s.moradmand md. systemic hypertension definition: a level of blood pressure that is associated with...
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S.Moradmand MD.
SYSTEMIC HYPERTENSION
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DEFINITION:
A level of blood pressure that is associated With increased morbidity & mortality
At some future time when compared With the whole population
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BP Range mm Hg Category
DBP <85 Normal BP85 – 89 High normal BP90 – 104 Mild hypertension105 – 114 Moderate hypertension>115 Severe hypertension SBP when DBP<90mm Hg < 140 Normal BP 140 – 159 Borderline isolated systolic hypertension >160 Isolated systolic hypertension
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CLASSIFICATION of BLOOD PRESSURE
Normal <130 <85
High Normal 130-139 85-89
Hypertension Stage 1(Mild) 140-159 90-99 Stage 2(Moderate) 160-179 100-109 Stage3(Severe) 180-209 110-119 Stage4(Very severe) >210 >120
Category Systolic Diastolic
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5
Guidelines
The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults: (Brashers, 2006, p.1)
Category Systolic Diastolic
Normal <120 and <80Pre-hypertension 120-139 or 85-89
Stage 1 hypertension
140-159 or 90-99
Stage 2 hypertension
>160 or >100
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Pulse Pressure: Systolic minus Diastolic Presurre
Mean BP = DP + 1/3 Pulse Pressure
( A good indicator of tissue perfusion)
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Angiotensinosion
Angiotensin 1
Angiotensin 2
Angiotensin3
Renin Renin Release
B-blocker
Coverting Enzyme
ACEIReceptor
Antagonist
Angiotensinases
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Persistently raisedClinic BP
Target organ damage
Home BP
Ambulatory BP
Continue to monitorClinic & home BP
StartTreatment
yes
high
high
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Systolic Pressure
1.Stroke volume
2.The velocity of ejection
3.The elastic properties of aorta
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Diastolic Pressure
1.Competency of aortic valve
2.The condition of arteries & their ability to stretch & store energy
3.Resistance of arterioles
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Blood PressureCardiac output X Peripheral resistance
cardiac
HR contractility
RenalFluid volume
humoral
sympathethic
local
Dilator (beta)
Constictor ( Alpha)
VasodilatorProstaglandins
VasoconstrictorsAngiotensin-endothelinn
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classification1. Essential HTN
2. Renal HTN
92-94%
ParanchymalRenovascular
3.Endocrine HTN Primary Hyperaldostronism Cushing’s syndrome Pheochromocytoma OCP
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Essential HTN
HerediteryEnviromentalSalt sensitivity High renine Low renine NonmodulatingCell membrane defectInsulin resistance
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Renin Release control
1. Blood volume , Renal perfusion
2. Na filtrated to Macula Densa
3. Sympathetic nervous system
4. Dietary Potassium
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Low renin HTN
1. 20% of patients2. Increased extracellular volme3. On high sodium diet mild degree of hyperaldostronism4. Increased sensitivity of adrenal cortex to angiotensin II
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Nonmodulating Essential HTN
1. Adrenal defect apposite to low renin2. 25-30% of patients 3. Normal or high renin4. Na intake dosen’t modulate adrenal or renal response5. Corrected with ACEI
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Cell Membrane Defect Abnormality in Na transport
Calcium accumulation inVascular smooth muscle cells
Increased vascular reactivity to Vasoconstrictor agents
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Calcium in HTN
1. Low ca++ intake increase BP
2. Ca++ blockers are effective antihypertensives
3. Salt loading increase NF
4. Digital sensitive Na-K ATPase lead to intracellular calcium accumulation
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Insulin Resistanse
1. Increased sympathetic activity
2. Vascular smooth muscle hypertrophy
4. Increase cytosolic calcium
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Natural hx of HTN
1.Progressive & lethal if untreated2.Shortening of life 10-20 years3.If untreated in 7-10 years develope 30 % athersclerosis, 50% CHF, Cardiomegaly ,CVA, Renal insufficeincy & retinopathy.4.Morbid Cardiovascular events by as much as 20 fold
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Hx., Ph.E., Lab. Tests1. Uncovering secondary HTN
2. Establishing a pretreatment baseline
3. The factors that may influence therapy
4. Determining if target organ damage?
5.Determining if other CAD risk factors?
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Renal Paranchymal HTN
1. Volume expansion
2. Renin-Angiotensin system
3. Unidentified pressure agent
4.Fail to produce vasodilator substance
5. Fail to inactivate vasopressores
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Endocrine HTN
1.Aldostronism2.Cushing Sndrome3.Adrenogenital Syndrome4.Pheochromocytoma5.Acromegaly6.Hypercalcemia7.Oral contraceptives
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Oral Contraceptives
1. Estogen stimulate hepatic angiotensinogen
2. 5% increase BP
3. Familial Factors
4. Age over 35
5. Obesity
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Symptoms & Signs
1.Elevated pressure itself headache,dizziness,palpitation, easy fatigability2.Hypertension vascular disease: epistaxis,hematuria,TIA,angina,dyspnea3.Underlying disease in secondary HTN: polyuria & polydipsia,…4.Most patients are asymptomatic
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Factors indicating adverse prognosis1. Black race 2. Youth age3. Male4. Persistent diastolic pressure >115 mmhg5. Smoking6. Diabetes Mellitus7. Hypercholesterolemia8. Obesity9. Excess alcohol intake10.Evidence of End Organ Damage
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Manifestation of Target Organ Disease
1.Cardiac :CAD LVH Cardiac Failure
2.Cerebrovascular:TIA / CVA
3.Peripheral Vascular
4.Renal
5.Retinopathy
InfarctionHemorrhageEncephalopathy
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Medical Therapy
1.DIURETICS
2.ACEI
3.BETA-BLOCKERS
4.CALCIUM BLOCKERS
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Drugs used in Emergency HTN
1.Hydralazine2.Minoxidil3.Diazoxide4.Nitroprusside
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Basis of Treatment
Salt restriction Na intake <100mm
Relaxation Reduce sympathetic
Weight loss Diet /Exercise
Exercise Aerobic
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Basic Tests for EvaluationUrinalysisCBC(Hct)Na-KCreatinine/BUNEKGFBS-Cholestrol(LDL-HDL)-TGCa++-Phosphate-Uric AcidChest-X-Ray / Echocardiogram
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Coarctation of Aorta
Diminished or delayed Femoral Pulses
Rib notching on chest-X-Ray
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PheochromocytomaUnusual lability of BPSymptomatic Paroxysm of HTNSpell of Pallor Palpitation Perspiration HeadacheHypertensive reaction to G/A or antihypertensive drugs
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Renovascular HTN1. Age under 302. DBP > 120 mmHg3. Continuous bruit in epigasrium or flanks4.Accelerated HTN5.Hx. Of flank pain,hematuria or renal truma6.palpable kidney
7.HTN resistant to treatment
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Conn’s Syndrome
1.Serum potassium less than 3.6
2.Urinary Potassium more than 30/24h in the absence of diuretic therapy
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Isolated Systolic HTNA.Decreased aortic compliance as in arteriosclerosisB.Increased stroke volume 1-AI 2-Thyrotoxicosis 3-Hyperkinetic heart syndrome 4-Fever 5-AVF 6-PDA
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