Download Hypertension

Hypertension (HT)
High Blood Pressure (HBP)
slide 1
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%) Secondary HP (5%)
slide 2
Etiology
• Genetic
• Environment
Dietary: Salt intake
Alcohol intake
Obesity
Infant dysnutrition
slide 3
Pathogenesis
1. High activity of the SNS (Sympathetic
Nervous System)
2. RAAS (Renin-Angiotension Aldosterone
System)
3. Renal Sodium Handling
4. Vascular Remodelling
5. Endothelial Cell Dysfunction
6. Insulin Resistance
slide 4
The pathological changes of small artery
slide 6
The pathological change of the Heart
Left ventricular hypertrophy (LVH)
Heart failure
Coronary artery atherosclerosis
Myocardial infarction
slide 7
Pathological change of the Brain
Stroke:
Ischemic stroke
Hemorrhagic stoke
Arterial
Aneurysm
slide 8
Pathological change of Renal
Hypertension induced nephrosclerosis,
atrophy of renal cortex
slide 9
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 asymptomatic
Symptoms often attributed to hypertension:
headache, tinnitus, dizziness, fainting
slide 10
Clinical Features
• Complications of Hypertension
Heart: LVH, CHD,HF
Brain: TIA, Stroke
Renal: Microalbuminuria, renal dysfunction
Ratinopathy
slide 11
Laboratory Examination
• Blood pressure measurement:
Clinic Blood Pressure
Home Blood Pressure
Ambulatory monitoring
slide 12
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 defined as
> 135/85 mm Hg)
slide 13
Laboratory Examination
•
•
•
•
•
•
Urinalysis
Blood examination
Chest X Ray
EKG
UCG (Ultrasound cardiography)
Retina examination
slide 14
slide 15
slide 16
slide 17
The Keith-Wagner Criteria
(change in retina)
KW I: Minimal arteriolar narrowing, irregularity
of the lumen, and increased light reflex
KW II: More marked narrowing and irregularity
with 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
slide 18
Pepilledema
Flame shaped hemorrhage
slide 19
Diagnosis &
Differential Diagnosis
slide 20
Classification of blood pressure for adult
Category
Normal
High normal
Hypertension
Stage 1
Stage 2
Stage 3
Systolic HBP
SBP (mmHg)
DBP (mmHg)
< 120
< 80
120-139
80-89
≥140
140-159
160-179
≥180
≥90
90-99
100-109
≥110
≥140
< 90
When the SBP and DBP fall into different categories, use the higher category
slide 21
Evaluation Objectives
• To identify cardiovascular risk factors
• To assess presence or absence of target
organ damage
• To identify other causes of hypertension
These evaluation may used in stratification
of the hypertension patients
slide 22
Cardiovascular Risk Factors
•
•
•
•
•
•
•
Blood pressure
Age
Gender
Dyslipidemia
Abdomen Obesity
Family History of cardiovascular disease
CRP ≥1mg/dl
slide 23
Target Organ Damage
•
•
•
•
Left ventricular hypertrophy
Echo shows IMT of carotid artery
Plasma creatinine slight elevation
Microalbuminuria
slide 24
Associated Clinical Condition
• Cerebrovascular diseases: Stroke, TIA
• Heart diseases: MI, AP, CHF, Coronary
artery revasculation
• Kidney diseases: DN, Dysfunction of the
kidney, Proteinuria, CRF
• Diabetes
• Peripheral artery disease
• Retinopathy
slide 25
Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
slide 26
Stratification of Hypertension patients
Blood Pressure
risk factors &
Disease History
Grade I
Grade II
Grade III
I . No risk factors
Low risk
Med risk
High risk
II. 1-2 risk factors
Med risk
Med risk
Very high risk
III. 3 or more risk
factors or TOD or
diabetes
IV. ACC
High risk
High risk
Very high risk
Very high risk Very high risk
Very high risk
TOD-Target Organ Damage; ACC-Associated Clinical Conditions
slide 27
Differential Diagnosis
Should exclude Secondary Hypertension
slide 28
Secondary Hypertension
Common Causes
• Renal
Glomerulonephritis
Pyelonephritis
Obstructive nephropathy
Collagen diseases,
Congenital diseases
Diabetes nephropathy
Renal tumor---- renin secreting tumor
• Pheochromocytoma
• Primary aldosteronism
slide 29
Phenochromocytoma
•
•
•
•
•
•
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 response
slide 30
Primary Aldosteronism
•
•
•
•
•
•
Mild or moderate hypertension
Hypokalemia, muscle weakness, paralysis
Polyuria, nocturia and polydipsia,
Hypochloremic alkalosis
Urine aldosterone elevation
Plasma renin active decrease
slide 31
Secondary Hypertension
•
•
•
•
•
Obstructive Sleep Apnea (OSA)
Renal artery stenosis
Cushing’s syndrome
Coarctation of the aorta
Drug-induced:
NSAIDs;
Prophylactic;
Mineralocorticoids;
Epogen
Sympathomimetic medications;
Monoamine oxidase inhibitors;
Immuno-inhibitors;
slide 32
Therapy
slide 33
Goal of Hypertension Management
• < 140/90 mm Hg
• With Diabetes or kidney dysfunction:
<130/80mmHg
– To reduce morbidity and mortality of cerebral
and cardiovascular complications.
– Controlling other cardiovascular risk factors
slide 34
Lifestyle Modifications
•
•
•
•
•
•
Stop smoking
Limit alcohol intake
Lose weight or keep fit
Suitable diet
Increase aerobic physical activity
Decrease psychological stress
slide 35
Principle of Drug Therapy
• Drug therapy 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.
slide 36
Antihypertensive Drugs
• Diuretics
•
•
•
•
ß-Adrenergic receptor blockers (BB)
Calcium channel blockers (CCB)
ACE inhibitors (ACEI)
Angiotensin II receptor blockers (ARB)
slide 37
Algorithm for Treatment of
Hypertension
Hypertension patient
Lifestyle Modifications
Not at Goal Blood Pressure
Initial Drug Choices
slide 38
Algorithm for Treatment of
Hypertension (continued)
Initial Drug Choices
No associated clinical condition
I stage hypertension:
Diuretics,
BB,CCB,ACEI,ARB
Associated clinical condition
II stage hypertension:
Two drugs
combination therapy
Choice the drugs
according to ACC
Not at Goal Blood Pressure
Increase dosage or add another agent from different class
slide 39
Drug choices in hypertension patient
associated with clinical condition
Drug
ACC
Diuretics BB ACEI ARB CCB Antialdosterone
√
√
√
√
HF
√
√
√
MI
√
√
√
√
CAD
√
√
√
√
√
DM
√
√
CRF
√
√
Stroke
slide 40
Combination Therapies
• May provide additional efficacy with fewer adverse
effects.
• Diuretics as the basement drug in combination therapy.
Diuretics ---- ACEI / ARB
Diuretics ---- BB
Diuretics ---- CCB
• CCB as the basement drug in combination therapy
CCB ---- ACEI
CCB ---- BB
• Others: Three drugs combination
slide 41
Causes for Inadequate
Response to Drug Therapy
• Incorrect measurement of the BP
• Volume overload or Pseudo-resistance
• Drug-related causes
• Associated conditions
slide 42
Hypertensive crisis
• Hypertensive Emergencies and Urgencies
• Emergencies: The blood pressure is elevated
severely and associated with target 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.
slide 43
Drugs Available for
Hypertensive Crisis
Vasodilators
Adrenergic Inhibitors
•Nitroprusside
•Labetalol
•Nicardipine
•Esmolol
•Nitroglycerin
•Phentolamine
•Hydralazine
slide 44
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 patient with symptoms, the BP would
elevate to 240-260/120-130mmHg, and HR
increase to 130-150 bpm.
slide 45
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 to 145 bpm.
slide 46
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
slide 47
CT scan of
abdomen:
Found a mass
at right
adrenal
Diagnosis as Phenochromocytoma
slide 48
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
slide 49
Diagnosis: Hypertensive crisis
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
slide 50
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.
slide 51