HYPERTENSION

1. HYPERTENSION V.V.L.N.S.N.Gupta

2. Risk stratification of patients with hypertension Blood pressure (mm Hg) Stage Other risk factors and disease history Stage 1 Stage 2 Stage 3 SBP 140-159 or DBP 90-99 SBP 160-179 or DBP 100-109 SBP 180 or DBP  110 I No other risk factors Low risk Medium risk High risk II 1-2 risk factors Medium risk Medium risk Very high risk

3. Risk stratification of patients with hypertension Blood pressure (mm Hg) Stage Other risk factors and disease history Stage 1 Stage 2 Stage 3 SBP 140-159 or DBP 90-99 SBP 160-179 or DBP 100-109 SBP 180 or DBP  110 III 3 or more risk factor or TOD or Diabetes High risk High risk Very high risk IV ACC Very high risk Very high risk Very high risk Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = Less than 15% Medium risk = about 15-20% High risk = about 20-30% Very high risk – 30% TOD: Targe Organ Damage ACC: Associated clinical condition, including clinical cardiovascular disease or renal disease

4. Risk factors for HTN: • Non-modifiable • Modifiable

5. Non-modifiable risks: • Age • Genetic factors

6. Modifiable risks: • Obesity • Salt intake • High salt intake (7-8 g/day) increases B.P proportionately • Low sodium intake lowers B.P • (Due to genetic abnormality of Kidney which makes salt excretion difficult except at raised levels of arterial pressure)

7. Modifiable risks: • Other minerals • Potassium lowers B.P • Calcium, Cadmium, Magnesium also lowers B.P

8. Modifiable risks: • Saturated fats: • Raise BP • Alcohol • High alcohol intake is associated with increased risk of high B.P • Alcohol consumption raises Systolic B.P more than Diastolic B.P • Abstinence brings B.P back to previous level

9. Modifiable risks: • Physical activity • Leads to weight reduction and hence B.P • Environmental stress • Over activity of sympathetic nervous system increase B.P

10. Modifiable risks: • Other factors • Oral contraceptive pills (due to oestrogens) • Noise • Vibration, Temperature, Humidity – consistent

11. Modifiable risks: • Smoking: • Nicotine and Carbon monoxide are potent vasoconstrictors • Smoking of 2 cigarettes raises SBP & DBP by 16 mm Hg for 20 minutes

12. HTN – 2 MAIN CATEGORIES: • Primary (essential) – causes unknown • Secondary – due to some cause e.g., Kidney disease, Adrenal gland tumors, Toxemia of pregnancy

13. CAUSES OF HYPERTENSION SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE • Decreased compliance of aorta (arteriosclerosis) • Increased stroke volume

14. CAUSES OF HYPERTENSION SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE • Aortic regurgitation • Thyrotoxicosis • Hyperkinetic heart syndrome • Fever • Arteriovenous fistula • Patent ductus arteriosus

15. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Renal • Chronic pyelonephritis • Acute and chronic glomerulonephritis • Polycystic renal disease

16. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Renovascular stenosis or renal infarction • Most other severe renal diseases (arteriolar nephrosclerosis, diabetic nephropathy etc.,) • Renin-producing tumors

17. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Endocrine • Oral contraceptives • Adrenocortical hyper function • Cushing’s disease and syndrome • Primary hyperaldosteronism • Congenital or hereditary adrenogenital syndromes (17-hydroxylase defects)

18. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Pheochromocytoma • Myxedema • Acromegaly

19. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Neurogenic • Psychogenic • Diencephalic syndrome • Familial dysautonomia (Riley-Day)

20. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Polyneuritis (acute poryphyria, lead poisoning) • Increased intracranial pressure (acute) • Spinal cord section (acute)

21. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Miscellaneous • Coarctation of aorta • Increased intravascular volume (excessive transfusion, polycythemia vera) • Plyarteritis nodosa • Hypercalcemia • Medications, e.g., glucocorticoids, cyclosporine

22. CAUSES OF HYPERTENSION SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR RESISTANCE • Unknown etiology • Essential hytypertension ( 90% of all cases of hypertension) • Toxemia of pregnancy • Acute intermittent prophyria

23. EFFECTS OF HTN • Effects on Heart • 1.1. Left Ventricular Hypertrophy •  • Deterioration of cardiac function •  • Dilatation & thinning of LV Cavity •  • Heart failure

24. EFFECTS OF HTN • 1.  Angina pectoris (due to increased 02 demand of a hypertrophied heart) • 2.     Ischaemia or Infarction • 3.     Death due to 1, 2,3

25. EFFECTS OF HTN B. Neurological effects Retinal changes CNS dysfunction

26. EFFECTS OF HTN Occipital headache especially in morning Dizziness Light headache Vertigo Tinnitis

27. EFFECTS OF HTN Dimmed vision Syncope Cerebral infarction Haemorrhage Encephalopathy

28. EFFECTS OF HTN Effects on Kidney: Arteriosclerosis of afferent & efferent glomerular arterioles Decreased Glomerular filtration rate Proteinemia Haematuria (Microspic ) Renal failure

29. EFFECTS OF HTN • Blood loss • from Kidneys • Epistaxis • Haemoptysis • Metrorrhagia

30. HTN-SOME FACTS • Anti hypertensive treatment is associated with decrease n incidence of • Stroke by 35-40% • MI by 20-25% • Heart failure by 50%

31. HTN-SOME FACTS • 5 mm of Hg reduction in DBP can reduce heart disease risk by 21% • For every fall of 20 mm Hg SBP & 10 mm Hg DBP, You need one intervention – • Lifestyle modification or treatment with one drug

32. Three sources of error in recording B.P • Observer errors e.g., hearing acuity interpretation of Korotkow sounds • Instrumental errors e.g., leaking valve Cuffs that do not encircle the arm • Small cuff – higher reading • Subject errors: e.g., Circumstances of examination • Physical environment • Position of the subject • External stimuli e.g., fear, anxiety

33. Three sources of error in recording B.P • Subject errors: e.g., Circumstances of examination • Physical environment • Position of the subject • External stimuli e.g., fear, anxiety

34. WHO Recommendation: • Sitting position • Uniform policy – consistently use the same arm for B.P measurement • Pressure at which the sounds are first heard (Phase I)  Systolic pressure • Near Diastolic B.P, sounds first become muffled (Phase-IV) & then disappear (Phase-V) Phase-V taken as DBP

35. Rule of halves: • ½ of the HTN patients, aware of this condition • ½ of these being treated • ½ of these being treated effectively

36. Investigations: • Urine for protein • Blood glucose • Microscopic urinalysis • Haematocrit or ESR • S.Potassium

37. Investigations: • S.Creatinine and/or BUN • FBS • Total Cholesterol • ECG in all cases

38. TREATMENT: • General measures: • Relief of stress • Dietary management • Regular aerobic exercise • Weigh reduction • Control of other risk factors contributing to development of arteriosclerosis

39. Drug treatment: • ACE Inhibitors e.g., Encaplril, Lisinopril, Ramipril • Angiotensin I antagonists e.g., Losartan, temisartan, Valsartan • Calcium channel Blockers e.g., Nifedipine, Amlodepine • Diuretics e.g., Furosemide, Hydrochlorothiazide, Spironolactone • Beta Aderenergic Blockers e.g,Atenolol, Metoprolol

40. Drug treatment: • Alpha Adrenergic Blockers e.g., Prazosin, Terazocin • Central Sympatholytics e.g., Methyldopa • Vasodilators • Arteriolar e.g, Hydralazine, Minoxidil, Diazoxide • Arteriolar + Venous – e.g., Sodium Nitrtoprusside