Hypertension causes and investigation and management according to jnc7 nad 8

1. diagnosis and management of
hypertension
PRESENTED BY
DR SHASHANK AGRAWAL
MEDICINE JR 2
Moderated by
Dr M.P RAWAL
M.D MEDICINE

2. Blood Pressure = Cardiac Output x
Systemic Vascular
Resistance

3. • Heart rate
• Vasoconstriction/vasodilation
• Fluid volume overload
• Renin-angiotensin
• Aldosterone
• ADH

4. • Hypertension is defined as
• Systolic blood pressure > 140 mm of Hg
• Diastolic blood pressure > 90 mm of Hg

5. BP Classification SBP mmHg DBP mmHg
Normal < 120 and < 80
Pre-hypertension* 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension > 160 or > 100
Isolated systolic hypertension grade 1
Grade ii
140 – 159
> 160
< 90
< 90
Hypertension classification

6. Primary ( essential ) hypertension
• elevated BP with unknown cause
• 90% to 95% of all cases
Secondary hypertension
• elevated BP with a specific cause
• 5% to 10 % in adults
Continue..

7. Primary hypertension contributing factors: -
• increase sinus node activity
• DM
• increase sodium intake
• excessive alcohol intake
continue..

8. Secondary HTN (05%)
A. Renal (80%) • AGN
• CGN,
• Polycyst. K.D
• Renal Artery stenosis
B. Endocrine • Adrenal • Primary aldosteronism
• Cushing’s syndrome
• Pheochromocytoma
• Acromegaly
• Exogenous hormone • Oral contraceptive
• Glucocorticoids
• Hypothyroidism &
• Hyperparathyroidism
Continue…

9. Others
• Coarctation of the aorta
• Pregnancy Induced HTN (Pre-eclampsia)
• Sleep Apnea Syndrome.

10. • Severe elevated BP > 180 /110 mm of Hg
• Without progressive end-organ dysfunction.
• Examples: Highly elevated BP without severe
headache, shortness of breath or chest pain.
• Usually due to under-controlled HTN.

11. • Severely elevated BP (>220 / 140 mmHg).
• With progressive target organ dysfunction.
• Require emergent lowering of BP.
• Examples: Severely elevated BP with:
Hypertensive encephalopathy
Acute left ventricular failure
Acute MI or unstable angina pectoris
Dissecting aortic aneurysm

12. • Age (> 55 for men; > 65 for women)
• Alcohol
• Cigarette smoking
• Diabetes mellitus
• Elevated serum lipids
• Excess dietary sodium
• Gender

13. • Family history
• Obesity (BMI > 30)
• Ethnicity (African Americans)
• Sedentary lifestyle
• Socioeconomic status
• Stress

14. • Frequently asymptomatic until severe and
target organ disease has occurred
• Fatigue, reduced activity tolerance
• Dizziness
• Palpitations, angina
• Dyspnea
Hypertension Clinical Manifestations

15. HYPERTENSION
Gangrene of the
Lower Extremities
Heart
Failure
Left
Ventricular
Hypertrophy
Myocardial
Infarction
Coronary Heart
Disease
Aortic
Aneurym
Blindness
Chronic
Kidney
Failure
Stroke Preeclampsia
/Eclampsia
Cerebral
Hemorrhage
Hypertensive
encephalopathy

16.  Complications are
primarily related to
development of
atherosclerosis
(“hardening of
arteries”), or fatty
deposits that
harden with age

17. • Common cause of secondary HTN (2-5%)
• HTN is both cause and consequence of renal
disease
• Multifactorial cause for HTN including
disturbances in Na/water balance,
vasodepressors/ prostaglandins imbalance

18. • Atherosclerosis 75-90% ( more common in
older patients)
• Fibromuscular dysplasia 10-25% (more
common in YOUNG/WHITE/ FEMALE )
• Other
• Aortic/renal dissection
• Takayasu’s arteritis
• Thrombotic/cholesterol emboli
• CVD
• Post transplantation stenosis
• Post radiation

19. • CVS (Heart and Blood Vessels)
• The kidneys
• Nervous system
• The Eyes

20. • Ventricular hypertrophy, dysfunction and
failure.
• Arrhithymias
• Coronary artery disease, Acute MI
• Arterial aneurysm, dissection, and rupture.

21. • Glomerular sclerosis leading to impaired kidney
function and finally end stage kidney disease.
• Ischemic kidney disease especially when renal
artery stenosis is the cause of HTN

22. • Stroke, intracerebral and subaracnoid
hemorrhage.
• Cerebral atrophy and dementia

23. • Retinopathy, retinal hemorrhages and impaired
vision.
• Vitreous hemorrhage, retinal detachment
• Neuropathy of the nerves leading to
extraoccular muscle paralysis and dysfunction

24. Normal Retina Hypertensive Retinopathy A: Hemorrhages
B: Exudates (Fatty Deposits)
C: Cotton Wool Spots
(Micro Strokes)
A B
C

25. Arteriolar Narrowing

26. AV Nicking
AV Nicking
AV Nicking

28. H
E

30. • Patient seated quietly for at
least 5minutes on a chair, arm
supported at heart level
•An appropriate-sized cuff (cuff bladder encircling at
least 80% of the arm)
•At least 2 measurements

31. • Systolic Blood Pressure is the point at which
the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
• Ambulatory BP Monitoring - information about
BP during daily activities and sleep
Range is > 125 /80 mm of Hg
Continue…

32. Avoid harmful habits ,smoking ,alcohol
Reduce salt and high fiber diets
Loose weight , if obese
Regular exercise
DASH
diet

34. • General population > 60 yr
B.P - < 150 /90
• General population < 60 yr
B.P < 140 /90
• Population > 18 yr with CKD
B.P < 140 /90
• Population > 18 yr with or without diabetes
B.P < 140 /90

35. • Non black including diabetes
initial treatment - CCB, ACEI, ARBs ,
DIURETICS
• IN BLACK POPULATION – DIURETIC, CCB
• IN > 18 yr age with CKD – ACEI , ARBs

36. BP Goal JNC-7 JNC-8 ASH/ISH ESC/ESH
Age < 60 <140/90 <140/90 <140/90 <140/90
Age 60-79 <140/90 <150/90 <140/90 <140/90
Age 80+ <140/90 <150/90 <150/90 <150/90
Diabetes <130/80 <140/90 <140/90 <140/85
CKD <130/80 <140/90 <140/90 <130/90

37. Continue….
AT1 receptor
ARB

39. Example: Hydrochlorothiazide , chlorothiazide , Indapamide ,
amiloride , triametrine , spironolactone,
• Act by decreasing blood volume and cardiac output
• Drugs of choice in elderly hypertensives
Side effects-
• Hypokalaemia
• Hyponatraemia
• Hyperlipidaemia
• Hyperuricaemia (hence contraindicated in gout)
• Hyperglycaemia (hence not safe in diabetes)
• Not safe in renal and hepatic insufficiency

40. Example: Atenolol, Metoprolol, nebivolol,
• Block b1 receptors on the heart
• Block b2 receptors on kidney and inhibit release of
renin
• Drugs of choice in patients with co-existent CHD
Side effects-
• lethargy, impotency, bradycardia
• Not safe in patients with co-existing asthma and
diabetes
• Have an adverse effect on the lipid profile

41. Example: Amlodipine
• Block entry of calcium through calcium channels
• Cause vasodilation and reduce peripheral resistance
• Drugs of choice in elderly hypertensives and those
with co-existing asthma
• Neutral effect on glucose and lipid levels
Side effects
Flushing, headache, Pedal edema

42. Example: Ramipril, Lisinopril, Enalapril
• Inhibit ACE and formation of angiotensin II and block
its effects
• Drugs of choice in co-existent diabetes mellitus,
Heart failure
Side effects-
dry cough, hypotension, angioedema

43. Example: Losartan , candesartan , valsartan
• Block the angiotensin II receptor and inhibit effects of
angiotensin II
• Drugs of choice in patients with co-existing diabetes
mellitus
Side effects-
safer than ACEI, hypotension,

44. Example: prazosin , doxazosin
• Block a-1 receptors and cause vasodilation
• Reduce peripheral resistance and venous return
• Exert beneficial effects on lipids and insulin
sensitivity
• Drugs of choice in patients with co-existing BPH
Side effects-
Postural hypotension,

45. • Example – clonidine , Alpha-methyldopa
• MOA – convert NA to alpha methyl NA which
act on alpha 2 receptor in brain – decrease in
adrenergic discharge – fall in PVR – fall in B.P
• D.O.C in hypertension in pregnancy.

46. Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or
chronic kidney disease)
Initial Drug Choices
With
Compelling
Indications
Lifestyle Modifications
Without
Compelling
Indications

47. Stage 1 Hypertension
(SBP 140–159 or DBP
90–99 mmHg)
Thiazide-type diuretics
for most.
May consider ACEI, ARB,
BB, CCB,
or combination.
Stage 2 Hypertension
(SBP >160 or DBP >100
mmHg)
2-drug combination for
most (usually thiazide-
type diuretic and
ACEI, or ARB, or BB, or
CCB)
Drug(s) for the
compelling indications
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB)
as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional
drugs
until goal blood pressure is achieved.
Consider consultation with
hypertension specialist.

48. Condition Preferred drugs Other drugs Drugs to be
that can be used avoided
Asthma Calcium channel a-blockers/Angiotensin-II b-blockers
blockers receptor blockers/Diuretics/
ACE-inhibitors
Diabetes a-blockers/ACE Calcium channel blockers Diuretics/
mellitus inhibitors/ b-blockers
Angiotensin-II
receptor blockers
High cholesterol a-blockers ACE inhibitors/ A-II b-blockers/
levels receptor blockers/ Calcium Diuretics
channel blockers
Elderly patients Calcium channel b-blockers/ACE-
(above 60 years) blockers/Diuretics inhibitors/Angiotensin-II
receptor blockers/a- blockers
BPH a-blockers b-blockers/ ACE inhibitors/
Angiotensin-II receptor
blockers/ Diuretics/
Calcium channel blockers

49. Class of drug Main side-effects Contraindications/ Special
Precautions
Calcium channel blockers Pedal edema, Headache
(e.g. Amlodipine
Diltiazem) Hypersensitivity,
Bradycardia, Conduction
disturbances, CHF, LV
dysfunction.
a-blockers Postural hypotension Hypersensitivity
(e.g. prazosin)
ACE-inhibitors Cough, Hypotension, Hypersensitivity, Pregnancy,
(e.g. Lisinopril) Angioneurotic edema Bilateral renal artery stenosis
Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy,
blockers (e.g. Losartan) Bilateral renal artery stenosis

50. Condition
• Pregnancy
• Coronary heart
disease
• Congestive heart
failure
Preferred Drugs
• Nifedipine, labetalol,
hydralazine, beta-
blockers, methyldopa,
prazosin
• Beta-blockers, ACE
inhibitors, Calcium
channel blockers
• ACE inhibitors,
beta-blockers

51.  Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs,
sympathomimetics, OCP)
• Over-the-counter drugs and some herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN