BLOOD PRESSURE Systolic Diastolic

NORMAL BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic

HIGH BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic Hypertensive

NOCTURNAL HIGH BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic Hypertensive

AMBULATORY TECHNOLOGY ECG Electrodes Blood Pressure Cuff Microphone Control Box

AVERAGE PRESSURES Work hrs Leisure hrs Night Time Mean =136 mmHg hrs Day Time Mean = 139 mmHg 0600 –2200 hrs 24 hour Mean =139 mmHg

SLOPE OF MORNING RISE 3:00 am 6:00 am

47% 48%

5177 mmHg hr 9876 mmHg hr AREA UNDER THE CURVE

CrestCPS = 10.4 Trough CPS = CrestCPS = 7.55 Trough CPS =- 12.5

FOURIER ANALYSIS BP(t) = c 0 + Σ [a j cos(jπt/12)+b j sin(jπt/12)]

FOURIER ANALYSIS

ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

Heart Arterial Vasculature Central Nervous System BARO & CHEMO RECEPTORS  Heart Rate  Contractility  Heart Rate  Contractility Vasoconstriction

Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Heart Rate  Contractility  Heart Rate  Contractility Vasoconstriction

Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Heart Rate  Contractility  Heart Rate  Contractility Vasodilation

Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Kidneys Lungs

RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Kidneys Lungs Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output

RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Lungs Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Renin Angiotensinogin Angiotensin I Kidneys

RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Angiotensin I Kidneys Converting Enzyme Angiotensin II Angiotensin III Lungs

RENIN ANGIOTENSIN Central Nervous System Heart Kidneys Angiotensin II Lungs Arterial Vasculature Vasoconstriction

RENIN ANGIOTENSIN Central Nervous System Heart Kidneys Angiotensin II Lungs Arterial Vasculature Vasoconstriction  Vegal Tone  Catecholamines  Heart Rate  Contractility  Heart Rate  Contractility

RENIN ANGIOTENSIN Central Nervous System Heart Angiotensin II Lungs Arterial Vasculature Aldosterone Kidneys Reabsorb Fluid

Renin-Angiotensin CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE Vasoconstriction  Heart Rate  Contractility  Fluid  Heart Rate  Contractility  Fluid

ATRIAL NATURETIC FACTOR Heart Central Nervous System Kidneys Arterial Vasculature Vasodilation  Renin  Fluid Loss

Heart CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Fluid Loss Vasodilation

ANTI-DIURETIC HORMONE Kidneys Pituitary Gland  Fluid Reabsorption

Atrial Naturetic Factor CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Fluid Reabsorption

ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

NATURAL HISTORY Genetic Predisposition Salt Stress Transient Changes Low High Stabilizing Factors

CategoryFollow-up OptimalRecheck 2 yrs PrehypertensionRecheck in 1 yr Hypertension Stage 1Confirm within 2 months Stage 2 Evaluate or refer within 1 mo >180/>110Evaluate and treat immediately or within 1 week depending on clinical situation and complications CategoryFollow-up OptimalRecheck 2 yrs PrehypertensionRecheck in 1 yr Hypertension Stage 1Confirm within 2 months Stage 2 Evaluate or refer within 1 mo >180/>110Evaluate and treat immediately or within 1 week depending on clinical situation and complications FOLLOW-UP JAMA 289: , 2003 Hypertension 42: , 2003 Department of Health & Human Services Pub No , 2003 JAMA 289: , 2003 Hypertension 42: , 2003 Department of Health & Human Services Pub No , 2003

TREATMENT: MEDICATIONS DIURETICS ALDOSTERONE-RECEPTOR BLOCKERS  BLOCKERS  1 BLOCKERS  2 AGONISTS ACE INHIBITORS ANGIOTENSIN II ANTAGONISTS (Angiotensin Receptor Blockers-ARB) Ca ++ CHANNEL BLOCKERS VASODILATORS DIURETICS ALDOSTERONE-RECEPTOR BLOCKERS  BLOCKERS  1 BLOCKERS  2 AGONISTS ACE INHIBITORS ANGIOTENSIN II ANTAGONISTS (Angiotensin Receptor Blockers-ARB) Ca ++ CHANNEL BLOCKERS VASODILATORS

ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

Lifestyle Modifications TREATMENT ALGORITHM Recheck Blood Pressure At Goal Continue Not at Goal Add Medications Stage of Hypertension Compelling Indications Add Medications Stage of Hypertension Compelling Indications

Initial Drug Choices Without Compelling Indications With compelling Indications Stage 1 Thiazide-type Diuretics Consider ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Thiazide-type Diuretics Consider ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Stage 2 Thiazide-type Diuretics With ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Thiazide-type Diuretics With ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers

COMPELLING INDICATIONS IndicationDIURBBACEIARBCa ++ AldoANT Heart Failure      Post MI    Hi Risk     Diabetes      Chronic   Kidney Stroke   IndicationDIURBBACEIARBCa ++ AldoANT Heart Failure      Post MI    Hi Risk     Diabetes      Chronic   Kidney Stroke  

Adjust dosage if not at Blood Pressure Goal

TREATMENT

Exercise Effectiveness Whelton, S.P., et al., Annals of Internal Medicine, (7): p Kelley, G.A. and K.S. Kelley, Hypertension, (3): p ResistanceCardiovascular

Med Sci Sports Exerc 36: , 2004

INTENSITY Fagard & Tipton, Physical Activity, Fitness and Health, p , Fagard & Tipton, Physical Activity, Fitness and Health, p , Change in Blood Pressure (mmHg)

The Interaction of Exercise and Medications? Kelelrman, M.H. et al, JAMA 263: , 1990

Padilla, MSSE 37: , 2005.

Accumulation of Four Short Exercise Sessions

One Continuous Exercise Session

Wallace, et al. J Human Hypertension 13: , 1999  8.3 mm Hg in SBP for 11 hr  6.0 mm Hg in DBP for 4 hr

TIME OF DAY FOR EXERCISE Park, S., et al., Journal of Human Hypertension 19: , 2005

TIME OF DAY FOR EXERCISE Park, S., et al., Medicine and Science in Sport and Exercise, in press.

Baro receptors Vasopressin Atrial Natriuretic Factor Renin-Angiotensin Central Nervous System

Alpha Blockers Ca ++ Channel Blockers ARBs Diuretics β Blockers ACE Inhibitors α 2 agonists Aldosterone Receptor Blockers

CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE Renin-Angiotensin Vasopressin Baroreceptors ANF Central Nervous System

CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE DiureticsVasodilators Cardioinhibitory Sympatholytics

BP = CARDIAC OUTPUT X VASCULAR RESISTANCE Cardioinhibitory Beta-Blockers Ca ++ Channel Blockers dihydropyridines Ca ++ Channel Blockers Penylkylamines Ca ++ Channel Blockers benzothiazepines