In the Name of God

Overview of Hypertension

Mahboob Lessan Pezeshki MDTehran University of Medical Sciences

Aban 1392

Definitions (1)

Normal blood pressure: systolic< 120 & diastolic <80 mmHg

Prehypertension: systolic 120-139 or diastolic 80-85 mmHg

Hypertension: Stage 1: systolic 140-159 or diastolic 90-99 Stage 2: systolic >160 or diastolic > 100

Definitions (2)

Isolated systolic hypertension: systolic >140 and diastolic < 90 mmHg

Isolated diastolic hypertension: systolic <140 and diastolic > 90 mmHg

Definitions and classification of office blood pressure levels (mmHg)

Hypertension based upon ABPM and home readings

ABPM: A 24 hour average above 135/85 mmHg Daytime (awake) average above 140/90 mmHg Nighttime (asleep) average above 125/75 mmHg

Home readings: The same as for daytime ambulatory blood pressure

Malignant Hypertension

Marked hypertension with retinal hemorrhages, exudates or papilledema

Diastolic hypertension usually >120 mmHg

Hypertensive Urgency

Diastolic blood pressure above 120 mmHg in asymptomatic patients

Hypertensive Emergency

Acute severe hypertension, generally>180/120 mmHg

Malignant hypertension with end organ damage

Hypertensive encephalopathy

Resistant Hypertension

Failure to achieve goal blood pressure(<140/90 mmHg) using:

A minimum of three antihypertensive drugs At maximal tolerated doses, one of which must be a diuretic

Controlled Resistant Hypertension

Patients who meet the definition of Resistant Hypertension but whose blood pressure is controlled on maximal tolerated doses of four or more antihypertensive medications

Refractory Hypertension

Patients who meet the definition of Resistant Hypertension but whose blood pressure is not controlled on maximal tolerated doses of four or more antihypertensive medications

Isolated Diastolic Hypertension

More common in men Associated with metabolic syndrome Elevated systemic vascular resistance Vasoconstriction of resistant arterioles Inappropriately normal cardiac output

Isolated Systolic Hypertension

Common in elderly hypertensives Diminished arterial compliance Elevated pulse pressure High risk of:

MI LVH Stroke Renal dysfunction

Primary Hypertension (1)

Pathogenesis : Genetic factors Increased sympathetic neural activity Increased angiotensin 2 actvity and

mineralocorticoid excess Reduced adult nephron mass

Primary Hypertension (2)

Risk factors: Excess sodium intake Excess alcohol intake Obesity and weight gain Physical inactivity Dyslipidemia Certain personality traits Vitamin D deficiency

Secondary Hypertension

Primary renal disease Oral contraceptives Drug induced Renovascular disease Obstructive sleep apnea Coarctation of aorta Endocrine disorders( primary aldosteronism,

pheochromocytoma….)

Complications of Hypertension

Ischemic stroke Intracerebral hemorrhage Chronic kidney disease Left ventricular hypertrophy Heart failure

Masked Hypertension

Normotensive by conventional clinic measurement

Hypertensive by ABPM

White coat Hypertension

Average office readings > 140/90 mmHg

Average out of office < 140/90 mmHg

Screening of Hypertension

Normal BP Every 2 years

Prehypertension Yearly

Indications for ABPM

Suspected white coat Hypertension Suspected episodic Hypertension Hypertension resistant to increasing

medications Hypotensive symptoms while taking

antihypertensive medications Autonomic dysfunction

Goals of Systolic Blood Pressure

Lower than 140 mmHg

No J shaped systolic curve

Goals of Diastolic Blood Pressure

Lower than 90 mmHg The goal may be lower in:

Atherosclerotic cardiovascular disease Diabetes mellitus Chronic kidney disease Heart failure

J shaped Diastolic curve

Methods of Diagnosis

Office-based measurement (AHA) ABPM (NICE) Home blood monitoring:

12-14 measurements Over a period of one week

Cuff Inflation Hypertension

Effect of muscular activity

Raise the blood pressure 12/9 mmHg Dissipates within 5-20 seconds

Office-based measurement

Time of measurement Type of measurement device Cuff size Patient position Cuff placement Technique of measurement Number of measurements

Pseudohypertension

Stiff vessels due to marked arterial calcification

10 mmHg or more higher systolic and Diastolic pressures

Measurement of Blood Pressure

Mild Hypertension: three to six visits (over a period of weeks to months)

Measurements should be in both arms

Detection of postural hypotension

Alternative sites for measurement

Leg blood pressure

Wrist blood pressure

Non Pharmacologic Therapy(1)

Dietary Salt Restriction Weight loss DASH Diet Exercise Vit D supplement

Non Pharmacologic Therapy(2)

Adequate Potassium intake Cessation of Smoking Limiting the use of NSAIDs Patient education

Drug Treatment(1)

Monotherapy in uncomplicated hypertension

Thiazide Diurtics Calcium Channel Blockers ACEIs or ARBs

Drug Treatment(2)

First Line Combination therapy

BP is more than 20/10 mmHg above the goal Calcium Channel Blockers plus a long acting

ACEI/ARB (ACCOMPLISH Trial)

Drug Treatment(3)

CCB or ACEI/ARB Discontinuing the thiazide and starting

combination therapy In all patients on beta blockers the preferred

second drug: Thiazide diuretics Dihydropyridine CCB

Bed time versus morning dosing

Shifting at least one medication to the evening in nondippers

Restores normal nocturnal blood pressure dip

Reduces 24 hour mean blood pressure

Treatment of Hypertensive Emergency(1)

Nitroprusside Nitroglycerin Calcium Channel Blockers Labetalol

Treatment of Hypertensive Emergency(2)

Fenoldopam Esmolol Hydralazine Enalaprilat Phentolamine

Treatment of Resistant Hypertension(1)

ACE or ARB(long acting) +

CCB(dehydropyridine) + Thiazide diuretic

Add spironolactone if patients remained uncontrolled

Direct vasodilators (hydralazine or minoxidil)

Treatment of Resistant Hypertension(2)Experimental therapies

Ablation of renal sympathetic nerves

Electrical stimulation of carotid sinus baroreceptors