Hypertension - Medicine - ATOT

Topic: Hypertension
Faculty: General Medicine
Course: BSc ATOT - 2nd year

1. HYPERTENSION Dr. Salman Ansari Kanachur Institute of Medical Sciences

2. Hypertension Definition Classification Causes and Risk factors Clinical features Investigations Treatment

3. Hypertension Definition : defined as persistently elevated systolic blood pressure (SBP) values of 130 mm Hg or more or diastolic blood pressure (DBP) of more than 80 mm Hg. 15% of the population suffers from hypertension Can affect the young as well as elderly

4. White coat hypertension : People with normal blood pressure show elevated blood pressure when recorded in a hospital or clinic Home value should be measured using BP monitor at home

5. Normal blood pressure : Systolic BP <120 mmHg Diastolic BP <80 mmHg Pre-hypertension: old term for BP between normal and hypertension

6. Classification of hypertension Primary or essential hypertension : 85% of cases Secondary hypertension : 15% of cases

7. Causes of HTN Primary HTN( 85%): cause is unknown - usually have positive family history Secondary HTN (15%): due to an abnormality or disease in the body

8. Causes of secondary HTN: Renal causes : diabetic nephropathy, glomerulonephritis, polycystic kidney disease Endocrine causes : Cushing’s syndrome, pheochromocytoma Cardiovascular causes : coarctation of aorta Neurological causes : psychogenic Medications/toxins : alcohol, drugs like corticosteroids, NSAIDs Stress

9. Risk factors for HTN Genetic : runs in families Environmental factors like: Obesity Alcohol intake Sodium intake stress

10. Pathogenesis Increased sodium absorption Impairment of renin-angiotensin-aldosterone system(RAAS) Increased sympathetic nervous system activation Increased total peripheral resistance Increased afterload on heart Development of hypertension

11. Clinical features Asymptomatic in majority of cases Transient headache, polyuria Long-standing HTN: left ventricular hypertrophy heaving apical impulse loud A2 heart sound fourth heart sound(S4)

12. Complications of HTN(Target Organ Damage)

13. CNS complications : Transient Ischemic Attack(TIA) Cerebrovascular accident(CVA) or stroke: due to cerebral bleeding Subarachnoid hemorrhage(SAH) Hypertensive encephalopathy

14. Ophthalmic or retinal complications : Hypertensive retinopathy: arterioles become narrow CVS complications : Coronary artery disease: angina, myocardial infarction Left ventricular failure Atrial fibrillation

15. Blood vessels complications : Atherosclerosis Aortic aneurysm Aortic dissection Renal complications : Proteinuria Hematuria Renal failure

16. “ Malignant hypertension ” or Hypertensive crisis/emergency : Clinical syndrome of markedly high blood pressure with retinal hemorrhage, and confusion, headache, vomiting, visual disturbances and worsening of renal function Mnemonic: Can’t see, can’t pee

17. Diagnosis At least 2 measurements on at least 2 separate occasions

18. Investigations Basic tests : Urine analysis Renal function test: urea, creatinine Serum electrolytes: hypokalemia, alkalosis Fasting blood sugar, postprandial blood sugar Serum cholesterol, triglycerides ECG Chest X-ray Thyroid profile fundoscopy

19. Secondary tests : Pheochromocytoma: 24 urinary catecholamine, metanephrines and VMA levels Cushing’s syndrome: plasma cortisol level, 24 hour urinary cortisol and dexamethasone suppression test Renal artery stenosis: doppler USG, CT angiogram PCKD: USG

20. Treatment Target BP: <140/90 mmHg General measures Drug therapy Treat the underlying cause

21. General measures Lifestyle modification Reassurance Control of obesity: weight loss Low sodium diet(<6 g of salt) More fruits, vegetables in diet Potassium, calcium Low sugar, low saturated fat, low fat dairy DASH diet : Dietary Approach to Stop Hypertension

22. Stop smoking Reduce alcohol intake Regular exercise Relaxation, meditation

23. DASH diet

24. 2) Drug therapy Use of antihypertensive medications If general measures are not successful, these medications are to be started Aim is lower SBP to <150 mmHg and DBP <90 mmHg

25. Guidelines: initial treatment with: thiazide diuretic or Calcium channel blocker or ACE inhibitor or Angiotensin Receptor Blocker(ARB) If goal BP is not reached, increase dose of initial drug or add a second drug

26. In black patient : thiazide diuretic. E.g: chlorthalidone, chlorothiazide I n young patient : beta blocker. E.g: propranolol Elderly patient with asthma : calcium channel blocker. E.g: nifedipine, verapamil Heart failure patient: ACE inhibitor. E.g: captopril, enalapril

27. Hypertensive emergencies/malignant hypertension Elevated systolic BP(> 180 mmHg) along with signs of acute target organ damage like hypertensive encephalopathy, acute heart failure with pulmonary oedema, acute renal failure, myocardial infarction, acute ischemic stroke, intracranial bleed or subarachnoid hemorrhage Drugs used in treatment of hypertensive emergencies : Labetalol Esmolol Nicardipine Nitroprusside

28. Hypertensive encephalopathy Very high BP and neurological disturbances such as vision, speech, disorientation, fits, loss of consciousness , papilloedema It can be reversed if HTN is controlled Treatment : Rapidly reduce BP to 100-105 mmHg within 2-6 hours I.V sodium nitroprusside can be used or labetalol B ed rest sedation and diuretics

29. Summary Definition Classification Risk factors + causes Clinical features Investigations Treatment

30. References: K. George Mathews - Prep Manual for Undergraduates - Medicine Questions: [email protected] For PPT, scan: For notes, click here or scan: