بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. SYSTEMIC HYPERTENSION

3. SYSTEMIC HYPERTENSION Definitions of hypertension Elevated arterial blood pressure is a major cause of premature vascular disease leading to cerebrovascular events, ischaemic heart disease and peripheral vascular disease.

4. Blood pressure is the pressure exerted by the blood against the walls of the blood vessels, especially the arteries. • It varies with the strength of the heartbeat, the elasticity of the arterial walls, the volume and viscosity of the blood, • and a person's (health, age, and physical condition

5. Age • onset between 30 - 50 years of age • increases over 65 years of age • sex - males in young adulthood and early middle age • females after the age of 55 years

6. The prevalence • hypertensions is higher among blacks and older persons, especially older women Hypertension increased with age, and is higher in young men than in young women, although the reverse is true in older adults.

7. Hypertension - Introduction • Silent Killer – painless complications • It is the leading risk factor –MI, HF, CRF Stroke • Responsible for the majority of office visits, • Number one reason for drug prescription. • 25% of population • Complications bring to diagnosis but late…

8. This requires the heart to work harder than normal to circulate blood through the blood vessels. • Blood pressure is summarised by two measurements, systolic and diastolic • which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole).

9. Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). • High blood pressure is said to be present if it is persistently at or above 140/90 mmHg.

10. Ideal Mean Aterial Pressure • (MAP) is defined as 93 mm of mercury, which corresponds to 120/80 and can be calculated by MAP = DP + 1/3 (SP-DP). • Mean Arterial blood pressure depends on the flow of blood from the heart (cardiac output) and the resistance to flow in the small arteries and microscopic resistance vessels (arterioles)

11. Regulation of BP: BP = Cardiac Output x Peripheral Resistance • Endocrine Factors • Renin, Angiotensin, ANP, ADH, Aldosterone. • Neural Factors • Sympathetic & Parasympathetic • Blood Volume • Sodium, Mineralocorticoids, ANP • Cardiac Factors • Heart rate & Contractility.

12. Classification of blood of blood pressure

14. Signs and symptoms • Hypertension is rarely accompanied by any symptoms, and its identification is usually through screening, or when seeking healthcare for an unrelated problem. A proportion of people with high blood pressure reports • headaches (particularly at the back of the head and in the morning),

15. lightheadedness, • vertigo, • tinnitus • (buzzing or hissing in the ears), • altered vision or fainting episodes • These symptoms however are more likely to be related to associated anxiety than the high blood pressure itself

16. Cardiac Output Peripheral Resistance BP Control of Blood Pressure: Humoral Factors Vasoconstrictors Angiotensin II Catecholamines Vasodilators Pg & Kinins Blood Volume Na+, Aldosterone Cardiac Factors Rate & Contract.. Local Factors pH, Hypoxia • Neural Factors • Adrenergic – Cons ß Adrenergic - Dil

17. Peak blood pressure • Peak blood pressure levels in humans occur during the mid morning (at about 10:00 AM) then decrease progressively throughout the remainder of the day to reach a trough value the following morning at around 3:00 AM

18. Definition of Circadian Rhythm • Circadian rhythms are daily cycles of physiology and behavior that are driven by an endogenous oscillator with a period of approximately one day

19. Normally, circadian rhythms • are synchronized with the 24.0 h environment by stimuli which alter the phase of the underlying brain circadian pacemaker. • For most organisms, including mammals, the primary phase-shifting stimulus is light

20. These processes include :- • -sleep-wake cycles, • -body temperature, • -blood pressure, • -release of hormones. • This activity is controlled by the biological clock, which is located in the supra-chiasmtic nuclei of the hypothalamus in human brains. • It is highly influenced by natural dark-light cycles, but will persist under constant environmental conditions. Examples: Disruptions to the circadian rhythm can cause problems with the sleep-wake cycle

21. Circadian rhythms are regulated by three components : • (1) the circadian pacemaker or "clock", • (2) an input mechanism which allows the clock to be reset by environmental stimuli, and • (3)an output mechanism which regulates physiological and behavioral Processes

22. Hypertension types • Primary Hypertension, High blood pressure of unidentified cause, Accounts for 90% of cases of high blood pressure. The identified risk factors in primary hypertension are as follows , age onset between 30 - 50 years of age , increases over 65 years of age, sex - males in young adulthood and early middle age, females after the age of 55 years • Secondary Hypertension is High blood pressure in which the cause can be identified.

23. Etiology 1- Essential: In more than 95% of cases, an underlying cause cannot be found. Proposed mechanisms include: • Excess renal sodium retention • Over activity of sympathetic nervous system • Renin angiotensin excess • Hyperinsulinemia • Alterations in vascular endothelium

24. Factors contributing to the development of Essential hypertension • Genetic Factors: hypertension is more common in some families and in some ethnic groups like African Americans • Environmental factors include obesity, alcohol, lack of exercise and excess salt

25. Emotional stress can cause quite large increases in blood pressure. Prominent amongst the physiological responses to stress is an increase in activity in the sympathetic nerves • Postural changes exert stresses on the cardiovascular system requiring effective reflex responses to constrict arteries and veins and stimulate the heart, to control blood pressure, maintain brain blood flow, and prevent loss of consciousness

26. Regular over-consumption of alcohol can raise blood pressure dramatically, as well as cause an elevation upon withdrawal The severity of obstructive sleep apnea syndrome OSAS is an independent factor correlated to diurnal hypertension

27. pathophysiology • There is some evidence that supports a hypothesis that the primary fault in the patho-physiology of hypertension is a defect in the:- • calcium binding of the plasma membrane of the cells of a pressure-regulating center in the nervous system.

28. 2- Secondary hypertension • Renal: These account for over 80% of the cases of secondary hypertension. The common causes are diabetic nephropathy, chronic glomerulonephritis, adult polycystic disease, chronic tubulointerstitial nephritis, and renovascular disease. • Endocrinal:These include • Conn's syndrome, adrenal hyperplasia, acromegaly, • Phaeochromocytoma, Cushing's syndrome. • Drugs and toxins • Pregnancy-induced hypertension • Vascular: coarctation of aorta, vasculitis

29. Children • Hypertension in neonates is rare, occurring in around 0.2 to 3% of neonates, • blood pressure is not measured routinely in the healthy newborn • Hypertension is more common in high risk newborns. • A variety of factors, such as gestational age, postconceptional age and birth weight needs to be taken into account when deciding if a blood pressure is normal in a neonate

30. Hypertensive crises • Severely elevated blood pressure (equal to or greater than a systolic 180 or diastolic of 110 — sometime termed malignant or accelerated hypertension) is referred to as a "hypertensive crisis", as blood pressures above these levels are known to confer a high risk of complications. • People with blood pressures in this range may have no symptoms, but are more likely to report headaches (22% of cases)and dizziness than the general population

31. Other symptoms accompanying a hypertensive crisis may include :- • 1-visual deterioration • 2-breathlessness due to heart failure • 3-general feeling of malaise due to renal failure • 4-Most people with a hypertensive crisis are known to have elevated blood pressure, but additional triggers may have led to a sudden rise

32. emergency hypertensive • "malignant hypertension", is diagnosed when there is evidence of :- • 1- direct damage to one or more organs as a result of the severely elevated blood pressure. • 1-This may include hypertensive encephalopathy, caused by brain swelling and dysfunction,

33. characterized by:- - headaches -altered level of consciousness (confusion or drowsiness). -Retinal papilloedema -fundal hemorrhages

34. -exudates are another sign of target organ damage. • -Chest pain may indicate heart muscle damage (which may progress to myocardial infarction) or sometimes aortic dissection, • -tearing of the inner wall of the aorta. • -Breathlessness, cough, and the expectoration of blood-stained sputum are characteristic signs of pulmonary edema, the swelling of lung tissue due to left ventricular failure

35. -inability of the left ventricle of the heart to adequately pump blood from the lungs into the arterial system

36. In pregnancy • Hypertension occurs in approximately 8-10% of pregnancies • Most women with hypertension in pregnancy have pre-existing primary hypertension, but high blood pressure in pregnancy may be • the first sign of pre-eclampsia, a serious condition of the second half of pregnancy and puerperium.[

37. Pre-eclampsia is characterised by • increased blood pressure • the presence ofprotein in the urine • It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal deaths globally • Pre-eclampsia also doubles the risk of perinatal mortality • ] Usually there are no symptoms in pre-eclampsia and it is detected by routine screening.

38. Complications • Cerebrovascular disease • coronary artery disease are the most common causes of death • although hypertensive patients are also prone to renal failure • peripheral vascular disease.

39. HYPERTENSION Classification of blood pressure levels: (according to the British Hypertension Society) Category Systolic blood pressure Diastolic blood pressure Optimal < 120 < 80 Normal < 130 < 85 High normal 130-139 85-89 Hypertension Grade I (mild) 140-159 90-99 Grade 2 (moderate) 160-179 100-109 Grade 3 (severe) ≥180 ≥110 Isolated systolic hypertension Grade 1 140-149 < 90 Grade 2 ≥160 < 90

40. HISTORY • The patient with mild hypertension is usually asymptomatic. • Attacks of sweating • headaches • palpitations. • Higher levels of blood pressure may be associated with, epitasis or nocturnal. • Breathlessness may be present owing to left ventricular hypertrophy or cardiac failure.

41. INVESTIGATIONS Routine investigation of the hypertensive patient should include: • ECG • Urine stix test for protein and blood • Fasting blood for lipids (total and high-density lipoprotein cholesterol) and glucose • Serum urea, creatinine and electrolytes.

42. Investigation of selected cases • Chest X-ray • Ambulatory BP recording • Echocardiogram • Renal ultrasound • Renal angiography • Urinary catecholamines • Urinary cortisol and dexamethasone suppression test • Plasma renin activity and aldosterone

43. Prevention Much of the disease burden of high blood pressure is experienced by people who are not labelled as hypertensive. population strategies are required to reduce the consequences of high blood pressure and reduce the need for antihypertensive drug therapy. Lifestyle changes are recommended to lower blood pressure, before starting drug therapy.

44. maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2) reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)

45. Engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week) limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women consume a diet rich in fruit and vegetables (e.g. at least five portions per day) Effective lifestyle modification may lower blood pressure as much an individual antihypertensive drug. Combinations of two or more lifestyle modifications can achieve even better results.

46. Management Lifestyle modifications includes • dietary changes • physical exercise • weight loss. • If hypertension is high enough to justify immediate use of medications, lifestyle changes conjunction with medication. • Anti-inflammatory approaches should be a promising strategy for treating both hypertension and atherosclerosis

47. Different programs aimed to reduce:- • psychological stress • such as biofeedback • relaxation • or meditation

48. Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables diet is also rich in potassium, magnesium, calcium, as well as protein

49. Non-pharmacological treatment • Weight reduction - BMI should be < 25 kg/m2 • Low-fat and saturated fat diet • Low-sodium diet - < 6 g sodium chloride per day • Limited alcohol consumption - ≤ 21 units/week for men and ≤ 14 units/week for women • eating plan, which is rich in potassium and calcium • Chronic intake of diets rich in pomace olive oil improves endothelial dysfunction in spontaneously hypertensive • Diets rich in fruits and vegetables reduce blood pressure

50. Dynamic exercise – • At least 30 minutes' brisk walk per day • Increased fruit and vegetable consumption • Reduce cardiovascular risk by stopping smoking • increasing oily fish consumption.