Systemic hypertension is defined as a usual blood pressure of 140/90 mmHg or higher. It doubles the risk of cardiovascular diseases and is a leading cause of death worldwide. There are two main types - primary/essential hypertension which accounts for 95% of cases and has no identifiable cause, and secondary hypertension which is caused by specific conditions like kidney disease or hormonal disorders. Untreated hypertension can lead to serious complications affecting the heart, brain, kidneys and eyes. Management involves identifying and treating any underlying causes, along with lifestyle modifications and medication to control blood pressure.

1. Systemic
Hypertension
DR. AH JAWID YOUSUFI

2. Definition
▪ HTN is defined as usual BP of 140/90 mmHg or persistently higher.

3. Hypertension and Its risk
▪ Doubles the risk of cardiovascular diseases.
▪ Approximately 7.6 million deaths (13 –15% of the total) and 92 million disability
adjusted life years worldwide
▪ Often is associated with additional cardiovascular disease risk factors.
▪ Antihypertensive therapy clearly reduces the risks of cardiovascular and renal
disease
▪ But large segments of the hypertensive population are either untreated or
inadequately treated.

4. Mechanisms of Hypertension
▪ Determinants of arterial pressure:
 Cardiac output
▪ Stroke volume
▪ Heart Rate
 Peripheral resistance
• Vascular structure
• Vascular functions

5. Etiology & Classification
▪ Primary Essential Hypertension
• It is the term applied to the 95% of hypertensive patients.
• Blood pressure results from complex interactions between multiple genetic
and environmental factors.
• Essential hypertension occurs in 10–15% of white adults and 20–30% of
black adults.
• The onset is usually between ages 25 and 50 years; it is uncommon before
age 20 years.

6. Essential Hypertension
▪ Pathways that underlying hypertension
• Over activation of the sympathetic nervous and renin–angiotensin– aldosterone
systems.
• Blunting of the pressure-natriuresis relationship.
• Variation in cardiovascular and renal development.
• Elevated intracellular sodium and calcium levels.
▪ Predisposing factors
▪ Genetic factors
▪ Age
▪ Race
▪ Family history
▪ Environmental factors

7. Conti…
▪ Environmental factors
• Obesity
• Sleep apnea
• Increased salt intake
• Cigarette smoking
• Exercise
• Polycythemia
• NSAIDs
• Low potassium intake
• Vit D deficiency
• Stress
• Alcohol intake

8. Secondary Hypertension
▪ Approximately 5% of patients have hypertension secondary to identifiable specific
causes.
▪ Secondary hypertension should be suspected in patients in whom:
o Hypertension develops at an early age or after the age of 50 years.
o In those, previously well controlled who become refractory to treatment.
▪ Secondary HTN causes
o Genetic syndromes
o Kidney disease
o Renal vascular disease
o Primary hyperaldosteronism
o Cushing syndrome
o Pheochromocytoma
o Coarctation of the aorta
o Hypertension associated with pregnancy
o Hypercalcemia and medications.

9. Conti…
▪ Genetic causes
 Glucocorticoid remediable aldosteronism
 Syndrome of apparent mineralocorticoid excess
 Hypertension exacerbated in pregnancy
 Liddle syndrome
▪ Kidney disease: Renal parenchymal disease is the most common cause of
secondary hypertension.
 Increased intravascular volume
 Increased activity of the renin–angiotensin–aldosterone system

10. Conti…
▪ Renal vascular hypertension: Renal artery stenosis is present in 1–2% of
hypertensive patients. The most common cause is:
 Atherosclerosis
 Excessive renin release
Renal vascular hypertension should be suspected in the following
circumstances:
 The documented onset is before age 20 or after age 50 years.
 Hypertension is resistant to three or more drugs.
 Epigastric or renal artery bruits.
 Atherosclerotic disease of the aorta or peripheral arteries.
 An abrupt increase (more than 25%) in the level of serum creatinine after
administration of angiotensin-converting enzyme (ACE) inhibitors.

11. Conti…
▪ Primary Hyperaldosteronism: should be considered in people with resistant
hypertension.
 Blood pressures consistently greater than 150/100 mm Hg
 Hypokalemia
 Family history of hyperaldosteronism
 Plasma aldosterone concentration is elevated
▪ Cushing syndrome: Hypertension occurs in about 80% of patients with
spontaneous Cushing syndrome.
 Glucocorticoid may act through salt and water retention (via mineralocorticoid
effects)
 Increased angiotensinogen levels
 Permissive effects in the regulation of vascular tone

12. Conti…
▪ Pheochromocytoma
 Uncommon, 0.1% of all patients with hypertension, two individuals per million
population.
 Blood pressure elevation caused by the catecholamine.
▪ Coarctation of the aorta
▪ Hypertension associated with pregnancy

13. Clinical Findings
▪ The clinical and laboratory findings are mainly referable to involvement of the
target organs: heart, brain, kidneys, eyes, and peripheral arteries.
▪ Symptoms
▪ Mild to moderate primary (essential) hypertension is largely asymptomatic for
many years.
▪ The most frequent symptom, headache, is also very nonspecific.
▪ Accelerated hypertension is associated with somnolence, confusion, visual
disturbances, and nausea and vomiting (Hypertensive Encephalopathy).
▪ Secondary HTN symptoms maybe exist.
▪ Complication symptoms

14. Conti…
▪ Signs
 Physical findings depend on the cause of hypertension, its duration and severity
 Blood pressure
 Left ventricular heave indicates severe hypertrophy
 Radial-femoral delay suggests coarctation of the aorta
▪ Laboratory Findings: Recommended testing includes:
 Hemoglobin
 Urinalysis and serum creatinine
 Fasting blood sugar level
 Plasma lipids
 Serum electrolytes
 Serum uric acid

15. Conti…
▪ Electrocardiography and Chest Radiographs
 Left ventricular hypertrophy
 Chest radiograph is not necessary in the workup for uncomplicated hypertension.
▪ Echocardiography
 Echocardiography should be to evaluate patients with clinical symptoms or signs of
cardiac disease.

16. Complications of Untreated Hypertension
▪ Hypertensive Cardiovascular Disease
▪ Hypertensive Cerebrovascular Disease and Dementia
▪ Hypertensive Kidney Disease
▪ Aortic Dissection
▪ Retinas
▪ Metabolic syndrome
▪ Aneurysms

17. Conti…
▪ Retina
▪ Grade 1
▪ Arteriolar thickening
▪ Tortuosity
▪ Increased reflectiveness - silver wiring
▪ Grade 2
▪ Grade 1
▪ Constriction of veins at arterial crossings - arteriovenous nipping
▪ Grade 3
▪ Grade 2
▪ Retinal ischaemia - flame-shaped or blot haemorrhages and ‘cotton wool’ exudates
▪ Grade 4
▪ Grade 3
▪ Papilloedema

18. Conti…