General medicine

1. - Dr. G.sireesha
Family Medicine
First year PG Resident

2.  HYPERTENSION IS SERIOUS MEDICAL
CONDITION CAN INCREASE THE RISK OF
HEART , BRAIN , KIDNEY , AND OTHER
DISEASES,.IT IS A MAJOR CAUSE OF
PREMATURE DEATH. WORLD WIDE WITH
UPWARDS OF 1IN 4 MEN AND 1 IN 5
WOMEN-OVER A BILLION PEOPLE- HAVING
THIS CONDITION.

3. DEFINATION OF HYPERTENSION
Blood pressure is the force exerted by circulating blood against the
walls of the body s arteries, the major blood vessels in the body .
Hypertension is when the blood pressure is too high .
Blood pressure is written as two numbers. The first ( systolic) number
represents the pressure in blood vessels when the heart contracts or
beats . The second ( diastolic ) number represents the pressure in
the vessels when the heart rests between beats
Hypertension is diagnosed if , when it is measured on two
different days , the systolic blood pressure readings on both days >
140 mm of hg and /or the diastolic blood pressure readings on both
days is >90 mm hg
BLOOD PRESSURE = CO* SVR

4. ACCORDING TO ACC/AHA GUIDELINES

5.  AGE
 FAMILY HISTORY
 ETHNICITY
 GENETIC FACTORS
 LOWER EDUCATION &SOCIOECONOMIC
STATUS
 OBESITY
 LOW PHYSICAL ACTIVITY
 TOBACCO USE

6.  There are 2 types on the basis of etiology:
 Primary hypertension 90-95% of cases –also
termed essential or idiopathic
 Secondary hypertension – about 5% of cases

7.  GENETIC
 OBESITY
 SALT INTAKE
 SYMPATHETIC SYSTEM OVERACTIVITY
 RENIN ANGIOTENSIN ACTIVITY
 ALCOHOL/SMOKING
 ABNORMAL CVS DEVELOPMENT

8.  RENOVASCULAR:RENAL PARENCHYMAL DISEASE,RENAL
ARTERY STENOSIS, FIBROVASCULAR DYSPLASIA
 VASCULAR :COARCTATION OF AORTA
 ENDOCRINOLOGICAL:THYROID
ASSOCIATED,CORTISOL EXCESS ASSOCIATED,
MINERALOCORTICOID EXCESS ASSOCIATED,CATECHOLAMINE
ASSOCIATED
 DRUGS
 OSA
 LIFESTYLE-DIET/NUTRITION

9.  HYPERTENSION URGENCY
 -SBP >180 or DBP>110 with out TOD
 HYPERTENSION EMERGENCY(MALIGNANT
HTN)
 SBP>180 or dbp>110(esp>120)or accelerated htn with TOD
 TODs
 1.BRAIN :HYPERTENSIVE ENCEPHALOPATHY/EDEMA,ICH,ISCHEMIC
STROKE .
 2.RETINA GRADE 4 RETINOPATHY(papilloedema)
 CVS:ACS,ACUTE PULMONARY EDEMA, CHF,AORTIC DISSECTION

10.  KIDNEY :accelerated nephrosclerosis,
nephritic syndrome
 BLOOD: MAHA,HELLP
 PREGNANCY;HELLP, ECLAMPSY

11.  MALIGNANT HYPERTENSION: it is defined as
markedly elevated blood pressure (diastolic
bp> 140mg ) with retinal haemorrhages,
exudates, or papilloedema,with or with out
evidence of target organ damage, typically
acute and progressive kidney injury with
proteinuria and haematuria.

12.  It is defined as a recent significance increase
over baseline bp that is associated with target
organ damage
 This is usually seen as vascular damage on
fundoscopic examination such as flame
shapped haemorrhages,or soft exudates,but
with out papillaoedema.

13.  SYMPATHETIC NERVOUS SYSTEM
 ACTIVITIES OF VASCULAR ENDOTHELIUM
 ACTIVITIES OF RENAL SYSTEM
 ACTIVITIES OF ENDOCRINE SYSTEM

15.  It regulates arterial blood pressure by
functionally influencing the vasculature,
kidney, heart.
 Indeed altered sympathetic function is firmly
established in the development maintainance,
and pathophysiology of numerous
cardiolvascular diseases

16.  The vascular endothelium plays a basal and dynamic regulation of
the circulation . Thus it has a crucial role in the pathogenesis of
hypertension .
 A spectrum of vasoactive substances is synthesized in the
endothelium , of these nitric oxide( NO),Prostacyclin( PGI2)and
endothelin ( ET1) are most important
 Systemic inhibition of NO synthesis or scavenging of NO through
oxidative stress causes an increase in arterial blood pressure

17.  Over the time uncontrolled high bp can cause arteries
around the kidneys to narrow, weaken or harden . These
damaged arteries are not able to deliver enough blood to
the kidney tissue . Damaged kidney arteries don’t filter the
blood well.
 The kidney has 4 major roles in hypertension
 One is production of renin , an aspartic protease that cleaves
the angiotensinogen to angiotensin 1
 Renin is the rate limiting step for activation of the
circulating renin angiotensin system .(RAS).

18. RENIN ANGIOTENSIN ALDOSTERON SYSTEM

19. A Second major role in kidney is hypertension is to reset or alter the
pressure, diuresis , and natriuresis.
A rise in blood pressure causes brisk diuresis and natriuresis , thereby
returning the bp towards the normal value.
A THIRD recently recognised role of the kidney in the hypertension is to
modulate systemic sympathetic tone by generating reflex signals via
renal afferent nerves
Approximately 90 % of the renal nerves are efferent nerves sending
sympathetic signals signals to the kidney, there by enhancing tubular
sodium resorption ,renin release and vasomotor tone depending on the
intensity of nerve traffic.

20. The fourth imp role of the kidney in htn is to serve as a site of immune
activation ., angiotensin 2 induced htn activates antigen presenting
dendritic cells in the kidney that migrates to lumphoid organs to activate
t cells which in turn return back to the kidney

21.  Due to the excess production of mineralocorticoids(primary
hyperaldosteronism), catecholamines (pheochromocytoma),
thyroid hormones and glucocorticoids ( cushing syndrome).
 The hormone aldosterone may be a common and
unrecognised contributer to high blood pressure , a leading
cause of heart disease and stroke.
 Cortisol increases the serum concentration of erythropoitin
and causes polycythemia, a well recognised complication of
chronic glucocorticoid excess. Erythropoitin has a direct
vasoconstrictor effect and might be a further mediater of
cortisole induced hypertension .

22.  HEADACHE
 DIZZINESS
 VISUAL DISTURBANCES
 VOMITINGS /NAUSEA
 PALPITATIONS
 SHORTNESS OF BREATH
 CHEST PAIN
 CONVULTIONS

24.  24hr ambulatory BP monitering .
 THE PORTABLE MONITER IS WORN ON A BELT CONNECTED TO
STANDARD CUFF ON THE UPPER ARM .
 WHEN COMPLETE , THE DEVICE IS CONNECTED TO THE COMPUTER
THAT PREPARES A REPORT OF THE 24 HR DAY TIME , NIGHT TIME
& SLEEP & AWAKE, AVERAGE SYSTOLIC AND DIASTOLIC BP AND HR.
 IT IS ALWAYS THE CHOICE TECHNIQUE

25.  Hypertension can be diagnosed at the first
visit only , if the patient presents in a
hypertensive emergency.
 On the second visit a diagnosis of
hypertension can be made only if bp >
180/110 or > 140 /90 with target organ
damage .
 on the third visit if bp > 160 / 100 mm of hg
its equal to hypertension

26.  Reduce weight to normal BMI(<25KG/M2):
5 to 20mmhg/10 kg loss
 Dash eating plan
 Dietary sodium reduction
 Increase physical activity
 Reduce alcohol consumption

27.  Dietary ; emphasizes fruits , vegetables,low
fat diary foods,and reduced sodium intake
 Approches to :include whole grains,
poultry, fish , nuts
 Stop :reduced amount of red meat ,
sugar, total and saturated fat and
cholesterol
 Hypertension

30. Thank you