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Hypertension (HT) High Blood Pressure (HBP) by maw52434


									    Hypertension (HT)

High Blood Pressure (HBP)

                        slide 1
• Definition: Hypertension is defined as
  elevated arterial blood pressure.
• Hypertension is one of the most common
  disease in the world
• In our country, 160 million people over the
  age of 15 have established or borderline HP
• HP Essential HP (95%) Secondary HP (5%)

                                           slide 2
• Genetic
• Environment
   Dietary: Salt intake
   Alcohol intake
   Infant dysnutrition

                          slide 3
1. High activity of the SNS (Sympathetic
   Nervous System)
2. RAAS (Renin-Angiotension Aldosterone
3. Renal Sodium Handling
4. Vascular Remodelling
5. Endothelial Cell Dysfunction
6. Insulin Resistance

                                   slide 4
The pathological changes of small artery

                                  slide 6
     The pathological change of the Heart
Left ventricular hypertrophy (LVH)
          Heart failure

Coronary artery atherosclerosis
        Myocardial infarction
                                      slide 7
Pathological change of the Brain

Ischemic stroke
Hemorrhagic stoke

                              slide 8
     Pathological change of Renal
Hypertension induced nephrosclerosis,
 atrophy of renal cortex

                                    slide 9
               Clinical Features
• The blood pressure varies widely over
  time, depending on many variables,
  including SNS activity, posture, state of
  hydration, and skeletal muscle tone.
• Symptoms:
  Always asymptomatic
  Symptoms often attributed to hypertension:
    headache, tinnitus, dizziness, fainting

                                           slide 10
              Clinical Features

• Complications of Hypertension
Heart: LVH, CHD,HF
Brain: TIA, Stroke
Renal: Microalbuminuria, renal dysfunction

                                       slide 11
        Laboratory Examination
• Blood pressure measurement:
  Clinic Blood Pressure
  Home Blood Pressure
  Ambulatory monitoring

                                 slide 12
         Ambulatory Measurement

• Ambulatory monitoring can provide:
  – readings throughout day during usual activities
  – readings during sleep to assess nocturnal changes
  – measures of SBP and DBP load
  – Exclude white coat or office hypertension
• Ambulatory readings are usually lower
  than in clinic (hypertension is defined as
  > 135/85 mm Hg)
                                                      slide 13
           Laboratory Examination

•   Urinalysis
•   Blood examination
•   Chest X Ray
•   EKG
•   UCG (Ultrasound cardiography)
•   Retina examination

                                    slide 14
slide 15
slide 16
slide 17
            The Keith-Wagner Criteria
                (change in retina)
KW I: Minimal arteriolar narrowing, irregularity
        of the lumen, and increased light reflex
KW II: More marked narrowing and irregularity
        with arteriovenous nicking (crossing defects)
KW III: Flame-shaped hemorrhages and exudates in
        addition to above arteriolar changes
KW IV: Any of the above with addition of papilledema

                                               slide 18

Flame shaped hemorrhage

                                        slide 19
     Diagnosis &
Differential Diagnosis

                         slide 20
     Classification of blood pressure for adult
Category                   SBP (mmHg)                 DBP (mmHg)
Normal                   < 120                       < 80
High normal               120-139                     80-89
Hypertension              ≥140                      ≥90
 Stage 1                  140-159                    90-99
 Stage 2                  160-179                   100-109
 Stage 3                   ≥180                     ≥110
Systolic HBP               ≥140                     < 90

When the SBP and DBP fall into different categories, use the higher category
                                                                slide 21
         Evaluation Objectives
• To identify cardiovascular risk factors
• To assess presence or absence of target
  organ damage
• To identify other causes of hypertension

These evaluation may used in stratification
 of the hypertension patients
                                            slide 22
         Cardiovascular Risk Factors

•   Blood pressure
•   Age
•   Gender
•   Dyslipidemia
•   Abdomen Obesity
•   Family History of cardiovascular disease
•   CRP ≥1mg/dl
                                         slide 23
             Target Organ Damage

•   Left ventricular hypertrophy
•   Echo shows IMT of carotid artery
•   Plasma creatinine slight elevation
•   Microalbuminuria

                                         slide 24
      Associated Clinical Condition
• Cerebrovascular diseases: Stroke, TIA
• Heart diseases: MI, AP, CHF, Coronary
  artery revasculation
• Kidney diseases: DN, Dysfunction of the
  kidney, Proteinuria, CRF
• Diabetes
• Peripheral artery disease
• Retinopathy
                                       slide 25
      Evaluation Components

• Medical history

• Physical examination

• Routine laboratory tests

                              slide 26
         Stratification of Hypertension patients
                                      Blood Pressure
risk factors &         Grade I        Grade II         Grade III
Disease History
I . No risk factors    Low risk       Med risk         High risk
II. 1-2 risk factors   Med risk       Med risk         Very high risk
III. 3 or more risk    High risk      High risk        Very high risk
factors or TOD or
IV. ACC                Very high risk Very high risk   Very high risk

 TOD-Target Organ Damage; ACC-Associated Clinical Conditions
                                                            slide 27
      Differential Diagnosis

Should exclude Secondary Hypertension

                                   slide 28
            Secondary Hypertension
                Common Causes
• Renal
 Glomerulonephritis            Pyelonephritis
 Obstructive nephropathy       Collagen diseases,
 Congenital diseases           Diabetes nephropathy
 Renal tumor---- renin secreting tumor
• Pheochromocytoma
• Primary aldosteronism

                                              slide 29
•   Ganglion-neurotomas and neuroblastomas
•   Excretion of large amounts of catecholamines
•   90% arise in the adrenal medulla
•   10% are malignant.
•   Paroxymal or persist HT
•   Clinic features: Headache, sweating,
    palpitations, nervousness, weight loss,
    hypermetabolism, orthostatic hypotension,
    severe presser response
                                         slide 30
            Primary Aldosteronism

•   Mild or moderate hypertension
•   Hypokalemia, muscle weakness, paralysis
•   Polyuria, nocturia and polydipsia,
•   Hypochloremic alkalosis
•   Urine aldosterone elevation
•   Plasma renin active decrease

                                          slide 31
              Secondary Hypertension
•   Obstructive Sleep Apnea (OSA)
•   Renal artery stenosis
•   Cushing’s syndrome
•   Coarctation of the aorta
•   Drug-induced:
    NSAIDs;               Sympathomimetic medications;
    Prophylactic;         Monoamine oxidase inhibitors;
    Mineralocorticoids;   Immuno-inhibitors;
                                               slide 32

          slide 33
     Goal of Hypertension Management

• < 140/90 mm Hg
• With Diabetes or kidney dysfunction:
  – To reduce morbidity and mortality of cerebral
    and cardiovascular complications.
  – Controlling other cardiovascular risk factors

                                             slide 34
             Lifestyle Modifications

•   Stop smoking
•   Limit alcohol intake
•   Lose weight or keep fit
•   Suitable diet
•   Increase aerobic physical activity
•   Decrease psychological stress

                                         slide 35
         Principle of Drug Therapy

• Drug therapy should be individually

• A low dose of initial drug therapy

• Combination therapies may provide additional
  efficacy with fewer adverse effects.

• Optimal formulation should provide 24-hour
  efficacy with once-daily dose.

                                         slide 36
       Antihypertensive Drugs

• Diuretics
• ß-Adrenergic receptor blockers (BB)
• Calcium channel blockers (CCB)
• ACE inhibitors (ACEI)
• Angiotensin II receptor blockers (ARB)

                                   slide 37
Algorithm for Treatment of
 Hypertension patient

Lifestyle Modifications

Not at Goal Blood Pressure

   Initial Drug Choices

                             slide 38
              Algorithm for Treatment of
                Hypertension (continued)
                        Initial Drug Choices

   No associated clinical condition      Associated clinical condition

I stage hypertension:    II stage hypertension:   Choice the drugs
      Diuretics,                Two drugs         according to ACC
 BB,CCB,ACEI,ARB          combination therapy

                  Not at Goal Blood Pressure

Increase dosage or add another agent from different class
                                                             slide 39
      Drug choices in hypertension patient
       associated with clinical condition
       Diuretics BB ACEI ARB CCB Antialdosterone
  HF      √       √  √    √
  MI              √  √                  √
 CAD      √       √  √        √
 DM       √       √  √    √   √
 CRF                 √    √
Stroke    √          √
                                        slide 40
             Combination Therapies
• May provide additional efficacy with fewer adverse
• Diuretics as the basement drug in combination therapy.
  Diuretics ---- ACEI / ARB
  Diuretics ---- BB
  Diuretics ---- CCB
• CCB as the basement drug in combination therapy
  CCB ---- ACEI
  CCB ---- BB
                                               slide 41
• Others: Three drugs combination
           Causes for Inadequate
         Response to Drug Therapy

• Incorrect measurement of the BP
• Volume overload or Pseudo-resistance
• Drug-related causes
• Associated conditions

                                         slide 42
               Hypertensive crisis
• Hypertensive Emergencies and Urgencies
• Emergencies: The blood pressure is elevated
  severely and associated with target organ damage,
  such as hypertensive encephalopathy, AMI,
  pulmonary edema, require immediate blood
  pressure reduction.
• Urgencies: The blood pressure is elevated
  severely but no target organ damage has acute
  target organ damage.
• Fast-acting drugs are available.
                                              slide 43
            Drugs Available for
            Hypertensive Crisis

Vasodilators        Adrenergic Inhibitors
•Nitroprusside      •Labetalol
•Nicardipine        •Esmolol
•Nitroglycerin      •Phentolamine

                                     slide 44
     Case 1
Male 29 years old
Blood pressure elevated for two years
With paroxysmal dizziness, blurred vision,
  sweating and palpitation
BP: 160-180/90-100mmHg
HR: 100-120 bpm
When the patient with symptoms, the BP would
  elevate to 240-260/120-130mmHg, and HR
  increase to 130-150 bpm.
                                        slide 45
Physical examination:
BP: 165/100mmHg        HR: 112 bpm
No positive sign in chest examination
Can find a mass at right abdomen, if press on it the
 BP of the patient elevated to 250/120mmHg, and
 the HR increased to 145 bpm.

                                             slide 46
Laboratory test:
Blood routine, Urinalysis, Blood biochemistry are
Plasma renine activation: 0.93ng/ml.h (0.93-6.56)
AT II: 51.5pg/ml ↓ (55.3-115.3)
Aldosterone: 129.4pd/ml (63-239.6)
NE: 33.40pmol/ml ↑↑ (0.51-3.26)
12-lead electrocardiogram: High voltage of LV
Chest X ray: Normal                        slide 47
                         CT scan of
                         Found a mass
                          at right

Diagnosis as Phenochromocytoma
                                 slide 48
                      Case 2

Male, 65 years old
Hypertension history for 30 years
Headache, blurred vision, vomiting for 2 hours
Paralysis of left side body
BP: 220/130mmHg
HR: 106 bpm
CT scan of the head: Normal
                                           slide 49
Diagnosis: Hypertensive crisis
Therapy: Controlled the BP, using fast-acting
  drug,such as Nitroprusside, Labetalol
The reduction of BP should less than 25% in 24
BP ≥ 160/100mmHg in 48 hours

                                         slide 50
• Specific therapy for patients with LVF, CAD, and
  HF. ACEI can be used for all type patients.
• In older persons, diuretics and CCB are preferred.
• Many patients need combination therapy.
• Goal of the patients with renal insufficiency with
  proteinuria (>1 g/day): 125/75 mmHg;
              (< 1 g/day): 130/80 mmHg.
• Patients with diabetes should be treated to a
  therapy goal of below 130/80 mm Hg.
                                               slide 51

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