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SYSTEMIC HYPERTENSION

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Title: SYSTEMIC HYPERTENSION


1
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2
SYSTEMIC HYPERTENSION
3
SYSTEMIC HYPERTENSION
  • Definitions of hypertension
  • Elevated arterial blood pressure is a major
    cause of premature vascular disease leading to
    cerebrovascular events, ischaemic heart disease
    and peripheral vascular disease.

4
  • Blood pressure is the pressure exerted by the
    blood against the walls of the blood vessels,
    especially the arteries.
  • It varies with the strength of the heartbeat, the
    elasticity of the arterial walls, the volume and
    viscosity of the blood,
  • and a person's (health, age, and physical
    condition

5
Age
  • onset between 30 - 50 years of age
  • increases over 65 years of age
  • sex - males in young adulthood and early middle
    age
  • females after the age of 55 years

6
The prevalence
  • hypertensions is higher among blacks and older
    persons, especially older women

Hypertension increased with age, and is higher
in young men than in young women, although the
reverse is true in older adults.
7
Hypertension - Introduction
  • Silent Killer painless complications
  • It is the leading risk factor MI, HF, CRF Stroke
  • Responsible for the majority of office visits,
  • Number one reason for drug prescription.
  • 25 of population
  • Complications bring to diagnosis but late

8
  • This requires the heart to work harder than
    normal to circulate blood through the blood
    vessels.
  • Blood pressure is summarised by two measurements,
    systolic and diastolic
  • which depend on whether the heart muscle is
    contracting (systole) or relaxed between beats
    (diastole).

9
  • Normal blood pressure at rest is within the range
    of 100-140mmHg systolic (top reading) and
    60-90mmHg diastolic (bottom reading).
  • High blood pressure is said to be present if it
    is persistently at or above 140/90 mmHg.

10
Ideal Mean Aterial Pressure
  • (MAP) is defined as 93 mm of mercury, which
    corresponds to 120/80 and can be calculated by
    MAP DP 1/3 (SP-DP).
  • Mean Arterial blood pressure depends on the flow
    of blood from the heart (cardiac output) and the
    resistance to flow in the small arteries and
    microscopic resistance vessels (arterioles)

11
Regulation of BP
  • BP Cardiac Output x Peripheral Resistance
  • Endocrine Factors
  • Renin, Angiotensin, ANP, ADH, Aldosterone.
  • Neural Factors
  • Sympathetic Parasympathetic
  • Blood Volume
  • Sodium, Mineralocorticoids, ANP
  • Cardiac Factors
  • Heart rate Contractility.

12
Classification of blood of blood pressure
13
You Have Diastolic Value Systolic Value
Normal blood pressure Less than 85 Less than 130
High-normal blood pressure Less than 85 130-139or
Stage 1 (mild) hypertension 90-99 140-159
Stage 2 (moderate) hypertension 100-109 160-179
Stage 3 (severe) hypertension 110-119 180-209
Stage 4 (very severe) hypertension 120 or higher 210 or higher

14
Signs and symptoms
  • Hypertension is rarely accompanied by any
    symptoms, and its identification is usually
    through screening, or when seeking healthcare for
    an unrelated problem. A proportion of people with
    high blood pressure reports
  • headaches (particularly at the back of the head
    and in the morning),

15
  • lightheadedness,
  • vertigo,
  • tinnitus
  • (buzzing or hissing in the ears),
  • altered vision or fainting episodes
  • These symptoms however are more likely to be
    related to associated anxiety than the high blood
    pressure itself

16
Control of Blood Pressure
Humoral Factors
Vasoconstrictors Angiotensin II Catecholamines
Vasodilators Pg Kinins
Blood Volume Na, Aldosterone
Cardiac Factors Rate Contract..
Local Factors pH, Hypoxia
  • Neural Factors
  • Adrenergic Cons
  • ß Adrenergic - Dil

17
Peak blood pressure
  • Peak blood pressure levels in humans occur during
    the mid morning (at about 1000 AM) then decrease
    progressively throughout the remainder of the day
    to reach a trough value the following morning at
    around 300 AM

18
Definition of Circadian Rhythm
  • Circadian rhythms are daily cycles of physiology
    and behavior that are driven by an endogenous
    oscillator with a period of approximately one day

19
Normally, circadian rhythms
  • are synchronized with the 24.0 h environment by
    stimuli which alter the phase of the underlying
    brain circadian pacemaker.
  • For most organisms, including mammals, the
    primary phase-shifting stimulus is light

20
  • These processes include -
  • -sleep-wake cycles,
  • -body temperature,
  • -blood pressure,
  • -release of hormones.
  • This activity is controlled by the biological
    clock, which is located in the supra-chiasmtic
    nuclei of the hypothalamus in human brains.
  • It is highly influenced by natural dark-light
    cycles, but will persist under constant
    environmental conditions. Examples Disruptions
    to the circadian rhythm can cause problems with
    the sleep-wake cycle

21
  • Circadian rhythms are regulated by three
    components
  • (1) the circadian pacemaker or "clock",
  • (2) an input mechanism which allows the clock to
    be reset by environmental stimuli, and
  • (3)an output mechanism which regulates
    physiological and behavioral Processes

22
Hypertension types
  • Primary Hypertension, High blood pressure of
    unidentified cause, Accounts for 90 of cases of
    high blood pressure. The identified risk factors
    in primary hypertension are as follows , age
    onset between 30 - 50 years of age , increases
    over 65 years of age, sex - males in young
    adulthood and early middle age, females after the
    age of 55 years
  • Secondary Hypertension is High blood pressure
    in which the cause can be identified.

23
Etiology
  • 1- Essential
  • In more than 95 of cases, an underlying
  • cause cannot be found. Proposed mechanisms
  • include
  • Excess renal sodium retention
  • Over activity of sympathetic nervous system
  • Renin angiotensin excess
  • Hyperinsulinemia
  • Alterations in vascular endothelium

24
Factors contributing to the development of
Essential hypertension
  • Genetic Factors hypertension is more common in
    some families and in some ethnic groups like
    African Americans
  • Environmental factors include obesity, alcohol,
    lack of exercise and excess salt

25
Emotional stress can cause quite large increases
in blood pressure. Prominent amongst the
physiological responses to stress is an increase
in activity in the sympathetic nerves
  • Postural changes exert stresses on the
    cardiovascular system requiring effective reflex
    responses to constrict arteries and veins and
    stimulate the heart, to control blood pressure,
    maintain brain blood flow, and prevent loss of
    consciousness

26
Regular over-consumption of alcohol can raise
blood pressure dramatically, as well as cause an
elevation upon withdrawal
  • The severity of obstructive sleep apnea syndrome
    OSAS is an independent factor correlated to
    diurnal hypertension

27
pathophysiology
  • There is some evidence that supports a hypothesis
    that the primary fault in the patho-physiology of
    hypertension is a defect in the-
  • calcium binding of the plasma membrane of the
    cells of a pressure-regulating center in the
    nervous system.

28
2- Secondary hypertension
  • Renal These account for over 80 of the cases of
    secondary hypertension. The common causes are
    diabetic nephropathy, chronic glomerulonephritis,
    adult polycystic disease, chronic
    tubulointerstitial nephritis, and renovascular
    disease.
  • Endocrinal These include
  • Conn's syndrome, adrenal hyperplasia,
    acromegaly,
  • Phaeochromocytoma, Cushing's syndrome.
  • Drugs and toxins
  • Pregnancy-induced hypertension
  • Vascular coarctation of aorta, vasculitis

29
Children
  • Hypertension in neonates is rare, occurring in
    around 0.2 to 3 of neonates,
  • blood pressure is not measured routinely in the
    healthy newborn
  • Hypertension is more common in high risk
    newborns.
  • A variety of factors, such as gestational age,
    postconceptional age and birth weight needs to be
    taken into account when deciding if a blood
    pressure is normal in a neonate

30
Hypertensive crises
  • Severely elevated blood pressure (equal to or
    greater than a systolic 180 or diastolic of 110
    sometime termed malignant or accelerated
    hypertension) is referred to as a "hypertensive
    crisis", as blood pressures above these levels
    are known to confer a high risk of complications.
  • People with blood pressures in this range may
    have no symptoms, but are more likely to report
    headaches (22 of cases)and dizziness than the
    general population

31
  • Other symptoms accompanying a hypertensive crisis
    may include -
  • 1-visual deterioration
  • 2-breathlessness due to heart failure
  • 3-general feeling of malaise due to renal failure
  • 4-Most people with a hypertensive crisis are
    known to have elevated blood pressure, but
    additional triggers may have led to a sudden rise

32
emergency hypertensive
  • "malignant hypertension", is diagnosed when there
    is evidence of -
  • 1- direct damage to one or more organs as a
    result of the severely elevated blood pressure.
  • 1-This may include hypertensive encephalopathy,
    caused by brain swelling and dysfunction,

33
  • characterized by-
  • - headaches
  • -altered level of consciousness (confusion or
    drowsiness).
  • -Retinal papilloedema
  • -fundal hemorrhages

34
  • -exudates are another sign of target organ
    damage.
  • -Chest pain may indicate heart muscle damage
    (which may progress to myocardial infarction) or
    sometimes aortic dissection,
  • -tearing of the inner wall of the aorta.
  • -Breathlessness, cough, and the expectoration of
    blood-stained sputum are characteristic signs of
    pulmonary edema, the swelling of lung tissue due
    to left ventricular failure

35
  • -inability of the left ventricle of the heart to
    adequately pump blood from the lungs into the
    arterial system

36
In pregnancy
  • Hypertension occurs in approximately 8-10 of
    pregnancies
  • Most women with hypertension in pregnancy have
    pre-existing primary hypertension, but high blood
    pressure in pregnancy may be
  • the first sign of pre-eclampsia, a serious
    condition of the second half of pregnancy and
    puerperium.

37
  • Pre-eclampsia is characterised by
  • increased blood pressure
  • the presence of protein in the urine
  • It occurs in about 5 of pregnancies and is
    responsible for approximately 16 of all maternal
    deaths globally
  • Pre-eclampsia also doubles the risk of perinatal
    mortality
  • Usually there are no symptoms in pre-eclampsia
    and it is detected by routine screening.

38
Complications
  • Cerebrovascular disease
  • coronary artery disease are the most common
    causes of death
  • although hypertensive patients are also prone to
    renal failure
  • peripheral vascular disease.

39
HYPERTENSION
  • Classification of blood pressure levels
  • (according to the British Hypertension Society)
  • Category Systolic blood pressure
    Diastolic blood pressure
  • Optimal lt 120
    lt 80
  • Normal lt 130
    lt 85
  • High normal 130-139
    85-89
  • Hypertension
  • Grade I (mild) 140-159
    90-99
  • Grade 2 (moderate) 160-179
    100-109
  • Grade 3 (severe) 180
    110
  • Isolated systolic hypertension
  • Grade 1 140-149
    lt 90
  • Grade 2 160
    lt 90

40
HISTORY
  • The patient with mild hypertension is usually
    asymptomatic.
  • Attacks of sweating
  • headaches
  • palpitations.
  • Higher levels of blood pressure may be associated
    with, epitasis or nocturnal.
  • Breathlessness may be present owing to left
    ventricular hypertrophy or cardiac failure.

41
INVESTIGATIONS
  • Routine investigation of the hypertensive
  • patient should include
  • ECG
  • Urine stix test for protein and blood
  • Fasting blood for lipids (total and high-density
    lipoprotein cholesterol) and glucose
  • Serum urea, creatinine and electrolytes.

42
Investigation of selected cases
  • Chest X-ray
  • Ambulatory BP recording
  • Echocardiogram
  • Renal ultrasound
  • Renal angiography
  • Urinary catecholamines
  • Urinary cortisol and dexamethasone suppression
    test
  • Plasma renin activity and aldosterone

43
Prevention
  • Much of the disease burden of high blood pressure
    is experienced by people who are not labelled as
    hypertensive.
  • population strategies are required to reduce the
    consequences of high blood pressure and reduce
    the need for antihypertensive drug therapy.
  • Lifestyle changes are recommended to lower blood
    pressure, before starting drug therapy.

44
  • maintain normal body weight for adults (e.g. body
    mass index 2025 kg/m2)
  • reduce dietary sodium intake to lt100 mmol/ day
    (lt6 g of sodium chloride or lt2.4 g of sodium per
    day)

45
  • Engage in regular aerobic physical activity such
    as brisk walking (30 min per day, most days of
    the week)
  • limit alcohol consumption to no more than 3
    units/day in men and no more than 2 units/day in
    women
  • consume a diet rich in fruit and vegetables (e.g.
    at least five portions per day)
  • Effective lifestyle modification may lower blood
    pressure as much an individual antihypertensive
    drug.
  • Combinations of two or more lifestyle
    modifications can achieve even better results.

46
Management
  • Lifestyle modifications includes
  • dietary changes
  • physical exercise
  • weight loss.
  • If hypertension is high enough to justify
    immediate use of medications, lifestyle changes
    conjunction with medication.
  • Anti-inflammatory approaches should be a
    promising strategy for treating both hypertension
    and atherosclerosis

47
  • Different programs aimed to reduce-
  • psychological stress
  • such as biofeedback
  • relaxation
  • or meditation

48
  • Dietary change such as a low sodium diet is
    beneficial. A long term (more than 4 weeks) low
    sodium diet in
  • Also, the DASH diet, a diet rich in nuts, whole
    grains, fish, poultry, fruits and vegetables
  • diet is also rich in potassium, magnesium,
    calcium, as well as protein

49
Non-pharmacological treatment
  • Weight reduction - BMI should be lt 25 kg/m2
  • Low-fat and saturated fat diet
  • Low-sodium diet - lt 6 g sodium chloride per day
  • Limited alcohol consumption - 21 units/week for
    men and 14 units/week for women
  • eating plan, which is rich in potassium and
    calcium
  • Chronic intake of diets rich in pomace olive oil
    improves endothelial dysfunction in spontaneously
    hypertensive
  • Diets rich in fruits and vegetables reduce blood
    pressure

50
  • Dynamic exercise
  • At least 30 minutes' brisk walk per day
  • Increased fruit and vegetable consumption
  • Reduce cardiovascular risk by stopping smoking
  • increasing oily fish consumption.

51
Pharmacological treatment should be based on the
following
  • The initiation of antihypertensive therapy in
    subjects with sustained systolic blood pressure
    (BP) 160 mmHg, or sustained diastolic BP 100
    mmHg.
  • In patients with diabetes mellitus, the
    initiation of antihypertensive drug therapy if
    systolic BP is sustained 140 mmHg, or diastolic
    BP is sustained 90 mmHg.

52
  • In non-diabetic hypertensive subjects, treatment
    goals BP lt 140/85 mmHg. In some hypertensive
    subjects these levels may be difficult to
    achieve.
  • Most hypertensive patients will require a
    combination of antihypertensive drugs to achieve
    the recommended targets.
  • In most hypertensive patients, therapy with
    statins and aspirin to reduce the overall
    cardiovascular risk burden.
  • Glycaemic control should be optimized in
    diabetics (HbA1c lt 7).

53
  • Anti-hypertensive medications are not effective
    for everyone
  • costly and result in adverse effects that impair
    quality of life and reduce adherence.
  • Moreover, abnormalities associated with high BP,
    such as insulin resistance and hyperlipidaemia,
    may persist or may even be exacerbated by some
    anti-hypertensive medications.

54
Pharmacological Treatment
  • Several classes of drugs are available to treat
  • hypertension. The usual are
  • ACE inhibitors or Angiotensin receptor
    antagonists
  • Beta-blockers
  • Calcium-channel blockers
  • Diuretics
  • Other drugs as a-blocker, direct vasodilator, or
    centrally acting drugs

55
  • Choice of antihypertensive therapy
  • The choice of antihypertensive therapy is usually
    dictated by
  • cost, convenience, the response to treatment and
    freedom of
  • side effects

56
  • Co morbid conditions may have an important
    influence on
  • initial drug selection e.g.
  • ?-blocker in angina
  • Thiazide diuretics and calcium antagonists in
    elderly people
  • ACE in heart failure, post MI, type 1 diabetic
    nephropathy
  • ARBs in type 2 diabetic nephropathy, intolerance
    to ACE
  • a-blocker in benign prostatic hypertrophy

57
Aerobic exercises
  • Aerobic exercises may play an important role in
    the treatment of blood pressure of hypertensive
    individuals treated in the long run

58
Exercises
  • For many years, physical inactivity has been
    recognized as a risk factor for coronary heart
    disease (CHD) and most recommendations suggest
    regular physical activity as a part of the
    strategy in preventing/reducing CHD

59
Physical Activity
  • Regular physical activity is the first treatment
    recommended
  • to lower BP and improve cardiovascular health,
  • The effect of physical activity on SBP and DBP is
    unequal. With increased levels of activity there
    is an almost linear increase in SBP, whereas DBP
    tends to decrease

60
Moderate-intensity (4070 VO2 max) aerobic
exercise is associated with a significant
reduction of blood pressure in hypertensive and
normotensives participants and in overweight, as
well as normal-weight participants reducing
_ 1-regional sympathetic outflow, 2- total
peripheral resistance 3- heart rate.

61
  • - exercise has been shown to augment vagal tone,
    endothelium-mediated vasodilatation
  • - insulin sensitivity and mood
  • - and to lower cholestero

62
  • -Resistive exercise training has been shown to
    decrease SNS activity
  • -increase baroreflex sensitivity (an index of
    reflex vagal control of the heart which carries
    relevant patho physiological
  • -High intensity training may paradoxically
    increase arterial stiffness in healthy
    middle-aged -

63
In hypertension, sympathetic activation
represents a mechanism potentially responsible
for the day-night blood pressure difference
  • evening exercise significantly reduced the
    nighttime blood pressure, Irrespective of a
    morning exercise period
  • nitric oxides release by moderate exercises as a
    vasodilator on endothelium cell of blood vessels
    that increases blood flow while lowering blood
    pressure.

64
  • Decreases in catecholamine and total peripheral
    resistance,
  • improved insulin sensitivity,
  • and alterations in vasodilators and
    vasoconstrictors are some of the postulated
    explanations for the antihypertensive effects of
    exercise
  • sympathy inhibition and enhanced vagal activity

65
  • increase in diastolic blood pressure of more than
    10 mmHg during or after exercise represents a
    coronary artery disease.

66
Summary
  • Hypertension is the commonest cause of major
    morbidity, but less than a quarter of patients
    are adequately treated.
  • A reduction in cardiovascular disease mortality
    and morbidity can be achieved through improved
    treatment and control of hypertension.
  • A greater choice of drugs are available for
    hypertension than for other chronic diseases.
  • Rational choice of single and combination drugs
    facilitated by understanding their effects on the
    renin system, but systematic trial and error may
    still be necessary.

67
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