Essential Hypertension Prof.Abdullah Saadeh

Definition Persistent elevation of BP ( ≥ 140/90 mmHg)

Classification of BP According to JNC – 7 report Normal ≤ 120 mmHg systolic and ≤ 80 mmHg diastolic Prehypertention 120 -139 mm Hg systolic and 80-90mm Hg diastolic Stage -1 Hypertension 140-159 mmHg systolic and 90- 99 mmHg diastolic Ssage -2 Hypertention ≥ 160 mmHg systolic and ≥ 100 mmHg diastolic

Life style modification Without compelling indication BP classification Life style modification Without compelling indication With compelling indication Normal encourage Prehypertension yes No anti-HTN drugs Drug(s) for the compelling indication Stage 1 HTN Thiazide-diuretics for most; may consider ACE,ARB, B-blockers,CCB,or combination Drug(s)for the compelling indicatios ( thiazides, ACEI,CCB,ARB,B-blocker) Stage 2 HTN 2-drug combination for most (thiazide,ACEI or ARB or B-blocker or CCB) Drug(s) for the compelling indications ( thiazides, ACEI, ARB, B-blocker, CCB) as indicated

CAUSES Essential Hypertention (95 %) Secondary ( 5%) DRUGS( steroids , Contraceptive pills,NSAIDS,carbenoxolone,Liquorice, sympathomimetics) 2. Cardiovascular (Coarctation of the aorta) 3. Renal (Renovascular i.e RAS and renal artery occlusion or Parenchymal i.e ch. Pyelonephritis,acute and ch.glomeronephritis,obstructive uropathy,polycystic kidney disease and hypernephromas.

CAUSES 4.Endocrine: ( pheochromocytoma, 5.Others 1° aldosteronism, cushing’s,acromegaly, hyperparathyroidism and hypothyroidism). 5.Others (brain tumors with increased intracranial pressure,bulbar poliomyelitis,connective tissue disorders i.e SLE and polyarteriti nodosa,DM nephropathy,Polycythemia rubra vera)

INITIAL or PRIMARY INVESTIGATIONS in HYPERTENSION Urinalysis Renal profile ECG Chest x-ray Plain U-T x-ray or renal ultrasound Urine culture HB, PCV FBS,s.lipids,s.urate Echocardiography

When to investigate for a secondary cause of hypertension Clues from the history Clues from physical examination Clues from initial investigations Malignant stage hypertension

Complications of hypertension Cardiovascular(angina,MI,LVH,HF,dissecting aortic aneurysm) Cerebrovascular(TIA,Thrombotic infarction,intracerebral hemorrhge,encephalopathy) Peripheral vascular disease(atherosclorosis,intermittent claudication, gangrene) Retinopathy(Grades1,2,3,4) Nephropathy(nephrosclerosis,fibrinoid necrosis) Malignant hypertension

Treatment of hypertension 1st. Non-pharmacological measures: 1. Diet 2. Weight reduction 3. Stopping smoking and excess alcohol consumption 4. Regular exercise ( behavioral, biofeedback therapy) 5. Treatment of other associated risk factors

B. Antihypertensive medications: 1. Diuretics Thiazide, loop, K+ sparing 2. B-Blockers Non-cardioselective Cardioselective Drugs with ISA Alpha and Beta-blockers(labetolol)

3. Alpha-blockers ( prazosin) 4. Central acting drugs (reserpine, methyldopa,clonidine) 5. vasodilators: 1st. Direct relaxation of arteriolar smooth muscle: -Hydralazine -Minoxidil -Diazoxide -Na-nitroprusside

2nd. Calcium-channel blockers: - Verapamil - Nifedipine - Amlodipine 3rd. ACE inhibitors : - Captopril - Enalapril - Lysinopril - Quinapril

6. ARBs - Losartan - Candesartan - Irbisartan - Valsartan

Hypertensive Crisis: Severe hypertension with one of the following: Heart failure MI Renal failure Encephalopathy Dissecting aneurysm Intracerebral hemorrhage Accelerated or malignant hypertension

Parentral Drugs Used In Hypertensive Emergencies: Na-nitroprusside infusion Diazoxide i.v Hydralazine iv Furosemide i.v Phentolamine i.v Nifedipine s/L Labetolol i.v ( N.B: B.P shouldn’t be reduced to below diastolic of 100 mmHg )