PD
Introduction
Definition
Pathophysiology
Pathogenesis
Pathophysiology of T.O.D
Measurement of blood pressure
History, Physical examination
Treatment
What is the JNC VII?
Seventh Report of the Joint National
Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure
Uses evidence-based medicine and consensus
Updates approaches to hypertension control
including diagnosis, evaluation, lifestyle
modification, and drug therapy
Objective
“The objective of identifying and treating high
blood pressure is to reduce the risk of
cardiovascular disease and associated morbidity
and mortality”
JNC VII
Why Control Hypertension?
Heart disease and stroke are the 1st and 3rd
leading causes of death in the U.S.
heart failure
renal failure
Blood pressure is a continuous variable which
fluctuates widely during the day
physical stress
mental stress
1. Patient conditions
1.1. Posture
Initialy, particularly in patients over age 65,
diabetic, or receiving antihypertensive therapy,
check for postural changes by taking readings after
5 minutes supine, then immediately and 2 minutes
after they stand
1.2. Circumstances
No caffeine during the hour preceeding the reading
No smoking during the 15 minutes precding the
reading
No exogenous adrenergic stimulants (e.g.
phenylephrine in nasal decongestants or eye drops
for pupillary dilation)
A quiet, warm setting.
Home readings taken under varying circumstances
and 24 hours ambulatory recordings may be
preferable and more accurate in predicting
subsequent cardiovascular disease.
Guidelines for Measurement of Blood
Pressure (continued)
2. Equipment :
4. Recordings
Note the pressure, patient position, the arm, cuff
size ; e.g. 140/90, seated, right arm, large adult
cuff.
Bladder Length
Centre of bladder
must be over Children > 5 years 12 cm
artery
Usually supplied 23 cm
Strongly
recommended Normal and lean arms 35 cm
for routine use
Fluid Volume
Volume Redistribution
Cardiac output
veins
venules heart
arterioles
Blood pressure
Angiotensin/ Renin release
aldosterone
Sympathetic Nervous System
Sympathetic system activation produces
vasoconstriction
reflex tachycardia
sodium depletion
ANGTIOTENSINASE A
Adrenergic
facilitation
Aldosterone Contractility
Sympathetic
discharge
Distal
nephron Sodium and water Thirst salt Vasopressin
Vasoconstriction
reabsorption reabsorption appetite release
Cardiac
Maintain or increase Total peripheral output
ECFV resistance
Angiotensinogen
Renin
Angiotensin I
ACE vasoconstriction
Complicated hypertension
40-60 years
(T. O. D)
HEREDITY - ENVIRONMENT
Age
PRE - HYPERTENSION 0 - 30
ESTABLISHED HYPERTENSION 30 - 50
UNCOMPLICATED COMPLICATED
Increased
Lipolysis Release of
Obesity + Androgen Abdominal
Fat Free Fatty
Acids
TYPE II
Peripheral Increased Decreased
DIABETES Insulin Pancreatic Hepatic Insulin
MELLITUS Resistance Insulin Secretion Extraction
Hyperinsulinemia
Sodium Vascular
Increased Retention
Sympathetic Hypertrophy
Nervous
Attenuated Activity
Vasodilatio
n
HYPERTENSION
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
polycystic kidneys
Drug Induced
NSAIDs
Oral contraceptive
Corticosteroids
Pregnancy
pre-eclampsia
Endocrine
Conn’s Syndrome
Cushings disease
Phaeochromocytoma
Acromegaly
Vascular
Coarctation of the aorta
Sleep Apnoea
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
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
Atheromatous disease
Sustained hypertension is associated with
accelerated atheromatous disease of the blood
vessels
Peripheral vascular disease
Cerebrovascular disease
The Heart
MI
Heart failure
Angina
The kidney
Hypertension produces an increase in renal vascular
resistance and a reduction in renal blood flow
Renal disease
glomerular hyperfiltration
exercise
alcohol restriction
caffeine restriction
relaxation techniques
potassium supplementation
Lifestyle Modification to Manage
Hypertension
Approximate Systolic BP
Modification Recommendation Reduction, Range
Weight reduction Maintain normal body weight 5-20 mm Hg/10-Kg
(BMI, 18.5-24.9) weight loss
Adopt DASH eating Consume a diet rich in fruits, vegetables, and 8-14 mm Hg
Plan low-fat dairy products with a reduced
content of saturated and total fat
Dietary sodium Reduce dietary sodium intake to no more 2-8 mm Hg
reduction than 100 mEg/L (2.4 g sodium or 6 g
sodium chloride)
Physical activity Engage in regular aerobic physical activity 4-9 mm Hg
such as brisk walking (at least 30 minutes
per day, most days of the week)
Moderation of alcohol Limit consumption to no more than 2 drnks 2-4 mm Hg
consumption per day (1 oz or 30mL ethanol (eg. 24 oz
beer, 10 oz wine, or 3 oz 80-proof
whiskey) in most men and no more than
1 drink per day in women and
lighter-weight persons
Figure. Algorithm for Treatment of Hypertension
Lifestyle Modification
Not at Goal BP
(<140/90 mm Hg or <130/80 mm Hg for Those With Diabetes
Or Chronic Kidney Disease)
Not at Goal BP
Is patient at:
Very High Risk
High Risk
Medium Risk
Low Risk
Management Strategy (2)
Stratify Risk
Very High
High
Begin drug
treatment
Begin drug
treatment
Management Strategy (3)
Stratify risk
Medium
Low
Monitor BP & other
risk factors for 3-6 months
Monitor BP & other
risk factors for 6-12 months
SBP >140 SBP <140
or DBP >90 or DBP <90
SBP >150 SBP <150
Begin drug Continue to or DBP >95 or DBP <95
treatment monitor
Begin drug Continue
treatment to monitor
Principles of Drug Treatment (1)
Use a low dose of one drug to initiate
therapy
If good response and tolerability but
inadequate control increase the dose of
the first drug
If little response or poor tolerability
change to another drug class
Principles of Drug Treatment (2)
Compelling Possible
Diuretics
Heart failure Diabetes
Elderly patients
Systolic hypertension
Contraindications
Compelling Possible
Gout Dyslipidaemia
Sexually active
males
Indications
Beta-Blockers Compelling Possible
Angina Heart failure
After myocardial infarct Pregnancy
Tachyarrhythmias Diabetes
Compelling
Contraindications
Possible
Asthma and Dyslipidaemia
Chronic obstructive Athletes and
Pulmonary disease Physically active
Heart block (AV 2,3) Patients
Peripheral
vascular disease
Indications
Contraindications
Compelling Possible
Heart block (AV 2,3) Heart failure*
* verapimil or diltiazem
Indications
ACE Inhibitors Compelling Possible
Heart failure
Left ventricular dysfunct
After myocardial infarct
Diabetic nephropathy
Contraindications
Compelling Possible
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
Indications
Alpha-Blockers
Compelling Possible
Prostatic Hypertrophy Glucose intolerance
Dyslipidaemia
Contraindications
Compelling Possible
Orthostatic
hypotension
Indications
Angiotensin II
Compelling Possible
Antagonists ACE-I cough Heart failure
Contraindications
Compelling Possible
Pregnancy
Bilateral renal
artery stenosis
Hyperkalaemia
Combination Therapy (1)
In most patients, appropriate combination
therapy produces BP reductions that are
twice as great as those obtained with
monotherapy,
for example, 12-22 mm Hg systolic BP and
7-14 mm Hg diastolic BP for patients with
initial BP of >160/95 mm Hg
Combination Therapy (2)
Effective drug combinations to treat
hypertension are:
• diuretic and beta-blocker
• diuretic and ACE inhibitor (or
Angiotensin II antagonist)
• calcium antagonist
(dihydropyridine) and beta-blocker
• calcium antagonist and ACE
Causes of Resistant Hypertension