DR.SYED FASIH AHMED
HASHMI
FCPS
HEAD OF CARDIOLOGY
DEPARTMENT, LUMHS
CARDIOLOGY
DEPARTMENT OF
LUMHS
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HTN contributes to all CV comorbidities like:
CAD
MIs
CVA
Systolic HF
Diastolic HF
PVD.
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Hypertension is the most common primary
care diagnosis worldwide.
It affects about 1 billion people around the
world.
HTN is associated with increased total
mortality among men and women of all ages
and ethnic groups regarless of CVD.
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Definition: It is a sustained elevation of blood
pressure more than 140 mmHg systolic and
more than 90 mmHg diastolic.
OR
The need for antihypertensive medicine.
Primary
Secondary
Also known as essential
Hypertension
Account to 5% - 10% cases
Account to 90% – 95% cases
Secondary to other potential
rectifiable causes
Cause not known
•HTN is a complex disease modified by
•Genetic and
•Environmental factors
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GENETIC:
HTN does not follow classic Mendalian
rule of inheritance
however variation in the genes that control
various components of renin-angiotensinAldosteron system, the kilikerin-kinin
system and the sympathetic nervous system
are potential causes of HTN.
Environmental Factors:
Excessive Sodium intake
Excessive Alcohol intake
Abnormal Renal function
Abnormal Vascular function
Dysfunction of Renin angiotensin system
Insulin resistance
There are number of diseases that cause secondary
Hypertension:
Renal Disease (Account for over 80% of cases)
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Diabetic nephropathy
Chronic glumerulonephritis
Adult polycystic disease
Chronic tubulointerstitial nephritis
Renovascular Disease
(Continue)
Endocrine Disease
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Conn’s syndrome
Adrenal hyperplasia
Acromegaly
Pheochromocytoma
Drug & Toxins
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OCPs
Corticosteriod
NSAIDs
Sympathomimetic
Vascular Disease
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Coarctation of aorta
Vasculitis
Pregnancy Induced
Hypertension
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MRFIT(11.6 yr follow up-361,000 subjects)
40% more deaths in stage 1 HTN!
Relationship was stronger for systolic than
diastolic HTN
Mortality can be decreased by 36% by primary
prevention of HTN in general population
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Mostly asymptomatic, it usually takes
several years for high BP to cause noticeable
symptoms and even when it does cause
problems, the symptoms are often mild and
non-specific(i.e, they could be caused by
several different conditions)
May be
 Dizziness
 Blurred or double vision
 Headache
 Nose bleeds
 Flushed face
 Palpitations
 SOB
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BP must be measures in a standardized
manner with equipment that meet
certification criteria
1. Sits in a chair with back supported and
arms bared and supported at heart level
2. refrain from smoking and caffeine 30 min
prior to the measurement
3.at least 5 min of rest
4.appropriaate cuff size must be used
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5. Hg sphygmomanometer is preferable
6. First appearance of sound is systolic BP
the disappearance(and not muffling) of
sound is diastolic BP
7. Two or more readings separated by 2 min
should be averaged.
Blood pressure measurement particularly
when performed by a doctor, can cause an
unrepresentative surge in blood pressure
which is termed as white coat or office
hypertension.
 As many as 20% of patients with apparent
hypertension in the clinic may have a normal
blood pressure.
 In such cases automated ambulatory blood
pressure(IABP) measurements obtained over
24 hours or longer provides a better profile.
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Usually unrewarding
Fundoscopic Examination
Examination of Neck
Heart:
for rate rhythm increased size precordial
heave murmur and S3 and S4
Lungs:
◦ Rales and broncospasm
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Abdomen;
Kidneys and bruits and abnormal aortic
pulsation
Examination of extremities
Neurological Examination
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to identify known cause of HTN
to assess the presence or absence of end
organ damage and CV disease ,the extent of
the disease and response to therapy
to identify other CV risk factors or
concomitant disorders that may define
prognosis and guide treatment
Cardiovascular
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Ventricular hypertrophy, dysfunction and failure.
Arrhythmias
Coronary artery disease, Acute MI
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Arterial aneurysm, dissection, and rupture.
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CNS
Stroke, intracerebral and subarachnoid hemorrhage.
Cerebral atrophy and dementia
Effects On Eye
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Retinopathy, retinal hemorrhages and impaired vision
Vitreous hemorrhage, retinal detachment
Neuropathy of nerves leading to extraoccular muscle paralysis
and dysfunction
Effects On Kidney
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Glomerular sclerosis leading to impaired kidney function and
finally end stage kidney disease
Ischemic kidney disease especially when renal artery stenosis is
cause of HTN.
In all patients,
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CBC
Urine analysis
Serum urea and creatinine
Serum Electrolytes especially potassium
Fasting blood sugar
Lipid profile
Serum uric acid
ECG
X-Ray Chest
Echocardiography
Category
SBP
(mm Hg)
DBP
(mm Hg)
Optimal
<120
80
Normal
120-129
80-84
prehypertension
130-139
85-89
Stage 1
140-159
90-99
Stage 2
≥160
≥100
Hypertension
Life Style Modification
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Weight reduction
Reduction in alcohol consumption
Stop cigarette smoking
Salt restriction
Avoid stress
DASH diet( dietary approach to stop hypertension)
It recommends:
o more fruits, vegetables, whole grain fruits, lower fat dairy, fish,
poultry, nuts, eat less red meat, saturated fats and sweets.
Diuretics
 Beta Blockers
 Calcium channel blockers
 ACE inhibitors
 Angiotensin II receptor blockers
 Alpha adrenergic blockers
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Mechanism Of Action
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It is often 1st drug of choice, if diet and exercise
changes are not enough
Also called the water pills
Help body to shed excess sodium and water to lower
the BP.
Side Effects
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Deplete body potassium leading to muscle weakness,
leg cramps and fatigue
Increase blood sugar
Erectile dysfunction less common.
Mechanism Of Action
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It act by causing the arteriolar vasodilatation
Side Effects
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Headache
Palpitation
Peripheral edema
Bradycardia
Constipation
Heart block
Mechanism Of Action
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Act by blocking the conversion of angiotensin I to angiotensin
II (a vasoconstrictor)
Produce arterial and venous vasodilatation
Side Effects
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Dry cough
Skin rashes
Dizziness
Hyperkalemia
Mechanism Of Action
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It act by relaxing the smooth muscles
Decreases the peripheral vascular resistance
These are drug of 1st choice if patient has benign prostate
hypertrophy along with hypertension because it reduces the
symptoms of prostatism.
Side Effects
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Headache
Dizziness
Fatigue
Insomnia
Mechanism Of Action
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Block receptors for angiotensin
ARBs takes several weeks to become fully effective
Side Effects
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Insomnia
Dizziness
Muscle cramps
Hyperkalemia
Mechanism Of Action
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Slows the heart rate
Inhibit the renin
Side Effects
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Insomnia
Dizziness
Fatigue
Cold hands and feet
Erectile dysfunction
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Patient should return for follow-up and adjustment of
medications until the BP goal is reached
More frequent visits for stage 2 HTN or with complicating comorbid conditions
Serum potassium and creatinine monitored 1-2 times per
year
After BP at goal and stable, follow up visits at 3 to 6 month
intervals
Co-morbidities such as Heart failure associated diseases,
diabetes, etc need laboratory tests influence the frequency of
visits.