Hypertension Cardiology Department, Shanghai Sixth People’s Hospital, Shanghai JiaoTong University

1. Hypertension Cardiology Department, Shanghai Sixth People’s Hospital, Shanghai JiaoTong University Qing Zhao

2. Hypertension • Clinical syndrome characterized as increased systemic arterial pressure • Primary Hypertension 90%-95% • Secondary Hypertension5%-10%

3. Diagnostic criteria of hypertension Chinese Guidelines for Preventive and Treatment of Hypertension (2004)

4. Definition • Without any anti-hypertensive medication，SBP≥140mmHgand/or DBP≥90mmHg • Blood pressure <140/90mmHg, but having a hypertensive history and currently taking an anti-hypertesive medication

5. Classification of Hypertension(2004)

6. Notice • SBPand DBPfall separately into different categories, the higher category should be taken • Isolated systolic hypertension can also be graded according to systolic blood pressure values in the ranges indicated

7. Epidemilology • Mobidity • In 2002, 18.8% • In 1991, 11.88% • In 1979, 7.73% • In 1959, 5.11% Most common cardiovascular diseases

8. Hypertension Prevalence

9. Epidemilology • Three high • High mobidity • High motality • High disable rate • Three low • Low awareness rate • Low treatment rate • Low control rate

10. General features and patterns of hypertension epidimiology 1. Age 2. Sex differences 3. Geographical differences 4. Seasonal variation exists 5. Differences in region, city and countryside, races and ethnicities 6. Diet, Genetics, etc.

11. Etiololgy • Multiple factor • genetic predisposition(40%) ＋environmental factor(60%)

12. Genetic predisposition • Familial aggregation • 60%, familial history • Genetic inheritance • Black men more white men

13. Diet factors • High dietary salt • Heavy alcohol drinking • Long-term over coffee intake • Low calcium, low potassium, low magnesium • High protein • High saturated fatty acid

14. Psychological factor • Mental status • Psychological diposition • More in Brainworker

15. Other factors • Overweight or obesity BMI=body weight（kg）／body height (m)2（20 ～24 ） • Contraceptives • Obstructive sleep apnea syndrome (OSAS)

16. Pathogenesy mean blood pressure( MBP ) ＝cardiac output(CO)×peripheral vascular resistance (PR)

17. Mechanisms of hypertension • Sympathetic nervous system • Renin-angiotensin system • Renal function • Insulin resistance • Decreased ralaxed factors and increased systolic factors • resistance vessel remodling • Others：arterial elasticity

18. Sympathetic nervous system • Sympathetic nervous hyperactivity-----catecholamine ↑----resistance arterioles contracted ↑---- hypertension

19. Liver Kid- ney Lung Renin-angiotensin system Angiotensinogen etc. Renin ingibitors Renin etc. Angiotensin Ⅰ ACE Inhibitors Angiotensin converting enzyme (ACE) Angiotensin Ⅱ etc. Angiotension II Receptor antangonists Receptor Vascular contraction

20. Circulating RAS Function of ATⅡ： ① vasoconstriction ② increased myocardial contractility ③ Sodium retention

21. Tissue RAS • RAS in vessel wall • Cardiac RAS

22. Circulating RASand tissue RAS • High renin hypertension correlates with circulating RAS activity • Normal renin and low renin hypertension correlates with tissue RASactivity

23. Insulin resistance, IR Tissue cells are resistant to insulin, thereby producing the hyperinsulinemia.

24. Pathology Artery • Arteriolosclerosis hyalinization • Smooth muscle cell proliferation and fibrosis • Vessel wall thickning，luminal stenoses • Vessel wall remodling • Macro- and medium-sized arteryatherosclerosis

25. Pathology Heart • Left ventricular hypertropghy • Heart failure • Hypertensive heart disease

27. Pathology Kidney • Renal arteriolar sclerosis • Glomerulus fibrosis, atrophy • Renal failure

28. Pathology Brain • microaneurysm、rupture、hemorrhage:cerebral hemorrhage • Cerebral atherosclerosis,thrombokinesis:cerebral infarction，lacunar infarction

29. Pathology • Retina arteriola spasm , exudation, hemorrhage

30. Clinical manifestation Symptom • No specific symptoms • Dizziness, headache, palpitations, easy fitigability,blurring of vision, etc • Symptoms not related to the level of blood pressure

31. Clinical manifestation • First onset as complication • heart：ACF、AP、AMI（ACS） • brain：cerebral hemorrhage, cerebral infarction,TIA • kidney：renal dysfunction • vessel：aotic dissection • others ：nasal hemorrhage、retinal hemmorrhage

32. Signs • A2 louder • S4 • Systolic murmur 、systolic early click • Sign of LVH

33. Target organ damage(TOD) LVH • ECG • UCG • Chest X-ray

35. Target organ damage(TOD) Arterial wall thickening • IMT ≥0.9mm • Atherosclerotic plaque

36. Target organ damage(TOD) Slight increase in serum creatinine • Male • 115-133µmol/L(1.3-1.5mg/dl) • Female • 107-124µmol/L(1.2-1.4mg/dl)

37. Target organ damage(TOD) • Microalbuminuria • 30-300mg/24h • Albunim-creatinine ratio • Male ≥22mg/g(2.5mg/ mmol/L) • Female ≥31mg/g(3.5mg/ mmol/L)

38. Associated clinical condition(ACC) Cerebrovascular disease ①ischemic stroke ②cerebral hemorrhage ③transient ischemic attack(TIA)

39. Associated clinical condition(ACC) Heart disease: ①history of myocardial infarction ②angina pectoris ③coronary revascularization(PCI，CABG) ④congestive heart failure

40. Associated clinical condition(ACC) Renal disease: ① diabetic nephropathy ② renal impairrment Male >133 µmol/L Female >124 µmol/L proteinurea >300mg/24h ③ renal failure creatinine ＞177µmol/L

41. Associated clinical condition(ACC) Peripheral vascular disease ①aotic dissection ②symptomatic peripheral arterial disease

42. Associated clinical condition(ACC) Advanced retinopathy ①hemorrhages of exudates ②papilloedema

45. Special type of hypertension Hypertension in the elderly • ≥60(65)岁 • Isolated systolic hypertension • Sensitivity of vessel baroreceptor ↓

46. Hypertensive crisis • Hypertensive emergency • Hypertensive urgency

47. Hypertensive crisis • Progress quickly • Marked blood pressure elevation，usually DBP≥130mmHg • Severe target organ damage in short term, especially renal impairment, retinal hemorrhages and exudates, papilloedema

48. Hypertension in pregnancy • Pregnancy-Induced Hypertension(PIH) • Gestational hypertension • Preeclampsia • Eclampsia

49. Diagnosis and Differential diagnosis Diagnosis ⒈ to define blood pressure is high ⒉ to exclude secondary hypertension ⒊ to classify hypertension and to stratify risk to quantify prognosis

50. Clinical history and familial history • To collect a history of hypertension, diabetes, dyslipidemia, coronary heart disease, renal disease, stroke, heart failure, etc • To identify risk factors, target organ damage, associated clinical condition • Previous anti-hypertensive regimen