Systemic Hypertension

1. Systemic Hypertension Dr. Mohammed AlMulhim KFU

2. Contents • Definition and classification . • Causes . • Prevalence . • HTN as a risk factor . • Mechanism of Essential HTN . • How to approach . • HTN Urgencies . • HTN Emergencies .

3. Definition • The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7 ) , 2004

4. Definition “ Our new definition incorporates the presence or absence of risk factors, early disease markers and target-organ damage, and more accurately represents the different physiological abnormalities in the cardiovascular system and other organs caused by hypertension.“ Dr. Thomas Giles, president of the American Society of Hypertension and professor of medicine at the Louisiana State University School of Medicine in New Orleans, LA.

5. “a progressive cardiovascular syndrome with many causes that result in both functional and structural changes to the heart and vascular system.” • American Society of Hypertension (ASH) , 9-2005

6. The new definition means “ 1- Early stages of hypertension can begin before an individual develops sustained elevated blood pressure, and can progress to damage in the heart, kidneys, brain, vasculature and other organs, often leading to premature morbidity and death . 2-Instead of relying on blood pressure numbers alone to predict each patient's risk of developing cardiovascular disease, this risk must be assessed on an individual basis by taking several factors into account “ American Society of Hypertension (ASH) , 9-2005

7. ASH Definition and Classification of Hypertension

8. Definition of pediatric HTN Average systolic & diastolic BP: Normal BP< 90th percentile. Prehypertension between 90th - 95th percentile. HTN> 95thpercentile + 5 mmHg. – Stage -1 > 95th -98th percentile + 5mmHg – Stage-2 ≥ 99th percentile + 5mmHg – MALIGNANT HTN = • Retinal Hemorrhage • papillary edema • Seizures Pediatric 2004; 114;

9. Causes

12. One adult in five has HTN

15. HTN as a risk factor

16. HTN commonly occurs with other risk factors

19. Mechanisms of Essential HTN

20. How to approach ?

21. History Renal week , 2005. ‘ in children , HTN is not a silent disease , and this should be spurring all as on to screening more diligently and evaluating children for HTN ‘ Dr.Feig , Prof of paediatric , and chief of Pediatric HTN program , Texas Hospital

27. Patient related standards • Physical rest for 3-5 min in quiet environment. • Sitting position with back support , and elbow in heart level . • Standing in some case ( elderly , DM ) . • Check BP in both arm during initial visit . • Upper arm should not be covered by clothing. • Avoid nicotine and caffeine one hour prior to measurement .

28. Equipments related standards

30. Examiner related standards • Inflate the cuff bladder rapidly to 30 mmHgabove the level of the estimated SB pressure . • Mild pressure over the stethoscope bellshould be expressed . • Deflate the cuff bladder at rate of 2 mmHg /sec . • Deflate the cuff bladder rapidly and completely at diastolic BP . • Avoid the reinflationand correction of the stethoscope position during measuring procedure • Remember Korotkoff sounds .

31. Investigation

32. Management of the essential HTN • Life style modification. • Pharmacotherapy. Treatment Guidelinesfor Medicine and Primary Care , 2008

34. lifestyle modification

35. Medication therapy • should be begun if the systolic pressure is persistently >140mmHg and/or the diastolic pressure is persistently >90mmHg. despite attempted non pharmacologic therapy. • In patients with DM or CKD antihypertensive therapy is indicated when the systolic pressure is persistently >130mmHg and/or the diastolic pressure is > 80mmHg . • Starting with two drugs may be considered in patients with a baseline blood pressure > 20/10mmHg above goal .

40. Considerations for Individualizing Antihypertensive Therapy

43. Management of pediatric HTN . ESCAPE Trial Group. Nephroprotection by intensified blood pressure control: final results of the ESCAPE trial. J Hypertens 2008

47. Hypertensive Urgencies -Severe hypertension without symptoms . 1-SBP180 mmHg and/or DBP 120 mmHg. 2-asymptomatic . 3-with no acute signs of end organ damage -Causes : 1-Noncompliant with antihypertensive regimens 2-ingestion of large quantities of salts .

48. Treatment of HTN Urgencies : Goal :to reduce the blood pressure to 160/100mmHg over several hours to days . Management of previously treated hypertension: 1-Increase the dose of existing antihypertensive medications, or add another agent . 2- Add a diuretic . 3- reinforcement of dietary sodium restriction .

49. Management of previously untreated hypertension: 1-Initial blood pressure reduction Take Place over several hours with small dose medications ( diuretics , ACEI ) • observed for a few hours, to observe a reduction in blood pressure of 20 to 30 mmHg . • a longer acting agent is prescribed • patient is sent home to follow-up within a few days 2- Blood pressure reduction over one to two day s .( CCB , BB , ACIE , ARB ) 3- chose the appropriate anti-HTN medication . 4- Adjust the medication dose over the next weeks or months .

50. Hypertensive Emergencies • severe hypertension associated with acute end organ. 1- SBP 180 mmHg and/or DBP 120 mmHg. 2- Acute end organ damage e.g. hypertensive encephalopathy, subarachnoid or intracerebral hemorrhage, acute pulmonary edema, or aortic dissection . • Immediate but careful reduction in blood pressure is indicated for hypertensive emergency. • Excessive hypotension caused by drug treatment is dangerous and could result in stroke, myocardial infarction or blindness .