Prof. Jamal Al Wakeel Head, Nephrology Division Department of Medicine

1. Hypertension Prof. Jamal Al Wakeel Head, Nephrology Division Department of Medicine

2. Case • 47 year old man came to your clinic with headache for 3 weeks. The nurse measure his Blood Pressure and was found to be 150/95 mmHg: • Does he have Hypertension? • What is the stage of Hypertension? • What investigation should you perform? • What could be your management on his case? • Is their any possible prevention to his disease and its complication?

3. The objective of this Lecture is: • To be able to recognize the definition of hypertension • To be able to identify the Stages of Hypertension • To find out the complication of Hypertension • To learn how to measure blood pressure • To familiarize with the test done for Hypertension • To acquire knowledge on how to measure hypertension • Reference: Current Medical Therapy and Diagnosis 2007

4. HYPERTENSION • The 4th most common cause of death world-wide • Directly and indirectly responsible for >20% of all deaths • 29-30% incidence of hypertension in the 18 year and older population of the United States • 9.1% and 8.7% the population of Saudi Arabia with hypertension 160/95 mmHg

5. HYPERTENSION • Onset stage 25-55 years mainly in 40-50y • occurs over 30%of persons older than 65 y • Only 34% of persons with hypertension have their blood pressure under control

6. Prevalence of Hypertensionin the United States* Hypertension Prevalence † Age *Based on NHANES 19992000 data. Hypertension is defined as blood pressure 140/90 mmHg or antihypertensive treatment. †Low reliability due to large relative error. Fields et al. Hypertension. 2004:44;398-404.

7. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

8. In 95% of cases no cause can be found primary hypretension (essential) • Secondary hpertension 5-10% HYPERTENSION

9. Essential (Primary) Hypertension Pathogenesis Sympathetic neural hyperactivity,insensitivitybaroreflex Increased angiotensin II activity and mineralocortoid excess Genetic factors Reduced adult nephron mass may predispose to hypertension Abnormal cardiovascular devolopment Intracellular Na &Ca Defect in natriuresis

10. Essential HTN • Risk factors • Obesity---metabolic syndrome • Excessive salt intake---low potassium intake • Excessive alcohol intake • Polycythimia • Lack of exercise • Nonsteroid anti-iflammatery drugs • Family history of essential HTN • Caffeine and smoking increase the BP acutely but are not risk factors for the development of chronic essential HTN

11. Secondary Hypertension • Primary renal disease • Oral contraceptives • Sleep apnea syndrome • Pheochromocytoma • Primary hyperaldosteronism • Renovascular disease • Cushing’s syndrome • Other endocrine disorders • Coarctation of the aorta

12. U.S. Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program The Seventh Report of the Joint National Committee Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) on

13. Blood Pressure Classification

14. Different definitions according to European Societies of Hypertension and Cardiology : • Optimal blood pressure : systolic <120 mmHg and diastolic <80 mmHg • Normal: systolic 120-129 mmHg and/or diastolic 80-84 mmHg • High normal: systolic 130-139 mmHg and/or diastolic 85-89 mmHg • Hypertension: • Grade 1: systolic 140-159 mmHg and/or diastolic 90-99 mmHg • Grade 2: systolic 160-179 mmHg and/or diastolic 100-109 mmHg • Grade 3: systolic ≥180 mmHg and/or diastolic ≥110 mmHg • Isolated systolic hypertension: systolic ≥140 mmHg and ≥90 mmHg

15. Blood Pressure Classification • apply to adults on no antihypertensive medications and who are not acutely ill • If there is a disparity in category between the systolic and diastolic pressures, the higher value determines the severity of the hypertension

16. Measurement: • Patient should be seated with the back straight and the arm supported at heart level • The patient should rest for 5 minutes • The bladder of the pressure cuff should encircle at least 80% of the upper arm • Use the average of two or more readings on at least two occasions

18. Measurement: • The diagnosis of mild hypertension should not be made until the blood pressure has been measured on at least three to six visits • Average of 10 to 15 mmHg decrease between visits 1 and three

19. WHITE COAT HYPERTENSION • Approximately 20 to 25% of patients with mild office hypertension • More common in elderly • Infrequent in patients with office diastolic pressures ≥105 mmHg

20. COMPLICATION CAD .ECG, ARRTHYM MI .SUDDEN DEATH Stroke Ischemia Hemorrage Alzaheimer COGNETIVE CHF LVH Aortic dissection Hypertension • hyprtensife • Emergency • And • emergencies Morbidity • Disability Renal disease Peripheral vascular disease

23. This left ventricle is very thickened (slightly over 2 cm in thickness), but the rest of the heart is not greatly enlarged. This is typical for hypertensive heart disease. The hypertension creates a greater pressure load on the heart to induce the hypertrophy.

24. The left ventricle is markedly thickened in this patient with severe hypertension that was untreated for many years. The myocardial fibers have undergone hypertrophy.

27. HYPERTENSIVE URGENCY Severe hypertension (diastolic blood pressure above 120 mmHg) in asymptomatic patients There is no proven benefit from rapid reduction in BP in asymptomatic patients who have no evidence of acute end-organ and are little short-term risk HYPERTENSIVE EMERGENCY Severe hypertension (diastolic blood pressure above 120 mmHg) in endorgan dammage(MI,STROKE,AKI,CHF)

28. MALIGNANT HYPERTENSION • Marked hypertension with encephapapathy& retinal hemorrhages, exudates, or papilledema • Associated with a diastolic pressure above 120 mmHg

29. Hypertensive RetinopathyGrade 4 • Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow)

30. DIAGNOSIS hypertension Screening: Asympatomatic- headache.chestheavance,Symptomofcmplications • Every two years for persons with systolic and diastolic pressures below 120 mmHg and 80 mmHg • Yearly for persons with a systolic pressure of 120 to 139 mmHg OR • Diastolic pressure of 80-89 mmHg

31. HISTORY • Presence of precipitating or aggravating factors • Natural course of the blood pressure • Extent of target organ damage • Presence scondry HTN of other risk factors for cardiovascular disease

33. PHYSICAL EXAMINTAION • To evaluate for signs of end-organ damage • For evidence of a cause of secondary hypertension

35. Hypertensive RetinopathyGrade 2 Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow)

36. Hypertensive RetinopathyGrade 3 Flame-shaped hemmorhage in association with severe hypertension Grade 3 (yellow arrow)

37. Laboratory Tests • Routine Tests • Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR, and calcium • Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides • Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio • More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

38. Who should be treated? • Persistently elevated blood pressure after three to six visits over a several month period • If the systolic pressure is persistently ≥140 mmHg and/or the diastolic pressure is persistently ≥90 mmHg • Systolic pressure is persistently above 130 mmHg and/or the diastolic pressure is above 80 mmHg in patients with cardiovascular disease,. post-myocardial infarction, heart failure,ckd & DM • Recommend a goal blood pressure ≤130/80 mmHg • Patients with office hypertension, normal values at home, and no evidence of end-organ damage should undergo ambulatory blood pressure monitoring

39. TREATMENT OF HYPERTENSION • LIFESTYLE MODIFICATIONS • Drug Therapy

40. Benefits of Lowering BP

41. Lifestyle Modification

42. CLASSIFICATION AND MANAGEMENT OF BP FOR ADULTS *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

43. COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES

44. COMPELLING INDICATIONS FOR INDIVIDUAL DRUG CLASSES

46. FOLLOW-UP AND MONITORING • Patients should return for follow-up after4weaks and adjustment of medications until the BP goal is reached. • More frequent visits for stage 2 HTN or with complicating comorbid conditions. • Serum potassium and creatinine monitored 1–2 times per year.

47. Drug Therapy • A low dose of initial drug should be used, slowly titrating upward. • Optimal formulation should provide 24-hour efficacy with once-daily dose. • Combination therapies may provide additional efficacy with fewer adverse effects.

48. DRUG THERAPY • Diuretics • β-Adrenergic Blocking Agents • Angiotensin-Converting Enzyme Inhibitors • Angiotensin II Receptor Blockers • Calcium Channel Blocking Agents • α-Adrenoceptor Antagonists • Drugs with Central Sympatholytic Action • Arteriolar Dilators

49. Combination Therapies • ACE inhibitors and diuretics • Angiotensin II receptor antagonists and diuretics • Calcium antagonists and ACE inhibitors • Angiotensin II receptor antagonists &-adrenergic blockers NOT RECOMENDED • Other combinations (-adrenergic blockers and diuretics)