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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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Secondary Hypertension
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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Secondary Hypertension
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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Secondary Hypertension
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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Hypertension Emergency
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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Hypertension Emergency
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.
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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
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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