Download systolic blood pressure

Cecil Medicine
Section VIII
Chapter 66
Arterial
Hypertension
Prof. Shen-Jiang Hu
1
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.
2
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.
3
Blood Pressure has a unimodal distribution
in the Population
4
Question:

Is it important if the person’s blood
pressure is higher?
5
“Hypertension may be an important
compensatory mechanism which should not be
tampered with, even were it certain that we
could control it.”
White PD, 1931
“The greatest danger to a man with high blood
pressure lies in its discovery, because then some
fool is certain to try to reduce it.”
Hay J, 1931
6
“Franklin D. Roosevelt’s health was
excellent”！？－1944

Franklin D. Roosevelt （FDR） was
referred to Dr. Howard Bruenn, a
cardiologist at Bethesda Naval
Hospital who, on March 27, 1944
found him cyanotic, breathless, with
an enlarged left ventricle and a
blood pressure of 186/108. Bruenn
diagnosed hypertensive heart
disease and wanted to give digitalis,
but was prohibited by Dr. Ross
McIntire, the president's personal
physician and then surgeon-general
of the U.S. Navy.
7
“Franklin D. Roosevelt’s health was
excellent”！？－1944


The next day, FDR developed
moist rales at the base of the
right lung. By March 30, Bruenn
diagnosed congestive heart
failure. On the next day, digitalis
was begun.
By April 3, FDR was better. His
color was better, he could lie flat
without dyspnea, and the crackles
disappeared from both lungs. His
blood pressure, however, was
210/110.
8
“Franklin D. Roosevelt’s health was
excellent”！？－1944

The nation was stunned when
FDR died unexpectedly on April
12, 1945 -- less than six months
after being elected to a fourth
term in office. The death was
unexpected because the
president's personal physician,
VADM Ross McIntire, whenever
asked, had proclaimed that FDR's
health was excellent.
9
Question:

How do we know the hypertension is
responsible for the total risk of CV
events?
10
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
11
The Relationship between DBP and
Cardiovascular Events
12
13
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
14
Question:

What is hypertension?
15
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.
16
Hypertension in China(1991)
 ≥15%
 ≥10%~14.9%
 ＜10%
黑龙江
吉林
河北
北京
新疆
内蒙古
宁夏
青海
甘肃
西藏
天津
山东
陕西
山西
辽宁
江苏
河南
安徽
湖北
四川
江西
湖南
贵州
云南
上海
浙江
广西
福建
广东
台湾
海南
Mortality in China City in 1999
Mortality
%
Circulatory system
- Cerebral disease
- Heart disease
38.5
16.8
Cancer
23.9
Respiratory system
13.9
Trauma, toxicosis
6.3
Digestive system
3.0
Others
6.4
Mortality in China Countryside in 1999
Mortality
%
Circulatory system
30.8
- Cerebral disease
18.4
- Heart disease
12.4
Respiratory system
22.0
Cancer
18.4
Trauma, toxicosis
11.0
Digestive system
4.0
Others
5.1
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
Question:

What is etiology of hypertension?
22
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.
23
Etiology
24
25
Question:

How about the pathogenesis in
hypertension is ?
26
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.
27
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.
28
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.
29
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.
30
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.
31
Question:

Which pathologic changes will be
happen in hypertension ?
32
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.
33
Pathology

Brain.
Hypertension is the major
predisposing cause of stroke,
especially intracerebral hemorrhage
but also ischemic cerebral infarction.
34
Pathology

Kidney.
Chronic hypertension leads to
nephrosclerosis, a common cause
of renal insufficiency.
35
Question:

How to know the patient with
hypertension?
36
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.
37
Clinical Findings
Symptoms:
 Mild to moderated essential
hypertension is usually associated
with normal health and well-being
for many years.
38
Clinical Findings
Symptoms:
 Suboccipital pulsating headaches,
but any type of headache, may
occur. Accelerated hypertension is
associated with somnolence,
confusion, palpitation.
39
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.
40
Question:

What should we do if the patient may
be with hypertension?
41
Initial Evaluation for
Hypertension

Goal 1: Accurate Assessment of Blood
Pressure
42
How to measure
blood pressure
43
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
44
Initial Evaluation for
Hypertension

Goal 2: Cardiovascular Risk
Stratification
45
Stratification of CV Risk
Stratification of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood
pressure; CV: Cardiovascular events; HT: hypertension. Low, moderate, high and very high risk
refer to 10 year risk of a CV fatal or non-fatal event. The term “added” indicates that in all
categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome.
The dashed line indicates how definition of hypertension may be variable, depending on the level
of total CV risk.
46
Estimate total cardiovascular risk
Framingham Study：Risk for cardiovascular
events over 10 years
Very high
>30%
High
Moderate
20-30%
15-20%
Low
<15%
SCORE charts：the risk of dying from
cardiovascular disease over 10 years
Very high
>8%
High
Moderate
Low
5-8%
4-5%
<4%
Factors influencing prognosis
48
Factors influencing prognosis
Risk factors
Systolic and diastolic BP levels
Levels of pulse pressure (in the elderly)
Age (M > 55 years; W > 65 years)
Smoking
Dyslipidaemia
•TC > 5.7 mmol/l (220 mg/dl) or:
•LDL-C > 3.3 mmol/l (130 mg/dl) or:
•HDL-C: < 1.0 mmol/l (40 mg/dl)
Fasting plasma glucose 6.1-6.9 mmol/L
Abnormal glucose tolerance test
Abdominal obesity (Waist circumference > 90 cm (M),
> 85 cm (W))
Family history of premature CV disease (M at age < 55
years; W at age < 65 years)
49
Factors influencing prognosis
Subclinical Organ Damage
Electrocardiographic LVH or:
Echocardiographic LVH
Carotid wall thickening (IMT > 0.9 mm) or plaque
Carotid-femoral pulse wave velocity > 12 m/s
Ankle/brachial BP index < 0.9
Slight increase in plasma creatinine:
M: 115-133 µmol/l (1.3-1.5 mg/dl);
W: 107-124 µmol/l (1.2-1.4 mg/dl)
Low estimated glomerular filtration rate (<60 ml/min/1.73 m2)
Microalbuminuria 30-300 mg/24 h or albumin-creatinine ratio:
≥ 30 mg/g
50
Factors influencing prognosis
Established CV disease
Cerebrovascular disease: ischaemic stroke;
cerebral haemorrhage; transient ischaemic attack
Heart disease: myocardial infarction; angina;
coronary revascularization; heart failure
Renal disease: diabetic nephropathy;
renal impairment (serum creatinine: M>133,
W>124 μmol/L; porteinuria ≥300 mg/24h)
Peripheral artery disease
Advanced retinopathy: haemorrhages or exudates,
papilloedema
Diabetes mellitus: fasting plasma glucose ≥ 7.0 mmol/L
(126 mg/dl); postload plasma glucose > 11.1 mmol/L
(200 mg/dl); HbA1c ≥ 6.5%
51
Initial Evaluation for
Hypertension

Goal 3: Identification and Treatment of
Secondary (Identifiable) Causes of
Hypertension
52
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
53
Physical
examination for
secondary
hypertension
54
Management
55
Goals of treatment
56
Goals of treatment
57
Stratification of CV Risk
Stratification of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood
pressure; CV: Cardiovascular events; HT: hypertension. Low, moderate, high and very high risk
refer to 10 year risk of a CV fatal or non-fatal event. The term “added” indicates that in all
categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome.
The dashed line indicates how definition of hypertension may be variable, depending on the level
of total CV risk.
58
Management
Lifestyle Modification







Weight Loss
Sodium Restriction
Potassium Supplementation
High-Fiber, Low-Fat Diet
Alcohol Moderation
Smoking cessation
Exercise
59
When to initiate antihypertensive
treatment

Based on two criteria:
-The level of systolic and diastolic blood
pressure
-The level of total cardiovascular risk
60
Initiation of antihypertensive
treatment
61
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.
62
Monotherapy versus combination therapy

Monotherapy could be the initial
treatment for a mild BP elevation
with a low or moderate total
cardiovascular risk.
63
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.
64
Monotherapy versus combination therapy

In several patients BP control is not
achieved by two drugs, and a
combination of three of more drugs
is required.
65
Goals of treatment
66
Choice of antihypertensive drugs
67
Choice of antihypertensive drugs
68
Antihypertensive treatment: Preferred drugs
69
Antihypertensive treatment: Preferred
drugs
70
Antihypertensive treatment:
Preferred drugs
71
Choice of antihypertensive drugs
72
Compelling and
possible
contraindications to
use of
antihypertensive
drugs
73
Choice of antihypertensive drugs
74
Choice of antihypertensive drugs
75
Choice of antihypertensive drugs
76
Monotherapy versus combination therapy
strategies
77
Possible combinations between some classes of
antihypertensive drugs
Diuretics
β-blockers
ACE inhibitors
Calcium
antagonists
α-blockers
Angiotesin II
antagonists
Journal of Hypertension 2007, 25:1105–1187.
78
References
1.
2.
3.
http://www.escardio.org/guidelinessurveys/Pages/welcome.aspx
http://www.acc.org/login/index.taf
中国高血压防治指南（2010年修订版)
79
Thanks for your attention!
80