HYPERTENSION

Yusra Pintaningrum

WHO 1999

JNC VII

ETIOLOGY

MECHANISM OF PRIMARY

HEMODYNAMIC SUBTYPE

Neurohormonal control of blood pressure

Blood pressure
Hypertension

= Cardiac output (CO) x Peripheral resistance (PR)

=

Increased CO

Preload

and/or

Contractility
Fluid volume

Increased PR

Vasoconstriction

Fluid volume

Renal sodium
retention
Excess
sodium
intake

Sympathetic
nervous
system

Reninangiotensinaldosterone
system

Genetic
factors
(Adapted from Kaplan, 1994)

Acute neurohormonal effects on blood

pressure homeostasis
Perfusion

RAA

Heart rate and cardiac output

Sodium and water retention

Blood pressure

SNS

Chronic neurohormonal effects on

vascular structure
Perfusion

RAA

Myocardial hypertrophy

Glomerular hypertention
and hypertrophy

Vascular hypertrophy

SNS

Haemodynamic Transition from Hyperkinetic

to Typical Essential Hypertension
HEART

RESISTANCE ARTERIOLES

Cardiac
compliance

Beta adrenergic
responsiveness

Wall/lumen
ratio

Endothelial
damage

Stroke
volume

Heart rate

Vasoconstriction

Vasodilation

CARDIAC OUTPUT

VASCULAR RESISTANCE

PATOPHYSIOLOGY
The factors affecting cardiac output:
- sodium intake, renal function, &
mineralocorticoids
- the inotropic effects occur via extracellular
fluid volume augmentation
- an increase in heart rate and contractility

Peripheral vascular resistance is dependent

upon the sympathetic nervous system,
humoral factors, and local autoregulation

NEURAL MECHANISM

VASCULAR MECHANISM

HORMONAL MECHANISM

Diagnosis Approach

"The Goal is to Get to Goal!

Hypertension

-PLUSDiabetes or Renal Disease

< 140/90 mmHg

Patients should return for follow-

< 130/80 mmHg

up and adjustment of medications

every 1-2 months until the BP
goal is reached

Algorithm for Treatment of Hypertension

Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Without Compelling
Indications

Stage 1 HTN (SBP 140159 or DBP

9099 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB, or
combination.

With Compelling
Indications

Stage 2 HTN (SBP >160 or DBP >100

mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)

Drug(s) for the compelling

indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.

Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314

Follow-up and Monitoring

Patients should return for follow-up and adjustment of
medications every 1-2 months until the BP goal is
reached
After BP at goal and stable, follow-up visits at 3- to 6month intervals
More frequent visits for stage 2 HTN or with
complicating comorbid conditions
Continue to encourage self BP monitoring
Serum potassium and creatinine monitored 12 times
per year

JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314