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Hypertension (HT)

High Blood Pressure (HBP)

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%)

Etiology

• Genetic

• Environment

Dietary: Salt intake

Alcohol intake

Obesity

Infant dysnutrition

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

The pathological changes of small artery

The pathological change of the Heart

Left ventricular hypertrophy (LVH)

Heart failure

Coronary artery atherosclerosis

Myocardial infarction

Pathological change of the Brain

Stroke:

Ischemic stroke

Hemorrhagic stoke

Arterial Aneurysm

Pathological change of Renal

Hypertension induced nephrosclerosis, atrophy of renal cortex

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

Clinical Features

• Complications of Hypertension

Heart: LVH, CHD,HF

Brain: TIA, Stroke

Renal: Microalbuminuria, renal dysfunction

Ratinopathy

Laboratory Examination

• Blood pressure measurement: Clinic Blood Pressure Home Blood Pressure Ambulatory monitoring

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)

Laboratory Examination

• Urinalysis

• Blood examination

• Chest X Ray

• EKG

• UCG (Ultrasound cardiography)

• Retina examination

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

Flame shaped hemorrhage

Pepilledema

Diagnosis & Differential Diagnosis

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

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

Cardiovascular Risk Factors

• Blood pressure

• Age

• Gender

• Dyslipidemia

• Abdomen Obesity

• Family History of cardiovascular disease

• CRP ≥1mg/dl

Target Organ Damage

• Left ventricular hypertrophy

• Echo shows IMT of carotid artery

• Plasma creatinine slight elevation

• Microalbuminuria

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

Evaluation Components

• Medical history

• Physical examination

• Routine laboratory tests

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

Differential Diagnosis

Should exclude Secondary Hypertension

Secondary Hypertension Common Causes

• Renal Glomerulonephritis Pyelonephritis

Obstructive nephropathy Collagen diseases, Congenital diseases Diabetes nephropathy Renal tumor---- renin secreting tumor

• Pheochromocytoma

• Primary aldosteronism

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

Primary Aldosteronism

• Mild or moderate hypertension

• Hypokalemia, muscle weakness, paralysis

• Polyuria, nocturia and polydipsia,

• Hypochloremic alkalosis

• Urine aldosterone elevation

• Plasma renin active decrease

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

Therapy

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

Lifestyle Modifications

• Stop smoking

• Limit alcohol intake

• Lose weight or keep fit

• Suitable diet

• Increase aerobic physical activity

• Decrease psychological stress

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.

Antihypertensive Drugs

• Diuretics

• ß-Adrenergic receptor blockers (BB)

• Calcium channel blockers (CCB)

• ACE inhibitors (ACEI)

• Angiotensin II receptor blockers (ARB)

Not at Goal Blood Pressure

Algorithm for Treatment of Hypertension

Hypertension patient

Lifestyle Modifications

Initial Drug Choices

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

Drug choices in hypertension patient associated with clinical condition

ACCDrug

Diuretics BB ACEI ARB CCB Antialdosterone

HF √ √ √ √

MI √ √ √

CAD √ √ √ √

DM √ √ √ √ √

CRF √ √

Stroke √ √

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

Causes for InadequateResponse to Drug Therapy

• Incorrect measurement of the BP

• Volume overload or Pseudo-resistance

• Drug-related causes• Associated conditions

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.

Drugs Available forHypertensive Crisis

Vasodilators

•Nitroprusside

•Nicardipine

•Nitroglycerin

•Hydralazine

Adrenergic Inhibitors

•Labetalol

•Esmolol

•Phentolamine

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.

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.

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

CT scan of abdomen:

Found a mass at right adrenal

Diagnosis as Phenochromocytoma

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

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

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.