HYPERTENSION
MEDICINE SEMINAR
DEFINITION
According to the World Health Organization (WHO), hypertension,
also known as high blood pressure, is defined as a systolic blood
pressure of 140 mmHg or higher, and/or a diastolic blood pressure of
90 mmHg or higher. This means that both systolic and diastolic
measurements, taken ontwo separate occasions, must be at or above
thesethresholds to be classified as hypertension
STAGES OF HYPERTENSION
According to standard guidelines, blood pressure levels are
categorized as:
Normal
Less than 120/80 mmHg
Hypertension Stage 2
Elevated
Systolic 140 or higher
Systolic 120–129 and
or diastolic 90 or
diastolic less than 80 mmHg
higher
Hypertensive Crisis
Hypertension Stage 1
Systolic over 180
Systolic 130–139 or
and/or diastolic over
diastolic 80–89 mmHg
120 mmHg
CAUSES AND RISK FACTORS
Genetic factors
• Blood pressure tends to run in families and children
of hypertensive parents tend to have higher blood pressure
Obesity
• Sixty percent of hypertensive adults are overweight Hypertension
and dyslipidemia frequently occur together and in association with
resistance to insulin-stimulated glucose uptake.
Sodium Intake
• Hypertension prevalence is related to dietary NaCl intake, and
the age-related increase in blood pressure may be augmented by a
high NaCl intake.
CAUSES AND RISK FACTORS
Alcohol intake and smoking
• People who consume large amount of alcohol have higher blood
pressure
Stress
• Acute stress can temporarily raise blood pressure.
Physical Activity
low levels of physical activity also may contribute to hypertension.
SECONDARY CAUSES
RENAL CAUSES
• Renal artery stenosis ,parenchymal diseases, renal cysts, renal
tumors
ENDOCRINE
• Primary aldosteronism, Cushing's
syndrome,pheochromocytoma,Hypothyroidism
DRUGS
• High dose estrogens, adrenal steroids, decongestants,
nonsteroidal anti-inflammatory agents, cocaine
SIGNS AND SYMPTOMS
Hypertension has been termed the "silent killer," because it hardly
produces any symptoms and is undetected in its long
asymptomatic phase
Breathlessness may be present due to left ventricular
hypertrophy, diastolic dysfunction,
Headache may be a complaint in hypertension, but - Intracerebral
hemorrhage. usually rare and episodes of headaches do not
correlate with fluctuations in ambulatory blood pressure.
SIGNS AND SYMPTOMS
Attacks of sweating, headache, and palpitations may point
towards the diagnosis of pheochromocytoma.
Sometimes patients may experience epistaxis when BP is very high
Breathlessness may be present due to left ventricular
hypertrophy, diastolic dysfunction, or heart failure.
Malignant hypertension may present with severe headache,
vomiting, visual disturbances, seizures ,altered sensorium, or
symptoms of heart failure.
CONSEQUENCES OF HYPERTENSION
HEART
•Hypertensive heart disease is the result of structural and functional
adaptations leading to left ventricular hypertrophy, CHF, atherosclerotic
coronary artery disease and microvascular disease, and cardiac arrhythmias,
including atrial fibrillation.
BRAIN
• Elevated blood pressure is the strongest risk factor for stroke .Elevated
blood pressure is the strongest risk factor for stroke. Hypertension is
associated with beta amyloid deposition, a major pathologic factor in
dementia
CONSEQUENCES OF HYPERTENSION
KIDNEY
•The kidney is both a target and a cause of [Link],
hypertension-related vascular lesions in the kidney primarily affect
preglomerular arterioles, resulting in ischemic changes in the glomeruli and
postglomerular structures. Glomerular injury also may be a consequence of
direct damage to the glomerular capillaries due to glomerular hyperperfusion
.Clinically, macroalbuminuria or microalbuminuria are early markers of renal
injury. These are also risk factors for renal disease progression and
cardiovascular disease.
CONSEQUENCES OF HYPERTENSION
PERIPHERAL ARTERIES
•Blood vessels are a target organ for atherosclerotic disease secondary to
longstanding elevated blood pressure. In hypertensive patients, vascular
disease is a major contributor to stroke, heart disease, and renal failure.
Further, hypertensive patients with arterial disease of the lower extremities are
at increased risk for future cardiovascular disease.
INVESTIGATIONS
Urea, creatinine and electrolytes (to assess renal function).
Urine examination for protein and blood.
Lipid profile.
Blood glucose (to rule out diabetes).
ECG usually shows evidence left ventricular hypertrophy
Chest X-ray usually shows cardiomegaly and rib notching if there
is coarctation of aorta.
APPROACH TO PATIENT
The initial assessment of a hypertensive patient should include a complete
history and physical examination to confirm a diagnosis of hypertension, screen
for other cardiovascular disease risk factors
Duration of hypertension
Previous therapies: responses and side effects
Family history of hypertension and cardiovascular disease
Dietary and psychosocial history
Other risk factors: weight change, dyslipidemia, smoking,
diabetes, physical inactivity
LIFE STYLE MODIFICATION
Weight reduction - Attain and maintain BMI <25 kg/m2
Dietary salt reduction - <6 g NaCl/day
Adapt DASH-type dietary plan - Diet rich in fruits, vegetables,
and low-fat dairy products with reduced content of saturated and
total fat
Moderation of alcohol consumption
Physical activity - Regular aerobic activity, e.g., brisk walking for
30 min/d
TREATMENT
Lowering systolic blood pressure by 10–12 mmHg and diastolic blood pressure by
5–6 mmHg confers relative risk reductions of 35–40% for stroke and 12–16% for
CHD within 5 years of the initiation of [Link] of antihypertensive
agents and combinations of agents should be individualized, taking into account
age, severity of hypertension, other cardiovascular disease risk factors, comorbid
conditions, and practical considerations related to cost, side effects, and
frequency of dosing
THIAZIDES
Examples - Hydrochlorothiazide , Chlorthalidone
Action - inhibit the Na+/Cl– pump in the distal convoluted
tubule and hence increase sodium excretion.
Contraindications - Diabetes, dyslipidemia, hyperuricemia
LOOP DIURETICS
Examples - Furosemide , Ethacrynic acid
Action - inhibit the Na/K+/2Cl– cotransporter and hence
increase sodium excretion.
Indications - CHF due to systolic dysfunction, renal failure
Contraindications - Diabetes, dyslipidemia, hyperuricemia
BETA BLOCKERS
Examples -
Cardioselective -Atenolol, Metoprolol
Nonselective - Propranolol
Combined alpha/beta - Labetalol , Carvedilol
Action - lower blood pressure by decreasing cardiac output
owing to a reduction of heart rate and contractility
Indications - Angina, CHF due to systolic dysfunction, post-
MI, sinus tachycardia
Contraindications - Asthma, COPD
ACE INHIBITORS
Examples - Captopril,Lisinopril,Ramipril
Action - decrease the production of angiotensin II
Indications - Post-MI, coronary syndromes,nephropathy
Contraindications - Acute renal failure, bilateral renal artery
stenosis, pregnancy, hyperkalemia
RENIN INHIBITORS
Examples - Aliskiren
Action - Blockade of the renin- angiotensin system is more
complete with renin inhibitors
Indications - Diabetic nephropathy
Contraindications - Pregnancy
CALCIUM CHANNEL BLOCKERS
Examples - verapamil , diltiazem , nifedipine
Action - reduce vascular resistance through L-channel
blockade, which reduces intracellular calcium and blunts
vasoconstriction
Side effects - flushing, headache, and edema
Contraindications- 2nd- or 3rd-degree heart block
ANGIOTENSIN II ANTAGONISTS
Examples - Losartan,Valsartan,Candesartan
Action - provide selective blockade of AT1 receptors
Indications - CHF with low ejection fraction, nephropathy
Contraindications - Renal failure, bilateral renal artery
stenosis
HYPERTENSIVE EMERGENCY
Acute, severe elevation in blood pressure associated with target
organ damage
Patients with hypertensive emergency usually present with a
systolic BP of >180 mmHg and /or diastolic BP of ≥120 mmHg
Target-organ damage includes hypertensives encephalapatly, pre-
eclampsia and eclampsia, acute left ventricular failure with
pulmonary edema, myocardial ischemia
Hypertensive emergency requires ICU admission and lowering of
blood pressure by intravenous medications.
PREFERRED PARENTERAL DRUGS FOR SELECTED
HYPERTENSIVE EMERGENCIES
Hypertensive
Nitroprusside, nicardipine, labetalol
encephalopathy
Malignant
Labetalol, nicardipine, nitroprusside, enalaprilat
hypertension
Stroke Nicardipine, labetalol, nitroprusside
Acute left
Nitroglycerin, enalaprilat, loop diuretics
ventricular failure
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