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1. Systemic Hypertension
Phitsanu Boonprasert, M.D.
Division of Cardiology,
Department of Internal Medicine,
School of Medicine,
MFU

2. Systemic hypertension
Pathophysiology of hypertension
Malignant hypertension
Hypertensive disorder in pregnancy

3. Systemic hypertension

4. Arterial blood pressure
Blood pressure related to…
Volume
Diameter of tube
Elasticity
Fluid properties
Arterial Blood Pressure = Cardiac Output x TPR
Stroke Volume x Heart Rate
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5. Arterial blood pressure
Systolic pressure (Ps) : Left ventricular contraction
maximum aortic or arterial pressure ~ 120 mmHg
Diastolic pressure (Pd) : Left ventricular relaxation
minimum aortic or arterial pressure ~ 80 mmHg
Pulse pressure (Pp) = Ps - Pd (normal ~ 40 mmHg)
Mean pressure = Pd + 1/3 (pulse pressure) or Pd + 1/3 (Ps
- Pd) (normal 93.3 mmHg)
Ps/Pd = 120/80 mmHg
Pressure : aorta and arteries >>> arterioles > capillaries
Resistance

6. Systemic hypertension
Definition
HT : Systolic blood pressure, SBP > 140 mmHg and/or
diastolic blood pressure, DBP > 90 mmHg
Isolated systolic hypertension (ISH) : SBP > 140 mmHg but
DBP < 90 mmHg
Isolated office hypertension or white-coat hypertension
(WCH) : High BP at clinic, hospital or public health service
(SBP > 140 mmHg and/or DBP > 90 mmHg) but normal BP at
home (SBP < 135 mmHg and DBP < 85 mmHg)
Masked hypertension (MH) : Normal BP at clinic, hospital or
public health service (SBP < 140 mmHg and DBP < 90 mmHg)
but high BP at home (SBP > 135 mmHg or DBP > 85 mmHg)
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7. Systemic hypertension
Classified
1.Essential (Primary or Idiopathic) HT
~ 90-95%
No known explanation, overconsumption of sodium and
underconsumption of potassium, related to genetics,
vascular disorder in obese, old age, or physical
inactivity
2.Secondary HT
Specific underlying condition with a well-known
mechanism : Chronic kidney disease, narrowing of the
aorta or kidney arteries, or endocrine disorders such as
excess aldosterone, cortisol, or catecholamines
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8. Pathophysiology of
hypertension

9. Behavioral Determinants
Nicotine in cigarette smoke transiently raises BP by 10-20 mmHg
Moderate alcohol drinkers (one to two drinks per day) generally
have less HT than teetotalers, but the risk for development of HT
increases in heavy drinkers (three or more drinks per day)
Caffeine consumption typically causes only a small transient rise
in BP
Physical inactivity also increases the risk for developing HT
Diets low in fresh fruit may increase risk, but excessive
consumption of calories and sodium are the two most important
behavioral determinants of HT
HT prevalence increases linearly with average body mass index
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10. Genetic Determinants
Concordance of BP is higher in
families than in unrelated persons
Higher for monozygotic than for
dizygotic twins
Single gene mutations affect blood
pressure by altering renal salt
handling
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11. Autonomic nervous system
Maintaining cardiovascular homeostasis via
pressure, volume, and chemoreceptor signals
Excess activity of the ANS (sympathetic nervous
system) Increases blood pressure
The mechanisms of increased sympathetic nervous
system activity in hypertension
Alterations in baroreflex and chemoreflex pathways at
both peripheral and central levels

12. Baroreceptor reflex
*
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Receptors (baroreceptors or pressoreceptors) afferent nerve fibers (carotid sinus nerves
and aortic sinus nerves) reflex centers (VMC and cardioinhibitory center) effective nerve
fibers (vagal efferent fibers and sympathetic nerves) effectors (heart and arterial vessels)
Chemoreceptor reflex
Chemosensitive cells
at carotid and aortic
bodies
Decreased oxygen, increased CO2,
increased H
+, or decreased pH
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13. Renin–angiotensin–aldosterone
system (RAAS)
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14. Endothelial dysfunction
HypertensionDyslipidemia
Obesity
Aging
Smoking
Diabetes
Oxidative stress
Endothelial dysfunction
Reduced NO bioavailability
Leukocyte adhesion &
inflammation
Lipid deposition
Vascular smooth
muscle cell proliferation
Vasoconstriction
Platelet aggregation &
thrombosis
Progression of atherosclerosis and cardiovascular disease
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15. Diagnosis and
initial evaluation of
hypertension

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17. 2019 Thai Guidelines on The Treatment of Hypertension
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18. Lifestyle Modification
Change in behaviorChange in BP
Decrease BWDecrease SBP 1 mmHg/1 kg
Low salt diet < 2,300 mg/dDecrease SBP 2-8 mmHg
DASH diet Decrease SBP 8-14 mmHg
Regular exerciseDecrease SBP 2-4 mmHg
Decrease alcoholDecrease SBP 2-4 mmHg
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19. Drug synergy
Green continuous lines: preferred combinations; green dashed line: useful
combination (with some limitations); black dashed lines: possible but less well-
tested combinations; red continuous line: not recommended combination
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20. Malignant hypertension

21. Hypertensive crisis
Systolic BP > 180 and/or Diastolic BP > 120 mmHg
Hypertensive crisis
Hypertensive urgency : Without target organ damage
Hypertensive emergency : With target organ damage
A hypertensive urgency is a clinical situation in which blood
pressure should be lowered within 24 to 48 hours, in contrast
to a hypertensive emergency where blood pressure must
be lowered immediately and carefully to prevent or limit end
organ damage
without
organ
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22. Malignant hypertension
Hypertensive emergency
High BP with acute impairment of one or more organ systems
(especially the central nervous system, cardiovascular system
or the kidneys)
BP > 180/120 mmHg
The pathophysiology of hypertensive emergency is not well
understood (failure of normal autoregulation and an abrupt rise
in systemic vascular resistance are typical initial components of
the disease process)
BP should be slowly lowered over a period of minutes to hours
with an antihypertensive agent
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23. Hypertensive disorder in
pregnancy

24. Hypertension
Convulsive condition associated
with pre-eclampsia
BP
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25. Pregnancy-induced hypertension (PIH)
Possible mechanism of action
Reduced uteroplacental perfusion as a result of abnormal
cytotrophoblast invasion of spiral arterioles
Decreased uterine placental blood flow
Placental ischemia
Placental release of cytokine factors
Endothelial dysfunction
Endothelin and Thromboxane Nitric oxide and Prostacyclin Vascular sensitivity to Angiotensin II
Renal pressure natriuresis
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