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Cecil Medicine
Section VIII
Chapter 66
Arterial
Hypertension
Prof. Shen-Jiang Hu
1
Question

How to measure the blood pressure?
2
made by a Cambridge Reverend, Stephen Hales, in 1733. He measured blood pressure by inserting the end of
a long glass tube into the carotid artery of a horse and noting that the blood came up the tube to a height of
nine feet eight inches, which was the blood pressure of the horse.
3
It took Riva-Rocci, together with a Prussian general called Korotkoff, to
develop the modern sphygmomanometer which was introduced into clinical
practice in about 1905. The device that probably many of us still use today
to measure blood pressure has changed very little from this early device.
4
Blood Pressure has a unimodal distribution
in the Population
5
Question:

Is it important if the person has a
higher blood pressure?
6
Knowledge about risk and
treatment of hypertension
2003
JNC VII：HBP to target BP is
central for reduction of the
total risk of CV events.
1970
Hypertension and Stroke
1980
JNC II: DBP for diagnosis
and treatment of
hypertension
WHO: HBP should be
reduced to target BP.
2006
1961
1992
Framingham Heart
Study: Hypertension
and CHD
1978
2005
JNC V: SBP and DBP is
China guideline for
same important for
hypertension: HBP should
hypertension
be reduced to target BP
World Health Organization
(WHO):Treatment of
Hypertension, firstly
7
The Relationship between DBP and
Cardiovascular Events
8
9
Complications of Hypertension
Atrial
Fibrillation
Heart
LV
Failure Hypertrophy
MI
Hypertensive
Encephalopathy
Aortic
Dissection
Hypertension
CHD
Dementia
Chronic Renal failure
Ischemic
Cerebral
Infarction
Intracerebral
Hemorrhage
10
Question:

What is hypertension?
11
Definition of Hypertension

Hypertension is a clinical syndrome,
defined as systolic blood pressure ≥ 140
mmHg and/or diastolic blood pressure ≥ 90
mmHg.

Hypertension should be considered a major
risk factor for an array of cardiovascular
and related disease as well as diseases
leading to a marked increase in
cardiovascular risk.
12
Trends in Awareness, Treatment, and Control of
Hypertension in China
Awareness(%) Treatment(%) Control(%)
1991
2002
26.6
30.2
12.2
24.7
2.9
6.1
中国心血管健康多中心合作研究
Question:

What is etiology of hypertension?
15
Etiology of Hypertension


Genetic factors play an important role.
Children with one- or two-hypertensive
parents have higher blood pressures.
Environmental factors also are significant.
Increased salt intake has long been
incriminated as a pathogenic factor in
essential hypertension. It alone is
probably not sufficient to elevate blood
pressure to abnormal levels; a
combination of too much salt plus a
genetic predisposition is required.
16
Etiology
17
18
Question:

How about the pathogenesis in
hypertension is ?
19
Pathogenesis


The pathogenesis of essential
hypertension is multifactorial.
Sympathetic nervous system
hyperactivity. It is most apparent in
younger hypertensives, who may
exhibit tachycardia and an elevated
cardiac output. However, correlations
between plasma catecholamines and
blood pressure are poor.
20
Pathogenesis

Renin-angiotensin system (RAS). Renin
acts on angiotensinogen to cleave of the
ten-amino-acid peptide angiotensin I.
This peptide is then acted upon by
angiotensin-converting enzyme to create
the eight-amino-acid peptide angiotensin
II, a potent vasoconstrictor and a major
stimulant of aldosterone release from the
adrenal glands.
21
Pathogenesis

Defect of natriuresis. Hypertensive
patients exhibit a diminished ability to
excrete a sodium load. This defect may
result in increased plasma volume and
hypertension.
22
Pathogenesis

Intracellular sodium and calcium.
An increase in intracellular Na+ may
lead to increased intracellular Ca2 +
concentrations as a result of
facilitated exchange. This could
explain the increase in vascular
smooth muscle tone.
23
Pathogenesis

Exacerbating factors. The best-documented
is obesity, which is associated with an
increase in intravascular volume and an
elevated cardiac output. Some
hypertensives respond to high salt intake
with substantial blood pressure increases.
Excessive use of alcohol also raises blood
pressure. Cigarette smoking acutely raises
blood pressure.
24
Question:

Which pathologic changes will be
happen in hypertension ?
25
Pathology

Heart.
Left ventricular hypertrophy may
cause or facilitate many cardiac
complications of hypertension,
including congestive heart failure,
ventricular arrhythmias, myocardial
ischemia, and sudden death.
26
Pathology

Brain.
Hypertension is the major
predisposing cause of stroke,
especially intracerebral hemorrhage
but also ischemic cerebral infarction.
27
Pathology

Kidney.
Chronic hypertension leads to
nephrosclerosis, a common cause
of renal insufficiency.
28
Question:

How to know the patient with
hypertension?
29
Clinical Findings
Symptoms:
 Mild to moderated essential
hypertension is usually associated
with normal health and well-being
for many years.
30
Clinical Findings
Symptoms:

Elevations in pressure are often
intermittent early. Even in established
case, the blood pressure fluctuates
widely in response to emotional stress
and physical activity.
31
Clinical Findings
Symptoms:
 Suboccipital pulsating headaches,
but any type of headache, may
occur. Accelerated hypertension is
associated with somnolence,
confusion, palpitation.
32
Signs：

High blood pressure.

Physical findings depend upon the
duration and severity, and the degree of
effect on target organs.

A loud aortic second sound and an early
systolic ejection click may occur.
33
Question:

What should we do if the patient may
be with hypertension?
34
Initial Evaluation for
Hypertension

Goal 1: Accurate Assessment of Blood
Pressure
35
Blood pressure (BP) measurement
When measuring BP, care should be taken to:
 Allow the patients to sit for 3-5 minutes in a
quiet room before beginning BP
measurements.
 Take at lease two measurements spaced by
1-2 minutes, and additional measurements if
the first two are quite different.
36
Blood pressure (BP) measurement


Use a standard bladder (12-13 cm long
and 35 cm wide) but have a larger and
a smaller bladder available for large
(arm circumference >32 cm) and thin
arms, respectively.
Have the cuff at the heart level,
whatever the position of the patient
37
Blood pressure (BP) measurement


Use phase I and V (disappearance)
Korotkoff sounds to identify systolic and
diastolic BP, respectively.
Measure BP in both arms at first visit to
detect possible differences. In this
instance, take the arm with the higher
value as the reference.
38
Blood pressure (BP) measurement


Measure at first visit BP 1 and 3 min after
assumption of the standing position in
elderly subjects, diabetic patients, and in
other conditions in which orthostatic
hypotension may be frequent or suspected.
Measure heart rate by pulse palpation (at
least 30 s) after the 2ed measurement.
39
Definition and Classification of Blood
Pressure Levels in different Country
Category
JNC 7（USA）
Optimal
European
China
<120 and <80
Normal
<120 and <80
120-129 and/or 80-84
<120 and <80
High-normal
120-139 or 80-89
130-139 and/or 85-89
120-139 or 80-89
Hypertension
≥ 140 or ≥ 90
Grade I
140-159 or 90-99
140-159 and/or 90-99
140-159 or 90-99
Grade II
≥ 160 or 100
160-179 and/or 100-109
160-179 or 100-109
Grade III
≥ 180 and/or ≥ 110
≥ 180 or ≥ 110
Isolated Systolic
Hypertension
≥ 140 and <90
≥ 140 and <90
40
Definition of hypertension by office and
out-of-office blood pressure levels
Category
SBP (mmHg)
DBP (mmHg)
Office BP
≥140
and/or
≥90
Daytime (or awake)
≥135
and/or
≥ 85
Nighttime (or asleep)
≥120
and/or
≥ 70
24-h
≥ 130
and/or
≥80
≥ 135
and/or
≥85
Ambulatory BP
Home BP
41
Initial Evaluation for
Hypertension

Goal 2: Cardiovascular Risk
Stratification
42
Stratification of total CV risk in
hypertension
43
Factors--other than office BP--influencing
prognosis; used for stratification of total CV risk
Risk factors
Male sex
Age (M > 55 years; W > 65 years)
Smoking
Dyslipidaemia
•TC > 5.0 mmol/L (190 mg/dL) and/or:
•LDL-C > 3.0 mmol/L (115 mg/dL) and/or:
•HDL-C: M < 1.0 mmol/L (40 mg/dL), W < 1.2 mmol/L (46
mg/dL) and/or:
•TG > 1.7 mmol/L (150 mg/dL)
Fasting plasma glucose 5.6-6.9 mmol/L (102-125 mg/dL)
Abnormal glucose tolerance test
Abdominal obesity (waist circumference > 102 cm (M), >
88 cm (W))
Family history of premature CV disease (M at age < 55
years; W at age < 65 years)
44
Factors--other than office BP--influencing
prognosis; used for stratification of total CV risk
Asymptomatic Organ Damage
Pulse pressure (in the elderly) ≥60 mmHg
Electrocardiographic LVH or:
Echocardiographic LVH
Carotid wall thickening (IMT > 0.9 mm) or plaque
Carotid-femoral pulse wave velocity > 10 m/s
Ankle-brachial index < 0.9
CKD with eGFR 30-60 ml/min/1.73 m2 (BSA)
Microalbuminuria (30-300 mg/24h), or albumincreatinine ratio (30-300 mg/g; 3.4-34 mg/mmol)
(preferentially on morning spot urine)
45
Factors--other than office BP--influencing
prognosis; used for stratification of total CV risk
Diabetes mellitus
Fasting plasma glucose ≥7.0 mmol/L (126 mg/dL) on
two repeated measurements, and/or:
HbA1C >7%, and/or
Post-load plasma glucose >11.0 mmol/L (198 mg/dL)
46
Factors--other than office BP--influencing
prognosis; used for stratification of total CV risk
Established CV or renal disease
Cerebrovascular disease: ischaemic stroke; cerebral
haemorrhage; transient ischaemic attack
CHD; myocardial infarction; angina; myocardial
revascularization with PCI or CABG
Heart failure, including heart failure with preserved EF
Symptomatic lower extremities peripheral artery
disease
CKD with eGFR <30 mL/min/1.73m2 (BSA);
proteinuria (>300 mg/24h)
Advanced retinopathy; haemorrhages or exudates,
papilloedema
47
Initial Evaluation for
Hypertension

Goal 3: Identification and Treatment of
Secondary (Identifiable) Causes of
Hypertension
48
two circumstances


when there is a compelling finding on
the initial evaluation
when the hypertensive process is so
severe that it either is refractory to
intensive multiple-drug therapy or
requires hospitalization
49
Management
50
Goals of treatment


In hypertensive patients, the primary
goal of treatment is to achieve
maximum reduction in the long-term
total risk of cardiovascular disease.
This requires treatment of the raised BP
per se as well as of all associated
reversible risk factors.
51
When to initiate antihypertensive
treatment

Based on two criteria:
-The level of systolic and diastolic blood
pressure
-The level of total cardiovascular risk
52
Initiation of lifestyle changes and
antihypertensive drug treatment
53
Blood pressure goals in hypertensive patients
54
Lifestyle Changes







Weight Reduction
Salt Restriction: 5-6g of salt/day
Calcium and Potassium Supplementation
High-Fiber, Low-Fat Diet
Alcohol Moderation: 20-30g(M), 1020g(F) of ethanol/day.
Smoking cessation
Regular Physical Exercise:30 min of
moderate dynamic exercise on 5-7
days/week
55
Choice of antihypertensive drugs

Five major classes of antihypertensive
agents – thiazide diuretics, calcium
antagonists, ACE inhibitors, angiotensin
receptor antagonists and β-blockers –
are suitable for the initiation and
maintenance of antihypertensive
treatment, alone or in combination.
56
Monotherapy versus combination therapy

Monotherapy could be the initial
treatment for a mild BP elevation
with a low or moderate total
cardiovascular risk.
57
Monotherapy versus combination therapy

A combination of two drugs at low
doses should be preferred as first
step treatment when initial BP is in
the grade 2 or 3 range or total
cardiovascular risk is high or very
high.
58
Monotherapy versus combination therapy

In several patients BP control is not
achieved by two drugs, and a
combination of three or more drugs
is required.
59
Choice of antihypertensive drugs
The choice of a specific drug or a drug
combination, and the avoidance of others,
should take into account the following:
 The previous favourable or unfavourable
experience of the individual patient with a
given class of compounds.
60
Choice of antihypertensive drugs


The effect of drugs on cardiovascular risk
factors in relation to the cardiovascular risk
profile of the individual patient.
The presence of asymptomatic organ damage,
clinical cardiovascular disease, renal disease
or diabetes which may be more favourably
treated by some drugs than others.
61
Choice of antihypertensive drugs
The choice of a specific drug or a drug
combination, and the avoidance of
others, should take into account the
following:
 The possibilities of interactions with
drugs used for other conditions.
62
Possible combination of classes of
antihypertensive drugs
63
Monotherapy vs. drug combination
strategies to achieve target BP
64
Choice of antihypertensive drugs
The choice of a specific drug or a drug
combination, and the avoidance of
others, should take into account the
following:
 The presence of other disorders that
may limit the use of particular classes of
antihypertensive drugs.
65
Compelling and possible contra-indications to
the use of antihypertensive drugs
66
Choice of antihypertensive drugs


The cost of drugs, either to the individual
patient or to the health provider, but cost
considerations should never predominate
over efficacy, tolerability, and protection of
the individual patient.
Continuing attention should be given to side
effects of drugs, because they are the most
important cause of non-compliance. Drugs
are not equal in terms of adverse effects,
particularly in individual patients.
67
Choice of antihypertensive drugs


The BP lowering effect should last 24 hours.
This can be checked by office or home BP
measurements at through or by ambulatory
BP monitoring.
Drugs which exert their anti hypertensive
effect over 24 hours with a once-a-day
administration should be preferred because a
simple treatment schedule favours
compliance.
68
References
1.
2.
http://www.escardio.org/guidelinessurveys/Pages/welcome.aspx
http://www.acc.org/login/index.taf
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Thanks for your attention!
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