Submitted by Swati chauhan MPT 1st year cardiopulmory

y Definition : sustained increase of systemic blood

pressure. y Hypertension or HT, also called High Blood Pressure, is a condition in which the blood pressure in either arteries or veins is abnormally high. Hypertension is one of the major causes of death and disability in the world. y Hypertension is known as "Silent Killer" because it may be present for years with no perceptible symptoms.

y High blood pressure is not only a serious condition by

itself, but it is also the leading cause of heart attacks, strokes and kidney failure. Severe and immediately life-threatening hypertension is called Malignant hypertension and usually requires hospitalization and acute medical care. y The measurement of blood pressure is written as two numbers. The normal blood pressure reading is systolic 120 over diastolic 80 represented as 120/80 mm of Hg.

y Blood pressure above this range is considered to be

high and should be viewed seriously. The best way to prevent hypertension is to undergo regular blood pressure checks and take treatments in case the pressure level is high.

classification that is suggested by the EMRO for adult aged > 18 years
Classification Systolic Blood Pressure (mmHg) Less than 120 and Diastolic Blood Pressure (mmHg) Less than 80

Normal

Prehypertension

120-139

or

80-89

Stage 1 hypertension

140-159

or

90-99

Stage 2 hypertension

> 160

or

> 100

EMR0 Technical Publications Series 29 Clinical guidelines

1997 JNC VI Classification of Blood Pressure

Blood Pressure Category Optimal Normal High Normal Hypertension Stage 1 (Mild) Stage 2 (Moderate) Stage 3 (Severe) Systolic <120 <130 130-139 140-159 160-179 > 180 Diastolic <80 <85 85-89 90-99 100-109 > 110

Classification according to the extent of organ damage

y hypertension with no other cardiovascular risk factors

and no target organ damage y hypertension with other cardiovascular risk factors y hypertension with evidence of target organ damage y hypertension with other cardiovascular risk factors and evidence of target organ damage.
Ala Din Alwan WHO, 1996, CINDI/EUROPHARM Forum WHO

y Blood pressure is usually classified based on the

systolic and diastolic blood pressures. Systolic blood pressure is the blood pressure in vessels during a heart beat. y Diastolic blood pressure is the pressure between heartbeats. y A systolic or the diastolic blood pressure measurement higher than the accepted normal values for the age of the individual is classified as prehypertension or hypertension.

y Hypertension has several sub-classifications including,

hypertension stage I, hypertension stage II, and isolated systolic hypertension. y Isolated systolic hypertension refers to elevated systolic pressure with normal diastolic pressure and is common in the elderly. y Hypertension is also classified as resistant if medications do not reduce blood pressure to normal levels

Causes of Resistant Hypertension

Pseudoresistance Poor compliance Drug Interactions Underdosing Improper combinations Obesity Excess Alcohol Volume Overload Sleep Apnea Secondary Hypertension

y Exercise hypertension is an excessively high elevation

in blood pressure during exercise. The range considered normal for systolic values during exercise is between 200 and 230 mm Hg. Exercise hypertension may indicate that an individual is at risk for developing hypertension at rest.

y Hypertension

can be classified as essential hypertension and secondary hypertension.

y y y y

Essential or primary hypertension or idiopathic hypertension most common form of hypertension occurs in almost 90 percent of cases causes are unknown however, medical studies and research have identified some factors causing it.

Causative factors y sedentary lifestyle y Smoking y Stress y visceral obesity y potassium deficiency (hypokalemia) y obesity(more than 85% of cases occur in those with a body mass index greater than 25) y salt (sodium) sensitivity y alcohol intake y vitamin D deficiency that increase the risk of developing hypertension

y Aging y genetic mutations y family history of hypertension y An elevated level of renin, a hormone secreted by the

kidney, is another risk factor y sympathetic nervous system overactivity y Insulin resistance, which is a component of syndrome X (or the metabolic syndrome), is also thought to contribute to hypertension y Recent studies have implicated low birth weight as a risk factor for adult essential hypertension

Hypertension: Risk Factors Essential Hypertension

y Sodium intake y Excess alcohol y Genetic factors y Obesity y Race

Prevalence of Other Risk Factors With Hypertension

Risk Factor Smoking LDL Cholesterol >140 mg/dl HDL Cholesterol < 40 mg/dl Obesity Diabetes Hyperinsulinemia Sedentary lifestyle
Kaplan NM. Dis Mon 1992; 38:769-838

Percent 35 40 25 40 15 50 >50

y Secondary hypertension is the result of a specific

disease, disorder, or other condition. A hypertension within the renal arteries causes renal hypertension and it affects the entire circulatory system.

Causes of Secondary Hypertension

Coarctation of aorta Conn s syndrome Pheochromacytoma Cushing syndrome Thyroid Disease Acromegaly Hyperparathyroidism

Renal Artery Stenosis Renin tumor Glomerulonephritis DM nephrosclerosis Polycystic disease Collagen disease Chronic Pyelonephritis

Drug Induced

Causes of 2 Hypertension
Diseases
y chronic kidney disease y Cushing's syndrome y coarctation of the aorta y obstructive sleep apnea y parathyroid disease y pheochromocytoma y primary aldosteronism y renovascular disease y thyroid disease

Causes of 2 Hypertension
drugs:
prednisone, amphetamines estrogens: usually oral contraceptives erythropoiesis stimulating agents: erythropoietin, darbepoietin NSAIDs, COX-2 inhibitors Carbamazepine ketamine metoclopramide

Causes of 2 Hypertension
y Street drugs, other natural products:

cocaine cocaine withdrawal ephedra alkaloids (e.g., ma-huang) herbal ecstasy phenylpropanolami neanalogs nicotine withdrawal

anabolic steroids narcotic withdrawal methylphenidate phencyclidine ketamine ergot-containing herbal products St. John's wort

y In general the major causes of hypertension are

the following:
y Hectic and stress filled life style y Unhealthy food habits y Obesity y Excessive consumption of liquors y Smoking y Over consumption of tea/coffee y Insufficient rest and sleep y Metabolic disorders

y Hardening of the arteries y Excessive use of pain killers and other strong y y y y y

medicines Genetic disorders Over consumption of oily food and fast food High salt intake Emotional and Physical stress Family history of hypertension

y y y y y y y y

The possibility of secondary hypertension young age family history of renal disease evidence of renal disease hypertension due to drugs episodes of sweating, headache, anxiety (phaeochromocytoma) episodes of muscle weakness and tetany (hyperaldosteronism)

Symptoms of Hypertension
y Mild to moderate essential hypertension is usually

asymptomatic y hypertension is not a disease, but it is a symptom itself. In most cases, hypertension produces no symptoms until dangerous complications occur. y However there are some known symptoms of hypertension, which a person with hypertension may experience now and then. y Headaches - Headaches may be experienced due to elevation in blood pressure. Sometimes morning headaches can also be due to hypertension.

y Dizziness - Dizziness is often experience by people

y y y

with high blood pressure. However dizziness cannot always be treated as a symptom of hypertension. Heart pain Palpitations Nosebleeds - Nosebleeds without particular reason might be a symptom of high blood pressure. It is better to check the blood pressure in such cases. Difficulty in breathing

y Confusion y Fatigue y Irregular heart beat y Tinnitus (ringing or buzzing in the ears) y Blurred Vision y Frequent urination

Arterial Pressure Determinants

Pathophysiology of hypertension
y Most of the mechanisms associated with secondary

hypertension are generally fully understood. y However, those associated with essential (primary) hypertension are far less understood. y cardiac output is raised early in the disease course, with total peripheral resistance (TPR) normal; y By the time cardiac output drops to normal levels but TPR is increased. Three theories have been proposed to explain this:

y Excess of sodium due to Inability of the kidneys to

excrete sodium, resulting in natriuretic factors such as Atrial Natriuretic Factor being secreted to promote salt excretion with the side effect of raising total peripheral resistance. y An overactive Renin-angiotensin system leads to vasoconstriction and retention of sodium and water. The increase in blood volume leads to hypertension. y An overactive sympathetic nervous system, leading to increased stress responses.

Laboratory investigations
y y y y y y y y y y y y

urine analysis plasma creatinine and/or blood urea nitrogen plasma potassium random blood glucose serum cholesterol heamatocrit electrocardiogram. lipids lipoprotein cholesterol plasma uric acid chest X-ray echocardiography.

Prevention
y The process of managing prehypertension according

to the guidelines of the British Hypertension Society suggest the following lifestyle changes: y Weight reduction and regular aerobic exercise (e.g., walking): Regular exercise improves blood flow and helps to reduce the resting heart rate and blood pressure. y Reducing dietary sugar. y Reducing sodium (salt) in the body by disuse of condiment sodium and the adoption of a high potassium diet which rids the renal system of excess sodium. Many people use potassium chloride salt substitute to reduce their salt intake.

y Additional dietary changes beneficial to reducing

blood pressure include the DASH diet (dietary approaches to stop hypertension) which is rich in fruits and vegetables and low-fat or fat-free dairy products. This diet has been shown to be effective based on research sponsored by the National Heart, Lung, and Blood Institute. In addition, an increase in dietary potassium, which offsets the effect of sodium has been shown to be highly effective in reducing blood pressure.

y Discontinuing tobacco use and alcohol consumption

has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol or nicotine consumption. Abstaining from cigarette smoking reduces the risk of stroke and heart attack which are associated with hypertension.

y Limiting alcohol intake to less than 2 standard drinks

per day can reduce systolic blood pressure by between 2-4mmHg y Reducing stress, for example with relaxation therapy, such as meditation and other mind body relaxation techniques,[by reducing environmental stress such as high sound levels and over-illumination can also lower blood pressure. Jacobson's Progressive Muscle Relaxation and biofeedback are also beneficial, such as device-guided paced breathing, although meta-analysis suggests it is not effective unless combined with other relaxation techniques.

y Increasing omega 3 fatty acids can help lower

hypertension. Fish oil is shown to lower blood pressure in hypertensive individuals. The fish oil may increase sodium and water excretion.

Lifestyle Modification
Lose weight if overweight Limit alcohol intake to no more than 1 oz (30 mL) of ethanol (ie, 24 oz [720 mL] of beer, 10 oz [300 mL] of wine, 2 oz [60 mL] of 100proof whiskey) per day or 0.5 (15 mL) ethanol per day for women and people of lighter weight Increase aerobic activity (30-45 min most days of the week) Reduce sodium intake to no more than 100 mmol/d (2.4 g sodium) Maintain adequate intake of dietary potassium (approximately 90 mmol/d) Maintain adequate intake of dietary calcium and magnesium for general health Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

JNC VII recommendations.Chobanian AV, et al. JAMA. 2003;289:2560-2572.

TREATMENT
y The main goal of treatment for hypertension is to

lower blood pressure to less than 140/90 - or even lower in some groups such as people with diabetes, and people with chronic kidney diseases.
y Treating hypertension is important for reducing the

risk of stroke, heart attack, and heart failure. High blood pressure may be treated medically, by changing lifestyle factors, or a combination of the two.

y Important lifestyle changes include losing weight, quitting smoking, eating a healthful diet, reducing sodium intake, exercising regularly, and limiting alcohol consumption.

y y y y y y y y y

Medical treatment include ANTIHYPERTENSIVE DRUGS Alpha blockers Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) Beta blockers Calcium channel blockers Central alpha agonists Diuretics Renin inhibitors, including aliskiren (Tekturna) Vasodilators

Effects of Antihypertensives on Renal Blood Flow (RBF) & Glomerular Filtration Rate (GFR)
Antihypertensive Mechanism of Action Agent ACE inhibitors/ARBs Reduce intraglomerular pressure Decrease sodium and volume retention Diuretics Sodium and volume depletion Increase vasodilatory prostaglandin levels (IV loop diuretics) Renal vasoconstriction (IV thiazide diuretics) -Adrenergic Decrease Cardiac output blockers Increase renal vascular resistance (nonselective agents) Increase renal vascular resistance ( 1-selective agents) Centrally acting Decrease renal vascular resistance (methyldopa) antiadrenergic drugs Decrease renal perfusion pressure (clonidine, 2adrenergic agonist) Peripherally acting Direct vasodilation (postsynaptic 1-adrenoreceptor antiadrenergic drugs blocking agents) Direct vasodilator agents Effects on Renal Hemodynamics Preserve GFR Decrease GFR, RBF Decrease GFR, RBF Increase RBF Decrease GFR, RBF Decrease GFR, RBF Decrease GFR, RBF No change in GFR, RBF No change in GFR, RBF Decrease GFR, RBF No change in GFR, RBF

Calcium channel blockers

Decrease renal vascular resistance (hydralazine, minoxidil) Increase RBF, no effect on GFR Arterial vasodilation plus dilatation of venous capacitance Decrease GFR & RBF (acute effect) vessels (nitroprusside) Decrease renal vascular resistance by vasodilation of Increase RBF, no change afferent arterioles (hypertensive patients) in GFR

DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy: A Pathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com

y These are the primary drugs used in treatment of

HTN. These medications may be used alone or in combination, and some are only used in combination y If blood pressure is successfully lowered, it is wise to have frequent checkups and to take preventive measures to avoid a relapse of hypertension.

y y y y y y y y

In addition to taking medicine, person can do many things to help control blood pressure, including: Eat a healthy diet, including potassium and fiber, drink plenty of water. Exercise regularly -- at least 30 minutes a day. Cessation of smoking Limit alcohol intake Limit the amount of sodium (salt) -- aim for less than 1,500 mg per day. Reduce stress -- try to avoid things that cause stress. try meditation or yoga. Maintain a healthy body weight

y Reduction of the blood pressure by 5 mmHg can

decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease. y The aim of treatment should be reduce blood pressure to <140/90 mmHg for most individuals, and lower for individuals with diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg)

Outlook (Prognosis)
y Most of the time, high blood pressure can be

controlled with medicine and lifestyle changes.

Target-Organ Damage
Brain: stroke, transient ischemic attack, dementia Eyes: retinopathy Heart: left ventricular hypertrophy, angina Kidney: chronic kidney disease Peripheral Vasculature: peripheral arterial disease

Diseases Attributable to Hypertension

Coronary heart disease Myocardial infarction Left ventricular hypertrophy Stroke Heart failure Cerebral hemorrhage

Hypertension

Chronic kidney failure

Aortic aneurysm Retinopathy Peripheral vascular disease

Hypertensive encephalopathy
All Vascular
...bridging the care gap

Continuing Medical Implementation Adapted from: Arch Intern Med 1996; 156:1926-1935.

Advantage of Controlling Hypertension

A 5-6 mmHg reduction in diastolic BP reduces stroke by 40%. Joint National Committee on Detection, 1992 lowering by 5-6mm can reduce mortality from cerebrovascular disease by 35%-40%, from ischemic heart disease by 15% 20% and reduction in all deaths from cardiovascular causes by 23%. Psaty, et al 1997 3 mmHg decrease in systolic BP reduces annual mortality from stroke, coronary heart diseases and all other causes by 8%, 5% and 4%. Whelton PK. 1994
y The chances of mortality from CVD in old hypertensive people

when taking anti hypertensive medications is decreased by 34%. MacMahon 1993