1 cecil medicine section viii chapter 66 arterial hypertension prof. shen-jiang hu

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Cecil Medicine Section VIII Chapter 66

Arterial HypertensionProf. Shen-Jiang Hu

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Definition of Hypertension

Hypertension is a clinical syndrome, defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg.

Hypertension should be considered a major risk factor for an array of cardiovascular and related disease as well as diseases leading to a marked increase in cardiovascular risk.

Hypertension in China(1991)

≥≥15%15%

≥≥10%~14.9%10%~14.9%

＜＜ 10%10%

河南河南青海青海

云南云南

山东山东

安徽安徽

湖南湖南四川四川

贵州贵州

甘肃甘肃

海南海南

天津天津

黑龙江黑龙江

北京北京

上海上海

河北河北

西藏西藏

吉林吉林

内蒙古内蒙古

辽宁辽宁

湖北湖北

江苏江苏

新疆新疆

山西山西

陕西陕西

广东广东

宁夏宁夏

广西广西

浙江浙江江西江西

福建福建

台湾台湾

Mortality %

Circulatory system

- Cerebral disease 38.5

- Heart disease 16.8

Cancer 23.9

Respiratory system 13.9

Trauma, toxicosis 6.3

Digestive system 3.0

Others 6.4

Mortality in China City in Mortality in China City in 1999

MortalityMortality

%%

Circulatory system 30.830.8

- - Cerebral disease 18.418.4

- - Heart disease 12.412.4

Respiratory system 22.022.0

Cancer 18.418.4

Trauma, toxicosis 11.011.0

Digestive system 4.0 4.0

Others 5.1Others 5.1

Mortality in China Countryside in Mortality in China Countryside in 1999

HypertensionHypertensionHypertensionHypertension

Atrial Fibrillation

Aortic Dissection

Dementia

Chronic Renal failure

Heart Failure

LV Hypertrophy MI

Hypertensive Encephalopathy

CHD

Intracerebral HemorrhageIschemic

CerebralInfarction

Complications of Hypertension

Trends in Awareness, Treatment, and Control of Hypertension in China

Awareness(%) Treatment(%) Control(%)

19911991 26.6 12.2 2.9 26.6 12.2 2.9

2002 30.2 24.7 6.12002 30.2 24.7 6.1

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Etiology of Hypertension Genetic factors play an important role.

Children with one- or two-hypertensive parents have higher blood pressures.

Environmental factors also are significant. Increased salt intake has long been incriminated as a pathogenic factor in essential hypertension. It alone is probably not sufficient to elevate blood pressure to abnormal levels; a combination of too much salt plus a genetic predisposition is required.

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Etiology

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Pathogenesis The pathogenesis of essential hyper

tension is multifactorial. Sympathetic nervous system hyperacti

vity. It is most apparent in younger hypertensives, who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pressure are poor.

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Pathogenesis Renin-angiotensin system (RAS). Renin

acts on angiotensinogen to cleave of the ten-amino-acid peptide angiotensin I. This peptide is then acted upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and a major stimulant of aldosterone release from the adrenal glands.

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Pathogenesis

Defect of natriuresis. Hypertensive patients exhibit a diminished ability to excrete a sodium load. This defect may result in increased plasma volume and hypertension.

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Pathogenesis

Intracellular sodium and calcium. An increase in intracellular Na+ may lead to increased intracellular Ca2 + concentrations as a result of facilitated exchange. This could explain the increase in vascular smooth muscle tone.

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Pathogenesis Exacerbating factors. The best-documented

is obesity, which is associated with an increase in intravascular volume and an elevated cardiac output. Some hypertensives respond to high salt intake with substantial blood pressure increases. Excessive use of alcohol also raises blood pressure. Cigarette smoking acutely raises blood pressure.

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Pathology

Heart.

Left ventricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death.

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Pathology

Brain.

Hypertension is the major predisposing cause of stroke, especially intracerebral hemorrhage but also ischemic cerebral infarction.

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Pathology

Kidney.

Chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency.

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Clinical Findings

Symptoms: Elevations in pressure are often

intermittent early. Even in established case, the blood pressure fluctuates widely in response to emotional stress and physical activity.

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Clinical Findings

Symptoms: Mild to moderated essential

hypertension is usually associated with normal health and well-being for many years.

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Clinical Findings

Symptoms: Suboccipital pulsating headaches,

but any type of headache, may occur. Accelerated hypertension is associated with somnolence, confusion, palpitation.

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Signs： High blood pressure.

Physical findings depend upon the duration and severity, and the degree of effect on target organs.

A loud aortic second sound and an early systolic ejection click may occur.

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Initial Evaluation for Hypertension

Goal 1: Accurate Assessment of Blood Pressure

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Blood pressure (BP) measurement

When measuring BP, care should be taken to:

Allow the patients to sit for several minutes in a quiet room before beginning BP measurements

Take at lease two measurements spaced by 1-2 minutes, and additional measurements if the first two are quite different

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Use a standard bladder (12-13 cm long and 35 cm wide) but have a larger and a smaller bladder available for fat and thin arms, respectively. Use the smaller in children

Have the cuff at the heart level, whatever the position of the patient

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Category JNC 7 （ USA ） European China

Optimal <120 and <80

Normal <120 and <80 120-129 and/or 80-84 <120 and <80

High-normal 120-139 or 80-89 130-139 and/or 85-89 120-139 or 80-89

Hypertension ≥ 140 or ≥ 90

Grade I 140-159 or 90-99 140-159 and/or 90-99 140-159 or 90-99

Grade II ≥ 160 or 100 160-179 and/or 100-109 160-179 or 100-109

Grade III ≥ 180 and/or ≥ 110 ≥ 180 or ≥ 110

Isolated Systolic Hypertension

≥ 140 and <90 ≥ 140 and <90

Definition and Classification of Blood Pressure Levels in different Country

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Goal 2: Cardiovascular Risk Stratification

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Stratification of CV Risk

Stratification of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: Cardiovascular events; HT: hypertension. Low, moderate, high and very high risk refer to 10 year risk of a CV fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome. The dashed line indicates how definition of hypertension may be variable, depending on the level of total CV risk.

Estimate total cardiovascular risk

Framingham Study ： Risk for cardiovascular events over 10 years

Very high High Moderate Low

>30% 20-30% 15-20% <15%

SCORE charts ： the risk of dying from cardiovascular disease over 10 years

Very high High Moderate Low

>8% 5-8% 4-5% <4%

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Factors influencing prognosis

Risk factorsSystolic and diastolic BP levelsLevels of pulse pressure (in the elderly)Age (M > 55 years; W > 65 years)SmokingDyslipidaemia •TC > 5.7 mmol/l (220 mg/dl) or:•LDL-C > 3.3 mmol/l (130 mg/dl) or:•HDL-C: < 1.0 mmol/l (40 mg/dl)Fasting plasma glucose 6.1-6.9 mmol/LAbnormal glucose tolerance testAbdominal obesity (Waist circumference > 90 cm (M), > 85 cm (W))Family history of premature CV disease (M at age < 55 years; W at age < 65 years)

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Factors influencing prognosis

Subclinical Organ Damage

Electrocardiographic LVH or:Echocardiographic LVHCarotid wall thickening (IMT > 0.9 mm) or plaqueCarotid-femoral pulse wave velocity > 12 m/sAnkle/brachial BP index < 0.9Slight increase in plasma creatinine: M: 115-133 µmol/l (1.3-1.5 mg/dl);

W: 107-124 µmol/l (1.2-1.4 mg/dl) Low estimated glomerular filtration rate (<60 ml/min/1.73 m2)Microalbuminuria 30-300 mg/24 h or albumin-creatinine ratio: ≥ 30 mg/g

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Factors influencing prognosisEstablished CV disease

Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attackHeart disease: myocardial infarction; angina; coronary revascularization; heart failureRenal disease: diabetic nephropathy; renal impairment (serum creatinine: M>133, W>124 μmol/L; porteinuria ≥300 mg/24h)Peripheral artery diseaseAdvanced retinopathy: haemorrhages or exudates, papilloedema Diabetes mellitus: fasting plasma glucose ≥ 7.0 mmol/L (126 mg/dl); postload plasma glucose > 11.1 mmol/L (200 mg/dl); HbA1c ≥ 6.5%

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Goal 3: Identification and Treatment of Secondary (Identifiable) Causes of Hypertension

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two circumstances when there is a compelling finding

on the initial evaluation when the hypertensive process is

so severe that it either is refractory to intensive multiple-drug therapy or requires hospitalization

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Physical examination for secondary hypertension

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Secondary Hypertension Renal disease: any disease of the rena

l parenchyma can cause hypertension, and these conditions are the most common causes of secondary hypertension. Hypertension may result from glomerular diseases, tubular interstitial disease, and polycystic kidneys. Diabetic nephropathy is another cause of chronic hypertension.

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Secondary Hypertension Renal vascular hypertension: it is due to artery s

tenosis, fibromuscular hyperplasia, and atherosclerotic stenoses.

It should be suspected in the following circumstances: (1) if the documented onset is below age 20 or after age 50; (2) if there are epigastric or renal artery bruits; (3) if there is atherosclerotic disease of aorta or peripheral arteries; or (4) if there is abrupt deterioration in renal function after administration of angiotensin-converting enzyme inhibitors.

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Secondary Hypertension Primary hyperaldosteronism and Cushing’s

syndrome: the diagnosis should be suspected when patients present with hypokalemia prior to diuretic therapy associated with excessive urinary potassium excretion, increased serum sodium, and suppressed levels of plasma renin activity. Aldosterone concentrations in urine and blood are elevated. The lesion can be demonstrated by CT scanning or MRI.

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Secondary Hypertension Pheochromocytoma: although hypert

ension due to pheochromocytoma may be episodic, most patients have sustained elevations. The majority of patients have orthostatic falls in blood pressure, the converse of essential hypertension; some develop glucose intolerance.

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Secondary Hypertension Other causes of secondary hypertensi

on: hypertension has also been associated with acromegaly, hyperthyroidism, hypothyroidism, and a variety of neurologic disorders causing increased intracranial pressure.

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Management

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Goals of treatment

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Goals of treatment

Relationship between BP reduction Relationship between BP reduction with CV events and Mortalitywith CV events and Mortality

Lancet 2003;362:1527-45

0

-5

-10

-15

-20

-25

-30

Stroke CHD HF Mortality

23%

15% 16%14%

－ 4/3 mmHg N ＝ 20 888

Major CV

15%

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Management

Lifestyle Modification Weight Loss Sodium Restriction Potassium Supplementation High-Fiber, Low-Fat Diet Alcohol Moderation Smoking cessation Exercise

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When to initiate antihypertensive treatment

Based on two criteria: -The level of systolic and diastolic

blood pressure -The level of total cardiovascular

risk

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Initiation of antihypertensive treatment

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Choice of antihypertensive drugs

Five major classes of antihypertensive agents – thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin receptor antagonists and β-blockers – are suitable for the initiation and maintenance of antihypertensive treatment, alone or in combination.

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Monotherapy versus combination therapy Monotherapy could be the initial tr

eatment for a mild BP elevation with a low or moderate total cardiovascular risk.

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Monotherapy versus combination therapy A combination of two drugs at

low doses should be preferred as first step treatment when initial BP is in the grade 2 or 3 range or total cardiovascular risk is high or very high.

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Monotherapy versus combination therapy In several patients BP control is

not achieved by two drugs, and a combination of three of more drugs is required.

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Antihypertensive treatment: Preferred drugs

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Compelling and possible contraindications to use of antihypertensive drugs

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Monotherapy versus combination therapy strategies

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Possible combinations between some classes of antihypertensive drugs

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References

1. http://www.escardio.org/guidelines-surveys/Pages/welcome.aspx

2. http://www.acc.org/login/index.taf

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Thanks for your attention!

1 cecil medicine section viii chapter 66 arterial hypertension prof. shen-jiang hu

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