This document provides an overview of hypertension. It defines hypertension as elevated blood pressure that exerts force against blood vessel walls. It then describes the mechanisms that regulate blood pressure, including the sympathetic nervous system, vascular endothelium, renal system, and endocrine system. When these systems are defective, it can lead to primary (essential) hypertension which accounts for 95% of cases. The document outlines risk factors, clinical manifestations, diagnosis, and medical management of primary hypertension through lifestyle modifications and drug therapy.
2. HypertensionHypertension
Definition:Definition: the force exerted by the bloodthe force exerted by the blood
against the walls of the bleed vesselsagainst the walls of the bleed vessels
Adequate to maintain tissue perfusion duringAdequate to maintain tissue perfusion during
activity and restactivity and rest
Arterial blood pressure: primary function ofArterial blood pressure: primary function of
cardiac output and systemic vascular resistancecardiac output and systemic vascular resistance
3. HypertensionHypertension
Arterial BP = Cardiac Output (CO) x SystemicArterial BP = Cardiac Output (CO) x Systemic
vascular resistance (SVR)vascular resistance (SVR)
Cardiac OutputCardiac Output = stroke volume x beats per min= stroke volume x beats per min
Systemic vascular resistanceSystemic vascular resistance = force opposing the= force opposing the
movement of blood within the blood vesselsmovement of blood within the blood vessels
What is the effect on BP if SVR increased and COWhat is the effect on BP if SVR increased and CO
remains constant?remains constant?
4. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Sympathetic Nervous SystemSympathetic Nervous System
Vascular EndotheliumVascular Endothelium
Renal SystemRenal System
Endocrine SystemEndocrine System
5. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Sympathetic Nervous System (SNS)Sympathetic Nervous System (SNS) ––
norepinephrine released from sympathetic nervenorepinephrine released from sympathetic nerve
endings - to receptors alpha1, alpha2, beta 1 & beta2endings - to receptors alpha1, alpha2, beta 1 & beta2
Reacts within secondsReacts within seconds
Increases Heart Rate - chronotropicIncreases Heart Rate - chronotropic
Increased cardiac contractility - inotropicIncreased cardiac contractility - inotropic
Produces widespread vasoconstriction inProduces widespread vasoconstriction in
peripheral arteriolesperipheral arterioles
Promotes release of renin from the kidneyPromotes release of renin from the kidney
7. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Sympathetic Nervous System (SNS)Sympathetic Nervous System (SNS)––
Sympathetic Vasomotor Center – located in theSympathetic Vasomotor Center – located in the
medulla – interacts with many areas of the brainmedulla – interacts with many areas of the brain
to maintain BP within normal range underto maintain BP within normal range under
various conditionsvarious conditions
Exercise – changes to meet oxygen demandExercise – changes to meet oxygen demand
Postural Changes – peripheral vasoconstrictionPostural Changes – peripheral vasoconstriction
8. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Sympathetic NervousSympathetic Nervous System (SNS)System (SNS) ––
BaroreceptorsBaroreceptors: specialized nerve cells the carotid: specialized nerve cells the carotid
arteries and the aortic archarteries and the aortic arch
Sensitive to BP changes:Sensitive to BP changes:
Increase: Inhibits SNSIncrease: Inhibits SNS – peripheral vessel dilation.– peripheral vessel dilation.
Decreased heart rate, and decreased contractility ofDecreased heart rate, and decreased contractility of
the heart + increased parasympathetic activity (vagusthe heart + increased parasympathetic activity (vagus
nerve) decreased heart ratenerve) decreased heart rate
Decrease: Activates SNSDecrease: Activates SNS – peripheral vessel– peripheral vessel
constriction, increased heart rate, and increasedconstriction, increased heart rate, and increased
contractility of the heartcontractility of the heart
9. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Vascular EndotheliumVascular Endothelium
Single cell layer that lines the blood vesselsSingle cell layer that lines the blood vessels
Produce vasoactive substancesProduce vasoactive substances::
EDRF Endothelium-derive relaxing factorEDRF Endothelium-derive relaxing factor ––
Helps maintain low arterial tone at restHelps maintain low arterial tone at rest
Inhibits growth of the smooth muscle layerInhibits growth of the smooth muscle layer
Inhibits platelet aggregationInhibits platelet aggregation
Vasodilation – prostacyclinVasodilation – prostacyclin
Endothelin (ET) potent vasoconstrictorEndothelin (ET) potent vasoconstrictor
Endothelial dysfunction may contribute toEndothelial dysfunction may contribute to
atherosclerosis & primary hypertensionatherosclerosis & primary hypertension
10. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Renal SystemRenal System
Control Na+ excretion & extracellular fluidControl Na+ excretion & extracellular fluid
volumevolume
Renal - Renin-angiotensin-aldosteroneRenal - Renin-angiotensin-aldosterone
Renin converts angiotensinogen to angiotensin IRenin converts angiotensinogen to angiotensin I
Angiotensin-converting enzyme (ACE) converts I intoAngiotensin-converting enzyme (ACE) converts I into
angiotsensin IIangiotsensin II
Immediate: Vasoconstrictor – increased systemicImmediate: Vasoconstrictor – increased systemic
vascular resistancevascular resistance
Prolonged: Stimulates the adrenal cortex to secretProlonged: Stimulates the adrenal cortex to secret
Aldosterone – Na+ and Water retentionAldosterone – Na+ and Water retention
Renal MedullaRenal Medulla - Prostaglandins - vasodilator effect- Prostaglandins - vasodilator effect
15. HypertensionHypertension
Mechanisms that Regulate BPMechanisms that Regulate BP
Regulatory mechanisms in the health person function in responseRegulatory mechanisms in the health person function in response
to the demands on the bodyto the demands on the body
When Hypertension develops, one or more of these mechanismsWhen Hypertension develops, one or more of these mechanisms
are defectiveare defective
Sympathetic Nervous SystemSympathetic Nervous System
Vascular EndotheliumVascular Endothelium
Renal SystemRenal System
Endocrine SystemEndocrine System
16. Secondary HypertensionSecondary Hypertension
PathophysiologyPathophysiology
Specific cause of hypertension can be identifiedSpecific cause of hypertension can be identified
5+% of adult hypertension5+% of adult hypertension
Causes:Causes:
Coarctation or congenital narrowing of the aortaCoarctation or congenital narrowing of the aorta
Renal disease – renal artery disease / parenchymalRenal disease – renal artery disease / parenchymal
Endocrine disorders: Pheochromocytoma, CushingEndocrine disorders: Pheochromocytoma, Cushing
Syndrome, HyperaldosteronismSyndrome, Hyperaldosteronism
Neurology disorders – brain tumors / head injuryNeurology disorders – brain tumors / head injury
Sleep apneaSleep apnea
Medications – sympathetic stimulantsMedications – sympathetic stimulants
Pregnancy-induced hypertensionPregnancy-induced hypertension
17. HypertensionHypertension
PathophysiologyPathophysiology
Primary (Essential) Hypertension:Primary (Essential) Hypertension:
Elevated BP without an identified causeElevated BP without an identified cause
Accounts for 95% of all cases of hypertensionAccounts for 95% of all cases of hypertension
Cause – unknownCause – unknown
Contributing Factors:Contributing Factors: Increased SNS activity,Increased SNS activity,
overproduction of Na+ retaining hormones &overproduction of Na+ retaining hormones &
vasoconstrictors, increased Na+ intakevasoconstrictors, increased Na+ intake
Risk Factors:Risk Factors: ModifiableModifiable
18. Primary HypertensionPrimary Hypertension
PathophysiologyPathophysiology
HeredityHeredity – interaction of genetic,– interaction of genetic,
environmental, and demographic factorsenvironmental, and demographic factors
Water & Sodium RetentionWater & Sodium Retention – 20% of pts– 20% of pts
with high Na+ diet develop HTNwith high Na+ diet develop HTN
Altered Renin-Angiotensin MechanismAltered Renin-Angiotensin Mechanism ––
found in 20% of patientsfound in 20% of patients
Stress & Increased SNS ActivityStress & Increased SNS Activity
Insulin Resistance & HyperinsulinemiaInsulin Resistance & Hyperinsulinemia
Endothelial Cell DysfunctionEndothelial Cell Dysfunction
19. HypertensionHypertension
Clinical ManifestationClinical Manifestation
Dx is made after multiple readings over several weeksDx is made after multiple readings over several weeks
NIH/Joint Committee Definition:NIH/Joint Committee Definition:
CategoryCategory SystolicSystolic DiastolicDiastolic
OptimalOptimal <110<110 andand < 80< 80
NormalNormal <120<120 andand <85<85
High NormalHigh Normal 130-139130-139 oror 85-8985-89
Stage 1 140-159140-159 oror 90-9990-99
Stage 2Stage 2 160-179160-179 oror 100-109100-109
Stage 3Stage 3 =>180=>180 oror => 110=> 110
23. HypertensionHypertension
Medical DiagnosisMedical Diagnosis
History and Physical ExaminationHistory and Physical Examination
Renal FunctionRenal Function
Serum Creatinine & Urine CreatinineSerum Creatinine & Urine Creatinine
ClearanceClearance
Electrolytes – especially K+Electrolytes – especially K+
Blood GlucoseBlood Glucose
Serum Lipids/EKGSerum Lipids/EKG
Ambulatory BP MonitoringAmbulatory BP Monitoring
24. Primary HypertensionPrimary Hypertension
Medical ManagementMedical Management
Risk StratificationRisk Stratification
Level of BPLevel of BP
Presence of Target Organ DiseasePresence of Target Organ Disease
Other Risk FactorsOther Risk Factors
29. Primary HypertensionPrimary Hypertension
Medical ManagementMedical Management
Stepped ApproachStepped Approach
Lifestyle modificationLifestyle modification
Not at Goal BPNot at Goal BP
Drug TherapyDrug Therapy
Not at Goal BPNot at Goal BP
Substitute med / add a 2nd med/ increase doseSubstitute med / add a 2nd med/ increase dose
Not at Goal BPNot at Goal BP
Continue adding / changing meds until controlContinue adding / changing meds until control