SYSTEMIC

HYPERTENSION
SYSTEMIC HYPERTENSION
Definitions of hypertension

Elevated arterial blood pressure
is a major cause of premature
vascular disease leading to
cerebrovascular events,
ischaemic heart disease and
peripheral vascular disease.
Blood pressure is the pressure exerted by
the blood against the walls of the blood
vessels, especially the arteries.

It varies with the strength of the heartbeat,
the elasticity of the arterial walls, the
volume and viscosity of the blood,
and a person's (health, age, and physical
condition
Age
onset between 30 - 50 years of age
increases over 65 years of age
sex - males in young adulthood and early
middle age
females after the age of 55 years
The prevalence
hypertensions is higher among blacks and
older persons, especially older women
Hypertension increased with age, and is
higher in young men than in young
women,
although the reverse is true in older
adults.
Hypertension - Introduction
Silent Killer painless complications
I t is the leading risk factor MI , HF, CRF
Stroke
Responsible for the majority of office visits,
Number one reason for drug prescription.
25% of population
Complications bring to diagnosis but late
This requires the heart to work harder than
normal to circulate blood through the blood
vessels.

Blood pressure is summarised by two
measurements, systolic and diastolic

which depend on whether the heart muscle
is contracting (systole) or relaxed between
beats (diastole).
Normal blood pressure at rest is within the
range of 100-140mmHg systolic (top
reading) and 60-90mmHg diastolic (bottom
reading).

High blood pressure is said to be present if
it is persistently at or above 140/90 mmHg.

Ideal Mean Aterial Pressure
(MAP) is defined as 93 mm of mercury,
which corresponds to 120/80 and can be
calculated by MAP = DP + 1/3 (SP-DP).
Mean Arterial blood pressure depends on
the flow of blood from the heart (cardiac
output) and the resistance to flow in the
small arteries and microscopic resistance
vessels (arterioles)
Regulation of BP:
BP = Cardiac Output x Peripheral Resistance
Endocrine Factors
Renin, Angiotensin, ANP, ADH, Aldosterone.
Neural Factors
Sympathetic & Parasympathetic
Blood Volume
Sodium, Mineralocorticoids, ANP
Cardiac Factors
Heart rate & Contractility.
Classification of blood
of blood pressure


You Have** Diastolic
Value*
Systolic
Value*
Normal blood pressure Less than 85 Less than 130
High-normal blood
pressure
Less than 85 130-139or
Stage 1 (mild)
hypertension
90-99 140-159
Stage 2 (moderate)
hypertension
100-109 160-179
Stage 3 (severe)
hypertension
110-119 180-209
Stage 4 (very severe)
hypertension
120 or
higher
210 or higher
Signs and symptoms

Hypertension is rarely accompanied by
any symptoms, and its identification is
usually through screening, or when
seeking healthcare for an unrelated
problem. A proportion of people with
high blood pressure reports

headaches (particularly at the back of the
head and in the morning),


lightheadedness,
vertigo,
tinnitus
(buzzing or hissing in the ears),
altered vision or fainting episodes

These symptoms however are more likely
to be related to associated anxiety than
the high blood pressure itself

Control of Blood Pressure:
BP
Cardiac
Output
Peripheral
Resistance
Blood Volume
Na+, Aldosterone
Vasoconstrictors
Angiotensin II
Catecholamines
Vasodilators
Pg & Kinins
Local Factors
pH, Hypoxia
Neural Factors
Adrenergic Cons
Adrenergic - Dil
Cardiac Factors
Rate & Contract..
Humoral Factors
Peak blood pressure
Peak blood pressure levels in humans occur
during the mid morning (at about 10:00
AM) then decrease progressively
throughout the remainder of the day to
reach a trough value the following morning
at around 3:00 AM
Definition of Circadian Rhythm


Circadian rhythms are daily cycles of
physiology and behavior that are driven by
an endogenous oscillator with a period of
approximately one day
Normally, circadian rhythms
are synchronized with the 24.0 h
environment by stimuli which alter the
phase of the underlying brain circadian
pacemaker.

For most organisms, including mammals,
the primary phase-shifting stimulus is light
These processes include :-
-sleep-wake cycles,
-body temperature,
-blood pressure,
-release of hormones.
This activity is controlled by the biological
clock, which is located in the supra-
chiasmtic nuclei of the hypothalamus in
human brains.
It is highly influenced by natural dark-light
cycles, but will persist under constant
environmental conditions. Examples:
Disruptions to the circadian rhythm can
cause problems with the sleep-wake cycle
Circadian rhythms are regulated by three
components :

(1) the circadian pacemaker or "clock",

(2) an input mechanism which allows the
clock to be reset by environmental stimuli,
and

(3)an output mechanism which regulates
physiological and behavioral Processes
Hypertension types
Primary Hypertension, High blood pressure of
unidentified cause, Accounts for 90% of cases of
high blood pressure. The identified risk factors in
primary hypertension are as follows , age onset
between 30 - 50 years of age , increases over 65
years of age, sex - males in young adulthood and
early middle age, females after the age of 55 years

Secondary Hypertension is High blood
pressure in which the cause can be identified.
Etiology
1- Essential:
In more than 95% of cases, an underlying
cause cannot be found. Proposed mechanisms
include:
Excess renal sodium retention
Over activity of sympathetic nervous
system
Renin angiotensin excess
Hyperinsulinemia
Alterations in vascular endothelium
Factors contributing to the development of Essential
hypertension
Genetic Factors:
hypertension is more
common in some families
and in some ethnic groups
like African Americans
Environmental factors
include obesity, alcohol,
lack of exercise and excess
salt
Emotional stress can cause quite large
increases in blood pressure.
Prominent amongst the physiological
responses to stress is an increase in activity
in the sympathetic nerves
Postural changes exert stresses on the
cardiovascular system requiring effective
reflex responses to constrict arteries and
veins and stimulate the heart, to control
blood pressure, maintain brain blood flow,
and prevent loss of consciousness

Regular over-consumption of alcohol can
raise blood pressure dramatically, as well as
cause an elevation upon withdrawal
The severity of obstructive sleep apnea
syndrome OSAS is an independent factor
correlated to diurnal hypertension
pathophysiology
There is some evidence that supports a
hypothesis that the primary fault in the
patho-physiology of hypertension is a defect
in the:-
calcium binding of the plasma membrane of
the cells of a pressure-regulating center in
the nervous system.
2- Secondary hypertension
Renal: These account for over 80% of the cases of
secondary hypertension. The common causes are
diabetic nephropathy, chronic glomerulonephritis,
adult polycystic disease, chronic tubulointerstitial
nephritis, and renovascular disease.
Endocrinal: These include
Conn's syndrome, adrenal hyperplasia,
acromegaly,
Phaeochromocytoma, Cushing's syndrome.
Drugs and toxins
Pregnancy-induced hypertension
Vascular: coarctation of aorta, vasculitis
Children

Hypertension in neonates is rare, occurring in
around 0.2 to 3% of neonates,
blood pressure is not measured routinely in the
healthy newborn
Hypertension is more common in high risk
newborns.
A variety of factors, such as gestational age,
postconceptional age and birth weight needs to
be taken into account when deciding if a blood
pressure is normal in a neonate
Hypertensive crises

Severely elevated blood pressure (equal to
or greater than a systolic 180 or diastolic of
110 sometime termed malignant or
accelerated hypertension) is referred to as a
"hypertensive crisis", as blood pressures
above these levels are known to confer a
high risk of complications.

People with blood pressures in this range
may have no symptoms, but are more likely
to report headaches (22% of cases)and
dizziness than the general population
Other symptoms accompanying a
hypertensive crisis may include :-
1-visual deterioration
2-breathlessness due to heart failure
3-general feeling of malaise due to renal
failure
4-Most people with a hypertensive crisis are
known to have elevated blood pressure, but
additional triggers may have led to a sudden
rise

emergency hypertensive
"malignant hypertension", is diagnosed
when there is evidence of :-
1- direct damage to one or more organs as a
result of the severely elevated blood
pressure.
1-This may include hypertensive
encephalopathy, caused by brain swelling
and dysfunction,

characterized by:-
- headaches
-altered level of consciousness
(confusion or drowsiness).
-Retinal papilloedema

-fundal hemorrhages
-exudates are another sign of target
organ damage.
-Chest pain may indicate heart muscle
damage (which may progress to
myocardial infarction) or sometimes
aortic dissection,
-tearing of the inner wall of the aorta.
-Breathlessness, cough, and the
expectoration of blood-stained sputum
are characteristic signs of pulmonary
edema, the swelling of lung tissue due to
left ventricular failure

-inability of the left ventricle of the
heart to adequately pump blood
from the lungs into the arterial
system
In pregnancy

Hypertension occurs in approximately 8-10%
of pregnancies

Most women with hypertension in pregnancy
have pre-existing primary hypertension, but
high blood pressure in pregnancy may be

the first sign of pre-eclampsia, a serious
condition of the second half of pregnancy and
puerperium.[
Pre-eclampsia is characterised
by
increased blood pressure
the presence of protein in the urine
It occurs in about 5% of pregnancies and is
responsible for approximately 16% of all
maternal deaths globally
Pre-eclampsia also doubles the risk of
perinatal mortality
] Usually there are no symptoms in pre-
eclampsia and it is detected by routine
screening.

Complications
Cerebrovascular
disease
coronary artery disease
are the most common
causes of death
although hypertensive
patients are also prone
to renal failure
peripheral vascular
disease.
HYPERTENSION
Classification of blood pressure levels:
(according to the British Hypertension Society)

Category Systolic blood pressure Diastolic blood pressure
Optimal < 120 < 80
Normal < 130 < 85
High normal 130-139 85-89

Hypertension
Grade I (mild) 140-159 90-99
Grade 2 (moderate) 160-179 100-109
Grade 3 (severe) 180 110

Isolated systolic hypertension
Grade 1 140-149 < 90
Grade 2 160 < 90
HISTORY
The patient with mild hypertension is
usually asymptomatic.
Attacks of sweating
headaches
palpitations.
Higher levels of blood pressure may be
associated with, epitasis or nocturnal.
Breathlessness may be present owing to left
ventricular hypertrophy or cardiac failure.
INVESTIGATIONS
Routine investigation of the hypertensive
patient should include:
ECG
Urine stix test for protein and blood
Fasting blood for lipids (total and high-
density lipoprotein cholesterol) and glucose
Serum urea, creatinine and electrolytes.
Investigation of selected cases
Chest X-ray
Ambulatory BP recording
Echocardiogram
Renal ultrasound
Renal angiography
Urinary catecholamines
Urinary cortisol and dexamethasone
suppression test
Plasma renin activity and aldosterone
Prevention
Much of the disease burden of high blood
pressure is experienced by people who are
not labelled as hypertensive.

population strategies are required to reduce
the consequences of high blood pressure
and reduce the need for antihypertensive
drug therapy.

Lifestyle changes are recommended to lower
blood pressure, before starting drug therapy.

maintain normal body weight
for adults (e.g. body mass
index 2025 kg/m2)
reduce dietary sodium intake
to <100 mmol/ day (<6 g of
sodium chloride or <2.4 g of
sodium per day)


Engage in regular aerobic physical activity such as
brisk walking (30 min per day, most days of the
week)

limit alcohol consumption to no more than 3 units/day
in men and no more than 2 units/day in women

consume a diet rich in fruit and vegetables (e.g. at
least five portions per day)

Effective lifestyle modification may lower blood
pressure as much an individual antihypertensive
drug.
Combinations of two or more lifestyle modifications
can achieve even better results.


Management
Lifestyle modifications includes
dietary changes
physical exercise
weight loss.

If hypertension is high enough to justify
immediate use of medications, lifestyle
changes conjunction with medication.

Anti-inflammatory approaches should be a
promising strategy for treating both
hypertension and atherosclerosis
Different programs aimed to
reduce:-

psychological stress
such as biofeedback
relaxation
or meditation
Dietary change such as a low sodium diet is
beneficial. A long term (more than 4 weeks)
low sodium diet in

Also, the DASH diet, a diet rich in nuts,
whole grains, fish, poultry, fruits and
vegetables

diet is also rich in potassium, magnesium,
calcium, as well as protein
Non-pharmacological
treatment
Weight reduction - BMI should be < 25 kg/m2
Low-fat and saturated fat diet
Low-sodium diet - < 6 g sodium chloride per day
Limited alcohol consumption - 21 units/week for
men and 14 units/week for women
eating plan, which is rich in potassium and
calcium
Chronic intake of diets rich in pomace olive oil
improves endothelial dysfunction in spontaneously
hypertensive
Diets rich in fruits and vegetables reduce blood
pressure
Dynamic exercise
At least 30 minutes' brisk walk per day
Increased fruit and vegetable consumption
Reduce cardiovascular risk by stopping
smoking
increasing oily fish consumption.

Pharmacological treatment should be
based on the following
The initiation of antihypertensive therapy in
subjects with sustained systolic blood
pressure (BP) 160 mmHg, or sustained
diastolic BP 100 mmHg.


In patients with diabetes mellitus, the
initiation of antihypertensive drug therapy if
systolic BP is sustained 140 mmHg, or
diastolic BP is sustained 90 mmHg.
In non-diabetic hypertensive subjects, treatment
goals: BP < 140/85 mmHg. In some hypertensive
subjects these levels may be difficult to achieve.

Most hypertensive patients will require a
combination of antihypertensive drugs to achieve
the recommended targets.

In most hypertensive patients, therapy with
statins and aspirin to reduce the overall
cardiovascular risk burden.
Glycaemic control should be optimized in
diabetics (HbA1c < 7%).

Anti-hypertensive medications are not
effective for everyone
costly and result in adverse effects that
impair quality of life and reduce adherence.

Moreover, abnormalities associated with
high BP, such as insulin resistance and
hyperlipidaemia, may persist or may even
be exacerbated by some anti-hypertensive
medications.
Pharmacological Treatment
Several classes of drugs are available to treat
hypertension. The usual are:
(a) ACE inhibitors or Angiotensin receptor
antagonists
(b) Beta-blockers
(c) Calcium-channel blockers
(d) Diuretics
(e) Other drugs as -blocker, direct
vasodilator, or centrally acting drugs
Choice of antihypertensive
therapy


The choice of antihypertensive therapy is
usually dictated by
cost, convenience, the response to treatment
and freedom of
side effects


Co morbid conditions may have an
important influence on
initial drug selection e.g.
-blocker in angina
Thiazide diuretics and calcium
antagonists in elderly people
ACE in heart failure, post MI, type 1
diabetic nephropathy
ARBs in type 2 diabetic nephropathy,
intolerance to ACE
-blocker in benign prostatic
hypertrophy
Aerobic exercises

Aerobic exercises may play an important
role in the treatment of blood pressure of
hypertensive individuals treated in the
long run

Exercises

For many years, physical inactivity has
been recognized as a risk factor for
coronary heart disease (CHD) and most
recommendations suggest regular physical
activity as a part of the strategy in
preventing/reducing CHD
Physical Activity
Regular physical activity is the first treatment
recommended
to lower BP and improve cardiovascular
health,

The effect of physical activity on SBP and DBP
is unequal. With increased levels of activity
there is an almost linear increase in SBP,
whereas DBP tends to decrease




Moderate-intensity (4070% VO2 max)
aerobic exercise is associated with a
significant reduction of blood pressure in
hypertensive and normotensives
participants and in overweight, as well as
normal-weight participants

reducing :_
1-regional sympathetic outflow,
2- total peripheral resistance
3- heart rate.




- exercise has been shown to augment
vagal tone, endothelium-mediated
vasodilatation
- insulin sensitivity and mood
- and to lower cholestero
-Resistive exercise training has been shown
to decrease SNS activity


-increase baroreflex sensitivity (an index of
reflex vagal control of the heart which
carries relevant patho physiological



-High intensity training may paradoxically
increase arterial stiffness in healthy
middle-aged -
In hypertension, sympathetic activation
represents a mechanism potentially
responsible for the day-night blood
pressure difference
evening exercise significantly reduced the
nighttime blood pressure, Irrespective of
a morning exercise period

nitric oxides release by moderate
exercises as a vasodilator on endothelium
cell of blood vessels that increases blood
flow while lowering blood pressure.
Decreases in catecholamine and total
peripheral resistance,
improved insulin sensitivity,

and alterations in vasodilators and
vasoconstrictors are some of the
postulated explanations for the
antihypertensive effects of exercise

sympathy inhibition and enhanced vagal
activity
increase in diastolic blood pressure of more
than 10 mmHg during or after exercise
represents a coronary artery disease.
Summary
Hypertension is the commonest cause of major morbidity,
but less than a quarter of patients are adequately treated.
A reduction in cardiovascular disease mortality and
morbidity can be achieved through improved treatment and
control of hypertension.
A greater choice of drugs are available for hypertension
than for other chronic diseases.
Rational choice of single and combination drugs facilitated
by understanding their effects on the renin system, but
systematic trial and error may still be necessary.