HYPERTENSION

Sequel of Hypertension

Mohammad Ilyas, M.D.

Assistant Clinical Professor

University of Florida / Health Sciences Center

Jacksonville, Florida USA1

Outline

1. Definition, Regulation and Pathophysiology

2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory Blood Pressure Monitoring

3. Evaluation of Primary Versus Secondary

4. Sequel of Hypertension and Hypertension Emergencies

5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)

6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep Disorders.

7. Hypertension in Renal diseases and Pregnancies

8. Pediatric, Neonatal and Genetic Hypertension

2

Who is at Risk?

• Poorly controlled blood pressure (systolic)

• Afro-American

• Male

• Poorly adherent

• Pre-existing target organ damage

• CVA, MI, HF, CKD

Hypertension

• Hypertension is a well-established risk factor for adverse cardiovascular

outcomes, including CHD mortality and stroke.

• In the worldwide INTERHEART study of patients from 52 countries,

hypertension accounted for 18 percent of the population-attributable risk of

a first MI.

Hypertension (cont.)

• Systolic blood pressure is at least as powerful a coronary risk factor as the

diastolic blood pressure, particularly in older patients, and isolated systolic

hypertension is now established as a major hazard for coronary heart disease

and stroke .

• There is also evidence that the pulse pressure, which is determined primarily

by large artery stiffness, is a predictor of risk

Hypertension (cont.)

• Although blood pressure at the time of risk assessment (current blood

pressure) is typically used in most prediction algorithms, this does not

accurately reflect an individual's past blood pressure experience.

• Past blood pressure duration as well as the degree of hypertension are both

risk factors.

Hypertension (cont.)

• Ambulatory blood pressure measurements may be more predictive in

outcome assessment.

• A separate issue is the goal blood pressure in patients who already have or

are at high-risk for cardiovascular disease.

• Epidemiologic studies in the general population have shown that the risk

of cardiovascular disease increases progressively at blood pressures above

110/75 mmHg .

Benefit of Rx of mild HTN

Target Organ Damage

• Heart

• Left ventricular hypertrophy

• Heart failure

• Angina

• Myocardial infarction

• Brain• Transient ischemic attack (TIA)

• Stroke

• Peripheral artery disease

• Intermittent claudication

• Aortic atherosclerosis

• Aortic aneurysm

• Aortic dissection

• Chronic kidney disease

• Retinopathy

General principles

• Atherosclerosis, hardening and narrowing of the arteries, is primarily

responsible for most complications.

• Atherosclerosis starts when high blood pressure damage the endothelium.

• This insidious process begins with endothelial dysfunction, cholesterol streak

formation, these lesions progress into plaques in early adulthood, and

culminate in thrombotic occlusions and coronary events in middle age and

later life.

Plaques from atherosclerosis

1. They can stay within the artery wall. There, the plaque grows to a certain

size and stops. Because they don't block blood flow, these plaques may

never cause any symptoms

2. They can grow in a slow, controlled way into the path of blood flow.

Eventually, they cause significant blockages. Pain on exertion (in the chest

or legs) is the usual symptom.

3. The worst-case scenario: plaques can suddenly rupture, allowing blood to

clot inside an artery, this causes a stroke or a heart attack.

The plaques to cardiovascular disease

• Coronary artery disease: Stable plaques in the heart's arteries cause angina.

Sudden plaque rupture and clotting causes heart attack, or myocardial

infarction.

• Cerebrovascular disease: Ruptured plaques in the brain's arteries causes

strokes, with the potential for permanent brain damage. Temporary

blockages in an artery can also cause transient ischemic attacks (TIAs), which

are warning signs of stroke; however, there is no brain injury.

• Peripheral artery disease: Narrowing in the arteries of the legs caused by

plaque. Peripheral artery disease causes poor circulation.

Risk factors on cardiovascular disease

HTN & CVD

• Hypertension is quantitatively the most important risk factor for premature

cardiovascular disease, being more common than cigarette smoking,

dyslipidemia, and diabetes, which are the other major risk factors.

• Hypertension accounts for an estimated 54 percent of all strokes and 47

percent of all ischemic heart disease events globally

HTN CVD

• Systolic blood pressure and isolated systolic hypertension are major risk factors at all ages in either sex.

• In patients <50 years of age, diastolic blood pressure was the strongest predictor; in those 50 to 59 years of age, all three blood pressure indices were comparable predictors while in those ≥60 years of age, pulse pressure was the strongest predictor

• Obesity or weight gain promotes or aggravates all the atherogenic risk factors and physical inactivity worsens some of them, predisposing subjects of all ages to coronary events.

CHD mortality related to blood pressure and age

Cardiovascular Risk factors

• Hypertension

• Cigarette smoking

• Obesity (body mass index ≥30 kg/m2)

• Physical inactivity

• Dyslipidemia

• Diabetes mellitus

• Microalbuminuria or estimated GFR <60 mL/min

• Age (older than 55 for men, 65 for women)

• Family history of premature cardiovascular disease (men under age 55 or women under age 65)

Effects On CVS

• Ventricular hypertrophy, dysfunction and failure.

• Arrhythmias

• Coronary artery disease - Acute MI

• Arterial aneurysm, dissection, and rupture.

Left ventricular hypertrophy

• High blood pressure forces heart to work harder than necessary in order to

pump blood to the rest of body.

• This causes the left ventricle to thicken or stiffen

• These changes limit the ventricle's ability to pump blood to body.

• This condition enhanced incidence of heart failure, ventricular arrhythmias,

death following myocardial infarction, and sudden cardiac death

• The risk of heart failure increases with the degree of blood pressure elevation

Left ventricular hypertrophy

• Manifestations of atherosclerosis occurred at two to three times than the

general population in persons with LVH

• Enlarged cardiac silhouette on a chest x-ray

• Electrocardiographic changes in LVH

• Echocardiographic evidence of LVH is more sensitive than the ECG, also is

predictive of cardiovascular risk.

Heart failure

• Over time, the strain on heart caused by high blood pressure can cause heart

muscle to weaken and work less efficiently.

• Eventually, overwhelmed heart simply begins to wear out and fail.

• Damage from heart attacks adds to this problem

Coronary Artery Disease (CAD)

• Atherosclerotic plaques, progressively narrow the coronary artery lumen and

impair ante grade myocardial blood flow.

• When blood can't flow freely to heart, its leads to chest pain, a heart attack

or irregular heart rhythms (arrhythmias).

• CAD is a chronic process that begins during adolescence and slowly

progresses throughout life

• Cardiovascular disease (CVD) remains the leading cause of mortality in the

United States, responsible for 1 in 4 deaths in the U.S. in 2008.

Aneurysm

• Over time, the constant pressure of blood moving through a weakened

artery can cause a section of its wall to enlarge and form a bulge (aneurysm).

• An aneurysm (AN-yoo-riz-um) can potentially rupture and cause life-

threatening internal bleeding.

• Aneurysms can form in any artery throughout your body, but they're most

common in the aorta, your body's largest artery.

Aortic dissection

• Separation of the aorta

walls. The small tear can

become larger. It can lead to

bleeding into and along the

wall of the aorta.