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LECTURE

ARTERIAL HYPERTENSIONS
Depatment of therapy 1
Professor L.V.DUDAR

Definition
Arterial hypertension is rise arterial blood pressure (BP), systolicus BP more than 140 mm.Hg. and dyastolicus more than 90 mm.Hg. Hypertension is rise pressure intravasculars or intracavitary. Hypertonia is rise muscular tonus. Hypertension is correct term in this case


Patient is diagnosed as hypertensive if at least two BP determinations performed at five-minute intervals suggest for increased BP level. Sporadic higher levels in patients who have been resting for > 5 min suggest an unusual labiality of BP that may precede sustained hypertension. For example, office or white coat hypertension refers to BP that is consistently elevated in the physician's office but normal when measured at home or by ambulatory BP monitoring.

NORMAL BLOOD PRESSURE


SYSTOLYCUS BLOOD PRESSURE 100 - 139 mmHg DYASTOLICUS BLOOD PRESSURE 60 - 89 mmHg

CLASSIFICATION OF BLOOD PRESSURE LEVELS Classification


Optimal
Normal High-normal Mild AH (stage 1)

Systolic (mm Hg)

Diastolic (mm Hg)

<120
100 - 139 130 139 140 - 159

< 80
60 89 85 89 90 99

Moderate AH (stage2 )
Severe AH (stage 3) Malignant AH

160 - 179
>180 >200

100 109
>110 >130

Essential and symptomatical AH


Essential arterial hypertension is arterial hypertension of unknown origin and not associated with other deseases. Symptomatical (secondary) arterial hypertension is symptom desease of the kedneys,endocrinsystem, heart, nervous system, exogenous(salt-,alcohol-,medicamental drugs,toxin associeted),pregnancy associated and other.

Malignant hypertension defines cases, when diastolic BP is not decreased even after administration pharmacological therapy.

Arterial hypertension values ranging from 140/90 to 160/95 mmHg also called borderline hypertension
The term isolated systolic hypertension associated with high systolic pressure and normal diastolic pressure. The term systole-diastolic hypertension applied when patient has increased both systolic and diastolic pressure level.

Factors of blood pressure regulation


cardiac output, peripheral vascular resistance, blood circulating volume.

Classification of arterial hypertension


Essential, or primary, hypertension is systemic arterial hypertension is not associated with other diseases, it cause is not completely understood. ; 90 to 95 percent of systemic hypertension cases fall under this category. Secondary hypertension is elevated systemic blood pressure of known cause and usually associated with other definite diseases ; five to ten percent of systemic hypertension cases are of this type.

Etiology of essential hypertension


1. 2. 3. 4. 5. 6. 7. 8. 9. Heredity Salt intake and low-calcium intake Obesity Occupation . Alcohol intake. Smoking. Coffee intake Reduced physical activity. Psychoemotional personal pecularity.

Pathogenesis of essential AG
1. Activation of sympathadrenal system. 2. Activation of renin-angiotensinaldosterone 3. Insulin resistance and/or hyperinsulinemia 4. Deficiency of kallikrein system 5. Deficiency of neutral lipid and a prostaglandin produced in renal medulla. 6. Disfunction of endothelial cells.

SYSTOLIC HYPERTENSION WITH WIDE


PULSE PRESSURE

I. Decreased compliance of aorta (arteriosclerosis) II. Increased stroke volume A. Aortic regurgitation B. Thyrotoxicosis C. Hyperkinetic heart syndrome D. Fever E. Arteriovenous fistula F. Patent ductus arteriosus

SYSTOLIC AND DIASTOLIC HYPERTENSION

I. Renal A. Chronic pyelonephritis B. Acute and chronic glomerulonephritis C. Polycystic renal disease D. Renovascular stenosis or renal infarction E. Most other severe renal diseases (arteriolar nephrosclerosis, diabetic nephropathy, etc.) F. Renin-producing tumors

SYSTOLIC AND DIASTOLIC HYPERTENSION II. Endocrine A. Oral contraceptives B. Adrenocortical hyperfunction 1. Cushing's disease and syndrome 2. Primary hyperaldosteronism 3. Congenital or hereditary adrenogenital syndromes (17a-hydroxylase and 11bhydroxylase defects) C. Pheochromocytoma D. Myxedema E. Acromegaly

SYSTOLIC AND DIASTOLIC HYPERTENSION

III. Neurogenic A. Psychogenic B. Diencephalic syndrome C. Familial dysautonomia (Riley-Day) D. Polyneuritis (acute porphyria, lead poisoning) E. Increased intracranial pressure (acute) F. Spinal cord section (acute)

SYSTOLIC AND DIASTOLIC HYPERTENSION

IV. Miscellaneous A. Coarctation of aorta B. Increased intravascular volume (excessive transfusion, polycythemia vera) C. Polyarteritis nodosa D. Hypercalcemia E. Medications, e.g., glucocorticoids, cyclosporine, NSAID

Morphologycaly changes
SPASM HYALINOSIS SCLEROSIS

Pathology of arterial hypertension

Hypertrophy of muscular layer

Hypertrophy of muscular layer

Myointima edema

Accelerating of atherosclerosis

Complaints
Occipital headaches, dizziness and vertigo, light-headedness, dimmed vision, cardialgia, angina pectoris, dyspnea, increased heart beating, edema of low extremities.

Physical exams
increased density of pulse, increased pulse rate in case of heart failure developed dilation of left border of heart dullness, mild decreased first sound, second sound aortic closure is accentuated, faint systolic murmur in the heart apex, enlarged liver size and edema of low extremities due to developing heart failure,

24-hour ambulatory monitoring

Funduscopic exam

ECG: left ventricular hypertrophy

ECG: left ventricular hypertrophy with blokade LbHisB

X-ray: dilatation of left ventricle

Cardiac ultrasound: thickness of left


ventricle wall

Laboratory findings
Proteinuria. Elevation of creatinin and urea levels. holesterol and triglycerides. Serum glucose ant glucose tolerant test.

Classification of arterial hypertension


I stage signs of target organs involvement are absent, but arterias on fundus eyes are spasmed II stage presents of target organs lesions without their insufficiency: left ventricle hypertrophy based on signs of ECG, cardiac ultrasound, X-ray), generalized narrowing of the retinal arterioles based on funduscopic exam,Silus-1,2 symptoms proteinuria and/or mild elevation of creatinine level (up to 133 mkmol/l in male and up to 124 mkmol/l in female).

Classification of arterial hypertension


III stage presents of target organs lesions with symptoms of their insufficiency (stage of AH complication): myocardial infarction, heart failure IIA-III stages, ischemic stroke, transient ischemic attack, cerebral hemorrhage syndrome, acute hypertensive encephalopathy, chronic hypertensive encephalopathy, dissecting aortic aneurysm, eclampsia, appearance of hemorrhages, exudates, and papilledema of retina in fundoscopy. renal insufficiency elevation of creatinine level over than 133 mkmol/l in male and up to 124 mkmol/l in female

Hypertensive emergencies
Hypertensive crisis is defined as sudden elevation of BP usually with a systolic blood pressure greater than 240 mm Hg or diastolic BP greater than 120 mm Hg associated with exacerbation of clinical manifestation of AH.

Hypertensive emergencies
Hypertensive emergencies are characterized by end organ damage and associated with the following: hypertensive encephalopathy, intracranial hemorrhage, stroke, pulmonary edema, acute myocardial infarction, adrenergic crisis, dissecting aortic aneurysm, and eclampsia. Hypertensive urgencies are characterized by a lack of end organ damage and reveled by anxiety of patients, cardialgia, angina pectoris, headache, dizziness without any evidence of AH complications and focal neurological manifestations.

Nondrug therapeutic intervention


(1) relief of stress, (2) dietary management, (3) regular aerobic exercise, (4) weight reduction (if needed), (5) control of other risk factors contributing to the development of arteriosclerosis: diabetes mellitus, smoking, hypercholesterolaemia,

Exercise ladies

Diuretics
Hydrochlorothiazide, 25 mg, 1 time per day Indapamide, 2,5 mg 1 time per day Spironolactone, 25-50mg, 2-3 times per day Triamterene, 50-100, 1-2 times per day Amiloride, 5-10, 1-2 times per day

b-adrenergic receptor blocking agents

Propranolol, 40 mg, 4 times per day Metoprolol, 50-100 mg, 2 times per day Atenolol, 25-50 mg, 2 times per day Labetalol, 200 mg, 2 times per day Bisoprolol, 5-10 mg, 1 time per day

Calcium entry blockers


Nifedipine, 10 mg, 3-4 times per day Amlodipine, 5-10 mg, 1 time per day Isradipine, 5-10 mg, 1-2 times per day

Angiotensin-converting enzyme inhibitors


Captopril, 25-50 mg, 2-3 times per day Enalapril, 10-20 mg, 1-2 times per day Lisinopril, 10-20 mg, 1-2 times per day Perindopril, 4-8 mg, 1 times per day

Angiotensin II receptor blockers


Candesartan, 8-16 mg, 1 time per day Losartan, 50-100 mg, 1 time per day

a-adrenergic receptor blocking agents


Prazosin, 1-5 mg, 2-3 times per day Doxazosin, 1-4 mg, 1time per day

Most preferable combination of antihypertensive medication


b-adrenergic receptor blocking agents + thiazid diuretics Angiotensin-converting enzyme inhibitors + thiazid diuretics b-adrenergic receptor blocking agents + Calcium entry blockers Calcium entry blockers + Angiotensin-converting enzyme inhibitors + thiazid diuretics

Additional preparations
Guanethidine, 10-50 mg, 1 time per day Clonidine, 0,075-0,15 mg, 3-4 times per day Reserpine, 0,05-0,15 mg, 1 time per day Hydralazine, 25-50 mg, 3-4 times per day

Treatment of hypertensive emergencies


Nitroprusside, I.V. infusion pump with a dose of 0.25-8 micrograms*kg/min Nitroglycerin, I.V. infusion pump with a dose of 5-100 micrograms/min Diazoxide, I.V. 50-150 mg during 5 min Trimethaphan, I.V. infusion pump with a dose of 0.5-5 mg/min Labetalol, 2 mg/min IV

Treatment of hypertensive emergencies


Hydralazine, 10-20 mg IV Enalaprilat, I.V. infusion pump with a dose of 1.25-5 mg I.V. during 6 hrs Propranolol, I.V. 5-10 mg during 5-10 min Phentolamine, I.V. 5 mg

Initial out-patients treatment of urgent hypertensive crisis


Clonidine 0,15 mg P.O. or S.L. Captopril 25 mg P.O. or S.L. Labetalol 200 mg P.O. Nifedipine 10 mg S.L.

happy end

THANK YOU FOR ETTENTION !