1、,Hypertension (HT) High Blood Pressure (HBP),Introduction,Definition: Hypertension is defined as elevated arterial blood pressure. Hypertension is one of the most common disease in the world In our country, 160 million people over the age of 15 have established or borderline HP HP Essential HP (95%)
2、 Secondary HP (5%),Etiology,Genetic EnvironmentDietary: Salt intakeAlcohol intakeObesityInfant dysnutrition,Pathogenesis,High activity of the SNS (Sympathetic Nervous System) RAAS (Renin-Angiotension Aldosterone System) Renal Sodium Handling Vascular Remodelling Endothelial Cell Dysfunction Insulin
3、Resistance,Pathological consequences,target organs hemorrhage the CNS stroke thrombosisLVH HF HBP the Heart CHD AP MI HF arrhythmia the Kidney progressive renal nephrosclerosisprogressive scarring of the glomerularenal failurethe Arteriosclerosis stenosis thrombosis occlusiondilatation rapture hemor
4、rhage,The pathological changes of small artery,The pathological change of the Heart,Left ventricular hypertrophy (LVH)Heart failureCoronary artery atherosclerosis Myocardial infarction,Pathological change of the Brain,Stroke: Ischemic stroke Hemorrhagic stoke,Arterial Aneurysm,Pathological change of
5、 Renal,Hypertension induced nephrosclerosis, atrophy of renal cortex,Clinical Features,The blood pressure varies widely over time, depending on many variables, including SNS activity, posture, state of hydration, and skeletal muscle tone. Symptoms:Always asymptomaticSymptoms often attributed to hype
6、rtension: headache, tinnitus, dizziness, fainting,Clinical Features,Complications of Hypertension Heart: LVH, CHD,HF Brain: TIA, Stroke Renal: Microalbuminuria, renal dysfunction Ratinopathy,Laboratory Examination,Blood pressure measurement:Clinic Blood PressureHome Blood PressureAmbulatory monitori
7、ng,Ambulatory Measurement,Ambulatory monitoring can provide: readings throughout day during usual activities readings during sleep to assess nocturnal changes measures of SBP and DBP load Exclude white coat or office hypertension Ambulatory readings are usually lower than in clinic (hypertension is
8、defined as 135/85 mm Hg),Laboratory Examination,Urinalysis Blood examination Chest X Ray EKG UCG (Ultrasound cardiography) Retina examination,The Keith-Wagner Criteria (change in retina),KW I: Minimal arteriolar narrowing, irregularityof the lumen, and increased light reflex KW II: More marked narro
9、wing and irregularitywith arteriovenous nicking (crossing defects) KW III: Flame-shaped hemorrhages and exudates in addition to above arteriolar changes KW IV: Any of the above with addition of papilledema,Flame shaped hemorrhage,Pepilledema,Diagnosis & Differential Diagnosis,Classification of blood
10、 pressure for adult,Category SBP (mmHg) DBP (mmHg) Normal 120 80 High normal 120-139 80-89 Hypertension 140 90Stage 1 140-159 90-99 Stage 2 160-179 100-109 Stage 3 180 110 Systolic HBP 140 90 When the SBP and DBP fall into different categories, use the higher category,Evaluation Objectives,To identi
11、fy cardiovascular risk factors To assess presence or absence of target organ damage To identify other causes of hypertensionThese evaluation may used in stratification of the hypertension patients,Cardiovascular Risk Factors,Blood pressure Age Gender Dyslipidemia Abdomen Obesity Family History of ca
12、rdiovascular disease CRP 1mg/dl,Target Organ Damage,Left ventricular hypertrophy Echo shows IMT of carotid artery Plasma creatinine slight elevation Microalbuminuria,Associated Clinical Condition,Cerebrovascular diseases: Stroke, TIA Heart diseases: MI, AP, CHF, Coronary artery revasculation Kidney
13、diseases: DN, Dysfunction of the kidney, Proteinuria, CRF Diabetes Peripheral artery disease Retinopathy,Evaluation Components,Medical history Physical examination Routine laboratory tests,Stratification of Hypertension patients,TOD-Target Organ Damage; ACC-Associated Clinical Conditions,Differentia
14、l Diagnosis,Should exclude Secondary Hypertension,Secondary Hypertension Common Causes,Renal Glomerulonephritis Pyelonephritis Obstructive nephropathy Collagen diseases, Congenital diseases Diabetes nephropathy Renal tumor- renin secreting tumor Pheochromocytoma Primary aldosteronism,Phenochromocyto
15、ma,Ganglion-neurotomas and neuroblastomas Excretion of large amounts of catecholamines 90% arise in the adrenal medulla 10% are malignant. Paroxymal or persist HT Clinic features: Headache, sweating, palpitations, nervousness, weight loss, hypermetabolism, orthostatic hypotension, severe presser res
16、ponse,Primary Aldosteronism,Mild or moderate hypertension Hypokalemia, muscle weakness, paralysis Polyuria, nocturia and polydipsia, Hypochloremic alkalosis Urine aldosterone elevation Plasma renin active decrease,Secondary Hypertension,Obstructive Sleep Apnea (OSA) Renal artery stenosis Cushings sy
17、ndrome Coarctation of the aorta Drug-induced: NSAIDs; Sympathomimetic medications; Prophylactic; Monoamine oxidase inhibitors; Mineralocorticoids; Immuno-inhibitors; Epogen,Therapy,Goal of Hypertension Management, 140/90 mm Hg With Diabetes or kidney dysfunction: 130/80mmHg To reduce morbidity and m
18、ortality of cerebral and cardiovascular complications. Controlling other cardiovascular risk factors,Lifestyle Modifications,Stop smoking Limit alcohol intake Lose weight or keep fit Suitable diet Increase aerobic physical activity Decrease psychological stress,Principle of Drug Therapy,Drug therapy
19、 should be individually A low dose of initial drug therapy Combination therapies may provide additional efficacy with fewer adverse effects. Optimal formulation should provide 24-hour efficacy with once-daily dose.,Antihypertensive Drugs,Diuretics -Adrenergic receptor blockers (BB) Calcium channel b
20、lockers (CCB) ACE inhibitors (ACEI) Angiotensin II receptor blockers (ARB),Not at Goal Blood Pressure,Algorithm for Treatment of Hypertension,Lifestyle Modifications,Initial Drug Choices,Not at Goal Blood Pressure,Initial Drug Choices,No associated clinical condition,Algorithm for Treatment of Hyper
21、tension (continued),Associated clinical condition,I stage hypertension: Diuretics, BB,CCB,ACEI,ARB,II stage hypertension: Two drugs combination therapy,Choice the drugs according to ACC,Increase dosage or add another agent from different class,Drug choices in hypertension patient associated with cli
22、nical condition,Combination Therapies,May provide additional efficacy with fewer adverse effects. Diuretics as the basement drug in combination therapy. Diuretics - ACEI / ARBDiuretics - BBDiuretics - CCB CCB as the basement drug in combination therapyCCB - ACEICCB - BB Others: Three drugs combinati
23、on,Causes for Inadequate Response to Drug Therapy,Incorrect measurement of the BP Volume overload or Pseudo-resistance Drug-related causes Associated conditions,Hypertensive crisis,Hypertensive Emergencies and Urgencies Emergencies: The blood pressure is elevated severely and associated with target
24、organ damage, such as hypertensive encephalopathy, AMI, pulmonary edema, require immediate blood pressure reduction. Urgencies: The blood pressure is elevated severely but no target organ damage has acute target organ damage. Fast-acting drugs are available.,Drugs Available for Hypertensive Crisis,V
25、asodilators Nitroprusside Nicardipine Nitroglycerin Hydralazine,Adrenergic Inhibitors Labetalol Esmolol Phentolamine,Case 1,Male 29 years old Blood pressure elevated for two years With paroxysmal dizziness, blurred vision, sweating and palpitation BP: 160-180/90-100mmHg HR: 100-120 bpm When the pati
26、ent with symptoms, the BP would elevate to 240-260/120-130mmHg, and HR increase to 130-150 bpm.,Physical examination: BP: 165/100mmHg HR: 112 bpm No positive sign in chest examination Can find a mass at right abdomen, if press on it the BP of the patient elevated to 250/120mmHg, and the HR increased
27、 to 145 bpm.,Laboratory test: Blood routine, Urinalysis, Blood biochemistry are normal Plasma renine activation: 0.93ng/ml.h (0.93-6.56) AT II: 51.5pg/ml (55.3-115.3) Aldosterone: 129.4pd/ml (63-239.6) NE: 33.40pmol/ml (0.51-3.26) 12-lead electrocardiogram: High voltage of LV Chest X ray: Normal,CT
28、scan of abdomen: Found a mass at right adrenal,Diagnosis as Phenochromocytoma,Case 2,Male, 65 years old Hypertension history for 30 years Headache, blurred vision, vomiting for 2 hours Paralysis of left side body BP: 220/130mmHg HR: 106 bpm CT scan of the head: Normal,Diagnosis: Hypertensive crisis
29、Therapy: Controlled the BP, using fast-acting drug，such as Nitroprusside, Labetalol The reduction of BP should less than 25% in 24 hours BP 160/100mmHg in 48 hours,Summary,Specific therapy for patients with LVF, CAD, and HF. ACEI can be used for all type patients. In older persons, diuretics and CCB are preferred. Many patients need combination therapy. Goal of the patients with renal insufficiency with proteinuria (1 g/day): 125/75 mmHg; ( 1 g/day): 130/80 mmHg. Patients with diabetes should be treated to a therapy goal of below 130/80 mm Hg.,
