1. Hypertension I Diagnosis, causes 1

2. Mean systolic and diastolic blood pressure by age for men and women Hypertension 1995 2

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4. Definition of hypertension „There is no dividing line. The relationship between arterial pressure and mortality is quantitative; the higher the pressure, the worse the prognosis.” (Pickering, 1972) The operational definition of hypertension is the level at which the benefit …of action exceed those of inaction.” (Rose, 1980) 4

5. 5 Definition of hypertension Gauss distribution No dividing line

6. 6 Incidence of hypertension

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8. 8 Natural course of hypertension Arteriosclerosis Vasc. dementia

9. Why is dangerous? Complications of hypertension –Cardiac (hypertrphy, failure, infarction) –Cerebral (ischemia, thrombosis, hemorrhage) –Renal (nephrosclerosis, failure) –Large vessel (aneurysm, dissection) –Atherosclerosis 9

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11. 2007 ESH/ESC (WHO 1999) Systolic BP Diastolic BP JNC VII (2003) Optimal<120<80Normal 120-12980-84Prehypertension High normal130-13985-89 Mild HT (1)140-15990-99HT stage I. Moderate HT (2)160-179100-109 Severe HT (3)>180>110HT stage II. Isolated systolic HT >140<90 11

12. Frequency of various diagnoses in hypertensive subjects Diagnosis Prevalence in population Prevalence in special ward Primary hypertension92-9465-85 Secunder HT - renoparenchymal2-34-5 - renovascular1-24-16 -primary aldosteronism0.30.5-12 - Cushing’s sy< 0.10.2 -Pheochromocytoma< 0.10.2 - Drug induced0.5-11-2 - OSASn.k.15-20% - Thyreoid gl.n.k.

13. OSACONTROL 13

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16. Cushing syndrome 16

17. Hypertension II Focus on therapy Tibor Kovacs MD 2nd Dept. of Internal Medicine 17

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19. 19 Alternative blood pressure measurements ABPM Much data Data about the night BP Diurnal rythm Avoid white coat effect Home BPM Improve the patient compliance Avoid white coat effect

20. Journal of Hypertension 2007, 25:1105-1187 20

21. 21 Ambulatory blood pressure monitor (ABPM)

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26. Recommended Lifestyle Modifications and Their Individual Effects on Blood Pressure Chobanian AV, et al. JAMA. 2003;289:2560-2572; Blumenthal JA, et al. Arch Intern Med. 2000;160:1947-1958. Modifications*Recommendation Approximate SBP Reduction Reduce weight Maintain normal body weight (BMI of 18.524.9 kg/m 2 ) 320 mm Hg Adopt DASH diet Rich in fruit, vegetables, and low-fat dairy; reduced saturated and total fat content 814 mm Hg Reduce dietary sodium <100 mmol (2.4 g)/day 28 mm Hg Increase physical activity Aerobic activity >30 min/day most days of the week 49 mm Hg Moderate alcohol consumption Men: ≤ 2 drinks/day Women: ≤ 1 drink/day 24 mm Hg *Combining 2 or more of these modifications may or may not have an additive effect on blood pressure reduction. SBP = systolic blood pressure; BMI = body mass index; DASH = Dietary Approaches to Stop Hypertension

27. Advantage and disadvantage of the antihypertensive drugs Drug groupIndicationPossibble indication Compelling contraindication Possibble contraindication DiureticsHF, elderly, syst. HT, black DiabeticGoutMS,IGT, Dyslipid. Pregnancy Beta-blockerAngina, p-AMI, tachyarrh HF, Pregnancy, Diabetic, Glaucoma Asthma, COPD, A-V block PAD, MS, IGT, Sport ACE-inhibHF, p-AMI, Diabetic, LV dysf., MS, AF, NP CV prevention, atherosclerosis Pregnancy, K↑, bilat. ren. a. sten Dry cough, aortastenosis ARBDry cough due ACEI, see : ACEI CV prevention?Pregnancy, K↑, bilat. ren. a. sten Stenotic aortic valve DRI??Pregnancy, K↑, bilat. ren. a. sten Ca-CBAngina, elderly syst. HT, LV hypertr., black Diabetic, PAD, Pregnancy, atherosclerosis A-V block, HF Alpha-BProstate hyperplasiaIGT, Dyslipidaemia, sexual. dysf. monotherapyOrthostatic hypotension, HF 27 HF-Heart failure, MS- Metabolic sy. IGT- Impaired glucose tolerance AF- atrial fibrillation PAD – peripheral artery disease, NP – nephropathy/proteinuria LV-left ventricular

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31. Initiation of antihypertensive treatment Journal of Hypertension 2007, 25:1105-1187 31

32. Hypertension in emergency Hypertensive urgency BP > 230/130 mmHg without symptoms of target organ damage Hypertensive emergency BP elevation with serious target organ damage Eg. Encephalopathy, acute heart failure, acute coronaria sy, aortic dissection – acute BP lowering therapy needed 32

33. Therapy of hypertensive urgency and emergency Nitroglycerin (sublingual or iv.) ACEI (captopril, enalapril p.o.) Urapidil i.v. Short acting nifedipine (CI: angina, AMI) Labetalol Clonidin Sodium nitroprussid In special cases: loop diuretics 33

34. Thank you for your attention! 34

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41. Journal of Hypertension 2007, 25:1105-1187 METABOLIC SYNDROME 41

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44. Conditions favouring use of some antihypertensive drugs versus others I. Journal of Hypertension 2007, 25:1105-1187 44

45. Conditions favouring use of some antihypertensive drugs versus others II. Journal of Hypertension 2007, 25:1105-1187 45

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