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DR.

MUSTAFA SHAHABAT

Hypertension

CORRECTED BY RAND AL-WAQFI

Hypertension

We will talk about blood pressure regulation and hypertension take care its important, now we will talk about blood pressure regulation. (Blood flow=blood pressure) (The variant in blood pressure is due to either the resistance in blood vessels or decrease in blood flow) Blood pressure regulation: blood pressure is regulated by nervous pathway and renal pathway so blood pressure is regulated by two mechanisms: Short term (moment to moment regulation): changing in blood pressure during changing in position (sleeping to setting.. ) , what involve in regulation of blood pressure? We have what is called baroreceptors which are located in the Aortic arch and internal carotid arteries , they are collection of neurons and it is sensitive to either decrease or increase in blood pressure for example when there is decrease in blood flow the baroreceptors will send impulse to the vasomotor center which is located in medulla oblongata and it will stimulate the sympathetic nervous system so as to increase the Heart rate, contractility, cardiac output and to cause peripheral vasoconstriction so by the end blood pressure will be increased and vise versa but it will make block for the sympathetic not stimulate parasympathetic cause the sympathetic system is the dominant so either stimulation or block of the sympathetic nervous system "important " Long-Term regulation of blood pressure: in case of loss of blood, bleeding, hemorrhage or hypovolmic shock "hypovolemia" in such situation we need more than baroreceptors to keep the balance in the circulation. we have what is called renin angiotensine aldosterone system the purpose of this system to maintain the volume of blood if there is hypotension for example due to bleeding or loss of fluids "hypervolemia" renin which is secreted by kidneys will convert angiotensinogen "protein released by the liver " ( why ?due to decrease of blood flow) to angiotensin I then Angiotensin I is subsequently converted to angiotensin II by the enzyme angiotensin converting enzyme found in the lungs. Angiotensin I is inactive but angiotensin II is active and important . What is the function of angotensine II ? it is the most potent vasoconstrictor in the body, it enhance the release of aldosterone from the cortex of the Superenal glands and aldoserone at the end will lead to sodium water retention it will lead also to increase

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the reabsorption of sodium and water from proximal tubules of the kidneys , and it will block the bradykinin(it is vasodilator ) and so it will lead to local constriction so by the end there will water sodium retention and vasoconstriction which lead to increase blood pressure. Keep in mind I am talking abut compensated loss "0.5 or 1 liter " and if the loss is decompensated loss like 5 liter this mechanism will not be effective Two mechanisms to maintain blood pressure in normal situation : nervous pathway which include baroreceptors related to heart rate of contractility and cardiac output renal pathway which include renin angiotensine aldosterone related to maintenance of the volume. These two mechanisms are extremely important because most of hypotensive drugs act as ATE inhibitors, they prevent the formation of angiotensin II from angiotensin I. About the first group of slides : every thing I said is here . Slide 12 : here two situation to two dogs one with baroreceptors and the other with denervated baroreceptors . The first one is normal, there is no fluctuation. In the second one blood pressure extremely is fluctuated, there is no control. As in the following diaghram :

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Now we will talk about hypertension Hypertension: it is sustained elevation of blood pressure beyond the normal average. Sustained: Normal average *systolic=120-139 *diastolic=80-89mmHg Blood pressure = systolic/diastolic. Systolic blood pressure: is created from the contraction of left ventricles. Diastolic: created from the recoil of the aorta. Main blood pressure = diastolic+1/3(systolic-diastolic). In intensive care unit I dont look from systolic or diastolic I directly look for main blood pressure at that moment. To a girl in our age "19 year" it is not acceptable that the blood pressure is 135/89 even it is within normal average; it is consider prehypertenion, but for the doctor it is good. We have always considered the age, for 70 years man 140/90 it is excellent (why? Because atherosclerosis (or thrombosis) is most common due to over-age ) but for you no it is hypertension. What are the signs and symptoms of hypertension ? Usually there is no signs and symptoms, mostly it is discovered accidently( that's why it's called silent killer), when the person go to the emergency department to the clinic for another and chick their blood pressure they discover hypertension and they must check the blood pressure over days. Rarely: Headache Blurry vision Chest Pain Frequent urination at night Dizziness . Why frequent urination? It is physiological mechanism to decrease the volume ( because water is released out of the body). We measure the blood pressure by sig manometer. There is 3 Categories of blood pressure: BP Systolic Diastolic Follow-up Category (mmHg) (mmHg) Optimal Normal < 120 < 130 And And < 80 < 85 Recheck 2 years Recheck 2 years

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High Normal

130-139

Or

85-89

Recheck 1 year

What causes hypertension ? 1-90-95% we dont know the cause "primary hypertension " 2- Secondary Hypertension = 5 to 10% The cause might be (Cardiac, renal or endocrine), why? Because these three system involve in maintenance of blood pressure (heart, kidney and endocrine" hormones: epinephrine, nor epinephrine, antidiuretic hormones and atrial natriuretic piptide") From the slides: Kidney Abnormalities Narrowing of certain arteries Rare tumors(ex: pheochromocytoma :tumor in adrenalin gland and this tumor will secrete adrenalin or norepinephrine and this will lead to increase in blood pressure) Adrenal gland abnormalities Pregnancy What Causes High Blood Pressure? We said mostly we dont know the reasons, Risk factors : Controllable Risk Factors Increased salt intake Obesity(most dangerous the central obesity(the abdominal region)) ,the best parameter to know if you are obese or not is the Waist circumference it should be the half of the height, which enhance the bad situation is the obesity ) Alcohol Stress Lack of exercise( girls should walk 10000 feet daily =45 minutes ) Uncontrollable Risk Factors Heredity Age Men between age 35 and 50 Women after menopause Race

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1 out of every 3 African Americans (not very important) Higher incidence in non-Hispanic blacks and Mexican Americans Blood pressure=Cardiac output * total peripheral resistance So increase in cardiac out put increase blood pressure or total peripheral resistance will increase blood pressure. Blood Pressure is the force exerted on a unit of area of blood vessels. Complications: -Hypertension will lead to ischemic heart diseases, and it may lead to myocardial infarction cause destroy the endothelial layer. There is strong relationship between hypertension and ischemic heart diseases. -Stroke: it is either thromboses (block of one artery which lead to death of beyond cell) or bleeding in the brain (interracial hemorrhage) . it caused CVA (cerebrovascular accident) -Congestive heart failure -Kidney failure -Heart attack -Heart rhythm problems -Aneurysm ( expansion of blood vessels ) What Can I Do? High blood pressure is a lifelong disease(chronic disease) Blood pressure can be controlled not cured" " Controlling blood pressure will reduce the risk of stroke, heart attack, heart failure and kidney disease What Can I Do? Loose weight if your overweight Get regular physical activity Avoid excessive alcohol Stop smoking Manage your stress Medication for High Blood Pressure Diuretics( first line) Rid the body of excess fluids and salt Beta-blockers ( second line) Reduce the heart rate, contractility and the work of the heart. Calcium antagonists

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Reduce heart rate and relax blood vessels. Angiotensin II receptor blockers(ACE) Interfere with the bodies production of angiotensin, a chemical that causes the arteries to constrict (narrow) Vasodialators Cause the muscle in the wall of the blood vessels to relax, allowing the vessel to dialate (widen) There is two types of hypertension we will talk about: *Malignant Hypertension: high blood pressure (180/130) highly developed blood pressure suddenly and if it is not treated its dangers ( fatal). * Resistant Hypertension: it dose not respond to a treatment of 3 medications one of it is diuretics. What is the blood vessel that is involved in regulation of blood pressure? Arteriole.

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