The document discusses hypertension (high blood pressure) and its pathogenesis and complications. It provides details on: 1) The classification and diagnosis of hypertension according to guidelines. 2) The types of hypertension including essential and secondary causes. Secondary causes include renal, endocrine, cardiovascular and neurological factors. 3) The role of the endothelium and kidneys in regulating blood pressure. Dysfunction can lead to hypertension. 4) Complications of both benign and malignant hypertension affecting organs like the brain, heart, kidneys, and vasculature.

1. Hypertension
Blood Vessel
Pathology of Organs and
Systems

2. Endothelium
• is critical for maintaining vessel wall homeostasis and
circulatory function.
• Endothelial cells contain Weibel-Palade bodies,
intracellular storage organelles for von Willebrand's
(vWF)factor
• Antibodies to vWF and/or platelet-endothelial cell
adhesion molecule-1 (PECAM-1 or CD31) can be used
to identify endothelial cells immunohistochemically.

3. Functions of Endothelium
Maintenance of
Permeability barrier
Elaboration of Anticoagulant,
Antithrombotic, Fibrinolytic
Regulators
Prostacyclin, Thrombomodulin, Heparin-
like molecules, Plasminogen activator
Elaboration of Prothrombotic
Molecules
Von Willebrand's factor, Tissue factor,
Plasminogen activator inhibitor
Extracellular Matrix Production Collagen, proteoglycans
Modulation of Blood Flow and
Vascular Reactivity
Vasconstrictors: endothelin, ACE,
Vasodilators: NO, prostacyclin
Regulation of Inflammation and
Immunity
IL-1, IL-6, chemokines, Adhesion
molecules: VCAM-1, ICAM, E- Selectin,
P-Selectin, Histocompatibility antigens
Regulation of cell Growth
Growth stimulators: PDGF, CSF, FGF
Growth inhibitors: heparin, TGF-β

4. Endothelial Activation/Dysfunction

5. Endothelium -Intimal Thickening
• a Stereotypic Response To Vascular Injury.
• Vascular injury—with endothelial cell loss or even just
dysfunction—stimulates smooth muscle cell growth and
associated matrix synthesis that thickens the intima. The
result is neointima

6. Regulation of Blood Pressure
• Blood pressure is a function of cardiac
output and peripheral vascular
resistance, the two hemodynamic
variables that are influenced by multiple
genetic, environmental, and
demographic factors.
• The major factors that determine blood
pressure variation within and between
populations include age, gender, body
mass index, and diet, particularly
sodium intake

9. Blood Pressure Measurement Techniques
Method Notes
In-office
Two readings, 5 minutes apart, sitting in
chair. Confirm elevated reading in
contralateral arm.
Ambulatory BP
monitoring
Indicated for evaluation of “white coat
hypertension.” Absence of 10–20
percent BP decrease during sleep may
indicate increased CVD risk.
Patient self-
check
Provides information on response to
therapy. May help improve adherence to
therapy and is useful for evaluating
“white coat hypertension.”

10. Classification of Blood Pressure (BP)
7th Report of the Joint National Committee (JNC 7)
Category
Systolic
mmHg
Diastolic
mmHg
Optimal <115 And <80
Normal <120 And <80
Pre-hypertension 120–139 Or 80–89
Hypertension, Stage 1 140–159 Or 90–99
Hypertension, Stage 2 ≥160 Or ≥100

11. 2017 classification of Hypertension

12. Hypertension
• Hypertension affects up to 20% of the population in
industrial countries and
• Blacks are particularly plagued by hypertension, and are
more likely than whites to experience severe
complications.
• The prevalence and vulnerability to complications of
hypertension increase with age;
• hypertension typically remains asymptomatic until late in
its course .

13. Hypertension –general Considerations
• is one of the major risk factors for atherosclerosis
• It can cause cardiac hypertrophy, heart failure, multi-
infarct dementia, aortic dissection, renal failure.
• is seen in more than half of cases of myocardial
infarction, stroke, and chronic renal disease. Three-
fourths of patients with dissecting aortic aneurysm, intra-
cerebral haemorrhage, or myocardial wall rupture also
have elevated blood pressure
• untreated, roughly half of patients die of IHD or CCF,
and another third die of stroke.

14. Clinical Features
• Hypertension by itself does not cause symptoms.
• Headaches, fatigue, and dizziness are sometimes
ascribed to hypertension, but these nonspecific
symptoms are no more common in hypertensives than in
normotensive controls.
• The condition is discovered during routine screening or
when patients seek medical advice for its complications.
They include MI, CCF, thrombotic and hemorrhagic
strokes, hypertensive encephalopathy, and renal failure.
This is why hypertension is called "the silent killer."

15. Types and Causes of Hypertension
• Essential hypertension (90% to 95% of cases)
• Secondary hypertension
• Accelerated or malignant hypertension:
– A small percentage (~ 5%) show a rapidly rising BP
that if untreated, leads to death within a year or two.
This is characterized by severe hypertension (systolic
> 200 mm Hg, diastolic > 120 mm Hg), renal failure,
retinal haemorrhages and exudates, with or without
papilloedema.
– It may develop in normotensive persons but more
often is superimposed on pre-existing benign
hypertension, either essential or secondary.

16. Causes of Secondary Hypertension
Renal Endocrine
Cardio-
vascular
Neurologic
Acute
glomerulo-
nephritis
Chronic renal
disease
Polycystic
disease
Renal artery
stenosis
Renal vasculitis
Renin -
producing
tumors
Adrenocortical
hyperfunction
Exogenous
hormones
Pheo-
chromocytoma
Acromegaly
Hypothyroidism
(myxedema)
Hyperthyroidism
(thyrotoxicosis)
Pregnancy-
induced
Coarctation
Polyarteritis
nodosa
Increased
intravascular
volume
Increased
cardiac output
Rigidity of the
aorta
Psychogenic
Increased
intracranial
pressure
Sleep apnoea
Acute stress,
including
surgery

17. Estimated Frequency of Various Forms of
Hypertension in the General Hypertensive Population Percentage
Essential hypertension 88
Renal hypertension
Renovascular 2
Parenchymal 3
Endocrine hypertension
Primary aldosteronism 5
Cushing's syndrome 0.1
Pheochromocytoma 0.1
Other adrenal forms 0.2
Estrogen treatment ("pill hypertension“) 1
Miscellaneous (Liddle's syndrome,

19. Pathogenesis - Genetic factors
• play a role as shown by studies comparing BP in
monozygotic & dizygotic twins, other family studies,
• Single-gene disorders cause severe but rare forms of
hypertension through several mechanisms
– Gene defects affecting enzymes involved in aldosterone
metabolism (e.g., aldosterone synthase, 11β-hydroxylase, 17α-
hydroxylase).
– Mutations affecting proteins that influence sodium
reabsorption (Liddle syndrome - mutations in an epithelial Na +
channel protein)
• Polymorphisms in both the angiotensinogen locus and
the angiotensin receptor locus

20. Pathogenesis
• Reduced renal sodium excretion in the presence of
normal arterial pressure may be a key initiating event in
essential hypertension and, indeed, a final common
pathway for the pathogenesis of hypertension.
• Vasoconstrictive influences
• Environmental factors can modify the impact of genetic
determinants: Stress, obesity, smoking, physical
inactivity, and heavy consumption of salt have all been
implicated as exogenous factors in hypertension.

21. Secondary Hypertension Pathogenesis
• For many of the secondary forms, the underlying
pathways are reasonably well understood.
• in renovascular hypertension, renal artery stenosis
causes decreased glomerular flow & pressure in the
afferent arteriole of the glomerulus. This induces
1. renin secretion, initiating angiotensin II–mediated
vasoconstriction and
2. increases sodium reabsorption.
• Primary Hyperaldosteronism is one of the most common
causes of secondary hypertension

24. 1. Through the renin-angiotensin system
2. By producing a variety of vascular relaxing, or antihypertensive,
substances (prostaglandins and NO),
3. Through variable reabsorption of sodium
4. By being the target of natriutrtic peptides
Role of
Kidneys in
BP
Regulation

25. Goal Blood Pressures for Hypertensive Patients
Hypertension without Co-morbidity <140/90
Diabetes Mellitus <130/80
Congestive Heart Failure <130/80
Renal Insufficiency <130/80
Renal Failure and >1g Proteinuria/24 hours <125/75

26. Diagnostic Workup of Hypertension
• Assess risk factors and comorbidities.
• Reveal identifiable causes of hypertension.
• Assess presence of target organ damage.
• Conduct history and physical examination.
• Obtain laboratory tests: urinalysis, blood glucose,
hematocrit and lipid panel, serum potassium, creatinine,
and calcium. Optional: urinary albumin/creatinine ratio.
• Obtain electrocardiogram.

27. Assess for Major Cardiovascular Disease (CVD)
Risk Factors
• Hypertension
• Obesity (body mass index >30 kg/m2)
• Dyslipidemia
• Diabetes mellitus
• Cigarette smoking
• Physical inactivity
• Microalbuminuria, estimated GFR <60 mL /min
• Age (>55 for men, >65 for women)
• Family history of premature CVD (age: men <55, women
<65)

28. Assess for Identifiable Causes of
Hypertension
• Sleep apnea
• Drug induced/related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Cushing’s syndrome or steroid therapy
• Pheochromocytoma
• Coarctation of aorta
• Thyroid/parathyroid disease

29. Pathogenesis of Complications

31. Benign Hypertension
• Renal lesion in chronic hypertension
is nephrosclerosis
• Hyaline Arteriolosclerosis: Arterioles
show homogeneous, pink hyaline
thickening with luminal narrowing due
to plasma protein leakage across
injured endothelial cells, and
increased smooth muscle cell matrix
synthesis.
• In late stages, glomerular scarring
occurs

32. malignant hypertension
• Hyperplastic
Arteriolosclerosis. vessels
exhibit “onion-skin lesions,”
characterized by concentric,
laminated thickening of the
walls and luminal narrowing
• they are accompanied by
fibrinoid deposits and vessel
wall necrosis (necrotizing
arteriolitis), particularly in the
kidney.

33. Lifestyle Modification
Recommendations
Lifestyle Modification SBP reduction
Weight reduction
(BMI 18.5-24.9 kg/m2)
5–20 mmHg /10
kg
DASH eating plan (Dietary approaches
to Stop Hypertension)
8–14 mmHg
Dietary sodium reduction
(2.4 g sodium or 6 g sodium chloride)
2–8 mmHg
Aerobic physical activity
(at least 30 minutes per day)
4–9 mmHg
Moderation of alcohol consumption
Men: limit to <2 drinks* per day.
Women: limit to <1 drink* per day.
2–4 mmHg

34. DASH Diet Plan
Type of food
Number of servings
for 1600 - 3100
Calorie diets
Servings on a
2000 Calorie
diet
Grains and grain products
(include at least 3 whole
grain foods each day)
6 - 12 7 - 8
Fruits 4 - 6 4 - 5
Vegetables 4 - 6 4 - 5
Low fat or non fat dairy
foods
2 - 4 2 - 3
Lean meats, fish, poultry 1.5 - 2.5 2 or less
Nuts, seeds, and legumes 3 - 6 per week 4 - 5 per week
Fats and sweets 2 - 4 limited