In the Name of God In the Name of God Overview of Hypertension Mahboob Lessan Pezeshki MD Tehran University of Medical Sciences Aban 1392

Definitions (1) Normal blood pressure: systolic< 120 & diastolic <80 mmHg Prehypertension: systolic or diastolic mmHg Hypertension: Stage 1: systolic or diastolic Stage 2: systolic >160 or diastolic > 100

Definitions (2) Isolated systolic hypertension: systolic >140 and diastolic < 90 mmHg Isolated diastolic hypertension: systolic 90 mmHg

Definitions and classification of office blood pressure levels (mmHg)

Hypertension based upon ABPM and home readings ABPM: A 24 hour average above 135/85 mmHg Daytime (awake) average above 140/90 mmHg Nighttime (asleep) average above 125/75 mmHg Home readings: The same as for daytime ambulatory blood pressure

Malignant Hypertension Marked hypertension with retinal hemorrhages, exudates or papilledema Diastolic hypertension usually >120 mmHg

Hypertensive Urgency Diastolic blood pressure above 120 mmHg in asymptomatic patients

Hypertensive Emergency Acute severe hypertension, generally>180/120 mmHg Malignant hypertension with end organ damage Hypertensive encephalopathy

Resistant Hypertension Failure to achieve goal blood pressure(<140/90 mmHg) using: A minimum of three antihypertensive drugs At maximal tolerated doses, one of which must be a diuretic

Controlled Resistant Hypertension Patients who meet the definition of Resistant Hypertension but whose blood pressure is controlled on maximal tolerated doses of four or more antihypertensive medications

Refractory Hypertension Patients who meet the definition of Resistant Hypertension but whose blood pressure is not controlled on maximal tolerated doses of four or more antihypertensive medications

Isolated Diastolic Hypertension More common in men Associated with metabolic syndrome Elevated systemic vascular resistance Vasoconstriction of resistant arterioles Inappropriately normal cardiac output

Isolated Systolic Hypertension Common in elderly hypertensives Diminished arterial compliance Elevated pulse pressure High risk of: MI LVH Stroke Renal dysfunction

Primary Hypertension (1) Pathogenesis : Genetic factors Increased sympathetic neural activity Increased angiotensin 2 actvity and mineralocorticoid excess Reduced adult nephron mass

Primary Hypertension (2) Risk factors: Excess sodium intake Excess alcohol intake Obesity and weight gain Physical inactivity Dyslipidemia Certain personality traits Vitamin D deficiency

Secondary Hypertension Primary renal disease Oral contraceptives Drug induced Renovascular disease Obstructive sleep apnea Coarctation of aorta Endocrine disorders( primary aldosteronism, pheochromocytoma….)

Complications of Hypertension Ischemic stroke Intracerebral hemorrhage Chronic kidney disease Left ventricular hypertrophy Heart failure

Masked Hypertension Normotensive by conventional clinic measurement Hypertensive by ABPM

White coat Hypertension Average office readings > 140/90 mmHg Average out of office < 140/90 mmHg

Screening of Hypertension Normal BP Every 2 years Prehypertension Yearly

Indications for ABPM Suspected white coat Hypertension Suspected episodic Hypertension Hypertension resistant to increasing medications Hypotensive symptoms while taking antihypertensive medications Autonomic dysfunction

Goals of Systolic Blood Pressure Lower than 140 mmHg No J shaped systolic curve

Goals of Diastolic Blood Pressure Lower than 90 mmHg The goal may be lower in: Atherosclerotic cardiovascular disease Diabetes mellitus Chronic kidney disease Heart failure J shaped Diastolic curve

Methods of Diagnosis Office-based measurement (AHA) ABPM (NICE) Home blood monitoring: measurements Over a period of one week

Cuff Inflation Hypertension Effect of muscular activity Raise the blood pressure 12/9 mmHg Dissipates within 5-20 seconds

Office-based measurement Time of measurement Type of measurement device Cuff size Patient position Cuff placement Technique of measurement Number of measurements

Pseudohypertension Stiff vessels due to marked arterial calcification 10 mmHg or more higher systolic and Diastolic pressures

Measurement of Blood Pressure Mild Hypertension: three to six visits (over a period of weeks to months) Measurements should be in both arms Detection of postural hypotension

Alternative sites for measurement Leg blood pressure Wrist blood pressure

Non Pharmacologic Therapy(1) Dietary Salt Restriction Weight loss DASH Diet Exercise Vit D supplement

Non Pharmacologic Therapy(2) Adequate Potassium intake Cessation of Smoking Limiting the use of NSAIDs Patient education

Drug Treatment(1) Monotherapy in uncomplicated hypertension Thiazide Diurtics Calcium Channel Blockers ACEIs or ARBs

Drug Treatment(2) First Line Combination therapy BP is more than 20/10 mmHg above the goal Calcium Channel Blockers plus a long acting ACEI/ARB (ACCOMPLISH Trial)

Drug Treatment(3) CCB or ACEI/ARB Discontinuing the thiazide and starting combination therapy In all patients on beta blockers the preferred second drug: Thiazide diuretics Dihydropyridine CCB

Bed time versus morning dosing Shifting at least one medication to the evening in nondippers Restores normal nocturnal blood pressure dip Reduces 24 hour mean blood pressure

Treatment of Hypertensive Emergency(1) Nitroprusside Nitroglycerin Calcium Channel Blockers Labetalol

Treatment of Hypertensive Emergency(2) Fenoldopam Esmolol Hydralazine Enalaprilat Phentolamine

Treatment of Resistant Hypertension(1) ACE or ARB(long acting) + CCB(dehydropyridine) + Thiazide diuretic Add spironolactone if patients remained uncontrolled Direct vasodilators (hydralazine or minoxidil)

Treatment of Resistant Hypertension(2) Experimental therapies Ablation of renal sympathetic nerves Electrical stimulation of carotid sinus baroreceptors