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HYPERTENSION

Dept of Cardiology & Vascular Medicine


FK UNUD
RSUP Sanglah
Denpasar

HYPERTENSION
95% Idiopatic
( Essential Hypertension )
5% Secondary Hypertension
Renal
Metabolic
Endocrine
Structural Causes

Definitions and classification of blood pressure


(BP) levels (mmHg) (ESC and ESH Guidelines 2007)
Category

Systolic

Optimal
Normal
High normal
Grade 1 hypertension
Grade 2 hypertension
Grade 3 hypertension
Isolated systolic
hypertension

< 120
120-129
130-139
140-159
160-179
> 180
> 140

Diastolic
and
and/or
and/or
and/or
and/or
and/or
and

< 80
80-84
85-89
90-99
100-109
> 110
< 90

JNC VII BP Classification


BP Classification

SBP mmHg

DBP mmHg

Normal

<120

Pre-hypertension

120139

or

8089

Hypertension stg 1

140159

or

9099

Hypertension stg 2

>160

or

>100

&

<80

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Hypertensive Crisis
Def :
Suddenly increase and progress of BP,
DBP > 120 mmHg

Hypertensive Emergencies
BP dysfunction and target organ
damage in few hours.
Include :
-

Hypertensive encephalopathy
Hypertensive in IC bleeding
Acute lung edema
ACS
Acute Renal Insufficiency
Eclampsia
Phaeochromocytoma
Hypertensive retinopathy stg III-IV Keith-Wagener
Syndrom of sedentary anti Htdrug
Burning

Hipertensive Urgencies
BP increase gradually and potential to be
organ treathening but not accompanying
with organ damage in few week.
Include:
- Hypertensif retinopathy grade I-II (Keith
Wagener)
- Uncontrol Hypertension or post operative.

Mechanisms of Primary
(Essential Hypertension)
Exses sodium
intake

Reduced nephron
number

Renal sodium
retention

Decreased
filtration
surface

Stress

Sympathetic
nervous
overactivity

Genetic
alteration

Reninangiotensin
exses

Obesity

Cell membrane
alteration

EndotheliumDerived factors

Hyperinsulinemia

Venous
constriction

Fluid
vulome

Preload

Contractility

Functional
constriction

Blood pressure = cardiac output x peripheral resistance


Hypertension = increased CO and/or increased PR
Autoregulation

Structural hypertrophy

Complication of Hypertension
BP
Systolic
dysfunction

Ejection fraction
End diastolic volume
LV dilation

LVH

Ventricular
arrhythmias

Diastolic
dysfunction

Ejection fraction or
End diastolic volume or
LV size normal

LV filling pressure
Low cardiac
Output syndrome
BP = arterial blood pressure
LVH = left ventricular hypertrophy

Pulmonary venous Congestion


Dyspnea

Goals of treatment
In hypertensive patients, the primary goal of treatments is to
achieve maximum reduction in the longterm total risk of
cardiovascular disease.
This requires treatment of the raised BP per se as well as of all
associated reversible risk factors.
BP should be reduced to at least below 140/90 mmHg
(systolic/diastolic), and to lower values, if tolerated, in all
hypertensive patients.
Target BP should be at least < 130/80 mmHg in diabetics and in
high risk patients, such as those with associated clinical
conditions (stroke, myocardial infarction, renal dysfunction,
proteinuria).
In order to more easily achieve goal BP, antihypertensive
treatment should be initiated before significant cardiovaslar
damage develops.

Lifestyle changes
Lifestyle measures should be instituted, whenever appropriate, in all
patients, including those who require drug treatment. The purpose is to
lower BP, to control other risk factors and to reduce the number of doses of
antihypertensive drugs to be sub sequently administered.
Lifestyle measures are also advisable in subjects with high normal BP and
additional risk factors to reduce the risk of developing hypertension.
The lifestyle measures that are widely recognized to lower BP or
cardiovascular risk, and that should be considered are :

Smoking cessation
Weight reduction (and weight stabilization)
Reduction of excessive alcohol intake
Physical exercise
Reduction of salt intake
Increase in fruit and vegetable intake and decrease in satureted and total
fat intake

Lifestyle recommendations should not be given as lip service but instituted


with adequate behavioural and expert support, and reinforced periodically.
Because long-term compliance with lifestyle measures is low and the BP
response highly variable, patients under non-pharmacological treatment
should be followed-up closely to start drug treatment when needed and in a
timely fashion.

Antihypertensive treatment: Preferred drugs


Subclinical organ damage
LVH
Asympt
atherosclerosis
Microalbuminuria
Renal dysfunction
Clinical event
Previous stroke
Previous MI
Angina pectoris
Heart failure

ACEI, CA, ARB


CA, ACEI
ACEI, ARB
ACEI, ARB

any BP lowering agent


BB, ACEI, ARB
BB, CA
diuretics, BB, ACEI, ARB,
antialdosterone agents

Atrial fibrilation
Recurrent
Permanent
ESRD/proteinuria
Peripheral artery
Disease
Condition
ISH (elderly)
Metabolic syndrome
Diabetes mellitus
Pregnancy
Blacks

ARB, ACEI
BB, non-dihydropiridine CA
ACEI, ARB, loop diuretics
CA

diuretics, CA
ACEI, ARB, CA
ACEI, ARB
CA, methyldopa, BB
diuretics, CA

Abbreviations: LVH: left ventricular hypertrophy; ISH: isolated


systolic hypertension; ESRD: renal failure, ACEI: ACE
inhibitors; ARB: angiotensin receptor antagonists; CA: calcium
antagonists; BB: -blokers

Conditions favouring use of some


antihypertensive drugs versus others
Thiazide diuretics
Isolated systolic
Hypertension (elderly)
Heart failure
Hypertension in blacks
Beta-blockers
Angina pectoris
Post-myocardial infarction
Heart failure
Tachyarrhythmias
Glaucoma
Pregnancy

Conditions favouring use of some


antihypertensive drugs versus others
Calcium antagonists (dihydropyridines)
Isolated systolic hypertension (elderly)
Angina pectoris
LV Hypertrophy
Carotid/Coronary Atherosclerosis
Pregnancy
Hypertension in blacks
Calcium antagonists (verapamil/diltiazem)
Angina pectoris
Carotid atherosclerosis
Supraventricular tachycardia

Conditions favouring use of some


antihypertensive drugs versus others
ACE inhibitors
Heart failure
LV dysfunction
Post myocardial infarction
Diabetic nephropathy
Non-diabetic nephropathy
LV hypertrophy
Carotid atherosclerosis
Proteinuria/Microalbuminuria
Atrial fibrilation
Metabolic syndrome
Diuretics (antialdosterone)
Heart failure
Post-myocardial infarction

Conditions favouring use of some


antihypertensive drugs versus others
Angiotensin receptors antagonists
Heart failure
Post myocardial infarction
Diabetic nephropathy
Proteinuria/Microalbuminuria
LV hypertrophy
Atrial fibrilation
Metabolic syndrome
ACEI-induced cough
Loop diuretics
End stage renal disease
Heart failure

Compelling and possible contraindications to use of


antihypertensive drugs
Compelling

Possible

Thiazide diuretics

Gout

Beta-blockers

Asthma
A-V block (grade 2 or 3)

Metabolic syndrome
Glucose intolerance
Pregnancy
Peripheral artery disease
Metabolic syndrome
Glucose intolerance
Athletes and physically active patients
Chronic obstructive pulmonary disease
Tachyarrhytmias
Heart failure

Calcium antagonists (dihydropiridines)


Calcium antagonists
(verapamil, dilitiazem)
ACE inhibitors

Angiotensin receptor
antagonists

A-V block (grade 2 or 3)


Heart failure
Pregnancy
Angioneurotic oedema
Hyperkalaemia
Bilateral renal artery stenosis
Pregnancy
Hyperkalaemia
Bilateral renal artery stenosis

Diuretics (antialdosterone) Renal failure


Hyperkalaemia.

Possible combinations of different classes


of antihypertensive agents
Thiazide
diuretics

-blokers

Angiotensin
receptor
antagonists

Calcium
antagonists

Alfa
Blockers

ACE inhibitors

SUMMARY
Cardiovascular morbidity and mortality rises
proportionately with increases in systolic
blood pressure.
Secondary causes (~ 5% of cases) should be
identified and treated.
In this asymptomatic condition, treatment is
associated with primary and secondary
preventative benefits.
Selection of antihypertensive agent is
dependent upon patient choice, side effects,
risk factor profile and co-morbidity.