Hypertension

Yogi PR, MD, FIHA

Outline
• Definition
• Patophysiology
• Diagnose
• Management
• Complication
Hypertension types
1. Primary (or essential) hypertension
• No identifiable cause – most common form and accounts for 95 % of
people with hypertension

2. Secondary hypertension
• Has a known underlying cause :
 Renal disorders (chronic pyelonephritis, diabetic nephropathy)
 Vascular disorders (coarctation of aorta)
 Endocrine disorders (primary hyperaldosteronism)
 Drugs (alcohol, cocaine)
 Miscellaneous causes (scleroderma, Obstructiive sleep apnoea)
Hypertension types
• Hypertension Crisis
Systolic  180 and/or diastolic  120 mmHg

1. Hypertensive urgency
• there is No Target organ damage. Blood pressure can be brought down safely within a
few hours with blood pressure medication

2. Hypertensive emergency
• Hypertensive emergency means blood pressure is so high with target organ damage can
occur. Blood pressure must be reduced immediately to prevent imminent organ damage
Organ damage associated with hypertensive emergency
may include:
• Changes in mental status, such as confusion
• Bleeding into the brain (stroke)
• Heart failure
• Chest pain (unstable angina)
• Fluid in the lungs (pulmonary edema)
• Myocardial infarction
• Aneurysm / aortic dissection
• Eclampsia
Hypertension types
• White coat hypertension, is a phenomenon in which blood pressure
level above the normal range, in a clinical setting, though they do not
exhibit it in other settings.
It is believed that the phenomenon is due to anxiety experienced
during a clinic visit.

• Masked hypertension is defined as a clinical condition in which a

patient's office blood pressure (BP) level is <140/90 mm Hg but
ambulatory or home BP readings are in the hypertensive range.
 Factors inducing Hypertension
• Renin-angiotensin system RAS, RAAS
• Sympathetic nervous system
• Insuline resistance
• Overweight
• Stiff vessel walls (endothelial dysfunction)
• Vasoactive substances (NO, Endotheline)
• Kallikrein secretion
• Natriuretic peptides
 Pathophysiology of Hypertension
prorenine, katecholamines

Angiotensinogene
Reni
Pathway of RAAS in the Organism
n
Pathway of RAAS in the Tissues:
(kidney, heart, Vessels) to maintain
Angiotensin e.g.
I
Fluid volume control, AC Vessel wall
Adjustment of CO and E
Resistance. Angiotensin II
If regulation fails, high blood
pressure occurs Competition of receptors:
AT1 vasoconstriction
AT2 vasodilatation
recept
or

AT AT
1 2
 Angiotensin II Actions
on endothelium and
NO =nitric oxide

AT1 AT2

AT1 stimulation AT2 stimulation

leads to: leads to:

differentiation
growth+
vasoconstricti
vasoactivity vasodilatation
NO inhibition
on NO
Smooth muscle cell
growth
Pathophysiology of Hypertension:
Angiotensin II Effects

synaptic
Brai conduction
n
vasoconstrictio
n

vessel Ang Hear hypertroph

s II t y

constricti
on

AT1 mediated effects Uteru contraction

of Angiotensin II s
Pathophysiology of Hypertension

constrictio
n

vascular
resistance
Endothelial dysfunction causing
hypertension
 Pathophysiology of Hypertension
Heart rate x stroke volume x Peripheral resistance = Blood pressure

n.sympathicus RAAS*

Stress Genetic/Familial Vasoconstriction

social ethnic
familia Hereditary Endothelial
l salt
sensitivity dysfunction
*renine angiotensine
aldosterone system
 Pathophysiology of Hypertension

Conclusion :
Primary Hypertension is a target disease mainly of the RAAS – intima – endothelium
system !

Endothelium is a major player

Screening and diagnosis of hypertension
ABPM (Ambulatory Blood Pressure Monitoring)
and HBPM (Home Blood Pressure Monitoring)
• ABPM provides the average of BP readings over a defined period, usually 24 h.
The device is typically programmed to record BP at 15 - 30 min intervals, and
average BP values are usually provided for daytime, night-time, and 24 h.

• HBPM is the average of all BP readings performed with a semiautomatic,

validated BP monitor, for at least 3 days and preferably for 6-7 consecutive days.
Two measurements should be taken at each measurement session, performed 1-
2 min apart.
WHAT INVESTIGATIONS ARE NECESSARY FOR
PATIENTS WITH HYPERTENSION?

[Investigation for

hypertension mediated organ damage (HMOD)

and compelling indications]

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 COMPELLING INDICATIONS IN HYPERTENSION

 Heart failure

 Post-myocardial infarction

 High coronary disease risk/angina pectoris

 Diabetes

 Chronic kidney disease

 Recurrent stroke prevention

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 Hypertension mediated organ Damage (HMOD)

Organ Organ damage

Heart Left ventricular hypertrophy

Brain Carotid wall thickening (IMT >0.9 mm) or

plaque

Kidney Albuminuria

Vascular Pulse wave velocity

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 Routine tests for Hypertension
Routine tests
Haemoglobin and/or haematocrit
Fasting plasma glucose
Serum total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein
cholesterol
Fasting serum triglycerides
Serum creatinine (with estimation of GFR)
Urine analysis: microscopic examination; urinary protein by dipstick test; test for
microalbuminuria
12-lead ECG
Intima media thickness
Pulse wave velocity

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 Management
LIFESTYLE CHANGES

• Salt restriction to 5–6 g per day

• Moderation of alcohol consumption to no more than 20–30 g of ethanol per

day in men and to no more than 10–20 g of ethanol per day in women

• Increased consumption of vegetables, fruits, and low-fat dairy products

• Reduction of weight to BMI of <23,5 kg/m2 and of waist circumference to

<90 cm in men and <80 cm in women*

• Regular exercise, i.e. at least 30 min of moderate dynamic exercise on 5 to 7

days per week

• Advice to quit smoking

 WHEN SHOULD I
INITIATE DRUG TREATMENT?

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CV risk in hypertension
Initiation of drug treatment
 SHOULD I START DRUG
TREATMENT WITH ONE OR A
COMBINATION OF DRUGS?

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Most hypertensive patients should initiate treatment with a single pill
combination comprising two antihypertensive drugs

EXCEPT

Monotherapy is indicated for:

• Low-risk patients with grade 1 hypertension
• Very high risk patients with high normal BP
• Frail older patients
Preferred drugs for uncomplicated hypertension, DM, Stroke/TIA, PAD, or with HMOD
Hypertension and CKD
Hypertension and CAD
Hypertension and HFrEF
Hypertension and atrial fibrillation
 First objective is to reduce BP to 130-139/80-89 mm Hg
3 months after drug treatment initiation

If tolerated

Age <65 years Age ≥65 years

Target 120-129/70-79 mm Hg Target 130-139/70-79 mm Hg

SBP should not <120 mm Hg

Thank you….