1. Hypertension Dr. Gerrard Uy

2. Hypertension doubles the risk of cardiovascular diseases present in all populations except for a small number of individuals living in primitive, culturally isolated societies accounts for 6% of deaths worldwide

3. Risk Factors Obesity and weight gain High dietary NaCl intake Low dietary Ca and Potassium Alcohol consumption Pyshosocial stress Low levels of physical activity genetic

4. Mechanism of hypertension Cardiac output and peripheral resistance are the two determinants of arterial pressure

5. Mechanism Intravascular Volume Autonomic Nervous System Renin-Angiotensin Aldosterone Vascular Mechanisms

6. Vascular Volume Vascular volume is a primary determinant of arterial pressure over the long term alterations in total extracellular fluid volume are associated with proportional changes of blood volume Sodium is predominantly an extracellular ion

7. Autonomic Nervous System Adrenergic reflexes: – norepinephrine, epinephrine, and dopamine Baroreceptor reflexes: – Carotid sinus, aortic arch

8. Renin-Angiotensin Aldosterone

9. Pathologic consequences Heart – most common cause of death in hypertensive patients Brain – Hypertension is an important risk factor for brain infarction and hemorrhage Kidney – Primary renal disease is the most common etiology of secondary hypertension Peripheral Arteries – blood vessels may be a target organ for atherosclerotic disease secondary to long-standing elevated blood pressure

10. Defining hypertension based on the average of two or more seated blood pressure readings during each of two or more outpatient visits Blood Pressure ClassificationSystolic, mmHgDiastolic, mmHg Normal<120and <80 Prehypertension120–139or 80–89 Stage 1 hypertension140–159or 90–99 Stage 2 hypertension160or 100 Isolated systolic hypertension140and <90

11. Home blood pressure and average 24-h ambulatory blood pressure measurements are generally lower than clinic blood pressures Increasing evidence suggests that home blood pressures, including 24-h blood pressure recordings, more reliably predict target organ damage than office blood pressures

12. Blood pressure tends to be higher in the early morning hours, soon after waking, than at other times of day Myocardial infarction and stroke are more frequent in the early morning hours white coat hypertension : 15 – 20 % with stage 1 hypertension have

13. Clinical disorders Essential hypertension – 80 – 95% – primary or idiopathic hypertension – No identifiable cause Secondary hypertension – 5 – 20 % – a specific underlying disorder causing the elevation of blood pressure can be identified

14. Essential Hypertension likely to be the consequence of an interaction between environmental and genetic factors increases with age

15. Secondary Hypertension Renal (Parenchymal disease, tumors) Renovascular (Arteriosclerotic) Adrenal (Primary aldosteronism, Cushing's syndrome) Aortic coarctation Obstructive sleep apnea Preeclampsia/ Eclampsia

16. Secondary Hypertension Neurogenic (psychogenic, polyneuritis) Endocrine (hypo/hyperthyroidism) Medications (estrogen, decongestant)

17. Approach to patient HISTORY – Duration – Associated symptoms (headache, etc) Occipital, early morning – Previous meds – Family history – Diet and social history – Risk factors: weight change, DM, smoking – Evidence of secondary causes

18. Approach to patient Measurement of BP – Before taking the blood pressure measurement, the individual should be seated quietly for 5 min in a private, quiet setting with a comfortable room temperature – center of the cuff should be at heart level – width of the bladder cuff should equal at least 40% of the arm circumference – length of the cuff bladder should encircle at least 80% of the arm circumference

19. Methods in determining BP Auscultatory method – Stethoscope over antecubital area – BP cuff inflated over upper arm – Korotkoff sounds – Mechanism: When cuff pressure is higher than systolic P, brachial artery remains occluded As cuff pressure is reduced, blood jets through the artery, hearing tapping sounds from antecubital artery When cuff pressure is equal diastolic pressure, blood no longer jets through squeezed artery, tapping stops

20. Approach to patient PE – Body habitus, weight, height – Arterial pulse, upper and lower extremities – Heart rate – Neck palpated – Eye exam – Abdominal palpation – Neurologic exam

21. Treatment LIFESTYLE intervention Weight reductionAttain and maintain BMI < 25 kg/m 2 Dietary salt reduction< 6 g NaCl/d Adapt DASH-type dietary planDiet rich in fruits, vegetables, and low- fat dairy products with reduced content of saturated and total fat Moderation of alcohol consumptionFor those who drink alcohol, consume 2 drinks/day in men and 1 drink/day in women Physical activityRegular aerobic activity, e.g., brisk walking for 30 min/d

22. Blood pressure may be lowered by 30 min of moderately intense physical activity, such as brisk walking, 6–7 days a week, or by more intense, less frequent workouts Alcohol use in persons consuming three or more drinks per day DASH (Dietary Approaches to Stop Hypertension) - 8-week period a diet

23. Pharmacologic therapy Drug therapy is recommended for individuals with blood pressures 140/90 mmHg Examples of drugs: – Diuretics : Thiazides: HCTZ – Beta blockers: Metoprolol – ACE Inhibitors: Captopril – Angiotensin II Antagonists: Losartan – Calcium blockers: Verapamil