cecil medicine section viii chapter 66

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Cecil Medicine Section VIII Chapter 66

Arterial HypertensionProf. Shen-Jiang Hu

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made by a Cambridge Reverend, Stephen Hales, in 1733. He measured blood pressure by inserting the end of a long glass tube into the carotid artery of a horse and noting that the

blood came up the tube to a height of nine feet eight inches, which was the blood pressure of

the horse.

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It took Riva-Rocci, together with a Prussian general called Korotkoff, to develop the modern sphygmomanometer which was

introduced into clinical practice in about 1905. The device that probably many of us still use today to measure blood pressure has

changed very little from this early device.

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Blood Pressure has a unimodal distribution in the Population

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Question: Is it important if the person’s

blood pressure is higher?

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“Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.”White PD, 1931

“The greatest danger to a man with high blood pressure lies in its discovery, because then some fool is certain to try to reduce it.”Hay J, 1931

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Franklin D. Roosevelt （ FDR ） was referred to Dr. Howard Bruenn, a cardiologist at Bethesda Naval Hospital who, on March 27, 1944 found him cyanotic, breathless, with an enlarged left ventricle and a blood pressure of 186/108. Bruenn diagnosed hypertensive heart disease and wanted to give digitalis, but was prohibited by Dr. Ross McIntire, the president's personal physician and then surgeon-general of the U.S. Navy.

“Franklin D. Roosevelt’s health was excellent”！？－ 1944

http://www.doctorzebra.com/Prez/dr_bruenn.htm

http://www.doctorzebra.com/Prez/dr_mcintire.htm

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The next day, FDR developed moist rales at the base of the right lung. By March 30, Bruenn diagnosed congestive heart failure. On the next day, digitalis was begun.

By April 3, FDR was better. His color was better, he could lie flat without dyspnea, and the crackles disappeared from both lungs. His blood pressure, however, was 210/110.


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The nation was stunned when FDR died unexpectedly on April 12, 1945 -- less than six months after being elected to a fourth term in office. The death was unexpected because the president's personal physician, VADM Ross McIntire, whenever asked, had proclaimed that FDR's health was excellent.


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Question: How do we know the hypertension

is responsible for the total risk of CV events?

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Knowledge about risk and treatment of hypertension

Framingham Heart Study: Hypertension and CHD

1961

Hypertension and Stroke

1970

World Health Organization (WHO):Treatment of Hypertension, firstly

1978

JNC II: DBP for diagnosis and treatment of hypertension

1980

JNC V: SBP and DBP is same important for hypertension

1992

JNC VII ： HBP to target BP is central for reduction of the total risk of CV events.

2003

China guideline for hypertension: HBP should be reduced to target BP

2005

WHO: HBP should be reduced to target BP.

2006

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The Relationship between DBP and Cardiovascular Events

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HypertensionHypertensionHypertensionHypertension

Atrial Fibrillation

Aortic Dissection

Dementia

Chronic Renal failure

Heart Failure

LV Hypertrophy MI

Hypertensive Encephalopathy

CHD

Intracerebral HemorrhageIschemic

CerebralInfarction

Complications of Hypertension

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Question: What is hypertension?

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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

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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Question: What is etiology of hypertension?

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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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Question: How about the pathogenesis in

hypertension is ?

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Pathogenesis The pathogenesis of essential

hypertension is multifactorial. Sympathetic nervous system

hyperactivity. 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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Question: Which pathologic changes will be

happen in hypertension ?

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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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Question: How to know the patient with

hypertension?

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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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Question: What should we do if the patient

may be with hypertension?

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Initial Evaluation for Hypertension

Goal 1: Accurate Assessment of Blood Pressure

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How to measure blood pressure

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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

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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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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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Management

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Goals of treatment

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Goals of treatment

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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.

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

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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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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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Goals of treatment

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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

β-blockers

Calcium antagonists

Diuretics

Angiotesin II antagonists

ACE inhibitors

Journal of Hypertension 2007, 25:1105–1187.

α-blockers

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References

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

2. http://www.acc.org/login/index.taf3. 中国高血压防治指南（ 2010年修订版 )

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Thanks for your attention!

cecil medicine section viii chapter 66

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