Hypertension (HT) High Blood Pressure (HBP)

1. Hypertension (HT) High Blood Pressure (HBP)

2. Introduction • Definition: Hypertension is defined as elevated arterial blood pressure. • Hypertension is one of the most common disease in the world • In our country, 160 million people over the age of 15 have established or borderline HP • HP Essential HP (95%) Secondary HP (5%)

3. Etiology • Genetic • Environment • Dietary: Salt intake • Alcohol intake • Obesity • Infant dysnutrition

4. Pathogenesis • High activity of the SNS (Sympathetic Nervous System) • RAAS (Renin-Angiotension Aldosterone System) • Renal Sodium Handling • Vascular Remodelling • Endothelial Cell Dysfunction • Insulin Resistance

5. The pathological changes of small artery

6. The pathological change of the Heart • Left ventricular hypertrophy (LVH) • Heart failure • Coronary artery atherosclerosis • Myocardial infarction

7. Pathological change of the Brain • Stroke: • Ischemic stroke • Hemorrhagic stoke Arterial Aneurysm

8. Pathological change of Renal • Hypertension induced nephrosclerosis, atrophy of renal cortex

9. Clinical Features • The blood pressure varies widely over time, depending on many variables, including SNS activity, posture, state of hydration, and skeletal muscle tone. • Symptoms: • Always asymptomatic • Symptoms often attributed to hypertension: • headache, tinnitus, dizziness, fainting

10. Clinical Features • Complications of Hypertension • Heart: LVH, CHD,HF • Brain: TIA, Stroke • Renal: Microalbuminuria, renal dysfunction • Ratinopathy

11. Laboratory Examination • Blood pressure measurement: • Clinic Blood Pressure • Home Blood Pressure • Ambulatory monitoring

12. Ambulatory Measurement • Ambulatory monitoring can provide: • readings throughout day during usual activities • readings during sleep to assess nocturnal changes • measures of SBP and DBP load • Exclude white coat or office hypertension • Ambulatory readings are usually lower than in clinic (hypertension is defined as > 135/85 mm Hg)

13. Laboratory Examination • Urinalysis • Blood examination • Chest X Ray • EKG • UCG (Ultrasound cardiography) • Retina examination

17. The Keith-Wagner Criteria (change in retina) • KW I: Minimal arteriolar narrowing, irregularity • of the lumen, and increased light reflex • KW II: More marked narrowing and irregularity • with arteriovenous nicking (crossing defects) • KW III: Flame-shaped hemorrhages and exudates in • addition to above arteriolar changes • KW IV: Any of the above with addition of papilledema

18. Pepilledema Flame shaped hemorrhage

19. Diagnosis & Differential Diagnosis

20. Classification of blood pressure for adult • CategorySBP (mmHg) DBP (mmHg) • Normal < 120 < 80 • High normal 120-139 80-89 • Hypertension≥140 ≥90 • Stage 1 140-159 90-99 • Stage 2 160-179 100-109 • Stage 3 ≥180 ≥110 • Systolic HBP ≥140 < 90 • When the SBP and DBP fall into different categories, use the higher category

21. Evaluation Objectives • To identify cardiovascular risk factors • To assess presence or absence of target organ damage • To identify other causes of hypertension • These evaluation may used in stratification of the hypertension patients

22. Cardiovascular Risk Factors • Blood pressure • Age • Gender • Dyslipidemia • Abdomen Obesity • Family History of cardiovascular disease • CRP ≥1mg/dl

23. Target Organ Damage • Left ventricular hypertrophy • Echo shows IMT of carotid artery • Plasma creatinine slight elevation • Microalbuminuria

24. Associated Clinical Condition • Cerebrovascular diseases: Stroke, TIA • Heart diseases: MI, AP, CHF, Coronary artery revasculation • Kidney diseases: DN, Dysfunction of the kidney, Proteinuria, CRF • Diabetes • Peripheral artery disease • Retinopathy

25. Evaluation Components • Medical history • Physical examination • Routine laboratory tests

26. Stratification of Hypertension patients TOD-Target Organ Damage; ACC-Associated Clinical Conditions

27. Differential Diagnosis • Should exclude Secondary Hypertension

28. Secondary Hypertension Common Causes • Renal • Glomerulonephritis Pyelonephritis Obstructive nephropathy Collagen diseases, Congenital diseases Diabetes nephropathy Renal tumor---- renin secreting tumor • Pheochromocytoma • Primary aldosteronism

29. Phenochromocytoma • Ganglion-neurotomas and neuroblastomas • Excretion of large amounts of catecholamines • 90% arise in the adrenal medulla • 10% are malignant. • Paroxymal or persist HT • Clinic features: Headache, sweating, palpitations, nervousness, weight loss, hypermetabolism, orthostatic hypotension, severe presser response

30. Primary Aldosteronism • Mild or moderate hypertension • Hypokalemia, muscle weakness, paralysis • Polyuria, nocturia and polydipsia, • Hypochloremic alkalosis • Urine aldosterone elevation • Plasma renin active decrease

31. Secondary Hypertension • Obstructive Sleep Apnea (OSA) • Renal artery stenosis • Cushing’s syndrome • Coarctation of the aorta • Drug-induced: • NSAIDs; Sympathomimetic medications; • Prophylactic; Monoamine oxidase inhibitors; • Mineralocorticoids; Immuno-inhibitors; • Epogen

32. Therapy

33. Goal of Hypertension Management • < 140/90 mm Hg • With Diabetes or kidney dysfunction: <130/80mmHg • To reduce morbidity and mortality of cerebral and cardiovascular complications. • Controlling other cardiovascular risk factors

34. Lifestyle Modifications • Stop smoking • Limit alcohol intake • Lose weight or keep fit • Suitable diet • Increase aerobic physical activity • Decrease psychologicalstress

35. Principle of Drug Therapy • Drug therapy should be individually • A low dose of initial drug therapy • Combination therapies may provide additional efficacy with fewer adverse effects. • Optimal formulation should provide 24-hour efficacy with once-daily dose.

36. Antihypertensive Drugs • Diuretics • ß-Adrenergic receptor blockers (BB) • Calcium channel blockers (CCB) • ACE inhibitors (ACEI) • Angiotensin II receptor blockers (ARB)

37. Hypertension patient Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure Initial Drug Choices

38. Algorithm for Treatment of Hypertension(continued) Initial Drug Choices Noassociated clinical condition Associated clinical condition I stage hypertension: Diuretics, BB,CCB,ACEI,ARB II stage hypertension: Two drugs combination therapy Choice the drugs according to ACC Not at Goal Blood Pressure Increase dosage or add another agent from different class

39. Drug choices in hypertension patient associated with clinical condition

40. Combination Therapies • May provide additional efficacy with fewer adverse effects. • Diuretics as the basement drug in combination therapy. • Diuretics ---- ACEI / ARB • Diuretics ---- BB • Diuretics ---- CCB • CCB as the basement drug in combination therapy • CCB ---- ACEI • CCB ---- BB • Others: Three drugs combination

41. Causes for InadequateResponse to Drug Therapy • Incorrect measurement of the BP • Volume overload or Pseudo-resistance • Drug-related causes • Associated conditions

42. Hypertensive crisis • Hypertensive Emergencies and Urgencies • Emergencies: The blood pressure is elevated severely and associated with target organ damage, such as hypertensive encephalopathy, AMI, pulmonary edema, require immediate blood pressure reduction. • Urgencies: The blood pressure is elevated severely but no target organ damage has acute target organ damage. • Fast-acting drugs are available.

43. Vasodilators Nitroprusside Nicardipine Nitroglycerin Hydralazine Adrenergic Inhibitors Labetalol Esmolol Phentolamine Drugs Available forHypertensive Crisis

44. Case 1 • Male 29 years old • Blood pressure elevated for two years • With paroxysmal dizziness, blurred vision, sweating and palpitation • BP: 160-180/90-100mmHg • HR: 100-120 bpm • When the patient with symptoms, the BP would elevate to 240-260/120-130mmHg, and HR increase to 130-150 bpm.

45. Physical examination: • BP: 165/100mmHg HR: 112 bpm • No positive sign in chest examination • Can find a mass at right abdomen, if press on it the BP of the patient elevated to 250/120mmHg, and the HR increased to 145 bpm.

46. Laboratory test: • Blood routine, Urinalysis, Blood biochemistry are normal • Plasma renine activation:0.93ng/ml.h(0.93-6.56)   • AT II:   51.5pg/ml ↓ (55.3-115.3)  • Aldosterone:  129.4pd/ml (63-239.6) • NE: 33.40pmol/ml ↑↑ (0.51-3.26) • 12-lead electrocardiogram: High voltage of LV • Chest X ray: Normal

47. CT scan of abdomen: • Found a mass at right adrenal Diagnosis as Phenochromocytoma

48. Case 2 • Male, 65 years old • Hypertension history for 30 years • Headache, blurred vision, vomiting for 2 hours • Paralysis of left side body • BP: 220/130mmHg • HR: 106 bpm • CT scan of the head: Normal

49. Diagnosis: Hypertensive crisis • Therapy: Controlled the BP, using fast-acting drug，such as Nitroprusside, Labetalol • The reduction of BP should less than 25% in 24 hours • BP ≥ 160/100mmHg in 48 hours

50. Summary • Specific therapy for patients with LVF, CAD, and HF. ACEI can be used for all type patients. • In older persons, diuretics and CCB are preferred. • Many patients need combination therapy. • Goal of the patients with renal insufficiency with proteinuria (>1 g/day): 125/75 mmHg; • (< 1 g/day): 130/80 mmHg. • Patients with diabetes should be treated to a therapy goal of below 130/80 mm Hg.