Systemic atherosclerosis develops with increased intimal-medium thickness leading to ischemic alterations in target organs such as heart, brain, kidney and peripheral artery.
Blood vessel change
Aorta and large arteries
recurrent pulsatile stress produces uncoiling, disruption and calcification of elasstic fibres. At the same time, relatively inelastic collagen is increased.
This is a result of ageing as well as hypertension : both processes therefore cause loss of the normal elastic reservoir funtion of the aorta and large arteries.
This explains one curious feature of elderly hypertensive patients. Diastolic blood pressure in patients with isolated systolic hypertension is inversely related to prognosis.
The predominant pathological change is wall thickening caused by increased deposition of collagenous material.
The characteristic structural change in smaller arteries and arterioles responsible for peripheral vascular resistance is an increase in wall:lumen ratio.
In recent years it has become clear that what was thought to be a trophic response is largely if not entirely due to rearrangement of smooth muscle cells around a smaller lumen.
Specific organ changes in hypertension
Angina and myocardial infarction in the hypertensive patient are usually due to coronary atheroma.
Left ventricular hypertrophy is demonstrable in about 50 per cent of untreated hypertensive patients when echocardiography is used, and in 5 to 10 per cent with electrocardiography using conventional criteria.
Hpertrophy of left ventricle
Central nervous system
Cerebral infarction in a hypertensive patient is usually attributable to atheroma of one of the larger cerebral arteries (usually the middle cerebral artery) and accounts for about 80 percent of the strokes which these patients suffer.
Intracerebral haemorrhage accounts for 10 to 15 percent, usually the result of rupture of a small intracerebral degenerative microaneurysm.
The long-term renal damage produced by glomerular hypertension probably accountd for progressive glomerulosclerosis in essential hypertension.
Atheromatous renal vascular disease much more commonly causes renal impairment in elderly hypertensive subjects than younger patients with treated mild to moderate hypertension.
肾动脉硬化 肾动脉硬化 致密的肾盂 X 线影象
Malignant hypertension: Fibrinoid necrosis of damaged arteriole of kidney
Stage I: constriction of retinal arterioles only.
Stage II: constriction and sclerosis of retinal arterioles.
Stage III: hemorrhages and exudates in addition to vascular changes.
Stages IV: papilledema.
the classic hypertensive headache is present on walking in the morning, situated in the occipital region of the head, radiating to the frontal area, throbbing in quality, and wears off during the course of the day.
Most headaches in hypertensive patients are tension headaches not directly related to blood pressure. Nevertheless, effective treatment of hypertension reduces the incidence of headache.
Whilst epistaxis is not associated with mild hypertension, it is much more common in moderate to severe hypertension.
this is one of the most frequent clinically apparent consequences of blood pressure elevation resulting from reduction in urine-concentrating capacity.
Symptoms associated with target organ damage
Effort dyspnoea and orthopnoea suggest cardiac failure. Increased left ventricular mass is associated with decreased compliance and impaired cardiac output response to exercise.
Central nervous system
Extensive disease of the perforating arteries may give rise to a lacunar state characterized by progressive pseudobulbar plasy and dementia.
Haematuria suggest the malignant phase of hypertension in the absence of any other cause.
Scotomas suggest fundal haemorrhages or exudates, whilst blurring of vision is associated with papilloedema.
Chronic kidney disease
Dissection of aorta
SBP>=140 mmHg or DBP>=90 mmHg.
Loud aortic second sound
Other physical signs indicate target organ damage
Diagnosis of primary hypertension depends on repeatedly demonstrating higher –than-normal systolic and /or diastolic BP and excluding secondary hypertension.
CVD Risk Factors
Obesity* (BMI > 30 kg/m 2 )
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
Cardiovascular risk category of hypertension Blood pressure （ mmHg ） Grade 1(SBP 140 ～ 159 or DBP 90 ～ 99) Grade 2(SBP 160 ～ 179 or DBP 100 ～ 109) Grade 3(SBP ≥180 or DBP ≥110) No other risk factors Low-risk Medium-risk High-risk 1 ～ 2 risk factors Moderate-risk Medium-risk Very High-risk 3 or more risk factors ， or diabetes ， or target organ damage High-risk High-risk Very High-risk complications Very High-risk Very High-risk Very High-risk
Serum potassium, creatine, blood glucose, blood lipids, complete blood count, uric acid, ECG, cardiac and chest x-ray exam and funduscopic exam for retinopathy.
Double peaks and one hollow
Goals of Therapy
Reduce CVD and renal morbidity and mortality.
Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons > 50 years of age .
Blood Pressure Reduction of 2 mmHg Decreases the Risk of Cardiovascular Events by 7–10%
Meta-analysis of 61 prospective, observational studies
1 million adults
12.7 million person-years
2 mmHg decrease in mean SBP 10% reduction in risk of stroke mortality 7% reduction in risk of ischaemic heart disease mortality Lewington et al. Lancet 2002;360:1903–13
the trial of hypertension prevention produced an average weight loss of 3.8 kg at 18 months, reduction of SBP and DBP by 2.9 and 2.3 mm Hg.
Following increased physical activity, BP falls up 6-7 mm Hg for both SBP and DBP.
Alcohol reduction and smoking cessation
Stress reduction/relaxing training
Dietary changes: low salt intake; potassium, magnesium and calcium supplementation; others.
Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
Calcium channel blockers
Angiotensin II receptor blockers
Indications : cardiac failure
systolic hypertension in elderly
after myocardial infarction
cardiac failure (with care)
Contraindications :asthma and chronic obstructive airway disease
peripheral vascular disease
Indications :systolic hypertension in the elderly
Contraindications:heart block (verapamil and diltiazem)
Indications: cardiac failure
left ventricular dysfunction
after myocardiac infarction (higher- risk patients)
diabetic nephropathy and other proteinuric renal disease
sodium and fluid depletion
Indications: as for ACEI in presence of ACEI induced cough or intolerance
Contraindications: as for ACEI
Contraindications: urinary incontience
Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal <120 and <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension > 160 or > 100 Yes Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
Other medications for hypertensive patients Primary prevention ( 1 ) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) ( 2 ) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies’ cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l ( 3 ) Vitamins—no benefit shown, do not prescribe
(including patients with type 2 diabetes)
Aspirin: use for all patients unless contraindicated
( 2 ) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration 3.5 mmol/l
(3) Vitamins— no benefit shown, do not prescribe
Other medications for hypertensive patients
Targets for lipid lowering Ideal - TC<4.0mmol/l or LDL <2.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater ‘ Audit’ - TC <5.0mmol/l or LDL <3.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater Lipid targets
Some key points of the 2007 ESH and ESC guidelines
CVD Risk Factors
There are some new risk factors :
fasting blood glucose 5.6 ～ 6.9mmol/L ;
pulse pressure (in the elderly)
Target organ damage
ECG shows Left ventricular hypertrophy;
PWV>12 m/s ;
GFR<50ml/ （ min·1.75m 2 ）
creatinine clearance rate <60ml/min
ESH - ESC Guidelines, J Hypertens 2008 -BP < 140/90 mmHg in all hypertensive patients < 130/80 mmHg in hypertensive patients with diabetes or renal disease -Control of all cardiovascular risk factors Goals of treatment
About drug treatment
Diuretics, ß –Blockers, Calcium channel blockers, ACE inhibitors and Angiotensin II receptor blockers can be used in onset and maintenane therapy.
Diuretics combined with ß –Blockers is not suitable for metabolic syndrome or high-risk diabetes patients.
Low-dose combination therapy as first line treatment of mild-to-moderate hypertension
Screening and treatment of secondary forms of hypertension