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Hypertensive Vascular Disease Hypertensive Heart Disease

Hypertensive Vascular Disease Hypertensive Heart Disease. Introduction. Systemic and local blood pressure must be tightly regulated Low pressure Inadequate perfusion of organs Dysfunction and death High pressure No additional benefit Induces damage. Introduction.

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Hypertensive Vascular Disease Hypertensive Heart Disease

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  1. Hypertensive Vascular DiseaseHypertensive Heart Disease

  2. Introduction • Systemic and local blood pressure must be tightly regulated • Low pressure • Inadequate perfusion of organs • Dysfunction and death • High pressure • No additional benefit • Induces damage

  3. Introduction • Elevated blood pressure is called Hypertension • Mechanisms of normal blood pressure • Mechanisms of Hypertension • Pathologic changes in small blood vessels

  4. Mechanisms of normal blood pressure • Continuously distributed variable • Hypertension is one end of spectrum • A sustained diastolic pressure of more than 90 mm Hg • A sustained systolic pressure of more than 140 mm Hg • 25% in general population have hypertension

  5. Types of Hypertension • Essential or Primary Hypertension • Secondary Hypertension • Renal • Endocrine • Cardiovascular • Neurologic

  6. Types of Hypertension • Secondary Hypertension • Renal • Acute glomerulonephritis • Chronic renal disease • Polycystic kidney disease • Renal artery stenosis • Renin Producing tumors

  7. Types of Hypertension • Secondary Hypertension • Endocrine • Adrenocortical hyperfunction • Exogenous hormones • Pheochromocytoma • Acromegaly • Hypothyroidism • Hyperthyroidism • Pregnancy induced

  8. Types of Hypertension • Secondary Hypertension • Cardiovascular • Coarctation of Aorta • Polyarteritis Nodosa • Increased intravascular volume • Increased cardiac output • Rigidity of Aorta

  9. Types of Hypertension • Secondary Hypertension • Neurologic • Psychogenic • Increased intracranial pressure • Sleep apnea • Acute stress including surgery and EXAMS!!!

  10. Regulation of normal blood pressure • Blood pressure is proportional to cardiac output and peripheral vascular resistance. • Cardiac output and Peripheral resistance determined by • Genetic factors • Environmental factors • Demographic factors

  11. Hypertension • Major factors that determine blood pressure are • Age • Gender • Body mass index • Diet (sodium intake)

  12. Normal pressure • Kidney plays an important role • Renin angiotensin mechanism • Kidney produces Prostaglandins and NO counter balance the effect of angiotensin • When blood volume decreases, GFR decreases which leads to reabsorption of sodium • Natriuretic factors - inhibit sodium reabsorption and cause diuresis • When renal excretory function is impaired, increased arterial pressure is a compensatory mechanism

  13. Renin Juxta Glomerular Apparatus 11 Secreted by liver Circulates in blood Angiotensinogen Angiotensin 1 ACE 11 Angiotensin 11 Walls of capillaries Medulla Oblangata to increase CO Vasoconstriction Adrenal gland Stimulates secretion Of ADH Aldosterone

  14. Constrictors Angiotensin11 Catecholamines Dilators Prostaglandins Kinins Sodium Mineralocorticoids 0 90 13 Blood Volume Humoral factors Cardiac output Peripheral resistance X = Blood pressure 0 90 0 90 Cardiac factors Cardiac factors 13 0 90 0 90 Constrictors Alpha adrenergic Dilators Beta adrenergic Heart rate Contractility

  15. Mechanism in Essential Hypertension • Results from an interaction of genetic and environmental factors that affect cardiac output and peripheral resistance Cardiac output Peripheral resistance X = Blood pressure

  16. Genetic disorders • Gene defects in enzymes: Aldosterone synthase, 11b-Hydroxylase • Mutations in proteins: Liddle syndrome

  17. Defects in vascular Smooth muscle growth and structure Defects in renal sodium balance Vasoconstriction Inadequate sodium excretion Salt and water retention Increased vascular wall thickness Increased Plasma and ECF volume Increased vascular reactivity 360 Increased total peripheral resistance Increased cardiac output 235 HYPERTENSION

  18. Pathology of Hypertension • Accelerates atherogenesis • Causes degenerative changes in the wall of large and medium sized arteries • Also affects small blood vessels • Hyaline aretriolosclerosis • Hyperplastic arteriolosclerosis

  19. Hyaline arteriolosclerosis • Consists of homogeneous, pink, hyaline thickening of the walls of arterioles, with loss of underlying structural details and narrowing of lumen • Frequently in elderly, normotensive and hypertensive • Common in diabetes • Major morphologic characteristic of Benign Nephrosclerosis

  20. Hyaline arteriolosclerosis • Lesions reflect • leakage of plasma proteins • Excessive ECM production

  21. Hyperplastic arteriolosclerosis • Related to more severe and acute elevations of blood pressure • Characteristic of but not limited to Malignant hypertension (Diastolic pressure > 120 mmHg) • Onion skin, concentric laminated thickening of the walls of arterioles with progressive narrowing of the lumen • If associated deposits of fibrinoid necrosis - necrotizing arteriolitis

  22. Hyaline arteriolosclerosis

  23. Hyperplastic arteriolosclerosis

  24. Necrotizing arteriolitis

  25. Blood Vessels Atherosclerosis, Arteriolosclerosis. Heart Enlarge, Ischemia, Infarction. Kidney Ischemia, Infarction, Nephrosclerosis. Eyes: Retinopathy – Ischemia, infarction. Brain: Ischemia, infarction, Haemorrhages. Consequences of Hypertension:

  26. Rapidly progressive end organ damage. May complicate any type of HTN. Artery necrosis with thrombosis. Rapidly developing renal failure. Hypertensive encephalopathy. Left ventricular failure. less time  No hypertrophy …! Malignant Hypertension:

  27. COMPARISON BETWEEN BENIGN AND MALIGNANT HYPERTENSION • characteristic - benign : malignant • aetiology - usually primary : primary or secondary • age - middle age, elderly : young, middle age • incidence - common : uncommon • course- very slow (years) : rapid (months) • blood pressure - diastolic 90-120, very slow rise : diastolic >120, very rapid rise

  28. Hypertensive heart disease • Hypertensive heart disease is the response to increased demand induced by systemic hypertension

  29. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Pulmonary (right sided) hypertensive heart disease (cor pulmonale)

  30. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Pressure overload can lead to • Myocardial dysfunction • Cardiac dilation • C H F • Sudden death

  31. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Criteria for diagnosis of Hypertensive heart disease • Left ventricular hypertrophy • History or pathologic evidence of hypertension

  32. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Morphology • Overload hypertrophy • No dilation of left ventricle • Increased ratio of wall thickness to radius • Increased weight of the heart disproportionate to the size (wt may exceed 500 gms) • Left ventricle over time becomes stiff and impairs ventricular filling leading to left atrial dilation

  33. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Morphology - Microscopy • Earliest change - increase in the transverse diameter of myocyte (difficult to appreciate on LM) • Later - cellular and nuclear enlargement • Variation in cell size • Interstitial fibrosis

  34. Hypertensive heart disease • Systemic (left sided) hypertensive heart disease • Clinical features • Compensated HHD may be asymptomatic • May present with atrial fibrillation or CHF with cardiac dilation • Consequences • Normal longevity • Progressive ischemic heart disease • Progressive renal or cerebral damage • Progressive heart failure

  35. Hypertensive heart disease • Pulmonary (right sided) hypertensive heart disease • Cor Pulmonale • Right ventricular hypertrophy • Dilation • Failure secondary to pulmonary hypertension

  36. Hypertensive heart disease • Pulmonary (right sided) hypertensive heart disease • May be acute or chronic • Acute - Massive pulmonary embolism • Chronic - implies right ventricular hypertrophy secondary to prolonged pressure overload

  37. Hypertensive heart disease • Pulmonary (right sided) hypertensive heart disease • Morphology • Rt ventricular shape is converted to ovoid • Rt ventricular wall thickens • Outflow tract muscle bundle hypertrophy • Secondary compression of left ventricular chamber • Tricuspid regurgitation

  38. Define essential hypertension? • Briefly describe pathogenesis of renal damage in hypertension. • Classify hypertension, briefly describe pathogenesis in each? • Summarize common complications of hptn? • What is nephrosclerosis? Briefly describe its pathogenesis? • What is meant by malignant hypertension? Briefly describe clinical and pathological features? • What are lacunar infarcts? arteriolosclerosis? • How does hptn cause stroke? Damage heart?

  39. Lacunar infarcts • Chronic hypertension • Arteriolosclerosis of deep penetrating arterioles of brain stem. • Single or multiple cavitary infarcts – lacunes. • Lenticular nucleus, thalamus • Slit Haemorrhages.

  40. Are there any question?

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