Download Hypertenzia

Hypertension
Lectures from Pathological
Physiology
Study materials from Pathological
Physiology, school year 2007/2008
© Oliver Racz
2017-05-23
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Syllabus
Repetition of physiology & basic terms
Microcirculation, perfusion & blood pressure
Regulators of perfusion & blood pressure
Central role of kidneys in regulation of circulating
volume & blood pressure
Hypertension – classification, forms
Primary hypertension
Secondary forms of hypertension
Monogenic forms of hypertension and the
genomic background of common hypertension
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Repetition of physiology, basic terms- 1
What is blood pressure (BP) ?
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Moving force of blood flow to overcome the
hemodynamic (peripheral) resistance
Force, exerted by blood on vessel wall in
arterial circulation
P = F/S = N/m2 (Pascals, Pa)
1 mmHg = 0,133 kPa
For the body the tissue perfusion is
essential = oxygen supply
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Repetition of physiology, basic terms- 2
Determinants of BP
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Heart function (pump) - catch 22
Circulating volume
Elasticity and tension of vessel wall
Which pressures and where ?
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sBP, dBP, mean arterial pressure
Mean filling pressure
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Blood pressure
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Repetition of physiology, basic terms – 3
Mean arterial BP
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= dBP + pulse pressure/3
150/90; Mean = 90 + (60/3) = 110
= CO * TPR
(total peripheral resistance = microcirculation!)
Peripheral resistance is the opposite of perfusion !
Determinant of CO is the venous return!
Mean filling pressure is cca 7 mmHg
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Experiment: Arterial pressure after heart arrest
This is determining the filling of right ventricle =
venous return
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The distribution of blood in
circulation
Region
%
Heart
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Pulmonary
circulation
Arteries
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Arterioles,
capillaries
Venous part of
circulation
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Microcirculation
Resistance arterioles  0,5 – 0,15 mm
4 – 5 branchings to terminal arterioles  10 mm
Capillaries
Blood flow velocity in aorta ( 3 – 4 cm2) 0,2 – 0,3 m/s
In capillaries 0,3 mm/s  3000 – 4000 cm2
Only one third of them is open  1000 cm2
The hemodynamic resistance is directly proportional
to the length of vessel and indirectly proportional to
the 4th square of vessel diameter
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Increase of diameter by 1,2 – resistance decreases to 50 %,
1,8-fold increase - decrease to 10 %
and conversely !!!
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Examples of changes in resistance without
changes of BP
Hypoxia
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Vasodilatation
Venous return 
Cardiac output 
Hyperkinetic
circulation without
hypertension
A-V shunts
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Decrease of TPR
Amputation of LE
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Increase of TPR
No change in BP
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Overview of blood pressure
regulators
Baroreceptors
Chemoreceptors
Ischemic response of CNS
Immediate reaction - limited effectivity
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Overview of blood pressure
regulators
Pressure relaxation of vessel wall
Fluid shift (Frank – Starling)
Renin – angiotensin – aldosterone system
(& its antagonists – natriuretic hormones)
Antidiuretic hormone
Slower reaction, limited effectivity
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Regulation of microcirculation
Extremely complicated mechanisms
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Metabolic – hypoxia, ATP, pH, etc.
Para-, autocrine – NO, CO (endothel)
Ion equilibrium (contractility of muscle cells)
Transport systems, channels, their regulators &
receptors
Tissue („bed“)specific!
Regulation of „individual demand“
Signals for higher systems
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Overview of blood pressure
regulators
LONG TERM, ALMOST UNLIMITED
EFFECTIVITY
kidney – regulation of volume
Proofs – kidney crosstransplantations
between HT & NT rats, human kidney
transplantations
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The effectivity of blood pressure regulators
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Goldblatt and his experiments
Bright 1832: Large, heavy heart
and scarred kidney
Harry Goldblatt, a recipient of
final-year prize at McGill, 1916
Cleveland 1928 - 1934
Goldblatt H et al: Studies on
experimental hypertension I. J
Exp Med 59, 1934, 347-379
Clamp on a. renalis
The discovery of renovascular
hypertension
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Autoregulation of blood flow and glomerular
filtration in kidneys
renal blood flow
ml/min
glomerular
filtration,
ml/min
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Constant filtration achieved by regulation
of vas afferens a efferens tonus
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Natriuresis
Filtration does not depend on blood
pressure, diuresis & natriuresis strongly
depends !!!
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Constant perfusion – variable
excretion
Perfusion is 1,3 l/min
 25 % CO
Daily filtrate
(180 l)  25 mol = 0,5 kg
sodium (kilogramm salt)
Excretion  250 mmol,
5 g Na or 10 g salt, 1 %
Resorbtion
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2/3 proximal tubules
1/4 Henle loop
1/12 distal tubules
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Pressure diuresis
Kidney blood flow does not depend on BP
Diuresis & natriuresis depend
Pressure increase by 10 – 20 mmHg –
twofold increase of diuresis
Rapid response – begins in 1 minute
Mechanism – reabsorbtion of sodium
Regulated by macula densa
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Hypertension is always connected with
change of kidney pressure diuresis !!!
Natriuréza
Natriuréza
Hypertension is not a „disease“ of heart
Hypertension is not a „disease“ of peripheral resistance
Hypertension is a distrubance of volume equlibrium – the kidneys are
not able excrete excess water and salt at normal pressure
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150
200
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Definition & diagnostics of
hypertension
Scipione Riva-Rocci: Un nuovo
sfigmomanometro. Gazetta Med Torino, 47, 981
– 1001, 1896
Long term increase of systolic blood pressure ≥
140 mmHg & diastolic blood pressure ≥ 90
mmHg (confirmed by repeated measurements),
or the use of antihypertensive therapy
Classic sphygmomanometers, digital & 24 hour
monitoring of BP, continuous monitoring
Lege artis (white coat HT)
Measure in everybody (The Chernobyl Effect)
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Classification of hypertension
According to values of BP, see 
According to its etiology (pathogenesis)
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primary (95 %?)
secondary forms of hypertension (5%?)
According to the stage of disease
1. Only hypertension
2. Manifest damage of organs – heart hypertrophy,
nephropathy & changes of ocular fundus =
remodelation of small vessels
3. Heart and kidney failure, hemorrhagic stroke
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WHO/ISH 1999 (JNC VI)
CATEGORY
sBP
dBP
Optimal
< 120
< 80
Normal
< 130
< 85
High normal
130 - 139
85 - 89
Mild HT (I)*
140 – 159
90 – 99
Middle (II)
160 – 179
100 – 109
Severe (III)
≥ 180
≥100
*And also borderline 140 – 149/90 - 94
Isolated systolic > 140/<90
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WHO/ISH 1999 (JNC VI)
CATEGORY
sBP
dBP
Optimal
< 120
< 80
Normal
< 130
< 85
High normal
130 - 139
85 - 89
Mild HT (I)*
140 – 159
90 – 99
Middle (II)
160 – 179
100 – 109
Severe (III)
≥ 180
≥100
*And also borderline 140 – 149/90 - 94
Isolated systolic > 140/<90
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CATEGORY
sBP
dBP
< 120
< 80
Prehypertension
120 - 139
80 - 89
Hypertension I
140 – 159
90 – 99
Hypertension II
≥ 160
≥ 100
Normal
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Circadian changes of BP
24 hour monitoring
Decrease after 8 p.m.
11 p.m. – 05 a.m. by 20 % (20 – 30 mmHg)
Increase in the morning, maximum before noon
Regulator: kidneys or catecholamines ?
New term – non-dippers, bad prognosis
Surprise if the treatment is bad – nocturnal
hypotension
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Epidemiology of hypertension
20 and more % of adult population
Already in children (2 – 5%) – very bad
prognosis
Treatment often not ideal
Association with salt intake – no hypertension in
aboriginal people from New Guinea & Amazonia
who do not use salt
Deficiency of Ca, Mg
Association with obesity
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Some more epidemiological data
Age:
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20 – 30
40 – 50
60 & more
< 10 %
 25 %
 33 %
Sex
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Up to age 50 y.
After 50 y.
f/m 0,6 – 0,7
f/m1,1 – 1,2
Weight
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Normal
Obesity
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8 – 15 %
15 – 35 %
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Primary hypertension
The cause and the pathogenesis is not
fully clear
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Our old and simple explanation
Disturbance of pressure diuretic curve of kidneys
Kitchen salt ?
Dysfunction of endothel ?
Hypertension as a „complex“ disease
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Monogenic diseases (also HT, rare)
Diseases caused by external factors
Genetic background and external factors
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Reaction of criculation on physical and
psychical stress
HYPERTENSION
150
???
NORMOTENSION
100
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„Kidney“ theory of primary
hypertension
Key role of kidneys in volume regulation –
the excretion of Na and water is strongly
pressure dependent.
Primary hypertension is caused by
disturbance of this function ???
Why and how ???
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Natriuresis
Change in pressure diuresis curve – 1
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200
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Natriuresis
Change in pressure diuresis curve – 2
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Hypertension is a complex disease
Gene polymorphism
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External factors
Renin, ACE, AT
NOS
Kallikreine
Endotheline
Na-K ATPase
Adducin
More than 50
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NaCl (10 g instead of
0,5)
Stress
Deficiency of Ca, Mg
Obesity
Smoking, alcohol
And many others
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Problems with genetic
background of complex diseases
How strong is the effect?
(genes with small and big effect)
What is the occurrence of allele in population
(1-2 % or 30-40 %)
Epistasis = Interaction between genes and their
products
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A = 1, B = 2
how much is A + B ?
In genetics from -10 to +10
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Monogenic hypertension – 1
problems with aldosterone
Some forms of congenital adrenal hyperplasia
Hyperaldosteronism responding to glucocorticoids (AD)
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The gene for aldosterone production is connected to the
regulatory sequence of glucocorticoid synthesis Aldosterone
production controlled by ACTH. Renin, angiotensin low,
hypokaliemia
Pseudohyperaldosteronism caused by defect of 11-bhydroxysteroid dehydrogenase
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Mineralocorticoid receptor sensitive to cortisol
Mutation of gene for mineralocorticoid receptor
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Ser810leu, receptor sensiotive to progesterone. The explanation
of preeklampisa?!)
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Monogenic hypertension – 2
sodium transport
Increased stimulation of Na-K ATPase caused by
mutation of adducin gene (cytoskeletal protein)
Liddle sy (AD). Gain of function mutation of the gene for
one subunikt of sodium channel ENaC
A common mutation in Africa?
Cys825Thr polymorphysm of gene for b subunit of a G
protein activating Na/H antiporter
Other mutations of Na-transport systems
Background of salt sensitivty???
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Monogenic hypertension – 3
other possibilities
Polymorphysm of ACE gene. Big gene, 26 exons, 17.
chromosome
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Insertion/deletion of 287 bp in the 16th intron
ID and DD have higher ACE activity than DD
Epistatic interactions with other genes – e.g. with gene for
angiotensin receptor.
Polymorphysm of angiotensinogen gene
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Met235thr – higher risk of coronary events and HT. No salt
sensitivity
Polymorphysm of NOS gene
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NO is an important antagonist of different vasoconstricting factors.
An important mediator of pressure diuresis.
And many others
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Secondary hypertension - 1
Renal
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Renoparenchymal (decrease of nephron number)
Renovascular (stenosis of a. renalis – RAAS)
Endocrine
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Phaeochromocytoma – paroxysmal HT
Conn, Cushing, other diseases of adrenal cortex
Acromegaly
HT during gravidity, EPH gestosis
(preeclampsia)
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Secondary hypertension - 2
Cardiovascular
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Coarctation of aorta (upper part of body)
Isolated systolic: loss of flexibility of vessel wall
in advanced age
Isolated systolic in aortal regurgitation & AV
shunts
Neurogenic
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High intracranial pressure – transitory
Lead intoxication
Iatrogenic
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Secondary hypertension - ???
How to classify hypertension
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Associated with obesity ?
Associated with insuline resistance ?
Associated with Type 2 diabetes mellitus ?
Associated with sleep apnoea syndrome ?
How to classify stress hypertension ?
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Natural history of hypertension
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Natural history of hypertension
yes, but...
Most cases of deaths occur in patients
wihth mild hypertension
Moderately elevated risk*high number of
patients
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Factors influencing prognosis
1 – CVS risk factors
II. Other factors
I. Basic factors
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 sBP and dBP
age m > 55, f > 65 y.
smoking
cholesterol > 6,5
mmol/l
diabetes mellitus
+ Family history
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 HDL CH  LDL CH
iGT
obesity
 fibrinogen
certain socioeconomic,
ethnic groups
certain geographic
regions
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Factors influencing prognosis
2 – organ damage
left heart hypertrophy
proteinuria and/or  creatinine
USG or RTG confirmed atherosclerotic
plaques (a. carotis, iliaca, femoralis, aorta)
generalised or focal narrowing of retinal
arteries
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Factors influencing prognosis
3 – other clinical conditions
cerebrovascular
diseases
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ischemic stroke
TIA
hemorrhagic stroke
diseases of heart
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myocardial infarct
angina pectoris
heart failure
revascularsation
diseases of kidneys
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vascular diseases
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dissecting aneurysma
symptomatic vascular
diseases
advanced retinopathy
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diabetic nephropathy
microalbuminuria in DM
kidney failure
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papillar oedema
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