1. Hypertension Prof . El Sayed Abdel Fattah Eid
Lecturer of Internal Medicine
Delta University

2. Definition: Systemic hypertension is present in an adult (age> 18 years) if SBP 140 mm Hg or DBP 90 mm Hg.
The long term risk of cardiovascular morbidity and mortality rises in direct relation to increases in blood pressure
30% of patients with hypertension are unaware of it (silent killer).

3. Classification: DBP SBP <85 <130 Normal 85-89 130-139
High normal
90-99
Stage 1 hypertension
Stage 2 hypertension
1 10
1 80
Stage 3 hypertension

4. Incidence
- The diagnosis of hypertension is based on finding an elevated blood pressure on at least three separate occasions.
- Children and pregnant women are slightly lower than others; However, care must be taken in making the diagnosis of hypertension in children and adolescents because the blood pressure normalizes in adulthood.
- The incidence↑with age • African-Americans > whites. • Younger men > women and men = women after the age of 55

5. Etiology
1-Primary or essential hypertension (Unknown): • 90%-95% of patients (no identifiable cause). • Genetic factors (familial patterns of primary hypertension) • Environmental factors: obesity, sedentary lifestyle, and salt intake • Pathophysiology: - Excessive renal sodium retention - Overactivity of the sympathetic nervous system, - Excess Renin-angiotensin activity - Hyperinsulinemia - Alterations in vascular endothelium 2ry to↓VD substances (nitric oxide)
2-Secondary hypertension: 5% of patients (with identifiable cause).

7. Evaluation:
1-Thorough history 2- Physical examination 3- Limited laboratoy studies.
The goals: 1. Assess the patient for the presence and treatment of hypertensive target organ damage (TOD) 2. Identity clinical factors that may influence the choice of therapy (renal failure,heart failure) 3. Determine the presence of other cardiovascular risk factors 4. Recognize patients with secondary potentially reversible cause

8. Thorough history
* Asymptomatic * Headaches (occipital) &Blurred vision * Fatigue & Dizziness * Epistaxis * Dyspnea & chest pain.
* History of alcohol * Drugs: oral contraceptives, steroids * Dietary sodium intake * Family history of hypertension
* Secondary hypertension : - Weakness, polyuria & muscle cramps: hypokalemia in primary hyperaldosteronism - Weight gain and emotional liability in Cushing’s syndrome - Headaches, palpitations, anhidrosis in pheochromocytoma. - Symptoms of tissue organ damage (TOD) • Congestive heart failure • Coronary heart diseases • Cerebrovascular disease • Uremia •Aortic dissection.

9. Physical examination
1-Check BP & pulse in both arms and legs for radiofemoral delay ( aortic coarctation).
2-Fundoscopic examination : Mild retinopathy (grade I and II): AV nicking” and “copper wire changes” in Retinal hemorrhages and exudates (grade III) and papilledema (grade IV) reflect severe and life threatening disease.
3-Evidence of LV failure
4-Carotid or peripheral vascular disease
5-Abdominal bruits (renal artery stenosis)
6-Neurologic examination: old strokes

10. Initial laboratory scanning
1.Serum electrolytes 2. Renal function 3.Urine analysis ( to DD function primary renal disease or as a result of hypertension.) 4. Glucose 5. Lipid levels 6.Echocardiography in selected patients.
7. ECG (LVH)
LVH by voltage criteria: S wave in V2 + R wave in V5 > 35 mm
LV strain pattern: ST depression and T wave inversion in the lateral leads

12. What is the difference between hypertensive urgency and emergency?
Accelerated hypertension = Hypertensive urgency.
- Extreme elevations of BP (SBP>200 and or DBP >120 mmHg) - Usually asymptomatic patients. - Without evidence of new or progressive end-organ damage. - Antihypertensive therapy aimed at lowering BP over several hours to several days by oral doses of fast-acting medications (β blockers, calcium blockers, ACEI)
Malignant hypertension = Hypertensive Emergency. - Extreme elevations of BP (SBP200 and or DBP >120 mn Hg) - Often associated with acute end-organ damage: - Hypertensive encephalopathy: Confusion, Visual changes, seizures, headaches and papiledema - Death from: (Intracranial bleeding, Unstable angina, Acute MI or Left Ventricular failure) - Hypertensive GN: proteinuria, hematuria & acute renal failure. - Hospital admission and therapy aimed at immediate blood pressure reduction to limit organ damage. - Acute organ damage may resolve after aggressive BP treatment

13. Secondary Causes of Hypertension
1. Renal - Renal parenchymal disease (GN, polycystic disease, DN) - Renovascular disease (RAS, fibromuscular dysplasia, vasculitis) 2. Endocrine - Hypo- or hyperthyroidism, Hyperparathyroidism - Adrenocorticoid excess (Cushing’s, primary aldosteromsm) - Pheochromocytoma - Exogenous hormones (oral contraceptives, estrogen replacement) Neurologic Disorders: (brain tumors, sleep apnea, spinal cord poisoning) 4. Stress-Induced: Pain, anxiety 5. Toxic/ Pharmacologic: (Alcohol, NSAIDs, Ephedrine, Monoamine oxidase inhibitors) 6. Miscellaneous: (Aortic coarctation, Carcinoid syndrome or Pregnancy)

14. How can you suspect patients with secondary causes for their hypertension?
1. Patients with new onset of hypertension at age < 30 or>55 years 2. Patients with poorly controlled blood pressure despite multiple antihypertensive medications 3. Patients with previous controlled hypertension who develop sudden increase in their blood pressure
- Before we start work up for 2ry causes we have to exclude causes of failure of adequate blood pressure control as: 1. Medical noncompliance 2. Excess dietary sodium intake.
3.Drugs as oral contraceptives, corticosteroids. NSAID, over-the- counter cold remedies containing ephedrine or sympathomimetics

15. How can you suspect patients with renal artery stenosis?
1. Sudden development of severe hypertension in a patient without a family- history of hypertension 2. Drug-resistant hypertension 3.The presence of diffuse atherosclerotic disease or an abdominal bruit. 4. Renal insufficiency in the settilig of severe hypertension 5. Worsening of renal function after institution of ACE inhihitor
Diagnosis 1. Plasma renin activity is normal or high and increased after ACE inhibitor. NB: Low plasma renin excludes RAS Nuclear renal scan perfusion and after administration of ACE inhibitors 3. US: decreased size’ of the affected kidney Definitive diagnosis: angiography> MRA.
Treatment:
Surgical or balloon angioplasty

16. Primary hyperaldosteronism:
- Unilateral adrenal adenoma (Conn ‘s syndrome) & more common in women. - Bilateral adrenal hyperplasia & more common in men. - Asymptomatic in most cases. - Hypokalemia: muscle eramps. Palpitations, polyurria.and polydipsia
How can you suspect patients with primary hyperaldosteronism? - Hypertension and spontaneous hypokalemia - Hypertension and severe hypokalemia after treatment with diuretics
Diagnosis: - Low Plasma renin level: screening test - High urine aldosterone levels - Definitive diagnosis: high serum aldosterone is not suppressed after saline. - CT differeniate between adrenal adenomas and hyperplasia.
Treatment:
Surgery for solitary adenomas or spironolactone

17. Pheochromocytoma
- A rare catecholamine-producing tumor arises from the chromaffin cells of the neural crest. 85% of these tumors are located in the adrenal medulla % bilateral, 10% malignant & 10% extra-adrenal (sympathetic chain) & 10% multiple tumors in familial syndromes MEN Adrenal pheochromocytomas secrete predominantly epinephrine => systolic hypertension, tachycardia, hyperhidrosis, flushing, and apprehension. - Extramedullary tumors secrete mainly norepinephrine => systolic and diastolic hypertension. - The secretion of catecholamines is episodic =< wild fluctuations in blood pressure =< Hypetensive crises and strokes
Autoimmune (type 1 diabetes)
type 2 diabetes

18. How can you suspect patients with pheochromocytoma?
The complex of headaches, sweating episodes, and tachycardia.
Diagnosis: 1- Laboratory diagnosis: ↑ serum or urine catecholamines or their metabolites (vanillylmandelic acid or metanephrines) Radiological Localization: CT or MRI, nuclear scanning
Treatment: - Surgical resection with preoperative: β blockade, α cblockade, and volume expansion - Chronic α blockade therapy for unresectable tumors

19. Treatment of Hypertension
The goal: Prevent long-term morbidity and mortality.
Non -pharmacologic therapy for 3 to 6 months (Lifestyle modifications) - Smoking cessation - weight reduction - Regular aerobic exercise - Avoid alcohol - Restriction of dietary sodium intake.
Pharmacologic therapy Recommendation: - β Blockers and diuretics are the initial drugs of choice for mild to moderate. - β Blockers for patients with Coronory heart diseases - Diuretics and ACEI for patients with depressed LV systolic function or HF. - ACE inhibitors slow the progression of nephropathy in patients with diabetes

20. CCB (short acting Nifedipine) β B & CCB Angina
Problematic drug
Preferred drug
β B & D in high dose
ACEI & CCB DM
β B* & CCB**
ACEI & D
Systolic HF D
ACEI & BB & CCB
diastolic HF
CCB (short acting Nifedipine)
β B & CCB
Angina
CCB (Nifedipine)
β B & ACEI Ml
Receptor blockers & ACEI
Aldomet & Hydralazine
Pregnancy
βB&B+AB
ACEI
COPD
Receptor blockers & ACEI & K- sparing D.
D & ACEI (if creatinine <3)
Renal insufficiency
* Except Carvedilol ** Except Amlodipine & Felodipine β B : Beta Blocker D : Diuretic ACEI : Angiotensin Converting enzyme inhibitor CCB: Calcium Chanel Blocker

21. References
What is high blood pressure? National Heart, Lung, and Blood Institute. Accessed April 3, What is high blood pressure? American Heart Association. Blood-Pressure_UCM_301759_Article.jsp. Accessed March 19, U.S. Preventive Services Task Force. Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. Annals of Internal Medicine. 2007;147:783. Kaplan NM, et al. Overview of hypertension in adults. Accessed March 19, Egan BM. Treatment of hypertension in blacks. Accessed March 19, Kaplan NM. Obesity and weight reduction in hypertension. Accessed March 19, Tobacco and blood pressure. American Heart Association. /Tobacco-and-Blood-Pressure_UCM_301886_Article.jsp. Accessed April 3, Understand your risk for high blood pressure. American Heart Association. e/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp. Accessed March 19, Kaplan NM, et al. Potassium and hypertension. Accessed April 6, Rosen CJ, et al. The nonskeletal effects of vitamin D: An Endocrine Society scientific statement. Endocrine Reviews ;33:456. High blood pressure and women. American Heart Association. e/High-Blood-Pressure-and-Women_UCM_301867_Article.jsp. Accessed April 6, High blood pressure in children. American Heart Association. e/High-Blood-Pressure-in-Children_UCM_301868_Article.jsp. Accessed April 6, Why blood pressure matters. American Heart Association. Pressure-Matters_UCM_002051_Article.jsp. Accessed April 6, 2015.

22. Thank You