nd

2 Case Analysis
Case
A 45-year-old man, presents at the clinic after having a reading of elevated blood
pressure at a health department screening. His blood pressure is 160/110 and is
equal in both arms and legs, he has no other concerns.
He is alert and cooperative but appears to be anxious. The patient reports being a
social drinker and smokes 1 ½ packs of cigarettes a day. He indicates that he is too
busy to exercise. There is a family history of heart disease but no family history of
diabetes.

Physical Examination
T : 37 C, pulse 80x/min, BP 165/110mmHg
BMI 32

Laboratory Studies
General screening test : All within normal ranges
ECG : Left axis deviation

Diagnosis
Essensial Hypertension
Findings

Anamnesis, Physical & Lab Findings

Age: 45
BP: 165/110
BMI 32
ECG : Left axis deviation
Findings

Recommended therapy:
Weight reduction to his ideal level
Low salt diet (< 2 gm/day sodium)
Prudent exercise
Alcohol consumption reduction (< 3 oz whiskey/day)

Medication:
Oral diuretic → β blocker → vasodilator to < 140/90
Problems

Hypertension
JNC Classification: HT stage II (systole ≥ 160, diastole ≥ 100)
Obesity
BMI : 32 (Class II Obesity)

Social drinker
Smoker 1 ½ packs of cigarettes a day
Esential Hypertension
Alexandra Gabriella
 Hormonal mechanism: Renin-
Angiotensin-Aldosterone System
• Prorenin bs jd biomarker baru u/ liat mikro & makrovaskular complication

Laragh, Sealey, & coworkers, 2001

 Plasma Renin Activity as a
Clinical Index of RAAS Activity

Alexandra Gabriella
 Clinical Assays

Plasma Renin Activity (PRA) & Plasma Renin

Concentration (PRC) can be measured

PRA: incubating pts’ plasma, which contains

angiotensinogen & renin, to generate Ang I,
then measured by radioimmunoassay

Ang I ∾ renin
Clinical Conditions Affecting PRA
⬆︎BP itself (vol expanded) ➔ suppress PRA

however, most puts have normal PRA

nephron heterogeneity : subpopulation of

ischemic nephron ⬆︎ renin ➔ ec ⬆︎RSNA

nonmodulation concept: defective feedback

regulation of RAAS in kidney & adrenal gland
Primary HT w/ Low Renin
usual finding

vol expansion w/ or w/o mineralocorticoid excess ➔ but

majority fail to indicate vol expansion or ⇡ level of
mineralocorticoids

u/ keeping w/ Normal level of aldosterone (despite of low

renin level) ➔ they show lesser rise in aldosterone
secretion on a low-sodium diet

7-year study: low renin HT no strokes/heart attacks; normal

renin 11%, high 14% had 1 stroke/heart attacks.
Natural History of HT
 Complications of HT

Makrovaskular

PAD, Ao Dissection, Cerebrovascular

Disease, CAD

Mikrovaskular

Renitopathy hypertensive, nephropathy

Retinopathy HT Classification
Funduscopy
Hypertension
Hypertension
Salt sensitivity & Pressure-Natriuresis Phenomenon
In normotensive person: BP ↑ → renal sodium & renal excretion ↑ → fluid
volume ↓ → normal BP (pressure-natriuresis phenomenon)

In hypertensive person:
• Salt sensitive → low salt diet → normotensive
→ high salt diet → hypertensive
• Salt resistance → low salt diet → normotensive
→ high salt diet → normotensive
• Salt sensitivity shown in renin plasma concentration
• also: pressure-natriuresis resetting (shifted)
Hypertension
Pressure-Natriuresis Phenomenon
Hypertension
Pressure-Natriuresis Resetting
Hypertension
Nocturia
Clinical sign of abnormal pressure-natriuresis and clue to uncontrolled
salt-sensitive hypertension related to aging, hypertension,
blunted/reveres nocturnal dipping pattern in BP
• nocturnal urine accounts 53% of urine output in 60 - 80 yo, ↑↑ in
hypertensive due to shifted pressure-natriuresis
• fluid retained peripherally during the day leads to central volume
expansion at night → ↑ nocturia
Hypertension
BP = CO x TPR (age related)
Hypertension Effect on Organ
Hypertension Effect on Organ
LVH
• ↑ Arterial Pressure → ↑ wall stress → LVH (→ ↑ LV
stiffness → diastolic dysfunction → ↑ LV filling pressure →
pulmonary congestion;)
• Normal pattern compensation (↑ Arterial Pressure) →
concentric hypertrophy;
• In ↑ circulating volume → eccentric hypertrophy
Hypertension Effect on Organ
Hypertension Effect on Organ
Hypertensive Retinopathy
• Acute severe hypertension (e.g., uncontrolled and/or malignant
hypertension) → burst small retinal vessels → haemorrhages,
exudation of plasma lipids & areas of local infarction;
• Chronically elevated blood pressure → Papilledema (-), but
vasoconstriction → arterial narrowing, medial hypertrophy thickens
the vessel wall, which “nicks” (indents) crossing veins.
• More severe chronic hypertension → arterial sclerosis, an increased
reflection of light through the ophthalmoscope (termed “copper” or
“silver” wiring)
Hypertension Crisis
BP or more than 180 in systole and 110 in diastole, with evidence of organ
damage, such as:
• Stroke
• Loss consciousness
• Memory loss
• Heart attack
• Damage to the eyes and kidneys
• Loss of kidney function
• Aortic dissection
• Angina (unstable chest pain)
• Pulmonary edema (fluid backup in the lungs)
• Eclampsia
Obesity
Hypertension & Obesity Relationship
Hypertension & Obesity
impaired insulin–dependent transport of glucose into many tissues
(termed insulin resistance)
Possible explanations for this relationship include:
1. The release of angiotensinogen from adipocytes as substrate for
the renin–angiotensin system,
2. Augmented blood volume related to increased body mass, and
3. Increased blood viscosity caused by adipocyte release of pro-
fibrinogen and plasminogen activator inhibitor 1
Hypertension & Obesity Relationship
Hypertension & Obesity Relationship
Hypertension & Obesity Relationship
Hypertension Management
Hypertension Management

Recommended therapy:
• Weight reduction to his ideal level →
• Low salt diet (< 2 g/day sodium) → ↓ BP by a mean 5.4/2.8 mmHg.
Additional effect:
• Antihypertensive drug’s efficacy enhanced
• Protective from Diuretic-Induced Potassium Loss (R-A)
• Prudent exercise → BP is lowered by exercise whether aerobic, or
resistance, even without weight loss
• Recommendation: as little as 15 minutes of walking per day
• Alcohol consumption reduction (< 3 oz whiskey/day) → < 20 - 24 ml of
alcohol
Hypertension Management
Lifestyle Changes:
Reduce or avoid:
• Smoking
• Obesity
• Poor dietary habits (High sodium intake)
• Sedentary lifestyle
• High alcohol consumption
• High stress
Hypertension Management
Hypertension Management
Hypertension Management

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Hypertension Management

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Hypertension Management

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Hypertension Management

Angiotensin-Converting Enzyme Inhibitor

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TERIMA KASIH

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