Download Document

In the name of God
Hypertention and Hypotention
By
Reza Ghaderi Dr
Medical university of yasudj-1393
IMPORTANCE;
THE MOST COMMON RISK FACTOR FOR HEART
ATTACK AND STROKE IS HYPERTENTION.
THE MOST COMMON CAUSE THAT PTS VISITD BY
PHYSICIAN IS HYPERTENTION.
DEFINITION
According to JNC-7 in more than 2 opd visits average of blood pressure ;
Nl ; <120/80
Pre hypertention; 120-139/80-89
Hypertention; stage 1; sys: 140-159
dia: 90-99
stage 2; sys >= 160
dia>= 100
Isolated sys hypertention; sys>=140 and dia< 90
Isolated dia hypertenton: dia>=90 and sys <140
All above definitions are true when in absence of any disease and any
drugs.
In any stage bigger numbers of sys or dia is important.
WHAT IS MORE IMPORTANT?
SYS HTN OR DIASTOLIC HTN?
IN AGE >50 SYS HTN IS MORE IMPORTANT
FOR PREDICTION OF C.V.DISEASE.
IN AGE<50 DIAS HTN IS MORE IMPORTANT
FOR PREDICTION OF C.V.DISEASE.
ANOTHER DEFINITION OF HTN;
AVERAGE OF 24 HOURS BP >= 135/85
DAY TIME (AWAKE) >=140/90
NIGHT TIME (ASLEEP) >=125/75
Malignant HTN; •
Malignant HTN is defined with Marked HTN and •
retinal hemorrhage / exudate / papilla edema /
encephalopathy.
Malignant HTN usually accompanied dias> 120 but •
in normotensive pts who affected with
Glomerulonephritis or preeclampsia was seen in
dias<100.
HTN urgency; •
HTN urgency is defined with dias>120 in •
asymptomatic pts.
Essential HTN; unknown pathogenesis ; •
Increased sympatic ,increased mineralocorticoid •
,genetic ,decreased nephron , infection, ….
Risk factor; black race, positive hx in parents , salt •
user , alcohol , obesity , immobility , dislipidemia ,
decreased vit D , specific personality
Secondary HTN; •
Acute and chronic kidney injury , Reno vascular •
disease, OCP , drugs , feo , aldostronism , cushing ,
hypopara , hypothyroidism , hyperthyroidism ,
coarctation of aorta , O.S.A.
Complication: •
Complication chance increased after BP more than •
125/75
Complications consist of •
Premature cardiovascular disease, heart failure , left •
ventricular hypertrophy that causes of arrhythmia ,
H.F , M.I , sudden death.
C.V.A , I.C.H , C.K.D •
Measurement ;
In absence of end organ damage HTN should be
established in 3-6 visits.
B.P measurement should be performed in both arms.
If difference value in both arms was obtained more
than 10 mmHg subclavian stenosis should be roll out.
Postural HTN should be performed.
White coat HTN •
DX; •
Ambulatory measurement that control of HTN every •
15 minute in days and every 30 minute.
Masked HTN is opposite of white coat HTN •
ABPM indication; •
white coat HTN •
Increased periodic HTN :feo •
Refractory HTN •
Hypotention after drug use •
Aoutonomic dysfunction •
Evaluation •
End organ damage is present •
Evaluation of C.V.D •
Treatable cause •
HX; causes •
P/E; end organ damage •
Corrected BP measurement •
Fat distribution •
Skin lesion •
Conciseness •
Fondoscopy •
Neck(carotid, thyroid) •
Heart ; sounds ,size , rhythm •
Lung; rales •
Abd ; mass,aortic size •
Ext; edema, pulses •
N/E; confusion, weakness, blurred vision •
Labs; •
U/A, HCT, Elec , Bun, Cr, ECG, TG, Chol must be •
measured
Alb/U , Echo in borderline Pts , ca may be measured •
Imaging should be performed if very doubtful •
Reno vascular disease may play role 1% in mild HTN •
and 10-45% in malignant or severe HTN.
Who should be treted?•
In absence of end organ damage •
HTN should be treated if average
of 24 hr monitor more than nl
Treatment; •
pharmacologic and non pharmacologic •
Non pharmacologic; •
Smoke cessation •
High K diet •
Stopped NSAIDS •
These items decreased prevalence of HTN from 32 •
to 22%
Decreased Wt; every 10 Kg decreased in wt causes •
decreased 5-20 mmHg
Decreased Na; less than 6 gram Nacl daily causes •
decreased 2-8 mmHg
Decreased alcohol; 2 drink per day for men and 1 drink per •
day for women causes decreased 2-4 mmHg
DASH diet; dietary approach to stop HTN •
Activity; at least 30 minutes daily that decreased 4-9 mmHg •
BP>=140/90 should be started drug •
If BP>160/100 should be started 2 drugs •
If P/U, CKD, CVD are present should be control of BP •
less than 130/80
If BP is abnl in office only should be performed 24 hr •
holter of BP
In specific disease use of specific drugs •
•
CHF……..ACEI,ARB,BB,diuretic,aldostron antagonist •
MI ……..ACEI,ARB,BB,aldostron antagonist •
CKD,Pr/U…….ACEI,ARB •
Angina pectoralis…BB,CCB •
AF………BB,CCB •
BPH…….alfa B •
Hyperthyroidism…..BB •
Migrane…..BB,CCb •
Raynod….CCB •
Perioperation….BB •
Contraindication ; •
Angioedema……………….ACEI •
Broncospasm……………….BB •
Depretion……………………BB •
Liver disease………………...methyl dopa •
Pregnancy………………......ACEI,ARB •
Heart block …………………BB,CCB •
Complication; •
BB…………………………………………...depression •
Diuretic……………….……………………Gout •
ACEi,ARB,Aldostron antagonist……….hyperkalemia •
Thiazid………………………………………hyponatremia •
ACEI,ARB…………………………………..renovascular •
disease
Monotherapy ; thiazid •
long acting CCB •
ACEI, ARB •
BB not use alone •
Combination therapy ; if BP>20/10 more than upper •
limit of nl
Combination of CCB and ACEI/ARB is of choice . •
•
Non dipping HTN; •
Nocturnal BP is <10% daily BP . •
If not is non dipping HTN that is potent predictore of •
out come of C.V.D
Rx; change time of one anti HTN drugs to evening •
•
Isolated sys HTN or age>65; •
ACEI, ARB •
thiazide •
long acting CCB •
In these pts diastolic BP is important thus should be careful in •
decreasing of diastole BP.
Refractory HTN; dia>90 despite of received 3 anti HTN drugs •
Why? •
Inadequate dose, overload, low compliancy , secondary •
HTN , white coat HTN , drug use that causes HTN
Stop of drugs •
Yes or no ? •
In 5 – 55% pts who recived one anti HTN drug may •
be left drug after 1- 2 years .
Sudden onset stoped of short acting BB and short •
acting alfe-2 agonist may be lethal thus should be
tapered until many weeks.
In grade 1 HTN may be could tapering of drugs. •
Hypertention emergency •
Definition;
HTN emergency is defined with sys BP>180 and/or
dias BP>120 that result of many dangerous events
such as encephalopathy, retinal hemorrhage,
papilledema, ARF, ICH, SAH, MI, HF, severe epistaxis.
HTN emergency may be asymptomatic or
accompanied with mild headache.
Treatment; •
In the past in HTN emergency state control of •
BP<160/100 mmHg was goal but in this time this goal
is controversial and slowly decreasing strategy was
replaced.
In fact rapidly decrease of BP is more dangerous •
because decreased of Bp suddenly impaired
cardiac and brain flow and MI and CVA risk
increased.
Streategy; •
In the absence of sign of acute end organ damage,
The goal of management of BP<= 160/100 over
several hours to days
All pts should be provided a quiet room to rest: this •
can lead to a fall in BP of 10-20 mmHg or more.
The approach varies depending on whether the pt •
has already been treated for HTN or is untreated.
•
Previously treated HTN; •
Among pts already treated with anti HTN drugs the following •
may be appropriate interventions;
Increase the dose of medication •
Reinstitution of medication in non-adherent pts •
Addition of diuretic and reinforcement of dietary sodium •
restriction
Untreated pts; •
we use one of the following agents;
Oral furosemide (20 mg) If no volume depletion •
Clonidine (0.2 mg) •
Captopril (6.25 or 12.5 mg)
After use of drugs pt f/u for several ours for reduction of Bpof •
20- 30mmHg.
Thereafter, a longer acting agent is prescribed and f/u •
Monitoring and F/U; •
•
The pts that developed with HTN emergency •
who managed in emergency room, since
exclusion of acute end organ damage
requires laboratory testing, and the pt may
require administration of medications and
several hours of observation.
Who should be admitted ? •
Hypertensive pts who affected by DM, CVA •
pervious HX, CKD should be admitted in
hospital and evaluation for complications.
Good luck •