1. Definitions of Hypertension (HTN) Three readings on separate occasions (>140/>90) to make the diagnosis, unless BP is found at >210/>120

2. Physiologic Types of Hypertension I Essential or Primary Hypertension (90-95% of all cases) II Secondary Hypertension: 5-10% of all cases (pheo, primary aldosteronism, renovascular) (Zollo: The Portable Internist. Hanley and Belfus/Philadelphia and Moseby/St. Louis 1995)

3. Significance of hypertension Prevalence US said to be 58 million (20% of the entire population, adults and children); Leading risk factor for stroke; When neglected, presents as hypertensive heart disease (LVH, pulmonary edema), CAD Largely asymptomatic

4. Hypertension Ranking risk factor for stroke> CAD> Renal Failure

5. Pathophysiology of essential hypertension 35 % Caucasians and most other groups’ hypertension characterized by salt/water retention („volume”); 65% African- Americans; majority of elderly 10% ± peripheral vascular resistance (PVR) (renin/angiotensin, catecholamines) 55% ± mixed PVR/salt retention) Hyperinsulinemia associated w/ volume dependent hypertension

6. Isolated Systolic Hypertension (ISH: SBP≥ 140 ): CVD risk More common in elderly; elderly more likely to have ISH; likely to be diuretic responsive.

7. Risk of CVD 0,0 1,0 2,0 3,0 4,0 5,0 6,0 <70 <110 70-74 110-119 75-79 120-129 80-84 130-139 85-89 140-149 90-94 150-159 95-99 160+ 100+ SBPSBP DBPDBP DBP SBP NHBPEPWG 1993

8. Renovascular hypertension  Average risk  DBP > 120 mm Hg  Start at the age 50   RR & vascular murmur  DBP> 105 mm Hg &  creatinine  BP normalizes after ACE-I  DBP > 120 mm Hg  Start at the age 50   RR & vascular murmur  DBP> 105 mm Hg &  creatinine  BP normalizes after ACE-I  High risk  DBP> 120 mm Hg and CRF  Malignant HT   BP and ARF after treatment with ACE-I   BP and asymmetry of the size of the kidneys (>2 cm)  DBP> 120 mm Hg and CRF  Malignant HT   BP and ARF after treatment with ACE-I   BP and asymmetry of the size of the kidneys (>2 cm)

9. Factors in primary prevention of Htn in high risk people : -salt restriction -stress management -weight control

10. Salt Restriction: opportunity for primary prevention of hypertension (Other mainstays of Rx of hypertension: ACEIs and ACERBs, Ca ++ channel blockers, ß blockers)

11. Relationship between diabetes and hypertension Diabetics have a 50% prevalence of hypertension (compare to 15-20% of US population); even when corrected for weight Hypertensives have prevalence of glucose intolerance (abn BS patterns) = 15-18% (compare to 5-6% of adult US pop. w D/M) - a significantly larger percentage is assumed to have insulin resistance w/o glucose intolerance

12. Hypertonic nephropathy Common in Afroamericans Effect of untreated or ineffectively treated HT

13. HN Long-lasting HT HT precedes proteinuria Hypertonic retinopathy (advanced) Hypertrophia of left ventricle Small kidneys in usg No other kidney disease

14. HN HT arteriolosclerosis (nephrosclerosis benigna) glomerulosclerosis, tubules atrophy fibrosis, sclerosis

15. HN Proteinuria 1,5 g/d Elevated PRA Small kidneys