S.Moradmand MD .

1. SYSTEMIC HYPERTENSION S.Moradmand MD.

2. DEFINITION: A level of blood pressure that is associated With increased morbidity & mortality At some future time when compared With the whole population

3. BP Range mm Hg Category DBP <85 Normal BP 85 – 89 High normal BP 90 – 104 Mild hypertension 105 – 114 Moderate hypertension >115 Severe hypertension SBP when DBP <90mm Hg < 140 Normal BP 140 – 159 Borderline isolated systolic hypertension >160 Isolated systolic hypertension

4. CLASSIFICATION of BLOOD PRESSURE Category Systolic Diastolic Normal <130 <85 High Normal 130-139 85-89 Hypertension Stage 1(Mild) 140-159 90-99 Stage 2(Moderate) 160-179 100-109 Stage3(Severe) 180-209 110-119 Stage4(Very severe) >210 >120

5. Guidelines The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults: (Brashers, 2006, p.1)

6. Pulse Pressure: Systolic minus Diastolic Presurre Mean BP = DP + 1/3 Pulse Pressure ( A good indicator of tissue perfusion)

7. Angiotensinosion Renin Renin Release B-blocker Angiotensin 1 Coverting Enzyme ACEI Angiotensin 2 Receptor Antagonist Angiotensinases Angiotensin3

8. Persistently raised Clinic BP yes Target organ damage high Start Treatment Home BP high Ambulatory BP Continue to monitor Clinic & home BP

9. Systolic Pressure • Stroke volume • The velocity of ejection • The elastic properties of aorta

10. Diastolic Pressure • Competency of aortic valve • The condition of arteries & their • ability to stretch & store energy • 3.Resistance of arterioles

11. Blood Pressure X Cardiac output Peripheral resistance local Renal Fluid volume humoral cardiac sympathethic contractility HR Dilator (beta) Constictor ( Alpha) Vasoconstrictors Angiotensin-endothelin Vasodilator Prostaglandins n

12. classification • Essential HTN • Renal HTN 92-94% Paranchymal Renovascular 3.Endocrine HTN Primary Hyperaldostronism Cushing’s syndrome Pheochromocytoma OCP

13. EssentialHTN Hereditery Enviromental Saltsensitivity High renine Low renine Nonmodulating Cell membrane defect Insulin resistance

14. Renin Release control • Blood volume , Renal perfusion • Na filtrated to Macula Densa • Sympathetic nervous system • Dietary Potassium

15. Low renin HTN • 20% of patients • Increased extracellular volme • On high sodium diet mild • degree of hyperaldostronism • 4. Increased sensitivity of adrenal • cortex to angiotensin II

16. Nonmodulating Essential HTN • Adrenal defect apposite to low renin • 25-30% of patients • Normal or high renin • Na intake dosen’t modulate adrenal • or renal response • 5. Corrected with ACEI

17. Cell Membrane Defect Abnormality in Na transport Calcium accumulation in Vascular smooth muscle cells Increased vascular reactivity to Vasoconstrictor agents

18. Calcium in HTN • Low ca++ intake increase BP • Ca++ blockers are effective antihypertensives • Salt loading increase NF • Digital sensitive Na-K ATPase lead to • intracellular calcium accumulation

19. Insulin Resistanse • Increased sympathetic activity • Vascular smooth muscle hypertrophy • 4. Increase cytosolic calcium

20. Natural hx of HTN 1.Progressive & lethal if untreated 2.Shortening of life 10-20 years 3.If untreated in 7-10 years develope 30 % athersclerosis, 50% CHF, Cardiomegaly ,CVA, Renal insufficeincy & retinopathy. 4.Morbid Cardiovascular events by as much as 20 fold

21. Hx., Ph.E., Lab. Tests • Uncovering secondary HTN • Establishing a pretreatment baseline • The factors that may influence therapy • Determining if target organ damage? • 5.Determining if other CAD risk factors?

22. Renal Paranchymal HTN • Volume expansion • Renin-Angiotensin system • Unidentified pressure agent • Fail to produce vasodilator substance • 5. Fail to inactivate vasopressores

23. Endocrine HTN • Aldostronism • Cushing Sndrome • Adrenogenital Syndrome • Pheochromocytoma • Acromegaly • Hypercalcemia • Oral contraceptives

24. Oral Contraceptives • Estogen stimulate hepatic angiotensinogen • 5% increase BP • Familial Factors • Age over 35 • Obesity

25. Symptoms & Signs • Elevated pressure itself • headache,dizziness,palpitation, • easy fatigability • 2.Hypertension vascular disease: • epistaxis,hematuria,TIA,angina,dyspnea • 3.Underlying disease in secondary HTN: • polyuria & polydipsia,… • 4.Most patients are asymptomatic

26. Factors indicating adverse prognosis • Black race • Youth age • Male • Persistent diastolic pressure >115 mmhg • Smoking • Diabetes Mellitus • Hypercholesterolemia • Obesity • Excess alcohol intake • Evidence of End Organ Damage

27. Manifestation of Target Organ Disease 1.Cardiac :CAD LVH Cardiac Failure 2.Cerebrovascular:TIA / CVA 3.Peripheral Vascular 4.Renal 5.Retinopathy Infarction Hemorrhage Encephalopathy

28. Medical Therapy • DIURETICS • ACEI • BETA-BLOCKERS • CALCIUM BLOCKERS

29. Drugs used in Emergency HTN • Hydralazine • Minoxidil • Diazoxide • Nitroprusside

30. Basis of Treatment Salt restriction Na intake <100mm Relaxation Reduce sympathetic Weight loss Diet /Exercise Exercise Aerobic

31. Basic Tests for Evaluation Urinalysis CBC(Hct) Na-K Creatinine/BUN EKG FBS-Cholestrol(LDL-HDL)-TG Ca++-Phosphate-Uric Acid Chest-X-Ray / Echocardiogram

32. Coarctation of Aorta Diminished or delayed Femoral Pulses Rib notching on chest-X-Ray

33. Pheochromocytoma Unusual lability of BP Symptomatic Paroxysm of HTN Spell of Pallor Palpitation Perspiration Headache Hypertensive reaction to G/A or antihypertensive drugs

34. Renovascular HTN • Age under 30 • DBP > 120 mmHg • Continuous bruit in epigasrium or • flanks • 4.Accelerated HTN • 5.Hx. Of flank pain,hematuria or renal • truma • 6.palpable kidney • 7.HTN resistant to treatment

35. Conn’s Syndrome • Serum potassium less than 3.6 • 2.Urinary Potassium more than 30/24h • in the absence of diuretic therapy

36. Isolated Systolic HTN • Decreased aortic compliance • as in arteriosclerosis • B.Increased stroke volume • 1-AI • 2-Thyrotoxicosis • 3-Hyperkinetic heart syndrome • 4-Fever • 5-AVF • 6-PDA