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AuthorsAbhinavMuktaSajaniDollySonia
VikramPawanPoornaAditya
(JAN 2004 MBBS BATCH) (Manipal College of Medical
Sciences,Pokhara,Nepal)
Dorland’s Medical Dictionary “Persistently high arterial blood pressure”
Diastolic Hypertension Elevated diastolic blood pressure with a
normal systolic pressure Essential Hypertension
Elevated blood pressure “having no obvious external cause,” or “idiopathic”
Statistically 2 SD above mean is uncommon or hyper Hypertension is the level of BPat which action is
warranted, balance between risk & benefit,not easy to estimate
So an specific cut off point is difficult WHO (1972) –systolic above 160/diastolic (phase V) more
than 95 Currently Optimal-<120mmHg and<80 mmHg Normal- < 130 and <85 High normal 130-139 or 85 to 89 High stage I –140 to 159 or 90 to 99 Stage II –160 to-179 or 100 to 109 Stage III –more than 180 or more than 110 mm Hg
Accuracy is essential Reliability is questionable as wide variability in
individual. Source of ERROR-1. Observer error e.g. hearing acuity,,interpretation
of Karotkow sound 2 Instrumental error eg loose cuff,leaking valve
etc3 subject error eg position , external stimuli-
fear ,anxiety, physical environment
Rule of halves
Uniform policy in all clinics &institutions to use rt or left arm
Recording in sitting position than supine Systolic at which sound first (phase I) heard Diastolic -sound muffled (phase IV) disappear
(phase V).most cases phase V is taken as Diastolic
Measured at least 3 times over a period of 3 minutes & lowest reading is taken
For comparability data should be taken every where in uniform way
Incidence has limitation.due to 1. individual variation,2. ambiguity of normal BP 3. insidious nature of condition Prevalence-Developed countries-25% in adult populationDeveloping countries-10 to 20% in adult popolationHigh altitude & places belonging to premitive
culture-very low
In some studies in India shows morbidity as in- Urban -male 6%, female 7% Rural –male 3.5%, female 4.0%
Mortality In western world:deaths due to coronary heart
disease In eastern parts of the world: stroke deaths more
common Decline in mortality in last 2 decades Fall is equal in both sexes Fall attributed to, use of effective drugs,modern
diagnosis &treatment
Tracking is phenomenon of ranking order of BP level through time
Follow up of cohort of individual BP level from childhood to adulthood
Initial low BP level will follow the same track up to adult
Initial high BP will tend to become higher in adult life
Child likely to be in risk in later life can be screened
1 & 2 Age /gender BP rises with age Responsible factor may be accumulation of environment
factors,or effect of genetically programmed senescence in body system
Genetic factor-partly determines Twin study-BP is correlated to mono zygotic twin than that
of zygotic twin No significant correlation between husband & wife or
adopted child & adopter parent Family study-chd of high BP parent has 45% chance but
with normotensive only 3%
OBESITY SALT INTAKE SATURATED FAT ALCOHOL PHYSICAL ACTIVITY ENVIRONMENTAL STRESS OTHERS - ORAL CONTRACEPTIVES -NOISE ,VIBRATION,TEMPERATURE, HUMIDITY
ETC LIKELY, NEEDS FURTHER STUDIES
Hypertension Cigarette smoking Obesity (BMI>30) Inactivity Dyslipidemia Diabetes Mellitus
Age >55 for men >65 for women
Microalbuminuria Or GFR <60mL/min
FH of Premature CVD Men <55 Women <65
GENETICS A history of hypertension tends to run in
families The closest correlation exists between sibs
rather parent and child It is also possible that environmental
factors common to members of the family also have a role in the development of hypertension
AGE
BP tends to rise with age, possibly as a result of decreased arterial compliance.
Hypertension in the elderly should be treated as aggressively as in the young.
Race
Caucasians have a lower BP than black populations living in the same environment
Black populations living in rural Africa have a lower BP than those living in towns
Respond in different ways to changes in diet
Birth weight is also associated with the development of hypertension in later life.
The lower the birth weight the higher the likelihood of developing hypertension and heart disease
Clearly in-utero factors affect health at a later stage.
Environment Mental and physical stress both increase
blood pressure However removing stress does not
necessarily return blood pressure to normal values
The scope of the problem: 50 million Americans have hypertension One billion people in the world are affected 30% don’t know they have it
Category Systolic BP Diastolic BP Optimal < 120 < 80 High normal 130 – 139 85 - 89 Mild HTN 140 – 159 90 - 99 Mod HTN 160 – 179 100 - 109 Severe HTN >180 > 110
Blood pressure is a continuous variable which fluctuates widely during the day physical stress mental stress
The definition of hypertension has been arbitrarily set as: That blood pressure above which the benefits of treatment outweigh the risks in terms of morbidity and mortality
Hypertension is not a disease
It is an arbitrarily defined disorder to which both environmental and genetic factors contribute
Histology of Elastic Arteries
POISIEULLI’S LAW
>> 100 100OrOr>160>160Hypertension,Hypertension,
Stage 2Stage 2
90-9990-99OrOr140-159140-159Hpyertension, Hpyertension, Stage 1Stage 1
80-9080-90OrOr120-139120-139PrehypertensiPrehypertensionon
<80<80AndAnd< 120< 120NormalNormal
DiastolicDiastolicSystolicSystolicCategoryCategory
Maximum Pressure exerted by the Blood against the arterial walls.
Results of ventricular Systole.
Renal disease 20% of resistant hypertensive patients chronic pyelonephritis renal artery stenosis polycystic kidneys
Drug Induced NSAIDs Oral contraceptive Corticosteroids
Sleep Apnea Chronic Kidney Ds. Primary
aldosteronism Renovascular Ds. Thyroid,
Parathyroid
Pheochromocytoma Coarctation of
aorta Steroids, Cushing
syndrome Drug-induced
Illicit Drugs Cocaine, amphetamines
Oral Contraceptives
Adrenal Steroids Prednisone
Licorice (in some chewing tobacco)
Decongestants (sympathomimetics)
Non-adherence, inadequate doses, inappropriate combinations
Non steroidal Anti-inflammatory drugs
Leathery Granularity due to minute scarring
Onion Skin ThickeningOnion Skin ThickeningOf arterioles.Of arterioles.
Narrow LumenNarrow Lumen
Fibrinoid NecrosisFibrinoid Necrosis
ThrombosisThrombosis
May complicate any type of HTN. Necrotizing arteriolitis. Intravascular thrombosis. Rapidly progressive end organ damage. Renal failure Hypertensive encephalopathy. Left ventricular failure.
Blood Vessels Atherosclerosis and its complications
aneurism, Dissection, Rupture, necrosis. Arteriolosclerosis,
Heart Hypertensive cardiomyopathy, IHD, MI.
Kidney Benign/Malignant nephrosclerosis. Infarction
Eyes: Hypertensive retinopathy
Brain: Haemorrhage, infarction, splinter & Lacunar hemorrhages
Left Ventricular HypertrophyLeft Ventricular Hypertrophy
HaemorrhagicHaemorrhagicNecrosisNecrosis
Chronic hypertension
Arteriolosclerosis of deep penetrating arterioles of brain stem.
Single or multiple cavitary infarcts – lacunes.
Lenticular nucleus, thalamus
Slit Haemorrhages.
Leathery GranularityBenign Nephrosclerosis
Grade I – Thickening of arterioles.
Grade II – Focal Arteriolar spasms. Vein constriction.
Grade III – Hemorrhages (Flame shape), dot-blot and Cotton wool and hard waxy exudates.
Grade IV - Papilloedema
Principle:- “lower the pressure, the better”
Goal:- to have maximally tolerated reduction in blood pressure
Monodrug therapy Drug of choice: 1. Thiazide diuretic eg. Hydrochlorthiazide 2. β1 blocker eg. PropanololIf monotherapy doesn’t work other drug
can be added eg.Thiazide+ β1blocker
Combination therapy: Advantages: synergistic action counter balance of ADRs balance in hemodynamic
ACE inhibitor=A β1 blocker = B Ca++ channel blocker = C Diuretics = D eg. Propanolol (β1 blocker) + Hydralazine
Bradycardia Tachycardia
1.PREGNANCY Toxemia of pregnancy Drug of choice: β1blocker vasodilator Ca++ channel blocker-Contraindicated drugs are Diuretics,Resperine,Na nitroprusside, Non selective β -blocker
2.Heart Disease All A,B,C and D are useful β 1 blocker are contraindicated in left
ventricular failure & bradycardia3.Diabetic ACE inhibitor (Captopril) low dose thiazide, beta 1 blocker and Ca
channel blocker for long term therapy contraindicated diuretics
4. Hypertensive Emergency Life threatening, DP > 130 mmHg Sodium nitroprusside (vasodilator) Diazoxide (arterial dilator ) Labetolol ( non selective adrenergic blocker )5. Hypertensive urgency Nifedipine (Sub lingual) Clonidine (oral or IM every 1-2 hrs) Captopril ( oral) Hydralazine (IM or IV slowly)
Divided into
PrimaryPopulation StrategyHigh-risk strategy
Secondary
Weight Reduction Maintain normal body weight
BMI: 18.5 – 24.9 BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan Dietary Approaches to Stop Hypertension
Fruits, Vegetables, Low-fat dairy Reduce saturated and total fat 8-14 mmHg BP reduction
Dietary Sodium Reduction 2.4 grams Sodium or 6 grams Sodium
Chloride 2-8 mmHg BP reduction
Physical Activity Regular aerobic physical activity
Brisk walking, treadmill, exercise bike, bicycling, swimming (30 min. a day, most days of the week)
4-9 mmHg BP reduction
Moderation of alcohol consumption No more than 2 drinks per day in most men No more than 1 drink per day in women and
lighter weight individuals One drink equals:
½ ounce liquor or 12 oz. Beer or 5 oz. Wine or 1 ½ oz. 80 proof whisky
Duration and prior Rx Pharmaceutical profile Family history Symptoms of secondary
causes Target organ damage Presence of other risk factors
Concomitant Diseases Dietary History Sexual Function Features of Sleep Apnea Ability to modify life-style
Accurate measure of BP, BMI Fundoscopy Carotid and thyroid abnormalities Heart sounds, rhythm, size Rales, rhonchi on lung exam
Renal masses, waist circumference Aorta bruits, femoral pulses Peripheral pulses and edema Neurologic assessment, i.e.
cognitive
Chest X-ray Abdominal Ultrasound 24 hour urine collection
Sodium and Potassium Thyroid function tests Kidney function tests Blood sugar & cholesterol (screening) Others: hormonal, etc.
Hematocrit Urinalysis Lipid profile ECG
Determine type of hypertension Identify target organ damage Assess risk for early CV event
JNC VI on Prevention, Detection, Evaluation, and Rx of High Blood Pressure (1997) 50 million hypertensive patients in the U.S.
National Health and Nutrition Examination Survey III (NHANES III) (1995) only 21% are controlled to <140/90 mm Hg 35% are unaware of their condition
High-normal BP is associated with an increased risk of cardiovascular disease
Department of
Biochemistry
Physiology
Anatomy
Pathology
Pharmacology
Community MedicineMCOMS,Pokhara,Nepal