Primary Hypertension   2. Pathophysiology   Prof. Dr. med. Günter Hennersdorf                Germany       SES consultant ...
Pathophysiology of Hypertension• Primary Hypertension 90%      – Prevalence about 60% (age 60+)      – Prevalence about 15...
Pathophysiology of Hypertension                   Primary Hypertension             H. without primary organic causeApril 2...
Pathophysiology of Hypertension                        Mean SBP                                                           ...
Cardiovascular risk factors• not modifyable      – Ethnic-genetic risk (black people)      – Age      – Gender• modifyable...
Specific hypertension risks• not modifyable      – Ethnic-genetic risk (black people)      – Age      – Gender• modifyable...
Prevalence of risk factors             within western populations             (FRAMINGHAM-Trial 1998):             Hyperte...
Pathophysiology of Hypertension: risks             mortality risk and blood pressureApril 2013         ghennersdorf SES FE...
Factors inducing Hypertension•    Renin-angiotensin system RAS, RAAS•    Sympathetic nervous system•    Insuline resistanc...
Factors inducing Hypertension• Neurohumoral system dysbalance      – Renin-angiotensin system RAS, RAAS      – Sympathetic...
Pathophysiology of HypertensionHeart Rate      x   Stroke volume      cardiac output                x   Peripheral resista...
Neuro-humoral Regulation of Hypertension    Heart rate x stroke volume   x   Peripheral resistance        =     Blood pres...
Pathophysiology of Hypertension             The role of endothelium             and the RAAS cascadeApril 2013         ghe...
Pathophysiology of Hypertension                                                        prorenine, katecholamines          ...
Pathophysiology of Hypertension:    Angiotensin II Stimulation                                      Sodium, renine        ...
Pathophysiology of Hypertension:     Angiotensin II Effects                                                 synaptic condu...
Pathophysiology of Hypertension                 basic structure and contents of the vessel intimaendothelium              ...
Pathophysiology of Hypertension                                               ACh    Vasoconstriction                     ...
Pathophysiology of Hypertension                                  platelets                 growth factorsEndothelial dysfu...
Angiotensin II Actions                               on endothelium and                                NO =nitric oxide   ...
Pathophysiology of Hypertension                               constriction                           vascular resistance  ...
Pathophysiology of Hypertension               Heart rate x stroke volume   x    Peripheral resistance      =   Blood press...
Pathophysiology of Hypertension                   Conclusion:                   Conclusion:             Primary Hypertensi...
Pathophysiology of Hypertension                               time course of hypertension development                 no s...
Pathophysiology of Hypertension              Trigger example: Obesity, Hyperinsulinism, Type-2-                           ...
Pathophysiology of Hypertension    Heart rate x stroke volume     x   Peripheral resistance       =      Blood pressure   ...
Pathophysiology of HypertensionApril 2013             ghennersdorf SES FESC DGK
Pathophysiology of Hypertension                    Target organ damage                          followed by               ...
Pathophysiology of Hypertension   • Target organ damage:         – Brain: Stroke (ischemic, hemorrhagic)         – Heart: ...
Typical target organ damages following arterial hypertension                           CAD                                ...
Pathophysiology of Hypertension                       Left ventricular                       hypertrophy                  ...
Pathophysiology of Hypertension             Left ventricular hypertrophy      remodeling             (w. anterior wall inf...
Heart failure and hypertension             Diastolic Heart failure: stiffness and relaxation disturbancesu             nor...
Pathophysiology of Hypertension                   Survival rate in relation to renal damage (by renal albuminuria)        ...
Pathophysiology of Hypertension                Secondary Hypertension              H. with primary organic causeApril 2013...
Pathophysiology of Hypertension:                                           secondary H.             •   Renal 5%          ...
Pathophysiology of Hypertension            Systolic Hypertension(H. of the aged w. or w/o. diastolic lowering April 2013  ...
Pathophysiology of Hypertension: Isolated                      systolic Hypertension (ISH).      • Rigidity of the aorta (...
Definition of arterial Hypertension AH*                        systolic blood pressure      diastolic blood pressure   Nor...
Pathophysiology of Hypertension:                 Systolic Hypertension.April 2013          ghennersdorf SES FESC DGK
Pathophysiology of Hypertension:                 Systolic Hypertension.April 2013          ghennersdorf SES FESC DGK
Pathophysiology of Hypertension:                       Systolic Hypertension (SAH).      • Risk of SAH in the elderly (SHE...
Pathophysiology of Hypertension: Morning              Hypertension.               Blood pressure               Heart rate ...
Increased cardiovascular morning risk               Increased cardiovascular morning risk                                 ...
Pathophysiology of Hypertension:                          diastolic blood pressure DBP                                    ...
Pathophysiology of Hypertension             understand                          Save lives and improve life quality       ...
Cardiovascular Diseases    Hypertension Management              part I          The End
Upcoming SlideShare
Loading in...5
×

Hypertension 2013 Pathophysiology

15,814

Published on

Published in: Health & Medicine
0 Comments
8 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
15,814
On Slideshare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
866
Comments
0
Likes
8
Embeds 0
No embeds

No notes for slide

Hypertension 2013 Pathophysiology

  1. 1. Primary Hypertension 2. Pathophysiology Prof. Dr. med. Günter Hennersdorf Germany SES consultant cardiologist
  2. 2. Pathophysiology of Hypertension• Primary Hypertension 90% – Prevalence about 60% (age 60+) – Prevalence about 15-25% (age 25+) – Prevalence mean 35%• Secondary Hypertension 10% – but: may normalize by special treatment (surgery, hormone treatment)!April 2013 ghennersdorf SES FESC DGK
  3. 3. Pathophysiology of Hypertension Primary Hypertension H. without primary organic causeApril 2013 ghennersdorf SES FESC DGK
  4. 4. Pathophysiology of Hypertension Mean SBP Female Male Normal courseof blood pressure over age Mean DBP age male female age April 2013 ghennersdorf SES FESC DGK
  5. 5. Cardiovascular risk factors• not modifyable – Ethnic-genetic risk (black people) – Age – Gender• modifyable – Hypertension – Hyperlipidemia (Cholesterol, TGs) – Smoking – Diabetes – Overweight – Inactivity (physical) – StressApril 2013 ghennersdorf SES FESC DGK
  6. 6. Specific hypertension risks• not modifyable – Ethnic-genetic risk (black people) – Age – Gender• modifyable – Diabetes – Overweight – Alcohol – Salt intake – combinationApril 2013 ghennersdorf SES FESC DGK
  7. 7. Prevalence of risk factors within western populations (FRAMINGHAM-Trial 1998): Hypertension 20 % >65 J.: 65% Smoking 31 % Overweight 54 % Hyperlipidemia 50 - 60 %April 2013 ghennersdorf SES FESC DGK
  8. 8. Pathophysiology of Hypertension: risks mortality risk and blood pressureApril 2013 ghennersdorf SES FESC DGK
  9. 9. Factors inducing Hypertension• Renin-angiotensin system RAS, RAAS• Sympathetic nervous system• Insuline resistance• Overweight• Stiff vessel walls (endothelial dysfunction)• Vasoactive substances (NO, Endotheline)• Kallikrein secretion• Natriuretic peptidesApril 2013 ghennersdorf SES FESC DGK
  10. 10. Factors inducing Hypertension• Neurohumoral system dysbalance – Renin-angiotensin system RAS, RAAS – Sympathetic nervous system Most important hypertension cause!April 2013 ghennersdorf SES FESC DGK
  11. 11. Pathophysiology of HypertensionHeart Rate x Stroke volume cardiac output x Peripheral resistance = Blood pressure Basic equation according to Law of OHM: Current I x Resistance R = Voltage UApril 2013 ghennersdorf SES FESC DGK
  12. 12. Neuro-humoral Regulation of Hypertension Heart rate x stroke volume x Peripheral resistance = Blood pressure alpha1 beta1 Norepinephrine Angiotensin II Nervous system Humoral RAAS* *RAAS or RAS: renine angiotensine aldosterone systemApril 2013 ghennersdorf SES FESC DGK
  13. 13. Pathophysiology of Hypertension The role of endothelium and the RAAS cascadeApril 2013 ghennersdorf SES FESC DGK
  14. 14. Pathophysiology of Hypertension prorenine, katecholamines Angiotensinogene Renin Pathway of RAAS in thePathway of RAAS in theOrganism (kidney, heart, Tissues: e.g. Angiotensin IVessels) to maintain Vessel wallFluid volume control, ACEAdjustment of CO andResistance. Angiotensin II Competition of receptors:If regulation fails, high AT1 vasoconstriction AT2 vasodilatationblood pressure occurs receptor AT1 AT2April 2013 ghennersdorf SES FESC DGK
  15. 15. Pathophysiology of Hypertension: Angiotensin II Stimulation Sodium, renine Kidney Ang II* *Ang II effects mediated by AT1 Hypophysis Adrenal gland Hormone release Aldosterone, katecholamines April 2013 ghennersdorf SES FESC DGK
  16. 16. Pathophysiology of Hypertension: Angiotensin II Effects synaptic conduction Brainvasoconstriction vessels Ang II Heart hypertrophy constrictionAT1 mediated effects of Uterus contractionAngiotensin II April 2013 ghennersdorf SES FESC DGK
  17. 17. Pathophysiology of Hypertension basic structure and contents of the vessel intimaendothelium Contents Smooth muscle cellsintima SMC SMCmedia Collagenes ThrombocytesOuter layer Ox-LDL NO Kinines Enzymes coagulation factors platelet activation factors thromboxane April 2013 prostacycline ghennersdorf SES FESC DGK
  18. 18. Pathophysiology of Hypertension ACh Vasoconstriction Vasodilatation NE Vessel dilatation; NE endothelium intact NE ACh NENE=NorepinephineAch=Acetylcholine NE NE no dilatation; endothelium removed Furchgott‘s basic experiment (1980): key role of endothelium April 2013 ghennersdorf SES FESC DGK
  19. 19. Pathophysiology of Hypertension platelets growth factorsEndothelial dysfunction causing atherosclerosis and vasoconstriction, infarction April 2013 ghennersdorf SES FESC DGK
  20. 20. Angiotensin II Actions on endothelium and NO =nitric oxide AT1 AT2 AT1 stimulation AT2 stimulation leads to: leads to: growth+ vasoconstriction differentiation vasodilatation vasoactivity NO inhibition NO Smooth muscle cell growthApril 2013 ghennersdorf SES FESC DGK modified acc. to Unger T et al 1996
  21. 21. Pathophysiology of Hypertension constriction vascular resistance Endothelial dysfunction causing hypertensionApril 2013 ghennersdorf SES FESC DGK
  22. 22. Pathophysiology of Hypertension Heart rate x stroke volume x Peripheral resistance = Blood pressure n.sympathicus RAAS* Stress Genetic/Familial Vasoconstriction social ethnic familial Hereditary Endothelial salt sensitivity dysfunction*renine angiotensine aldosterone system April 2013 ghennersdorf SES FESC DGK
  23. 23. Pathophysiology of Hypertension Conclusion: Conclusion: Primary Hypertension Primary Hypertension is a target disease mainly is a target disease mainly of the RAAS -- intima -- endothelium system! of the RAAS intima endothelium system! the endothelium is the major playerApril 2013 ghennersdorf SES FESC DGK
  24. 24. Pathophysiology of Hypertension time course of hypertension development no symptoms Nonspecific Symptoms: Head ache, Palpitation,Onset,Trigger Chronic stage Exertional dyspnea target organ damage death 3 4 5 6 6+ (x10th years) accelerated course April 2013 ghennersdorf SES FESC DGK
  25. 25. Pathophysiology of Hypertension Trigger example: Obesity, Hyperinsulinism, Type-2- Diabetes Hypertension Metabolic syndrome (X)April 2013 ghennersdorf SES FESC DGK
  26. 26. Pathophysiology of Hypertension Heart rate x stroke volume x Peripheral resistance = Blood pressure AT2 - beta1 + (NO ) AT1 + alpha1 Norepinephrine Angiotensin II Hyperinsulinemia Sympathicus RAASApril 2013 ghennersdorf SES FESC DGK
  27. 27. Pathophysiology of HypertensionApril 2013 ghennersdorf SES FESC DGK
  28. 28. Pathophysiology of Hypertension Target organ damage followed by arterial hypertensionApril 2013 ghennersdorf SES FESC DGK
  29. 29. Pathophysiology of Hypertension • Target organ damage: – Brain: Stroke (ischemic, hemorrhagic) – Heart: CAD, Heart failure (mainly diastolic) – Vessels: • Peripheral arterial disease • Central arterial disease: aortic dissection, aneurysm • Renovascular diseaseApril 2013 ghennersdorf SES FESC DGK
  30. 30. Typical target organ damages following arterial hypertension CAD stroke LV hypertrophy Peripheral artery disease: necrosis, gangreneApril 2013 ghennersdorf SES FESC DGK
  31. 31. Pathophysiology of Hypertension Left ventricular hypertrophy Coronary Atherosclerosis Heart failure (prevalence ~50%) Main target lesions Brain: Stroke (prevalence ~20%) Wall damage Cerebral Atherosclerosis Renovascular damageApril 2013 ghennersdorf SES FESC DGK
  32. 32. Pathophysiology of Hypertension Left ventricular hypertrophy remodeling (w. anterior wall infarction) Heart failureApril 2013 ghennersdorf SES FESC DGK
  33. 33. Heart failure and hypertension Diastolic Heart failure: stiffness and relaxation disturbancesu normal Early stage Late stage Ultrasound appearance of mitral flow patterns (EA relation) April 2013 ghennersdorf SES FESC DGK
  34. 34. Pathophysiology of Hypertension Survival rate in relation to renal damage (by renal albuminuria) Survival rate% Alb. < median Alb. > median Median 7,52 µg/min P=0,0078April 2013 ghennersdorf SES FESC DGK
  35. 35. Pathophysiology of Hypertension Secondary Hypertension H. with primary organic causeApril 2013 ghennersdorf SES FESC DGK
  36. 36. Pathophysiology of Hypertension: secondary H. • Renal 5% – Parenchymal – Renovascular (0,3%) (corrected to normal by balloon treatment or surgery!) – Tumors – Little‘s disease • Endocrine – Thyroid dysfunction (1%) – Adrenal (0,3%) – Carcinoid – hormones • Aortic coarctation • Pregnancy • Neurogenic (brain tumor, lead, porphyria, sleep apnea) • Acute stress (including surgery) • iv. volume increase • Alcohol abuse Some may induce primary hypertension, so that the relationships sometimes are weakApril 2013 ghennersdorf SES FESC DGK
  37. 37. Pathophysiology of Hypertension Systolic Hypertension(H. of the aged w. or w/o. diastolic lowering April 2013 ghennersdorf SES FESC DGK
  38. 38. Pathophysiology of Hypertension: Isolated systolic Hypertension (ISH). • Rigidity of the aorta (aged aorta) • Increased cardiac output – Aortic Valve regurgitation – AV fistula – Thyreotoxic crisis – Paget‘s disease (bone vessel fistulas) – Beriberi (Vit. B deficiency) – Hyperkinetic circulation (young, unfit)April 2013 ghennersdorf SES FESC DGK
  39. 39. Definition of arterial Hypertension AH* systolic blood pressure diastolic blood pressure Normal <140 and <90 (diabetic <130 <80) mild AH 140-179 and/or 90-104 borderline AH 140-159 90-94 intermediate >=180 and/or >=105 severe AH isolated >=160 and <90 systolic AH 140-159 (ISH)April 2013 ghennersdorf SES FESC DGK *WHO 2000
  40. 40. Pathophysiology of Hypertension: Systolic Hypertension.April 2013 ghennersdorf SES FESC DGK
  41. 41. Pathophysiology of Hypertension: Systolic Hypertension.April 2013 ghennersdorf SES FESC DGK
  42. 42. Pathophysiology of Hypertension: Systolic Hypertension (SAH). • Risk of SAH in the elderly (SHEP, SYST-EUR Trials) – Stroke 20% Reduction) – Heart failure 54% Reduction) – Death 24% These results were maintained over 5 years observationApril 2013 ghennersdorf SES FESC DGK
  43. 43. Pathophysiology of Hypertension: Morning Hypertension. Blood pressure Heart rate Resistance Cardiac output Renal functionApril 2013 ghennersdorf SES FESC DGK
  44. 44. Increased cardiovascular morning risk Increased cardiovascular morning risk Morning BP rise Stroke /2h Infarction /1 h 6 pm 0:00 6 am 12 amApril 2013 ghennersdorf SES FESC DGK
  45. 45. Pathophysiology of Hypertension: diastolic blood pressure DBP Prognosis Stroke risk and DBP CAD risk and DBP4,0 4,0 2,01,0 1,0 76 84 91 98 105 76 84 91 98 105 April 2013 ghennersdorf SES FESC DGK
  46. 46. Pathophysiology of Hypertension understand Save lives and improve life quality diagnose treat controlApril 2013 ghennersdorf SES FESC DGK
  47. 47. Cardiovascular Diseases Hypertension Management part I The End
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×