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In the Name of God
Overview of Hypertension
Mahboob Lessan Pezeshki MDTehran University of Medical Sciences
Aban 1392
Definitions (1)
Normal blood pressure: systolic< 120 & diastolic <80 mmHg
Prehypertension: systolic 120-139 or diastolic 80-85 mmHg
Hypertension: Stage 1: systolic 140-159 or diastolic 90-99 Stage 2: systolic >160 or diastolic > 100
Definitions (2)
Isolated systolic hypertension: systolic >140 and diastolic < 90 mmHg
Isolated diastolic hypertension: systolic <140 and diastolic > 90 mmHg
Definitions and classification of office blood pressure levels (mmHg)
Hypertension based upon ABPM and home readings
ABPM: A 24 hour average above 135/85 mmHg Daytime (awake) average above 140/90 mmHg Nighttime (asleep) average above 125/75 mmHg
Home readings: The same as for daytime ambulatory blood pressure
Malignant Hypertension
Marked hypertension with retinal hemorrhages, exudates or papilledema
Diastolic hypertension usually >120 mmHg
Hypertensive Urgency
Diastolic blood pressure above 120 mmHg in asymptomatic patients
Hypertensive Emergency
Acute severe hypertension, generally>180/120 mmHg
Malignant hypertension with end organ damage
Hypertensive encephalopathy
Resistant Hypertension
Failure to achieve goal blood pressure(<140/90 mmHg) using:
A minimum of three antihypertensive drugs At maximal tolerated doses, one of which must be a diuretic
Controlled Resistant Hypertension
Patients who meet the definition of Resistant Hypertension but whose blood pressure is controlled on maximal tolerated doses of four or more antihypertensive medications
Refractory Hypertension
Patients who meet the definition of Resistant Hypertension but whose blood pressure is not controlled on maximal tolerated doses of four or more antihypertensive medications
Isolated Diastolic Hypertension
More common in men Associated with metabolic syndrome Elevated systemic vascular resistance Vasoconstriction of resistant arterioles Inappropriately normal cardiac output
Isolated Systolic Hypertension
Common in elderly hypertensives Diminished arterial compliance Elevated pulse pressure High risk of:
MI LVH Stroke Renal dysfunction
Primary Hypertension (1)
Pathogenesis : Genetic factors Increased sympathetic neural activity Increased angiotensin 2 actvity and
mineralocorticoid excess Reduced adult nephron mass
Primary Hypertension (2)
Risk factors: Excess sodium intake Excess alcohol intake Obesity and weight gain Physical inactivity Dyslipidemia Certain personality traits Vitamin D deficiency
Secondary Hypertension
Primary renal disease Oral contraceptives Drug induced Renovascular disease Obstructive sleep apnea Coarctation of aorta Endocrine disorders( primary aldosteronism,
pheochromocytoma….)
Complications of Hypertension
Ischemic stroke Intracerebral hemorrhage Chronic kidney disease Left ventricular hypertrophy Heart failure
Masked Hypertension
Normotensive by conventional clinic measurement
Hypertensive by ABPM
White coat Hypertension
Average office readings > 140/90 mmHg
Average out of office < 140/90 mmHg
Screening of Hypertension
Normal BP Every 2 years
Prehypertension Yearly
Indications for ABPM
Suspected white coat Hypertension Suspected episodic Hypertension Hypertension resistant to increasing
medications Hypotensive symptoms while taking
antihypertensive medications Autonomic dysfunction
Goals of Systolic Blood Pressure
Lower than 140 mmHg
No J shaped systolic curve
Goals of Diastolic Blood Pressure
Lower than 90 mmHg The goal may be lower in:
Atherosclerotic cardiovascular disease Diabetes mellitus Chronic kidney disease Heart failure
J shaped Diastolic curve
Methods of Diagnosis
Office-based measurement (AHA) ABPM (NICE) Home blood monitoring:
12-14 measurements Over a period of one week
Cuff Inflation Hypertension
Effect of muscular activity
Raise the blood pressure 12/9 mmHg Dissipates within 5-20 seconds
Office-based measurement
Time of measurement Type of measurement device Cuff size Patient position Cuff placement Technique of measurement Number of measurements
Pseudohypertension
Stiff vessels due to marked arterial calcification
10 mmHg or more higher systolic and Diastolic pressures
Measurement of Blood Pressure
Mild Hypertension: three to six visits (over a period of weeks to months)
Measurements should be in both arms
Detection of postural hypotension
Alternative sites for measurement
Leg blood pressure
Wrist blood pressure
Non Pharmacologic Therapy(1)
Dietary Salt Restriction Weight loss DASH Diet Exercise Vit D supplement
Non Pharmacologic Therapy(2)
Adequate Potassium intake Cessation of Smoking Limiting the use of NSAIDs Patient education
Drug Treatment(1)
Monotherapy in uncomplicated hypertension
Thiazide Diurtics Calcium Channel Blockers ACEIs or ARBs
Drug Treatment(2)
First Line Combination therapy
BP is more than 20/10 mmHg above the goal Calcium Channel Blockers plus a long acting
ACEI/ARB (ACCOMPLISH Trial)
Drug Treatment(3)
CCB or ACEI/ARB Discontinuing the thiazide and starting
combination therapy In all patients on beta blockers the preferred
second drug: Thiazide diuretics Dihydropyridine CCB
Bed time versus morning dosing
Shifting at least one medication to the evening in nondippers
Restores normal nocturnal blood pressure dip
Reduces 24 hour mean blood pressure
Treatment of Hypertensive Emergency(1)
Nitroprusside Nitroglycerin Calcium Channel Blockers Labetalol
Treatment of Hypertensive Emergency(2)
Fenoldopam Esmolol Hydralazine Enalaprilat Phentolamine
Treatment of Resistant Hypertension(1)
ACE or ARB(long acting) +
CCB(dehydropyridine) + Thiazide diuretic
Add spironolactone if patients remained uncontrolled
Direct vasodilators (hydralazine or minoxidil)
Treatment of Resistant Hypertension(2)Experimental therapies
Ablation of renal sympathetic nerves
Electrical stimulation of carotid sinus baroreceptors