Essential hypertension management and treatment


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Essential Hypertension management and treatment

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Essential hypertension management and treatment

  1. 1. KGMU 2011 Fabio Grubba
  2. 2.  Essential hypertension or idiopathic hypertension is the form of hypertension that by definition, has no identifiable cause. Hypertension can increase the risk of cerebral, cardiac, and renal events.
  3. 3.  US national institute of health –JNC guide lines for hypertension JCN-7 Joint national committee on prevention , detection, evaluation, and treatment of High blood pressure JCN-8
  4. 4.  BP mm/hg Lower than 120/80 NORMAL 120-139/80-89 PREHYPERTENSION 140-159/90-99 STAGE 1 Hypertension Above 160/100 STAGE 2 HypertensionAmerican Heart Association
  5. 5.  Stage I Hypertension. systolic pressure 140 to 159 mm Hg and or diastolic pressure measurements 90-99 mm Hg. Tachycardia Stage II Hypertension. Stage II systolic elevation (160 to 179 mm of Hg) and or diastolic pressure (100 to 109 mm Hg). Symptoms are the same as noted in Stage I. Stage I and II hypertension may be treated no pharmacologically with diet and exercise or pharmacologically with antihypertensive medications. Stage III Hypertension. persistent elevation (systolic >180mm Hg; diast olic >110mm Hg) with target end organ Damage. This stage is often treated immediately with antihypertensive medications. Hypertensive urgency is a condition of persistent elevation in blood Pressure . symptoms of dizziness, chest pain, or confusion. Hypertensive crisis is similar condition,however the patient has sympt oms of target end organ damage. ESH (European society of cardiology)
  6. 6.  Labile hypertension: AP are sometimes but not always in the hypertensive range Accelerated Hypertension: Significant increase of pressure that previous Hytpertensive levels (Vascular damage) White coat hypertension:Persistent higher but only in doctors presence Isolated Systolic Pressure:Related with patients above 50 Years of age caused by arterial stiffness
  7. 7.  Family history Obesity Advanced age Inactivity Cigarette smoking Excessive salt consumption Excessive alcohol consumption
  8. 8.  Abnormal Na transport: Na-K pump (Na+, K+-ATPase) is defective or inhibited intracellular Na = cell sensitive to sympathetic stimulation Sympathetic nervous system:Sympathetic stimulation increases BP Renin-angiotensin-aldosterone system Vasodilator deficiency:Deficiency of a vasodilator (eg, bradykinin, nitric oxide) Pathology and complications: No pathologic changes occur early in hypertension. Most of the patients with essential hypertension have the normal cardiac output but raised peripheral resistance
  9. 9.  Hypertension is usually asymptomatic until complications develop in target organs Dizziness, flushed facies, headache, fatigue, epistaxis, and nervousness are not caused by essential hypertension. ONLY Severe hypertension can cause severe cardiovascular, neurologic, renal, and retinal symptoms (eg, symptomatic coronary atherosclerosis, HF, hypertensive encephalopathy, renal failure).
  10. 10.  Multiple measurements of BP to confirm Urinalysis and urinary albumin:creatinine ratio Renal ultrasonography if creatinine increased Blood tests: Fasting lipids, creatinine, K Evaluate for aldosteronism if K decreased ECG: If left ventricular hypertrophy, consider echocardiography Sometimes thyroid-stimulating hormone measurement
  11. 11.  BP must be measured twice—first with the patient supine or seated, then after the patient has been standing for ≥ 2 min—on 3 separate days. Classification BP (mm Hg) Normal: < 120/80 Pre-hypertension: 120–139/80–89 Stage 1: 140–159 (systolic) or 90–99 (diastolic) Stage 2: ≥ 160 (systolic) or ≥ 100 (diastolic)
  12. 12.  Weight loss and exercise Smoking cessation Diet: Increased fruits and vegetables, decreased salt, limited alcohol Drugs if BP is initially high (> 140/90 mm Hg) or unresponsive to lifestyle modifications
  13. 13.  Lifestyle recommendations include regular aerobic physical activity :at least 30 min/day; weight loss to a body mass index of 18.5 to 24.9; smoking cessation; a diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat content; dietary sodium[Na + ] of < 2.4 g/day (< 6 g NaCl); and alcohol consumption of ≤ 1 oz/day in men and ≤ 0.5 oz/day in women
  14. 14.  If systolic BP remains > 140 mm Hg or diastolic BP remains > 90 mm Hg after 6 or more years of lifestyle modifications, antihy For most hypertensive patients, one drug, usually a thiazide-type diuretic, is given initially. pertensive drugs are required. Low-dose aspirin (81 mg once/day) appears to reduce incidence of cardiac events in hypertensive patients
  15. 15. •Some antihypertensives arecontraindicated in certain disorderslike β-blockers in asthma• OR indicated particularly for certaindisorders as β-blockers or Ca channelblockers for angina pectoris•ACE inhibitors or angiotensin IIreceptor blockers for diabetes•When a single drug is used, blackmen may respond best to a Cachannel blocker (eg, diltiazem).• Thiazide-type diuretics appear tobe particularly effective inpeople > 60 and in blacks.
  16. 16.  Diuretics: modestly reduce plasma volume and reduce vascular resistance, possibly via shifts in Na from intracellular to extracellular loci. These drugs are the least expensive initial therapyMain are thiazide-type diuretics, loop diuretics, and K-sparing diuretics. Loop diuretics are used to treat hypertension only in patients who have lost > 50% of kidney function. Thiazide-type diuretics are most commonly used. In addition to other antihypertensive effects, they cause vasodilation as long as intravascular volume is normal. Thiazide-type diuretics can increase serum cholesterol slightly (mostly low-density lipoprotein) and also increase triglyceride levels, All diuretics except the K-sparing distal tubular diuretics cause significant K loss.
  17. 17.  β−Blockers: These slow heart rate and reduce myocardial contractility, thus reducing BP. All β-blockers are similar in antihypertensive efficacy. In patients with diabetes, chronic peripheral arterial disease, or COPD, a cardioselective β-blocker acebutolol, atenolol, betaxolol,bisoprolol, metoprolol) cardioselective β-blockers are contraindicated in patients with asthma or in patients with COPD with a prominent bronchospastic component. β-Blockers have CNS adverse effects (sleep disturbances, fatigue, lethargy) and exacerbate depression
  18. 18.  Ca channel blockers: are potent peripheral vasodilators and reduce BP by decreasing TPR; they sometimes cause reflexive tachycardia. Nondihydropyridines,verapamil,anddiltiazem slow the heart rate, decrease atrioventricular conduction, and decrease myocardial contractility. Long-acting nifedipine,verapamil,ordiltiazem,is used to treat hypertension, but short-acting nifedipine and diltiazem are associated with a high rate of MI and are not recommended. A Ca channel blocker is preferred to a β-blocker in patients with angina pectoris and a bronchospastic disorder, with coronary spasms
  19. 19.  ACE inhibitors: These drugs reduce BP by interfering with the conversion of angiotensin I to angiotensin II and by inhibiting the degradation of bradykinin, thereby decreasing peripheral vascular resistance without causing reflex tachycardia. These drugs reduce BP in many hypertensive patients, regardless of plasma renin activity. these drugs provide renal protection, they are the drugs of choice for patients with diabetes and may be preferred for blacks. A dry irritating cough is the most common adverse effect
  20. 20.  Adrenergic modifiers: This class includes central α2-agonists, postsynaptic α1-blockers, and peripheral-acting adrenergic blockers. α 2-Agonists: methyldopa, clonidine,guanabenz, guanfacine stimulate α2-adrenergic receptors in the brain stem and reduce sympathetic nervous activity, lowering BP. Because they have a central action, they are more likely than other antihypertensives to cause drowsiness, lethargy, and depression; they are no longer widely used.
  21. 21.  Direct vasodilators: These drugs work directly on vessels, independently of the autonomic nervous system. but has more adverse effects, including Na and water retention and hypertrichosis, which is poorly tolerated by women.
  22. 22.  Age,sex,alcohol intake,blood serum cholesterol,glucose intolerance and weight Hypertension is a progressive and lethal disease with not treated properly Untreated hypertension is associated with shortening of life by 10 till 20. Nearly 30 % of patients acquires atherosclerosis complication More than 50 % will have a end organ damage
  23. 23.  IMC lower than 25 always Limit salt , caffeine and alcohol excessive consumption Exercise regularly
  24. 24.  The ultimate public health goal of antihypertensive therapy is to reduce the morbidity and mortality from cardiovascular and renal events. It is well established that lowering BP reduces cardiovascular risk. Study has estimated the absolute benefit associated with a 12-mm Hg reduction in systolic BP over 10 years. For the patient with stage 1 hypertension (systolic BP 140-159 mm Hg and/or diastolic BP 90- 99 mm Hg) and additional cardiovascular risk factors, one death would be prevented for every 11 patients treated. In the presence of cardiovascular disease with target organ damage, only nine patients would require BP reduction to prevent a death. Evidence exists that treating systolic BP and diastolic BP to a target below 140/90 mm Hg is associated with reduction in cardiovascular disease complications. Data now support treatment to a BP goal below 130/80 mm Hg in patients with hypertension, diabetes mellitus, or renal disease. Hypertension is an important modifiable risk factor. Although a majority of patients with hypertension remain asymptomatic, a careful early evaluation identifies those with or at risk for target organ damage The effective management of hypertension is therefore an important primary health care objective in managing cardiovascular and renal disease. The majority of patients with uncontrolled hypertension are older adults with isolated stage 1 or 2 systolic hypertension, most of whom have access to and regular visits with their health care providers.
  25. 25. 1. hypertension/2. Pickering TG, Miller NH, Ogedegbe G, et al: American Heart Association; American Society of Hypertension; Preventive Cardiovascular Nurses Association: Call to action on use and reimbursement for home blood pressure monitoring: A joint scientific statement from the American Heart Association, American Society Of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008, 52: (1): 10-29.3. Guyton AC. Blood pressure control—Special role of the kidneys and body fluid. Science. 1991, 252: 1813-1816.4. _of_hypertension.html6. ab&hl=en&source=hp&q=hypertension+JNC&pbx=1&oq=hypertension+JNC&aq=f&aqi=g4&aq l=1&gs_sm=e&gs_upl=4063l5601l1l5820l4l4l0l0l0l0l1665l1665l8- 1l1l0&bav=on.2,or.r_gc.r_pw.,cf.osb&fp=2196ee66493014b2&biw=1920&bih=9798.