Hypertension (Ref. Hari. 18 ed., pg - 2047)

Extra Edge: Hypertension (also known as Silent killerdisease) Rule of half applies to it (MCQ)

Recent Advances: (Ref. Hari. 18 ed., pg -2047, table241-1)

Measuring blood pressure

1. Cuff width should be > 80% of the armcircumference. (AIPG 2012)

2. Systolic pressure. The appearance ofsustained repetitive tapping sound (Korotkoff1 )

3. Diastolic pressure usually the disappearanceof sounds (Korotkoff V )

4. In some individual (eg. pregnant women)sounds are present until the zero point.

5. In this case the muffing of sounds (KorotkoffIV ) should be used.

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White coat hypertension = BP is high in the hospital /clinic but BP is normal at home.Ankle brachial index (LQ 2012)

1. It is the ratio of Systolic BP at ankle / systolicBP of arm.

2. It indicate the degree of lower extremityarterial occlusive disease.

3. ABI < 0.9 = abnormal

4. ABI < 0.3 = critical ischemia for peripheralarterial disease.

Recent AdvancesCilostazol is used in the alleviation of the symptom ofintermittent claudication in individuals with peripheralvascular disease

Recent Advance - J-curve phenomenon

1. People with high BP and/or high bloodcholesterol levels have a greater risk ofdeveloping cardiovascular diseases (CVD).

2. The higher the BP and/or cholesterol level, thegreater the risk. We also know that loweringblood pressure and cholesterol levels lowersthe risk for CVD.

3. When the BP or blood cholesterol levels oflarge groups of people are plotted on a graphagainst CVD mortality, it often results in a J-shaped curve.

4. This curve shows that those with higher BPand/or cholesterol levels, closer to the top ofthe curve, are more likely to die from CVD.

5. The curve also shows that those at the lowestend of the curve (with very low BP and/or lowcholesterol levels) also have higher CVD

mortality. This accounts for the J shape and isknown as the J-curve phenomenon. (Ref. Hari.18 ed., Pg-2058)

Pseudohypertension (Oslers Sign) Isolated systolichypertension (ISH):

1. Pseudohypertension is when only systolicblood pressure (>140) is elevated.

2. Pseudohypertension is almost always found inolder patients.

3. As people get older, the walls of the arteriessometimes get very thick, and calcium may bedeposited in the arterial wall (arteriosclerosis).This makes the arteries very stiff and difficultto compress.

4. Because measuring blood pressure dependson measuring how much force it takes tocompress an artery, having thick, difficult-to-compress arteries falsely elevates thesphygmomanometer reading.

5. It is not benign : It has doubles risk of MI,triples risk of CVA

Treatment : Diuretics, Calcium channel blocker

Essential hypertension (primary, cause unknown). Seenin 95% of cases of HT.

Secondary hypertension "5% of cases.

Table 247-2 Systolic Hypertension with Wide PulsePressure (Ref. Hari. 18 ed., Page - 1554,Table 247-2)

1. Decreased vascular compliance (arteriosclerosis)

2. Increased cardiac output

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a. AR (LQ 2012)

b. Thyrotoxicosis

c. Hyperkinetic heart syndrome

d. Fever

e. Arteriovenous fistula

f. Patent ductus arteriosus

g. Pregnancy

h. Beri Beri

Causes of secondary hypertensionRenal disease: The most common secondary cause.

1. Glomerulonephritis, (Acute & Chronic)

2. Chronic pyelonephritis,

3. Renovascular disease (Renal artery stenosis)most frequently atheromatous (elderly,cigarette smokers with periphery vasculardisease) or fibro muscular dysphasia inyoung patients.RAS, can occur in Takayasu disease but itdoes not occur in PAN. (LQ, AIPG 2010)

4. Polycystic kidneys.

5. Renin secreting tumor.

Extra Edge:

1. Renovascular Hypertension (Ref. Hari. 18 ed.,pg - 2049)

a. As a screening test, renal blood flowmay be evaluated with a radionuclide[ I]-orthoiodohippurate (OIH) scan orglomerular filtration rate may beevaluated with a DTPA scan beforeand after a single dose of captopril (or

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another ACE inhibitor).

b. Gadolinium-contrast magneticresonance angiography offers clearimages of the proximal renal artery butmay miss distal lesions.

c. Contrast arteriography remains the"gold standard" for evaluation andidentification of renal artery lesions.

2. Endocrine disease: Cushing's Conn'ssyndromes , pheochromocytoma ,acromegaly , Hyperparathyroidism.Hypothyroid, Hyperthyroid.

3. Connective tissue disorders - PAN, systemicsclerosis, Takayasu disease.

4. Others: Coarctation , porphyria , GuillainBarre syndrome

5. Pregnancy

6. Drugs : steroids , MAOI, oral contraceptivePill', Amphetamine, Alcohol, NSAID

Table 2474. Example of Mendelian Forms ofHypertension (Ref. Hari. 18 ed., pg - 2051)Autosomal recessive Autosomal dominent1. 17-hydroxylasedeficiency2. 11-hydroxylasedeficiency3. 11-hydroxysteroiddehydrogenasedeficiency (apparentmineralocorticoidexcess syndrome)

1. Liddle's syndrome2. Pseudohypoaldosteronismtype II (Gordon's syndrome)3. Polycystic kidney disease4. Pheochromocytoma

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Hypertensive retinopathyGrade

1. Tortuous with thick shiny walls

2. A-V nipping (narrowing where arteries crossveins)

3. Flame hemorrhages and cotton wool spots

4. Papilledema

Hypertension ManagementBasic Physiology of BPPhysiological Parameters on which BP depends

1. Cardiac output

2. Peripheral resistance

3. Blood volume

BP = Cardiac output (COP) x Peripheral resistance (PR)COP = Heart Rate (HR) x Stroke volume (SV)BP = HR x SV x PR

(Mean Arterial Pressure = Diastolic BP + 1/3 pulsepresence)

A. Drugs which reduce HR

a. Beta blockers

b. Ivabridine ( acts on funny Na channels)

Uses of Beta blockers (In hypertensive patients)

a. Angina (LQ 2012)

b. MI

c. Hyperthyroidism

Contraindication of beta blockers

a. Erectile dysfunction

b. Peripheral vascular disease

c. Pheochromocytoma, (If given alone). Shouldbe given only with alpha blockers.

d. CHF

B. Drugs which reduce stroke volume

1. Beta blockers (beta blockers havenegative inotropic & negativechronotropic effects) so beta blockershould be used with cautious or shouldbe avoided in CHF with HT.

2. Diuretics: They reduce blood volume sothey reduce the preload

a. Uses in hypertension

i. HT with CHF

b. Contraindication in HT

i. HT with hyperuricemia

ii. Pheochromocytoma

iii. Thiazides are ContraIndicated in diabetes

3. Nitrates: They primarily dilate thevenules thereby they cause peripheralpooling of the blood. So they reduce thepreload.

Uses of nitrates in HT (AIIMS Nov 2012)

a. HT with CHF

b. HT with CAD

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c. Severe hypertension

C. Drugs which reduce the peripheral resistance

1. Alpha blockers

2. Calcium channel blockers

3. ACEI

4. Direct vasodilators

1. Alpha blockers: They act on the peripheral alphareceptors thereby dilate the arteriole.Examples: Prazosin,Uses of alpha blockers in hypertension

a. Elderly

b. HT with BHP

c. HT with CRF

d. HT with hyperuricemia

2. Calcium channel blockers : They dilate thearteriole so reduce the peripheral resistanceExample: Nifedipin

Uses

a. Elderly hypertensive

b. HT with CRF

c. HT with PVD

d. HT with SAH (Nimodipine is used) (MCQ)

Contraindication

a. HT with CAD

b. Malignant hypertension

c. HT with CHF

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New Drug: Clevidipine is a dihydropyridine calciumchannel blocker indicated for the reduction of bloodpressure when oral therapy is not feasible or notdesirable. (Its name is not given in 18 Edition ofHarrison)!!!

3. ACEI:Examples: Captopril, LisinoprilUses in HT

a. Young patients

b. Unilateral renal artery stenosis

c. HT with DM

d. HT with CHF

e. HT with MI

f. HT with hyperuricemia

g. HT with erectile dysfunction

Side Effects: Cough (M/C), Hyperkalemia (LQ, AIIMSNov 2010), Angioneurotic edema, First dosehypotension.Captopril causes leukopenia & nephrotic syndrome.

Contraindication

a. Bilateral renal artery stenosis

b. CRF

c. With potassium sparing diuretics

d. Pregnancy

4. Direct Vaso dilatorsExample: Hydralazine, alpha Methyl dopa,Sodium nitroprusside, indapamide

a. Hydralazine

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Pregnancy with HTSide effect : SLE like syndrome

b. Alpha methyl dopaUsesPregnancy with HTSide effects: Coombs positive hemolyticanemia, black tongue

c. Sodium nitroprussideUses: Hypertensive emergencies,Malignant hypertension

d. d IndapamideUses

i. HT with hyperuricemia

ii. HT with CRF

iii. HT with diabetes

iv. Elderly hypertensive

Extra Edge: (Ref. Hari. 18 ed., pg - 2010)

1. Verapamil ordinarily should not be combinedwith beta blockers because of the combinedadverse effects on heart rate and contractility.

2. Diltiazem can be combined with beta blockersin patients with normal ventricular functionand no conduction disturbances.

3. Amlodipine and beta blockers havecomplementary actions on coronary bloodsupply and myocardial oxygen demands.

Recent Advances:

1. Bosentan is a new drug. It is a endothelinreceptor antagonist. It is a vaso dilator It hasbeen approved for PAH and for Raynaudsphenomena.

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2. Aliskiren is a new drug. It is a non-peptiderenin inhibitor that acts by inhibitingconversion of angiotensin-I to angiotension-II.It is used in hypertension. (Ref. Hari. 18 ed.,pg - 2055)

3. Fenoldopam has a peripheral vasodilatoryaction which acts as a peripheral selective D1receptor weak partial agonist. It is given ascontinuous IV infusion for the treatment ofhypertensive emergencies. (It is a new drugnot given in Harrison 18 Edition)

4. Naftopidil It is an antihypertensive drugwhich acts as a selective 1-adrenergicreceptor antagonist or alpha blocker.

5. Urapidil It acts as an 1-adrenoceptorantagonist and as an 5-HT1A receptor agonist(It is a new drug not given in Harrison 18Edition)

Resistant Hypertension

1. It refers to patients with BP persistently >140/90mmHg despite taking three or moreantihypertensive agents, including a diuretic, inreasonable combination and at full doses.

2. Resistant hypertension may be related to

a. "Pseudoresistance" (high office bloodpressures and lower home bloodpressures),

b. Non adherence to therapy,

c. Identifiable causes of hypertension(including obesity and excessive alcoholintake), and use of any of a number ofnonprescription and prescription drugs.

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d. Rarely, in older patients,pseudohypertension may be related tothe inability to measure blood pressureaccurately in severely sclerotic arteries.This condition is suggested if the radialpulse remains palpable despiteocclusion of the brachial artery by thecuff (Osler maneuver).

3. The actual blood pressure can be determined bydirect intraarterial measurement (Ref. Hari. 18ed., pg - 2058)

Malignant hypertension

1. A hypertensive emergency (formerly called"malignant hypertension") is severe hypertensionwith acute impairment of one or more organsystems (especially the central nervous system,cardiovascular system and/or the renal system)that can result in irreversible organ damage.

2. So in Malignant hypertension. Abrupt increasingin BP, clinically has very high BP associated withpapilledema, proteinuria, microangiopathichemolytic anemia and encephalopathy.)

3. In a hypertensive emergency, the blood pressureshould be substantially lowered over a period ofminutes to hours with an antihypertensive agent.

4. Complications of malignant hypertension :

1. acute renal failure,

2. heart failure,

3. encephalopathy,

4. CAD

5. Pathological hallmark is fibrinoid necrosis .

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6. Treatment: Avoid sudden drops in BP as cerebralautoregulation is poor

Table 24710. Antihypertensive Agents Used inHypertensive Emergencies. (Ref. Hari. 18 ed., pg -2058)Antihypertensive

1. Nitroprusside (LQ 2012)

2. Nicardipine

3. Labetalol (LQ 2012)

4. Esmolol

5. Phentolamine

6. Nitroglycerin (LQ 2012)

7. Hydralazine

8. Fenoldopam (LQ 2012)

Recent Advances:

1. Previously sublingual nifedipine and injectionfrusemide were used in severe hypertension.But now both these drugs are contraindicatedin severe hypertension.

2. Never use sublingual nifedipine to reduce BP(big drop in BP and increase CAD risk)

3. Injection frusemide should not be used insevere HT But can be used in severe HT withLVF.

Hypertensive urgency

1. Sometimes, patients can have very high bloodpressure but have no symptoms.In these cases, the elevated BP is discoveredincidentally. These cases severe high BPwithout serious symptoms are called

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hypertensive urgency.

2. Hypertensive urgency indicates that the bloodpressure is high enough to cause serious riskof sudden, life threatening events, but that nosuch events are currently occurring.

3. In other words, these patients have no organfailure or other immediately life threateningconditions, but could quickly develop them iftheir blood pressure isnt quickly broughtunder control.

4. Patient should be treated on the OPD basis.(i.e. Hospitalization not needed)

Diet in Hypertensive patient:

The DASH Diet Eating Plan

The DASH (Dietary Approaches to Stop Hypertension)diet is recommended to many people with hypertension.

The DASH diet provides more than the traditional lowsalt or low sodium diet to reduce blood pressure. It isbased on an eating plan rich in fruits and vegetables, andlow-fat or non-fat diet

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