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Hypertension

Definitions and pathophysiology

Epidemiology

The treatment of hypertension is the

most common reason for office visits of


adults to physicians and for use of
prescription drugs

The number of patients with

hypertension is likely to grow as the


population ages, since either isolated
systolic hypertension or combined
systolic and diastolic hypertension occurs
in the majority of persons older than 65
years

Definition
Category
(mmHg)

Systolic (mmHg) Diastolic

Optimal
<120
< 80
Normal
120129
8084
High normal
130139
8589
Grade 1 hypertension (mild)
140159
90
99
Grade 2 hypertension (moderate)
160179
100109
Grade 3 hypertension (severe)
>180
>110
Isolated systolic hypertension
>140 < 80
90
Normal
< 120
Prehypertension
120139
8089
Stage 1 hypertension
140159
90
99
Stage 2 hypertension
160
100

Definitions based upon


ambulatory measuremnt

depends upon the time span over which


it is interpreted:

A 24-hour average above 135/85 mmHg


Daytime (awake) average above 140/90
mmHg

Nighttime (asleep) average above 125/75


mmHg

Definitions based upon


presentation

Malignant hypertension refers to marked


hypertension with retinal hemorrhages,
exudates, or papilledema

These findings may be associated with


hypertensive encephalopathy

Hypertensive urgency
Severe hypertension (as defined by a
diastolic blood pressure above 120
mmHg) in asymptomatic patients

Pathogenesis

The pathogenesis of primary, or

essential, hypertension is poorly


understood.

A variety of factors have been implicated,


including:

Increased sympathetic neural activity,


with enhanced beta-adrenergic
responsiveness.

Increased angiotensin II activity and


mineralocorticoid excess.

Pathogenesis

Hypertension is about twice as common in subjects


who have one or two hypertensive parents and
epidemiologic studies suggest that genetic factors
account for approximately 30 percent of the
variation in blood pressure in various populations

Reduced adult nephron mass may predispose to


hypertension, which may be related to

genetic factors,
intrauterine developmental disturbance (eg,
hypoxia, drugs, nutritional deficiency),

post-natal environment (eg, malnutrition,


infections)

Risk factors
A variety of risk factors have been associated with
essential hypertension:

Hypertension tends to be both more common and


more severe in blacks

Hypertension in maternal, paternal or both parents


Excess alcohol intake is associated with the
development of hypertension

Obesity and weight gain are major risk factors for


hypertension

Physical inactivity increases the risk for hypertension


certain personality traits, such as hostile attitudes
and time urgency/impatience, as well as depression

Secondary hypertension

acute and chronic kidney disease,

particularly with glomerular or vascular


disorders

Pheochromocytoma
Renovascular disease
Primary aldosteronism (presence of primary
mineralocorticoid excess)

Hypothyroidism, hyperthyroidism, and


hyperparathyroidism may also induce
hypertension

Secondary hypertension

Coarctation of the aorta is one of the

major causes of secondary hypertension


in young children

Oral contraceptives often raise the blood

pressure within the normal range but can


also induce overt hypertension

Chronic nonsteroidal antiinflammatory


agents and many antidepressants can
induce hypertension

Measurement

the patient should sit quietly with the

back supported for five minutes and the


arm supported at the level of the heart

No caffeine during the hour preceding

the reading and no smoking during the


preceding 30 minutes

A quiet, warm setting


The length of the bladder should be 80
percent and the width of the bladder
should be at least 40 percent of the

Measurement
Initially, take blood pressure in both arms; if
pressures differ, use the higher arm

For the diagnosis of hypertension, take three


readings at least one week apart

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


Systolic blood pressure readings in the left and right
arms should be roughly equivalent.

A discrepancy of more than 15 mmHg may indicate


subclavian stenosis

White coat hypertension

"white-coat" or isolated office hypertension in

that their blood pressure is repeatedly normal


when measured at home, at work, or by
ambulatory blood pressure monitoring

This problem is more common in the elderly, but


is infrequent (less than 5 percent) in patients
with office diastolic pressures 105 mmHg

Ambulatory blood pressure monitoring (ABPM),

can be used to confirm or exclude the presence


of white coat hypertension in patients with
persistent office hypertension but normal blood
pressure readings out of the office

Masked hypertension

elevated out-of-office readings despite


normal office readings (eg, masked
hypertension)

Cardiovascular risk appears to be

elevated in such patients to a similar


extent as patients with sustained
hypertension

This is consistent with the risk of

hypertensive cardiovascular
complications being more closely
correlated with 24-hour or daytime
ambulatory monitoring than with the

Ambulatory blood pressure monitoring


(ABPM)

every 15 to 20 minutes during the day

and every 30 to 60 minutes during sleep

Suspected episodic hypertension (eg,


pheochromocytoma)

Hypertension resistant to increasing


medication

Hypotensive symptoms while taking


antihypertensive medications

Autonomic dysfunction

Diagnostic

Once it has been determined that the

patient has persistent hypertension, an


evaluation should be performed to
ascertain the following information:

To determine the extent of target organ


damage.

To assess the patient's overall


cardiovascular risk status.

To rule out identifiable and often


curable causes of hypertension

History

presence of precipitating or aggravating factors

(including prescription medications, nonprescription nonsteroidal antiinflammatory agents,


and alcohol consumption),

Last known normal blood pressure


Course of the blood pressure
Family history
Hypertension
Premature cardiovascular disease or death
Familial diseases: pheochromocytoma, renal
disease, diabetes, gout

History
Presence of other risk factors
Smoking
Diabetes
Dyslipidemia
Physical inactivity
Dietary history
Sodium
Alcohol
Saturated fats
Psychosocial factors

Physical examination

to evaluate for signs of end-organ damage (such as


retinopathy) and for evidence of a cause of
secondary hypertension

Distribution of body fat


Palpation and auscultation of carotids
Heart: size, rhythm, sounds
Lungs: rhonchi, rales
Abdomen: renal masses, bruits over aorta or renal
arteries, femoral pulses

Extremities: peripheral pulses, edema

Laboratory testing

Hematocrit, urinalysis, routine blood

chemistries (glucose, creatinine,


electrolytes), and estimated glomerular
filtration rate

Lipid profile (total and HDL-cholesterol,


triglycerides)

Electrocardiogram
Additional tests maybe indicated in certain
settings:

Microalbuminuria
Echocardiography is indicated to detect

Hypertension
Treatment

Lifestyle modifications
Dietary sodium reduction (2 to 8 mmHg)
no more than 100 meq/day (2.4 g sodium or 6 g
sodium chloride)

Weight reduction (5 to 20 mmHg per 10-kg weight


loss)

diet of increased intake of fruits and vegetables and


low-fat dairy products, can be combined with salt
restriction. (8 to 14 mmHg)

Aerobic exercise: brisk walking (at least 30 minutes


per day, most days of the week) (4 to 9 mmHg)

Limited alcohol intake: no more than 2 drinks per day


in most men and no more than 1 drink per day in
women and lighter-weight persons(2 to 4mmHg)

Drug treatment

there are three main classes of drugs that are


used for initial monotherapy:

thiazide diuretics,
long-acting calcium channel blockers (most

often a dihydropyridine such as amlodipine),

and ACE inhibitors or angiotensin II receptor


blockers

Beta blockers are not commonly used for initial


monotherapy in the absence of a specific
indication

It is the attained blood pressure, not the specific


drug(s) used, which is the primary determinant

Drug treatment

Single agent therapy may not adequately


control the blood pressure, particularly in
those whose blood pressure is more than
20/10 mmHg above goal.

Combination therapy with drugs from

different classes has a substantially


greater blood pressure lowering effect
than doubling the dose of a single agent

long-acting ACE inhibitor or angiotensin


receptor blocker in concert with a longacting dihydropyridine calcium channel

Resistant hypertension

Resistance is usually defined as a diastolic blood


pressure (BP) above 90 mmHg despite intake of
three or more antihypertensive medications
including a diuretic.

Suboptimal therapy
Extracellular volume expansion
Poor compliance with medical or dietary
therapy

Identifiable or secondary hypertension


Office or "white coat" hypertension
Ingestion of substances that can elevate the

Hypertensive emergencies

acute, life-threatening, and usually associated


with marked increases in blood pressure (BP),
generally 180/120 mmHg

Hypertensive encephalopathy
Acute aortic dissection
Acute left ventricular failure
Pheochromocytoma crisis
Eclampsia
Severe epistaxis

Cerebral autoregulation in
hypertension

Clinical manifestations

often occurs in patients with long-standing


uncontrolled hypertension, many of whom
have discontinued antihypertensive
therapy

Neurologic symptoms related to cerebral


edema, insidiousonset of headache,
nausea, and vomiting,

followed by restlessness, confusion, and,


if the hypertension is not treated,
seizures and coma

acute kidney injury, hematuria, and


proteinuria

Treatment

The initial aim of treatment in

hypertensive crises is to rapidly lower the


diastolic pressure to about 100 to 105
mmHg

this goal should be achieved within two to


six hours, with the maximum initial fall in
BP not exceeding 25 percent of the
presenting value

More aggressive hypotensive therapy is

both unnecessary and may reduce the


blood pressure below the autoregulatory
range, possibly leading to ischemic events

Treatment IV

Nitroglycerin: 5-100 g/min as IV infusion


Nitroprusside an arteriolar and venous

dilator, given as an intravenous infusion. I

nitial dose: 0.25 to 0.5 g/kg per min; maximum


dose: 8 to 10 g/kg per min.

Nitroprusside acts within seconds and has a

duration of action of only two to five minutes.


Thus, hypotension can be easily reversed by
temporarily discontinuing the infusion

Labetalol an alpha- and beta-adrenergic


blocker, given as an intravenous bolus or
infusion

Treatment PO

A slower onset of action and an inability to

control the degree of BP reduction has limited


the use of oral antihypertensive agents

useful when there is no rapid access to the


parenteral medications

sublingual nifedipine(10 mg) and sublingual

captopril(25 mg) can substantially lower the BP


within 10 to 30 minutes in many patients

The major risk with these drugs is ischemic


symptoms (eg, angina pectoris, myocardial
infarction, or stroke) due to an excessive and
uncontrolled hypotensive response

Management of severe
preeclampsia

Preeclampsia refers to the new onset of


hypertension and proteinuria after 20
weeks of gestation in a previously
normotensive woman

Systolic blood pressure 140 mmHg


Diastolic blood pressure 90 mmHg
Proteinuria 0.3 grams in a 24-hour
urine specimen

Drugs contraindicated in
pregnancy

Nitroprussideis contraindicated in the later

stages of pregnancy due to possible fetal


cyanide poisoning if used for more than four
hours

Angiotensin converting enzyme (ACE)

inhibitors, angiotensin II receptor blockers


(ARBs) and direct renin inhibitors are
contraindicated at all stages of pregnancy, as
they are associated with significant fetal renal
abnormalities

diuretics has been a source of controversy,

although some data suggest that these agents


can be continued as long as volume depletion

Treatment

The goal of treatment is to prevent

maternal cerebrovascular complications.

initiate antihypertensive therapy in adult

women at systolic pressures >150 mm Hg


and diastolic blood pressures >100 mmHg.

initiate treatment at a lower threshold in


younger women whose baseline blood
pressure was low, and in those with
symptoms that may be attributable to
elevated blood pressure (eg, headache,
visual disturbances, chest discomfort)

Treatment

acute blood pressure therapy, intravenous


labetalolor hydralazine.

Methyldopa (central acting

Alpha2-

adrenergic agonist)

250 mg two to three times daily, increase

every two days as needed, maximum dose


3 g/day

Nifedipine
30 to 60 mg once daily as a sustained
release tablet, increase at 7 to 14 day
intervals, maximum dose 120 mg/day

ABPM

Ambulatory Blood Pressure Monitoring

Monitorizare ambulatorie a TA
discrepan marcat ntre valorile msurate n cabinet
i la domiciliu

valorile crescute n cabinet fara semne de afectare a


organelor int
rezisten la tratamentul medicamentos
evaluarea eficienei tratamentului antihipertensiv
condiii profesionale speciale
135/85 mmHg ziua 140/90 mmHg
120/75 mmHg noaptea 120/80mmHg

ABPM

Ambulatory Blood Pressure Monitoring

60 ani, sex F
Istoric de DZ tip II de 5 ani
Hipertensiune de 9 ani
Hipertrigliceridemie de 3
ani

Microalbuminurie
Examinare fizica :
TA: 152/93 mmHg
Greutate: 87 kg
Circumferinta: 100 cm
IMC: 30 kg/m2

Teste de laborator:
HbA1c: 8,2%
Trigliceride: (253 mg/dl)
Colesterol: (201mg/dl)
Albumina/creatinina: 6,8
Schema de tratament:
Dieta
Metformin 2 x 500 mg
Simvastatin 20 mg
Metoprolol 2 x 50 mg
Perindopril 4 mg