Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Pathophysiology of Primary Hypertension Risk Factors
1. Primary Hypertension
2. Pathophysiology
Prof. Dr. med. Günter Hennersdorf
Germany
SES consultant cardiologist
2. Pathophysiology of Hypertension
• Primary Hypertension 90%
– Prevalence about 60% (age 60+)
– Prevalence about 15-25% (age 25+)
– Prevalence mean 35%
• Secondary Hypertension 10%
– but: may normalize by special treatment (surgery,
hormone treatment)!
April 2013 ghennersdorf SES FESC DGK
4. Pathophysiology of Hypertension
Mean SBP
Female
Male
Normal course
of blood pressure over age
Mean DBP age
male
female
age
April 2013 ghennersdorf SES FESC DGK
10. Factors inducing Hypertension
• Neurohumoral system dysbalance
– Renin-angiotensin system RAS, RAAS
– Sympathetic nervous system
Most important hypertension cause!
April 2013 ghennersdorf SES FESC DGK
11. Pathophysiology of Hypertension
Heart Rate x Stroke volume
cardiac output x Peripheral resistance = Blood pressure
Basic equation according to
Law of OHM:
Current I x Resistance R = Voltage U
April 2013 ghennersdorf SES FESC DGK
12. Neuro-humoral Regulation of Hypertension
Heart rate x stroke volume x Peripheral resistance = Blood pressure
alpha1
beta1
Norepinephrine Angiotensin II
Nervous system Humoral RAAS*
*RAAS or RAS: renine angiotensine aldosterone system
April 2013 ghennersdorf SES FESC DGK
14. Pathophysiology of Hypertension
prorenine, katecholamines
Angiotensinogene
Renin Pathway of RAAS in the
Pathway of RAAS in the
Organism (kidney, heart, Tissues: e.g.
Angiotensin I
Vessels) to maintain Vessel wall
Fluid volume control, ACE
Adjustment of CO and
Resistance. Angiotensin II Competition of receptors:
If regulation fails, high AT1 vasoconstriction
AT2 vasodilatation
blood pressure occurs
receptor
AT1 AT2
April 2013 ghennersdorf SES FESC DGK
15. Pathophysiology of Hypertension:
Angiotensin II Stimulation
Sodium, renine
Kidney
Ang II* *Ang II effects mediated by AT1
Hypophysis Adrenal gland
Hormone release Aldosterone, katecholamines
April 2013 ghennersdorf SES FESC DGK
16. Pathophysiology of Hypertension:
Angiotensin II Effects
synaptic conduction
Brain
vasoconstriction
vessels Ang II Heart hypertrophy
constriction
AT1 mediated effects of Uterus contraction
Angiotensin II
April 2013 ghennersdorf SES FESC DGK
17. Pathophysiology of Hypertension
basic structure and contents of the vessel intima
endothelium
Contents
Smooth muscle cells
intima SMC SMC
media Collagenes
Thrombocytes
Outer layer Ox-LDL
NO
Kinines
Enzymes
coagulation factors
platelet activation factors
thromboxane
April 2013 prostacycline
ghennersdorf SES FESC DGK
18. Pathophysiology of Hypertension
ACh
Vasoconstriction Vasodilatation
NE Vessel dilatation;
NE endothelium intact
NE
ACh
NE
NE=Norepinephine
Ach=Acetylcholine NE
NE no dilatation;
endothelium removed
Furchgott‘s basic experiment (1980): key role of endothelium
April 2013 ghennersdorf SES FESC DGK
19. Pathophysiology of Hypertension
platelets
growth factors
Endothelial dysfunction causing atherosclerosis and vasoconstriction, infarction
April 2013 ghennersdorf SES FESC DGK
20. Angiotensin II Actions
on endothelium and
NO =nitric oxide
AT1 AT2
AT1 stimulation AT2 stimulation
leads to: leads to:
growth+
vasoconstriction differentiation
vasodilatation
vasoactivity
NO inhibition NO
Smooth muscle cell
growth
April 2013 ghennersdorf SES FESC DGK modified acc. to Unger T et al 1996
21. Pathophysiology of Hypertension
constriction
vascular resistance
Endothelial dysfunction causing hypertension
April 2013 ghennersdorf SES FESC DGK
22. Pathophysiology of Hypertension
Heart rate x stroke volume x Peripheral resistance = Blood pressure
n.sympathicus RAAS*
Stress Genetic/Familial Vasoconstriction
social ethnic
familial Hereditary Endothelial
salt sensitivity dysfunction
*renine angiotensine aldosterone system
April 2013 ghennersdorf SES FESC DGK
23. Pathophysiology of Hypertension
Conclusion:
Conclusion:
Primary Hypertension
Primary Hypertension
is a target disease mainly
is a target disease mainly
of the RAAS -- intima -- endothelium system!
of the RAAS intima endothelium system!
the endothelium is the major player
April 2013 ghennersdorf SES FESC DGK
24. Pathophysiology of Hypertension
time course of hypertension development
no symptoms Nonspecific Symptoms:
Head ache,
Palpitation,
Onset,Trigger Chronic stage Exertional dyspnea target organ damage death
3 4 5 6 6+ (x10th years)
accelerated course
April 2013 ghennersdorf SES FESC DGK
25. Pathophysiology of Hypertension
Trigger example: Obesity, Hyperinsulinism, Type-2-
Diabetes
Hypertension
Metabolic syndrome (X)
April 2013 ghennersdorf SES FESC DGK
26. Pathophysiology of Hypertension
Heart rate x stroke volume x Peripheral resistance = Blood pressure
AT2 -
beta1 + (NO )
AT1 +
alpha1
Norepinephrine Angiotensin II Hyperinsulinemia
Sympathicus RAAS
April 2013 ghennersdorf SES FESC DGK
29. Pathophysiology of Hypertension
• Target organ damage:
– Brain: Stroke (ischemic, hemorrhagic)
– Heart: CAD, Heart failure (mainly diastolic)
– Vessels:
• Peripheral arterial disease
• Central arterial disease: aortic dissection, aneurysm
• Renovascular disease
April 2013 ghennersdorf SES FESC DGK
30. Typical target organ damages following arterial hypertension
CAD
stroke
LV hypertrophy
Peripheral artery disease:
necrosis, gangrene
April 2013 ghennersdorf SES FESC DGK
31. Pathophysiology of Hypertension
Left ventricular
hypertrophy
Coronary Atherosclerosis
Heart failure
(prevalence ~50%)
Main target lesions
Brain: Stroke
(prevalence ~20%)
Wall damage
Cerebral Atherosclerosis
Renovascular damage
April 2013 ghennersdorf SES FESC DGK
32. Pathophysiology of Hypertension
Left ventricular hypertrophy remodeling
(w. anterior wall infarction) Heart failure
April 2013 ghennersdorf SES FESC DGK
33. Heart failure and hypertension
Diastolic Heart failure: stiffness and relaxation disturbances
u
normal Early stage Late stage
Ultrasound appearance of mitral flow patterns (EA relation)
April 2013 ghennersdorf SES FESC DGK
34. Pathophysiology of Hypertension
Survival rate in relation to renal damage (by renal albuminuria)
Survival rate% Alb. < median
Alb. > median
Median 7,52 µg/min
P=0,0078
April 2013 ghennersdorf SES FESC DGK
42. Pathophysiology of Hypertension:
Systolic Hypertension (SAH).
• Risk of SAH in the elderly (SHEP, SYST-EUR Trials)
– Stroke 20% Reduction)
– Heart failure 54% Reduction)
– Death 24%
These results were maintained over 5 years observation
April 2013 ghennersdorf SES FESC DGK
43. Pathophysiology of Hypertension: Morning
Hypertension.
Blood pressure
Heart rate
Resistance
Cardiac output
Renal function
April 2013 ghennersdorf SES FESC DGK
44. Increased cardiovascular morning risk
Increased cardiovascular morning risk
Morning BP rise
Stroke /2h
Infarction /1 h
6 pm 0:00 6 am 12 am
April 2013 ghennersdorf SES FESC DGK
45. Pathophysiology of Hypertension:
diastolic blood pressure DBP
Prognosis
Stroke risk and DBP CAD risk and DBP
4,0 4,0
2,0
1,0 1,0
76 84 91 98 105 76 84 91 98 105
April 2013 ghennersdorf SES FESC DGK
46. Pathophysiology of Hypertension
understand
Save lives and improve life quality
diagnose
treat
control
April 2013 ghennersdorf SES FESC DGK