Hypertension

An adult is considered to be hypertensive

when the systemic blood pressure is 140/90

mm hg or more on at least two occasions
measured at least 1 or 2 weeks apart.

Blood pressure levels are a function of cardiac

output multiplied by peripheral resistance (the

resistance in the blood vessels to the flow of
blood)

Hypertension

Hypertension
The major factors which help maintain

blood pressure (BP) include the

sympathetic nervous system and the
kidneys.

Optimal healthy blood pressure is a systolic

blood pressure of <120 mmHg and a

diastolic blood pressure of <80

Hypertension
Category

Systolic Blood
Pressure

Diastolic Blood
Pressure

Normal

< 120

<80

Pre-hypertension

120-139

80-89

Hypertension
Stage 1

140-159

90-99

Hypertension
Stage 2

>160

>100

Hypertension

Approximately one in four American adults has

hypertension.
The prevalence of hypertension increases with

age.
When the normal regulatory mechanisms fail,

hypertension develops.
Hypertension is so dangerous because it gives

off no warning signs or symptoms.

Untreated

hypertension can result in:

Arteriosclerosis
Heart Attack
Enlarged

heart

--Kidney damage
--Stroke
--Blindness

Essential or primary
When a cause for the increased blood pressure
hypertension
cannot be identified.
o

Accounts for more than 95 % of all cases of

hypertension,is characterised by a familial
incidence and inherited biochemical
abnormalities.

Secondary hypertension
It is termed as secondary hypertension when an

identifiable cause is present,

accounts for less than 5 % of all cases.

Pathophysiology of essential

hypertension
Pathophysiologic factors include-increased sympathetic nervous system activity in
response to stress
-over production of sodium retaining harmones and
vasoconstrictors
-high sodium intake
-inadequate dietary intake of potassium and calcium
-increased renin secretion
-deficiencies of endogenous vasodilators such as
prostaglandins and nitric oxide
-presence of medical diseases such as DM and obecity

The final common pathway in the

pathophysiology of essential hypertension is salt

and water retention.
Hypertension ,insulin resistance ,dyslipidemia

,and obesity often occur concomitantly

A history of ischemic heart disease ,angina

pectoris ,left ventricular hypertrophy ,congestive

heart failure ,cerebrovascular disease ,stroke
,peripheral vascular disease or renal insufficiency
suggests end organ disease due to chronic
,poorly controlled essential hypertension.

Secondary hypertension
Common causesRenovascular disease (most common cause)
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Cushings syndrome
Renal parenchymal disease
Pregnancy induced hypertension

Treatment of essential
hypertension
The standard goal of therapy is to decrease systemic blood

pressure to lower than 140/90 mm hg ,but in the presence

of DM or renal disease ,the goal is lower than 130/80
mmhg.
Decreasing BP by life style modification and pharmacologic
therepy is intended to decrease morbidity and mortality.

Lifestyle modification-weight reduction or prevention of weight gain

-increased physical activity
-moderation of alcohol intake
-maintenance of recommended levels of dietary calcium
and potassium
-moderation in dietary salt intake
-smoking cessation

Pharmacologic
therapy
Initiation of drug therapy should occur in tandem with
life-style modification.
After drug therapy is started ,patients are seen every
1 to 4 weeks to titrate the antihypertensive drug dose
and then every 3 to 4 months once the desired
degree of blood pressure control has been achieved.
Use of long acting drugs is preferable because patient
compliance and consistency of blood pressure control
are superior with once daily dosing.
Thiazide diuretics are recommended as initial therapy
for uncomplicated hypertension.
The hypertensive pt may have comorbid conditions
that present compelling indications for
antihypertensive therapy with drugs of a particular
class.

Treatment of secondary
Treatment of secondary hypertension is often
hypertension
surgical.
Pharmacologic therapy is reserved for patients in
whom surgery is not possible.
Certain disease entities ,such as
pheochromocytoma ,may require a combined
approach for optimal outcome.

Surgical therapySurgical therapy is reserved for identifiable cause

of secondary hypertension ,and includes
correction of renal artery stenosis via angioplasty
or direct repair and adrenalectomy for adrenal
adenoma or pheochromocytoma.

Pharmacologic therapy

For patients in whom renal artery

revascularization is not possible ,blood pressure

control may be accomplished with ACE inhibitors
alone or in combination with diuretics.
Renal function and serum potassium

concentration must be carefully monitored when

ACE inhibitor therapy is initiated in these patients.
Primary aldosteronism in women is treated with an

aldosterone antagonist such as spironolactone ,but

amiloride is used in men for this purpose because
spironolactone may cause gynecomastia.

Hypertensive Crises

Hypertensive crises typically present with a

blood pressure of higher than 180/120 and can

be categorised as either a hypertensive
urgency or a hypertensive emergency ,based
on the presence or absence of impending or
progressive target organ damage.
Patients with chronic systemic hypertension

can tolerate a higher systemic blood pressure

than previously normotensive individuals and
are more likely to present with urgencies rather
than emergencies.

Hypertensive Emergency
Patients with evidence of acute or ongoing target organ

damage (encephalopathy ,intracerebral hemorrhage

,acute left ventricular failure with pulmonary edema
,unstable angina ,dissecting aortic aneurysm ,acute
myocardial infarction ,eclampsia ,microangiopathic
hemolytic anemia , or renal insufficiency )require
prompt pharmacologic intervention to lower the
systemic blood pressure.
Encephalopathy rarely develops in patients with chronic

hypertension until the diastolic blood pressure exceeds

150 mm hg ,whereas parturients with pregnancy
induced hypertension may develop signs of
encephalopathy with diastolic blood pressures less than
100 mm hg.

Even in the absence of symptoms , a parturient with a

diastolic blood pressure higher than 109 mm hg is

considered a hypertensive emergency and requires
immediate management.
The goal of treatment in hypertensive emergencies is to
decrease the diastolic blood pressure promptly but
gradually.
A precipitous decrease in blood pressure to
normotensive levels may provoke coronary or cerebral
ischemia.
Typically ,mean arterial pressure is reduced by about 20
% within the first 60 minutes and then more gradually.
Thereafter ,the blood pressure can be reduced to
160/110 over the next 2 to 6 hours as tolerated by the
absence of symptomatic hypoperfusion of target organs.

Hypertensive Urgency
Hypertensive urgencies are situations in which

BP is severely elevated ,but the patient is not

exhibiting evidence of target organ damage .
These patients can present with headache
,epistaxis ,or anxiety.
Selected patients may benefit from oral
antihypertensive therapy because
noncompliance with or unavailability of
prescribed medications is often the factor
responsible for this problem.

Pharmacologic Therapy
The initial choice of pharmacologic therapy for a

hypertensive emergency lies in an analysis of the

patients comorbidities and the symptoms and
signs at presentation.
An intra-arterial catheter to continuously monitor
systemic blood pressure is recommended during
treatment with potent vasoactive substances.
For most types of hypertensive emergencies
,sodium nitroprusside 0.5 to 10 mcg/kg/min
intravenously is a drug of choice.

The immediate onset and short duration of action

allow effective minute-by-minute titration ,but sodium

nitroprusside use can be complicated by lactic
acidosis and cyanide toxicity.
Nicardipine infusion is another option and may
improve both cardiac and cerebral ischemia .
The dopamin (DA1-specific)agonist fenoldopam
increases renal blood flow and inhibits sodium
reabsorption ,making it an excellent drug in patients
with renal insufficiency.
Esmolol infusion can be effective alone or in
combination with other drugs.
Labetalol, an alpha and beta blocker ,can also be very
effective in the acute treatment of hypertension.

The DASH Diet

The

Dietary Approaches to Stop

Hypertension clinical trial (DASH)

Diet rich in fruits, vegetables, and low fat

dairy foods, can substantially lower blood

pressure in individuals with hypertension and
high normal blood pressure.