HYPERTENSION

rof.Dr.dr. Syakib Bakri, SpPD-KGH

Hypertension :

• Sustained elevation of systemic arterial pressure

• Primarily an asymptomatic disease
• Accompanied by increased arterial resistance
Frequency of Hypertension
According to Age

Age Percentage
18-29 years old 4%

30-39 years old 11%

40-49 years old 21%

50-59 years old 44%

60-69 years old 54%

70-79 years old 62%

More than 80 years 65%

old
Hypertension :

Primary Hypertension ( 90-95%)

• Interaction between genetic and environment factors

Secondary Hypertension ( 5-10%)

• Kidney Disease :
Renovascular
Renoparenchym (Chronic Kidney Disease)
• Coarctation of the aorta
• Pheochromocytoma
• Drug-induced or drug related causes
• Primary aldosteronism
 Common Substances Associated With
Hypertension in Humans
Prescription Drugs
Cortisone and other steroids (both cortico- and mineralo-), ACTH
Estrogens (usually just oral contraceptive agents with high estrogenic activity)
Nonsteroidal anti-inflammatory drugs
Phenylpropanolamines and analogues
Cyclosporine and tacrolimus
Erythropoietin
Sibutramine

Street drugs and other “natural products”

Cocaine and cocaine withdrawal
Ma huang, “herbal ecstasy,” and other phenylpropanolamine analogs

Food substances
Sodium chloride
Ethanol
Systolic Hypertension

Increased Cardiac Output

Aortic valvular insufficiency
Arteriovenous fistula
Thyrotoxicosis
Paget’s disease of bone
Beri-beri
Arterial Rigidity (Ageing)
Complication of Hypertension

Hemorrhagic or ischemic stroke

Transient ischemic attack

Hypertensive encephalopathy

Myocardial infarction / angina

Congestive heart failure

Renal failure

Peripheral artery disease

Mancia G. J Hypertens 1998 ; 16 (suppl 6) : S35.

 Risk of Hypertension (1)

Adjusted relative risk of CHD death according to deciles of baseline SBP and DBP in men screened
for the MRFIT. Relative risk was adjusted for age, race, serum cholesterol, cigarettes per day, use of
medication for diabetes, and income, using a multiple Cox proportional hazards model.
(He J, & Whelton P. J Hypertens 17 (Suppl. 2) 1999)
 Risk of Hypertension (2)

Adjusted relative risk of stroke death according to deciles of baseline SBP and DBP in men screened for
the MRFIT. Relative risk was adjusted for age, race, serum cholesterol, cigarettes per day, use of
medication for diabetes, and income, using a multiple Cox proportional hazards model.
(He J, & Whelton P. J Hypertens 7 (Suppl. 2), 1999)
 Risk of Hypertension (3)

Adjusted relative risk of end-stage renal disease according to quantile of baseline SBP and DBP in
men screened for the MRFIT. Relative risk was adjusted for age, race, serum cholesterol, cigarettes
per day, use of medication for diabetes, and income, using a multiple Cox proportional hazards
model. He J, & Whelton P. J Hypertens. 17 (Suppl. 2) 1999
BLOOD PRESSURE CLASSIFICATION

JNC 6,1997/ISH-WHO, 2003 JNC 7,2003

 Pathogenesis of Essential
Hypertension
• Genetic
• Environment
• Systemic nervous system
• Renin angiotensin system
• Vascular remodelling, hypertrophy, and
increased peripheral resistance
• Role of kidney
The Clinical and laboratory evaluation of
the hypertensive patient should be conducted
with four aims :

 To confirm a chronic elevation of BP and determine

the level
 To exclude or identify secondary causes of
hypertension
 To determine the presence of target organ damage
and quantify its extent
 To search for other cardiovascular risk factors and
clinical conditions that may influence the
prognosis and treatment
Evaluation Components

• Medical history

• Physical examination

• Laboratory tests
 Medical History (1)
Duration of the hypertension
Last known normal blood pressure
Course of the blood pressure

Prior treatment of the hypertension

Drugs : types, doses, side effects

Intake of agents that may be interfere

Nonsteroidal antiinflammatory drugs
Oral contraceptives
Sympathomimetics
Adrenal steroids
Excessive sodium intake
Alcohol (>2 drinks/day)
Herbal remedies
 Medical History (2)

Family history
Hypertension
Premature cardiovascular disease or death
Familial diseases : pheochromocytoma, renal disease, diabetes, gout

Symptoms of secondary causes

Muscle weakness
Spells of tachycardia, sweating, tremor
Thinning of the skin
Flank pain
 Medical History (3)

Symptoms of target organ damage

Headaches
Transient weakness or blindness
Loss of visual acuity
Chest pain
Dyspnea
Edema
Claudication
Presence of other risk factors
Smoking
Diabetes
Dyslipidemia
Physical inactivity
 Medical History (4)

Concomitant diseases
Asthma bronchiale
Gouty arthritis
Diabetes Mellitus
etc
Dietary history
Weight changes
Fresh vs processed foods
Sodium
Saturated fats
 Physical examination for
secondary hypertension and
organ damage

• Signs suggesting secondary

hypertension and organ damage
• Signs of organ damage
 Signs suggesting secondary
hypertension and organ damage

• Features of Cushing syndrome

• Skin stigmata of neurofibromatosis
(phaeochromocytoma)
• Palpation of enlarged kidneys (polycystic kidney)
• Auscultation of precordial or chest murmurs (aortic
coartation or aortic disease)
• Diminished and delayed femoral and reduced
femoral blood pressure (aortic coartation, aortic
disease)
 Signs of organ damage

• Brain : murmurs over neck arteries, motor or

sensory defects
• Retina : funduscopic abnormalities
• Heart : location and characteristics of apical
impulse, abnormal cardiac rhythms, ventricular
gallop, pulmonary rales, dependent oedema
• Peripheral arteries : absence, reduction, or
asymmetric of pulses, cold extremities, ischaemic
skin lesions.
 Blood Pressure Measurement

• Patients should be seated with back supported and arm bared and
supported.

• Patients should refrain from smoking or ingesting caffeine for 30

minutes prior to measurement.

• Measurement should begin after at least 5 minutes of rest.

• Appropriate cuff size and calibrated equipment should be used.

• Both SBP and DBP should be recorded.

• Two or more readings should be averaged.

 Blood Pressure recorded at home between
clinic visits
Second Clinic Reading
First Clinic
Reading (mercury Home Series Electronic device Mercury
manometer) (electronic device) manometer

Patient group SBP DBP SBP DBP SBP DBP SBP DBP
(mmHg) (mmHg) (mmHg) (mmHg) (mmHg) (mmHg) (mmHg) (mmHg)

Untreated ( n = 114) 174 103 148 90 165 95 164 97

Treated ( n = 154) 177 104 147 87 163 95 164 95

DBP, Diastolic blood pressure; SBP, Systolic blood pressure

.
Hall CL, et al. J Hum Hypertens 1990 ; 4 : 501-507.
Advantages of Self Measurement

• Identifies “white-coat hypertension”

• Assesses response to medication
• Improves adherence to treatment
• Potentially reduces costs
• Usually provides lower readings than those
recorded in clinic
Laboratory Investigations
• Routine tests
• Recommended tests
• Extended evaluation (domain of the
specialist)
 Routine tests
• Plasma glucose
• Lipid profile
• Serum uric acid
• Serum creatinine
• Serum potassium
• Haemaglobin and haematocrit
• Urimalysis (dipstick test complemented by
urinary sediment examination)
• Electrocardiogram
 Recommended tests
• Echocardiogram
• Carotid (and femoral) ultrasound
• C-reactive protein
• Microalbuminuria (essential test in diabetics)
• Quantitative proteinuria (if dipstick test positive)
• Funduscopy (in severe hypertension)
 Extended evaluation
(domain of the specialist)

• Complicated hypertension : tests of cerebral,

cardiac and renal function
• Search for secondary hypertension :
measurement of renin, aldosterone,
corticosteroids, catecholamines; arteriography;
renal and adrenal ultrasound; computer-assisted
tomography (CAT); brain magnetic resonance
imaging.
 TREATMENT of HYPERTENSION

Non-Pharmacologic : Lifestyle modification

Pharmacologic
LIFESTYLE MODIFICATION

Alcohol moderation
Exercise
Smoking cessation
Decrease salt intake
Weight reduction
Increase fruit / vegetables intake
 HYPERTENSION STAGE I
(140-159 / 90-99 mmHg)--- at least 3 different measurement
Lifestyle Modifications

Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices (one drug)

Without Compelling With Compelling

Indications Indications

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
HYPERTENSION STAGE II
( ≥ 160 / ≥ 100 mmHg)

Lifestyle Modifications
Initial Drug Choices (one drug)

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
 Special Considerations
in Selecting Drug Therapy

• Age
• Demographics
• Coexisting diseases and therapies
• Hemodynamic profile
• Complication of hypertension
• Economic considerations
 Classes of
Antihypertensive Drugs

• ACE inhibitors
• β-blockers
• Angiotensin II receptor blockers
• Calcium antagonists
• Direct vasodilators
• Diuretics
• Central symphatolytic
• α1- blockers
Guidelines for selecting drug treatment of hypertension

a
Grade 2 or 3 atrioventricular block; b Grade 2 or 3 atrioventricular block with verapamil or diltiazem
WHO-ISH. J Hypertens 1999 ; 17 : 162.
 Patient Education About Treatment

Assess patient’s understanding and acceptance of the diagnosis of

hypertension

Discuss patient’s concerns and clarify misunderstandings

Tell patient the BP reading and provide a written copy

Inform patient about recommended treatment and provide specific written

information about the role of lifestyle including diet, physical activity, dietary
supplements, and alcohol intake. Use standard brochures when available.

Elicit concerns and questions and provide opportunities for the patient to
state specific behaviors to carry out treatment recommendations

Emphasize:
Need to continue treatment
Control does not mean cure
One cannot tell if BP is elevated by feeling or symptoms; BP must be
measured
THANK YOU