The document provides a comprehensive overview of hypertension, defining its types, causes, and the risk factors associated with it. It discusses the evaluation, classification, and management strategies for hypertension, including the importance of proper blood pressure measurement and treatment approaches tailored to individual patient profiles. Additionally, the document highlights hypertensive urgency and emergencies, emphasizing the need for timely intervention and appropriate therapy to manage associated target-organ damage.

1. HYPERTENSION
Dr. Chaitra M
Moderator: Prof. Rajeshwari S
www.anaesthesia.co.in
anaesthesia.co.in@gmail.com

2. INTRODUCTION AND
DEFINITIONS

3. HYPERTENSION - DEFINITION
 “Hypertension is a progressive cardiovascular
syndrome arising from complex and interrelated
etiologies. Early markers of the syndrome are often
present before blood pressure elevation is
sustained; therefore, hypertension cannot be
classified solely by discrete blood pressure
thresholds. Progression is strongly associated with
functional and structural cardiac and vascular
abnormalities that damage the heart, kidneys,
brain, vasculature, and other organs and lead to
premature morbidity and death.”
—American Society of Hypertension Writing
Group, 2006

4. HYPERTENSION - DEFINITION
 Essential hypertension can be defined as a rise in
blood pressure of unknown cause that increases
risk for cerebral, cardiac, and renal events.
Messerli et al, Lancet 2007; 370:591-603
 Secondary hypertension – rise in blood pressure
due to an identifiable cause
 Usually develops before the age of 35 or after 55
years

5. ISOLATED SYSTOLIC
HYPERTENSION
 ISH - SBP > 140 mm Hg and DBP < 90 mmHg
 Prevalence of systolic hypertension increases
with age
 Systolic hypertension represents the most
common form of hypertension above the age of 50
years
 Trials have shown that control of isolated systolic
hypertension reduces total mortality,
cardiovascular mortality, stroke, and HF events
Kostis et al. JAMA. 1997;278:212–216
Staessen et al. JAMA. 1999;282:539–546

6. WHITE COAT HYPERTENSION
 WCHT is an ill-defined phenomenon
 Most accepted definition is “…a high BP in the
physician's office with normal BP at rest or while
ambulatory”
Angeli et al. Blood Press Monit. 2005 Dec;10(6):301-5
 Patients who are diagnosed as being hypertensive on
first visit, BP drops by a mean of 15 mm Hg systolic
and 7 mm Hg diastolic by third visit
 Some patients do not reach a stable value until their
sixth visit
Watson et al. J Hypertens. 1987;5:207–211

7. HYPERTENSIVE URGENCY
 Definition of hypertensive urgency - diastolic BP
(DBP) >120 mm Hg
 Distinguished from hypertensive emergencies by
the lack of acute progressive target organ
damage
 Pt to be observed for a few hours following the
use of a short-acting agent
 Data suggest that an aggressive approach may be
harmful
Vidt, J Clin Hypertens 2004;6:520–525

8. HYPERTENSIVE EMERGENCY
 A hypertensive emergency is a clinical diagnosis that
is appropriate when marked hypertension is
associated with acute target-organ damage
Elliot Prog Cardiovasc Dis. 2006; 48(5):316-25
Examples of target-organ damage
 hypertensive encephalopathy
 intracerebral hemorrhage or infarction
 unstable angina pectoris or acute myocardial infarction
 acute left ventricular failure with pulmonary edema
 dissecting aortic aneurysm
 eclampsia of pregnancy

9. EVALUATION AND
CLASSIFICATION OF
HYPERTENSION

10. WHEN TO LABEL ‘HYPERTENSIVE”
 Elevated blood pressure on two separate
occasions, after initial screening measurement
which reveals high BP
 Measurement of BP for more occasions (~6) may
be needed in some individuals

11. MEASUREMENT OF BLOOD PRESSURE
 Equipment, whether aneroid, mercury, or electronic, should be
regularly inspected
 Operator should be trained and regularly retrained in the
standardized technique and patient must be properly prepared
and positioned
 Auscultatory method of BP measurement should be used
 Persons should be seated quietly for at least 5 minutes in a chair,
with feet on the floor, and arm supported at heart level
 Caffeine, exercise, and smoking should be avoided for at least 30
minutes prior to measurement

12. Copyright ©2003 American Heart Association
Chobanian, A. V. et al. Hypertension 2003;42:1206-1252
TABLE 2

13. IDENTIFIABLE CAUSES OF
HYPERTENSION
 Chronic kidney disease
 Coarctation of the aorta
 Cushing syndrome and other glucocorticoid excess states
including chronic steroid therapy
 Drug-induced or drug-related
 Obstructive uropathy
 Pheochromocytoma
 Primary aldosteronism and other mineralocorticoid excess
states
 Renovascular hypertension
 Sleep apnea
 Thyroid or parathyroid disease

14. TARGET ORGAN DAMAGE
IN HYPERTENSION

15. END ORGAN INVOLVEMENT
Hypertension
Eye
Kidneys
Vessels
CNS
Heart

16. TARGET ORGAN DAMAGE
 Heart
 Left ventricular hypertrophy
 Angina or myocardial infarction
 Heart failure
 Brain
 Transient ischemic attacks
 Cerebrovascular accident : infarcts/haemorrhage
 Global or focal neurodeficits
 Hypertensive encephalopathy

17. TARGET ORGAN DAMAGE
 Chronic kidney disease
• Arteriosclerosis of renal arterioles
• Proteinuria
• Haematuria
• Renal failure
 Peripheral arterial disease
• Generalised atherosclerosis
• Peripheral vascular disease
• Aortic dissection/aneurysms
 Retinopathy

18. RISK FACTORS FOR ADVERSE
PROGNOSIS
 Young age
 Male
 Diastolic BP>115 mmHg
 Smoking
 Diabetes mellitus
 Hypercholesterolemia
 Obesity
 Alcohol
 Evidence of end-organ damage

19. HYPERTENSION - THERAPY

20. APPROACH TO DRUG THERAPY
 Risk stratification
 Risk factors
 Target organ damage
 Clinical cardiovascular disease
 Goals of therapy
 Blood pressure≤140/90 mm Hg
 Diabetics and patients with renal disease need
aggressive approach
 Goal is ≤ 130/80 mm Hg

21. Chobanian A. V. et al. Hypertension 2003;42:1206-1252
Algorithm for treatment of hypertension

22. COMPELLING INDICATIONS FOR
INDIVIDUAL DRUG CLASSES
Compelling Indication Initial Therapy Options
THIAZ, BB, ACEI, ARB,
ALDO ANT
BB, CCB
BB, ACEI, ALDO ANT
THIAZ, BB, ACE, CCB
THIAZ, CCB
Heart failure
AF
Postmyocardial
infarction
High CAD risk
ISH

23. Diabetes
Chronic kidney disease
Recurrent stroke
prevention
Hyperthyroidism
Pre-op hypertension
COMPELLING INDICATIONS FOR
INDIVIDUAL DRUG CLASSES
Compelling Indication Initial Therapy Options
ACEI, ARB, CCB
ACEI, ARB
THIAZ, ACEI
BB
BB

24. CONTRAINDICATIONS FOR DRUG/
DRUG CLASSES
 Brochospasm – BB
 Depression – centrally acting α-agonists
 Diabetes – high dose diuretics
 Gout – thiazides
 Heart block/CHF – BB, non DHP CCB
 Liver disease – Labetalol
 Pregnancy – ACEI
 PVD – BB
 Renal insufficiency – K+
sparing diuretics

25. DIURETICS – ACTING ON RENAL
TUBULE

26. BETA BLOCKERS

27. CALCIUM CHANNEL BLOCKERS

28. ANGIOTENSIN CONVERTING
ENZYME INHIBITORS AND
RECEPTOR BLOCKERS

29. ANTIADRENERGIC AGENTS-ALPHA
ANTAGONISTS

30. ANTIADRENERGIC AGENTS

31. VASODILATORS

32. HIGH BP, URGENCY AND EMERGENCY
HANDLER, JOURNAL OF CLINICAL HYPERTENSION. 8;1:61-64 JAN 2006
(EDITORIAL)
High BP Urgency Emergency
BP >180/110 mm Hg >180/110 mm Hg
Usually >220/140
mm Hg
Symptoms
Headache,
anxiety, often
symptomatic
Severe headache,
shortness of
breath, edema
Shortness of
breath, chest
pain, altered
consciousness
Exam
No target damage,
no cardiovascular
disease
Target organ
damage,
Cardiovascular
disease
present/stable
Encephalopathy,
pulm edema,
renal
insufficiency,
cardiac ischemia
Therapy
Observe 1–3 h,
initiate/resume
medication
Observe 3–6 h,
short-acting oral
agent
parenteral
therapy in
emergency
department

33. DRUGS USED IN HYPERTENSIVE
EMERGENCIES

34. INODILATORS
Drugs Bolus Infusion
Amrinone 0.5-1.5mg/kg 5-10μ/kg/min
Milrinone 50μ/kg 0.375-0.75μ/kg/min

35. www.anaesthesia.co.in
anaesthesia.co.in@gmail.com