Hypertension PDF

Hypertension Dr. Mohammed Essam Hypertension (HTN) is a persistent elevation of arterial blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. - It is the most common cardiovascular condition in the world. - The prevalence of HTN in Egypt is 26.3% among adult...

Hypertension Dr. Mohammed Essam Hypertension (HTN) is a persistent elevation of arterial blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. - It is the most common cardiovascular condition in the world. - The prevalence of HTN in Egypt is 26.3% among adult population. - Its incidence increases with aging, around 50% of Egyptians above 60 years have hypertension. - Blood pressure is the amount of force your blood uses to get through your arteries. - Blood pressure is a measure of the force that your heart uses to pump blood around your body. - Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. - Blood pressure is the pressure, measured in millimeters of mercury, within the major arterial system of the body. - Blood pressure is conventionally separated into systolic and diastolic determinations. - Systolic pressure is the maximum blood pressure during contraction of the ventricles. - Diastolic pressure is the minimum pressure recorded just prior to the next contraction. - To measure blood pressure, we use an instrument call a sphygmomanometer. BP is determined by cardiac output and total peripheral resistance, or systemic vascular resistance, each of which are affected by a number of other factors. Cardiac output is affected by heart rate and stroke volume (SV). - Total peripheral resistance is affected by the caliber of the BP rises when cardiac arteriolar bed (i.e. peripheral output, total peripheral vascular resistance), the viscosity of resistance, or both are the blood, and the elasticity of the increased.. arterial walls. Classification of Blood Pressure in Adults  Mechanism - BP regulated by various systems: the sympathetic nervous system, the renin-angiotensin, aldosterone system, vasopressin, nitric oxide, and a number of vasoactive peptides (e.g., endothelin and adrenomedullin). - HTN develops when an imbalance occurs among these Systems. Mechanism 1- The sympathetic nervous system. 2- The renin-angiotensin, aldosterone system. 3- vasopressin (ADH). 4- nitric oxide. 5- vasoactive peptides (e.g., endothelin and adrenomedullin).  by water retention and increase blood volume Mechanism by vc HTN develops when an imbalance adrenal gland occurs among the various systems that regulate BP: the sympathetic nervous system, the renin, angiotensin, aldosterone system, vasopressin, nitric oxide, and a number of vasoactive peptides (e.g., endothelin and adrenomedullin).  Mechanism HTN develops when an imbalance occurs among the various systems that regulate BP: the sympathetic nervous system, the renin, angiotensin, aldosterone system, vasopressin, nitric oxide, and a number of vasoactive peptides (e.g., endothelin and adrenomedullin).  Mechanism HTN develops when an imbalance occurs among the various systems that regulate BP: the sympathetic nervous system, the renin, angiotensin, aldosterone system, vasopressin, nitric oxide, and a number of vasoactive peptides (e.g., endothelin and adrenomedullin). Regardless of cause, without effective treatment and control, HTN begets more HTN due to arteriolar remodeling, which leads to target organ damage (e.g., retinopathy, left ventricular hypertrophy [LVH], renal insufficiency, and encephalopathy), organ failure, and premature death. - In addition, patients with HTN are more likely to be obese and to have insulin resistance, type 2 diabetes mellitus (DM), and dyslipidemia (high triglycerides and low levels of high-density lipoprotein cholesterol).  2. Types of HTN ➔ Primary, or essential HTN is diagnosed when no known cause can be identified (about 90% to 95% of cases). ➔ Secondary HTN can be directly attributed to a specific cause, such as renal, endocrine, vascular, and neurologic disorders and various drugs and toxins.  2. Types of HTN ➔ Labile HTN occurs when BP is sometimes elevated and other times normal. ➔ White-coat HTN, which is defined as elevated BP that occurs in the clinic but not during normal daily life.  2. Types of HTN: ➔ Masked HTN exists when an individual has a normal clinic BP but high ambulatory BPs, which may occur in up to 10% of the general population and is associated with an increased rate of target organ damage and increased mortality.  2. Types of HTN: ➔ Malignant HTN: involves markedly elevated BP (usually >160/110 mm Hg) causing retinal hemorrhages, exudates, or papilledema. Risk factors: Include age, ethnicity, obesity, glucose intolerance, smoking, stress, excess sodium or alcohol intake, decreased intake of potassium, calcium, and magnesium, and lack of exercise. 3. Pathophysiology: Alterations in endothelial and arteriolar structure, mechanical properties, and function lead to HTN, which creates a pressure load on the left ventricle (LV) followed by compensatory LVH. In addition, stiffening of the large systemic arteries with age increases LV afterload and widens the pulse pressure, leading to greater LVH and eventual heart failure.  Initially, normal LV systolic function is maintained by the hypertrophied LV, but diastolic dysfunction develops early in the disease process. LVH and associated myocardial fibrosis results in prolonged relaxation time as well as a stiffer (less compliant) LV, both of which produce higher LV end-diastolic, left atrial, and pulmonary venous pressures, which leads to pulmonary congestion. ❏ To achieve adequate filling, the stiffer LV becomes more dependent on active atrial contraction and is adversely affected by tachycardia and arrhythmias where active atrial contraction is absent (e.g., atrial fibrillation) ❏ When filling volume is inadequate, SV is reduced and symptoms of pulmonary congestion and inadequate cardiac output may develop (i.e., diastolic heart failure). ❏ Higher filling pressures inhibit coronary flow and reduce coronary reserve, increasing the risk of myocardial ischemia and arrhythmias. LVH, although initially adaptive and desirable, has long-term deleterious effects on cardiac energy balance and contractile function. Ventricular remodeling, and LV systolic function becomes impaired with resultant decrease in SV and increases in end-systolic and end-diastolic volumes (ESV and EDV, respectively). In the presence of LVH with its reduced compliance, this increase in EDV causes a rise in end-diastolic pressure (EDP), which is reflected back to the LA and pulmonary vessels, resulting in pulmonary edema if the pressure rises high enough to produce transudation of fluid from the capillaries into the interstitial spaces. Initially systolic dysfunction is manifested as reduced LV functional reserve during exercise, but later symptoms can develop even at rest (i.e., CHF). However, systolic dysfunction is asymptomatic in up to one half of patients. HTN is associated with an increased incidence of all-cause and CVD mortality, stroke, coronary artery disease, peripheral arterial disease, and renal insufficiency. Both increased systolic blood pressure (SBP) and pulse pressure (the difference between SBP and diastolic blood pressure [DBP]) if ≥ 60 mm Hg are strong predictors of CVD risk. 4. Clinical manifestations HTN is generally asymptomatic until complications develop in target organs, resulting in: - Cerebral vascular accident (cerebral embolism or hemorrhage). - Hypertensive heart disease. - Atherosclerotic heart disease. - Renal insufficiency or failure, nephrosclerosis. - Aortic aneurysm. - Peripheral vascular disease. - Retinopathy. The clinical manifestations of hypertensive heart disease include the following:  Exertional dyspnea  Fatigue  Impaired exercise tolerance  Increased symptoms with tachycardia and loss of active atrial contraction  Exertional chest discomfort  Signs and symptoms of heart failure. 5. Accurate blood pressure measurement The equipment should be regularly inspected and validated. The operator should be trained. The patient must be properly prepared and positioned and seated quietly for at least 5 minutes in a chair. The auscultatory method should be used. 5. Accurate blood pressure measurement Caffeine, exercise, and smoking should be avoided for at least 30 minutes before BP measurement. An appropriately sized cuff should be used. The device should be on the same level of the heart. At least two measurements should be made and the average recorded. 6. Treatment: - Successful treatment of HTN usually requires two or more medications along with lifestyle Treatment modifications. Components: - For most patients the goal is to achieve a BP 1- Pharmacologic less than 140/90 mm Hg; however, lower levels therapy. (