Pressure Ambulatory monitoring
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Ambulatory Measurement
• Ambulatory monitoring can provide:– readings throughout day during usual activities
– readings during sleep to assess nocturnal changes
– measures of SBP and DBP load
– Exclude white coat or office hypertension
• Ambulatory readings are usually lower than in clinic (hypertension is defined as > 135/85 mm Hg)
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Laboratory Examination
• Urinalysis
• Blood examination
• Chest X Ray
• EKG
• UCG (Ultrasound cardiography)
• Retina examination
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The Keith-Wagner Criteria (change in retina)
KW I: Minimal arteriolar narrowing, irregularity
of the lumen, and increased light reflex
KW II: More marked narrowing and irregularity
with arteriovenous nicking (crossing defects)
KW III: Flame-shaped hemorrhages and exudates in
addition to above arteriolar changes
KW IV: Any of the above with addition of papilledema
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Flame shaped hemorrhage
Pepilledema
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Diagnosis & Differential Diagnosis
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Classification of blood pressure for adult
Category SBP (mmHg) DBP (mmHg)
Normal < 120 < 80
High normal 120-139 80-89
Hypertension ≥140 ≥90
Stage 1 140-159 90-99
Stage 2 160-179 100-109
Stage 3 ≥180 ≥110
Systolic HBP ≥140 < 90
When the SBP and DBP fall into different categories, use the higher category
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Evaluation Objectives
• To identify cardiovascular risk factors
• To assess presence or absence of target organ damage
• To identify other causes of hypertension
These evaluation may used in stratification of the hypertension patients
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Cardiovascular Risk Factors
• Blood pressure
• Age
• Gender
• Dyslipidemia
• Abdomen Obesity
• Family History of cardiovascular disease
• CRP ≥1mg/dl
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Target Organ Damage
• Left ventricular hypertrophy
• Echo shows IMT of carotid artery
• Plasma creatinine slight elevation
• Microalbuminuria
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Associated Clinical Condition
• Cerebrovascular diseases: Stroke, TIA• Heart diseases: MI, AP, CHF, Coronary
artery revasculation• Kidney diseases: DN, Dysfunction of the
kidney, Proteinuria, CRF • Diabetes• Peripheral artery disease• Retinopathy
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Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
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Stratification of Hypertension patients
Blood Pressure
risk factors & Disease History
Grade I Grade II Grade III
I . No risk factors Low risk Med risk High risk
II. 1-2 risk factors Med risk Med risk Very high risk
III. 3 or more risk factors or TOD or diabetes
High risk High risk Very high risk
IV. ACC Very high risk Very high risk Very high risk
TOD-Target Organ Damage; ACC-Associated Clinical Conditions
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Differential Diagnosis
Should exclude Secondary Hypertension
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Secondary Hypertension Common Causes
• Renal Glomerulonephritis Pyelonephritis
Obstructive nephropathy Collagen diseases, Congenital diseases Diabetes nephropathy Renal tumor---- renin secreting tumor
• Pheochromocytoma
• Primary aldosteronism
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Phenochromocytoma• Ganglion-neurotomas and neuroblastomas • Excretion of large amounts of catecholamines• 90% arise in the adrenal medulla • 10% are malignant.• Paroxymal or persist HT • Clinic features: Headache, sweating,
palpitations, nervousness, weight loss, hypermetabolism, orthostatic hypotension, severe presser response
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Primary Aldosteronism
• Mild or moderate hypertension
• Hypokalemia, muscle weakness, paralysis
• Polyuria, nocturia and polydipsia,
• Hypochloremic alkalosis
• Urine aldosterone elevation
• Plasma renin active decrease
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Secondary Hypertension
• Obstructive Sleep Apnea (OSA)• Renal artery stenosis • Cushing’s syndrome• Coarctation of the aorta• Drug-induced: NSAIDs; Sympathomimetic medications; Prophylactic; Monoamine oxidase inhibitors; Mineralocorticoids; Immuno-inhibitors; Epogen
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Therapy
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Goal of Hypertension Management
• < 140/90 mm Hg
• With Diabetes or kidney dysfunction: <130/80mmHg
– To reduce morbidity and mortality of cerebral and cardiovascular complications.
– Controlling other cardiovascular risk factors
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Lifestyle Modifications
• Stop smoking
• Limit alcohol intake
• Lose weight or keep fit
• Suitable diet
• Increase aerobic physical activity
• Decrease psychological stress
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Principle of Drug Therapy
• Drug therapy should be individually
• A low dose of initial drug therapy
• Combination therapies may provide additional efficacy with fewer adverse effects.
• Optimal formulation should provide 24-hour efficacy with once-daily dose.
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Antihypertensive Drugs
• Diuretics
• ß-Adrenergic receptor blockers (BB)
• Calcium channel blockers (CCB)
• ACE inhibitors (ACEI)
• Angiotensin II receptor blockers (ARB)
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Not at Goal Blood Pressure
Algorithm for Treatment of Hypertension
Hypertension patient
Lifestyle Modifications
Initial Drug Choices
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Not at Goal Blood Pressure
Initial Drug Choices
No associated clinical condition
Algorithm for Treatment of Hypertension (continued)
Associated clinical condition
I stage hypertension: Diuretics,
BB,CCB,ACEI,ARB
II stage hypertension: Two drugs
combination therapy
Choice the drugs according to ACC
Increase dosage or add another agent from different class
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Drug choices in hypertension patient associated with clinical condition
ACCDrug
Diuretics BB ACEI ARB CCB Antialdosterone
HF √ √ √ √
MI √ √ √
CAD √ √ √ √
DM √ √ √ √ √
CRF √ √
Stroke √ √
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Combination Therapies• May provide additional efficacy with fewer adverse
effects.
• Diuretics as the basement drug in combination therapy.
Diuretics ---- ACEI / ARB
Diuretics ---- BB
Diuretics ---- CCB
• CCB as the basement drug in combination therapy
CCB ---- ACEI
CCB ---- BB • Others: Three drugs combination
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Causes for InadequateResponse to Drug Therapy
• Incorrect measurement of the BP
• Volume overload or Pseudo-resistance
• Drug-related causes• Associated conditions
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Hypertensive crisis• Hypertensive Emergencies and Urgencies
• Emergencies: The blood pressure is elevated severely and associated with target organ damage, such as hypertensive encephalopathy, AMI, pulmonary edema, require immediate blood pressure reduction.
• Urgencies: The blood pressure is elevated severely but no target organ damage has acute target organ damage.
• Fast-acting drugs are available.
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Drugs Available forHypertensive Crisis
Vasodilators
•Nitroprusside
•Nicardipine
•Nitroglycerin
•Hydralazine
Adrenergic Inhibitors
•Labetalol
•Esmolol
•Phentolamine
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Case 1Male 29 years oldBlood pressure elevated for two years With paroxysmal dizziness, blurred vision,
sweating and palpitation BP: 160-180/90-100mmHg HR: 100-120 bpmWhen the patient with symptoms, the BP would
elevate to 240-260/120-130mmHg, and HR increase to 130-150 bpm.
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Physical examination:
BP: 165/100mmHg HR: 112 bpm
No positive sign in chest examination
Can find a mass at right abdomen, if press on it the BP of the patient elevated to 250/120mmHg, and the HR increased to 145 bpm.
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Laboratory test:Blood routine, Urinalysis, Blood biochemistry are
normalPlasma renine activation: 0.93ng/ml.h (0.93-6.56) AT II: 51.5pg/ml ↓ (55.3-115.3) Aldosterone: 129.4pd/ml (63-239.6)NE: 33.40pmol/ml ↑↑ (0.51-3.26)12-lead electrocardiogram: High voltage of LV
Chest X ray: Normal
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CT scan of abdomen:
Found a mass at right adrenal
Diagnosis as Phenochromocytoma
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Case 2
Male, 65 years old
Hypertension history for 30 years
Headache, blurred vision, vomiting for 2 hours
Paralysis of left side body
BP: 220/130mmHg
HR: 106 bpm
CT scan of the head: Normal
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Diagnosis: Hypertensive crisis
Therapy: Controlled the BP, using fast-acting drug , such as Nitroprusside, Labetalol
The reduction of BP should less than 25% in 24 hours
BP ≥ 160/100mmHg in 48 hours
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Summary• Specific therapy for patients with LVF, CAD, and
HF. ACEI can be used for all type patients.
• In older persons, diuretics and CCB are preferred.
• Many patients need combination therapy.
• Goal of the patients with renal insufficiency with proteinuria (>1 g/day): 125/75 mmHg;
(< 1 g/day): 130/80 mmHg. • Patients with diabetes should be treated to a
therapy goal of below 130/80 mm Hg.