Hypertension Cardiology Department, Shanghai Sixth People’s Hospital, Shanghai JiaoTong University

transcript

HypertensionHypertension

Cardiology Department, Shanghai Sixth People’s Cardiology Department, Shanghai Sixth People’s

Hospital, Shanghai JiaoTong UniversityHospital, Shanghai JiaoTong University

Qing ZhaoQing Zhao

HypertensionHypertension

Clinical syndrome characterized as Clinical syndrome characterized as increased systemic arterial pressureincreased systemic arterial pressure

Primary Hypertension Primary Hypertension 90%-95%90%-95%

Secondary HypertensionSecondary Hypertension 5%-10%5%-10%

Diagnostic criteria of hypertension

Chinese Guidelines for Preventive and Chinese Guidelines for Preventive and Treatment of HypertensionTreatment of Hypertension (2004) (2004)

CategoryCategory SBP(mmHg)SBP(mmHg) DBP(mmHg)DBP(mmHg)

NormalNormal ＜＜ 120(≥90)120(≥90) ＜＜ 80(≥60)80(≥60)

High High normalnormal 120-139120-139 80-8980-89

HypertensiHypertensionon ≥≥140140 ≥≥9090

DefinitionDefinition Without any anti-hypertensive medicationWithout any anti-hypertensive medication ，，

SBPSBP≥140mmHg≥140mmHg and/or DBP≥90mmHgand/or DBP≥90mmHg

Blood pressure <140/90mmHg, but having Blood pressure <140/90mmHg, but having

a hypertensive history and currently a hypertensive history and currently

taking an anti-hypertesive medicationtaking an anti-hypertesive medication

Classification of Classification of Hypertension(2004)Hypertension(2004)

CategoryCategory SBP(mmHg)SBP(mmHg) DBP(mmHg)DBP(mmHg)

Grade Grade 11(mild(mild)) 140-159140-159 90-9990-99

Grade 2 Grade 2 (moderate(moderate)) 160-179160-179 100-109100-109

Grade Grade 33(severe(severe)) ≥≥180180 ≥≥110110

Isolated Isolated systolic systolic

hypertensionhypertension≥≥140140 ＜＜ 9090

NoticeNotice

SBPSBP and and DBPDBPfall separately fall separately into different categories, the into different categories, the higher category should be higher category should be takentaken

Isolated systolic hypertension Isolated systolic hypertension can also be graded according can also be graded according to systolic blood pressure to systolic blood pressure values in the ranges indicatedvalues in the ranges indicated

EpidemilologyEpidemilology

MobidityMobidity

In 2002, In 2002, 18.8%18.8%

In 1991, 11.88% In 1991, 11.88%

In 1979, 7.73%In 1979, 7.73%

In 1959, In 1959, 5.11%5.11%

Most common cardiovascular Most common cardiovascular

diseasesdiseases

Hypertension PrevalenceHypertension Prevalence

MobidiMobidityty

AwarenAwareness Rateess Rate

TreatmeTreatment Ratent Rate

Control Control Rate Rate

2000 USA

70% 59% 34%

2002 China

18.8% 30.2% 24.7% 6.1%

19911991 11.11.88%88% 26.3%26.3% 1212.1%.1% 2.8%2.8%1991 1991 UrbanUrban 35.6%35.6% 17.1%17.1% 4.1%4.1%1991 1991 RuralRural 13.9%13.9% 5.4%5.4% 1.2%1.2%

EpidemilologyEpidemilology

Three highThree high High High

mobiditymobidity High High

motalitymotality High High

disable rate disable rate Three lowThree low

Low awareness Low awareness raterate

Low treatment Low treatment raterate

Low control rateLow control rate

General features and General features and patterns of hypertension patterns of hypertension

epidimiologyepidimiology1. Age1. Age

2. Sex differences2. Sex differences

3. Geographical differences3. Geographical differences

4. Seasonal variation exists4. Seasonal variation exists

5. Differences in region, 5. Differences in region, city and city and countrysidecountryside, races and , races and ethnicitiesethnicities

6. Diet, Genetics, etc.6. Diet, Genetics, etc.

EtiololgyEtiololgy

Multiple factorMultiple factor

genetic predispositiongenetic predisposition (40%) (40%)

＋＋ environmental factorenvironmental factor (60%)(60%)

Genetic predispositionGenetic predisposition

Familial Familial aggregationaggregation

60%60%, familial , familial history history

Genetic inheritanceGenetic inheritance Black men more Black men more

white menwhite men

Diet factorsDiet factors

High dietary saltHigh dietary salt Heavy alcohol drinkingHeavy alcohol drinking Long-term over Long-term over coffee intake Low calcium, low potassium, low Low calcium, low potassium, low

magnesium High proteinHigh protein High saturated fatty acid

Psychological factorPsychological factor

Mental status

Psychological diposition

More in More in Brainworker Brainworker

Other factorsOther factors

Overweight or Overweight or obesityobesity

BMI=body BMI=body weightweight （（ kgkg ）／）／body height (m)body height (m)2 （（ 20 20 ～～ 24 24 ））

Contraceptives Obstructive sleep

apnea syndrome (OSAS)

Pathogenesy

mean blood pressure( MBP )

＝ cardiac output(CO)×peripheral vascular

resistance (PR)

Mechanisms of hypertension

Sympathetic nervous systemSympathetic nervous system Renin-angiotensin systemRenin-angiotensin system Renal functionRenal function Insulin resistanceInsulin resistance Decreased ralaxed factors and Decreased ralaxed factors and

increased systolic factorsincreased systolic factors resistance vessel remodlingresistance vessel remodling OthersOthers ：： arterial elasticityarterial elasticity

Sympathetic nervous Sympathetic nervous systemsystem

Sympathetic nervous Sympathetic nervous hyperactivity-----catecholamine hyperactivity-----catecholamine ↑----resistance arterioles ↑----resistance arterioles contracted contracted ↑↑ ---- hypertension---- hypertension

Renin-angiotensin system

AngiotensinogenAngiotensinogenLiver

Kid-ney

Angiotensin ⅠAngiotensin Ⅰ

Angiotensin ⅡAngiotensin Ⅱ

Vascular contractionVascular contraction

Angiotension IIReceptor antangonists

ACEInhibitors

Angiotensin converting enzyme

ReninRenin ingibitors

Receptor

Circulating RAS

Function of ATⅡ ：

① vasoconstriction

② increased myocardial contractility

③ Sodium retention

Tissue RAS

1. RAS in vessel wall

2. Cardiac RAS

• High renin hypertension correlates with

circulating RAS activity

• Normal renin and low renin hypertension

correlates with tissue RAS activity

Circulating RAS and tissue RAS

Insulin resistance, IR

Tissue cells are resistant to insulin,

thereby producing the

hyperinsulinemia.

PathologyPathology

ArteryArtery Arteriolosclerosis hyalinization Smooth muscle cell proliferation

and fibrosis Vessel wall Vessel wall

thickningthickning ，， luminal stenoses Vessel wall remodlingVessel wall remodling Macro- and medium-sized artery

atherosclerosisatherosclerosis

PathologyPathology

HeartHeart Left ventricular Left ventricular

hypertropghyhypertropghy Heart failureHeart failure Hypertensive heart Hypertensive heart

diseasedisease

PathologyPathology

KidneyKidney Renal arteriolar Renal arteriolar

sclerosissclerosis Glomerulus fibrosis, Glomerulus fibrosis,

atrophyatrophy Renal failureRenal failure

PathologyPathology

BrainBrain

microaneurysm 、、 rupturerupture 、、 hemorrhage:

cerebral hemorrhagecerebral hemorrhage

Cerebral atherosclerosis,,thrombokinesis:

cerebral infarctioncerebral infarction ，， lacunar lacunar

infarctioninfarction

PathologyPathology RetinaRetina

arteriola spasm , exudation,

hemorrhage

Clinical manifestation

SymptomSymptom No specific symptomsNo specific symptoms Dizziness, headache, palpitations, Dizziness, headache, palpitations,

easy fitigability,blurring of vision, easy fitigability,blurring of vision, etcetc

Symptoms not related to the level Symptoms not related to the level of blood pressureof blood pressure

Clinical manifestation

First onset as complicationFirst onset as complication heartheart ：： ACFACF 、、 APAP 、、 AMIAMI （（ ACSACS ）） bbrainrain ：： cerebral hemorrhage, cerebral cerebral hemorrhage, cerebral

infarction,TIAinfarction,TIA

kkidneyidney ：： rrenal dysfunctionenal dysfunction

vvesselessel ：： aotic dissectionaotic dissection oothersthers ：： nnasal hemorrhageasal hemorrhage 、、 rretinal etinal

hemmorrhagehemmorrhage

SignsSigns A2 louderA2 louder S4S4 Systolic murmur Systolic murmur 、、 systolic early systolic early

clickclick Sign of LVHSign of LVH

Target organ Target organ damage(TOD)damage(TOD)

LVHLVH ECGECG UCGUCG Chest X-rayChest X-ray

Arterial wall Arterial wall thickeningthickening

IMT IMT ≥0.9≥0.9mmmm

Atherosclerotic plaqueAtherosclerotic plaque

Slight increase in serum Slight increase in serum creatininecreatinine

MaleMale 115-133115-133µµmol/Lmol/L((1.3-1.5mg/dl1.3-1.5mg/dl))

FemaleFemale 107-124107-124µµmol/Lmol/L((1.2-1.4mg/dl1.2-1.4mg/dl))

MicroalbuminuriaMicroalbuminuria 30-30030-300mg/24hmg/24h

Albunim-creatinine ratioAlbunim-creatinine ratio Male Male ≥22mg/g≥22mg/g((2.5mg/ 2.5mg/ mmol/Lmmol/L)) Female Female ≥31mg/g≥31mg/g((3.5mg/ 3.5mg/ mmol/Lmmol/L))

Associated clinical condition(ACC)Associated clinical condition(ACC)

Cerebrovascular Cerebrovascular diseasedisease①①ischemic strokeischemic stroke

②②cerebral hemorrhagecerebral hemorrhage

③③transient ischemic transient ischemic attack(attack(TIATIA) )

Heart disease:Heart disease:①①history of myocardial history of myocardial

infarctioninfarction

②②angina pectorisangina pectoris

③③coronary coronary revascularization(revascularization(PCIPCI ，， CACABGBG))

④④congestive heart failurecongestive heart failure

Renal disease:Renal disease:① ① diabetic nephropathydiabetic nephropathy② ② renal impairrmentrenal impairrment Male Male >133 >133 µµmol/Lmol/L Female Female >124 >124 µµmol/Lmol/L proteinurea proteinurea >300mg/24h>300mg/24h③ ③ renal failurerenal failure creatinine creatinine ＞＞ 177µ177µmol/Lmol/L

Peripheral vascular Peripheral vascular diseasedisease①①aotic dissectionaotic dissection

②②symptomatic symptomatic peripheral arterial peripheral arterial diseasedisease

Advanced Advanced retinopathyretinopathy①①hemorrhages of hemorrhages of

exudatesexudates

②②papilloedemapapilloedema

Special type of Special type of hypertensionhypertension

Hypertension in the elderlyHypertension in the elderly ≥≥60(65)60(65) 岁岁 Isolated systolic hypertensionIsolated systolic hypertension Sensitivity of vessel baroreceptor Sensitivity of vessel baroreceptor

↓↓

Hypertensive crisisHypertensive crisis Hypertensive emergencyHypertensive emergency

Hypertensive urgency Hypertensive urgency

Hypertensive crisisHypertensive crisis

Progress quicklyProgress quickly Marked blood pressure Marked blood pressure

elevationelevation ，， usually usually DBPDBP≥130≥130mmHgmmHg Severe target organ damage in short Severe target organ damage in short

term, especially renal impairment, term, especially renal impairment, retinal hemorrhages and exudates, retinal hemorrhages and exudates, papilloedemapapilloedema

Hypertension in pregnancyHypertension in pregnancy

Pregnancy-Induced Pregnancy-Induced Hypertension(PIH)Hypertension(PIH)

Gestational hypertensionGestational hypertension PreeclampsiaPreeclampsia EclampsiaEclampsia

Diagnosis and Differential Diagnosis and Differential diagnosisdiagnosis

DiagnosisDiagnosis

⒈ ⒈ to define blood pressure is highto define blood pressure is high

⒉ ⒉ to exclude secondary to exclude secondary hypertensionhypertension

⒊ ⒊ to classify hypertension and to to classify hypertension and to stratify risk to quantify prognosisstratify risk to quantify prognosis

Clinical history and familial Clinical history and familial historyhistory

To collect a history of hypertension, To collect a history of hypertension, diabetes, dyslipidemia, coronary heart diabetes, dyslipidemia, coronary heart disease, renal disease, stroke, heart disease, renal disease, stroke, heart failure, etcfailure, etc

To identify risk factors, target organ To identify risk factors, target organ damage, associated clinical conditiondamage, associated clinical condition

Previous anti-hypertensive regimenPrevious anti-hypertensive regimen

Physical examinationPhysical examination

Measure blood pressure, upper Measure blood pressure, upper limbs, lower limbslimbs, lower limbs

BMI, WCBMI, WC Optic funduscopy examination Optic funduscopy examination

Routine examinationsRoutine examinations

Blood sugar, serum lipid, serum Blood sugar, serum lipid, serum potassium, serum uric acid, serum potassium, serum uric acid, serum creatininecreatinine

Hemoglobin and hematocritHemoglobin and hematocrit UrinalysisUrinalysis ElectrocardiogramElectrocardiogram

Recommended Recommended examinationsexaminations

24hABPM24hABPM EchocardiogramEchocardiogram Echograms of carotid arteries and femoral Echograms of carotid arteries and femoral

arteriesarteries C-reactive proteinC-reactive protein Microproteinuria analysisMicroproteinuria analysis Quantitative assessment of urine proteinQuantitative assessment of urine protein Chest X-ray filmChest X-ray film

Risk factorsRisk factors

①①Levels of systolic Levels of systolic and diastolic blood and diastolic blood pressurepressure

②②Male Male ＞＞ 55 55 yearsyears ，， FemaleFemale ＞＞ 6655yearsyears

③③smokingsmoking

④④DyslipidemiaDyslipidemia TC TC ≥≥ 5.7mmol/L 5.7mmol/L ((220mg/dl220mg/dl)) Or LDL-C Or LDL-C ＞＞ 3.3mmol/L 3.3mmol/L ((130mg/dl130mg/dl)) Or HDL-C Or HDL-C ＜＜ 1.0mmol/L 1.0mmol/L ((40mg/dl40mg/dl))

⑤⑤Family history of premature Family history of premature cardiovascular disease at age <50 cardiovascular disease at age <50 yearsyears

⑥⑥Abdominal obesity or obesityAbdominal obesity or obesity WCWC Male Male ≥85cm≥85cm ，， Female Female ≥80cm≥80cm

⑦⑦Obesity BMIObesity BMI≥28≥28kg/mkg/m22

⑧⑧C-reactive protein C-reactive protein ≥1.0mg/dl≥1.0mg/dl

Diabetes mellitusDiabetes mellitus Fasting plasma glucoseFasting plasma glucose≥ ≥

7.0mmol/L 7.0mmol/L ((126mg/dl126mg/dl)) Postprandial plasma glucose Postprandial plasma glucose ≥ ≥

11.1mmol/L 11.1mmol/L ((200mg/dl200mg/dl))

Stratification of risk to quantify Stratification of risk to quantify prognosisprognosis

Grade 1Grade 1 Grade 2Grade 2 Grade 3Grade 3

ⅠⅠ No other risk No other risk factorsfactors

Low added Low added riskrisk

Moderate Moderate added riskadded risk

High added High added riskrisk

ⅡⅡ1-2 1-2 risk factors risk factors Moderate Moderate added riskadded risk

Moderate Moderate added riskadded risk

Very High Very High added riskadded risk

Ⅲ ≥Ⅲ ≥33 个个 risk factors,risk factors, TOD or diabetesTOD or diabetes

High added High added riskrisk

ⅣⅣ ACCACCVery High Very High added riskadded risk

Incidence of cardiovascular Incidence of cardiovascular diseases in ten yearsdiseases in ten years

Low added risk, Low added risk, ＜＜ 15%15% Moderate added risk, Moderate added risk, 1515

%-20%%-20% High added risk, High added risk, 20%-3020%-30

%% Very high added risk, Very high added risk,

＞＞ 30%30%

Differential DiagnosisDifferential Diagnosis

To exclude secondary hypertensionTo exclude secondary hypertension Incidence rate, 5-10%Incidence rate, 5-10% Blood pressure could be controlled Blood pressure could be controlled

by treatment of primary diseasesby treatment of primary diseases

⒈⒈Renal parenchymal Renal parenchymal hypertensionhypertension

Acute or chronic glomerulonephritisAcute or chronic glomerulonephritis Diabetic nephropathyDiabetic nephropathy nephritisnephritis Polycystic kidney Polycystic kidney After renal transplantationAfter renal transplantation

Renal dysfunction before the Renal dysfunction before the course of hypertensioncourse of hypertension

⒉⒉Renovascular Renovascular hypertensionhypertension

Unilateral or bilateral renal artery stenosis Unilateral or bilateral renal artery stenosis Renal artery fibromuscular dysplasia Renal artery fibromuscular dysplasia arteritisarteritis Renal atherosclerosisRenal atherosclerosis

Radionuclide renal scanRadionuclide renal scan Renal artery angiogramRenal artery angiogram Measurements of renin in renal Measurements of renin in renal venousvenous

⒊⒊PheochromocytomaPheochromocytoma Fluctution sin blood pressureFluctution sin blood pressure Sign of Sympathetic nervous Sign of Sympathetic nervous

hyperactivity hyperactivity 24h urine catecholamines and their 24h urine catecholamines and their

metabolitesmetabolites↑↑ Serum MN, NMN Serum MN, NMN ↑↑ EchocardiogramEchocardiogram ，， nuclide nuclide

imagingsimagings ，， CTCT ，， MRIMRI

⒋⒋Primary AldosteronismPrimary Aldosteronism Hypertension accompanied by Hypertension accompanied by

hypokalemiahypokalemia Renin activity decreased, Renin activity decreased,

aldosterone level increasedaldosterone level increased ARR ARR CTCT ，， echocardigramechocardigram

5. Cushing’s Syndrome5. Cushing’s Syndrome

6. Aortic coarctation6. Aortic coarctation

Further investigationsFurther investigations

Renin activityRenin activity AldosteroneAldosterone CatecholamineCatecholamine AteriogramAteriogram Echogram of Echogram of

kidney and adrenal kidney and adrenal glandsglands

CT or MRICT or MRI

TreatmentTreatment

Goals of treatmentGoals of treatment

Uncomplicated hypertensionUncomplicated hypertension ＜＜

140/90140/90mmHgmmHg

Elderly, SBPElderly, SBP ＜＜ 150150mmHgmmHg

Combined with diabetes and renal Combined with diabetes and renal

disease, disease, ＜＜ 130/80130/80mmHgmmHg

Main purposeMain purpose

To achieve a maximum reduction in To achieve a maximum reduction in

the long-term total risk of the long-term total risk of

cardiovascular morbidity and mortalitycardiovascular morbidity and mortality

To treat all the reversible risk factorsTo treat all the reversible risk factors

To treat ACCTo treat ACC

Patients with high and very Patients with high and very high riskhigh risk

Drug therapy on Drug therapy on elevated blood elevated blood pressurepressure

Drug therapy on risk Drug therapy on risk factorsfactors

Drug therapy on Drug therapy on clinical conditionsclinical conditions

Improvement of Improvement of lifestylelifestyle

Patients with moderate Patients with moderate riskrisk

Observe the blood Observe the blood pressure for several pressure for several weeksweeks

Drug therapy targeted Drug therapy targeted on risk factorson risk factors

Improvement of lifestyleImprovement of lifestyle

Patients with low riskPatients with low risk

Observed for a period of Observed for a period of timetime

Improvement of lifestyleImprovement of lifestyle

Non-pharmacological Non-pharmacological therapytherapy

Improving lifestyleImproving lifestyle Giving up smokingGiving up smoking Losing body weightLosing body weight Reducing excessive alcohol Reducing excessive alcohol

intakeintake Appropriate physical exerciseAppropriate physical exercise Cutting down salt intakeCutting down salt intake Eating more fruit and Eating more fruit and

vegetable and cutting down vegetable and cutting down saturated fatty acid and total saturated fatty acid and total fat in food fat in food

Reducing stress and Reducing stress and maintaining mental maintaining mental equilibriumequilibrium

Pharmacological therapy of Pharmacological therapy of hypertensionhypertension

DiureticsDiuretics Β-blockersΒ-blockers Calcium antagonistsCalcium antagonists Angiotensin-converting enzyme Angiotensin-converting enzyme

inhibitor (ACEI)inhibitor (ACEI) Angiotensin II receptor Angiotensin II receptor

blocker(ARB)blocker(ARB) -blockers-blockers

Principles of durg Principles of durg treatmenttreatment

To start with a small To start with a small and efficacious doseand efficacious dose

The blood pressure The blood pressure within 24 hours within 24 hours should be kept stably should be kept stably under the target under the target levellevel

Combination therapyCombination therapy

DiureticsDiuretics

Drug: Thiazides: hydrocholorothiazideDrug: Thiazides: hydrocholorothiazide Loop-acting: fursemideLoop-acting: fursemide Potassium-sparing: spironolactone, Potassium-sparing: spironolactone,

amilorideamiloride Indications: Mild hypertension, Indications: Mild hypertension, Isolated systolic hypertension in elderly Isolated systolic hypertension in elderly acompanied by heart failureacompanied by heart failure Contraindications: GoutContraindications: Gout

ββ-blockers-blockers

Drugs dosageDrugs dosage acting course acting course selectivityselectivity

MetoprololMetoprolol 25mg bid short 25mg bid short ββ11

AtenololAtenolol 25mg bid short 25mg bid short ββ11

BisololBisolol 5mg qd long 5mg qd long ββ11

CarvediolCarvediol 25mg bid short 25mg bid short ,,ββ

LabetalolLabetalol 100mg tid short 100mg tid short ,,ββ

ββ-blockers-blockers IndicationsIndications: :

Moderate to severe hypertension Moderate to severe hypertension

ContraindicationsContraindications: :

Congestive heart failure Congestive heart failure

Asthma Asthma

Diabetes mellitus (on hypoglycemic Diabetes mellitus (on hypoglycemic

therapy) therapy)

During MAO inhibitor During MAO inhibitor

administrationadministration

COPD COPD

Sick sinus syndrome Sick sinus syndrome

II degree or III degree heart block II degree or III degree heart block

Calcium Channel AntagonistsCalcium Channel Antagonists Dihydropyridines Dihydropyridines

Nifedipine 10mg tidNifedipine 10mg tid

Nitrendipine 10mg tid Nitrendipine 10mg tid

Felodipine XL 5mg qd Felodipine XL 5mg qd

Amlodipine 5mg qd Amlodipine 5mg qd

Nifedipine XL 30mg qd Nifedipine XL 30mg qd

Lacidipine 4mg qd Lacidipine 4mg qd

Calcium Channel AntagonistsCalcium Channel Antagonists Benzothiazepines: Benzothiazepines: Diltiazem Diltiazem short-acting : 30mg tidshort-acting : 30mg tid long-acting: 90mg qd long-acting: 90mg qd

Phenylalkylamine:Phenylalkylamine: Verapamil Verapamil short-acting: 40mg tidshort-acting: 40mg tid long-acting: 240mg long-acting: 240mg or 120mg or 120mg qdqd

Calcium Channel Calcium Channel

AntagonistsAntagonistsIndications:Indications:

Mild to Moderate hypertensionMild to Moderate hypertension

Contraindications:Contraindications:

Heart failureHeart failure

II degree or III degree heart block II degree or III degree heart block

Side effectsSide effects

1.Dihydropyridines: 1.Dihydropyridines:

tachycardia, flushing, dizziness, tachycardia, flushing, dizziness,

weakness, fluid weakness, fluid

retention retention

2. 2. Non-dihydropyridines:Non-dihydropyridines:

heart blockheart block

constipation constipation

liver dysfuction liver dysfuction

ACEIACEI 1.Drugs : Captopril 1.Drugs : Captopril Benazepril Benazepril Enalapril Enalapril FosinoprilFosinopril Lisinopril Lisinopril Peridopril Peridopril Ramipril Ramipril

ACEIACEI

Indications:Indications:

Mild to severe hypertensionMild to severe hypertension

renal artery stenosis renal artery stenosis

Renal failure Renal failure

Bilateral renal artery stenosis Bilateral renal artery stenosis

Pregnancy Pregnancy

Side effects of ACEISide effects of ACEI1.dry cough 1.dry cough

2.angioedema2.angioedema

3.leukopenia, pancytopenia3.leukopenia, pancytopenia

4. hyperkalemia 4. hyperkalemia

5. acute renal failure5. acute renal failure

6. hypotension6. hypotension

7. urticarial rash7. urticarial rash

ARBARB Drugs : LosartanDrugs : Losartan Valsartan Valsartan Irbesartan Irbesartan

ARBARB

Indications:Indications:

Mild to severe hypertensionMild to severe hypertension

renal artery stenosis renal artery stenosis

Renal failure Renal failure

Bilateral renal artery stenosis Bilateral renal artery stenosis

Pregnancy Pregnancy

Side effects of ARBSide effects of ARB1. hyperkalemia 1. hyperkalemia

2. acute renal failure in bilateral renal 2. acute renal failure in bilateral renal

artery stenosisartery stenosis

3. hypotension3. hypotension

11-blockers-blockersDrugsDrugs:: PhentolaminePhentolamine IV 1-5mg bolus IV 1-5mg bolus PrazosinPrazosin 2-30mg bid,tid 2-30mg bid,tid DoxazosinDoxazosin 1-16mg qd 1-16mg qd TerazosinTerazosin 1-20mg qd 1-20mg qdIndications:Indications:

1. Suspected or proved 1. Suspected or proved pheochromocytomapheochromocytoma

2.Mild or moderate hypertension2.Mild or moderate hypertension Contraindications and Cautions:Contraindications and Cautions: Severe coronary artery disease Severe coronary artery disease Use with caution in the elderly Use with caution in the elderly

11-blockers-blockers

Side effectsSide effects:: tachycardiatachycardia weakness weakness dizziness dizziness flushing flushing postural hypotension postural hypotension tachycardia tachycardia miosis miosis headache headache

Combination therapyCombination therapy diuretic and β-blocker

diuretic and ACE inhibitor or angiotensin

receptor antagonist

calcium antagonist and diuretic

calcium antagonist (dihydropyridine) and β-

blocker

calcium antagonist and diuretic

-blocker and β-blocker

Anti-hypertensive treatment in special Anti-hypertensive treatment in special populationspopulations

Angina pectorisAngina pectoris β-blocker, Calcium channel antagonistβ-blocker, Calcium channel antagonist

MIMI β-blocker, ACEIβ-blocker, ACEI ，， AldosteroneAldosterone

Heart failureHeart failure Diuretic, ACEI, ARBsDiuretic, ACEI, ARBs β-blockerβ-blocker （（ stable in cardiac functiostable in cardiac functio

nn ）） pregnancypregnancy

Labetalol , Methyldopa, Calcium Labetalol , Methyldopa, Calcium channel antagonistchannel antagonist

Cerebral vascular diseaseCerebral vascular disease Calcium channel antagonistCalcium channel antagonist DiureticDiuretic , ACEI, ACEI

Renal dysfunctionRenal dysfunction Calcium channel antagonist, Calcium channel antagonist,

DiureticDiuretic ACEISACEIS ，， ARBsARBs Not indicated :β-blockerNot indicated :β-blocker

Diabetes mellitusDiabetes mellitus ACEIACEI or ARBsor ARBs Calcium channel antagonistCalcium channel antagonist ，， ββ--

blocker, Direticsblocker, Diretics

DyslipidemiaDyslipidemia Calcium channel antagonistCalcium channel antagonist , ACEI, ACEI Not indicated: βNot indicated: β--blockerblocker, , DireticsDiretics

Treatment of associated risk factorsTreatment of associated risk factors

Lipid loweringLipid lowering Anti-platelet therapyAnti-platelet therapy Glycolic controlGlycolic control

Refractory hypertensionRefractory hypertension

Definition ： Lifestyle modifications and the

administration of at least 3 anti-hypertensive

drugs including diuretics, the systolic or diastolic

blood pressure still cannot be controlled at the

target level.

unidentified secondary causesunidentified secondary causespoor patient compliancepoor patient compliancecurrent using of pressor agentscurrent using of pressor agentsfailure of lifestyle modificationsfailure of lifestyle modificationsblood volume overloadblood volume overload

Causes of Refractory hypertensionCauses of Refractory hypertension

To refer the refractory To refer the refractory hypertensive patients to hypertensive patients to specialized hypertension clinicsspecialized hypertension clinicsTo take effective treatmentTo take effective treatmentTo re-start a new simple anti-To re-start a new simple anti-hypertensive regimenhypertensive regimen

Therapeutic principles of Refractory Therapeutic principles of Refractory hypertensionhypertension

Thanks for attention

Hypertension Cardiology Department, Shanghai Sixth People’s Hospital, Shanghai JiaoTong University

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