HYPERTENSION

Systemic hypertension

• long-lasting, usually permanent increase of systolic and diastolic blood pressure

primary (essential) hypertension – unknown cause; usually coincidence of more factors – neural,

hormonal, kidney dysfunction, ...

secondary (symptomatic) hypertension – symptom (sign) of other disease

SECONDARY HYPERTENSION

essential hypertension – 90 to 95 % of high blood pressure

prevalence:

• children...about 4 %, mostly secondary

• middle age ... 11-21 %

• 50-59 years old ... approximately 44 %

• 60-69 years old ... approximately 54 %

• more than 70 years old ... ≥ 64 %

(Standard guidelines, 2nd edition)

CLASSIFICATION OF HYPERTENSION

7th report of

Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

JNC 7

CLASSIFICATION OF ADULT´S HYPERTENSION

Previous classification of hypertension (JNC 6, WHO)

REASONS FOR ACTUALISATION OF CLASSIFICATION JNC 6 (1997):

Completing of more new clinical studies with substantial consequences for the treatment of hypertension.

Need for less complicated classification of hypertension.

Need for new and clear guidelines suitable for physicians.

Previous reports didn´t bring expected benefits.

RISK OF CARDIOVASCULAR DISEASES

the higher BP, the higher risk of heart failure, stroke, renal diseases

each increase of systolic BP by 20 and diastolic BP by 10 mm Hg doubles the risk of CVD

BENEFIT OF BP REDUCTIONIn clinical studies was during antihypertensive

therapy recorded:

35-40% incidence reduction of stroke 20-25% incidence reduction of myocardial infarction

more than 50% share at incidence reduction of heart failure

it is assumed that among patients at first stage of hypertension (140-159/90-99 mm Hg) and with other cardiovascular risk factors, permanent reduction of BP by 12 mm Hg during 10 years prevents one death from 11 treated patients (when CVS disease or organ affection, it is one from 9)

EFFECTIVITY OF BP REDUCTION

Despite the fact that decreasing of BP below 140/90 mm Hg is successful among more and more patients, still their number (34%) is less than intention (50%), 30% still doesn´t know about their disease

EVALUATION OF PATIENTS

All of these datas influence the prognosis and therapy selection.

Evaluation of patients with diagnosed hypertension has importance to:

evaluate the way of living + reveal other CVS risk factors and/or associated diseases

Very important is the circadian rhythm of blood pressure.

Physiological profound nocturnal decline, mostly around 4 a.m. ("dipping"), acts as a protection against pathological lesions of blood vessels, resp. reduces them

Hypertensive patients with significant nightime BP decrease have a more favorable prognosis ,as patients whose blood pressure at night compared to daytime values doesn´t decrease (worse prognosis)

-→ according to it are patients diveded to „dippers“ versus „non-dippers“

Improvement of diagnosis ← broader application of 24-hour blood pressure monitoring

Circadian rythm of BP (dippers vs. non-dippers)

WE GAIN INFORMATION ABOUT PATIENT FROM :

Anamnesis Physical examination (BP measurement, eyeground examination, BMI calculation, listening to murmurs at large arteries, detailed examination of heart, lungs, stomach, searching for enlarged kidneys, palpation of glandula thyroidea, resistency and abnormal pulsation of aorta, palpation of lower extremities to search for oedemas and pulsations, neurologic examination)

Laboratory examinations (ECG, urine, blood glucose, haematokrit, kallium, calcium, creatin in serum, lipid spectrum of serum)

TREATMENT The final goal of antihypertensive therapy is reduction

of mortality and morbidity to CVS and renal diseases.

Primary goal is reduction of systolic BP. We want to reach BP less than 140/90 mm Hg (Torr), or less than 130/80 mm Hg among diabetic patients and patients with kidney diseases

Needed is also early detection.

NONPHARMACOLOGICAL TREATMENT

Change of life-style:

• intake of salt ... ≤ 5 – 6 g per day

• prevention of obesity – dietetic modification

• alcohol ... ≤ 30 g per day

• smoking – stop

• physical activity

• psychical relaxation

PHARMACOLOGIC TREATMENT

Antihypertensives

1st choice drugs: 1. diuretics

2. β-blockers

3. inhibitors of ACE

4. blockers of AT1 receptors (ARB)

5. calcium channel blockers

2nd choice drugs – mainly to drug combinations: α1-sympatholytics; α2-sympathomimetics; direct

vasodilators; kallium channel openers;

agonists of I1 receptors in CNS; other mechanisms of action

Therapeutic algorithm of hypertension treatment (JNC 7)