Systemic Hypertension:

Mechanisms and Diagnosis

นายแพทย์อนุวัตร์ รินทรวิฑูรย์
แพทย์ผู้เชี่ยวชาญโรคหัวใจ
รพ.มหาราชนครศรีธรรมราช
rintaravitoon@hotmail.com
 PREVALENCE
1 billion worldwide, hypertension remains the
most common
Reversible risk factor for myocardial infarction
(MI), stroke, heart failure, atrial fibrillation, aortic
dissection, and peripheral arterial disease
Most patients diagnosed with HT do not manifest
a single disease-causing mechanism.
Treatment remains empirical, often requiring
three or more pharmacologic agents with
complementary mechanisms of action
 Definition
Hypertension is defined as a usual office blood pressure of
140/90 mmHg or higher

European Heart Journal (2013) 34, 2159–2219

 MECHANISMS
The vast majority (90% to 95%) of hypertension
is idiopathic
Vascular Mechanisms
Neural Mechanisms
Renal Mechanisms
Genetic factors influence
 MECHANISMS OF
PRIMARY (ESSENTIAL)
Pulse pressure indicates stiffening of the central aorta
Rapid return of refected pulse waves from the periphery

continued collagen
deposition, smooth muscle
hypertrophy and changes
in the elastin media fibers
 MECHANISMS OF
PRIMARY (ESSENTIAL)
Autonomic nervous system

autonomic imbalance reduced parasym pathetic tone

increased sympathetic nervous activity,

 Renin-Angiotensin-Aldosterone System
blockers
1.Decreased NaCl transport
2.Decreased pressured renal
afferent arteriole (Baroreceptor)
3.Sympathetic nervous system
Renin-Angiotensin-Aldosterone System
blockers
 DIAGNOSIS AND INITIAL EVALUATION OF
HYPERTENSION

Accomplish three goals:

Accurate measurement of blood pressure
Assessment of the patient’s overall
cardiovascular risk
Detection of secondary (i.e., identifiable
and potentially curable)



 DIAGNOSIS AND INITIAL EVALUATION OF
HYPERTENSION

Home and ambulatory monitoring

White coat hypertension
Masked hypertension
Primary or secondary HT
Isolated systolic hypertension
Emergency hypertension
Urgency Hypertension
Severe Hypertension
DIAGNOSIS AND INITIAL EVALUATION OF
HYPERTENSION

European Heart Journal (2013) 34, 2159–2219

 Medical history

First diagnosis of arterial hypertension:

Current and past BP measurements
Current and past antihypertensive
medications
Attention of secondary causes of
hypertension
Risk of renal and CV complications (CHD;
heart failure; stroke; PAD; CV death)
Medical history

European Heart Journal (2013) 34, 2159–2219

Medical history

European Heart Journal (2013) 34, 2159–2219

Medical history

European Heart Journal (2013) 34, 2159–2219

BP by Sphygmomanometric measurement
BP
BP
BP
Abnormal BP

BP แขน2ข้างต่างกัน 10mmHg
-Subclavian Artery disease
-Aorta:Aneurysm,Dissection
-Takayasu diease
-Supravalvular AS(Rt>Lt)
 Physical examination

Diagnosis of hypertension
Establish current BP
Screen for secondary causes of hypertension
Refine global CV risk estimation
Physical examination

European Heart Journal (2013) 34, 2159–2219

Physical examination

European Heart Journal (2013) 34, 2159–2219

Physical examination

European Heart Journal (2013) 34, 2159–2219

Physical examination

European Heart Journal (2013) 34, 2159–2219

Evaluation of Target Organ
Disease
 Hypertensive Heart Disease
Heart disease is the most common cause of death in
hypertensive patients
Result of structural and functional adaptations leading
LVH
CHF
Abnormal blood flow to coronary artery disease
Microvascular disease
Cardiac arrhythmia
 Brain
Stroke is the second most frequent cause of death in
the word
Elevated blood pressure is the strongest risk factor
for strokes
Hypertension related cognitive impairment and
dementia
Encephalopathy related to failure of auto regulation
of cerebral blood flow resulting in vasodilation and
hyperperfusion
Encephalopathy include severe headache , nausea ,
vomiting , focal neurologic sign alterations in mental
status
 Kidney
Diminished capacity to excrete sodium , excessive
renin secretion in relation to volume status and
sympathetic nervous system overactivity
HT risk factor for Chronic kidney disease and
ESRD
HT related vascular (atherosclerotic) resulting in
ischemic changes in the glomeruli
Macroaluminuria (urine albumin > 300 mg) or
microalbuminuria ( urine albumin 30-300 mg) early
markers of renal injury
Secondary causes HT