DR K BEMAUL-SUKHU

Epidemiology
• 30 % of adults meet criteria for a diagnosis of hypertension
• Seventy-three million Americans are hypertensive
• 20 % of hypertensive patients are unaware of their condition
• In the US hypertension is the second leading cause of CKD
• In 2010, hypertension was said to have caused 32,000 new cases of kidney
failure

Source: United States Renal data system, Centre of Disease Control and Prevention
 More common in blacks, Filipinos, and Native Americans and less
in whites and Mexican Americans, rates increase with age, and is
greater in the southeastern United States.

 Hypertension is more common in men (though menopause tends

to decrease this difference) and in those of low socioeconomic
status.

 WHO has identified hypertension as the leading cause of

cardiovascular mortality
 Hypertension (HTN) sometimes called arterial
hypertension, is a chronic medical condition in which the
blood pressure in the arteries is elevated.
Regulation
Endogenous regulation of arterial pressure is not completely understood, but
the following mechanisms of regulating arterial pressure have been well-
characterized:
 Baroreceptor reflex
Baroreceptors (carotid sinuses, aortic arch) detect changes in bp. These send
signals to the medulla via the ANS, adjusts the MAP by altering the total
peripheral resistance , rate & force of cardiac contractions

Baroreceptors (venae cavae ,pulmonary veins, atria) regulate secretion of

ADH/Vasopressin, renin and aldosterone

 Renin-angiotensin system (RAS)

Juxtaglomerular cells sense the decrease in bp and release renin.

 Converts angiotensinogen to angiotensin I

 Angiotensin I flows in the bloodstream until it reaches the capillaries of
the lungs where angiotensin converting enzyme (ACE) acts on it to convert
it into angiotensin II.

Angiotensin II
 vasoconstrictor thus increases bloodflow to the heart and subsequently
the preload, ultimately increasing the co.
 increases in the release of aldosterone from the adrenal glands.

Aldosterone further increases the Na+ and H2O reabsorption in the distal
convoluted tubule
Decrease in GFR is sensed as a decrease in Na + levels by the macula densa.

 increases Na+ reabsorption.

 macula densa releases adenosine which causes constriction of the afferent

arterioles.
 RAS is targeted -ACE inhibitors and ARB.

 Aldosterone system -spironolactone, an aldosterone antagonist.

 Fluid retention -diuretics; the antihypertensive effect of diuretics is due

to its effect on blood volume.
 baroreceptor reflex is not targeted in HTN because if blocked, individuals
may suffer from orthostatic hypotension & syncopy.
HTN is classified as either primary (essential) or secondary hypertension:
 90–95% of cases are categorized as "primary HTN" which means high blood
pressure with no obvious underlying medical cause.
 Remaining 5–10% of cases (secondary HTN) are caused by other conditions
that affect the kidneys, arteries, heart or endocrine system.
 Essential Hypertension

•tends to be familial and is likely to be the consequence of an interaction between environmental and genetic factors

Non modifiable risk factors Modifiable risk factors

 Age ≥ 55 yrs  Sendentary lifestyle
 Male sex  High fat high cholesterol diet
 FHx of premature CAD  Smoking
 < 55 yrs in men  Abdominal obesity
 < 65 yrs in women  Impaired glucose tolerance
 Dyslipidemia
 Stress
Secondary hypertension

Kidney diseases or endocrine diseases.

 Renal artery stenosis- abdominal bruit

 Aortic coarctation -decreased bp in the lower extremities and/or
delayed or absent femoral arterial pulses.
 Cushing's syndrome -truncal obesity, glucose intolerance, moon
face, a hump of fat behind the neck/shoulder, and purple stretch
marks
 Pheochromocytoma- Labile or paroxysmal HTN, associated
headache, palpitations, pallor, sweat
 Primary Hyperaldosteronism
 Thyroid disease.
 Drugs – steroids, oral contraceptives, decongestants
 Secondary Hypertension
Investigate for secondary hypertension in the following situations

 Sudden onset of hypertension or worsening in patient > 55yrs

or < 30yrs
 Serum creatinine increase by more than 30% after starting ACE
inhibitor or ARB
 Hypokalemia of < 3.5 without an obvious cause or < 3.0 with
diuretic use
 Paroxysmal hypertension > 180/110 systolic
 Hypertension with headaches, sweating or panic attack
 Hypertension triggered by beta-blockers or micturition
 Incidentally discovered adrenal mass
 Severely elevated blood pressure ( 180 / 110—termed
malignant or accelerated hypertension) is referred to as a
"hypertensive crisis", as blood pressure at this level confers a
high risk of complications.
People with bp in this range may have no symptoms, but are
more likely to report headaches (22% of cases) and dizziness
than the general population. May include visual deterioration
or SOB due to heart failure or a general feeling of malaise due
to RF.
Hypertensive emergency:
 diagnosed when there is evidence of direct damage to one or more organs
as a result of severely elevated blood pressure greater than 180/120
mmHg.
 Encephalopathy-brain swelling and dysfunction, characterized by
headaches, AMS.
 Retinal papilloedema and/or fundal hemorrhages and exudates.
 Chest pain may indicate heart muscle damage (MI), aortic dissection.
 Sob, cough, and the expectoration of blood-stained sputum are
characteristic signs of pulmonary edem due to LVF
 AKI and microangiopathic hemolytic anemia .
 In these situations, rapid reduction of the blood pressure is mandated
to stop ongoing organ damage
 In contrast there is no evidence that blood pressure needs to be
lowered rapidly in hypertensive urgencies where there is no
evidence of target organ damage and over aggressive reduction of
blood pressure is not without risks.

 Use of oral medications to lower the BP gradually over 24 to 48h is

advocated in hypertensive urgencies.
 Systolic pressure Diastolic pressure
JNC7
mmHg mmHg
Normal 90–119 60–79

High normal or
prehypertensio
n 120–139 80–89

Stage 1 140–
90–99
hypertension 159

Stage 2
≥160 ≥100
hypertension
Isolated
systolic ≥140 <90
hypertension
Signs and symptoms
 Rarely symptomatic, and its identification is usually through screening.
 May report headaches (particularly at the back of the head, in the
morning), as well as lightheadedness, vertigo, tinnitus (buzzing or hissing
in the ears), altered vision or fainting episodes.
 On physical examination, hypertension may be suspected on the basis of
the presence of hypertensive retinopathy
 Classically, the severity of the hypertensive retinopathy changes is graded
from grade I–IV, although the milder types may be difficult to distinguish
from each other.
 Ophthalmoscopy findings may also give some indication as to how long a
person has been hypertensive
 System Tests

Microscopic urinalysis,
Renal proteinuria, BUN and/or
creatinine
Serum sodium, potassium,
Endocrine
calcium, TSH
Fasting blood glucose,
Metabolic HDL, LDL, and total
cholesterol, triglycerides

Other ECG, and CXR

Management
Lifestyle modifications
 dietary changes
 physical exercise
 weight loss.

These have all been shown to significantly reduce

blood pressure. Their potential effectiveness is
similar to and at times exceeds a single
medication.
Prevention
 Lifestyle changes are recommended to lower blood pressure, before
starting drug therapy.
2004 British Hypertension Society guidelines/ consistent with those outlined
by the US National High BP Education Program in 2002 for the primary
prevention of hypertension:
 body weight for adults (e.g BMI 20–25 kg/m2)
 Na intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of Na/day)
 regular aerobic physical activity such as brisk walking (≥30 min per day, 4-
7 days/ wk)
 limit alcohol-< 3 units/day M & < 2 units/day F
 diet rich in fruit & vegetables (at least 5 portions/ day);
A drink is defined:

13.6 g of pure ethanol

44ml or 1.5 oz of 40% proof liquor
12 oz of 355 ml of beer or I glass of wine 148 ml or 5 oz of 12 % wine.

Canadian guidelines suggests a more aggressive approach to Sodium :

< 1200mg for > 70yrs olds
1300mg for 51 – 70 yr olds
1500 mg for ≤ 50yrs
DASH diet (Dietary Approaches to Stop Hypertension)
 nuts, whole grains, fish, poultry, fruits and vegetables lowers blood
pressure.
 A major feature of the plan is limiting intake of sodium, although the diet
is also rich in potassium, magnesium, calcium, as well as protein.
Programs aimed to reduce psychological stress:
 yoga, relaxation and other forms of meditation do not appear to reduce
blood pressure, and, of the techniques with supportive evidence, there is
limited information on whether the modest reduction in blood pressure
results in prevention of cardiovascular disease.
 Several exercise regimes—including isometric resistance exercise, aerobic
exercise, resistance exercise and device-guided breathing—may be useful
in reducing blood pressure.
Benefits of Smoking Cessation

 Daytime blood pressure was reduced by about 3.6

mmHg one week after quitting smoking
 Heart rate decreased by about 7 beats/min after
smokers quit for one week
 The above difference is the effect of quitting and not
the same for those who never smoked

Am J Hypertens. 2001 Sep;14(9 Pt 1):942-9.

 If drug treatment is initiated JNC-7 recommends that the physician not
only monitor for response to treatment but should also assess for any side
effects resulting from the medication.

 Reduction of the blood pressure by 5 mmHg can decrease the risk of

stroke by 34%, of ischaemic heart disease by 21%, and reduce the
likelihood of dementia, heart failure, and mortality from cardiovascular
disease
 The Cochrane collaboration, WHO & US guidelines supports low dose
thiazide-based diuretic as first line treatment.

 UK guidelines emphasise CCB > 55 yrs /African/Caribbean family origin,

with ACE-I as first line for younger people.

 Compared to placebo and other anti-hypertensive drugs as first-line

therapy for hypertension, beta-blockers have greater benefit in stroke
reduction.
Elderly
 Tx moderate- severe HTN decreases death rates & cardiovascular
morbidity & mortality in 60yrs & older.

 Goal as <150/90 mm Hg with thiazide diuretic, CCB, ACEI, or ARB being

the first line medication in the US, & in the revised UK guidelines CCB are
advocated as first line with targets of clinic readings <150/90, or <145/85
on ambulatory or home Bp monitoring
Medication Therapy

 Recommended if systolic BP > 140mmHg or diastolic >

90mmHg with lifestyle modification

 Or systolic > 140mmHg & diastolic > 90 mmHg with

target organ damage or diagnosed CAD

 DM systolic BP > 130 mmHg & diastolic > 80mmHg

Medication Therapy
 Isolated systolic HTN and widened pulse pressure (SBP ≥ 160 mmHg and
DBP ≤ 70 mmHg)

 One or more associated conditions or evidence of end-organ damage

 high absolute risk for cardiovascular disease assessed according to clinical

indicators or the risk calculator
Specific Agents in Special Patient Populations
 Getting to Target
• Only 30 % would reach target with one agent

• Close to 60% of patients would require 2 or more agents to reach targets

• Combinations of ACE-I with thiazide diuretics preferred

• Avoid combinations of ACE inhibitors & ARBs

• Avoid combination of non-dihydropyridine CCB with BB

Prognosis
 HTN is the most important, preventable risk factor for premature death
worldwide.
 It increases the risk of IHD, CVA, PVD, and other cardiovascular diseases,
including HF, aortic aneurysms, diffuse atherosclerosis, and PE.
 Risk factor for cognitive impairment, dementia, and CRF.
 Hypertensive retinopathy and hypertensive nephropathy.