the overview of hypertension 2009

8/12/2019 The Overview of Hypertension 2009

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The Overview of Hypertension

Dr. Ira Andaningsih SpJP

2010


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Purpose Why JNC 7?

Publication of any new studies

Needed for a clear and concise guidelineuseful for clinicians

Need to simplify the classification of BP


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BP classification

BPclassification

SBP mmHg DBP mmHg

Normal < 120 and 160 or > 100


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CVD Risk

The BP relationship to risk of CVD is continuous,consistent and independent of others RF

Each increment of 20/10 mmHg doubles the riskof CVD across the entire BP range starting from115/75 mmHg

Pre hypertension signals need for increased

education to reduce BP in order to preventhypertension


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Benefits of lowering BP

Stroke incidence reduction 35-40 %

Myocardial Infarction reduction 20-25 %

Heart Failure reduction 50 %


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Patient evaluation

1.Assess lifestyle and identify other CV riskfactors or concomitant disorders that

affects prognosis and guided treatment2.Reveal identifiable causes of high BP

3.Assess the presence or absence of target

organ damage and CVD


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Causes of Hypertension

Primary Hypertension

Secondary Hypertension


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Primary Hypertension

Primary ( Essential ) Hypertension is

Hypertension of undetermined cause

90 % population or higher

Genetic: 30-60 %


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Chronic kidney disease

Renovascular disease

Primary aldosteronism

Sleep apnea

Coarctation of the aorta

Thyroid or parathyroid disease

Pheochromocytoma

Drug induced or related causes

Chronic steroid therapy and cushing syndrome


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Mechanism of Hypertension

Factors in maintaining normal bloodpressure

BP = C.O. X PERIPHERAL RESISTANCE

Hypertension = Increased CO and/or PR


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Feedback System Control BP

Heart Rate

Stroke Volume

Systemic Vascular Resistance Blood Volume

Venous Return:skeletal and respiratory pump

Neural Regulation Hormonal Regulation

Local Regulation


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Target organ damage (TOD)

Heart :-Left Ventricle Hypertrophy

-Angina/prior myocardial infarction

-Heart Failure-Aneurysm aorta

Brain: - Stroke or TIA

Kidney:- Chronic Kidney Disease Peripheral Artery:- PAD

Eyes:- Retinopathy


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SECONDARY HYPERTENSION

1. Renal Parenchymal Disease a. Chronic glomerulonephritis b. Diabetic nephropathy

Progressively worsening renal damage a. Acute renal diseases that are often reversible. b. Unilateral and bilateral diseases without renal

insufficiency

c. Chronic renal disease with renal insufficiency d. Hypertension in the a nephric state and after

renal transplantation.


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2. Renovacular Hypertension a. Extensive atherosclerotic b. Renal artery stenosis

c. Partial obstruction of one main renal artery3. Renin secreting tumors a. In young patient with severe hypertension

b. Secondary aldosteronism manifested byhypokalemia.c. Willmss tumor in children


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SECONDARY HYPERTENSION

4. Primary aldosteronism a. Solitary benign adenoma. b. Bilateral adrenal hyperplasia.

c. Severe hypertension with hypokalemia.5. Cushing syndrome a. The secretion of a mineralocorticoid

b. High free cortisol c. Patient with central obesity, thin skin, muscleweakness and osteoporosis


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6. Pheochromocytoma

a. Wild fluctuation in blood pressure

b. May beincorrectly ascribed topsychoneurosis.

c. In the adrenal medulla

d. Sudden spell


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Special consideration

Hypertension urgencies and emergency

Hypertension in woman

Hypertension in children and adolescent Hypertension in older person and

dementia

Obesity and metabolic syndrome Left Ventricular Hypertrophy (Hypertensive

Heart Disease)


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Hypertensive Emergency

Severe hypertension

> 220mmHg/120mmHg

Acute impairment organ system

Possibility irreversibleorgan-damage.

Lowered aggressively over minutes tohours with an antihypertensiveagent.
http://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Irreversiblehttp://en.wikipedia.org/wiki/Antihypertensivehttp://en.wikipedia.org/wiki/Antihypertensivehttp://en.wikipedia.org/wiki/Irreversiblehttp://en.wikipedia.org/wiki/Organ_systemhttp://en.wikipedia.org/wiki/Hypertension


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Hypertension Emergency

1. Cerebro vascular

a. Hypertensive encephalopathy

b. Intracerebral hemorrhage

c. Subarachnoid hemorrhage

d. Atherothrombotic brain infarction withsevere hypertensive


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2. Cardiac

a. Acute aortic dissection b. Acute left ventricular failure/acute lung

edema

c. Acute coronary insufficiency

d. After coronary bypass surgery


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Others:

Acute glomerulonephritis

Pheochromocytoma crisis

Eclampsy

Severe epistaxis

Drug induced or interaction with MAOinhibitor


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Hypertension Urgencies

1. Accelerated and malignant hypertension

2. Rebound hypertension after sudden cessationof antihypertension

3. Surgical

a. Post operative hypertension

b. Severe hypertension after kidneytransplantation

4. Severe body burns


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Management of Hypertension

Emergency and Urgency Hospitalization and parenteral drug

therapy,decreased BP in minute-hours.

5-120 min.20-25 %(mean arterial pressure)

2-6 hours 160/100 mmHg

6-24 hours


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Specific Conditions of HT

Emergency Need specific management:

1.Stroke Infarction and Hemorrhagic

2.Encephalopathy 3.Head Trauma

4.Brain Tumor

5.Dissection of Aortic Aneurysm 6.Acute Lung Edema

7.Acute Coronary Syndrome


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WHITE COAT HYPERTENSION

- elevated BP in a clinical setting but not inother settings

- due to the anxietysome peopleexperience during a clinic visit.
http://en.wikipedia.org/wiki/Anxietyhttp://en.wikipedia.org/wiki/Anxiety


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Ambulatory Blood PressureMonitoring

Continually monitored during sleep, A night time fall is normal. Correlates with sleep quality, age, hypertensive

status, marital status, and social networksupport

Absence of a night time dip : associated withpoorer health outcomes.

Nocturnal hypertension is associated with endorgan damage and is a much better indicatorthan the daytime blood pressure reading.


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Ambulatory Blood PressureMonitoring

Morning surge The day-night time fluctuates : Values rising in the daytime and falling after midnight

calculate the BP dip Independent studies: Blunted or abolished fall dip andabnormal ABP higher incidences of LVH and CVmortality

AHA: Excessive morning blood pressure surge

predictor of stroke in elderly people with high bloodpressure


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DIPPER/Non DIPPER

American Heart Association's calculation

using systolic blood pressure(SBP):

Dip= 1(Syst sleeping : Syst waking)100% RangeClass

20%Extreme Dipper
http://en.wikipedia.org/wiki/Systolic_blood_pressurehttp://en.wikipedia.org/wiki/Systolic_blood_pressure


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Rebound Hypertension

Withdrawl of chronically used anti-hypertensive medication

especially with beta blockers.


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Treatment Overview

Goals of therapy

Lifestyle modification

Pharmacologic treatment

Classification and management of BP foradult and special consideration

Follow up and monitoring


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Goal of therapy

Reduce CVD and renal morbidity andmortality

Achieve SBP goal specially in persons > 50years of age

Treat to BP


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Lifestyle Modification

Modification Approximate SBPreduction (range)

Weight reduction 5-20mmHg/10 kgweight loss

Dietary sodiumreduction

2-8 mmHg

Physical activity 4-9 mmHg

Alcohol consumption 2-4 mmHg

Eating plan 8-14 mmHg


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Weight Reduction

Increased insulin sensitivity (Mark 1998)

Decreased symphatic activity(Masuo,2001)

Improved baroreflex controle(Grassi 1998) Improved endothelial cell by increase NO

which is induced vasodilatation(Perticone2001)


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Dietary Sodium Reduction

Decreasing sodium has always been thefirst line dietary intervention

Decrease Plasma Atrial NatriureticHormone (Jula 1992)

Increased B adrenergic response(Feldman1992)

Decreased hyperfiltration of glomeruly(Weir 1995)


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Physical Activity andHypertension

Lower sympathetic nerve traffic accompanied bypotentiation of baroreceptor reflex

Reduced arterial stiffness and increased totalsystemic arterial compliance

Increased release of endothelium derived nitricoxide that maybe related to lower plasma

cholesterol Increased insulin sensitivity


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Resistant Hypertension

Improper BP measurement

Excess sodium intake

Inadequate diuretic therapy

Inadequate doses

Drug action and interaction

Excess alcohol intake

Identifiable causes of hypertension


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Hypertension in elderly

SBP > 140 mmHg and DBP >90 mmHg or more

Insidence 60-70 % (NHANES III)

Isolated Systolic Hypertension (ISH) : SBP>140mmHg and DBP < 90 mmHg

Insidence 8 % (60 y) and 25 % (>80 y)

Lower initial drug dose may be indicated to

avoid symptom. Standard doses and multiple drugs will be

needed to reach BP target.


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Hypertension in elderly

Common misconception :

1. a normal systolic pressure is "100 plus your age" (SBP170 in a 70-year-old person wrongly be considered

normal)2. too rapid or too great of a reduction of BPmay be poorly

tolerated in older people.

Important to measure BP:

while they are standing in addition to while they aresitting or lying develop postural hypotension(episodesof lightheadedness or falling)


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Pathophysiology Hypertension inOlder Person

Stiffness of vascular

Stiffness of myocardium (Cross linking of

myocardial collagen Decreased CO

LV dysfunction /LV thickness

Atherosclerotic renal vascular

Primary Aldosteronism


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Hypertension Elderly

> 65 y old < 65 y oldPlasma renin decreased Normal/decrease

Cardiac output decreased Normal/decrease

Renal blood flow decreased Normal

Plasma volume decreased Normal

Perpheral vascularresistance

increased Normal/decrease/increase

Left ventricular

hypertrophy

increased Normal


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HYPERTENSION IN WOMEN

Risk Factors/ Family history

With birth control

In pregnancy

After menopause


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Hypertension in Pregnancy

CHRONIC HYPERTENSION

GESTATIONAL HYPERTENSION (PIH,

pre-eclampsia, or "toxemia"), which ismuch more dangerous, and

COMBINED:chronic hypertension +

gestational hypertension (the worstpossibility)


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CHRONIC HYPERTENSION inPregnancy

Affect the baby

Placental exchange

Age the placenta prematurely Intrauterine growth restriction (IUGR--small babies) and

oligohydramnios (low amount of amniotic fluid).

Abnormal nutritional exchange low BP in fetus

danger the fetal kidneys

decreasing the amount ofurine the unborn baby produces (urine is the mostsignificant portion of amniotic fluid).

Gestational hypertension or


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Gestational hypertensionorpregnancy-induced

hypertensionDefinition :

The development of newarterial hypertensionin a

pregnantwoman after 20 weeks gestation. Pre-eclampsia and eclampsia are sometimes

treated as components of a common syndrome

Hypertension before week 20 :

if the woman has multiple fetusesor ahydatidiform mole
http://en.wikipedia.org/wiki/Arterial_hypertensionhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Multiple_birthhttp://en.wikipedia.org/wiki/Hydatidiform_molehttp://en.wikipedia.org/wiki/Hydatidiform_molehttp://en.wikipedia.org/wiki/Multiple_birthhttp://en.wikipedia.org/wiki/Pregnancyhttp://en.wikipedia.org/wiki/Arterial_hypertension


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Gestational Hypertension

Unknown

Immunologic rejection of the pregnancy ( babyas a hostile tissue-graft reaction)

More dangerous condition than chronichypertension more alteration in the maternalbody than just high BP

Chemical shift of maladaptative reactions death in the pregnant patient.


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Gestational Hypertension

High BP Edema (central of the face rather than

peripheral of the ankles--peripheral swelling isnormal)

Brain swelling is the cause of seizures, lethargy,and visual disturbances

Hyperproteinurea or spilling protein in the urine Hyper-reflexia or exaggerated deep tendonreflexes (the knee-jerk)


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Treatment Pregnant InducedHypertension

Bedrest (either at home or in the hospital maybe recommended)

Hospitalization (as specialized personnel andequipment may be necessary)

Magnesium sulfate (or other antihypertensivemedications for PIH)

Fetal monitoring


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Hypertension and Birth Control

Taking birth control pills is linked with high BP insome women

Risk Factors:

Overweight

High BP during pregnancy

Predisposing condition (mild kidney disease or

family history of high BP) Combination of birth control pills and cigarette

smoking :especially dangerous in some women

the overview of hypertension 2009

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