S.Moradmand MD. SYSTEMIC HYPERTENSION DEFINITION: A level of blood pressure that is associated With increased morbidity & mortality At some future time.

S.Moradmand MD.

SYSTEMIC HYPERTENSION

DEFINITION:

A level of blood pressure that is associated With increased morbidity & mortality

At some future time when compared With the whole population

BP Range mm Hg Category

DBP <85 Normal BP85 – 89 High normal BP90 – 104 Mild hypertension105 – 114 Moderate hypertension>115 Severe hypertension SBP when DBP<90mm Hg < 140 Normal BP 140 – 159 Borderline isolated systolic hypertension >160 Isolated systolic hypertension

CLASSIFICATION of BLOOD PRESSURE

Normal <130 <85

High Normal 130-139 85-89

Hypertension Stage 1(Mild) 140-159 90-99 Stage 2(Moderate) 160-179 100-109 Stage3(Severe) 180-209 110-119 Stage4(Very severe) >210 >120

Category Systolic Diastolic

5

Guidelines

The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults: (Brashers, 2006, p.1)

Category Systolic Diastolic

Normal <120 and <80Pre-hypertension 120-139 or 85-89

Stage 1 hypertension

140-159 or 90-99

Stage 2 hypertension

>160 or >100

Pulse Pressure: Systolic minus Diastolic Presurre

Mean BP = DP + 1/3 Pulse Pressure

( A good indicator of tissue perfusion)

Angiotensinosion

Angiotensin 1

Angiotensin 2

Angiotensin3

Renin Renin Release

B-blocker

Coverting Enzyme

ACEIReceptor

Antagonist

Angiotensinases

Persistently raisedClinic BP

Target organ damage

Home BP

Ambulatory BP

Continue to monitorClinic & home BP

StartTreatment

yes

high

high

Systolic Pressure

1.Stroke volume

2.The velocity of ejection

3.The elastic properties of aorta

Diastolic Pressure

1.Competency of aortic valve

2.The condition of arteries & their ability to stretch & store energy

3.Resistance of arterioles

Blood PressureCardiac output X Peripheral resistance

cardiac

HR contractility

RenalFluid volume

humoral

sympathethic

local

Dilator (beta)

Constictor ( Alpha)

VasodilatorProstaglandins

VasoconstrictorsAngiotensin-endothelinn

classification1. Essential HTN

2. Renal HTN

92-94%

ParanchymalRenovascular

3.Endocrine HTN Primary Hyperaldostronism Cushing’s syndrome Pheochromocytoma OCP

Essential HTN

HerediteryEnviromentalSalt sensitivity High renine Low renine NonmodulatingCell membrane defectInsulin resistance

Renin Release control

1. Blood volume , Renal perfusion

2. Na filtrated to Macula Densa

3. Sympathetic nervous system

4. Dietary Potassium

Low renin HTN

1. 20% of patients2. Increased extracellular volme3. On high sodium diet mild degree of hyperaldostronism4. Increased sensitivity of adrenal cortex to angiotensin II

Nonmodulating Essential HTN

1. Adrenal defect apposite to low renin2. 25-30% of patients 3. Normal or high renin4. Na intake dosen’t modulate adrenal or renal response5. Corrected with ACEI

Cell Membrane Defect Abnormality in Na transport

Calcium accumulation inVascular smooth muscle cells

Increased vascular reactivity to Vasoconstrictor agents

Calcium in HTN

1. Low ca++ intake increase BP

2. Ca++ blockers are effective antihypertensives

3. Salt loading increase NF

4. Digital sensitive Na-K ATPase lead to intracellular calcium accumulation

Insulin Resistanse

1. Increased sympathetic activity

2. Vascular smooth muscle hypertrophy

4. Increase cytosolic calcium

Natural hx of HTN

1.Progressive & lethal if untreated2.Shortening of life 10-20 years3.If untreated in 7-10 years develope 30 % athersclerosis, 50% CHF, Cardiomegaly ,CVA, Renal insufficeincy & retinopathy.4.Morbid Cardiovascular events by as much as 20 fold

Hx., Ph.E., Lab. Tests1. Uncovering secondary HTN

2. Establishing a pretreatment baseline

3. The factors that may influence therapy

4. Determining if target organ damage?

5.Determining if other CAD risk factors?

Renal Paranchymal HTN

1. Volume expansion

2. Renin-Angiotensin system

3. Unidentified pressure agent

4.Fail to produce vasodilator substance

5. Fail to inactivate vasopressores

Endocrine HTN

1.Aldostronism2.Cushing Sndrome3.Adrenogenital Syndrome4.Pheochromocytoma5.Acromegaly6.Hypercalcemia7.Oral contraceptives

Oral Contraceptives

1. Estogen stimulate hepatic angiotensinogen

2. 5% increase BP

3. Familial Factors

4. Age over 35

5. Obesity

Symptoms & Signs

1.Elevated pressure itself headache,dizziness,palpitation, easy fatigability2.Hypertension vascular disease: epistaxis,hematuria,TIA,angina,dyspnea3.Underlying disease in secondary HTN: polyuria & polydipsia,…4.Most patients are asymptomatic

Factors indicating adverse prognosis1. Black race 2. Youth age3. Male4. Persistent diastolic pressure >115 mmhg5. Smoking6. Diabetes Mellitus7. Hypercholesterolemia8. Obesity9. Excess alcohol intake10.Evidence of End Organ Damage

Manifestation of Target Organ Disease

1.Cardiac :CAD LVH Cardiac Failure

2.Cerebrovascular:TIA / CVA

3.Peripheral Vascular

4.Renal

5.Retinopathy

InfarctionHemorrhageEncephalopathy

Medical Therapy

1.DIURETICS

2.ACEI

3.BETA-BLOCKERS

4.CALCIUM BLOCKERS

Drugs used in Emergency HTN

1.Hydralazine2.Minoxidil3.Diazoxide4.Nitroprusside

Basis of Treatment

Salt restriction Na intake <100mm

Relaxation Reduce sympathetic

Weight loss Diet /Exercise

Exercise Aerobic

Basic Tests for EvaluationUrinalysisCBC(Hct)Na-KCreatinine/BUNEKGFBS-Cholestrol(LDL-HDL)-TGCa++-Phosphate-Uric AcidChest-X-Ray / Echocardiogram

Coarctation of Aorta

Diminished or delayed Femoral Pulses

Rib notching on chest-X-Ray

PheochromocytomaUnusual lability of BPSymptomatic Paroxysm of HTNSpell of Pallor Palpitation Perspiration HeadacheHypertensive reaction to G/A or antihypertensive drugs

Renovascular HTN1. Age under 302. DBP > 120 mmHg3. Continuous bruit in epigasrium or flanks4.Accelerated HTN5.Hx. Of flank pain,hematuria or renal truma6.palpable kidney

7.HTN resistant to treatment

Conn’s Syndrome

1.Serum potassium less than 3.6

2.Urinary Potassium more than 30/24h in the absence of diuretic therapy

Isolated Systolic HTNA.Decreased aortic compliance as in arteriosclerosisB.Increased stroke volume 1-AI 2-Thyrotoxicosis 3-Hyperkinetic heart syndrome 4-Fever 5-AVF 6-PDA