The Overview of Hypertension

Dr. Ira Andaningsih SpJP 2010

Purpose Why JNC 7?

Publication of any new studies Needed for a clear and concise guideline
useful for clinicians Need to simplify the classification of BP

BP classification
BP classification Normal SBP mmHg
< 120

DBP mmHg
and <80 or 80 -89 or 90 -99 or > 100

Prehypertensio 120 - 139 n St I 140 -159 Hypertension St 2 > 160 Hypertension

CVD Risk
The BP relationship to risk of CVD is continuous,

consistent and independent of others RF Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg Pre hypertension signals need for increased education to reduce BP in order to prevent hypertension

Benefits of lowering BP
Stroke incidence reduction 35-40 % Myocardial Infarction reduction 20-25 % Heart Failure reduction 50 %

Patient evaluation
1.Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guided treatment 2.Reveal identifiable causes of high BP 3.Assess the presence or absence of target organ damage and CVD

Causes of Hypertension

Primary Hypertension Secondary Hypertension

Primary Hypertension
Primary ( Essential ) Hypertension is Hypertension of undetermined cause 90 % population or higher Genetic: 30-60 %

Secondary Hypertension

Chronic kidney disease Renovascular disease Primary aldosteronism Sleep apnea Coarctation of the aorta Thyroid or parathyroid disease Pheochromocytoma Drug induced or related causes Chronic steroid therapy and cushing syndrome

Mechanism of Hypertension
Factors in maintaining normal blood pressure

BP = C.O. X PERIPHERAL RESISTANCE Hypertension = Increased CO and/or PR

Feedback System Control BP

Heart Rate Stroke Volume Systemic Vascular Resistance Blood Volume Venous Return:skeletal and respiratory pump Neural Regulation Hormonal Regulation Local Regulation

Target organ damage (TOD)

Heart :-Left Ventricle Hypertrophy
-Angina/prior myocardial infarction -Heart Failure -Aneurysm aorta Brain: - Stroke or TIA Kidney:- Chronic Kidney Disease Peripheral Artery:- PAD Eyes:- Retinopathy

SECONDARY HYPERTENSION
1. Renal Parenchymal Disease a. Chronic glomerulonephritis b. Diabetic nephropathy Progressively worsening renal damage a. Acute renal diseases that are often reversible. b. Unilateral and bilateral diseases without renal insufficiency c. Chronic renal disease with renal insufficiency d. Hypertension in the a nephric state and after renal transplantation.

Secondary Hypertension
2. Renovacular Hypertension a. Extensive atherosclerotic b. Renal artery stenosis c. Partial obstruction of one main renal artery 3. Renin secreting tumors a. In young patient with severe hypertension b. Secondary aldosteronism manifested by hypokalemia. c. Willmss tumor in children

SECONDARY HYPERTENSION
4. Primary aldosteronism a. Solitary benign adenoma. b. Bilateral adrenal hyperplasia. c. Severe hypertension with hypokalemia. 5. Cushing syndrome a. The secretion of a mineralocorticoid b. High free cortisol c. Patient with central obesity, thin skin, muscle weakness and osteoporosis

Secondary Hypertension
6. Pheochromocytoma a. Wild fluctuation in blood pressure b. May beincorrectly ascribed to psychoneurosis. c. In the adrenal medulla d. Sudden spell

Special consideration
Hypertension urgencies and emergency Hypertension in woman Hypertension in children and adolescent Hypertension in older person and

dementia Obesity and metabolic syndrome Left Ventricular Hypertrophy (Hypertensive Heart Disease)

Hypertensive Emergency
Severe hypertension > 220mmHg/120mmHg Acute impairment organ system Possibility irreversible organ-damage. Lowered aggressively over minutes to

hours with an antihypertensive agent.

Hypertension Emergency
1. Cerebro vascular a. Hypertensive encephalopathy b. Intracerebral hemorrhage c. Subarachnoid hemorrhage d. Atherothrombotic brain infarction with severe hypertensive

Hypertension Emergency
2. Cardiac a. Acute aortic dissection b. Acute left ventricular failure/acute lung edema c. Acute coronary insufficiency d. After coronary bypass surgery

Hypertension Emergency
Others: Acute glomerulonephritis Pheochromocytoma crisis Eclampsy Severe epistaxis Drug induced or interaction with MAO
inhibitor

Hypertension Urgencies
1. Accelerated and malignant hypertension 2. Rebound hypertension after sudden cessation
of antihypertension 3. Surgical a. Post operative hypertension b. Severe hypertension after kidney transplantation 4. Severe body burns

Management of Hypertension Emergency and Urgency

Hospitalization and parenteral drug

therapy,decreased BP in minute-hours. 5-120 min.20-25 %(mean arterial pressure) 2-6 hours 160/100 mmHg 6-24 hours<140/90 mmHg

HYPERTENSION SEVERE without TOD Hospitalization (-) Immediate combination oral anti hypertensive therapy.

Specific Conditions of HT Emergency

Need specific management: 1.Stroke Infarction and Hemorrhagic 2.Encephalopathy 3.Head Trauma 4.Brain Tumor 5.Dissection of Aortic Aneurysm 6.Acute Lung Edema 7.Acute Coronary Syndrome

WHITE COAT HYPERTENSION

- elevated BP in a clinical setting but not in other settings - due to the anxiety some people experience during a clinic visit.

Ambulatory Blood Pressure Monitoring

Continually monitored during sleep, A night time fall is normal. Correlates with sleep quality, age, hypertensive

status, marital status, and social network support Absence of a night time dip : associated with poorer health outcomes. Nocturnal hypertension is associated with end organ damage and is a much better indicator than the daytime blood pressure reading.

Ambulatory Blood Pressure Monitoring

Morning surge The day-night time fluctuates : Values rising in the daytime and falling after midnight

calculate the BP dip Independent studies: Blunted or abolished fall dip and abnormal ABP higher incidences of LVH and CV mortality AHA: Excessive morning blood pressure surge predictor of stroke in elderly people with high blood pressure

DIPPER/Non DIPPER
American Heart Association's calculation using systolic blood pressure (SBP): Dip= 1 (Syst sleeping : Syst waking)100% RangeClass <0%Reverse Dipper 0% - 10%Non-Dipper 10% - 20%Dipper >20%Extreme Dipper

Rebound Hypertension
Withdrawl of chronically used antihypertensive medication especially with beta blockers.

Treatment Overview
Goals of therapy Lifestyle modification Pharmacologic treatment Classification and management of BP for
adult and special consideration Follow up and monitoring

Goal of therapy
Reduce CVD and renal morbidity and
mortality Achieve SBP goal specially in persons > 50 years of age Treat to BP <140/90 or 130/80 mmHg in patients with diabetes or chronic kidney disease

Lifestyle Modification
Modification Weight reduction
Dietary sodium reduction Physical activity

Approximate SBP reduction (range) 5-20mmHg/10 kg weight loss 2-8 mmHg

4-9 mmHg

Alcohol consumption
Eating plan

2-4 mmHg
8-14 mmHg

Weight Reduction
Increased insulin sensitivity (Mark 1998) Decreased symphatic activity(Masuo,2001) Improved baroreflex controle(Grassi 1998) Improved endothelial cell by increase NO
which is induced vasodilatation(Perticone 2001)

Dietary Sodium Reduction

Decreasing sodium has always been the
first line dietary intervention Decrease Plasma Atrial Natriuretic Hormone (Jula 1992) Increased B adrenergic response (Feldman1992) Decreased hyperfiltration of glomeruly (Weir 1995)

Physical Activity and Hypertension

Lower sympathetic nerve traffic accompanied by

potentiation of baroreceptor reflex Reduced arterial stiffness and increased total systemic arterial compliance Increased release of endothelium derived nitric oxide that maybe related to lower plasma cholesterol Increased insulin sensitivity

Resistant Hypertension
Improper BP measurement Excess sodium intake Inadequate diuretic therapy Inadequate doses Drug action and interaction Excess alcohol intake Identifiable causes of hypertension

Hypertension in elderly
SBP > 140 mmHg and DBP >90 mmHg or more Insidence 60-70 % (NHANES III) Isolated Systolic Hypertension (ISH) : SBP>140

mmHg and DBP < 90 mmHg Insidence 8 % (60 y) and 25 % (>80 y) Lower initial drug dose may be indicated to avoid symptom. Standard doses and multiple drugs will be needed to reach BP target.

Hypertension in elderly
Common misconception : 1. a normal systolic pressure is "100 plus your age" (SBP 170 in a 70-year-old person wrongly be considered normal) 2. too rapid or too great of a reduction of BPmay be poorly tolerated in older people. Important to measure BP: while they are standing in addition to while they are sitting or lying develop postural hypotension(episodes of lightheadedness or falling)

Pathophysiology Hypertension in Older Person

Stiffness of vascular Stiffness of myocardium (Cross linking of
myocardial collagen Decreased CO LV dysfunction /LV thickness Atherosclerotic renal vascular Primary Aldosteronism

Hypertension Elderly
> 65 y old < 65 y old Plasma renin Cardiac output Renal blood flow Plasma volume Perpheral vascular resistance Left ventricular hypertrophy decreased Normal/decrease decreased Normal/decrease decreased Normal decreased Normal increased Normal/decrease /increase increased Normal

HYPERTENSION IN WOMEN
Risk Factors/ Family history
With birth control In pregnancy After menopause

Hypertension in Pregnancy
CHRONIC HYPERTENSION GESTATIONAL HYPERTENSION (PIH,
pre-eclampsia, or "toxemia"), which is much more dangerous, and COMBINED: chronic hypertension + gestational hypertension (the worst possibility)

CHRONIC HYPERTENSION in Pregnancy

Affect the baby Placental exchange Age the placenta prematurely Intrauterine growth restriction (IUGR--small babies) and oligohydramnios (low amount of amniotic fluid). Abnormal nutritional exchange low BP in fetus danger the fetal kidneys decreasing the amount of urine the unborn baby produces (urine is the most significant portion of amniotic fluid).

Gestational hypertension or pregnancy-induced hypertension

Definition : The development of new arterial hypertension in a pregnant woman after 20 weeks gestation. Pre-eclampsia and eclampsia are sometimes treated as components of a common syndrome Hypertension before week 20 : if the woman has multiple fetuses or a hydatidiform mole

Gestational Hypertension
Unknown Immunologic rejection of the pregnancy ( baby
as a hostile tissue-graft reaction) More dangerous condition than chronic hypertension more alteration in the maternal body than just high BP Chemical shift of maladaptative reactions death in the pregnant patient.

Gestational Hypertension
High BP Edema (central of the face rather than

peripheral of the ankles--peripheral swelling is normal) Brain swelling is the cause of seizures, lethargy, and visual disturbances Hyperproteinurea or spilling protein in the urine Hyper-reflexia or exaggerated deep tendon reflexes (the knee-jerk)

Treatment Pregnant Induced Hypertension

Bedrest (either at home or in the hospital may
be recommended) Hospitalization (as specialized personnel and equipment may be necessary) Magnesium sulfate (or other antihypertensive medications for PIH) Fetal monitoring

Hypertension and Birth Control

Taking birth control pills is linked with high BP in

some women Risk Factors: Overweight High BP during pregnancy Predisposing condition (mild kidney disease or family history of high BP) Combination of birth control pills and cigarette smoking :especially dangerous in some women