Essential Essential HypertensionHypertension

Prof. Samir S. al- msalhaProf. Samir S. al- msalha

DefinitionDefinition

Persistent elevation of BP Persistent elevation of BP

( ≥ 140/90 mmHg)( ≥ 140/90 mmHg)

Classification of BP According Classification of BP According to JNC – 7 reportto JNC – 7 report

Normal ≤ 120 mmHg systolic and ≤ Normal ≤ 120 mmHg systolic and ≤ 80 mmHg diastolic80 mmHg diastolic

Prehypertention 120 -139 mm Hg Prehypertention 120 -139 mm Hg systolic and 80-90mm Hg diastolicsystolic and 80-90mm Hg diastolic

Stage -1 Hypertension 140-159 mmHg Stage -1 Hypertension 140-159 mmHg systolic and 90- 99 mmHg diastolicsystolic and 90- 99 mmHg diastolic

Ssage -2 Hypertention ≥ 160 mmHg Ssage -2 Hypertention ≥ 160 mmHg systolic and ≥ 100 mmHg diastolicsystolic and ≥ 100 mmHg diastolic

BP classification

Life style modification

Without compelling indication

With compelling indication

Normal encourage

Prehypertension

yes No anti-HTN drugs Drug(s) for the compelling indication

Stage 1 HTN yes Thiazide-diuretics for most; may consider ACE,ARB,

B-blockers,CCB,or combination

Drug(s)for the compelling indicatios

( thiazides, ACEI,CCB,ARB,B-blocker)

Stage 2 HTN yes 2-drug combination for most (thiazide,ACEI or ARB or B-blocker or CCB)

Drug(s) for the compelling indications

( thiazides, ACEI, ARB, B-blocker, CCB) as indicated

CAUSESCAUSES Essential Hypertention (95 %)Essential Hypertention (95 %) Secondary ( 5%)Secondary ( 5%)1.1. DRUGS( steroids , Contraceptive DRUGS( steroids , Contraceptive

pills,NSAIDS,carbenoxolone,Liquorice,pills,NSAIDS,carbenoxolone,Liquorice,sympathomimetics)sympathomimetics)2. Cardiovascular (Coarctation of the 2. Cardiovascular (Coarctation of the

aorta)aorta)3. Renal (Renovascular i.e RAS and renal 3. Renal (Renovascular i.e RAS and renal

artery occlusion or Parenchymal i.e artery occlusion or Parenchymal i.e ch. Pyelonephritis,acute and ch. Pyelonephritis,acute and ch.glomeronephritis,obstructive ch.glomeronephritis,obstructive uropathy,polycystic kidney diseaseuropathy,polycystic kidney disease and hypernephromas.and hypernephromas.

CAUSESCAUSES

4.Endocrine:4.Endocrine: ( ( pheochromocytoma, pheochromocytoma,

1° aldosteronism, cushing’s,acromegaly,1° aldosteronism, cushing’s,acromegaly, hyperparathyroidism and hypothyroidism).hyperparathyroidism and hypothyroidism).

55..Others Others (brain tumors with increased intracranial (brain tumors with increased intracranial

pressure,bulbar poliomyelitis,connective pressure,bulbar poliomyelitis,connective tissue disorders i.e SLE and polyarteriti tissue disorders i.e SLE and polyarteriti nodosa,DM nephropathy,Polycythemia nodosa,DM nephropathy,Polycythemia rubra vera)rubra vera)

INITIAL or PRIMARY INITIAL or PRIMARY INVESTIGATIONSINVESTIGATIONS in in HYPERTENSIONHYPERTENSION

UrinalysisUrinalysis Renal profileRenal profile ECGECG Chest x-rayChest x-ray Plain U-T x-ray or renal ultrasoundPlain U-T x-ray or renal ultrasound Urine cultureUrine culture HB, PCVHB, PCV FBS,s.lipids,s.urateFBS,s.lipids,s.urate EchocardiographyEchocardiography

When to investigate for a When to investigate for a secondary cause of secondary cause of

hypertensionhypertension1.1. Clues from the historyClues from the history

2.2. Clues from physical examination Clues from physical examination

3.3. Clues from initial investigationsClues from initial investigations

4.4. Malignant stage hypertensionMalignant stage hypertension

Complications of Complications of hypertensionhypertension

Cardiovascular(angina,MI,LVH,HF,dissectinCardiovascular(angina,MI,LVH,HF,dissecting aortic aneurysm)g aortic aneurysm)

Cerebrovascular(TIA,Thrombotic Cerebrovascular(TIA,Thrombotic infarction,intracerebral infarction,intracerebral hemorrhge,encephalopathy)hemorrhge,encephalopathy)

PeripheralPeripheral vascular vascular disease(atherosclorosis,intermittent disease(atherosclorosis,intermittent claudication, gangrene)claudication, gangrene)

Retinopathy(Grades1,2,3,4)Retinopathy(Grades1,2,3,4) Nephropathy(nephrosclerosis,fibrinoid Nephropathy(nephrosclerosis,fibrinoid

necrosis)necrosis) Malignant hypertensionMalignant hypertension

Treatment of hypertensionTreatment of hypertension

11stst. Non-pharmacological measures:. Non-pharmacological measures:

1. Diet1. Diet

2. Weight reduction2. Weight reduction

3. Stopping smoking and excess 3. Stopping smoking and excess alcohol consumptionalcohol consumption

4. Regular exercise ( behavioral, 4. Regular exercise ( behavioral, biofeedback therapy)biofeedback therapy)

5. Treatment of other associated risk 5. Treatment of other associated risk factorsfactors

B. Antihypertensive medications:B. Antihypertensive medications:

1.1. Diuretics Diuretics

Thiazide, loop, K+ sparingThiazide, loop, K+ sparing

22. B-Blockers. B-Blockers

Non-cardioselectiveNon-cardioselective

CardioselectiveCardioselective

Drugs with ISADrugs with ISA

Alpha and Beta-blockers(labetolol)Alpha and Beta-blockers(labetolol)

3.3. Alpha-blockers ( prazosin) Alpha-blockers ( prazosin)

4.4. Central acting drugs (reserpine, Central acting drugs (reserpine, methyldopa,clonidine)methyldopa,clonidine)

5.5. vasodilators: vasodilators:

11stst. Direct relaxation of arteriolar . Direct relaxation of arteriolar smooth muscle:smooth muscle:

-Hydralazine-Hydralazine

-Minoxidil-Minoxidil

-Diazoxide-Diazoxide

-Na-nitroprusside-Na-nitroprusside

22ndnd. Calcium-channel blockers:. Calcium-channel blockers:

- Verapamil- Verapamil

- Nifedipine- Nifedipine

- Amlodipine- Amlodipine

33rdrd. ACE inhibitors :. ACE inhibitors :

- Captopril- Captopril

- Enalapril- Enalapril

- Lysinopril- Lysinopril

- Quinapril- Quinapril

6. 6. ARBsARBs

- Losartan- Losartan

- Candesartan- Candesartan

- Irbisartan- Irbisartan

- Valsartan- Valsartan

Hypertensive Crisis:Hypertensive Crisis:

Severe hypertension with one of the Severe hypertension with one of the following:following:

1.1. Heart failureHeart failure

2.2. MIMI

3.3. Renal failureRenal failure

4.4. EncephalopathyEncephalopathy

5.5. Dissecting aneurysmDissecting aneurysm

6.6. Intracerebral hemorrhageIntracerebral hemorrhage

7.7. Accelerated or malignant Accelerated or malignant hypertensionhypertension

Parentral Drugs Used In Parentral Drugs Used In Hypertensive Emergencies:Hypertensive Emergencies:1.1. Na-nitroprusside infusionNa-nitroprusside infusion

2.2. Diazoxide i.vDiazoxide i.v

3.3. Hydralazine ivHydralazine iv

4.4. Furosemide i.vFurosemide i.v

5.5. Phentolamine i.vPhentolamine i.v

6.6. Nifedipine s/LNifedipine s/L

7.7. Labetolol i.vLabetolol i.v

( N.B: B.P shouldn’t be reduced to ( N.B: B.P shouldn’t be reduced to below diastolic of 100 mmHg )below diastolic of 100 mmHg )