Hypertension
S. Danish Hasan MD
March 2nd 2013
Objectives
Basic Concepts
 Definitions
 Screening and Diagnosis
 Guidelines
 Risk Factors
 Complications
 Treatment and Adverse Effects

Basic Concepts

Blood Pressure
◦ Amount of pressure on the arterial walls as
the blood is pumped through them by the
heart and circulated through the body

Systolic Blood Pressure
◦ Pressure on the walls when the heart
contracts

Diastolic Blood Pressure
◦ Pressure on the walls when the heart is
relaxed (in between heart beats)
Basic Concepts
Systolic goes on top and Diastolic on the Botton
Example
120 =
80
Systolic
Diastolic
Definitions
Normal Blood Pressure
 Pre Hypertension
 Stage 1 Hypertension
 Stage 2 Hypertension
 Isolated Systolic
Hypertension
 Isolated Diastolic
Hypertension
 Malignant Hypertension
 Hypertensive Urgency


<120/<80
120-139/80-89
140-159/90-99
>159/99
>139/<90

<140/>89
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End organ damage
 >179/>119
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Definitions

Primary/Essential Hypertension
Hypertension without a known or identifiable cause

Secondary/Identifiable Hypertension
Hypertension with a known or identifiable cause.
Some causes include:
1.
Primary Renal Disease – AKD/CKD with glomerular or vascular disorders
2.
OCPs
3.
Drug induced – Chronic NSAID/Alcohol use/abuse, Antidepressants.
4.
Pheochromocytoma (adrenal tumor) - paroxysmal hypertension
5.
Primary hyperaldosteronism – htn(specially resistant), unexplained hypoK
6.
Renovascular dz – pt. with atherosclerosis ex. Renal artery stenosis
7.
Other Endocrine issues – hypo/hyperthyroidism, hyperparathyroid
8.
Cushing’s Syndrome
9.
OSA
10.
Coarctation of aorta
Screening and Diagnosis

Screening
◦ Every 2 years for those in normal category
◦ Every year for pre-hypertensive category

Who is diagnosed with HTN?
◦ Initial screen +
◦ 2 or more visits with documented high blood
pressure
◦ Over a period of weeks to months
◦ Should be measured in both arms (>15mmHg
difference = Subclavian stenosis/PAD)
◦ Postural BPs in >65, diabetics, dizziness weakness
upon standing. Difference >20mmHg from supine to
standing(Orthostatic Hypotension)
Guidelines for proper blood
pressure measurement

Patient Conditions
◦ Posture
◦ Circumstances

Equipment
◦ Cuff
◦ Manometer

Technique
◦ Number of Readings
◦ Performance

Recordings
Guidelines – Posture


Sitting pressures are recommended for
routine follow-up; the patient should sit
quietly with the back supported for five
minutes and the arm supported at the level
of the heart
Check for postural changes by taking
readings after five minutes supine, then
immediately and two minutes after standing;
this is particularly important in patients over
age 65 years, diabetics, or those taking
antihypertensive drugs
Guidelines - Circumstances
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No caffeine during the hour preceding the
reading
no smoking during the preceding 30 minutes
No exogenous adrenergic stimulants, such as
phenylephrine in decongestants or eye drops
for pupillary dilatation
A quiet, warm setting
Home readings should be taken upon
varying circumstances (patient might be
asked to keep a home log)
Guidelines - Equipment

Cuff size
◦ length of the bladder should be 80 percent
◦ width of the bladder should be at least 40
percent of the circumference of the upper
arm

Manometer
◦ Aneroid gauges should be calibrated every six
months against a mercury manometer
Guidelines – Number of Readings

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


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Take at least two readings on each visit
separated by as much time as possible
if readings vary by more than 5 mmHg, take
additional reading until two consecutive readings
are close
For the diagnosis of hypertension
take three readings at least one week apart
Initially, take blood pressure in both arms; if
pressures differ, use the higher arm
If the arm pressure is elevated, take the pressure
in one leg, particularly in patients under age 30
years
Korotkoff Sounds–Reviewing BP 101
5 Phases
 Phase 1 – Clear Tapping Sound (SBP)
 Phase II – Swishing sound/soft murmur onset
 Phase III – Loup slapping/instense sound
 Phase IV – Sudden Muffling Sound
 Phase V – Silence Phase/Disappearance of
Sound
 “Tap – Murmur – Slap – Muffle – Silence”

Guidelines - Performance




Inflate the bladder quickly to 20 mmHg
above the systolic pressure as estimated
from loss of radial pulse
Deflate the bladder 3 mmHg per second
Record the Korotkoff phase V
(disappearance) as the diastolic pressure
except in children in whom use of phase IV
(muffling) may be preferable
If the Korotkoff sounds are weak, have the
patient raise the arm, open and close the
hand five to ten times, and then inflate the
bladder quickly
Guidelines - Recording
Recordings
 Note the pressure, patient position, arm,
and cuff size: eg, 140/90, seated, right arm,
large adult cuff

Risk Factors – Non Modifiable

Ethnicity - Asian, Inuit, First
Nations/Aboriginal, African Americans
◦ Tends to be most common and most severe in
Blacks



Family History – mother, father or both
parents
Age >65
Certain personality traits, such as hostile
attitudes and time urgency/impatience, as
well as among those with depression
Risk Factors - Modifiable
Smoking
 Excessive alcohol use (>14 drinks for M and
>9 drinks for F per week)
 Diet high in fat and salt (AHA <1500 mg)
 Weight / obesity
 Dyslipidemia regardless of obesity/weight
 Lack of exercise
 Vitamin D Deficiency
 Other medication

Prime suspects are canned soups and lunch
meat
Complciations
Complications
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CVD - Hypertension is quantitatively the major risk factor for premature
CVD, being more common than cigarette smoking, dyslipidemia, or
diabetes, the other major risk factors. In older patients, systolic pressure
and pulse pressure are more powerful determinants of risk than diastolic
pressure .
CHF - The risk of heart failure increases with the degree of blood
pressure elevation.
Dysrythmias, MI, Sudden Cardiac Death – LVH is a common finding
in patients with hypertension, and is associated with an enhanced incidence
of heart failure, ventricular arrhythmias, death following myocardial
infarction, and sudden cardiac death.
Ischemic Stroke - Hypertension is the most common and most
important risk factor for ischemic stroke, the incidence of which can be
markedly reduced by effective antihypertensive therapy.
Intracerebral hemorrhage - Hypertension is the most important risk
factor for the development of intracerebral hemorrhage.
CKD/ESRD - Hypertension is a risk factor for chronic kidney disease and
end-stage renal disease. It can both directly cause kidney disease, called
hypertensive nephrosclerosis, and accelerate the progression of a variety of
underlying renal diseases.
Treatments
Diet
 Exercise
 Dieuretics
 Beta Blockers
 ACE-Inhibitors
 ARBs
 Calcium Channel Blockers
 Other Medications
 Complementary Therapies

Treatment – Lifestyle, Diet and
Exercise

DASH Diet – Dietary Approaches to Stop
Hypertension
◦ eating more fruits, vegetables, whole-grain foods, low-fat
dairy, fish, poultry, and nuts. You should eat less red meat,
saturated fats, and sweets. Reducing sodium in your diet
can also have a significant effect.

Exercise
◦ 50 minutes of moderate exercise per week - gardening,
walking briskly, bicycling, or other aerobic exercise.
Muscle-strengthening activities are recommended at least
two days a week and should work all major muscle groups.

Lifestyle
◦ Quit smoking and alcohol
Treatment - Diuretics
Often the first choice if diet and exercise changes
aren't enough
 Also called "water pills”
 Help the body shed excess sodium and water
 Side Effects:

◦ urinate more often
◦ some may deplete potassium, causing muscle weakness, leg
cramps, and fatigue
◦ Some can increase blood sugar levels in diabetics
◦ Erectile dysfunction is a less common side effect

hydrochlorothiazide (HydroDiuril), furosemide (Lasix),
spironolactone (Aldactone)
Treatment – beta-Blockers
Slows the heart rate
 Used to treat other heart conditions
 May be prescribed along with other
medications
 Side effects: insomnia, dizziness, fatigue,
cold hands and feet, and erectile
dysfunction.
 atenolol (Tenormin), metoprolol
(Betaloc/Lopressor), bisoprolol

Treatment – ACE Inhibitors
ACE inhibitors reduce your body's supply of
angiotensin II -- a substance that makes blood
vessels contract and narrow.
 The result is more relaxed, open (dilated)
arteries,
 Side effects: dry cough, skin rash, or dizziness, and
high levels of potassium. Women should not
become pregnant while taking an ACE
inhibitor(teratogenic).
 lisinopril (Zestril), perindopril, enalapril, ramipril
(Altace)

Treatment - ARBs
Block receptors for angiotensin -- as if
placing a shield over a lock
 Prevents artery-tightening effects, and lowers
your blood pressure.
 ARBs can take several weeks to become
fully effective.
 Side effects: dizziness, muscle cramps,
insomnia, and high levels of potassium
Teratogenic as well.
 candesartan (Atacand), losartan (Cozaar),
valsartan (Diovan)

Treatment – Calcium Channel
Blockers
Slow the movement of calcium into the cells of
the heart and blood vessels. Since calcium causes
stronger heart contractions, these medications
ease the heart's contraction and relax the blood
vessels.
 Side Effects: dizziness, heart palpitations, swelling
of the ankles, and constipation.
 Take with food or milk and avoid grapefruit juice
and alcohol because of possible interactions.
 amlodipine (Norvasc), diltiazem (Cardizem), felodipine
(Renedil)

Other Medications
Other medications that relax the blood
vessels include vasodilators, alpha
blockers, and central agonists.
 Side effects: dizziness, a fast heart beat or
heart palpitations, headaches, or diarrhea.
 Usually if HTN is not controlled or if
another comorbitity

Complimentary Therapies
Along with lifestyle, diet and exercise
these help for HTN
 Yoga
 tai chi
 deep breathing exercises
 Other relaxation techniques
 Herbal Remedies? Unproven benefits and
some actually increase blood pressure.
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Questions?