HYPERTENSION

PRESENTATION FROM O.P.D UNIT OF SDH

PRESENTED BY

VICTOR OGUNTUNDE

LEARNING OBJECTIVES

By the end of the presentation, one should be able to;

1. Define hypertension(HPT)
2. Know the types of HPT
3. Know the Classifications of HPT
4. Know the aetiology
5. Know the management of HPT
6. Debrief

OVERVIEW

• Hypertension is defined as systolic blood pressure(SBP) of 140mmHg or more, and/ or a diastolic blood pressure(DBP) of 90mmHg or more, or taking antihypertensives
• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) classifies BP for adults(>/= 18yrs) as follows:

OVERVIEW CONT'D

• HPT may be primary ( due to environmental or genetic causes) or secondary ( due to etiologies such as renal, vascular and endocrine causes)
• Primary HPT or Essential HPT accounts for 90-95% of adult cases and secondary HPT accounts for 5-10%

TYPES OF HYPERTENSION

• Primary or Essential
• 95%
• No underlying course
• Secondary Hypertension
• Underlying course

SECONDARY CAUSES

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HAEMODYNAMIC PATTERN IN HYPERTENSION

• Young : ↑BP = ↑CO X TPR
• Elderly : ↓ BP = ↑CO X ↑↑ TPR

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AETIOLOGY OF SYSTEMIC HYPERTENSION

AETIOLOGY OF �SYSTEMIC HYPERTENSION

• Others
• Coarctation of the aorta
• Pregnancy Induced HPT (Pre-eclampsia)
• Sleep Apnea Syndrome.

DISEASES ATTRIBUTABLE TO HYPERTENSION

HYPERTENSION

Gangrene of the Lower Extremities

Heart Failure

Left Ventricular Hypertrophy

Myocardial Infarction

Coronary Heart Disease

Aortic Aneurym

Blindness

Chronic Kidney Failure

Stroke

Preeclampsia/Eclampsia

Cerebral Hemorrhage

Hypertensive encephalopathy

Adapted from Dustan HP et al. Arch Intern Med. 1996; 156: 1926-1935

TARGET ORGAN DAMAGE

• Heart
• Left ventricular hypertrophy
• Angina or myocardial infarction
• Heart failure
• Brain
• Stroke or transient ischemic attack
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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CVD RISK

• The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.
• Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.

DIAGNOSIS

CLINICAL MANIFESTATIONS

• No specific complains or manifestations other than elevated systolic and/or diastolic BP (Silent Killer )
• Morning occipital headache
• Dizziness
• Fatigue
• In severe hypertension, epistaxis or blurred vision

SELF-MEASUREMENT OF BP

• Provides information on:
• Response to antihypertensive therapy
• Improving adherence with therapy
• Evaluating white-coat HTN
• Home measurement of >135/85 mmHg is generally considered to be hypertensive.
• Home measurement devices should be checked regularly.

MEASURING BLOOD PRESSURE

• Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level

• An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm)
• At least 2 measurements

MEASURING BLOOD PRESSURE CONT’D

• Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of disappearance of the sounds (Korotkoff 5th)
• Ambulatory BP Monitoring - information about BP during daily activities and sleep.
• Correlates better than office measurements with target-organ injury.

LABORATORY TESTS

• Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose,
• Serum potassium, creatinine, or the corresponding estimated GFR, and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides
• Optional tests
• Measurement of urinary albumin excretion or albumin/creatinine ratio
• More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

TREATMENT OVERVIEW

• Goals of therapy
• Lifestyle modification
• Pharmacologic treatment
• Algorithm for treatment of hypertension
• Follow up and monitoring

�GOALS OF THERAPY�

• Reduce Cardiac and renal morbidity and mortality.
• Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

NON PHARMACOLOGICAL �TREATMENT OF HYPERTENSION

Avoid harmful habits ,smoking ,alcohal

Reduce salt and high fat diets

Loose weight , if obese

Regular exercise

DASH

diet

LIFE STYLE MODIFICATIONS

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• Lose weight, if overweight
• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and cholesterol
• Increase consumption of fruits and vegetables
• Limit alcohol intake

LIFESTYLE MODIFICATION

ANTIHYPERTENSIVE DRUGS

Continue….

AT₁ receptor

ARB

ANTIHYPERTENSIVE DRUGS

DIURETICS

Example: Hydrochlorothiazide

• Act by decreasing blood volume and cardiac output
• Decrease peripheral resistance during chronic therapy
• Drugs of choice in elderly hypertensives

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Side effects

• Hypokalaemia
• Hyponatraemia
• Hyperlipidaemia
• Hyperuricaemia (hence contraindicated in gout)
• Hyperglycaemia (hence not safe in diabetes)
• Not safe in renal and hepatic insufficiency

BETA BLOCKERS

Example: Atenolol, Metoprolol, nebivolol,

• Block β₁ receptors on the heart
• Block β₂ receptors on kidney and inhibit release of renin
• Decrease rate and force of contraction and thus reduce cardiac output
• Drugs of choice in patients with co-existent coronary heart disease

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Side effects

• lethargy, impotency, bradycardia
• Not safe in patients with co-existing asthma and diabetes
• Have an adverse effect on the lipid profile

CALCIUM CHANNEL BLOCKERS

Example: Amlodipine

• Block entry of calcium through calcium channels
• Cause vasodilation and reduce peripheral resistance
• Drugs of choice in elderly hypertensives and those with co-existing asthma
• Neutral effect on glucose and lipid levels

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Side effects

Flushing, headache, Pedal edema

ACE INHIBITORS

Example: Ramipril, Lisinopril, Enalapril

• Inhibit ACE and formation of angiotensin II and block its effects
• Drugs of choice in co-existent diabetes mellitus, Heart failure

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Side effects

dry cough, hypotension, angioedema

ANGIOTENSIN II RECEPTOR BLOCKERS

Example: Losartan

• Block the angiotensin II receptor and inhibit effects of angiotensin II
• Drugs of choice in patients with co-existing diabetes mellitus

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Side effects

safer than ACEI, hypotension,

ALPHA BLOCKERS

Example: prazosin

• Block a-1 receptors and cause vasodilation
• Reduce peripheral resistance and venous return
• Exert beneficial effects on lipids and insulin sensitivity
• Drugs of choice in patients with co-existing BPH

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Side effects

Postural hypotension,

ANTIHYPERTENSIVE THERAPY:�SIDE-EFFECTS AND CONTRAINDICATIONS

ALGORITHM FOR �TREATMENT OF HYPERTENSION

Not at Goal Blood Pressure (<140/90 mmHg) �(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Lifestyle Modifications

CHOICE OF DRUG

ANTIHYPERTENSIVE THERAPY: SIDE-EFFECTS AND CONTRAINDICATIONS (CONT’D)

1999 WHO-ISH guidelines

CAUSES OF �RESISTANT HYPERTENSION

• Improper BP measurement
• Excess sodium intake
• Inadequate diuretic therapy
• Medication
• Inadequate doses
• Drug actions and interactions (e.g., (NSAIDs), illicit drugs, sympathomimetic, OCP)
• Over-the-counter drugs and some herbal supplements
• Excess alcohol intake
• Identifiable causes of HTN

TAKE HOME MESSAGE

• Hypertension is a major cause of morbidity and mortality, and needs to be treated
• It is an extremely common condition; however it is still under-diagnosed and undertreated
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from the deleterious effect
• Besides pharmacology we have other choices and one has to be acquainted with that choice
• Life style modification should always be encouraged in all Hypertensive patients

ANY QUESTIONS?