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Hypertension etiology, clinical features and management
- 1. HYPERTENSION DR MD ASHRAFUDDIN CHOWDHURY FCPS (MEDICINE), MD (CARDIOLOGY), FACP (USA) SHEIKH SAYERA KHATUN MEDICAL COLLEGE, GOPALGANJ.
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- 4. What is hypertension? ļ§The relationship between BP and CV and renal events and mortality is continuous, making the distinction between normotension and hypertension somewhat arbitrary. ļ§ In practice, threshold BP values are used for pragmatic reasons, to simplify the diagnosis and decisions about treatment.
- 5. ļ§ Hypertension isdefined as the level of BP at which the benefits of, unequivocally outweigh the risks of treatment, as documented by clinical trials.
- 6. ļ§ Hypertension isa condition in which arterial pressure is chronically elevated. ļ§ 95% unknown cause- essential hypertension ļ§ Peripheral resistance vessel tone, renal dysfunction, endothelial dysfunction, autonomic tone, neurohumoral factors, insulin resistance
- 7. ļ§ Genetic factorsplays important role ļ§ High salt intake, obesity, alcohol, sedentary life, impaired intrauterine growth contribute ļ§ 5 % of cases- specific disease or abnormality is found.
- 8. Causes of secondary hypertension ļ§Obesity ļ§ Pregnancy (pre-eclampsia) ļ§ Renal disease- ļŗ Renal vascular disease ļŗ Parenchymal renal disease, ie. GN, CRF ļŗ Polycystic kidney disease
- 9. ļ§ Endocrine diseases ļŗPhaechromocytoma ļŗ Cushingās syndrome ļŗ Primary hyperaldosteronism ļŗ Hyperparathyroidism ļŗ acromegaly ļŗ Primary hypothyroidism ļŗ Thyrotoxicosis ļŗ Congenital adrenal hyperplasia ļŗ Liddleās syndrome ļŗ 11 beta hydroxysteroid deficiency
- 10. ļ§ Drugs ļŗ OCP,NSAID, corticosteroids, sympathomimetic agents ļ§ Coarctation of aorta
- 11. How to measureBP ļ§ Rest, no smoking, sitting, arm supported, BP cuff size 2/3rd arm circumference ļ§ White coat hypertension ļ§ Masked hypertension ļ§ Ambulatory and home BP measurement ļ§ 2 times in 1st visit, both arms. ļ§ In elderly- standing BP also.
- 12. Definition of hypertension Category SystolicBP Diastolic BP Optimal Normal High normal <120 <130 130-139 <80 <85 85-89 hypertension Grade 1 mild Grade 2 moderate Grade 3 severe 140-159 160-179 >180 90-99 100-109 >110 Isolated systolic hypertension Grade 1 Grade 2 140-159 >160 <90 <90
- 13. High BP clinicalpractice guideline ACC/AHA 2017 BP category SBP DBP Normal <120 mm Hg and <80 mm Hg Elevated 120-129 mm Hg and <80 mm Hg Hypertension Stage 1 130-139 mm Hg or 80-89 mm Hg Stage 2 ā„140 mm Hg or ā„ 90 mm Hg Individuals with SBP and DBP in2 categories should be designated to the higher BP category. Blood pressure is based on an average of 2 careful readings obtained on ā„ 2 occasions. ā„
- 14. Classification of bloodpressure -European society of cardiology Category Systolic (mm Hg) Diastolic (mm Hg) Optimal <120 and <80 Normal 120-129 and/or 80-84 High normal 130-139 and/or 85-89 Grade 1 hypertension 140-159 and/or 90-99 Grade 2 hypertension 160-179 and/or 100-109 Grade 3 hypertension ā„180 and/or ā„110 Isolated systolic hypertension ā„140 and/or <90
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- 17. Prospective Studies Collaboration,Lancet 2002;360:1903ā13 CV mortality risk 0 2 4 8 115/75 135/85 155/95 175/105 6 SBP/DBP (mmHg) 2X risk 4X risk 8X risk 1X risk Hypertension doubles CV mortality risk
- 20. History ļ§ Family history ļ§Smoking ļ§ Drug history ļ§ Alcohol or drug abuse ļ§ Excess salt intake ļ§ Sedentary life style ļ§ Any complications- chest pain or breathlessness for IHD, edema
- 21. Examination ļ§ Normal inessential hypertension (except BP) ļ§ Radio-femoral delay ā coarctation of aorta ļ§ Enlarged kidney ā PKD ļ§ Renal bruits- RAS ļ§ Cushing facies ļ§ Hypothyroid facies ļ§ Central obesity ļ§ Xanthoma ļ§ Fundoscopy
- 22. Target organ damage ļ§Blood vessel ļŗ Widespread atherosclerosis ļŗ Larger arteries thickened, dilated, tortuous and non compliant ļŗ Smaller arteries lumen narrows, further increase in pressure ļŗ Aortic aneurysm ļŗ Aortic dissection ļŗ Peripheral vascular disease ā claudication pain in legs.
- 23. ļ§ Central nervoussystem ļŗ Stroke- hemorrhage or infarction ļŗ TIA ļŗ Subarachnoid hemorrhage ļŗ Hypertensive encephalopathy ļŗ Papilloedema
- 24. ļ§ Heart ļŗ LVH> CAD ļŗ Arrhythmia āAF ļŗ LVF ļ§ Kidney ļŗ Chronic renal failure
- 25. ļ§ Retina ļŗ Hypertensiveretinopathy ļŗ Central retinal vein thrombosis
- 26. Investigations ļ§ Urine analysis-protein, glucose and blood ļ§ Urea, creatinine & electrolytes ļ§ Glucose ļ§ Cholesterol ļ§ ECG ļ§ Others- according to etiology of htn and target organ damage.
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- 28. Treatment ļ§ Non pharmacological/ lifestyle measures ļŗ Reduce salt intake ļŗ Reduce obesity ļŗ Regular exercise ļŗ Increased consumption of fruits and vegetables ļŗ Diet high in fish and less saturated fat ļŗ Stop smoking
- 29. Non pharmacological interventions ļ§Weight loss is recommended to reduce BP in adults with elevated BP or hypertension who are overweight or obese. ļ§ A heart-healthy diet, such as DASH (dietary approaches to stop hypertension) diet, that facilitates a desirable weight is recommended for adults with elevated BP or hypertension. ļ§ Sodium reduction is recommended for adults with elevated BP or hypertension.
- 30. ļ§ Potassium supplementation,preferably in dietary modification, unless contraindicated. ļ§ Increased physical activity with a structured exercise program is recommended for adults with elevated BP or hypertension. ļ§ Adult men and women with elevated BP or hypertension who currently consume alcohol should be advised to drink no
- 31. Other Non pharmacologicalinterventions (clinical trial experiences less persuasive) ļ§ Consumption of probiotics ļ§ Increased intake of proteins, fibre, flaxseed or fish oil, ļ§ Supplementation with calcium or magnesium, ļ§ Dietary pattern other than the DASH diet, including low carbohydrate and vegetarian diets ļ§ Consumption of garlic, dark chocolates, tea, coffee ļ§ Behavioural therapies, i.e. yoga, meditation etc.
- 32. ļ§ Pharmacological ļŗ Diureticsā thiazides ļŗ ACE inhibitors ļŗ Angiotensin receptor blockers (ARB) ļŗ Calcium channel blockers (CCB) ļŗ Alpha blockers ļŗ Beta blockers
- 33. Oral antihypertensive drugs ā¢Thiazide or thiazide type diuretics- Chlorthalidone, Hydrochlorthiazide, Indapamide, Metolazone ā¢ ACE inhibitors ļ Benazepril, captopril, enlapril, fosinopril, lisinopril, perindopril, ramipril, trandolapril. ļ§ ARBs ļŗ Azilsartan, candesartan, eprosartan, irbesartan, losartan, olmesartan, telmisartan, valsartan. ļ§ CCB ā dihydropyridines ā amlodipine, nifedipine, nicardipine. ļ§ CCB - non dihydropyridines ā verapamil, diltiazem
- 34. ļ§ Diuretics āloop ā furosemide, torsemide, bumetanide ļ§ Diuretics ā potassium sparing ā amiloride, triamterene ļ§ Diuretis ā aldosterone antagonists- spironolactone ļ§ Beta blockers ļ§ Direct renin inhibitors ā Aliskiren ļ§ Alpha -1 blockers- prazosin, terazosin ļ§ Centrally acting drugs- methyl dopa, clonidine ļ§ Direct vasodilators - minoxidil
- 35. 2018 ESC/ESH HypertensionGuidelines Core drug-treatment strategy for uncomplicated hypertension The core algorithm is also appropriate for most patients with HMOD, cerebrovascular disease, diabetes, or PAD Williams, Mancia et al., J Hypertens 2018;36:1953-2041 and Eur Heart J 2018;39:3021-3104
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