Hypertension and Hypotension: Key Factors and Definitions

In the name of God Hypertention and Hypotention By Reza Ghaderi Dr Medical university of yasudj-1393

IMPORTANCE; THE MOST COMMON RISK FACTOR FOR HEART ATTACK AND STROKE IS HYPERTENTION. THE MOST COMMON CAUSE THAT PTS VISITD BY PHYSICIAN IS HYPERTENTION.

DEFINITION According to JNC-7 in more than 2 opd visits average of blood pressure ; Nl ; <120/80 Pre hypertention; 120-139/80-89 Hypertention; stage 1; sys: 140-159 dia: 90-99 stage 2; sys >= 160 dia>= 100 Isolated sys hypertention; sys>=140 and dia< 90 Isolated dia hypertenton: dia>=90 and sys <140 All above definitions are true when in absence of any disease and any drugs. In any stage bigger numbers of sys or dia is important.

WHAT IS MORE IMPORTANT? SYS HTN OR DIASTOLIC HTN?

IN AGE >50 SYS HTN IS MORE IMPORTANT FOR PREDICTION OF C.V.DISEASE. IN AGE<50 DIAS HTN IS MORE IMPORTANT FOR PREDICTION OF C.V.DISEASE.

ANOTHER DEFINITION OF HTN; AVERAGE OF 24 HOURS BP >= 135/85 DAY TIME (AWAKE) >=140/90 NIGHT TIME (ASLEEP) >=125/75

Malignant HTN; Malignant HTN is defined with Marked HTN and retinal hemorrhage / exudate / papilla edema / encephalopathy. Malignant HTN usually accompanied dias> 120 but in normotensive pts who affected with Glomerulonephritis or preeclampsia was seen in dias<100.

HTN urgency; HTN urgency is defined with dias>120 in asymptomatic pts.

Essential HTN; unknown pathogenesis ; Increased sympatic ,increased mineralocorticoid ,genetic ,decreased nephron , infection, . Risk factor; black race, positive hx in parents , salt user , alcohol , obesity , immobility , dislipidemia , decreased vit D , specific personality

Secondary HTN; Acute and chronic kidney injury , Reno vascular disease, OCP , drugs , feo , aldostronism , cushing , hypopara , hypothyroidism , hyperthyroidism , coarctation of aorta , O.S.A.

Complication: Complication chance increased after BP more than 125/75 Complications consist of Premature cardiovascular disease, heart failure , left ventricular hypertrophy that causes of arrhythmia , H.F , M.I , sudden death. C.V.A , I.C.H , C.K.D

Measurement ; In absence of end organ damage HTN should be established in 3-6 visits. B.P measurement should be performed in both arms. If difference value in both arms was obtained more than 10 mmHg subclavian stenosis should be roll out. Postural HTN should be performed.

White coat HTN DX; Ambulatory measurement that control of HTN every 15 minute in days and every 30 minute. Masked HTN is opposite of white coat HTN

ABPM indication; white coat HTN Increased periodic HTN :feo Refractory HTN Hypotention after drug use Aoutonomic dysfunction

Evaluation End organ damage is present Evaluation of C.V.D Treatable cause

HX; causes P/E; end organ damage Corrected BP measurement Fat distribution Skin lesion Conciseness Fondoscopy Neck(carotid, thyroid) Heart ; sounds ,size , rhythm Lung; rales Abd ; mass,aortic size Ext; edema, pulses N/E; confusion, weakness, blurred vision

Labs; U/A, HCT, Elec , Bun, Cr, ECG, TG, Chol must be measured Alb/U , Echo in borderline Pts , ca may be measured Imaging should be performed if very doubtful Reno vascular disease may play role 1% in mild HTN and 10-45% in malignant or severe HTN.

Who should be treted?

In absence of end organ damage HTN should be treated if average of 24 hr monitor more than nl

Treatment; pharmacologic and non pharmacologic Non pharmacologic; Smoke cessation High K diet Stopped NSAIDS These items decreased prevalence of HTN from 32 to 22%

Decreased Wt; every 10 Kg decreased in wt causes decreased 5-20 mmHg Decreased Na; less than 6 gram Nacl daily causes decreased 2-8 mmHg Decreased alcohol; 2 drink per day for men and 1 drink per day for women causes decreased 2-4 mmHg DASH diet; dietary approach to stop HTN Activity; at least 30 minutes daily that decreased 4-9 mmHg

BP>=140/90 should be started drug If BP>160/100 should be started 2 drugs If P/U, CKD, CVD are present should be control of BP less than 130/80 If BP is abnl in office only should be performed 24 hr holter of BP In specific disease use of specific drugs

CHF..ACEI,ARB,BB,diuretic,aldostron antagonist MI ..ACEI,ARB,BB,aldostron antagonist CKD,Pr/U .ACEI,ARB Angina pectoralis BB,CCB AF BB,CCB BPH .alfa B Hyperthyroidism ..BB Migrane ..BB,CCb Raynod .CCB Perioperation .BB

Contraindication ; Angioedema .ACEI Broncospasm .BB Depretion BB Liver disease ...methyl dopa Pregnancy ......ACEI,ARB Heart block BB,CCB

Complication; BB ...depression Diuretic . Gout ACEi,ARB,Aldostron antagonist .hyperkalemia Thiazid hyponatremia ACEI,ARB ..renovascular disease

Monotherapy ; thiazid long acting CCB ACEI, ARB BB not use alone Combination therapy ; if BP>20/10 more than upper limit of nl Combination of CCB and ACEI/ARB is of choice .

Non dipping HTN; Nocturnal BP is <10% daily BP . If not is non dipping HTN that is potent predictore of out come of C.V.D Rx; change time of one anti HTN drugs to evening

Isolated sys HTN or age>65; ACEI, ARB thiazide long acting CCB In these pts diastolic BP is important thus should be careful in decreasing of diastole BP. Refractory HTN; dia>90 despite of received 3 anti HTN drugs Why? Inadequate dose, overload, low compliancy , secondary HTN , white coat HTN , drug use that causes HTN

Stop of drugs Yes or no ?

In 5 55% pts who recived one anti HTN drug may be left drug after 1- 2 years . Sudden onset stoped of short acting BB and short acting alfe-2 agonist may be lethal thus should be tapered until many weeks. In grade 1 HTN may be could tapering of drugs.

Hypertention emergency

Definition; HTN emergency is defined with sys BP>180 and/or dias BP>120 that result of many dangerous events such as encephalopathy, retinal hemorrhage, papilledema, ARF, ICH, SAH, MI, HF, severe epistaxis. HTN emergency may be asymptomatic or accompanied with mild headache.

Treatment; In the past in HTN emergency state control of BP<160/100 mmHg was goal but in this time this goal is controversial and slowly decreasing strategy was replaced. In fact rapidly decrease of BP is more dangerous because decreased of Bp suddenly impaired cardiac and brain flow and MI and CVA risk increased.

Streategy; In the absence of sign of acute end organ damage, The goal of management of BP<= 160/100 over several hours to days All pts should be provided a quiet room to rest: this can lead to a fall in BP of 10-20 mmHg or more. The approach varies depending on whether the pt has already been treated for HTN or is untreated.

Previously treated HTN; Among pts already treated with anti HTN drugs the following may be appropriate interventions; Increase the dose of medication Reinstitution of medication in non-adherent pts Addition of diuretic and reinforcement of dietary sodium restriction

Untreated pts; we use one of the following agents; Oral furosemide (20 mg) If no volume depletion Clonidine (0.2 mg) Captopril (6.25 or 12.5 mg) After use of drugs pt f/u for several ours for reduction of Bpof 20- 30mmHg. Thereafter, a longer acting agent is prescribed and f/u

Monitoring and F/U; The pts that developed with HTN emergency who managed in emergency room, since exclusion of acute end organ damage requires laboratory testing, and the pt may require administration of medications and several hours of observation.

Who should be admitted ?

Hypertensive pts who affected by DM, CVA pervious HX, CKD should be admitted in hospital and evaluation for complications.

Good luck