Arterial hypertension facultative therapy.ppt

Arterial hypertension
Facultative therapy
MBBS
Internal medicine

1. Bashkir state medical University Bashkir state medical University
Department of faculty therapyDepartment of faculty therapy
Essential hypertensionEssential hypertension
((hypertensive diseasehypertensive disease))
20202020

2. 
Arterial hypertension (AH) is a condition Arterial hypertension (AH) is a condition
in which the blood pressure in the in which the blood pressure in the
arteries is persistently elevated. In this arteries is persistently elevated. In this
condition systolic blood pressure is at condition systolic blood pressure is at
or above 140 mmHg and / or diastolic or above 140 mmHg and / or diastolic
blood pressure at or above 90 mmHg.blood pressure at or above 90 mmHg.

3. DEFINITIONDEFINITION
Hypertensive disease is a chronically
occurring disease, the main
manifestation of which is hypertension
that is not associated with pathological
processes in which an increase in blood
pressure is due to known, in modern
conditions, often eliminated causes.

4. EpidemiologyEpidemiology

AH affects about 40% of the adult AH affects about 40% of the adult
population.population.

Among persons over 65 years old - Among persons over 65 years old -
50-65%50-65%

5. AH
Etiology and pathogenesisEtiology and pathogenesis
Overweight
Stress
Genetic
factors
Excess salt
intake
Membrane
  violations
Baroreceptors
and chemo
receptors
Endothelin
RAAS
Sodium metabolism
disorders
Increased activity
SAS

6. Target organ damage Target organ damage
Action on the heart Action on the heart
Left Left
ventricular ventricular
hypertrophy hypertrophy
(LVH)(LVH)

Heart failureHeart failure

7. Target organ damage. Action on the Target organ damage. Action on the
brainbrain
acute disorders of cerebral acute disorders of cerebral
circulation (stroke, circulation (stroke,
transient ischemic transient ischemic
attack);attack);

chronic disorders of chronic disorders of
cerebral circulation cerebral circulation
(hypertensive (hypertensive
encephalopathy, lacunar encephalopathy, lacunar
infarctions, cognitive infarctions, cognitive
impairmentimpairment))

8. Target organ damageTarget organ damage
Action on the kidneys Action on the kidneys
Hypertensive Hypertensive
nephropathynephropathy

Hypertensive Hypertensive
nephrosclerosisnephrosclerosis

9. Target organ damageTarget organ damage
Action on the eyes Action on the eyes
Hypertensive Hypertensive
retinopathyretinopathy

10. Classification of AH according to WHO Classification of AH according to WHO
(1993)(1993)
Stage 1:
Lack of objective signs of target
organ damage

11. Classification of AH according to Classification of AH according to
WHO (1993)WHO (1993)
Stage 2:Stage 2: The presence of at least one of the signs The presence of at least one of the signs
of target organ damageof target organ damage

• • LVHLVH (ECG, EchoCG or radiography) (ECG, EchoCG or radiography)

• • Microalbuminuria Microalbuminuria 30-300 mg / day, proteinuria 30-300 mg / day, proteinuria
and / or creatininemia 1,2-1,5 mg / dl (107-133 and / or creatininemia 1,2-1,5 mg / dl (107-133
μmol / l), reduced GFR less than 60 ml / minμmol / l), reduced GFR less than 60 ml / min

• • Ultrasound signs of arterial wall thickening Ultrasound signs of arterial wall thickening
(CMI> 0.9) or atherosclerotic plaque of the great (CMI> 0.9) or atherosclerotic plaque of the great
arteriesarteries

12. Classification of AH according to Classification of AH according to
WHO (1993)WHO (1993)
Stage 3 Stage 3
The presence of clinical manifestations of The presence of clinical manifestations of
target organ damagetarget organ damage
BrainBrain
• • Ischemic strokeIschemic stroke
• • Hemorrhagic strokeHemorrhagic stroke
• • Transient ischemic attackTransient ischemic attack

13. Classification of AH according to Classification of AH according to
WHO (1993)WHO (1993)
Stage 3
Heart
• Myocardial infarction
• Angina pectoris
• Chronic heart failure
  Coronary revascularization
Kidney
• Renal failure: Creatininemia> 133 µmol/l,
GFR <30 ml/min/1,73m2
• Diabetic nephropathy

14. Classification of AH according to Classification of AH according to
WHO (1993)WHO (1993)
Stage 3 Stage 3

Peripheral vesselsPeripheral vessels

• • Dissecting aortic aneurysmDissecting aortic aneurysm

• • Clinically pronounced lesion of peripheral Clinically pronounced lesion of peripheral
arteries (intermittent claudication)arteries (intermittent claudication)

RetinaRetina

• • Hemorrhages or exudateHemorrhages or exudate

• • Edema of the optic discEdema of the optic disc

15. Cardiovascular Risk Factors Cardiovascular Risk Factors
MainMain

Men > 55 yearsMen > 55 years

Women > 65 yearsWomen > 65 years

SmokingSmoking

Total cholesterol > 4.9 mmol/lTotal cholesterol > 4.9 mmol/l

LDL > 3.0 mmol/l, TG > 1.7 mmol/lLDL > 3.0 mmol/l, TG > 1.7 mmol/l

Diabetes mellitus, IGTDiabetes mellitus, IGT

Cases of early manifestations of cardiovascular Cases of early manifestations of cardiovascular
disease in family historydisease in family history

Abdominal obesity (waist size > 102 Abdominal obesity (waist size > 102 ссm for men m for men
and > 88 cm for women), body mass index (BMI) and > 88 cm for women), body mass index (BMI)
30 kg/m2
≥
30 kg/m2
≥

16. Risk distributionRisk distribution
B.P. B.P. ((mmHgmmHg))
Another risk Another risk
factorsfactors (RF) (RF) + +
AnamnesisAnamnesis
Stage Stage 11
SBP SBP 140-159 140-159 / /
DBPDBP 90-99 90-99
StageStage 2 2
SBPSBP 160-179 160-179 //
DBPDBP 100-109 100-109
StageStage 3 3
SBPSBP >> 180 180 // DBPDBP
>> 110 110
Without an Without an
another RFanother RF
Low riskLow risk Medium riskMedium risk High riskHigh risk
1-2 1-2 RFRF Medium riskMedium risk Medium riskMedium risk Extremely high Extremely high
riskrisk
3 3 and more RF, and more RF,
DM, Target DM, Target
organ damageorgan damage
High riskHigh risk High riskHigh risk Extremely high Extremely high
riskrisk
SCPSCP Extremely high Extremely high
riskrisk
Extremely high Extremely high
riskrisk
Extremely high Extremely high
riskrisk

17. Complaints of patients with AHComplaints of patients with AH

Headaches, dizziness, nausea, Headaches, dizziness, nausea,
flickering "fly" before the eyesflickering "fly" before the eyes

Heartache, palpitations, shortness Heartache, palpitations, shortness
of breath, fatigueof breath, fatigue

Nasal bleedingNasal bleeding

Complaints may be missingComplaints may be missing

18. AnamnesisAnamnesis
Family history of AH, diabetes mellitus, Family history of AH, diabetes mellitus,
dyslipidemia, coronary artery disease, stroke dyslipidemia, coronary artery disease, stroke
and kidney diseaseand kidney disease
Lifestyle assessment (consumption of salt, fat, Lifestyle assessment (consumption of salt, fat,
alcohol, smoking, physical activity)alcohol, smoking, physical activity)
The duration of hypertension and the degree The duration of hypertension and the degree
of increase in blood pressure, efficacy and of increase in blood pressure, efficacy and
tolerability of previous antihypertensive tolerability of previous antihypertensive
therapytherapy

19. AnamnesisAnamnesis
The presence of coronary artery disease or The presence of coronary artery disease or
heart failure, cerebrovascular diseases, other heart failure, cerebrovascular diseases, other
diseases in this patient (gout, diabetes, diseases in this patient (gout, diabetes,
kidney disease, dyslipidemia, bronchospastic kidney disease, dyslipidemia, bronchospastic
conditions)conditions)
Taking drugs that increase blood pressure Taking drugs that increase blood pressure
(oral contraceptives, NSAIDs, cocaine, (oral contraceptives, NSAIDs, cocaine,
erythropoietin, cyclosporine, glucocorticoids)erythropoietin, cyclosporine, glucocorticoids)

20. Physical examinationPhysical examination

The main method of diagnosing The main method of diagnosing
hypertension is two to three times the hypertension is two to three times the
measurement of blood pressure in measurement of blood pressure in
accordance with international standards.accordance with international standards.

21. Physical examinationPhysical examination
Terms and rules for measuring blood Terms and rules for measuring blood
pressurepressure
The measurement of blood pressure is The measurement of blood pressure is
made after at least 5 minutes of rest of made after at least 5 minutes of rest of
the patient, for 1 hour before the the patient, for 1 hour before the
measurementmeasurement
The patient should not smoke, drink The patient should not smoke, drink
coffee, alcoholcoffee, alcohol
The lower edge of the cuff should be 2 cm The lower edge of the cuff should be 2 cm
above the cubital fossa.above the cubital fossa.

22. Physical examinationPhysical examination
Terms and rules for measuring blood pressureTerms and rules for measuring blood pressure

Air in the cuff should be injected at 20-30 Air in the cuff should be injected at 20-30
mm Hg above the disappearance of the mm Hg above the disappearance of the
pulse on the radial artery. Cuff pressure pulse on the radial artery. Cuff pressure
reduction speed - 2 mm/s.reduction speed - 2 mm/s.

During the first inspection, pressure is During the first inspection, pressure is
measured on both hands, and later on that measured on both hands, and later on that
arm, where it was higher. During each arm, where it was higher. During each
examination of a patient, blood pressure is examination of a patient, blood pressure is
measured at least 2 times with an interval of measured at least 2 times with an interval of
2 minutes. Estimate the average.2 minutes. Estimate the average.

23. Laboratory and instrumental methods Laboratory and instrumental methods
of research of research
Complete blood count
Urinalysis
Microalbuminuria Test (MAU)
Biochemical profile (potassium, sodium,
creatinine, glucose, cholesterol, LDL, HDL)
ECG - left ventricular hypertrophy (Sokolov-
Lion index SV1 + RV5,6 > 35 mm

24. Laboratory and instrumental methods Laboratory and instrumental methods
of research of research
All patients with hypertension are
recommended to determine the clearance of
blood creatinine (ml/min) using the Cockroft-
Gault formula
Or the glomerular filtration rate (GFR) in
ml/min/1.73m2 according to the MDRD / CKD-
EPI formula
Decrease in creatinine clearance < 60 ml/min or
GFR < 60 ml/min/1.73m2 is an evidence of
impaired renal function

25. Laboratory and instrumental methods Laboratory and instrumental methods
of researchof research

Daily monitoring of blood pressure (SMAD)Daily monitoring of blood pressure (SMAD)

Self-monitoring of blood pressure (SCAD)Self-monitoring of blood pressure (SCAD)

Echocardiography: left ventricular Echocardiography: left ventricular
hypertrophy (TSSLZH > 1.2 cm; TMZHP > hypertrophy (TSSLZH > 1.2 cm; TMZHP >
1.2 cm; increase MLJ index > 115g/m2 for 1.2 cm; increase MLJ index > 115g/m2 for
men and 95g/m2 for women), a violation men and 95g/m2 for women), a violation
of diastolic, later left ventricular systolic of diastolic, later left ventricular systolic
functionfunction

26. Laboratory and instrumental Laboratory and instrumental
methods of researchmethods of research

Ultrasound of major vessels (common carotid Ultrasound of major vessels (common carotid
artery) - measurement of TIM (CMM) to detect artery) - measurement of TIM (CMM) to detect
vascular wall thickening (TIM 0.9 mm) or
≥
vascular wall thickening (TIM 0.9 mm) or
≥
the presence of an atherosclerotic plaquethe presence of an atherosclerotic plaque

Study of the fundus vesselsStudy of the fundus vessels

Ultrasound of the kidneys, adrenal glands, Ultrasound of the kidneys, adrenal glands,
renal arteries to detect secondary renal arteries to detect secondary
hypertensionhypertension

27. Electrocardiography for left Electrocardiography for left
ventricular hypertrophyventricular hypertrophy
Sokolov-Lyon Index
Sv1 + Rv5,6 > 35mm (3.5mV)
Cornell indicator
(RAVL + SV3) ≥ 20 mm for women
(RAVL + SV3) ≥ 28 mm for men;
Cornell work (RAVL + SV5) mm x QRS ms >
2440 mm x ms)

28. ECG for left ventricular hypertrophy

29. Treatment of AHTreatment of AH
Non-drug measures to reduce blood Non-drug measures to reduce blood
pressurepressure

Smoking give upSmoking give up

Weight lossWeight loss

Alcohol reductionAlcohol reduction

Limiting the use of salt to 5-2 g/dayLimiting the use of salt to 5-2 g/day

30. Treatment of AHTreatment of AH
Non-drug measures to reduce blood Non-drug measures to reduce blood
pressurepressure

Modification of the diet - an increase in Modification of the diet - an increase in
consumption of fruits and vegetables, foods consumption of fruits and vegetables, foods
rich in potassium, magnesium, calcium, fish rich in potassium, magnesium, calcium, fish
and seafood, limiting animal fatsand seafood, limiting animal fats

Increase in physical activity - dynamic loads Increase in physical activity - dynamic loads
of low intensity (walking, skiing or cycling, of low intensity (walking, skiing or cycling,
swimming). Isometric loads, such as swimming). Isometric loads, such as
weightlifting, can cause an increase in blood weightlifting, can cause an increase in blood
pressure.pressure.

31. Drug treatment of AHDrug treatment of AH
General ProvisionsGeneral Provisions

The beginning of drug therapy is preceded by The beginning of drug therapy is preceded by
non-drug treatment of hypertension in non-drug treatment of hypertension in
groups of groups of low and medium risklow and medium risk. Start . Start
treatment with a treatment with a minimum dose of one drugminimum dose of one drug

Drug therapy is started immediately Drug therapy is started immediately in groups in groups
of high and extremely high riskof high and extremely high risk, it is , it is
recommended to start AGT with recommended to start AGT with a a
combination of two drugs.combination of two drugs.

32. Drug treatment of AHDrug treatment of AH
General ProvisionsGeneral Provisions
Preferential use Preferential use of long-acting drugs of long-acting drugs (12-24 hours (12-24 hours
with a single dose)with a single dose)
The target for all categories The target for all categories of patients is the level of patients is the level
of blood pressure of blood pressure <140/90 mm Hg. <140/90 mm Hg.
The exceptions : The exceptions : patients with hypertension with patients with hypertension with
diabetes - the target blood pressure is < diabetes - the target blood pressure is <
130/85 mm Hg.130/85 mm Hg.
For persons older than 80 years is recommended For persons older than 80 years is recommended
to reduce the SBP to 140 - 150 mm Hgto reduce the SBP to 140 - 150 mm Hg

33. Drug treatment of AHDrug treatment of AH
The main groups of antihypertensive drugsThe main groups of antihypertensive drugs
1.1.ACE Inhibitors (ACE inhibitors)ACE Inhibitors (ACE inhibitors)
2.2.AT1 receptor blockers (ARB)AT1 receptor blockers (ARB)
3.3.Calcium Antagonists (AK)Calcium Antagonists (AK)
4.4.β-β-blockers (BB)blockers (BB)
5.5.DiureticsDiuretics
6.6.α-α-blockersblockers
7.7.centrally acting drugscentrally acting drugs

34. Group of Group of
drugsdrugs
RepresentatiRepresentati
vesves
IndicationsIndications ContraindicContraindic
ationsations
ACE ACE
inhibitorsinhibitors
Captopril Captopril
Enap Enap
RamiprilRamipril
LisinoprilLisinopril
PerindoprilPerindopril
Heart Heart
failure, failure,
Coronary Coronary
artery artery
disease, disease,
NephropathNephropath
y, Diabetesy, Diabetes
PregnancyPregnancy
, Bilateral , Bilateral
renal renal
artery artery
stenosis, stenosis,
HyperkaleHyperkale
miamia

35. Group of Group of
drugsdrugs
RepresentatiRepresentati
vesves
IndicationsIndications ContraindicContraindic
ationsations
AngiotensiAngiotensi
n I n I
Receptor Receptor
BlockersBlockers
LosartanLosartan
ValsartanValsartan
Cough while Cough while
taking ACE taking ACE
inhibitorsinhibitors
PregnancyPregnancy
, Bilateral , Bilateral
renal renal
artery artery
stenosis, stenosis,
HyperkaleHyperkale
miamia

36. Group of Group of
drugsdrugs
RepresentativRepresentativ
eses
IndicationsIndications ContraindicContraindic
ationsations
Calcium Calcium
AntagonisAntagonis
tsts
Verapamil Verapamil
120-480 mg120-480 mg
Diltiazem Diltiazem
180-360 mg180-360 mg
Amlodipine Amlodipine
5-10 mg5-10 mg
Nifedipine Nifedipine
SR 30 mgSR 30 mg
Angina,Angina,
Elderly age,Elderly age,
Systolic Systolic
hypertensiohypertensio
nn
AV AV
blockade blockade
and CHF and CHF
(for (for
verapamil, verapamil,
diltiazem)diltiazem)

37. Group of Group of
drugsdrugs
RepresentativRepresentativ
eses
IndicationsIndications ContrainContrain
dicationsdications
DiureticsDiureticsHypothiazideHypothiazide
IndapamideIndapamide
FurosemideFurosemide
SpironolactoSpironolacto
nene
CHFCHF
Elderly ageElderly age
Systolic Systolic
hypertensionhypertension
GoutGout

38. Group of Group of
drugsdrugs
RepresentativRepresentativ
eses
IndicationsIndications ContraindicContraindic
ationsations
β-β-blockersblockersPropranololPropranolol
Atenolol Atenolol
Metoprolol Metoprolol
Bisoprolol Bisoprolol
Angina,Angina,
IM in IM in
history, history,
tachyarrhyttachyarrhyt
hmiahmia
Broncho-Broncho-
obstructive obstructive
syndrome, syndrome,
AV-AV-
blockade blockade
of 2-3 of 2-3
degreesdegrees

39. Group of Group of
drugsdrugs
RepresentatRepresentat
ivesives
IndicationsIndications ContraindicaContraindica
tionstions
PreparatioPreparatio
ns of ns of
Central Central
actionaction
Clonidine Clonidine
MethyldopMethyldop
aa
MoxonidinMoxonidin
ee
BronchoobsBronchoobs
tructive tructive
syndrome, syndrome,
gipersimpatigipersimpati
kotoniakotonia
Bradycardia Bradycardia
Heart Heart
blockages, blockages,
DepressionDepression

40. Group of Group of
drugsdrugs
RepresentatiRepresentati
vesves
IndicationsIndications ContraindicContraindic
ationsations
α-α-blockersblockersDoxazosinDoxazosin
PrazosinPrazosin
Prostate Prostate
adenomaadenoma
AH at AH at
pregnancypregnancy
Orthostatic Orthostatic
hypotensiohypotensio
nn

41. Complications/ EmergencyComplications/ Emergency

Hypertensive crisis Hypertensive crisis - a sudden increase - a sudden increase
in blood pressure, accompanied by in blood pressure, accompanied by
signs of deterioration of cerebral, signs of deterioration of cerebral,
coronary or renal blood circulation, coronary or renal blood circulation,
and autonomic symptoms.and autonomic symptoms.

42. Conditions requiring a decrease in blood Conditions requiring a decrease in blood
pressure within 1 hourpressure within 1 hour
Dissecting aortic aneurysmDissecting aortic aneurysm
Pulmonary edemaPulmonary edema
Myocardial infarctionMyocardial infarction
Unstable AnginaUnstable Angina
Nasal bleedsNasal bleeds
Hypertensive encephalopathyHypertensive encephalopathy
Brain strokeBrain stroke
Skull traumaSkull trauma
EclampsiaEclampsia
Crisis with pheochromocytomaCrisis with pheochromocytoma
Postoperative bleeding from the region of vascular Postoperative bleeding from the region of vascular
suturessutures
Severe RetinopathySevere Retinopathy

43. DrugDrug DoseDose Special Special
indicationsindications
Sodium Sodium
Nitro Nitro
PrussidePrusside
0,25-100,25-10
mcg/kg/min i/v mcg/kg/min i/v
dripdrip
Hypertensive Hypertensive
encephalopathy, encephalopathy,
subarachnoid subarachnoid
hemorrhagehemorrhage
NitroglyNitrogly
cerinecerine
5-1005-100
mcg/kg/min i/v mcg/kg/min i/v
dripdrip
Myocardial Myocardial
infarction, infarction,
pulmonary edemapulmonary edema
Recommended drugs for treatment of
hypertensive crisis

44. Drugs for edema hypertensive Drugs for edema hypertensive
crisiscrisis
DrugDrug DoseDose Special Special
indicationsindications
FurosemFurosem
ideide
20-120 20-120 mg i/v mg i/v Pulmonary edema, Pulmonary edema,
hypertensive hypertensive
encephalopathyencephalopathy
ClonidinClonidin
ee
0,075-0,150 0,075-0,150 mg mg
i/v slowlyi/v slowly
With clonidine With clonidine
withdrawalwithdrawal

45. Drugs for hypertensive crisisDrugs for hypertensive crisis

EnalaprilatEnalaprilat

DroperidolDroperidol

PentaminePentamine

46. Uncomplicated hypertensive crisisUncomplicated hypertensive crisis
DrugDrug DoseDose
CaptoprilCaptopril 6.25-50 mg orally, 6.25-50 mg orally,
sublinguallysublingually
NifedipineNifedipine 10-30 10-30 mg orally, sublinguallymg orally, sublingually
ClonidineClonidine 0,75 0,75 mg orally, sublinguallymg orally, sublingually
AnaprilinAnaprilin 20-40 20-40 mg orally, sublinguallymg orally, sublingually

47. Complications of AH:Complications of AH:

Myocardial infarctionMyocardial infarction

StrokeStroke

Renal failureRenal failure

Heart failureHeart failure

Hypertensive encephalopathyHypertensive encephalopathy

RetinopathyRetinopathy

Dissecting aortic aneurysmDissecting aortic aneurysm

48. IndicationsIndications for hospitalization for hospitalization

The uncertainty of the diagnosis and The uncertainty of the diagnosis and
the need for special studies to clarify the need for special studies to clarify
the form of hypertensionthe form of hypertension

  Selection of drug therapy (with Selection of drug therapy (with
frequent crises, refractory frequent crises, refractory
hypertension)hypertension)

49. Indications for emergency Indications for emergency
hospitalizationhospitalization

HC, not stopped on the prehospital HC, not stopped on the prehospital
stagestage

Hypertensive encephalopathyHypertensive encephalopathy

Complicated HCComplicated HC

Malignant AHMalignant AH

50. PrognosisPrognosis

Depends on the adequacy of Depends on the adequacy of
prescribed therapy and patient prescribed therapy and patient
compliance with medical compliance with medical
recommendationsrecommendations
In case of adequate therapy and In case of adequate therapy and
clinical examination - the prognosis clinical examination - the prognosis
is favorableis favorable