Hypertension

Hypertension

• What is Blood Pressure?– Pressure created by the heart as it pumps blood

through the arteries and the circulatory system

• What do Blood Pressure Numbers Mean?– Top number (Systolic)= Pressure while heart is

beating– Bottom number (Diastolic)= Pressure while heart

is resting between beats

Lifestyles, fitnessand rehabilitation

Hypertension

• Normal Blood Pressure– Blood Pressure of < 140/ 90– Blood Pressure of 130 to 139/ 85 to 89 should be

closely watched

• High Blood Pressure– Blood Pressure > 140/ 90

Lifestyles, Fitnessand Rehabilitation

Hypertension

• How can I tell if I have High Blood Pressure?– Usually NO SYMPTOMS!– “The Silent Killer”– May have: • Headache• Blurry vision• Chest Pain• Frequent urination at night

Lifestyles, Fitnessand Rehabilitation

Hypertension

• Blood Pressure Measurement– Sphygmomanometer– Systolic pressure= pressure when 1st sound is heard– “Diastolic pressure= pressure when last sound is

heard

• Blood Pressure Cuff Size– Small – children and small adults– Average– Large – overweight and large adults

American Heart AssociationRecommended Blood Pressure Levels

BP Category

Systolic (mmHg)

Diastolic (mmHg)

Follow-up

Optimal < 120 and < 80 Recheck

2 years

Normal < 130 and < 85 Recheck 2 years

High Normal

130-139 or 85-89 Recheck 1 year

American Heart AssociationRecommended Blood Pressure Levels

BP Category

Systolic (mmHg)

Diastolic (mmHg)

Follow-up

Stage 1(mild HTN) 140-159 or 90-99

Confirm within months

Stage 2(moderate HTN)

160-179 or 100-109Evaluate within 1 month

Stage 3(severe HTN)

180 or > or 110 or >Evaluate immediately

Hypertension

• What Causes High Blood Pressure?– Cause unknown in 90 to 95% of cases = Primary

Hypertension– Secondary Hypertension = 5 to 10%• Kidney Abnormalities• Narrowing of certain arteries• Rare tumors• Adrenal gland abnormalities• Pregnancy

Hypertension

• What Causes High Blood Pressure?– Controllable Risk Factors• Increased salt intake• Obesity• Alcohol• Stress• Lack of exercise

Hypertension

• What Causes High Blood Pressure?– Uncontrollable Risk Factors• Heredity• Age

– Men between age 35 and 50– Women after menopause

• Race– 1 out of every 3 African Americans– Higher incidence in non-Hispanic blacks and Mexican

Americans

Hypertension

• Women and High Blood Pressure– Birth Control Pill– Pregnancy– Overweight– After Menopause– African Americans

Hypertension

• What does High Blood Pressure do to my Body?– Stroke– Congestive heart failure– Kidney failure– Heart attack– Heart rhythm problems– Aneurysm

Drugs used in Treatment HTN

1. Diuretics 2. Sympatholytics3. Calcium channel blocker 4. Angiotensin converting enzyme inhibitirs

(ACE-I)5. Angiotensin 2 receptor blockers 6. Vasodilators

Drugs used to treat HTN will affect one of these parameters

CO TPR

SVSV HR HR

Preload Contractility

Venous tone Venous tone Intravascular volume Intravascular volume

Na\H2O retentionNa\H2O retention

BP

Drugs used to treat HTN will affect one of these parameters

TPR CO

Direct innervation Direct innervation Circulating regulatorsCirculating regulators

Local reglators BP

Drugs that reduce CO

• Drugs that reduce SV– Drugs that reduce contractility

• Beta blockers • CCB (NDHP)

– Drugs that reduce preload• Drugs that decrease venous tone

– Alpha 1nblockers– Sodium nitroprusside– ACE inhibitors– AT1 antagonist

• Drugs that decrease intravascular volume– Diuretics– ACE inhibitors– AT1 antagonist

Drugs that reduce CO

• Drugs that reduce HR– Beta blockers – CCB

Drugs that reduce TPR• Drugs that affect smooth muscle contraction

– CCB– Direct arteriolar vasodilators

• Drugs that affect direct innervation– Alpha 1 blockers– Central alpha 2 agonist

• Drugs that affect circulating regulators– Alpha 1 blockers– Central alpha 2 agonist– ACE inhibitors– AT1 antagonist

• Drugs that affect local regulators– Endothelin antagonist– ACE inhibitors– AT1 antagonist– Na nitroprusside

1. Diuretics

• Hydrochlorothiazide• Furosamide

• Combination HCT+amiloride• Spironolactone in HTN caused by hyper

aldosteronismREVIEW DIURETICS LECTUREREVIEW DIURETICS LECTURE

Diuretics and HTN

• Diuretics is useful in volume based HTN• HCT is the first line of treatment why?• Loop diuretics is preferred over thiazide in

these situations1. Volume based HTN with renal insufficiency2. Malignant HTN

• Spironolactone is preferred in HTN induced by hyperaldosteronism

2. Sympatholytics 1. Ganglionic blockers :trimethaphan (last line TMT )2. A1 blocker :prazocin ,doxazocin – Was previously used in HTN – Very useful in patients suffering from BPH and HTN

3. A2 agonist :clonidine ,methyldopa– Methyldopa is th drug of choice for pregnant women with HTN

4. B blocker : atenolol ,propranolol– B1 selective is preferred – Review their contraindications !

REVIEW SYMPATHETIC NERVOUS SYSTEM LECTURESREVIEW SYMPATHETIC NERVOUS SYSTEM LECTURES

B blocker

Beta Blockers• Labetolol is available in IV form and it is limited to

treat HTN emergencies

• Side effects– Tiredness– Cold hands and feet

• Because of vasoconstriction of blood vessels

– Impotence and sexual dysfunction– May mask the effect of hypoglycemia in DM– Dyslipidemia how to correct this SE?

Beta Blockers

B blocker

• Relative contraindications– Asthma/COPD– Decompensated CHF– Raynaud’s phenomenon– Peripheral vascular disease– Depression

Calcium channel blocker(CCB)

• Nifedipine • Amlodipine • Verapamil • Diltiazem

Calcium Channel Antagonists

• Direct vasodilators• Used in combination with other antihypertensive

drugs • Avoid in patients with Congestive Heart Failure

(especially short duration DHP)• Most common side effects – Constipation – Peripheral edema– Headache – Exacerbate myocardial ischemia

ACE-I

• Captopril • Enalapril • Ramipril

ACE (angiotensin converting enzyme) Inhibitors

• First line TMT • Method of action– Block the enzyme that converts angiotensin I to

angiotensin II ( a vasoconstrictor)– Promote vasodilatation– Lowers aldosterone secretion

• Especially useful– HTN with CHF or DM

• Side effects– Dry Cough

• Accumulation of bradykinin– Rash– Angioneurotic edema– Taste disturbance– Hyperkalemia

ACE-I

• Contraindications– Pregnancy– Bilateral renal artery stenosis– Athma – COPD’s

ACE-I

Angiotensin receptor antagonist

• Valsartan • Losartan

Angiotensin receptor blockers

• Method of action– Block the AT2 receptor causing a fall in peripheral

resistance

• Very similar to ACE inhibitors but does not cause a cough why?

Vasodilators

Vasodilators

• Hydralazine• Minoxidil

• Sodium nitroprusside

Hydralazine PO

• Direct vasodilation of arteriolar smooth muscle decrease TPR

• The decrease in TPR cause :– Reflex tachycardia– Sodium water retention

• Use of beta blockers minimize these symp. effects

• Clinical uses:1.Hypertension 2.Congestive heart failure

• Used in combination with nitrates

Hydralazine side effects

• Lupus like syndrome• Cardiovascular effects– Hypotension– Tachycardia– Palpitation – Angina

• Headache• Nausea• Diarrhea

Minoxidil

• Direct vasodilation of arteriolar smooth muscle decrease TPR

• The decrease in TPR cause :– Reflex tachycardia– Sodium water retention • Use of beta blockers minimize these symp. effects

• It works by opening of potassium channels

Minoxidil • Clinical uses:

1. Severe HTN2. Hair replacement (bladness)

• Side effects:1. Cardiovascular effects

• Hypotension• Tachycardia• Palpitation • Angina

2. Headache3. Hypertrichosis

Sodium nitroprusside

• Vasodilatation of arteriolar and venous smooth muscle decrease TPR

• Vasodilataion mediated by NO production• Works by releasing nitric oxide• It has short duration of action and rapid onset

of action• It is available as intravenous infusion

Sodium nitroprusside • Clinical uses:

1. HTN emergencies 2. Severe HF

• Side effects:1. Cyanide toxicity2. Thiocyanate toxicity 3. Cardiovascular effects

• Hypotension• Tachycardia• Palpitation • Angina

4. Headach

Cardiac arrhythmia ,acid base imbalance and death

Convulsions ,muscle spasm

Hypertension management

• High blood pressure is a lifelong disease and need lifelong TMT – Except if it was secondary HTN and we treat the

underlying cause

• Blood pressure can be controlled not cured• Controlling blood pressure will reduce the risk

of stroke, heart attack, heart failure and kidney disease

HTN management : Non pharmacological treatment

• Lifestyle modification is always recommended but is frequently inadequate on its own– Salt restriction to 4 grams per day

• The antihypertensive effect of many medicines is enhanced by sodium restriction

– Weight loss to within 15% of ideal body weight is the goal• Although as little as a 10 lb loss may decrease BP significantly

– Alcohol restriction– Regular exercise even without weight loss– Reduce all other cardiovascular risk factors

Hypertension management:drug therapy

• If the patient is not suffering from severe hypertension begin with single drugchoosing one of these – ACE –I is the best choic if there wasn’t ACE –I is the best choic if there wasn’t

contraindications contraindications – Thiazide diuretic – Beta blockers

• If the BP remains uncontrolled add another agent see the next slide

Uncontrolled

Uncontrolled

Uncontrolled

Uncontrolled

Uncontrolled

Continue therapy

Reduce dose of the initial drug

Reduce dose of the beta blocker

Continue thearapy

Continue therapy

Controlled

Controlled

Controlled

Controlled

Controlled

Disease processes which are affected by anti-hypertensive drugs:

• Diabetes – Beta-blockers and thiazide diuretics may make glycemic control difficult. ACE inhibitors can protect the kidney.

• Coronary Artery Disease – Beta-blockers offer a mortality benefit (in general). Short-acting calcium channel blockers can worsen ischemia

Disease processes which are affected by anti-hypertensive drugs:

• Congestive Heart Failure (compensated vs. un-compensated) – Beta-blockers offer a mortality benefit as do ACE inhibitors. Beta-blockers should not be used in uncompensated CHF.

• Hyperlipidemia – Beta-blockers and thiazide diuretics may affect lipid profile unfavorably.

• COPD/Asthma – Beta-blockers need to be used with caution.

Disease processes which are affected by anti-hypertensive drugs:

• Renal Failure – ACE inhibitors may cause a reduction in renal performance

• Pregnancy – ACE inhibitors and ARB’s are contraindicated.

• Aortic Stenosis – Vasodilators need to be introduced with caution.

• Hyperuricemia (Gout) – Thiazide diuretics may increase uric acid levels

Disease processes which are affected by anti-hypertensive drugs:

• Benign Prostatic Hypertrophy – Alpha-1 blockers can provide symptomatic improvement.

• Depression – Beta-blockers may exacerbate.• Raynaud’s Syndrome – Beta-blockers may

exacerbate.

Disease processes which are affected by anti-hypertensive drugs:

• Peripheral Vascular Disease (with Symptoms) – Beta-blockers need to be used with discretion.

• Renal Artery Stenosis (bilateral vs. unilateral) – ACE inhibitor or ARB’s are relatively contraindicated.

• Cardiac Conduction Defects – Beta-blockers, diltiazem and verapamil can exacerbate conduction defects.

What is the malignant hypertension?

• Clinical syndromes characterized by severe(typically acute) elevation in BP and this abrupt increase in BP associated with target organ vascular damage– Retinal hemorrhage– encephalopathy– Renal insufficiency– Left ventricular failure

• Life threatening condition

How we can treat it?

• Intravenous antihypertensive agents– Labetalol – Sodium nitroprusside– Furosemide The goal is not normalization of BPBecause sudden hypoperfusion may result in brain

injury

• Excess fluid may be removed with loop diuretics

Demographic factors that affect drug therapy selection for the HTN patients

• Elderly people– Maximum response seen with• Diuretics• CCB

– Beta blockers cause AV node blockage and MI– They have decreased levels of renin so they show

little response to ACE-I

• African people– Maximum response seen with• Diuretics• CCB

– Beta blockers show little response • Mutation in beta receptors

– They have decreased levels of rennin so they show little response to ACE-I

Demographic factors that affect drug therapy selection for the HTN patients