Hypertension (HT) High Blood Pressure (HBP)

1. Hypertension (HT) High Blood Pressure (HBP) Renji Hospital Cardiology Department Li Hongbo

2. Introduction • Definition: Systemic arterial blood pressure elevated. • One of the most common disease in the world

3. Current situation of HT in our country

4. Etiology • Genetic • Environment • Dietary: Salt intake • Alcohol intake • Obesity • Infant dysnutrition • Psychological stress

5. Pathogenesis • High activity of the Sympathetic Nervous System • Renin-Angiotension Aldosterone System (RAAS) • Renal Sodium Handling • Vascular Remodelling • Endothelial Cell Dysfunction • Insulin Resistance

6. Pathological consequences

7. Pathological changes of small artery

8. Pathological changes of the heart Left ventricular hypertrophy

11. Arterial Aneurysm

12. Pathological change of Renal • Hypertension induced nephrosclerosis, atrophy of renal cortex

13. Clinical Features • The blood pressure varies widely over time, depending on many variables, including SNS activity, posture, state of hydration, and skeletal muscle tone. • Symptoms: • Always asymptomatic • Symptoms often attributed to hypertension: • headache, tinnitus, dizziness, fainting

14. Clinical Features • Complications of Hypertension • Heart: LVH, CAD,HF • Brain: TIA, Stroke • Renal: Microalbuminuria, renal dysfunction • Ratinopathy

15. Laboratory Examination • Blood pressure measurement: • Clinic Blood Pressure • Home Blood Pressure • Ambulatory monitoring

16. Ambulatory Measurement • Ambulatory monitoring can provide: • readings throughout day during usual activities • readings during sleep to assess nocturnal changes • measures of SBP and DBP load • Exclude white coat or office hypertension • Ambulatory readings are usually lower than in clinic (hypertension is defined as > 135/85 mm Hg)

17. Laboratory Examination • Urinalysis • Blood examination • Chest X Ray • EKG • UCG (Ultrasound cardiography) • Retina examination

22. The Keith-Wagner Criteria (change in retina) • KW I: Minimal arteriolar narrowing, irregularity • of the lumen, and increased light reflex • KW II: More marked narrowing and irregularity • with arteriovenous nicking (crossing defects) • KW III: Flame-shaped hemorrhages and exudates in • addition to above arteriolar changes • KW IV: Any of the above with addition of papilledema

23. Pepilledema Flame shaped hemorrhage

24. Diagnosis & Differential Diagnosis

25. Classification of blood pressure for adult • CategorySBP (mmHg) DBP (mmHg) • Normal < 120 < 80 • High normal 120-139 80-89 • Hypertension≥140 ≥90 • Stage 1 140-159 90-99 • Stage 2 160-179 100-109 • Stage 3 ≥180 ≥110 • Systolic HBP ≥140 < 90 • When the SBP and DBP fall into different categories, use the higher category

26. Definition of HT using different methods

28. Evaluation Components • Medical history • Physical examination • Routine laboratory tests

29. Physical Examination • Blood pressure readings (2 or more) • Height, weight, and waist circumference • Examination of the neck, heart, lungs, abdomen, and extremities • Neurological assessment

30. Urinalysis Complete blood count Blood biochemistry (potassium, sodium, calcium, creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram Chest X Ray Laboratory Tests Recommended Before Initiating Therapy

31. Evaluation Objectives • To identify cardiovascular risk factors • To assess presence or absence of target organ damage • To identify associated clinical condition • To identify other causes of hypertension • These evaluation may used in stratification of the hypertension patients

32. Cardiovascular Risk Factors • Blood pressure • Age • Gender • Dyslipidemia • Abdomen Obesity • Family History of cardiovascular disease • CRP ≥1mg/dl

33. Target Organ Damage • Left ventricular hypertrophy • Echo shows IMT of carotid artery • Plasma creatinine slight elevation • Microalbuminuria

34. Associated Clinical Condition • Cerebrovascular diseases: Stroke, TIA • Heart diseases: MI, AP, CHF, Coronary artery revasculation • Kidney diseases: DN, Dysfunction of the kidney, Proteinuria, CRF • Diabetes • Peripheral artery disease • Retinopathy

35. Stratification of Individual Risk

36. Stratification of Risk to Quantity Prognosis • Risk stratification (typical 10 years risk of stroke or myocardial infarction ) • Low risk = less than 15% • Medium risk = about 15-20% • High risk = about 20-30% • Very high risk = 30% or more

37. Stratification of Hypertension patients OD-Organ Damage; MS-Metabolic Syndrome; CV-Cardiovascular Disease

38. Differential Diagnosis • Should exclude Secondary Hypertension

39. Secondary Hypertension Common Causes • Renal Dysfunction • Glomerulonephritis Pyelonephritis Obstructive nephropathy Collagen diseases, Congenital diseases Diabetes nephropathy Renal tumor---- renin secreting tumor • Phenochromocytoma • Primary aldosteronism

40. Phenochromocytoma • Ganglion-neurotomas and neuroblastomas • Excretion of large amounts of catecholamines • 90% arise in the adrenal medulla • 10% are malignant. • Paroxymal or persist HT • Clinic features: Headache, sweating, palpitations, nervousness, weight loss, hypermetabolism, orthostatic hypotension, severe presser response

41. Primary Aldosteronism • Mild or moderate hypertension • Hypokalemia, muscle weakness, paralysis • Polyuria, nocturia and polydipsia, • Hypochloremic alkalosis • Urine aldosterone elevation • Plasma renin active decrease

42. Secondary HypertensionOther Causes • Sleep Obstructive Apnea Syndrome • Renal artery stenosis • Cushing’s syndrome • Coarctation of the aorta • Drug-induced: • NSAIDs; Sympathomimetic medications; • Epogen Monoamine oxidase inhibitors; • Mineralocorticoids; Immuno-inhibitors;

43. Therapy

44. Goal of Hypertension Management • < 140/90 mm Hg • With Diabetes or kidney dysfunction: <130/80mmHg • To reduce morbidity and mortality of cerebral and cardiovascular complications.

45. Hypertension patient Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure Initial Drug Choices

46. Algorithm for Treatment of Hypertension(continued) Initial Drug Choices Noassociated clinical condition Associated clinical condition I stage hypertension: Diuretics, BB,CCB,ACEI,ARB II stage hypertension: Two drugs combination therapy Choice the drugs according to ACC Not at Goal Blood Pressure Increase dosage or add another agent from different class

48. Lifestyle Modifications • Stop smoking • Limit alcohol intake • Lose weight and keep fit • Suitable diet • Increase aerobic physical activity • Decrease psychologicalstress

49. Principle of Drug Therapy • Drug therapy should be individually • A low dose of initial drug therapy • Combination therapies may provide additional efficacy with fewer adverse effects. • Optimal formulation should provide 24-hour efficacy with once-daily dose.

50. Antihypertensive Drugs • Diuretics • ß-Adrenergic receptor blockers (BB) • Calcium channel blockers (CCB) • ACE inhibitors (ACEI) • Angiotensin II receptor blockers (ARB)