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Primary Hypertension

Cindy Chan, MD

Hypertension Outline
I.

Definition of Essential Hypertension II. Epidemiology III. Physiology of Hypertension IV. Diagnosis and Evaluation V. Treatment of Essential Hypertension VI. Complications of uncontrolled HTN

Definition of High Blood Pressure


Per seventh report of the Joint National Committee (JNC 7), published in 2003: based upon the average of two or more properly measured readings at each of two or more visits after an initial screen, the following classification is used.

Normal blood pressure: systolic <120 mmHg and diastolic <80 mmHg

Prehypertension: systolic 120-139 mmHg or diastolic 80-89 mmHg

Hypertension: Stage 1: systolic 140-159 mmHg or diastolic 90-99 mmHg Stage 2: systolic 160 or diastolic 100 mmHg

If

there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension.

Isolated Systolic Hypertension

Isolated systolic hypertension is defined as SBP >140 mm Hg and DBP<90 mm Hg. It occurs predominantly in older persons Occurence in adolescents and young may indicate hyperdynamic circulation and predict future diastolic elevation.

Hypertension Awareness, Treatment, and Control: NHANES III


Hypertensive population (%)

100.00% 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00%

68.40% 53.60%

27.40%

Aware of their disease

Treated pharmacologically

Controlled

NHANESIII = Third National Health and Nutrition Examination Survey. 1988 - 1991. Control of hypertension was defined as pharmacologic treatment resulting in systolic BP <140mm Hg and diastolic BP <90 mm Hg. Adapted from Burt VL et al. Hypertension. 1995;25:305-313.

Facts About High Blood Pressure


50

million Americans
Increases with age Greater among Blacks Greater for low-SES groups Greater in Southeastern States
Greater

Prevalence

in men than in women (in young and middle age; thereafter reverse is true)

Source: NHBPEP, Fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V),1993.

Facts About High Blood Pressure


Africa

Lower prevalence c/w US Urban > Rural Varies with region


30% in S. Africa 5% in Cameroon

Facts About High Blood Pressure

Risk factor/contributing factors


African descent Family hx Sodium intake ETOH use Obesity Hyperlipidemia Personality

Hypothesis for the Pathogenesis of Essential Hypertension


Na* excretion Stress +
High Sodium intake - reset pressure-natriuresis --counters KIDNEY

Sympathetic activity

Constriction of renal efferent arterioles

Filtration fraction

Na reabsorption

Relative vascular volume

Natriuretic hormone

Na-K ATPase

Vascular
Renin angiotensin Intracellular Na*

counters

Hypertension

Vascular resistance

Vascular tone and reactivity

Intracellular Ca**
Primary Membrane defect

membrane permeability (inherited) +


High sodium intake

Kaplan NM. in: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 4th ed. Philadelphia, Pa: WB Saunders Co: 1992:829

But really..

????
Unknown etiology

Interplay of Multiple Factors That Affect BP Regulation


Autoregulation

BLOOD PRESSURE

CARDIAC OUTPUT

PERIPHERAL RESISTANCE

Hypertension

Increased CO

and/or

Increased PR

Preload
Fluid Volume Venous Constriction

Contractility

Functional Constriction

Structural hypertrophy

Renal sodium retention

Decreased filtration surface

Sympathetic nervous overactivity

Reninangiotensin excess

Cell membrane alteration

Hyperinsulinemia

Excess sodium intake

Genetic alteration

Stress

Genetic alteration

Obesity

Endothelium

derived factors

Adapted from Kaplan NM. Clinical Hypertension. 5th ed. Baltimore, MD: Williams & Wilkins; 1990:57.

Primary or essential hypertension is a multifactorial disease but most hypertensives seem to have at least one of the following mechanisms involved:

An inability to handle sodium and water appropriately in comparison to normotensives Overactivity and overstimulation of the sympathetic/adrenergic nervous system A defect in the handling of intracellular calcium in vascular smooth muscle thereby giving more vasoconstriction in hypertensives versus normotensives A defect in the Renin-Angiotensin-Aldosterone system

Renin-Angiotensin System
ANGIOTENSINOGEN RENIN ANGIOTENSIN I
LOW MACULA DENSA SIGNAL LOW RENAL ARTERY BP HIGH RENAL NERVE ACTIVITY

CONVERTING ENZYME
ANGIOTENSIN II ALDOSTERONE PRODUCTION etc.

Target-Organ Sequelae of Hypertension

Target damage
Eyes
Retinal vein and artery thrombosis

Acute Events
Cerebral
Cerebrovascular accident

Heart
Coronary artery disease Left ventricular hypertrophy Dysrhythmia Congestive heart failure

Heart
Myocardial infarction

Kidney
Renal failure

Vasculature
Atherosclerosis Peripheral vascular disease
Source: Blood Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Pressure. Arch Intem Med. 1993;153:154-183.

Screening
2007

United States Preventive Services Task Force (USPSTF) guidelines:


every two years for persons with systolic and diastolic pressures below 120 mmHg and 80 mmHg, respectively yearly for persons with a systolic pressure of 120 to 139 mmHg or a diastolic pressure of 80 to 89 mmHg

Diagnosis

Posture - initially, check for postural changes by taking readings after five minutes supine, then immediately and two minutes after standing - this is particularly important in patients over age 65, diabetics, or those taking antihypertensive drugs. Sitting pressures are recommended for routine follow-up; the patient should sit quietly with the back supported for five minutes and the arm supported at the level of the heart.

Circumstances - no caffeine during the hour preceding the reading and no smoking during the preceding 30 minutes. No exogenous adrenergic stimulants, such as phenylephrine in decongestants or eye drops for pupillary dilatation. A quite, warm setting. Home readings should be taken upon varying circumstances. Equipment - cuff size: length of the bladder should be 80 percent and the width of the bladder should be at least 40 percent of the circumference of the upper arm
Manometer - aneroid gauges should be calibrated every six months against a mercury manometer

Diagnosis

Technique - number of readings. Take at least two readings on each visit, separated by as much time as possible; if readings vary by more than 5 mmHg, take additional reading until two consecutive readings are close. For the diagnosis of hypertension, take three readings at least one week apart. Initially, take blood pressure in both arms; if pressures differ, use the higher arm. If the arm pressure is elevated, take the pressure in one leg, particularly in patients under age 30 Performance - inflate the bladder quickly to 20 mmHg above the systolic pressure as estimated from loss of radial pulse. Deflate the bladder 3 mmHg per second. Record the Korotkoff phase V (disappearance) as the diastolic pressure except in children in whom use of phase IV (muffling) may be preferable. If the Korotkoff sounds are weak, have the patient raise the arm, open and close the hand five to ten times, and then inflate the bladder quickly. Recordings - note the pressure, patient position, arm, and cuff size: eg, 140/90, seated, right arm, large adult cuff.

White Coat HTN


approximately

20 to 25 percent of patients with mild office hypertension (diastolic pressure 90 to 104 mmHg) blood pressure is repeatedly normal when measured at home, at work, or by ambulatory blood pressure monitoring

Ambulatory Blood Pressure Monitoring

ABPM typically involves automated inflation of the BP cuff and recording of the blood pressure at preset intervals (usually every 15 to 20 minutes during the day and every 30 to 60 minutes during sleep) White Coat HTN Suspected episodic hypertension (eg, pheochromocytoma) Hypertension resistant to increasing medication Hypotensive symptoms while taking antihypertensive medications Autonomic dysfunction

Evaluation
Hx meds, lifestyle, diet, family hx, sleep, symptoms of end-organ damage PE papilledema, cotton-wool spots, palpation and auscultation of carotids, cardiac & pulm exam, renal bruits pulses, edema, visual disturbance, confusion Labs - Hematocrit, urinalysis, routine blood chemistries (glucose, creatinine, electrolytes), estimated glomerular filtration rate, fasting lipid profile Electrocardiogram

Fundus Changes
I Minimal changes II Arteriovenous Nicking III Exudate, flame-shaped hemorrhages IV Papilledema and changes I through III

Fundus Changes in Hypertension, Grade I through IV


Arrows Red: Exudate Blue: Crossing signs Green: hemorrhage; Circle: Papilledema

Grade I

Grade II Grade III

Grade IV

Strive for Five to treat BP


Eyes

(check fundi, consult ophthalmology) Cardiac/EKG (assess for any prior CAD) CNS (assess for any prior Stroke) Renal (assess urinalysis - U/A, BUN, creatinine) Cholesterol/Glucose

Blood Pressure Goals


To

reduce morbidity and mortality by the least intrusive means possible Achieving and maintaining the following levels; lower if tolerated
<140/90 mmHg <130/80 mmHg All patients Diabetes mellitus Renal disease

Components of CV Risk Stratification in Hypertensive Patients


Major Risk Factors Smoking Dyslipidemia Diabetes Renal impairment Age >60 years Gender (men and postmenopausal women) Family history of CVD Target Organ Damage/Clinical CVD Heart Diseases LVH angina or prior MI prior coronary revascularization heart failure Stroke or TIA Nephropathy Peripheral arterial disease Retinopathy

Adapted from JNC VI. Arch Intern Med. 1997;157:2413-2446.

Complications of uncontrolled HTN:

Complications of uncontrolled HTN:

Complications of uncontrolled HTN:

Complications of uncontrolled HTN:

Complications of uncontrolled HTN:

Complications of uncontrolled HTN:

Complications
Premature CHF LVH

CVD

CVA
Intracerebral

hemorrhage CRI & ESRD

Definitions

Malignant hypertension/Hypertensive emergency Hypertension with end-organ damage (retinal hemorrhages, exudates, or papilledema), usually associated with a diastolic pressure above 120 mmHg. Hypertensive encephalopathy Altered mental status (AMS) secondary to HTN, can be seen at diastolic pressures as low as 100 mmHg (in previously normotensive patients with acute hypertension due to preeclampsia or acute glomerulonephritis).

Hypertensive urgency Severe hypertension (as defined by a diastolic blood pressure above 120 mmHg) in asymptomatic patients. (No proven benefit from rapid reduction in BP in asymptomatic patients who have no evidence of acute endorgan damage and are at little short-term risk)

Hypertensive Emergency
Accelerated-malignant hypertension with papilloedema Cerebrovascular Hypertensive encephalopathy Atherothrombotic brain infarction with severe hypertension Intracerebral hemorrhage Subarachnoid hemorrhage Cardiac Acute aortic dissection Acute left ventricular failure Acute or impending myocardial infarction After coronary bypass surgery Renal Acute glomerulonephritis Renal crises from collagen vascular diseases Severe hypertension after kidney transplantation Excessive circulating catecholamines Pheochromocytoma crisis Food or drug interactions with monoamineoxidase inhibitors Sympathomimetic drug use (cocaine) Rebound hypertension after sudden cessation of antihypertensive drugs Eclampsia Surgical Severe hypertension in patients requiring immediate surgery Postoperative hypertension Postoperative bleeding from vascular suture lines Severe body burns Severe epistaxis

A bit of pharm.
First

line drug to tx hypertensive emergencies


Nitroprusside Labetalol Hydralazine

Break Time!!