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Hypertension

Hypertension (Ref. Hari. 18th ed., pg - 2047)


Extra Edge: Hypertension (also known as Silent killer
disease) Rule of half applies to it (MCQ)
Recent Advances: (Ref. Hari. 18th ed., pg -2047, table
241-1)

Measuring blood pressure


1. Cuff width should be > 80%Q of the arm
circumference. (AIPG 2012)
2. Systolic pressure. The appearance of
sustained repetitive tapping sound (Korotkoff
1 Q)
3. Diastolic pressure usually the disappearance
of sounds (Korotkoff V Q)
4. In some individual (eg. pregnant women)
sounds are present until the zero point.
5. In this case the muffing of sounds (Korotkoff
IV Q) should be used.

White coat hypertension = BP is high in the hospital /


clinic but BP is normal at home.

Ankle brachial index (LQ 2012)


1. It is the ratio of Systolic BP at ankle / systolic
BP of arm.
2. It indicate the degree of lower extremity
arterial occlusive disease.
3. ABI < 0.9 = abnormal
4. ABI < 0.3 = critical ischemia for peripheral
arterial disease.
Recent Advances
Cilostazol is used in the alleviation of the symptom of
intermittent claudication in individuals with peripheral
vascular disease
Recent Advance - J-curve phenomenon
1. People with high BP and/or high blood
cholesterol levels have a greater risk of
developing cardiovascular diseases (CVD).
2. The higher the BP and/or cholesterol level, the
greater the risk. We also know that lowering
blood pressure and cholesterol levels lowers
the risk for CVD.
3. When the BP or blood cholesterol levels of
large groups of people are plotted on a graph
against CVD mortality, it often results in a Jshaped curve.
4. This curve shows that those with higher BP
and/or cholesterol levels, closer to the top of
the curve, are more likely to die from CVD.
5. The curve also shows that those at the lowest
end of the curve (with very low BP and/or low
cholesterol levels) also have higher CVD

mortality. This accounts for the J shape and is


known as the J-curve phenomenon. (Ref. Hari.
18th ed., Pg-2058)
Pseudohypertension (Oslers Sign) Isolated systolic
hypertension (ISH):
1. Pseudohypertension is when only systolic
blood pressure (>140) is elevated.
2. Pseudohypertension is almost always found in
older patients.
3. As people get older, the walls of the arteries
sometimes get very thick, and calcium may be
deposited in the arterial wall (arteriosclerosis).
This makes the arteries very stiff and difficult
to compress.
4. Because measuring blood pressure depends
on measuring how much force it takes to
compress an artery, having thick, difficult-tocompress arteries falsely elevates the
sphygmomanometer reading.
5. It is not benign Q: It has doubles risk of MI,
triples risk of CVA
Treatment : Diuretics, Calcium channel blocker
Essential hypertension (primary, cause unknown). Seen
in 95% of cases of HT.
Secondary hypertension "5% of cases.

Table 247-2 Systolic Hypertension with Wide Pulse


Pressure (Ref. Hari. 18th ed., Page - 1554,Table 247-2)
1. Decreased vascular compliance (arteriosclerosis)
2. Increased cardiac output

a. AR (LQ 2012)
b. Thyrotoxicosis
c. Hyperkinetic heart syndrome
d. Fever
e. Arteriovenous fistula
f. Patent ductus arteriosus
g. Pregnancy
h. Beri Beri
Causes of secondary hypertension
Renal disease: The most common Q secondary cause.
1. Glomerulonephritis, (Acute & Chronic)
2. Chronic pyelonephritis,
3. Renovascular disease (Renal artery stenosis)
most frequently atheromatous (elderly,
cigarette smokers with periphery vascular
disease) or fibro muscular dysphasia Q in
young patients.
RAS, can occur in Takayasu disease but it
does not occur in PAN. (LQ, AIPG 2010)
4. Polycystic kidneys.
5. Renin secreting tumor.
Extra Edge:
1. Renovascular Hypertension (Ref. Hari. 18th ed.,
pg - 2049)
a. As a screening test, renal blood flow
may be evaluated with a radionuclide
[131I]-orthoiodohippurate (OIH) scan or
glomerular filtration rate may be
evaluated with a DTPA scan before
and after a single dose of captopril (or

another ACE inhibitor).


b. Gadolinium-contrast magnetic
resonance angiography offers clear
images of the proximal renal artery but
may miss distal lesions.
c. Contrast arteriography remains the
"gold standard" for evaluation and
identification of renal artery lesions.
2. Endocrine disease: Cushing's Q, Conn's
syndromes Q, pheochromocytoma Q,
acromegaly Q , Hyperparathyroidism. Q
Hypothyroid, Hyperthyroid.
3. Connective tissue disorders - PAN, systemic
sclerosis, Takayasu disease.
4. Others: Coarctation Q, porphyria Q, Guillain
Barre syndrome
5. Pregnancy Q
6. Drugs : steroids Q, MAOI, oral contraceptive
Pill', Amphetamine, Alcohol, NSAID
Table 2474. Example of Mendelian Forms of
Hypertension (Ref. Hari. 18th ed., pg - 2051)

Autosomal recessive

Autosomal dominent

1. 17-hydroxylase
deficiency
2. 11-hydroxylase
deficiency
3. 11-

1. Liddle's syndrome
2. Pseudohypoaldosteronism
type II (Gordon's syndrome)
3. Polycystic kidney disease
4. Pheochromocytoma

hydroxysteroid
dehydrogenase
deficiency (apparent
mineralocorticoid
excess syndrome)


Hypertensive retinopathy
Grade
1. Tortuous with thick shiny walls

2. A-V nipping (narrowing where arteries cross


veins)
3. Flame hemorrhages and cotton wool spots

4. Papilledema
Hypertension Management
Basic Physiology of BP
Physiological Parameters on which BP depends
1. Cardiac output
2. Peripheral resistance
3. Blood volume
BP = Cardiac output (COP) x Peripheral resistance (PR)
COP = Heart Rate (HR) x Stroke volume (SV)
BP = HR x SV x PR
(Mean Arterial Pressure = Diastolic BP + 1/3 pulse
presence)

A. Drugs which reduce HR


a. Beta blockers
b. Ivabridine ( acts on funny Na channels)
Uses of Beta blockers (In hypertensive patients)
a. Angina (LQ 2012)
b. MI
c. Hyperthyroidism

Contraindication of beta blockers


a. Erectile dysfunction Q
b. Peripheral vascular disease Q
c. Pheochromocytoma, (If given alone). Should
be given only with alpha blockers. Q
d. CHF Q
B. Drugs which reduce stroke volume
1. Beta blockers (beta blockers have
negative inotropic & negative
chronotropic effects) so beta blocker
should be used with cautious or should
be avoided in CHF with HT.
2. Diuretics: They reduce blood volume so
they reduce the preload Q
a. Uses in hypertension
i. HT with CHF
b. Contraindication in HT
i. HT with hyperuricemia Q
ii. Pheochromocytoma Q
iii. Thiazides are Contra
Indicated in diabetes Q
3. Nitrates: They primarily dilate the
venules thereby they cause peripheral
pooling of the blood. So they reduce the
preload.
Uses of nitrates in HT (AIIMS Nov 2012)
a. HT with CHF Q
b. HT with CAD Q

c. Severe hypertension Q
C. Drugs which reduce the peripheral resistance
1. Alpha blockers
2. Calcium channel blockers
3. ACEI
4. Direct vasodilators
1. Alpha blockers: They act on the peripheral alpha
receptors thereby dilate the arteriole.
Examples: Prazosin,
Uses of alpha blockers in hypertension
a. Elderly Q
b. HT with BHP
c. HT with CRF
d. HT with hyperuricemia
2. Calcium channel blockers : They dilate the
arteriole so reduce the peripheral resistance
Example: Nifedipin
Uses

a. Elderly hypertensive
b. HT with CRF
c. HT with PVD
d. HT with SAH (Nimodipine is used) (MCQ)
Contraindication

a. HT with CAD
b. Malignant hypertension
c. HT with CHF

New Drug: Clevidipine is a dihydropyridine calcium


channel blocker indicated for the reduction of blood
pressure when oral therapy is not feasible or not
desirable. (Its name is not given in 18th Edition of
Harrison)!!!
3. ACEI:
Examples: Captopril, Lisinopril
Uses in HT
a. Young patients
b. Unilateral renal artery stenosis

c. HT with DM
d. HT with CHF
e. HT with MI
f. HT with hyperuricemia
g. HT with erectile dysfunction
Side Effects: Cough (M/C), Hyperkalemia (LQ, AIIMS
Nov 2010), Angioneurotic edema, First dose
hypotension.
Captopril causes leukopenia & nephrotic syndrome.
Contraindication
a. Bilateral renal artery stenosis
b. CRF
c. With potassium sparing diuretics
d. Pregnancy
4. Direct Vaso dilators
Example: Hydralazine, alpha Methyl dopa,
Sodium nitroprusside, indapamide
a. Hydralazine

Pregnancy with HT
Side effect : SLE like syndrome
b. Alpha methyl dopa
Uses
Pregnancy with HT
Side effects: Coombs positive hemolytic
anemia, black tongue
c. Sodium nitroprusside
Uses: Hypertensive emergencies,
Malignant hypertension
d. d Indapamide
Uses
i. HT with hyperuricemia
ii. HT with CRF
iii. HT with diabetes
iv. Elderly hypertensive
Extra Edge: (Ref. Hari. 18th ed., pg - 2010)
1. Verapamil ordinarily should not be combined
with beta blockers because of the combined
adverse effects on heart rate and contractility.
2. Diltiazem can be combined with beta blockers
in patients with normal ventricular function
and no conduction disturbances.
3. Amlodipine and beta blockers have
complementary actions on coronary blood
supply and myocardial oxygen demands.
Recent Advances:
1. Bosentan is a new drug. It is a endothelin
receptor antagonist. It is a vaso dilator It has
been approved for PAH and for Raynauds
phenomena.

2. Aliskiren is a new drug. It is a non-peptide


renin inhibitor that acts by inhibiting
conversion of angiotensin-I to angiotension-II.
It is used in hypertension. (Ref. Hari. 18th ed.,
pg - 2055)
3. Fenoldopam has a peripheral vasodilatory
action which acts as a peripheral selective D1
receptor weak partial agonist. It is given as
continuous IV infusion for the treatment of
hypertensive emergencies. (It is a new drug
not given in Harrison 18th Edition)
4. Naftopidil It is an antihypertensive drug
which acts as a selective 1-adrenergic
receptor antagonist or alpha blocker.
5. Urapidil It acts as an 1-adrenoceptor
antagonist and as an 5-HT1A receptor agonist
(It is a new drug not given in Harrison 18th
Edition)

Resistant Hypertension
1. It refers to patients with BP persistently >140/90
mmHg despite taking three or more
antihypertensive agents, including a diuretic, in
reasonable combination and at full doses.
2. Resistant hypertension may be related to
a. "Pseudoresistance" (high office blood
pressures and lower home blood
pressures),
b. Non adherence to therapy,
c. Identifiable causes of hypertension
(including obesity and excessive alcohol
intake), and use of any of a number of
nonprescription and prescription drugs.

d. Rarely, in older patients,


pseudohypertension may be related to
the inability to measure blood pressure
accurately in severely sclerotic arteries.
This condition is suggested if the radial
pulse remains palpable despite
occlusion of the brachial artery by the
cuff (Osler maneuver).
3. The actual blood pressure can be determined by
direct intraarterial measurement (Ref. Hari. 18th
ed., pg - 2058)
Malignant hypertension
1. A hypertensive emergency (formerly called
"malignant hypertension") is severe hypertension
with acute impairment of one or more organ
systems (especially the central nervous system,
cardiovascular system and/or the renal system)
that can result in irreversible organ damage.
2. So in Malignant hypertension. Abrupt increasing
in BP, clinically has very high BP associated with
papilledema, proteinuria, microangiopathic
hemolytic anemia and encephalopathy.)
3. In a hypertensive emergency, the blood pressure
should be substantially lowered over a period of
minutes to hours with an antihypertensive agent.
4. Complications of malignant hypertension Q :
1. acute renal failure,
2. heart failure,
3. encephalopathy,
4. CAD
5. Pathological hallmark is fibrinoid necrosis Q.

6. Treatment: Avoid sudden drops in BP as cerebral


autoregulation is poor
Table 24710. Antihypertensive Agents Used in
Hypertensive Emergencies. (Ref. Hari. 18th ed., pg 2058)
Antihypertensive
1. Nitroprusside (LQ 2012)
2. Nicardipine
3. Labetalol (LQ 2012)
4. Esmolol
5. Phentolamine
6. Nitroglycerin (LQ 2012)
7. Hydralazine
8. Fenoldopam (LQ 2012)
Recent Advances:
1. Previously sublingual nifedipine and injection
frusemide were used in severe hypertension.
But now both these drugs are contraindicated
in severe hypertension.
2. Never use sublingual nifedipine Q to reduce BP
(big drop in BP and increase CAD risk) (PNQ)
3. Injection frusemide should not be used in
severe HT But can be used in severe HT with
LVF. (PNQ)
Hypertensive urgency
1. Sometimes, patients can have very high blood
pressure but have no symptoms.
In these cases, the elevated BP is discovered
incidentally. These cases severe high BP
without serious symptoms are called

hypertensive urgency.
2. Hypertensive urgency indicates that the blood
pressure is high enough to cause serious risk
of sudden, life threatening events, but that no
such events are currently occurring.
3. In other words, these patients have no organ
failure or other immediately life threatening
conditions, but could quickly develop them if
their blood pressure isnt quickly brought
under control.
4. Patient should be treated on the OPD basis.
(i.e. Hospitalization not needed)
Diet in Hypertensive patient:

The DASH Diet Eating Plan

The DASH (Dietary Approaches to Stop Hypertension)


diet is recommended to many people with hypertension.

The DASH diet provides more than the traditional low


salt or low sodium diet to reduce blood pressure. It is
based on an eating plan rich in fruits and vegetables, and
low-fat or non-fat diet
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