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1. (G) HYPERTENSION ... Dr. Diptiman Shukla.pptx
- 1. HYPERTENSION DR ( MAJ) DIPTIMAN SHUKLA PG 1ST YEAR DEPT OF ORTHODONTICS
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- 3. History of Hypertension • Historicalrecords as far back as 2600 B.C. as mention of “hard pulse disease” • First treatments: Leeching/phlebotomy, acupuncture • Hippocrates recommended phlebotomy • 120 AD – cupping of the spine to draw animal spirits down and out was recommended
- 4. Lithograph showing the leechingof a patient, date unknown. National Library of Medicine, Bethesda, Maryland
- 5. Measurement of HTN •No way to measure prior to 1700s • Physicians could estimate by feeling pulse
- 6. Measurement of HTN • 1733– Reverend Stephen Hales measured the intra- arterial BP of a horse
- 7. • 1905 –N.C. Korotkoff reported on the method of auscultation of brachial artery, the method which is widely used today • Allowed auscultation of diastolic BP as well
- 9. Factors Influencing Blood Pressure BloodPressure = Cardiac Output x Systemic Vascular Resistance
- 10. Factors Influencing BP •HR • SNS/PNS • Vasoconstriction/vasodilation • Fluid volume – Renin-angiotensin – Aldosterone – ADH
- 11. Hypertension Definition • Hypertension issustained elevation of BP – Systolic blood pressure 140 mm Hg – Diastolic blood pressure 90 mm Hg
- 12. Classification (JNC7) Systolic pressure Diastolicpressure mmHg mmHg Normal 90–119 60–79 High normal or prehypertension 120–139 80–89 Stage 1 hypertension 140–159 90–99 Stage 2 hypertension ≥160 ≥100 Isolated systolic ≥140 <90
- 13. Accurate BP measurement •Who checks your patients BP? – You or Staff • Staff – Do they know what to listen for or do they use automated equipment – Seated quietly for 5 minutes – Appropriate size cuff – Inflate 20-30 mmHg above loss of radial pulse – Deflate at 2mmHg per second – 1st sound SBP ; Disappearance of Korotkoff sound (phase 5) is DBP – Confirm Elevated blood pressure within 2months(stage 1) – shorter for stage 2 if new onset
- 14. Hypertension • For personsover age 50, SBP is more important than DBP as a CVD risk factor • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range
- 15. Classification of Hypertension •Primary (Essential) Hypertension - Elevated BP with unknown cause - 90% to 95% of all cases • Secondary Hypertension - Elevated BP with a specific cause - 5% to 10% in adults
- 16. Classification of Hypertension •Primary Hypertension - Contributing factors: • SNS activity • Diabetes mellitus • Sodium intake • Excessive alcohol intake
- 17. Classification of Hypertension •Secondary Hypertension - Contributing factors: • Coarctation of aorta • Renal disease • Endocrine disorders • Neurologic disorders - Rx: Treat underlying cause
- 18. Risk Factors forPrimary Hypertension • Age (> 55 for men; > 65 for women) • Alcohol • Cigarette smoking • Diabetes mellitus • Elevated serum lipids • Excess dietary sodium • Gender
- 19. Risk Factors forPrimary Hypertension • Family history • Obesity (BMI > 30) • Ethnicity (African Americans) • Sedentary lifestyle • Socioeconomic status • Stress
- 20. Hypertension Clinical Manifestations • Frequentlyasymptomatic until severe and target organ disease has occurred – Fatigue, reduced activity tolerance – Dizziness – Palpitations, angina – Dyspnea
- 21. Hypertension: Complications • Complicationsare primarily related to development of atherosclerosis (“hardening of arteries”), or fatty deposits that harden with age
- 22. Hypertension Complications The common complicationsare target organ diseases occurring in the Heart Brain Kidney Eyes
- 23. Hypertension Complications Hypertensive Heart Disease •Coronary artery disease • Left ventricular hypertrophy • Heart failure
- 24. Hypertension Complications Cerebrovascular Disease •Stroke Peripheral Vascular Disease Nephrosclerosis Retinal Damage
- 27. Malignant Hypertension B.P >200/140 With evidence of retinal vascular damage (dot and blot hemorrhages ) and papillary oedema
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- 30. Hypertension Diagnosis • Diagnosis requiresseveral elevated readings over several weeks (unless > 180/110) • BP measurement in both arms - Use arm with higher reading for subsequent measurements
- 31. Hypertension Diagnosis • Ambulatory BPMonitoring – For “white coat” phenomenon, hypotensive or hypertensive episodes, apparent drug resistance
- 32. Treatment Goals • Goalis to reduce overall cardiovascular risk factors and control BP by the least intrusive means possible – BP < 140/90 – In patients with diabetes or renal disease, goal is < 130/80
- 33. Benefits of LoweringBP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
- 36. Hypertension Collaborative Care • LifestyleModifications - Weight reduction - Dietary changes (DASH diet) - Limitation of alcohol intake (< 2 drinks/day for men; < 1/day for women) - Regular physical activity - Avoidance of tobacco use - Stress management
- 37. Hypertension Collaborative Care • NutritionalTherapy: DASH Diet = Dietary Approahes to Stop HTN - Sodium restriction - Rich in vegetables, fruit, and nonfat dairy products - Calorie restriction if overweight
- 41. Table 3. LifestyleModifications to Manage Hypertension*
- 42. Hypertension Collaborative Care • DrugTherapy - Reduce SVR - Decrease volume of circulating blood
- 43. Hypertension Collaborative Care • DrugTherapy • Diuretics • Adrenergic inhibitors • β - Adrenergic blockers • ACE Inhibitors • Calcium channel blockers
- 44. Hypertension: Drug Therapy •Thiazide-type Diuretics • ( hydrochlorothiazide,metolazone) – Inhibit NaCl reabsorption – Side effects: • Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K** (advise K rich foods) • Fluid volume depletion (monitor for orthostatic hypotension) • Impotence, decreased libido
- 45. Hypertension: Drug Therapy •Adrenergic Inhibitors • ( prazosin,terazosin) – Reduce sympathetic effects that cause HTN by: • Reducing sympathetic outflow • Blocking effects of sympathetic activity on vessels – Side effects • Postural Hypotension • Varied, depending on specific drug
- 46. Hypertension: Drug Therapy •β – adrenergic blockers (suffix “olol”) – (metoprolol, propranolol) – Block β – adrenergic receptors • ↓ HR, ↓ inotropy, reduces sympathetic vasoconstriction) – Side effects • Bradycardia, hypotension, heart failure, impotence
- 47. Hypertension: Drug Therapy •ACE Inhibitors (suffix “pril) – Enalapril, captopril – Prevents conversion of angiotensin I to angiotensin II, thereby preventing the vasoconstriction associate with A II. – Side effects • Hypotension, cough
- 48. Hypertension: Drug Therapy •Calcium Channel Blockers • ( amlodipine,nifedipine) – Block movement of calcium into cells, causing vasodilation – Side effects • Bradycardia, heart block
- 49. Algorithm for Treatmentof Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
- 50. Hypertensive Crisis Clinical Manifestations - Hypertensiveencephalopathy (H/A, N & V, seizures, confusion, coma) - Renal insufficiency - Heart failure - Pulmonary edema
- 51. Hypertensive Crisis Collaborative Management Hospitalization - IVdrug therapy - Monitor cardiac and renal function - Neurologic checks - Determine cause - Education to avoid future crises
- 53. This is notthe end…
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- 55. How to PreventHTN Lifestyle modifications prevent HTN and include: Maintaining a Healthy Weight Reduce Salt/Sodium Intake Increase Physical Exercise Smoking Cessation Limit Alcohol Consumption Limit Fat Intake Control Diabetes Stress Relieving Techniques