Essential Hypertension

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Hypertension
Hypertension is not a disease It is an arbitrarily defined disorder to which both environmental and genetic factors contribute Major risk factor for:
cerebrovascular disease myocardial infarction heart failure peripheral vascular disease renal failure
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This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.
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The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.
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 Blood pressure is a continuous variable which fluctuates widely during the day
physical stress mental stress

The definition of hypertension has been arbitrarily set as: That blood pressure above which the benefits of treatment outweigh the risks in term of morbidity and mortality
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Blood Pressure
Exhibits a normal distribution within the population Increasing blood pressure is associated with a progressive increase in the risk of stroke and cardiovascular disease Risk however rises exponentially and not linearly with pressure
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At what blood pressure is a patient hypertensive?

BHS 140/90 JNC-VI 140/90 Opt <120/<80 WHO-ISH 140/90 The current recommendation in the UK is 140/90 However risk is important and in diabetes 130/80
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 In 95% of cases no cause can be found

In 5-10% a cause can be found

Chronic renal disease Renal artery stenosis Endocrine disease, Cushings, Conns Syndrome, Phaeochromocytoma, GRA

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Risks of Hypertension
The risk of hypertension is considerable The 4th most common cause of death world-wide Directly and indirectly responsible for >20% of all deaths The risks of hypertension have been most thoroughly determined by the Framingham Study a longitudinal study performed in the USA

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Framingham Study
This study clearly demonstrated that the relative risk to a patient with a DBP of 99 mmHg compared to a DBP of 84 mm Hg for
Stroke increases 4 fold MI increases 2 times

The same was also found to be true for systolic blood pressure These pressure are common
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 Despite the clear relationship between blood pressure and morbidity the risk from hypertension also depends on and increases exponentially with other factors
Cigarette smoking Adds 20/10 mmHg Diabetes mellitus 5-30 X increase MI Renal disease Male 2X risk Hyperlipidaemia Previous MI or stroke Left ventricular hypertrophy 2X risk
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Control of blood pressure

Blood pressure is controlled by an integrated system Prime contributors to blood pressure are:
Cardiac output
Stroke volume Heart rate

Peripheral vascular resistance

Each of these factors can be manipulated by drug therapy

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Sympathetic Nervous System

Sympathetic system activation produces
vasoconstriction reflex tachycardia increased cardiac output

In this way blood pressure is increased The actions of the sympathetic system are rapid and account for second to second blood pressure control
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The renin-angiotensin-aldosterone system

The RAAS is pivotal in long-term BP control The RAAS is responsible for:

maintenance of sodium balance control of blood volume control of blood pressure

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 The RAAS is stimulated by:

fall in BP fall in circulating volume sodium depletion

Any of the above stimulate renin release from the juxtaglomerular apparatus Renin converts angiotensinogen to angiotensin I Angiotensin I is converted to angiotensin II by angiotensin converting enzyme (ACE)
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 Angiotensin II is a potent
vasoconstrictor anti-natriuretic peptide stimulator of aldosterone release from the adrenal glands

Aldosterone is also a potent antinatriuretic and antidiuretic peptide Angiotensin II is also a potent hypertrophic agent which stimulates myocyte and smooth muscle hypertrophy in the arterioles
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 Myocyte and smooth muscle hypertrophy:

are both poor prognostic indicators in patients with hypertension partially explain why hypertension and the risks of hypertension persist in some patients despite treatment

Both the sympathetic and RAAS are key targets in the treatment of hypertension

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Aetiology of essential hypertension

The aetiology of hypertension is
Polygenic
Major genes Poly genes

Polyfactorial
Environment Individual and Shared

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 Likely causes: Increased reactivity of resistance vessels and resultant increase in peripheral resistance
as a result of an hereditary defect of the smooth muscle lining arterioles

A sodium homeostatic effect

In essential hypertension the kidneys are unable to excrete appropriate amounts of sodium for any given BP. As a result sodium and fluid are retained and the BP increases
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Other factors
Age Genetics and family history Environment Weight Alcohol intake Race
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 AGE
BP tends to rise with age, possibly as a result of decreased arterial compliance. Hypertension in the elderly should be treated as aggressively as in the young. They have more to lose Studies such as EWPHE, Primary Care Study,MRC Hypertension in the Older Adult, SHEP, SYSTEUR and STOP-1 and 2 have proven that treating both diastolic and systolic hypertension in the elderly significantly reduces stoke and MI.
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 GENETICS
A history of hypertension tends to run in families The closest correlation exists between sibs rather than parent and child It is also possible that environmental factors common to members of the family also have a role in the development of hypertension

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 Environment
Mental and physical stress both increase blood pressure However removing stress does nor necessarily return blood pressure to normal values True stress responders who have very high BP when they attend their doctor but low normal pressures otherwise tend to be highly resistant to treatment

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 Sodium Intake
The SALT study and more recently the DASH study have confirmed a strong relationship between hypertension, stroke and salt intake Reducing salt intake in hypertensive individuals does lower blood pressure However reducing salt intake in normotensives appears to have no effect Reducing salt intake to <1.5gm/day or better <0.5gm/day does lower BP However there are real difficulties in achieving this level of salt restriction (fast food)
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 ALCOHOL
The most common cause oh hypertension in the young Scot Affects 1% of the population Small amounts of alcohol tend to decrease BP Large amounts of alcohol tend to increase BP If alcohol consumption is reduced BP will fall over several days to weeks. Average fall is small 5/3 mmHg

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 Weight
Obese patients have a higher BP Up to 30% of hypertension is attributable in part or wholly to obesity If a patient loses weight BP will fall In untreated patients a weight loss of 9Kg has been reported to produce a fall in BP of 19/18 mmHg In treated patients a fall in BP of 30/21 mmHg has been reported Weight reduction is the most important nonpharmacological measure available
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Birth Weight
Birth weight is also associated with the development of hypertension in later life. The lower the birth weight the higher the likelihood of developing hypertension and heart disease Clearly in-utero factors affect health at a later stage.
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 Race
Caucasians have a lower BP than black populations living in the same environment Black populations living in rural Africa have a lower BP than those living in towns Reasons are not clear Possibly black populations are more susceptible to stress when living in towns Respond in different ways to changes in diet Black populations are genetically selected to be salt retainers and so are more sensitive to an increase in dietary salt intake
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Secondary Hypertension
5-10% of all hypertension has an identifiable cause Removal of the cause does not guarantee that the hypertension or risk will return to normal Sustained hypertension produces end-organ damage to blood vessels, heart and kidney This type of damage tends to increase BP further and so a vicious self-propagating cycle is established
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Causes for Secondary Hypertension

Renal disease
20% of resistant hypertensive patients chronic pyelonephritis renal artery stenosis polycystic kidneys

Drug Induced
NSAIDs Oral contraceptive Corticosteroids
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 Pregnancy
pre-eclampsia

Endocrine
Conns Syndrome Cushings disease Phaeochromocytoma Hypo and hyperthyroidism Acromegaly

Vascular
Coarctation of the aorta

Sleep Apnoea
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The risks of hypertension

The risks of hypertension are well recognised Cerebrovascular disease
Thromboembolic Intra cranial bleed TIA

Cardiovascular disease
Myocardial infarction Heart failure Coronary artery disease
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The risks of hypertension

Peripheral vascular disease Renal failure

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The risks of hypertension

A sustained increase in BP increases the load on the heart and blood vessels This has two effects
Myocardial hypertrophy Smooth muscle hypertrophy in the resistance vessels

Hypertrophy of this type increases the strength of the heart and vasculature However it also reduces compliance
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 The effects of reduced compliance are:

A reduction in the ability of the heart to to respond to increased or variable loads a decrease in the ability of the resistance vessels to relax

For the same level of BP and irrespective of age the presence of left ventricular hypertrophy increases 5 year mortality by
33% in men 21% in women

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 Atheromatous disease
Sustained hypertension is associated with accelerated atheromatous disease of the blood vessels Peripheral vascular disease Coronary artery disease Cerebrovascular disease Renal artery disease

The Heart
MI Heart failure Angina
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Detection and Diagnosis

Initial assessment History Office blood pressure ABPM Abdominal ultrasound scan Inpatient assessment Assess risk
Smoking Diabetes Previous pathology
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Hypertension
Medication for High Blood Pressure
Diuretics
Rid the body of excess fluids and salt

Beta-blockers
Reduce the heart rate and the work of the heart

Calcium antagonists
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Reduce heart rate and relax blood vessels 38

Hypertension
Medication for High Blood Pressure
Angiotensin II receptor blockers(ACE)
Interfere with the bodies production of angiotensin, a chemical that causes the arteries to constrict (narrow)

Vasodialators
Cause the muscle in the wall of the blood vessels to relax, allowing the vessel to 39 dialate (widen)

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Hypertension
Medication for High Blood Pressure
Sympathetic nerve inhibitors
Sympathetic nerves go from the brain to all parts of the body, including the arteries Cause arteries to constrict raising blood pressure These drugs reduce blood pressure by inhibiting these nerves from constricting blood vessels 40

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Hypertension
Home Blood Pressure Monitoring
Mercury sphygmomanometer

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Standard for BP monitoring No calibration May be bulky Need a second person to use machine May be difficult for hearing impaired or patients with arthritis
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Hypertension
Home Blood Pressure Monitoring
Aneroid equipment

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Inexpensive, lightweight and portable Two person operation/need stethoscope Delicate mechanism, easily damaged Needs calibration with mercury sphygmomanometer
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Hypertension
Home Blood Pressure Monitoring
Automatic equipment
Contained in one unit Portable with easy-to-read digital display Expensive, fragile Must be calibrated Requires careful cuff placement
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Treatment of Adults with Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification therapy

Thiazide

ACE-I

ARB

Longacting CCB

Betablocker*

* Not indicated as first line therapy over 60

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Summary: Treatment of Hypertension without Other Compelling Indications

TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification therapy

Thiazide diuretic

ACE-I

ARB

Long-acting CCB

Betablocker*

CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?

Dual Combination

Triple or Quadruple Therapy

* Not indicated as first line therapy over 60

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Thank you for attention!

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