hypertention by dr muxyidin nagadon

1. Hypertension.
 Learning objectives: at the end of this lesson the
student will be able to:
 1. Define Hypertension.
 2. List the etiologies of Hypertension.
 3. Describe the different types of Hypertension.
 4. Understand the epidemiology of Hypertension.
 5. Understand the pathophysiology of
Hypertension.
 6. Identify the clinical manifestation of
Hypertension.
 7. Identity consequences of Hypertension.
 8. Understand the diagnostic approach of
Hypertension.
 9. Understand the management of chronic

2. Definition:
Hypertension is defined as arterial blood
pressure that exceeds 140/90mmHg at several
determinations. This is an arbitrary definition
because a diastolic pressure of even 85 mm Hg
may be associated with increased
cardiovascular morbidity and mortality.
• Hypertension is one of the most common
diseases afflicting humans throughout the world.
Because of the associated morbidity and
mortality and the cost to society, hypertension is
an important public health challenge.
• It is easily detectable, usually easily treatable,
and often leads to lethal complications if left
untreated

3.  Hypertension is the most important modifiable
risk factor for coronary heart disease, stroke,
congestive heart failure, end-stage renal
disease, and peripheral vascular disease.
 Therefore, health care professionals must not
only identify and treat patients with
hypertension but also promote a healthy
lifestyle and preventive strategies to decrease
the prevalence of hypertension in the general
population.

4. Epidemiology
Overall, approximately 20% of the world's adults
are estimated to have hypertension in excess
of 140/90 mm Hg. Some studies done in
developed countries show almost 50 % of the
population may have hypertension.
• The prevalence dramatically increases in
patients older than 60 years.
• The prevalence is higher among balks than
whites.

5. Classification
Because the risk to an individual patient may
correlate with the severity of hypertension, a
classification system is essential for making
decisions about aggressiveness of treatment
or therapeutic interventions.

6. BLOOD PRESSURE ( in mm Hg)
CATEGORY Systolic Diastolic
Optimal <120 And <80
Normal <130 And <85
High-normal 130–139 Or 85–89
Hypertension
Stage 1 140–159 Or 90–99
Stage 2 160–179 Or 100–109
Stage 3 180 or N 110
Table III-7-1. Classification of blood pressure for
adults and older children *

7.  When systolic and diastolic blood pressure levels fall into
different categories, the higher category should be
selected to classify the individual's blood pressure status.
 E.g. 160/92 mm Hg should be classified as stage 2
hypertension
 174/120 mm Hg should be classified as stage 3
hypertension.
Isolated systolic hypertension is defined as systolic blood
pressure 140 mm Hg or greater and diastolic blood
pressure less than 90 mm Hg and staged approximately
(e.g., 170/82 mm Hg is defined as stage 2 isolated
systolic hypertension).
In addition to classifying stages of hypertension on the basis of average
blood pressure levels, clinicians should specify the presence or absence of
target organ damage and additional risk factors. This specificity is important
for risk classification and treatment.

8.  Optimal blood pressure with respect to
cardiovascular risk is ≤ 120/80 mm Hg.
 Hypertension should be diagnosed based on
the average of two or more readings taken at
each of two or more visits after an initial
screening.

9. The natural history of essential
hypertension:
It evolves from occasional to established
hypertension. After a long invariable asymptomatic
period, persistent hypertension develops into
complicated hypertension, in which target organ
damage to the aorta and small arteries, heart,
kidneys, retina, and central nervous system is evident.
• The progression begins with prehypertension in
persons aged 10-30 years (by increased cardiac
output) to early hypertension in persons aged 20-40
years (in which increased peripheral resistance is
prominent) to established hypertension in persons
aged 30-50 years, and, finally, to complicated

10. Etiologic Classification of
Hypertension:
Hypertension may be classified as either essential or
secondary.
 I. Primary or essential hypertension (90-95%):
 Essential hypertension is diagnosed in individuals
in whom generalized or functional abnormalities may
be the cause of hypertension but no specific
secondary causes are identified.
 The pathophyisoliogy of essential hypertension is
multifactorial and highly complex. A number of factors
modulate the blood pressure. These factors include
humeral mediators, vascular reactivity, circulating
blood volume, vascular caliber, blood viscosity,
cardiac output, blood vessel elasticity, and neural
stimulation.

11. Some factors that may contribute for the
development of essential hypertension
include:
1. Genetic predisposition: the exact mechanism
has not been established
2. Environment: a number of environmental
factors have been implicated
 Dietary salt intake and Salt sensitivity
 Obesity
 Occupation
 Family size and crowding
3. Pregnancy-induced hypertension: Toxemia of
pregnancy

12.  II. Secondary causes of hypertension: In 5-10 %
of patients with hypertension, the hypertension is
secondary to an identifiable disorder.
A. Renal Hypertension (2.5-6%) a variety of renal
diseases may be accompanied by hypertension
Renal parenchymal disease :
 Chronic pyelonephritis
 Acute and chronic glomerulonephritis
 Polycystic kidney disease
 Urinary tract obstruction
 Renin-producing tumor
Renovascular hypertension (0.2-4%)
 Coarctation of aorta
 Vasculitis
 Collagen vascular disease

13. B. Endocrine (1-2%)
• Oral contraceptives
• Adrenocoritical
hypertension
 Primary aldosteronism
 Cushing syndrome
 Congenital adrenal
hyperplasia
• Pheochromocytoma
• Acromegally
• Myxoedema
• Thyrotoxicosis
C. Neurogenic :
 • Psychogenic
 • Increased intracranial
pressure
 • Acute spinal cord
section
D. Drugs and toxins
• Alcohol
• Adrenergic medications

14. (End organ /target organ
damage)
Patients with hypertension die prematurely, the most
common cause of death is heart disease, with
stroke and renal failure also frequent, particularly
in patients with retinopathy
1. Effects on the Heart :
• Left ventricular hypertrophy as a
compensatory mechanism
• Coronary artery disease /Ischemic heart
disease:
 Angina Pectoris
 Myocardial infarction which may lead to heart failure

15. 2. Neurologic effects
A. Retinal changes :
i. Exudates: hard and soft exudates
ii. Hemorrhages: dot and bloat hemorrhages
iii. Thickening of arterioles – copper wiring Æ silver wiring
iv. Abnormalities on arteriolo –venular crossings ( A/V crossings
)
v. Papilledema
B. Central nervous system dysfunction
i. Cerebrovascular disease
 Transient ischemic attacks : episodic dizziness ,
unilateral blindness , hemiparesis etc
 Stroke
 Ischemic stroke : due to atherosclerosis of cerebral blood
vessels

16.  ii. Hypertensive encephalopathy: consists
of severe hypertension, altered state of
consciousness, increased intracranial
pressure with papilledema and seizure. Focal
neurologic deficits are not common.

17. 3. Effects on the kidneys :
Arteriolosclerosis of the afferent and efferent
arterioles and the glumerular capillary tuft
impairs renal function. Patients may have
proteinuria and microscopic hematuria and
later on develop chronic renal failure.

18. Risk factors for an adverse prognosis in
hypertension:
1. Black race
2. Youth
3. Male sex
4. Smoking
5. Diabetes mellitus
6. Hypercholesterolemia
7. Obesity
8. Excess alcohol intake
9. Evidence of end organ damage

19. Approach to a patient with
Hypertension:
 Diagnosis of hypertension: is confirmed after an
elevated blood pressure ≥ 140/90 mm Hg, properly
measured, has been documented on at least 3 separate
occasions (based on the average of 2 or more readings
taken at each of 2 or more visits after initial screening).
 An accurate measurement of blood pressure is the
key to diagnosis.
 • Several determinations should be made over a period
of several weeks.
 • At any given visit, an average of 3 blood pressure
readings taken 2 minutes apart using a mercury
manometer is preferable.
 • Blood pressure should be measured in both the
supine and sitting positions, auscultating with the bell of
the stethoscope.

20.  On the first visit, blood pressure should be checked in
both arms and in one leg to avoid missing the
diagnosis of coarctation of aorta or subclavian artery
stenosis.
 • As the improper cuff size may influence blood
pressure measurement, a wider cuff is preferable,
particularly if the patient's arm circumference exceeds
30 cm.
 • The patient should rest quietly for at least 5
minutes before the measurement.
 • Although somewhat controversial, the common
practice is to document phase V (a disappearance of

21. Patient evaluation:
In evaluating a patient with hypertension the
initial history, physical examination and
laboratory should be directed at
1) Establishing pretreatment base line hypertension :
2) Identifying correctable secondary caused of
hypertension
3) Determining if target organ damage is present:
patients may have undiagnosed hypertension for
years without having had their blood pressure
checked. Therefore, a search for end organ
damage should be made through proper history
and physical examination.
4) Determining whether other cardiovascular risk
factors are present

22. Clinical symptoms and
History:
 Most patients with hypertension have no
specific symptoms and are identified only in
the course of physical examination
 If patients develop symptoms, the they may
be attributable to
 The elevated BP itself or
 The end organ damage associated with
hypertension or
 The underlying secondary disease

23. Some of the symptoms may be
 Headache: though popularly considered symptom of high BP, it is
a characteristic of only sever hypertension. Such headaches are
localized to the occipital region and present when the patient
awakens in the morning but subsides spontaneously after several
hours
 Dizziness , palpitation , easy fatigability and impotence
 Symptoms referable to vascular diseases or evidences of
target organ damage include
 Epistaxiis , hematuria
 Retinal changesÆblurring of vision
 Cerebrovascular damages : Transient ischemic attacks Æ
episodes of weakness or dizziness or Stroke may occur (
hemorrhagic or ischemic )
 Cardiovascular damages : chest pain /angina pectoris or
myocardial infarction which may cause dyspnea due to heat failure
 Pain due to dissecting aorta

24. Predisposing factors for
hypertension
 Strong family history of hypertension
 Age : secondary hypertension often develops before the
age of 35 or after 55
Associated cardiovascular risk factors:
 • Cigarette smoking
 • Lipid abnormality or hypercholesterolemia,
 • Diabetes mellitus
 • Family history of early deaths due to cardiovascular
diseases
 • Alcoholism.
 • Obtain a history of over-the-counter medication
use, current and previous unsuccessful antihypertensive
medication trials

25. Physical Examination:
General appearance:
 Round face and truncal obesity suggests Cushing
syndrome
 Muscular development in the upper extremities out of the
proportion of the lower extremities suggests coarctation
of the aorta
Proper measurement of blood pressure
 Compare the BP and pulses in the two upper extremities
and in supine and standing position
 A rise in diastolic pressure when the patient goes from
supine to standing position is most compatible with
essential hypertension while a fall in BP in the

26.  Funduscopic evaluation of the eyes
 Palpation of all peripheral pulses should be
performed
 A careful cardiac examination
 Abdominal examination:

27. Diagnostic workup
 Laboratory investigations:
 Unless a secondary cause for hypertension is
suspected, only the following routine laboratory
studies should be performed:
 CBC and Hematochrite
 Urinalysis including microscopy , protein , blood and ,
glucose
 Fasting blood glucose
 Serum electrolytes : serum K+
 Lipid profile (total cholesterol, low-density lipoprotein
[LDL] and high-density lipoprotein [HDL], and
triglycerides).
 Serum creatinine, uric acid,

28. Imaging Studies:
 Echocardiography: to detect LVH
 Special studies to screen for Secondary
hypertension: should be requested only when
secondary hypertension is strongly suspected.
 Renovascular disease : ultrasound and Doppler flow
study
 Pheochromocytoma : 24 hrs urine assay of
metanehprines and catecholamine
 Cushing’s syndrome: overnight dexamethason
suppression test or 24 hrs urine cortisol
 Primary aldosteronism: plasma aldostrone
 Thyrotoxicosis or Myxoedema : Thyroid function

29. Therapy of Hypertension
 Indication for treatment:
 Patients with a diastolic pressure >90mm Hg or
systolic pressure > 140 mm Hg repeatedly
 Isolated systolic hypertension (systolic BP > 160
with diastolic BP < 89 mmHg) if the patient is older
than 65 years.
 Goal of therapy :
• Reducing the diastolic BP to < 90 mmHg and
systolic BP < 150mmHg.


30. 1. General measures : non pharmacologic
therapy
A. Sodium restriction: intake not more than 100 mmol/d
(2.4 g sodium or 6 g sodium chloride).
B. Lifestyle modifications.
1. Weight reduction in obese patients
2. Limitation of alcohol intake : alcohol potentiates
the action of catecholamines and may exacerbate
hypertension
3. Regular physical exercise: increase aerobic activity (30-
45 min most
4. days of the week).
5. Maintain adequate intake of dietary potassium,
calcium and magnesium for general health. ( healthy
diet like fruits, vegetables, etc)
6. Stop smoking
7. Reduce intake of dietary saturated fat and cholesterol

31. 2. Pharmacologic therapy.
A. Diuretics : are often the first line drugs , and reduce
extra cellular fluid volume
 Thiazide diuretics : are more effective anti-
hypertensive agents than loop diuretics
 Dose: Hydrochlorothiazide 25 mg PO daily and
may be increased gradually
 Side effects: hypokalemia, hyperuricemia,
hyperglycemia
 Contraindcation: Gout
 Potassium-sparing diuretics (e.g. Spironolactone
) : is a competitive inhibitor of aldosteron and may
be used in primary hyperaldosteronism (as an
additional therapy in combination with thiazide
diuretics)

32. B. β-adrenergic blocking
agents
reduce cardiac output and rennin release
 • β-blockers : Propanolol , Metoprolol ,
Labetolol , Carvidolol , Atenolol
 Doses: Propranolol 20 mg PO /day to
Maximum of 120 mg PO 4X/day
 Metoprolol: 25 – 150 mg PO BID Atenolol: 25-100
mg PO/day
 Side effects: bronchospasm, bradycardia,
worsening of heart failure, impotence,
depression
 Contraindication: Asthma, peripheral vascular
disease (severe)

33. C. Centrally acting agents
 These agents inhibit sympathetic out flow from the CNS.
 • Methyldopa : 250 mg -1000 mg PO BID , TID or QID
 Side effects: postural hypotension, depression,
gyneacomastia.
D. Vasodilators: dilate arteriols and arteries,
reducing peripheral vascular resistance which inturn
reduces high blood pressure.
• Hydrallazine : Oral 10-75 mg PO QID
 Paraneteral: 10-50 mg IV or PO every 6 hours.
 Side effects: – headache, lupus erythromatosis like
syndrome
• Minoxidil : 2.5 -40 mg PO BID

34. E. Calcium channel blockers:
 by modulating calcium release in smooth muscles,
calcium channel blockers reduce smooth muscle
tone, resulting vasodilatation. Dihydropyridines:
Nifedipine, Felodipine, Amlodipine
Non dihydropyridines : Diltiazime, and
Verapamil
 Doses: Nifedipine: 30 – 90 mg PO daily
 Amlodipine: 2.5 -10 mg PO daily
 Side effects : Dihydropyridines: headache ,
tachycardia , GI disturbance Non dihydropyridines
have cardio depressant effect and their use may
be problematic in CHF patients
 Contraindication: Heart block, heart failure

35. F. ACE inhibitors:
Inhibit the conversion of angiotensin I to angiotensin II (a potent
vasoconstrictor). By doing so ACE inhibitors reduce peripheral
resistance. In addition they reduce aldosteron production, reducing the
retention of sodium and water. Captopril , Nezapril , Enalapril ,
Fosinopril , Ramipril.
Doses: Captopri : 12.5 -75 mg PO BID
Enalapril: 2.5-40 mg daily
Side effects: Cough, Leucopenia, angioedema, hyperkalemia.
Contraindicated in: Bilateral renal artery stenosis, Renal failure.
G. Angiotensin receptor blockers: they block the angiotensin system
without causing some of the annoying side effects of ACE inhibitors such
as cough. Losartan: 25-50 mg once or twice daily
Side effects: hypotension

36. Hypertensive crisis
 Is defined as severe hypertension characterized by diastolic
blood pressure greater than 130 mmHg. Blood pressure
elevation to such degree can cause vascular damage,
encephalopathy, retinal hemorrhage, renal damage and
death. 1 –2% of the hypertensive population develop this
complication. It is categorized into two:
• Hypertensive Emergency in which there is acute
impairment of an organ system (CNS,
 CVS, Renal). In these conditions, the blood pressure should
be lowered aggressively over minutes to hours.
• Hypertensive Urgency in which BP is high and there is
potential risk but not yet caused
 acute end-organ damage. These patients require BP control
over several days to weeks.
 Diagnosis: A diastolic pressure of 130 mmHg, funduscopic
finding of papilledema, change in neurologic and mental
status and abnormal renal sediments are the hallmarks
of hypertensive

37. Approach to patients with hypertensive
crisis:
 • Rapid assessment of the patient with brief history
and targeted physical examination (of the CNS, CVS , retina
),
 • Laboratory investigations :
 o CBC
 o Urinalysis
 o Renal function test
 o ECG
 Treatment “treats the patient, not the number” General
measures:
 Initial considerations: look if the patient is in a stressful
situation .Place the patient in a quiet room and reevaluate
after initial interview, some patient’s BP lowers below a critical
level after relaxation.