Arterial hypertensionsArterial hypertensions. . Hypertonic diseaseHypertonic disease. . Hypertonic crisisHypertonic crisis. .

Ethiology. Clinical pattern. Ethiology. Clinical pattern. Daignostics. Principles of Daignostics. Principles of

treatmenttreatment

N. BilkevychN. Bilkevych

Arterial hypertension is defined as Arterial hypertension is defined as rising of arterial blood pressure rising of arterial blood pressure excess of 140 mm Hg systolic one excess of 140 mm Hg systolic one (SBP), and/or excess of 90 mm Hg (SBP), and/or excess of 90 mm Hg diastolic blood pressure (DBP). diastolic blood pressure (DBP). Recommendations from the Joint Recommendations from the Joint National Committee on the National Committee on the Prevention, Detection, Evaluation Prevention, Detection, Evaluation and treatment of High Blood Pressure and treatment of High Blood Pressure (JNC-VI report) now regard a BP of (JNC-VI report) now regard a BP of 140/90 mm Hg as high normal and 140/90 mm Hg as high normal and 130/85 mm Hg as normal.130/85 mm Hg as normal.

EpidemiologyEpidemiology

Hypertension is one among the most Hypertension is one among the most wide-spread among all cardiovascular wide-spread among all cardiovascular diseasesdiseases..

15 – 25 % 15 – 25 % of people in the population of people in the population have hypertension have hypertension + 15 % + 15 % have have bordeline hypertensionbordeline hypertension..

Primary hypertensionPrimary hypertension occupiesoccupies 80 – 95 80 – 95 % % of all arterial hypertensions and 1of all arterial hypertensions and 10 % 0 % of them are secondary hypertensions.of them are secondary hypertensions.

Поширеність основних серцево-судинних захворювань в Україні

16%28%

41%

15%

ЦВЗ - цереброваскулярні захворювання ІХС - ішемічна хвороба серця

ГХ - гіпертонічна хвороба

Essential, primary, or idiopathic Essential, primary, or idiopathic hypertension is defined as high BP in hypertension is defined as high BP in which secondary causes forms are not which secondary causes forms are not

presentpresent

Aetiology and pathogenesis:Aetiology and pathogenesis: Overstrain of the central nervous system Overstrain of the central nervous system nervous-functional disorder in regulation of nervous-functional disorder in regulation of

the vascular tone the vascular tone vegetative-endocrine disorders and changes vegetative-endocrine disorders and changes

in the renal regulation of the vascular tonein the renal regulation of the vascular tone vasopressor adrenal reaction by which vasopressor adrenal reaction by which

arterioles of internal organs are narrowed arterioles of internal organs are narrowed production of rennin, stimulation of rennin-production of rennin, stimulation of rennin-

angiotensin system and systemic angiotensin system and systemic vasodilatationvasodilatation

activation of aldosterone secretion.activation of aldosterone secretion.

Pathogenesis Pathogenesis of AHof AH

Risk-factorsRisk-factorsNon-modified Age Genetics and family history Sex( male or female) Family and personal history of hyperlipidaemia Family and personal history of diabetes Race

Modified Cigarette smoking, alkohol Environment (stress, sedentary lifestyle) Weight (obesity and metabolic syndrome) Dietary habits (high alcohol intake, high sodium intake, low

potassium intake) Hypodinamia Personality

An assessment of dietary and lifestyle An assessment of dietary and lifestyle factors is important. Excessive alcohol factors is important. Excessive alcohol use (more than three or four drinks per use (more than three or four drinks per day) and a high sodium intake day) and a high sodium intake (typically defined by a urinary sodium (typically defined by a urinary sodium excretion of more than 150 mmol per excretion of more than 150 mmol per day) may contribute to resistant day) may contribute to resistant hypertension; the frequency of salt hypertension; the frequency of salt sensitivity is increased among patients sensitivity is increased among patients who are at least 60 years of age, who are at least 60 years of age, patients who are black or obese, and patients who are black or obese, and patients with renal impairment.patients with renal impairment.

ClassificationClassification According to According to

blood pressureblood pressure::- - normalnormal: : SBPSBP << 130 130

andand DBPDBP << 90 90 mm mm of Hgof Hg. .

- - Bordeline Bordeline hypertensionhypertension: : SBPSBP = 140-160 = 140-160 andand DBPDBP = 90-95 = 90-95 mm of Hgmm of Hg;;

- Arterial Arterial hypertension:hypertension: SBPSBP >> 1 1660 0 andand DBPDBP >> 9955 mm of Hgmm of Hg. .

SBPSBP DBPDBP

OptimalOptimal <120<120 <80<80

NormalNormal <130<130 <85<85

High High normalnormal

130-139130-139 85-8985-89

HyperteHypertensionnsion

I (mild)I (mild) 140-159140-159 90-9990-99

II(moderaII(moderate)te)

160-179160-179 100-109100-109

III III (severe)(severe)

>180>180 >110>110

Isolated Isolated systolicsystolic

>140>140 <90<90

WHPO classification of arterial WHPO classification of arterial hypertension (1993)hypertension (1993)

Stage I – no evident signs of target organ Stage I – no evident signs of target organ damagedamage

Stage II – presence of at least one of the Stage II – presence of at least one of the following signs of target organ damage:following signs of target organ damage:

Heart:Heart: LVH (diagnosed radiologically, on ECG or by Echocardiography) LVH (diagnosed radiologically, on ECG or by Echocardiography) Retina:Retina: generalized or focal narrowing of retinal arteries generalized or focal narrowing of retinal arteries Kidney:Kidney: microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) microalbuminurua, proteinuria, creatinine<2mg/dl (176 µmol/l) Vessels:Vessels: increased IMT or plaques in carotid, iliac, or femoral arteries increased IMT or plaques in carotid, iliac, or femoral arteries

• Stage III – signs of severe target organ damage:Stage III – signs of severe target organ damage:

Heart:Heart: angina pectoris, myocardial infarction, heart failure angina pectoris, myocardial infarction, heart failure Brain:Brain: stroke, TIA, vascular dementia stroke, TIA, vascular dementia Retina:Retina: haemorrhages, exudates, papilloedema haemorrhages, exudates, papilloedema Kidney:Kidney: renal insufficiency (creatinine>2mg/ml) renal insufficiency (creatinine>2mg/ml) Vessels:Vessels: dissecting aortic aneurysm, symptomatic occlusive peripheral dissecting aortic aneurysm, symptomatic occlusive peripheral

arterial diseasearterial disease

Past medical historyPast medical history

1.1. Duration and previous level of high BPDuration and previous level of high BP2.2. Indications of secondary hypertensionIndications of secondary hypertension Family history of renal disease (polycystic kidney)Family history of renal disease (polycystic kidney) Renal disease, UTI, haematuria, analgesic abuse (parenchymal Renal disease, UTI, haematuria, analgesic abuse (parenchymal

renal disease)renal disease) Drug/substance intake: oral contraceptives, liquorice, nasal Drug/substance intake: oral contraceptives, liquorice, nasal

drops, cocaine, steroids, NSAID’s, erythropoietin, cyclosporindrops, cocaine, steroids, NSAID’s, erythropoietin, cyclosporin Episodes of sweating, headache, anxiety, palpitation Episodes of sweating, headache, anxiety, palpitation

(phaeochromocytoma)(phaeochromocytoma) Episodes of muscle weakness (aldosteronism)Episodes of muscle weakness (aldosteronism)3.3. Risk factorsRisk factors4.4. Symptoms of organ damageSymptoms of organ damage5.5. Previous antihypertensive therapy Previous antihypertensive therapy (drugs used, efficacy, (drugs used, efficacy,

adverse effects)adverse effects)

6.6. Personal, family, environmental factorsPersonal, family, environmental factors

Clinical manifestationClinical manifestation The main objective sign The main objective sign

of the disease is elevated of the disease is elevated arterial pressure (over arterial pressure (over 140/90 mm Hg) . Blood 140/90 mm Hg) . Blood pressure is liable in early pressure is liable in early stage of the disease but stage of the disease but later stabilizes. later stabilizes.

Manifestation of Manifestation of hypertension hypertension depends ondepends on::

Course of the Course of the diseasedisease

Its stageIts stage;; Presence of Presence of

complications and complications and crisescrises;;

Pathogenetic variantPathogenetic variant ((benign and maligantbenign and maligant).).

I stageI stageComplaintsComplaints:: may be abcentmay be abcent patients would usually complain of neurotic patients would usually complain of neurotic

disorders: general weakness, impaired work disorders: general weakness, impaired work capacity, inability to concentrate during work, capacity, inability to concentrate during work, deranged sleep, trancient headache, e feeling of deranged sleep, trancient headache, e feeling of heaviness in the heart, vertigo, noise in the ears, heaviness in the heart, vertigo, noise in the ears, and sometimes palpitation, hain in heart region. and sometimes palpitation, hain in heart region. Exertional dyspnoea develops later.Exertional dyspnoea develops later.

Data of objective examinationData of objective examination Signs if lesions of internal organs are abcentSigns if lesions of internal organs are abcent Stable or trancient elevation of BPStable or trancient elevation of BP

II stageII stageComplaintsComplaints headacheheadache DizzinessDizziness Pain in heart regionPain in heart region Exertional dyspnoeaExertional dyspnoea Presence of hpertonic crisesPresence of hpertonic crises Data of obyective examinationData of obyective examination : : rddness of skin, sweatingrddness of skin, sweating, , decreased decreased

tolerance to physical loadtolerance to physical load.. PalpationPalpation: : PsPs – – firm and tensefirm and tense, , fastfast. . AApex beatpex beat is is expanded and expanded and

displaced leftward and downwarddisplaced leftward and downward.. PercussionPercussion: : widened vascular bundle, displacement of the left border of widened vascular bundle, displacement of the left border of

relative cardiac dullnessrelative cardiac dullness.. AuscultationAuscultation: : The second heart sound is accentuated over the aorta. The second heart sound is accentuated over the aorta.

Systolic murmur over heart apexSystolic murmur over heart apex

There are signs of internal ograns without functional disordersThere are signs of internal ograns without functional disorders:: Hypertrophty of the left ventricle (according to data of ECG and X-ray, Hypertrophty of the left ventricle (according to data of ECG and X-ray,

ultrasound examination)ultrasound examination).. Generalized or focal narrowing of retinal vesselsGeneralized or focal narrowing of retinal vessels.. MicroalbumiuriaMicroalbumiuria, , proteinuria andproteinuria and//ormild elevation of blood plasma creatininormild elevation of blood plasma creatinin

((up toup to 177 177 mkmmkm//ll).).

III stageIII stage

HighHigh, , stable elevation of BPstable elevation of BPDevelopment of complicationsDevelopment of complications::- Myocardial infarctionMyocardial infarction- Heart failureHeart failure- InsultInsult- Trancient ischemic attackTrancient ischemic attack- Retinal hemorrhageRetinal hemorrhage- Dissecting aortic aneurismDissecting aortic aneurism

The set if obvious The set if obvious examinations:examinations:

Complete blood countComplete blood count;; Urinalyses;Urinalyses;- - Biochemical blood serum testsBiochemical blood serum tests;;- Urine analyses ny Nechyporenco and Urine analyses ny Nechyporenco and

ZymnitskyZymnitsky;;- - ECGECG, , ultrasound of a heartultrasound of a heart;;- - ultrasound of kidneysultrasound of kidneys;;- - chestchest X-rayX-ray;;- - OphthalmoskopyOphthalmoskopy..

Complete blood count and Complete blood count and biochemical lab testsbiochemical lab tests::

- - In I stage there are no changesIn I stage there are no changes;;- During crisisDuring crisis – – trancient trancient

leucocitosisleucocitosis, , dys- and dys- and hyperlipidemiahyperlipidemia, , elevated level of elevated level of K+K+, , creatinin and ureacreatinin and urea

In III stage – stable changes, In III stage – stable changes, azotaemia.azotaemia.

Examination of urineExamination of urine::- In III stage isohyposthenuria, In III stage isohyposthenuria,

nicturianicturia

ECGECG

І І stst. – . – specific signs are abcentspecific signs are abcent..ІІ – ІІІ ІІ – ІІІ stst . – . – hypertrophy of the hypertrophy of the

left ventricle, heart electrical left ventricle, heart electrical axis is deviated leftwardaxis is deviated leftward, ,

RvRv5-65-6>Rv>Rv44, , elevation of STelevation of ST, , biphasic biphasic Т (+-)Т (+-)

Increased amplitude of RIncreased amplitude of R in left in left leads and Sleads and S - - in right leadsin right leads..

ECG in hypertrophy of the left ventricleECG in hypertrophy of the left ventricle

Ultrasoung examination of hypertensive heart (B- Ultrasoung examination of hypertensive heart (B- and M-modesand M-modes))

Left-ventricular hypretrophy on Left-ventricular hypretrophy on X-rayX-ray

Symptoms of organs damageSymptoms of organs damage Heart:Heart: palpitations, chest pain, shortness of breath, swollen ankles palpitations, chest pain, shortness of breath, swollen ankles

Brain and eyes:Brain and eyes: headaches, vertigo, impaired vision, TIA’s, sensory or headaches, vertigo, impaired vision, TIA’s, sensory or motor deficitmotor deficit

Kidney:Kidney: thirst, polyuria, nocturia, haematuria thirst, polyuria, nocturia, haematuria

Peripheral arteries:Peripheral arteries: cold extremities, intermittent claudication cold extremities, intermittent claudication Brain: Brain: murmurs over neck arteries, motor or sensory deficitsmurmurs over neck arteries, motor or sensory deficits

Eyes:Eyes: funduscopic abnormalities funduscopic abnormalities

Heart:Heart: location and characteristics of apical impulse, abnormal cardiac location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, peripheral oedemarhythms, ventricular gallop, pulmonary rales, peripheral oedema

Peripheral arteries:Peripheral arteries: absence, reduction, or asymmetry of pulses, cold absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesionsextremities, ischaemic skin lesions

Damage to internal organsDamage to internal organs The adverse effects of hypertension principally involve the The adverse effects of hypertension principally involve the

blood vessels, the central nervous system, the retina, the blood vessels, the central nervous system, the retina, the heart and the kidneys, and can often be detected by heart and the kidneys, and can often be detected by simple clinical means.simple clinical means.

Blood vesselsBlood vessels In larger arteries (over 1 mm in diameter) the internal In larger arteries (over 1 mm in diameter) the internal

elastic lamina is thickened, smooth muscle is elastic lamina is thickened, smooth muscle is hypertrophied and fibrous tissue is deposited. The vessels hypertrophied and fibrous tissue is deposited. The vessels dilate and become tortuous and their walls become less dilate and become tortuous and their walls become less compliant.compliant.

Central nervous systemCentral nervous system Stroke is a common complication of hypertension and may Stroke is a common complication of hypertension and may

be due to cerebral haemorrhage or cerebral infarction. be due to cerebral haemorrhage or cerebral infarction. Hypertensive encephalopathy is a rare condition Hypertensive encephalopathy is a rare condition characterised by high blood pressure and neurological characterised by high blood pressure and neurological symptoms, including transient disturbances of speech or symptoms, including transient disturbances of speech or vision, paraesthesiae, disorientation, fits and loss of vision, paraesthesiae, disorientation, fits and loss of consciousness.consciousness.

KidneysKidneys Long-standing hypertension may cause proteinuria and Long-standing hypertension may cause proteinuria and

progressive renal failure by damaging the renal progressive renal failure by damaging the renal vasculature.vasculature.

HYPERTENSIVE RETINOPATHYHYPERTENSIVE RETINOPATHY

I degree: Arteriolar I degree: Arteriolar thickening, tortuosity thickening, tortuosity and increased and increased reflectiveness ('silver reflectiveness ('silver wiring') II degree: plus wiring') II degree: plus constriction of veins at constriction of veins at arterial crossings arterial crossings ('arteriovenous ('arteriovenous nipping') III degree: nipping') III degree: plus evidence of retinal plus evidence of retinal ischaemia (flame-ischaemia (flame-shaped or blot shaped or blot haemorrhages and haemorrhages and 'cotton wool' exudates) 'cotton wool' exudates) IV degree: plus IV degree: plus papilloedema papilloedema

Hypertensive retinopatyHypertensive retinopaty

HeartHeart The excess cardiac mortality The excess cardiac mortality and morbidity associated with and morbidity associated with hypertension is largely due to hypertension is largely due to a higher incidence of a higher incidence of coronary artery disease. High coronary artery disease. High blood pressure places a blood pressure places a pressure load on the heart pressure load on the heart and may lead to left and may lead to left ventricular hypertrophy with ventricular hypertrophy with a forceful apex beat and a forceful apex beat and fourth heart sound.fourth heart sound.

Atrial fibrillation is common Atrial fibrillation is common and may be due to diastolic and may be due to diastolic dysfunction caused by left dysfunction caused by left ventricular hypertrophy or the ventricular hypertrophy or the effects of coronary artery effects of coronary artery disease.disease.

Severe hypertension can Severe hypertension can cause left ventricular failure cause left ventricular failure in the absence of coronary in the absence of coronary artery disease, particularly artery disease, particularly when renal function, and when renal function, and therefore sodium excretion, is therefore sodium excretion, is impaired.impaired.

Secondary hypertensionSecondary hypertension CAUSES OF SECONDARY HYPERTENSIONCAUSES OF SECONDARY HYPERTENSION

AlcoholAlcohol Pregnancy (pre-eclampsia)Pregnancy (pre-eclampsia) Renal disease Renal disease • • Renal vascular diseaseRenal vascular disease • • Parenchymal renal Parenchymal renal

disease, particularly disease, particularly glomerulonephritisglomerulonephritis

• • Polycystic kidney diseasePolycystic kidney disease Endocrine disease Endocrine disease PhaeochromocytomaPhaeochromocytoma

Cushing's syndromeCushing's syndrome Primary Primary

hyperaldosteronism hyperaldosteronism (Conn's syndrome)(Conn's syndrome)

HyperparathyroidismHyperparathyroidism AcromegalyAcromegaly Primary hypothyroidismPrimary hypothyroidism ThyrotoxicosisThyrotoxicosis Congenital adrenal Congenital adrenal

hyperplasia due to 11 -p-hyperplasia due to 11 -p-hydroxylase orhydroxylase or

17-hydroxylase deficiency17-hydroxylase deficiency

Classification of secondary Classification of secondary hypertensionhypertension

Renoparenchimatous (pyelonephritis, Renoparenchimatous (pyelonephritis, glomerulonephritis) or renovascular (renal glomerulonephritis) or renovascular (renal artery stenosis) diseaseartery stenosis) disease

Endocrine disease (Phaeochomocytoma, Endocrine disease (Phaeochomocytoma, Cusings syndrome, Conn’s syndrome, Cusings syndrome, Conn’s syndrome, Acromegaly and hypothyroidism etc.)Acromegaly and hypothyroidism etc.)

Due to disorders of emodynamics (coarctation Due to disorders of emodynamics (coarctation of the aorta, heart valvular diseases, of the aorta, heart valvular diseases, atherosclerosisatherosclerosis))

Neurogenic (brain commotion, tumor etc.)Neurogenic (brain commotion, tumor etc.)

Induced by exogenic factors (noise, heat etc.)Induced by exogenic factors (noise, heat etc.) Complication of pregnancyComplication of pregnancy Iatrogenic:Iatrogenic:

hypertensions induces by surgical treatmenthypertensions induces by surgical treatment Hormonal / oral contraceptive, corticosteroids etc.Hormonal / oral contraceptive, corticosteroids etc.

Differential features of Differential features of symptomatic hypertensionsymptomatic hypertension

Age less thanAge less than 20 20 years or more than years or more than 60; 60; quick elevation of BP and its stable high quick elevation of BP and its stable high

levellevel very high BPvery high BP ( (> 220/120 mm of Hg)> 220/120 mm of Hg);; - - malignant course of hypertensionmalignant course of hypertension;; - - sympathoadrenal crisessympathoadrenal crisesееss;; - - renal diseases in anamnesisrenal diseases in anamnesis;; - - development of hypertension during development of hypertension during

pregnancypregnancy;; - - appearance of changes in patient’s urineappearance of changes in patient’s urine..

Features of secondary hypentensionsFeatures of secondary hypentensions RenoparenchimatousRenoparenchimatous: : - - acute and chronic acute and chronic pyelonephritis, pyelonephritis,

glomerulonephritisglomerulonephritis - - nephritis in collagenosesnephritis in collagenoses ( (endarteriiris nodosaendarteriiris nodosa, , lupus lupus

erytematodus, scleroderma etcerytematodus, scleroderma etc);); - - Development of AH is possible in unilateral lesionDevelopment of AH is possible in unilateral lesion

((nephrolothiasisnephrolothiasis, , hydronephrishydronephris,, cancer) cancer)Special appention is paid for anamnesis and data of objective Special appention is paid for anamnesis and data of objective

examinationexamination Endocrine hypertensionEndocrine hypertension Develops in Develops in 2- 3 % 2- 3 % of casesof cases.. They are combined withThey are combined with::- Sympathoadrenal crisesSympathoadrenal crises;;- myastheniamyasthenia;;- changes in urinechanges in urine;;- abecityabecity;;- thyrotoxicosisthyrotoxicosis..

Hemodynamic hypertensionsHemodynamic hypertensions

Are combined with dieases of heart and Are combined with dieases of heart and vesselsvessels. . Main causesMain causes::

- Atherosclerosis of aortaAtherosclerosis of aorta; ; coarctation of coarctation of aortaaorta, , aortal incompetenceaortal incompetence, , open aortal open aortal ductduct;;

- Complete AV blockComplete AV block;;- erhthraemiaerhthraemia,,- Bronchial asthmaBronchial asthma;;- Heart failureHeart failure

There AH are easly diagnosed whe the There AH are easly diagnosed whe the patient is exemined completelypatient is exemined completely..

Hypertensive crisisHypertensive crisis Essential hypertension is characterized by periodically Essential hypertension is characterized by periodically

recurring trancient elevations of arterial pressure recurring trancient elevations of arterial pressure (hypertensive crisis). Development of such crises is preceded (hypertensive crisis). Development of such crises is preceded by psychic traumas, nervous overstrain, variations in by psychic traumas, nervous overstrain, variations in atmospheric pressure, etc.atmospheric pressure, etc.

Hypertensive crisis develops with a sudden elevation of the Hypertensive crisis develops with a sudden elevation of the arterial pressure that can persist from a few hours to several arterial pressure that can persist from a few hours to several days. The crisis is manifested by sharp headache, feeling of days. The crisis is manifested by sharp headache, feeling of heat, perspiration, palpitation, giddiness, piercing pain in the heat, perspiration, palpitation, giddiness, piercing pain in the heart, sometimes by deranged vision, nausea, aid vomiting. In heart, sometimes by deranged vision, nausea, aid vomiting. In severe crisis, the patient may lose consciousness. The patient severe crisis, the patient may lose consciousness. The patient is excited, haunted by fears, or is indifferent, somnolent, and is excited, haunted by fears, or is indifferent, somnolent, and inhibited. Auscultation of the heart reveals accentuated second inhibited. Auscultation of the heart reveals accentuated second sound over the aorta, and also tachycardia. The pulse is sound over the aorta, and also tachycardia. The pulse is accelerated but can remain unchanged or even decelerated; accelerated but can remain unchanged or even decelerated; its tension increases. Arterial pressure increases significantly. its tension increases. Arterial pressure increases significantly. ECG shows decreased S-T interval and flattening of the T ECG shows decreased S-T interval and flattening of the T wave. In the late stages of the disease, with organic changes wave. In the late stages of the disease, with organic changes in the vessels, cerebral circulation may be deranged during in the vessels, cerebral circulation may be deranged during crisis; myocardial infarction and acute left-ventricular failure crisis; myocardial infarction and acute left-ventricular failure may also develop.may also develop.

Complications of hypertonic Complications of hypertonic crisiscrisis

CardialCardial::

- - acute or chronic heart failureacute or chronic heart failure;;

- - accelerated development of atherosclerosis accelerated development of atherosclerosis of caoronary arteries followed by symptoms of caoronary arteries followed by symptoms of angina pectoris and myocardial infarctionof angina pectoris and myocardial infarction;;

- - arrhythmiasarrhythmias.. AortalAortal::

- - atherosclerosis atherosclerosis ;;

- - dissecting aortal aneurismdissecting aortal aneurism..

CerebralCerebral:: - - atherosclerosis of atherosclerosis of cerebral vessels and cerebral vessels and impaired cerebral impaired cerebral circulationcirculation ((encephalopathyencephalopathy);); - - dynamic and organic dynamic and organic disorders of brain disorders of brain circulationcirculation і органічні і органічніOcularOcular:: - - retinal hemorrhage retinal hemorrhage and its separationand its separation;; - - decreased visiondecreased vision ((edema of ophthalmic edema of ophthalmic nervenerve))..

TreatmentTreatmentModification of life-styleModification of life-style

DietDiet ( (Decreased salt intake Decreased salt intake to to 4-6 4-6 gg//dayday, , alkoholalkohol,, animal fatsanimal fats).).

Decreased body weightDecreased body weight.. Avoiding of smokingAvoiding of smoking.. Dynamical physical Dynamical physical

examinationsexaminations.. PhytotherapyPhytotherapy, ,

acopunctureacopuncture, , psychtherapypsychtherapy, , authotreningauthotrening

Influence of modification of Influence of modification of life-style of the course of life-style of the course of the disease:the disease:

Decreased body weight - Decreased body weight - 5-20 mm of Hg/10 kg of 5-20 mm of Hg/10 kg of lost weightlost weight

Diet – 8-14 mm of Hg Diet – 8-14 mm of Hg Decreased salt intake (6 g Decreased salt intake (6 g

per day) – 2-8 mm of Hgper day) – 2-8 mm of Hg Physical activity (30 min Physical activity (30 min

per day) – 4-9 mm of Hgper day) – 4-9 mm of Hg Decreased alkohol Decreased alkohol

consumption (to 1 ounce consumption (to 1 ounce per day) – 2-4 mm of Hgper day) – 2-4 mm of Hg

Appropriate lifestyle measures may obviate Appropriate lifestyle measures may obviate the need for drug therapy in patients with the need for drug therapy in patients with borderline hypertension, reduce the dose borderline hypertension, reduce the dose and/or the number of drugs required in and/or the number of drugs required in patients with established hypertension, and patients with established hypertension, and directly reduce cardiovascular risk.directly reduce cardiovascular risk.

Correcting obesity, reducing alcohol intake, Correcting obesity, reducing alcohol intake, restricting salt intake, taking regular restricting salt intake, taking regular physical exercise and increasing physical exercise and increasing consumption of fruit and vegetables can all consumption of fruit and vegetables can all lower blood pressure. Moreover, quitting lower blood pressure. Moreover, quitting smoking, eating oily fish and adopting a diet smoking, eating oily fish and adopting a diet that is low in saturated fat may produce that is low in saturated fat may produce further reductions in cardiovascular risk.further reductions in cardiovascular risk.

Aims of antihypertensive Aims of antihypertensive medicamentous therapymedicamentous therapy

Immediate: achieve target BP levels

Intermediate: prevent target organs disfuction (TOD) or regression of TOD

Final: improve long-term prognosis

Main groups of hypertensive Main groups of hypertensive drugsdrugs

DiureticsDiuretics --blockersblockers Ca- channels antagonistsCa- channels antagonistsAngiotensine-converting enzyme Angiotensine-converting enzyme

inhibitorsinhibitors Blockers of angiotensine-II receptorsBlockers of angiotensine-II receptorsάά1-1-adrenoblochersadrenoblochers

* Not indicated as first line therapy over 60

Dual Combination

Triple or Quadruple Therapy

Lifestyle modificationtherapy

Thiazidediuretic ACE-I Long-acting

CCBBeta-

blocker* ARB

TARGET <140 mm Hg systolic and < 90 mmHg diastolic