Essential hypertension

1. OPTOM FASLU MUHAMMED
.

2. What is Hypertension
Hypertension is also referred to as high blood
pressure or high BP in common terms
It is a medical condition in which the arterial
blood pressure is elevated.
It is termed as silent killer – Patients
asymptomatic - leads to fatal complications

3. Definition
Greater than 140 mm hg of systolic blood pressure
and
or
more than 90 mm hg of diastolic blood pressure
at least on 2 of 3 occasions while measuring the
pressure.

4. 1. How to measure
blood pressure?

5. Nokolai Korotkoff, 1905
Ascultatory method of
blood pressure measurement

6. How to measure Blood pressure???
Always measure B.P when the patient is completely
relaxed.
The instrument used is mercury
sphygmomanometer .
The cuff of the apparatus should cover up to three –
fourth of his arm.

7. How to measure Blood
pressure???
The tubings must be parallel to arteries of the arm.
You must then inflate it until there is radial pulse
depression.
Then deflate and measure the value.
The sound as korotkoff sound
Details in the video link and audio link
http://www.youtube.com/watch?v=u6saTO8_o2g&feature=related
http://www.thinklabsmedical.com/stethoscope_community/Sound_Library

8. Terms
What is Systolic blood pressure- upper limit of
the pressure at which korotko’s sounds start
appearing ---state of contraction in heart.
Diastolic blood pressure is the lower limit of
sounds heard - state of relaxation in peripheral
blood vessels.

9. Normative values
Systolic-90 mm hg – 120 mm hg.
Diastolic-60 mm hg -80 mm hg.

10. JNC classification
Systolic diastolic interpretation
Less than 120
mm Hg
Less than 80
mm Hg
Normal
120 to 139 80 to 89 Pre hypertensive
140 to 159 90 to 99 Stage 1 Hypertension
More than or
equal to 160
More than or
equal to 100
Stage 2 Hypertension
> 220 > 120 Hypertensive emergency
Source: Joint national committee on cardiovascular diseases 2003

11. Nearly 1 in 3 adults (31%) in the US has hypertension
Fields LE et al. Hypertension. 2004;44:398-404.
Hypertension:
How Big Is the Problem?
At Least 65 Million Americans Require
Treatment for Hypertension

12. Magnitude of problem in India
Prevalence 1 in 3 in urban population among 40 yrs or
more
More than 50% among persons aged 65 or more
India is the capital of Diabetes Mellitus and the
associated HT is > 60%
The prevalence increasing with years

13. Types of Hypertension
The most common cause for Hypertension is
idiopathic and hence if the cause is not known it is
called as primary or essential Hypertension--90%
If it is secondary to other diseases -it is called as
secondary hypertension.-10%

14. Pathophysiology
The main reason is vasoconstriction which occurs due
to sympathetic over-activity
An overactive renin – angiotensin system leads to
vasoconstriction and retention of sodium and water.

15. ESSENTIAL HTN
Benign(chronic)
Rise in B.P is slight to moderate
Complications: heart failure, cerebrovascular accident
or MI
Risk factors

16. Malignant (accelerated)
Rapid & aggressive acceleration
Diastolic pressure in excess of 120 mmHg
Eg: haemorrhages into the retina, pappillo-edema &
progressive renal disease- cardiac failure

17. SECONDARY(ACCELERATED)
Kidney disease: retention of salt and water
Endocrine disorders:
Secretion of excess aldosterone and cortisol
stimulates the retention of excess sodium & water by
the kidneys, raising the Blood volume & pressure

18. Endocrine causes
 Acromegaly - increased secretion of growth
hormone in adults.
Cushings syndrome – increased secretion of
steroid hormone in children and adults .
Pheochromocytoma - tumor of adrenal medulla.
Drug such as corticosteroid and hormones like
estrogen.

19. Renal causes of Hypertension
Glomerulo nephritis-- acute or chronic or / and infective
or non infective.
. Bacterial infection of kidney-chronic pylo-nephritis.
. Polycystic kidney disease – It is a genetic cystic disorder of the
kidney.
Apart from these any renal disease which can cause renal
failure like Diabetes Mellitus will result in secondary hyper
tension.

21. Risk factors
Primary hypertension
Age (older the risk is higher)
Diet (High salt intake/ fatty diet)
Physical activity (sedentary life style)
Alcohol >15ml /day
Obesity----BMI>30
Drugs (steroids, oral contraceptives)
Stress - Chronic job stress
Family history—overcrowding
Ethnic groups- black africans
Males

22. Diagnosis of Hypertension
The gold standard for hypertension is only clinical
measurement using mercury sphygmomanometer
But we need to do investigations to rule out
secondary causes
Better to screen everyone above 40 years every year
and every six months if there is a risk factor

23. Hypertensive at first visit
In the first measurement if there is >220 mm hg of
systolic pressure and >120 mm hg of diastolic pressure
then we can call the patient as hypertensive - an
emergency.

24. Symptoms
No specific symptoms in majority.
weakness
Sub-occipital headache
Restlessness.
Sleepiness.
Dizziness.
Epistaxis– nose bleed

25. TIA = transient ischemic attack; LVH = left ventricular
hypertrophy; CHD = coronary heart disease;
HF = heart failure.
Retinopathy
Renal failure
Peripheral vascular disease
Complications of Hypertension:
LVH, CHD, HF
TIA, stroke
HypertensionHypertension
is a risk factoris a risk factor

26. Complications
• Myocardial infarction (Heart attack) or
coronary artery disease
• Cerebro vascular accident / stroke
• Left ventricular hypertrophy causes cardiac
failure
• Renal failure
• Hypertensive Retinopathy

27. Investigations
• We have to rule out secondary hypertension by
investigating for other diseases.
• Renal – urine microscopy is done to detect the
presence of albumin.
• Presence of RBC, Cast is an indications of
glomerulo- nephritis.
• Excess of WBC indicates kidney infection.
• Renal doppler / technicium scan (nuclear scan) is
done to know about blood supply to the kidney.

29.  Most patients will experience better control if they
modify diet and exercise.
 Physician advice sometimes works and should
always be given along with a follow-up visit
appointment to monitor both blood pressure and
lifestyle change efforts.
 Most of us do not do lifestyle counseling beyond
simple advice and admonishment – the time factor
is a problem.
 Nevertheless, lifestyle modification is at the top of
medical management.

30. Modification
Approximate SBP
reduction (range)
Weight reduction 5-20 mmHg / 10 kg
weight loss
Adopt DASH eating plan 8-14 mmHg
Dietary sodium reduction 2-8 mmHg
Physical activity 4-9 mmHg
Moderation of alcohol
consumption
2-4 mmHg
Benefits of Lifestyle Modification

31. Management of patients
• Diet
• Use <5 gms of salt per day
• Avoid oily food / fatty diet
• Low calorie high fiber diet
• Exercise
• Brisk walking, jogging, Swimming etc…
Avoid smoking & alcohol.

32. Average Percent Reduction
Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%
TROPHY Study ACC 2006: Even lowering BP in those with pre-HTN appears
to reduce incidence of new HTN by up to 60%

33. Drugs For Hypertension
• Usually divided into 4 categories:
• Diuretics
• ACE (Angiotensin converting enzyme) inhibitors and AT
receptor blockers
• Beta blockers
• CCB (calcium channel blockers)
• vasodilators

34. ACE inhibitors
Blocks the conversion of Angiotensin to Renin by inhibiting
angiotensin converting enzyme Eg: Enalapril , Lisinopril.
• Side effects
• Produce dry cough
• Altered taste sensations (dysguesia)

35. AT receptors blocker
• More potent than ACE inhibitors - it blocks the
receptors on which enzymes will act Eg :
Losartan

36. Beta blockers
Beta 1:cardiac selective ( Eg: Atenolol )
Non cardiac selective beta blockers
( Eg:Timolol, Propanalol).
Beta blockers with intrinsic
sympathomimetic activity.

37. Beta Blockers
• Mechanism of action:
• Acts on the beta adrenergic receptors.
Side effects:
• Can precipitate asthma in asthmatics-Beta
receptors are present on the bronchus causing broncho
constriction.
• Decreases the cardiac output as well as the heart
rate.
• Can increase the cholesterol level.
• Can mask hypoglycemia in diabetics

38. Calcium channel blockers(CCB)
Allows peripheral vaso dilatation
Causes decrease in the peripheral vascular
resistance
Very safe during pregnancy
 Eg: Nifidepine, Amlodepine.
Side effect: Postural hypotension, Headache,
Edema, Tachycardia

39. Other drugs
• Diuretics Eg: Thiazide diuretics, Hydro chlor
thiazide
• Alpha blockers: Prazosin
• Vasodilators: Hydralazine and sodium nitroprusside
• Centrally acting drugs: Methyldopa, Arkamine

40. Management of Hypertension
• Depends upon the blood pressure
• If person is pre-hypertensive or stage 1 is – life
style modification should be done first.
• Diet and exercises are first modes to control
mild hypertension
• If Blood pressure is high – Polypharmacy 3 or 4
drugs can be given.

41. Some guidelines for drugs
• If the patient has
• Renal problem – ACE inhibitors
• Diabetes mellitus – ACE inhibitors
• Asthma – ACE inhibitors
• Diabetic / pregnancy – CCB
• Anxiety /hyperthyroidism – Beta blockers

42. Hypertensive emergencies
• They may result in end organ damage e,g., Kidney
retina
• Blood pressure should be reduced fast to prevent
end organ damage. Drugs commonly used are:
• Alpha blockers –Prazosin
• Vasodilators – Sodium nitroprusside / Nitrates
• Alpha + beta blockers – Labatelol
• CCB - Nifedepine

43. Barriers to Controlling
Hypertension
Healthcare
System
Patients Providers

44. The Initial Confrontation of the HTN
Problem
Upon making a diagnosis of HTN, tell patient
the BP reading and what it should be (provide a
written copy).
Prepare patient for the probable necessity for
polypharmacy to control BP with a minimum
of side effects
Advise Home BP measurement (135/85
mmHg is considered to be hypertensive).
Table 28. JNC 7 Report. Hypertension. 2003;42(6):1240.

45. Self-Measurement of BP
 Provides information useful for:
1. assessing response to antihypertensive Rx
2. improving adherence with therapy
3. evaluating white-coat HTN
 Home BP is more strongly related to target
organ damage and has better prognostic
accuracy than office BP.

46. Thank you for your
patience