1 Cecil Medicine Section VIII Chapter 66 Arterial Hypertension Prof. Shen-Jiang Hu

2 Question How to measure the blood pressure?

3 made by a Cambridge Reverend, Stephen Hales, in He measured blood pressure by inserting the end of a long glass tube into the carotid artery of a horse and noting that the blood came up the tube to a height of nine feet eight inches, which was the blood pressure of the horse.

4 It took Riva-Rocci, together with a Prussian general called Korotkoff, to develop the modern sphygmomanometer which was introduced into clinical practice in about The device that probably many of us still use today to measure blood pressure has changed very little from this early device.

5 Blood Pressure has a unimodal distribution in the Population

6 Question: Is it important if the person has a higher blood pressure?

7 Knowledge about risk and treatment of hypertension Framingham Heart Study: Hypertension and CHD 1961 Hypertension and Stroke 1970 World Health Organization (WHO): Treatment of Hypertension, firstly 1978 JNC II: DBP for diagnosis and treatment of hypertension 1980 JNC V: SBP and DBP is same important for hypertension 1992 JNC VII ： HBP to target BP is central for reduction of the total risk of CV events China guideline for hypertension: HBP should be reduced to target BP 2005 WHO: HBP should be reduced to target BP. 2006

8 The Relationship between DBP and Cardiovascular Events

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10 HypertensionHypertension Atrial Fibrillation Aortic Dissection Dementia Chronic Renal failure Heart Failure LV Hypertrophy MI Hypertensive Encephalopathy CHD Intracerebral Hemorrhage Ischemic Cerebral Infarction Complications of Hypertension

11 Question: What is hypertension?

12 Definition of Hypertension Hypertension is a clinical syndrome, defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Hypertension should be considered a major risk factor for an array of cardiovascular and related disease as well as diseases leading to a marked increase in cardiovascular risk.

Trends in Awareness, Treatment, and Control of Hypertension in China Awareness(%) Treatment(%) Control(%) 中国心血管健康多中心合作研究

15 Question: What is etiology of hypertension?

16 Etiology of Hypertension Genetic factors play an important role. Children with one- or two-hypertensive parents have higher blood pressures. Environmental factors also are significant. Increased salt intake has long been incriminated as a pathogenic factor in essential hypertension. It alone is probably not sufficient to elevate blood pressure to abnormal levels; a combination of too much salt plus a genetic predisposition is required.

17 Etiology

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19 Question: How about the pathogenesis in hypertension is ?

20 Pathogenesis The pathogenesis of essential hypertension is multifactorial. Sympathetic nervous system hyperactivity. It is most apparent in younger hypertensives, who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pressure are poor.

21 Pathogenesis Renin-angiotensin system (RAS). Renin acts on angiotensinogen to cleave of the ten-amino-acid peptide angiotensin I. This peptide is then acted upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and a major stimulant of aldosterone release from the adrenal glands.

22 Pathogenesis Defect of natriuresis. Hypertensive patients exhibit a diminished ability to excrete a sodium load. This defect may result in increased plasma volume and hypertension.

23 Pathogenesis Intracellular sodium and calcium. An increase in intracellular Na + may lead to increased intracellular Ca 2 + concentrations as a result of facilitated exchange. This could explain the increase in vascular smooth muscle tone.

24 Pathogenesis Exacerbating factors. The best-documented is obesity, which is associated with an increase in intravascular volume and an elevated cardiac output. Some hypertensives respond to high salt intake with substantial blood pressure increases. Excessive use of alcohol also raises blood pressure. Cigarette smoking acutely raises blood pressure.

25 Question: Which pathologic changes will be happen in hypertension ?

26 Pathology Heart. Left ventricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death.

27 Pathology Brain. Hypertension is the major predisposing cause of stroke, especially intracerebral hemorrhage but also ischemic cerebral infarction.

28 Pathology Kidney. Chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency.

29 Question: How to know the patient with hypertension?

30 Clinical Findings Symptoms: Mild to moderated essential hypertension is usually associated with normal health and well-being for many years.

31 Clinical Findings Symptoms: Elevations in pressure are often intermittent early. Even in established case, the blood pressure fluctuates widely in response to emotional stress and physical activity.

32 Clinical Findings Symptoms: Suboccipital pulsating headaches, but any type of headache, may occur. Accelerated hypertension is associated with somnolence, confusion, palpitation.

33 Signs ： High blood pressure. Physical findings depend upon the duration and severity, and the degree of effect on target organs. A loud aortic second sound and an early systolic ejection click may occur.

34 Question: What should we do if the patient may be with hypertension?

35 Initial Evaluation for Hypertension Goal 1: Accurate Assessment of Blood Pressure

36 Blood pressure (BP) measurement When measuring BP, care should be taken to: Allow the patients to sit for 3-5 minutes in a quiet room before beginning BP measurements. Take at lease two measurements spaced by 1-2 minutes, and additional measurements if the first two are quite different.

37 Blood pressure (BP) measurement Use a standard bladder (12-13 cm long and 35 cm wide) but have a larger and a smaller bladder available for large (arm circumference >32 cm) and thin arms, respectively. Have the cuff at the heart level, whatever the position of the patient

38 Blood pressure (BP) measurement Use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively. Measure BP in both arms at first visit to detect possible differences. In this instance, take the arm with the higher value as the reference.

39 Blood pressure (BP) measurement Measure at first visit BP 1 and 3 min after assumption of the standing position in elderly subjects, diabetic patients, and in other conditions in which orthostatic hypotension may be frequent or suspected. Measure heart rate by pulse palpation (at least 30 s) after the 2ed measurement.

40 Category JNC 7 （ USA ） European China Optimal <120 and <80 Normal <120 and < and/or 80-84<120 and <80 High-normal or and/or or Hypertension ≥ 140 or ≥ 90 Grade I or and/or or Grade II ≥ 160 or and/or or Grade III ≥ 180 and/or ≥ 110 ≥ 180 or ≥ 110 Isolated Systolic Hypertension ≥ 140 and <90 Definition and Classification of Blood Pressure Levels in different Country

41 CategorySBP (mmHg) DBP (mmHg) Office BP≥140and/or≥90 Ambulatory BP Daytime (or awake)≥135and/or≥ 85 Nighttime (or asleep)≥120and/or≥ h≥ 130and/or≥80 Home BP≥ 135and/or≥85 Definition of hypertension by office and out-of-office blood pressure levels

42 Initial Evaluation for Hypertension Goal 2: Cardiovascular Risk Stratification

43 Stratification of total CV risk in hypertension

44 Factors--other than office BP--influencing prognosis; used for stratification of total CV risk Risk factors Male sex Age (M > 55 years; W > 65 years) Smoking Dyslipidaemia TC > 5.0 mmol/L (190 mg/dL) and/or: LDL-C > 3.0 mmol/L (115 mg/dL) and/or: HDL-C: M < 1.0 mmol/L (40 mg/dL), W < 1.2 mmol/L (46 mg/dL) and/or: TG > 1.7 mmol/L (150 mg/dL) Fasting plasma glucose mmol/L ( mg/dL) Abnormal glucose tolerance test Abdominal obesity (waist circumference > 102 cm (M), > 88 cm (W)) Family history of premature CV disease (M at age < 55 years; W at age < 65 years)

45 Factors--other than office BP--influencing prognosis; used for stratification of total CV risk Asymptomatic Organ Damage Pulse pressure (in the elderly) ≥60 mmHg Electrocardiographic LVH or: Echocardiographic LVH Carotid wall thickening (IMT > 0.9 mm) or plaque Carotid-femoral pulse wave velocity > 10 m/s Ankle-brachial index < 0.9 CKD with eGFR ml/min/1.73 m 2 (BSA) Microalbuminuria ( mg/24h), or albumin- creatinine ratio ( mg/g; mg/mmol) (preferentially on morning spot urine)

46 Factors--other than office BP--influencing prognosis; used for stratification of total CV risk Diabetes mellitus Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on two repeated measurements, and/or: HbA1C >7%, and/or Post-load plasma glucose >11.0 mmol/L (198 mg/dL)

47 Factors--other than office BP--influencing prognosis; used for stratification of total CV risk Established CV or renal disease Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack CHD; myocardial infarction; angina; myocardial revascularization with PCI or CABG Heart failure, including heart failure with preserved EF Symptomatic lower extremities peripheral artery disease CKD with eGFR <30 mL/min/1.73m 2 (BSA); proteinuria (>300 mg/24h) Advanced retinopathy; haemorrhages or exudates, papilloedema

48 Initial Evaluation for Hypertension Goal 3: Identification and Treatment of Secondary (Identifiable) Causes of Hypertension

49 two circumstances when there is a compelling finding on the initial evaluation when the hypertensive process is so severe that it either is refractory to intensive multiple-drug therapy or requires hospitalization

50 Management

51 Goals of treatment In hypertensive patients, the primary goal of treatment is to achieve maximum reduction in the long-term total risk of cardiovascular disease. This requires treatment of the raised BP per se as well as of all associated reversible risk factors.

52 When to initiate antihypertensive treatment Based on two criteria: -The level of systolic and diastolic blood pressure -The level of total cardiovascular risk

53 Initiation of lifestyle changes and antihypertensive drug treatment

54 Blood pressure goals in hypertensive patients

55 Lifestyle Changes Weight Reduction Salt Restriction: 5-6g of salt/day Calcium and Potassium Supplementation High-Fiber, Low-Fat Diet Alcohol Moderation: 20-30g(M), g(F) of ethanol/day. Smoking cessation Regular Physical Exercise:30 min of moderate dynamic exercise on 5-7 days/week

56 Choice of antihypertensive drugs Five major classes of antihypertensive agents – thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin receptor antagonists and β-blockers – are suitable for the initiation and maintenance of antihypertensive treatment, alone or in combination.

57 Monotherapy versus combination therapy Monotherapy could be the initial treatment for a mild BP elevation with a low or moderate total cardiovascular risk.

58 Monotherapy versus combination therapy A combination of two drugs at low doses should be preferred as first step treatment when initial BP is in the grade 2 or 3 range or total cardiovascular risk is high or very high.

59 Monotherapy versus combination therapy In several patients BP control is not achieved by two drugs, and a combination of three or more drugs is required.

60 Choice of antihypertensive drugs The choice of a specific drug or a drug combination, and the avoidance of others, should take into account the following: The previous favourable or unfavourable experience of the individual patient with a given class of compounds.

61 Choice of antihypertensive drugs The effect of drugs on cardiovascular risk factors in relation to the cardiovascular risk profile of the individual patient. The presence of asymptomatic organ damage, clinical cardiovascular disease, renal disease or diabetes which may be more favourably treated by some drugs than others.

62 Choice of antihypertensive drugs The choice of a specific drug or a drug combination, and the avoidance of others, should take into account the following: The possibilities of interactions with drugs used for other conditions.

63 Possible combination of classes of antihypertensive drugs

64 Monotherapy vs. drug combination strategies to achieve target BP

65 Choice of antihypertensive drugs The choice of a specific drug or a drug combination, and the avoidance of others, should take into account the following: The presence of other disorders that may limit the use of particular classes of antihypertensive drugs.

66 Compelling and possible contra-indications to the use of antihypertensive drugs

67 Choice of antihypertensive drugs The cost of drugs, either to the individual patient or to the health provider, but cost considerations should never predominate over efficacy, tolerability, and protection of the individual patient. Continuing attention should be given to side effects of drugs, because they are the most important cause of non-compliance. Drugs are not equal in terms of adverse effects, particularly in individual patients.

68 Choice of antihypertensive drugs The BP lowering effect should last 24 hours. This can be checked by office or home BP measurements at through or by ambulatory BP monitoring. Drugs which exert their anti hypertensive effect over 24 hours with a once-a-day administration should be preferred because a simple treatment schedule favours compliance.

69 References 1. surveys/Pages/welcome.aspx surveys/Pages/welcome.aspx

70 Thanks for your attention!