Transcript National High Blood Pressure Education Program The Sixth

Hypertension (HT)
High Blood Pressure (HBP)
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Introduction
• Definition: Hypertension is defined as
elevated arterial blood pressure.
• Hypertension is one of the most common
disease in the world
• In our country, 160 million people over the
age of 15 have established or borderline HP
• HP Essential HP (95%) Secondary HP (5%)
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Etiology
• Genetic
• Environment
Dietary: Salt intake
Alcohol intake
Obesity
Infant dysnutrition
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Pathogenesis
1. High activity of the SNS (Sympathetic
Nervous System)
2. RAAS (Renin-Angiotension Aldosterone
System)
3. Renal Sodium Handling
4. Vascular Remodelling
5. Endothelial Cell Dysfunction
6. Insulin Resistance
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The pathological changes of small artery
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The pathological change of the Heart
Left ventricular hypertrophy (LVH)
Heart failure
Coronary artery atherosclerosis
Myocardial infarction
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Pathological change of the Brain
Stroke:
Ischemic stroke
Hemorrhagic stoke
Arterial
Aneurysm
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Pathological change of Renal
Hypertension induced nephrosclerosis,
atrophy of renal cortex
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Clinical Features
• The blood pressure varies widely over
time, depending on many variables,
including SNS activity, posture, state of
hydration, and skeletal muscle tone.
• Symptoms:
Always asymptomatic
Symptoms often attributed to hypertension:
headache, tinnitus, dizziness, fainting
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Clinical Features
• Complications of Hypertension
Heart: LVH, CHD,HF
Brain: TIA, Stroke
Renal: Microalbuminuria, renal dysfunction
Ratinopathy
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Laboratory Examination
• Blood pressure measurement:
Clinic Blood Pressure
Home Blood Pressure
Ambulatory monitoring
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Ambulatory Measurement
• Ambulatory monitoring can provide:
– readings throughout day during usual activities
– readings during sleep to assess nocturnal changes
– measures of SBP and DBP load
– Exclude white coat or office hypertension
• Ambulatory readings are usually lower
than in clinic (hypertension is defined as
> 135/85 mm Hg)
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Laboratory Examination
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Urinalysis
Blood examination
Chest X Ray
EKG
UCG (Ultrasound cardiography)
Retina examination
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The Keith-Wagner Criteria
(change in retina)
KW I: Minimal arteriolar narrowing, irregularity
of the lumen, and increased light reflex
KW II: More marked narrowing and irregularity
with arteriovenous nicking (crossing defects)
KW III: Flame-shaped hemorrhages and exudates in
addition to above arteriolar changes
KW IV: Any of the above with addition of papilledema
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Pepilledema
Flame shaped hemorrhage
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Diagnosis &
Differential Diagnosis
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Classification of blood pressure for adult
Category
Normal
High normal
Hypertension
Stage 1
Stage 2
Stage 3
Systolic HBP
SBP (mmHg)
DBP (mmHg)
< 120
< 80
120-139
80-89
≥140
140-159
160-179
≥180
≥90
90-99
100-109
≥110
≥140
< 90
When the SBP and DBP fall into different categories, use the higher category
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Evaluation Objectives
• To identify cardiovascular risk factors
• To assess presence or absence of target
organ damage
• To identify other causes of hypertension
These evaluation may used in stratification
of the hypertension patients
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Cardiovascular Risk Factors
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Blood pressure
Age
Gender
Dyslipidemia
Abdomen Obesity
Family History of cardiovascular disease
CRP ≥1mg/dl
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Target Organ Damage
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Left ventricular hypertrophy
Echo shows IMT of carotid artery
Plasma creatinine slight elevation
Microalbuminuria
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Associated Clinical Condition
• Cerebrovascular diseases: Stroke, TIA
• Heart diseases: MI, AP, CHF, Coronary
artery revasculation
• Kidney diseases: DN, Dysfunction of the
kidney, Proteinuria, CRF
• Diabetes
• Peripheral artery disease
• Retinopathy
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Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
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Stratification of Hypertension patients
Blood Pressure
risk factors &
Disease History
Grade I
Grade II
Grade III
I . No risk factors
Low risk
Med risk
High risk
II. 1-2 risk factors
Med risk
Med risk
Very high risk
III. 3 or more risk
factors or TOD or
diabetes
IV. ACC
High risk
High risk
Very high risk
Very high risk Very high risk
Very high risk
TOD-Target Organ Damage; ACC-Associated Clinical Conditions
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Differential Diagnosis
Should exclude Secondary Hypertension
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Secondary Hypertension
Common Causes
• Renal
Glomerulonephritis
Pyelonephritis
Obstructive nephropathy
Collagen diseases,
Congenital diseases
Diabetes nephropathy
Renal tumor---- renin secreting tumor
• Pheochromocytoma
• Primary aldosteronism
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Phenochromocytoma
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Ganglion-neurotomas and neuroblastomas
Excretion of large amounts of catecholamines
90% arise in the adrenal medulla
10% are malignant.
Paroxymal or persist HT
Clinic features: Headache, sweating,
palpitations, nervousness, weight loss,
hypermetabolism, orthostatic hypotension,
severe presser response
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Primary Aldosteronism
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Mild or moderate hypertension
Hypokalemia, muscle weakness, paralysis
Polyuria, nocturia and polydipsia,
Hypochloremic alkalosis
Urine aldosterone elevation
Plasma renin active decrease
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Secondary Hypertension
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Obstructive Sleep Apnea (OSA)
Renal artery stenosis
Cushing’s syndrome
Coarctation of the aorta
Drug-induced:
NSAIDs;
Prophylactic;
Mineralocorticoids;
Epogen
Sympathomimetic medications;
Monoamine oxidase inhibitors;
Immuno-inhibitors;
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Therapy
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Goal of Hypertension Management
• < 140/90 mm Hg
• With Diabetes or kidney dysfunction:
<130/80mmHg
– To reduce morbidity and mortality of cerebral
and cardiovascular complications.
– Controlling other cardiovascular risk factors
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Lifestyle Modifications
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Stop smoking
Limit alcohol intake
Lose weight or keep fit
Suitable diet
Increase aerobic physical activity
Decrease psychological stress
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Principle of Drug Therapy
• Drug therapy should be individually
• A low dose of initial drug therapy
• Combination therapies may provide additional
efficacy with fewer adverse effects.
• Optimal formulation should provide 24-hour
efficacy with once-daily dose.
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Antihypertensive Drugs
• Diuretics
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ß-Adrenergic receptor blockers (BB)
Calcium channel blockers (CCB)
ACE inhibitors (ACEI)
Angiotensin II receptor blockers (ARB)
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Algorithm for Treatment of
Hypertension
Hypertension patient
Lifestyle Modifications
Not at Goal Blood Pressure
Initial Drug Choices
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Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices
No associated clinical condition
I stage hypertension:
Diuretics,
BB,CCB,ACEI,ARB
Associated clinical condition
II stage hypertension:
Two drugs
combination therapy
Choice the drugs
according to ACC
Not at Goal Blood Pressure
Increase dosage or add another agent from different class
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Drug choices in hypertension patient
associated with clinical condition
Drug
ACC
Diuretics BB ACEI ARB CCB Antialdosterone
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HF
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MI
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CAD
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DM
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CRF
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Stroke
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Combination Therapies
• May provide additional efficacy with fewer adverse
effects.
• Diuretics as the basement drug in combination therapy.
Diuretics ---- ACEI / ARB
Diuretics ---- BB
Diuretics ---- CCB
• CCB as the basement drug in combination therapy
CCB ---- ACEI
CCB ---- BB
• Others: Three drugs combination
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Causes for Inadequate
Response to Drug Therapy
• Incorrect measurement of the BP
• Volume overload or Pseudo-resistance
• Drug-related causes
• Associated conditions
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Hypertensive crisis
• Hypertensive Emergencies and Urgencies
• Emergencies: The blood pressure is elevated
severely and associated with target organ damage,
such as hypertensive encephalopathy, AMI,
pulmonary edema, require immediate blood
pressure reduction.
• Urgencies: The blood pressure is elevated
severely but no target organ damage has acute
target organ damage.
• Fast-acting drugs are available.
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Drugs Available for
Hypertensive Crisis
Vasodilators
Adrenergic Inhibitors
•Nitroprusside
•Labetalol
•Nicardipine
•Esmolol
•Nitroglycerin
•Phentolamine
•Hydralazine
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Case 1
Male 29 years old
Blood pressure elevated for two years
With paroxysmal dizziness, blurred vision,
sweating and palpitation
BP: 160-180/90-100mmHg
HR: 100-120 bpm
When the patient with symptoms, the BP would
elevate to 240-260/120-130mmHg, and HR
increase to 130-150 bpm.
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Physical examination:
BP: 165/100mmHg
HR: 112 bpm
No positive sign in chest examination
Can find a mass at right abdomen, if press on it the
BP of the patient elevated to 250/120mmHg, and
the HR increased to 145 bpm.
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Laboratory test:
Blood routine, Urinalysis, Blood biochemistry are
normal
Plasma renine activation: 0.93ng/ml.h (0.93-6.56)
AT II: 51.5pg/ml ↓ (55.3-115.3)
Aldosterone: 129.4pd/ml (63-239.6)
NE: 33.40pmol/ml ↑↑ (0.51-3.26)
12-lead electrocardiogram: High voltage of LV
Chest X ray: Normal
slide 47
CT scan of
abdomen:
Found a mass
at right
adrenal
Diagnosis as Phenochromocytoma
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Case 2
Male, 65 years old
Hypertension history for 30 years
Headache, blurred vision, vomiting for 2 hours
Paralysis of left side body
BP: 220/130mmHg
HR: 106 bpm
CT scan of the head: Normal
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Diagnosis: Hypertensive crisis
Therapy: Controlled the BP, using fast-acting
drug，such as Nitroprusside, Labetalol
The reduction of BP should less than 25% in 24
hours
BP ≥ 160/100mmHg in 48 hours
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Summary
• Specific therapy for patients with LVF, CAD, and
HF. ACEI can be used for all type patients.
• In older persons, diuretics and CCB are preferred.
• Many patients need combination therapy.
• Goal of the patients with renal insufficiency with
proteinuria (>1 g/day): 125/75 mmHg;
(< 1 g/day): 130/80 mmHg.
• Patients with diabetes should be treated to a
therapy goal of below 130/80 mm Hg.
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