Systemic hypertension: By Dr.Mohamed Abd AlMoneim

Definition: Persistent or recurrent elevation of systemic blood pressure above 140/90mmHg even after period of rest Blood pressure should be measured with the patient in sitting position after 5 minutes of rest and at least 30 minutes after smoking or coffee. Diagnosis of hypertension should be made only after finding an elevated blood pressure on three readings on different occasions. However, patients with very high blood pressure reading should be started on therapy immediately. Ambulatory 24 hours –blood pressure (monitoring) reading may be helpful in evaluating patients with (white coat hypertension). N.B: (systolic B.P is the highest value of B.P recorded during systole while diastolic B.P is the lowest value of B.P recorded during diastole )

Hypertension is a condition that affect almost 1 billion people worldwide and is a leading cause of morbidity and mortality. More than 20% of Americans are hypertensive, and one-third of these Americans are not even aware they are hypertensive. Therefore, this disease is sometimes called the "silent killer" nt

Blood Pressure = Cardiac Output X Peripheral Resistance

Level classification of hypertension =Categorization according to SBP and DBP : 1- High Normal BP Systolic BP (mmHg)<140 Diastolic BP (mmHg)<90 2-Mild hypertension Systolic BP (mmHg)140 – 160 Diastolic BP (mmHg) 90 – 100 3-Moderate hypertension Systolic BP (mmHg) 160 – 180 Diastolic BP (mmHg)100 – 110 4-Severe hypertension Systolic BP (mmHg) 180 – 210 Diastolic BP (mmHg) 110 – 120 5-Very severe hypertension Systolic BP (mmHg) ≥ 210 Diastolic BP (mmHg) ≥ 120 6-Malignant hypertension Diastolic BP > 125 with papilledema, renal failure, heart failure, or encephalopathy.

Classification: A) According to type and etiology: 1-Systolic hypertension : due to *Increased stroke volume pumped by the left ventricle e.g (aortic regurge, patent ductus arteriosus and thyrotoxicosis). *Atherosclerosis of aorta and big arteries. 2- Mixed systolic and diastolic hypertension (most dangerous type).

3-Diastolic hypertension: DBP is classified according to the etiology into : (1)Primary= idiopathic (essential) hypertension with the following risk factors: This is hypertension of unknown cause which represents about 90% of cases of hypertension. Predisposing factors *Age :between 25-55 years i.e Age > 60 years *Sex: more in males(2:1) and postmenopausal women . *Built: more in obese. *Habit :more in alcoholics and cigarette smokers (Adds 20/10 mmHg) . *Family history of cardiovascular disease *High cholesterol diet *Co-existing disorders such as diabetes (5-30 mmHg X increase MI), obesity and hyperlipidaemia *Sedentary life style

2-Secondary hypertension: About 5% of cases of hypertension has known cause. The common causes of secondary hypertension are: 1) Renal diseases: Renal artery stenosis (renovascular hypertension). Glomerulonephritis. Pyelonephritis. Polycystic kidney disease……. 2) Endocrine diseases: Pheochromocytoma. Cushing disease. Primmary hyperaldosteronism (conn syndrome). thyrotoxicosis

3) Pre-eclampsia. 4) Coarctation of the aorta. 5) Drugs: Oral contraceptives, corticosteroids, NSAIDs, cyclosporine, sympathomimetic agents, clonidine withdrawal, eating cheese in patients taking MAOIs , liquorice, carbenoxolone……

B) According to persistence: *Labile hypertension: occasionally elevated. Labile hypertension occur I (early phase of hypertension ,paroxysmal attacks of pheochromocytoma, tyramine diet and with drug intake). Early B.P is intermittently increased (labile) and it increased on exposure to (4 E) *Persistent hypertension: continuously elevated. C) Benign or malignant hypertension: *Benign means affection of medium and large sized arteries. *Malignant: it affects arterioles and small arteries with endarteritis obliterans and necrosis which lead to organ damage.

The risks of hypertension A sustained increase in BP increases the load on the heart and blood vessels This has two effects Myocardial hypertrophy Smooth muscle hypertrophy in the resistance vessels Hypertrophy of this type increases the strength of the heart and vasculature However it also reduces compliance 18/09/2018

Atheromatous disease Sustained hypertension is associated with accelerated atheromatous disease of the blood vessels Peripheral vascular disease Coronary artery disease Cerebrovascular disease Renal artery disease 18/09/2018

Complications of untreated hypertension: 1- Cardiovascular complications: Left ventricular hypertrophy and failure, angina pectoris, coronary thrombosis, atrial fibrillation and aortic dissection. 2- Cerebral complications: Cerebral atherosclerosis with its complications as thrombosis and hemorrhage, hypertensive encephalopathy. 3-Renal complications: Chronic renal failure. 4-Retinal complications: retinal hemorrhage and papilledema.

Malignant hypertension is characterized by: 1-DBP more than 125mmHg Malignant hypertension is characterized by: 1-DBP more than 125mmHg. 2-organ damage (CCRR): * Renal: haematuria, uremia and renal failure. *Retinal: hemorrhage, papilledema….. *Cardiac: ischemic heart disease, heart failure, AF…. *Cerebral: sroke, hypertensive encephalopathy.

Clinical picture: It should be noted that the diagnosis of hypertension depends on measurement of blood pressure and not upon symptoms reported by the patient. (1) Secondary hypertension: clinical picture of the cause. (2) Primary hypertension: may be *Uncomplicated: usually symptomless but may be (headache, dizziness, tinnitus, vertigo irritability, epistaxis… *complicated cases: see CCRR

The pathogenesis of primary type is unknown but multiple theories and the most important is multifactorial theory: *Anxiety: increases catecholamine release. *If vasoconstriction is prolonged: renal ischemia occurs which stimulates rennin angiotensin system which leads to Na and H2O retention which leads to hypervolaemia with Na retention in SMF which sensitizes blood vessel wall to sympathetic stimulation and to circulating vasopressors (catecholamines and angiotensin) so, increases calcium in blood vessel which leads to vasoconstriction. *Resetting of baroreceptors to a higher level.

Treatment of hypertension: The aim of treatment is to reduce blood pressure to normal levels i.e below 140/90 mmHg with minimal side effects. Benefits of treatment: Control of hypertension reduces the excess risk of stroke and congestive heart failure associated with high blood pressure. Lines of treatment: A) Non pharmacological therapy: B) Antihypertensive drug therapy. C) Treatment of hypertensive emergencies. D) Treatment of the cause in secondary hypertension: E.g. surgical removal of pheochromocytoma or renal artery stenosis.

Treatment: Lifestyle Recommendations To reduce the possibility of becoming hypertensive and in hypertensive patients: Avoid stress. 1-Healthy diet; High in fresh fruits, vegetables and low fat dairy products, low in saturated fat and salt . 2. Regular physical activity: accumulation of 30-60 minutes of moderate intensity dynamic exercise 4-7/week at least 4/week 3. Low risk alcohol consumption (≤2 drinks/day or less than 14/week for men and less than 9/week for women) 4.Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2) 5.Waist Circumference < 102 cm for men < 88 cm for women 6.Restriction of salt intake to less than 100 mmol/day in individuals considered salt-sensitive, such as: age over 45, individuals with impaired renal function or with diabetes. 7.Smoke free environment

N.B 1-Weight reduction: recommended in overweight patients: 1.0 kg decrease in body weight was accompanied by an average reduction of 1.6 / 1.3 mm Hg in blood pressure ,this appears at a threshold around 4kg decrease in body weight to observe an effect in reduction in blood pressure. Weight reduction reduces C.V.S risks even without control of blood p. Drug therapy can be reduced if weight reduction is successful. 2-Exercise Endurance exercise (aerobic exercise) may reduce many of the major C.V.S. risk factors including blood pressure, serum cholesterol, and weight and glucose tolerance. Some antihypertensive drugs can interfere with exercise. e.g. Patients on a regular exercise program should be prescribed drug that allows them to continue long-term therapy. *diuretic induced hypokalemia and decrease muscle blood flow *B-Blocker and CCBs, can reduce performance by inhibiting exercise induced increase in heart rate and cardiac output

3-Dietary sodium restriction Do not add sodium chloride to food during cooking or at the table. Avoid or minimize the use of fast foods (contain high sodium content).   4-potassium supplementation High potassium intake may reduce blood pressure by (increasing excretion of sodium, suppressing renin secretion, arteriolar dilatation (possibly by stimulating sodium – potassium ATpase and decreasing intracellular calcium and impairing responsiveness to endogenous vasoconstrictors). 5-Magnesium supplementation: Is needed in patients who are hypomagnesmia due to diuretic therapy.

Avoid drugs as…….. Patients failing to normalize blood pressure after 2 weeks of non-pharmacological therapy should be considered for drug treatment.

2-For primary hypertension: Indications for Pharmacotherapy Drug Therapy : 1-For secondary hypertension (curable hypertension): all can be treated except bilateral renal failure. 2-For primary hypertension: Indications for Pharmacotherapy Strongly consider prescription if: 1-Average DBP equal or over 90 mmHg and: Hypertensive Target-organ damage (or CVD) or Independent cardiovascular risk factors Elevated systolic BP Cigarette smoking Abnormal lipid profile Strong family history of premature CV disease Truncal obesity Sedentary Lifestyle 2-Average DBP equal or over 80 mmHg in a patient with diabetes  

Antihypertensives The Ideal Antihypertensive: Maintain adequate BP Maintain perfusion Reduce workload of heart No undesirable effects Allow for long term administration