HYPERTENSION
Akhtar Fajar M, MD, FIHA
Department of Cardiology & Vascular Medicine
Faculty of Medicine, University of Hasanuddin
Hypertension: Definition
Persistent elevation of
▪ Systolic blood pressure ≥140 mm Hg
or
▪ Diastolic blood pressure ≥90 mm Hg
• Worldwide an estimated 1 billion people have
hypertension; about 1 in 3 Americans affected
• Direct relationship between hypertension and
cardiovascular disease (CVD)
Prehypertension: Definition
• Systolic blood pressure:
120–139 mm Hg
or
• Diastolic blood pressure:
80–89 mm Hg
Blood Pressure Classification
Category SBP DBP
(mm Hg) (mm Hg)
Normal < 120 < 80
Prehypertension 120–139 80–89
Stage 1 hypertension 140–159 90–99
Stage 2 hypertension > 160 or > 100
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Hypertension
• It is estimated that 1/3 of the general population in
the US have hypertension (Fields et al, 2004)
• Healthy People 2010: reduce the # of persons with
HTN by 14%, increase the control of BP by 68%,
increase the # of adults taking action by weight loss,
activity, low sodium diet by 98% and increase the
proportion of adults measuring their BP by 95%
Hypertension
• Risk of hypertension increases with age; if you don’t
have it by age 55 –— 90% chance of getting it later in
life
• CVD is #1 cause of death in women in US & other
developed areas of world; < 50% of women are aware
of this fact
• Before age 55 hypertension more common in men
and they have MIs
• > 55 yrs, hypertension more common in women and
they have strokes
Factors Influencing
Blood Pressure (BP)
Systemic
Blood = Cardiac x Vascular
Pressure Output
Resistance
Cardiac output is total blood flow through systemic or pulmonary
circulation per min. CO =stroke volume (amt pumped out of
L ventricle per beat [70 ml]) times the HR for 1 min.
SVR + force opposing movement of blood in vessels;
determined primarily by radius of small arteries & arterioles
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Factors Influencing BP
Cardiac
•Heart rate
•Inotropic state
•Neural (pons and medulla)
•Humoral (hormones)
Cardiac Output
Renal Fluid Volume Control
•Renin–angiotensin
•Aldosterone
•Atrial natriuretic factor
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Sympathetic Nervous System
• Baroreceptors
▪ Nerve cells in carotid artery & aortic arch
▪ Maintain BP during normal activities
▪ React to increases & decreases in BP
• BP – impulse to brain to inhibit SNS; HR
& force of contraction; vasodilation of
arterioles
• BP – activates SNS; vasoconstriction of
arterioles; HR & heart contractility
• Increased BP send inhibitory
impulse to sympathetic vasomotor
center in brainstem;
• In long-standing hypertension,
baroreceptors adjust to elevated BP
and reads it as normal; doesn’t make
adjustments; also becomes less
responsive in some older adults
Renin-Angiotensin-Aldosterone System
Mechanism of Action of Aldosterone
Increases CO by increasing blood volume
.
Etiology of Hypertension
• Primary (essential or idiopathic)
hypertension
▪ Elevated BP without an identified
cause
▪ 90% to 95% of all cases
Etiology of Hypertension
• Primary (essential or idiopathic)
hypertension
▪ Contributing factors
• ↑ SNS activity
• ↑ Sodium retaining hormones and
vasoconstrictors
• Diabetes mellitus
• > Ideal body weight
• ↑ Sodium intake
• Excessive alcohol intake
Secondary Hypertension
▪ Elevated BP with a specific cause
• 5% to 10% of adult cases
▪ Contributing factors:
• Coarctation of aorta name given to a congenital condition whereby the aorta
narrows in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts.
• Renal disease
• Endocrine disorders
• Neurologic disorders
• Cirrhosis
• Sleep apnea
▪ If someone under 20 or over 50 suddenly develops
hypertension, esp. severe then suspect secondary cause
Risk Factors for - Primary Hypertension
• Age (>55)
• Alcohol
• Cigarette smoking
• Diabetes mellitus
• Elevated serum lipids
• Excess dietary sodium
• Gender
Risk Factors for - Primary Hypertension
▪ SBP rises with age
▪ Alcohol – excessive use strongly correlated to
hypertension
▪ Smoking – increases risk for CV disease ;
vasoconstriction
▪ Diabetes – along with hypertension greater risk for
target organ disease and usually more severe
▪ Hyperlipidemia elevated in people with hypertension;
increases risk of atherosclerosis
▪ Some pts Na sensitive
▪ Males have higher rates of hypertension <55 and
increased in women>55
Risk Factors for
Primary Hypertension
• Family history
• Obesity
• Ethnicity
• Sedentary lifestyle
• Stress
Pathophysiology of
Primary Hypertension
• Heredity
▪ In most cases, hypertension results from
the interaction of:
• Environmental factors
• Demographic factors
• Genetic factors
Primary Hypertension
• Water and sodium retention
▪ A high sodium intake may result in water
retention
▪ Some people are Na sensitive (about 20%) ;
not everyone with high salt diet develops
hypertension
Pathophysiology of
Primary Hypertension
• Water and sodium retention
▪ Certain demographics are associated
with “salt sensitivity”
• Obesity
• Increasing age
• African American ethnicity
• People with diabetes, renal disease
Pathophysiology of
Primary Hypertension
• Stress and increased SNS activity
▪ Produces increased vasoconstriction
▪ ↑ HR
▪ ↑ Renin release
▪ Angiotensin II causes direct arteriolar
constriction, promotes vascular hypertrophy and
induces aldosterone secretion
Pathophysiology of
Primary Hypertension
• Insulin resistance & hyperinsulinemia
▪ High insulin concentration stimulates SNS
activity and impairs nitric oxide–mediated
vasodilation
▪ Not present in secondary hypertension and
don’t improve when hypertension is treated
Pathophysiology of
Primary Hypertension
• Altered renin–angiotensin mechanism
▪ High plasma renin activity
• Endothelial cell dysfunction
▪ Source of many vasoactive substances
▪ Role of endothelial cell dysfunction in cause and
treatment of hypertension is ongoing
Hypertension
Clinical Manifestations
• Referred to as the “silent killer”
• Frequently asymptomatic until target
organ disease occurs
▪ Or recognized on routine screening
Hypertension
Clinical Manifestations
• Symptoms often secondary to target
organ disease
• Can include:
▪ Fatigue, reduced activity tolerance
▪ Dizziness
▪ Palpitations, angina
▪ Dyspnea
Hypertension
Complications
• Target organ diseases occur most
frequently in:
▪ Heart
▪ Brain
▪ Peripheral vasculature
▪ Kidney
▪ Eyes
Hypertension
Complications
• Hypertensive
heart disease
▪ Coronary artery
disease
▪ Left ventricular
hypertrophy
▪ Heart failure
Increased systemic vascular resistance causes left ventricle to work to
hard; initially increases in size as compensatory mechanism; eventually
becomes too large and requires more oxygen and energy; can’t keep
up with demand and end up with heart failure
Hypertension-Complications
• Cerebrovascular disease : Stroke
• Peripheral vascular disease
• Nephrosclerosis
• Retinal damage
• Atherosclerosis most common cause of cerebrovascular disease;
hypertension major risk factor for cerebral atherosclerosis and stroke
• Atherosclerosis in peripheral blood vessels too; can lead to PVD,
aortic aneurysm, aortic dissection
• Hypertension one of leading causes of end-stage renal disease, esp. in
African-Americans; some degree of renal dysfunction usual in person with
even mild BP elevations
• Retina is only place blood vessels can be directly visualized; if see
damage there then indicates damage in brain, heart, & kidney too; Can
cause blurring, retinal hemorrhage and blindness
Hypertension
Diagnostic Studies
• History and physical examination
• BP measurement in both arms
▪ Use arm with higher reading for subsequent
measurements
▪ BP highest in early morning, lowest at night
Hypertension
Office BP Measurement
• Use auscultatory method with a properly calibrated
instrument
• Patient seated quietly for 5 min in a chair, feet on the floor,
and arm supported at heart level
• Appropriate-sized cuff is necessary to ensure accurate reading
• At least two measurements should be obtained
• Allow at least 1 minute between readings. If one arm higher
than other; take BP in higher arm for subsequent
measurements
Hypertension
Diagnostic Studies
• Urinalysis, creatinine clearance
• Serum electrolytes, glucose
• BUN and serum creatinine
• Serum lipid profile
• ECG
• Echocardiogram
• Know normal lab values! Use your lab book
Hypertension
Diagnostic Studies
• “White coat” phenomenon may precipitate the need
for ambulatory blood pressure monitoring (ABPM)
▪ Noninvasive, fully automated system that measures
BP at preset intervals over a 24-hour period
▪ Also used when suspect drug resistance,
hypotensive symptoms with drug therapy, episodic
hypertension, or SNS dysfunction
Hypertension
Collaborative Care
• Overall goals
▪ Control blood pressure
▪ Reduce CVD risk factors
• Strategies for adherence to regimens
▪ Empathy increases patient trust, motivation,
adherence to therapy
▪ Consider patient’s cultural beliefs, individual
attitudes in formulating treatment goals
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35%–40%
Myocardial infarction 20%–25%
Heart failure 50%
Collaborative Care
Lifestyle Modifications
• Wt. reduction
▪ 10 kg (22 lb) loss; SBP by 5-20 mm Hg
• DASH eating plan (dietary approaches to stop
hypertension)
• Na reduction
▪ <2.4 g of sodium/day
• Moderate alcohol intake
▪ Men: 2 drinks/day or less
▪ Women: 1 drink/day or less
Collaborative Care
Lifestyle Modifications
• Physical activity:
▪ Regular physical (aerobic) activity,
▪ At least 30 min, most days of week
• Avoidance of tobacco products
• Stress management
Collaborative Care HTN
Drug Therapy
• Primary actions
▪ Reduce SVR (afterload)
▪ Reduce volume of circulating blood (preload)
• Classifications
▪ Diuretics
▪ Adrenergic inhibitors
▪ Direct vasodilators
▪ Angiotensin converting enzyme inhibitors
▪ Angiotension receptor blockers
▪ Calcium channel blockers
Treatment Algorithm (JNC 8)
Treatment Algorithm (JNC 8)
Treatment Algorithm (JNC 8)
Treatment Algorithm (JNC 8)
Collaborative Care
Drug Therapy
• Patient teaching
▪ Identify, report, minimize side effects to
enhance compliance
• Orthostatic hypotension
• Sexual dysfunction
• Dry mouth
• Frequent urination
Hypertension in Older Persons
• Isolated systolic hypertension (ISH):
▪ Most common form of hypertension in people
> 50 years of age
• Lifetime risk of developing hypertension:
▪ About 90% for normotensive men and women over age 55
• Reasons for increased BP in elderly:
▪ Loss of elasticity
▪ Increased collagen and stiffness of myocardium
▪ Increased PVR
▪ Decreased adrenergic receptor sensitivity
▪ Blunting of baroreceptor reflexes
▪ Decreased renal function
▪ Decreased renin response to Na/H2O depletion
▪ May have altered drug absorption; delayed metabolism and excretion; be
careful when medicating
Hypertension in Older Persons
• More likely to have “white coat”
hypertension
• Often a wide gap between 1st Korotkoff
sound and subsequent beats called the
auscultatory gap
▪ Failure to inflate the cuff high enough may
result in seriously underestimating the SBP
Hypertension in Older Persons
• Have varying degrees of impaired
baroreceptor reflex mechanisms
• Consequently, orthostatic hypotension
occurs often
▪ Especially in patients with ISH
Hypertensive Crisis
• Severe, abrupt increase in DBP
▪ Defined as >140 mm Hg
• Rate of increase in BP more important than
absolute value
• Often occurs in patients with Hx of HTN who
failed to comply with medications or who have
been undermedicated
• Monitor MAP mean arterial pressure: MAP = (SBP +
2DBP)
3
Hypertensive Crisis
Clinical Manifestations
• Hypertensive emergency = evidence
of acute target organ damage:
▪ Hypertensive encephalopathy, cerebral
hemorrhage
▪ Acute renal failure
▪ Myocardial infarction
▪ Heart failure with pulmonary edema
Hypertensive Emergency
• Develops over hours-days
• BP > 180/120 mm Hg
• Evidence of acute target organ damage, esp. to CNS
▪ Hypertensive encephalopathy
▪ Sx may be similar to stroke, but no focal or lateral
signs
• Can see sudden rise in BP with HA, N&V, SZ,
confusion, stupor & coma; Increased ICP due to edema
• Common to have blurred vision and transient
blindness
• Renal insufficiency to complete shutdown
• Rapid cardiac decompensation; MI, dyspnea
Hypertensive Urgency
• Develops over days to weeks
• BP severely elevated but no evidence of
target organ damage
▪ Usually treat with oral meds as outpatient
Thank You
