Beruflich Dokumente
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Disease
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Conclusion
Flow of Lecture
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Conclusion
Prevalence of hypertension in the
Asia-Pacific region
Martiniuk ALC, for the Asia-Pacific Cohort Studies Collaboration, J Hypertens 2007; 25:7379.
Hypertension in Malaysia from the National Health
and Morbidity Surveys
( > 30 years )
Stroke
Ischaemic Heart Disease
Chronic Heart Failure
Chronic Kidney Disease
Peripheral Vascular Disease
Dementia
WORLD HEALTH STATISTICS 2014
( WHO )
What were the leading cause of Years
of Life Lost ( YLL ) due to premature
mortality ?
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Conclusion
Physiology of BP Control
BP = CO x TPVR
CO = SV x HR
Angiotensin
converting
Blood Renin enzyme
(ACE)
Angiotensin II
+ + +
+
-
Pglom
Aldosterone
+
Proximal Na+-
reabsorption Na+-reabsorption
Arterial Ageing - Pathophysiology
Advanced Glycation
Mechanical Strain- (AGEs):
induced: Endothelial Dysfunction: Impaired Glucose
Elastin Fragmentation Reactive Oxygen Species Tolerance
Collagen Deposition Oxidised LDL Modification of Collagen
Angiotensin II
Aortic Dilatation
Wall Hypertrophy
Accelerators
Williams B, J Am Coll Cardiol 2009
Importance of Arterial Pulse Waveform
Age 25 years
Importance of Arterial Pulse Waveform
Age 47 yrs
Importance of Arterial Pulse Waveform
Age 80 yrs
RAAS in cardiovascular pathology
Risk factors: diabetes, obesity, smoking, age
RAAS
Vasoconstriction
Vascular hypertrophy
Endothelial dysfunction
Arteriosclerosis Apoptosis Arrhythmia
LVH Heart failure
Fibrosis MI
Death
Stroke
Vascular
Hypertension Cognitive
disease
dysfunction
vasoconstrictors
RAAS
SNS
Endothelin
vasodilators
Arginine
Natriuretic Vasopressin
peptides
Bradykinin
Nitric oxide
Adrenomedullin
Flow of Lecture
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Future Hypertension Research
Diagnosis depends accurate
measurements of Blood Pressure
Measure BP Properly
Within doctors control
Calibration of sphygmomanometer
Appropriate bladder size
Be proactive and do the above
Diagnosis of hypertension in the
adult DOES NOT depend on age
Definition of hypertension is
>140/90 mmHg
Normotension Masked
Hypertension
CBP <140/90mmHg
HBP/ABP < 135/85mmHg CBP < 140/90mmHg
HBP/ABP > 135/85mmHg
History Taking the specifics
History of diabetes,
hyperlipidaemia,IHD, CVA/TIA, PVD ,
heart failure, renal failure
Smoking status
Family history of pre mature CV
events
History to suggest undiagnosed IHD,
CVA/TIA, PVD
Physical Examinations the
specifics
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Conclusion
Dont Forget the Holistic Approach
to Management
Advice on Healthy Lifestyle
Healthy eating
Physical activity
Coping with stress
Patients education
Pharmacology of BP Reduction
BP = CO x TPVR
Low
SBP >180
and/or
DBP >110 High Very high Very high Very high
Choice of anti-hypertensive drugs with concomitant conditions
Concomitant Condition Diuretics -blockers ACEIs CCBs Peripheral ARBs
-blockers
Diabetes mellitus + +/- +++ + +/- ++
(without nephropathy)
Diabetes mellitus (with ++ +/- +++ ++* +/- +++
nephropathy)
Gout +/- + + + + ++
Dyslipidaemia +/- +/- + + + +
A C
Step 1 (ACE inhibitor or Angiotensin Calcium channel blocker
receptor blocker ) )
Step 2 A+C
http://www.bpassoc.org.uk/information/nice2006.htm
*Black means a person of African or
http://www.nice.org.uk/page.aspx?o=CG34
Caribbean descent, not mixed race or Asian
Follow up visits
What if BP still not controlled after 2
drugs?
A C
Step 1 (ACE inhibitor or Angiotensin Calcium channel blocker
receptor blocker ) )
Step 2 A+C
Step 3 A+C +D
http://www.bpassoc.org.uk/information/nice2006.htm
*Black means a person of African or
http://www.nice.org.uk/page.aspx?o=CG34
Caribbean descent, not mixed race or Asian
Follow up visits
What if BP is still not controlled after
3 drugs , including a diuretics
A C
Step 1 (ACE inhibitor or Angiotensin Calcium channel blocker
receptor blocker ) )
Step 2 A+C
Step 3 A+C +D
Add
Step 4 Further diuretic therapy or
Alpha-blocker or
Beta-blocker
Consider seeking specialist advice
To Admit or Not ?
Urgency is when there is NO
emergency and patients are NOT
asymptomatic
iv nitroglycerine
Suitable for a more gradual
reduction( onset 2-5 min lasting 3-5
min )
especially useful with ACS and APO
Hypertensive Emergency
iv nimodipine/nicardipine
suitable for a fairly rapid reduction (
onset 5-10min and lasting 1-4 hours
)
esp in SAH ( nimodipine )
Caution with nicardipine in AHF and
ACS
Hypertensive Emergency
iv labetolol
suitable for a more gradual
reduction( onset less than 5 minutes
lasting 3-6 hrs)
especially useful in ACS and
Eclampsia
Care with AHF
Hypertensive Emergency
iv esmolol
1. Li H, et al. J Hypertens 2010;28:432-8. 2. Sharma AK, et al. Indian Heart J 2006;58:21-7. 3. Lee HS, et al. Clin Exp
Hypertens 2010;32:166-78. 4. Korean National Health and Nutrition Examination Survey (KNHANES) 2008 [Korean].
Available at: http://knhanes.cdc.go.kr. 5. Institute of Public Health (IPH) 2008. The Third National Health and Morbidity
Survey 2006 Vol. 2. Ministry of Health Malaysia pp 199-316 ISBN 978-983-3887-30-9. 6. Sison J, et al. Philipp J
Cardiol 2007;35:1-9. 7. Wu Y, et al. J Hypertens 2009;27:190-7.
Flow of Lecture
Epidemiology of Hypertension
Pathophysiology of Hypertension
Diagnostic Work up
Therapeutics of Hypertension and
Hypertension Guidelines
Conclusion
Evolution of
Antihypertensive Therapies
Effectiveness
Tolerability