systemic hypertension - general medicine by - hardik.pptx

General medicine

1. SYSTEMIC HYPERTENSION

2. Previous Year Questions Q.-1. Discuss pathogenesis, clinical features , investigation & management of systemic hypertension ? [10 Marks , 2016] Q. 2. Diagnostic criteria for hypertension & white coat hypertension. [5 Marks , 2014]

3. Systemic Hypertension Persistent elevation of BP above normal values i.e. 140/90 , when the patient is resting and relaxed. Labile hypertension :- patients who sometimes but not always , have BP within the hypertensive range. These patients often have borderline hypertension. White-coat hypertension :- in some patients the BP , though remaining in normal range , increases whenever he/she visits a doctor.

4. In adults , diastolic pressure :- Below 90 mmHg – Normal 90-104 mmHg – Mild Hypertension 105-114 mmHg – Moderate Hypertension 115 or more – Severe Hypertension BP – 120-139/80-89 mmHg is considered as prehypertension and patient may develop hypertension in 4-5 yrs.

5. Etiology Primary cause :- more than 95% of patients have no identifiable underlying cause of hypertension . They are said to have Essential or Idiopathic hypertension . In 70% of individual it is inherited. Environmental factors (obesity , alcohol , smoking) , humoral mechanisms ( ANS hyperactivity, RAAS stimulation, defect in natriuretic peptide synthesis) , hormonal mechanism play role in it. Secondary cause :- In about 5 % cases. Renal disorders Endocrine disorders Drug induced Pregnancy related

6. Complications Hypertensive Retinopathy :- cotton wool exudates, haemorrhages and pappiloedema are seen. Hypertension offers a pressure overload to left ventricular output , leads to left ventricular failure ultimately . Coronary artery disease is more common in hypertensive patients. Long standing hypertension can lead to proteinuria and uraemia (chronic renal failure).

7. Management The management includes :- General measures Drug therapy (anti-hypertensives) General Measures Relief of stress Reducing sodium intake Regular exercise Stop smoking Moderation of alcohol consumption

8. Drug therapy (anti-hypertensives) Diuretics A daily dose of bendrofluazide (5mg) or cyclopenthiazide (0.5mg) is appropriate. Chlorthalidone (a non-thiazide) does better bp control than thiazide . More potent diuretics , such as frusemide (40mg daily) or torsemide (20mg) or bumetanide (1mg daily) are less frequently used because of their less duration of action and less well tolerated. Potassium sparing diuretics such as, spironolactone 25-100 mg daily are effective.

9. Anti-adrenergic Drugs Central acting agents :- clonidine , alpha-methyldopa acts on vasomotor centre . postural hypotension is its side effect. Ganglion blockers :- trimethophan , used for rapidly lowering the BP by parentral administration. Post-ganglionic adrenergic nerve endings acting drugs :- reserpine & guanethidine , inhibit storage and release of norepinephrine. depression, nightmares & postural hypotension are its side effects. Alpha & beta adrenergic receptor blockers :- phentolamine , phenoxybenzamine , tetrazozin & doxazosin are some of its drugs used.

10. Betablockers :- These drugs blocks beta-receptors thus the sympathetic and RAAS system becomes less effective. Atenolol (50-100mg daily) or metoprolol (100-200mg/day) are commonly used slow released preparations. Propranolol is lipid soluble and crosses blood brain barrier , hence produces CNS effects such as drowsiness , depression , nightmares , etc. and is not preferred. other drugs used are sotalol , labetalol , carvidelol , etc.

11. ACE Inhibitors :- they inhibit the conversion of angiotensin I to angiotensin II and thus reduces effects of RAAS. They are usually started in small dose – captopril (6.25 mg daily) , enalapril (2.5 mg daily). The dose is slowly increased to an effective maintenance dose of , captopril (25-75mg daily) , enalapril (15-20mg daily) or lisinopril (10-20 mg daily). Recently , angiotensin receptor blockers have been introduced for treatment of mild to moderate hypertension. These include , Losartan ( 25-100mg in single or two doses) , irbesartan (150-300mg in one or two doses).

12. Renin inhibitors :- Aliskiren can be used in combination therapy of hypertension. Calcium channel blockers :- diltiazem (60mg 8hourly or slow release 90-120mg once daily), verapamil (80mg 8 hourly) or long acting nifedipine (30-90mg once daily). Short acting nifedipine (5-10mg sublingual) is used in case of hypertensive emergencies as a first aid measure. Vasodilators :- hydralazine – previously used but now not preferred due to its side effects. Diazoxide & nitroprusside are the drugs used in hypertensive emergency.