1. Presented by
Nand Kishor Jha

2.  Basics Understanding of hypertension:
. Introduction
. Symptoms
.Types
. Risk factors
. Pathophysiology
. Classifications
. Causes & complications
. Work sheet /recap
• Treatment : Algorithm
• RAAS
• Antihypertensive drugs
• Compelling Indication for hypertensive drugs
• Diabetes and hypertension
• CVD risks in CKD
• Work sheet/recap

3.  A sustained elevation in arterial blood
pressure above the normal value is called
hypertension.
 Normal value for blood pressure varies
greatly from person to person.

4. • Tiredness
• Confusion
• Vision changes
• Angina-like chest pain
• Heart failure
• Blood in urine
• Bleeding nose
• Irregular heartbeat etc

5. . Primary hypertension: also called essential
hypertension, the cause of this type is unknown.
. Secondary hypertension: have specific identified
cause for elevated BP that due to any other medical problems
or medication.
. Pseudo hypertension: Osler’s sign of pseudo
hypertension, a falsely elevated BP regarding due to
calcification of blood vessel which can not be compressed.
. White coat hypertension: A syndrome whereby a
patient’s feeling of anxiety in a medical environment results
in an abnormally high reading when their blood pressure is
measured.

7.  There are two values for blood pressure in a
human being.
◦ Systolic blood pressure : Blood pressure
recorded during ventricular systole ( contraction
of ventricles).
◦ Diastolic blood pressure : Blood pressure
recorded during ventricular diastole ( relaxation
of ventricle) .
For the diagnosis blood pressure should be
measured at least on two separate occasions.
Continue….

8. Continue….

9. Continue….
Pathophysiology of hypertension:
Blood pressure = cardiac output x total
peripheral resistance
• Cardiac output = Hear rate X Stroke volume
(cardiac output: the amount of blood that the heart flows in a minute.
stroke volume: the amount of blood that heart flows during a cardiac cycle.
Cardiac cycle: the sequences of events that occurs when the heart beats)

10.  The National High Blood Pressure Education
Program presents the complete Seventh
Report of the Joint National Committee on
Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure.
 Table below provides a classification of BP
for adults aged 18 and older.
 The classification is based on the average of
2 or more properly measured, seated BP
readings on each of 2 or more office visits.

11. Category SBP (mm Hg) DBP (mm Hg)
Normal < 120 and < 80
Pre-hypertension 120-139 or 80-89
Hypertension, Stage-1 140-159 or 90-99
Hypertension, Stage-2 > 160 or > 100

12. Pt age SBP (mm Hg) DBP (mm Hg)
>/= 60 yrs < 150 and < 90
< 60 yrs < 140 and <90
< 60 yrs with CKD <140 and <90
< 60 yrs with DM <140 and < 90

14.  The prevalence of hypertension increases
with advancing age to point where more than
half people aged 60 to 69 years old and
approximately three fourths of those aged 70
years and older are affected.
 The age-related rise in SBP is primarily
responsible for an increase in both incidence
and prevalence of hypertension with
increasing age.

15.  95% of hypertensive patients have no
apparent identifiable cause, hence called
primary or essential hypertension.
 5% have some underlying cause to account
for the hypertension and called secondary
hypertension.

16. Renal: related to kidney disease
 Acute Renal Failure : Loss of function of
kidney over a short period of time.
 Chronic Renal Failure: failure of function of
kidney over a long time.
 Glomerulonephritis : ( inflammation of
glomerulus, a structural & functional unit of
kidney)

17. Endocrine system:
 Cushing Disease: It is a disorder caused by
high levels of cortisol (hormone ) in the
blood from a variety of causes, including
cancer of pituitary gland
 Hypothyroidism: low levels of thyroid
hormone
 Pheochromocytoma : It is a tumour (cancer )
that arises from the centre of the adrenal
gland
 Primary Hyperaldosteronism : increase
secretion of aldosterone

18. Renovascular
 Renal artery stenosis ( narrowing of arteries
of kidney)
Miscellaneous
 Pregnancy Induced hypertension
 Drug induced

19. Untreated hypertension can develop damage to
heart, kidney, retina and brain.
 Stroke : Sustained persistent high blood
pressure may lead to rupture of an artery in
the brain causing brain
haemorrhage/stroke ( bleeding )
 Retinopathy : Similarly it cause damage to
the blood vessels of retina and swelling of
retina which may lead to blindness.

20.  Nephropathy : Kidneys are also severely
damaged and ultimately may develop renal
failure (hypertensive nephropathy).
 Myocardial infarction : Accelerates
atherosclerosis, which may predispose to
development of blood clot in the artery
(thrombosis).Thrombosis in the brain or
heart ultimately causes brain infract or
myocardial infract (heart attack).

21. Summary :
Heart damage – MI,CHF
Kidney damage – nephropathy
Eye damage – retinopathy, loss of vision
Blood vessel damage – arteriosclerosis
Brain damage - stroke

23.  The relationship between BP and risk of CVD
events is continuous, consistent and
independent of other risk factors.
 Higher the BP, the greater is the chance of
heart attack, HF, stroke, and kidney disease.

25.  a) Systolic BP
 b ) Diastolic BP
 c) Pulse Pressure
 d) None of Above

26. Ans :

27.  a) Essential or Primary
 b) Secondary
 c) Malignant
 d) None of Above

28. Ans :

29.  a) Inconsistent
 b) Continuous
 c) Continuous, consistent & independent
 d) None of above

30.  a) <140/90
 b) > 140/90
 c) < 130/80
 d) None of above

33.  Kidney in response to low BP, reduced blood volume or low
sodium content release an enzyme, renin
 Renin interacts with angiotensinogen to form angiotensin I
 Angiotensin I gets converted to angiotensin II with the help of
ACE
 Angiotensin II causes aldesterone release from kedney,which
causes sodium and water retention leading to increase blood
volume.
 Similarly, angiotensin II causes vasoconstriction.
 These effects lead to increase in blood pressure.

34.  Weight reduction
 DASH (Dietary approach to stop hypertension)
eating plan: diet rich in fruits, vegetables, low
fat dairy products with a reduced content of
saturated and total fat
 Dietary sodium restriction
 Physical activity & Moderation of alcohol
consumption

36. ACE inhibitors : Enlapril, Ramipril etc.
 ACE inhibitors inhibit the conversion
of angiotensin I into angiotensin II by
inhibiting ACE ( Angiotensin
converting enzyme). They blunt the
effects mediated by angiotensin II (
like vasoconstriction , release of
aldosterone etc.)
β blockers : Metoprolol, Bisoprolol etc.
 β blockers act by reducing heart rate
and myocardial contractility by
blocking β1 receptors primarily in the
heart.

37. Angiotensin II receptor blockers(ARBs
): Losartan,Telmisartn, Olmesartan
etc.
 ARBs block the activation of
angiotensin II AT1 receptors.
Blockade of AT1 receptors directly
causes vasodilation, reduces
secretion of vasopressin, reduces
production and secretion of
aldosterone, amongst other actions –
the combined effect of which is
reduction of blood pressure.

38. Calcium channel blockers: Amlodipine, long acting
Nifedipine etc.
 Calcium channel blockers work by blocking
calcium channels in the heart and in the blood
vessels. This prevents calcium levels from
increasing as much in the cells when stimulated,
leading to less contraction.
α1 blockers like Prazosin, Terazosin etc.
 α1 blockers act by blocking the alpha1-receptors
of vascular smooth muscle, thus preventing the
uptake of catecholamine(harmones produced by
adrenal gland) by the smooth muscle cells.
 This causes vasodilatation and allows blood to flow
more easily.

39. Diuretics: Hydrochlorothiazide, Torsemide
etc.
 Diuretics act by enhanced urinary excretion
of sodium , chloride and water.
Aldosterone antagonists: Spironolactone,
Eplerenone etc.
 Aldosterone antagonists act by inhibits the
effect of aldosterone by competing for
intracellular aldosterone receptors the distal
tubule cells. This increases the secretion of
water and sodium, while decreasing the
excretion of potassium

40.  -adrenergic blockers and diuretics
 ACE inhibitors and diuretics
 Angiotensin II receptor antagonists and
diuretics
 Calcium antagonists and ACE inhibitors
 Other combinations

41. Compelling Indication : Initial therapy options
Heart Failure : THIAZ,BB,ACEI,ARB,ALDO ANT
Post myocardial infraction : BB,ACEI,ALDO ANT
High CVD risk : THIAZ,BB,ACEI,CCB
Diabetes : THIAZ,BB,ACEI,ARB,CCB
Chronic kidney disease : ACEI,ARB
Recurrent stroke prevention : THIAZ,ACEI

42.  Good therapeutic efficacy.
 Longer duration of action.
 Permitting once a day dosing.
 Cost effective.
 Minimal or no adverse effect.
 Minimal or no drug interaction.
 Should be safe in elderly patients.
 Should effectively reduces the
consequences of hypertension.

43.  Compelling indications: Hypertension may
exist in association with other conditions in
which there are compelling indications for
use of a particular treatment based on
clinical trial data demonstrating benefit of
such therapy.
 Example: hypertension associated diabetes
 In this case, ACEI or ARB should be used as
the first line therapy
 In this , the drug of first choice is either ACE
inhibitor or ARB (angiotensin receptor
blocker )

44.  Type 2 diabetes constitutes over 90% of
diabetes in the United States and is
associated with a 70% to 80% chance of
premature death from CVD and stroke.
 The concordance of hypertension and
diabetes is increased in the population;
hypertension is disproportionately higher in
diabetics while persons with elevated BP are
2.5 times more likely to develop diabetes
within 5 years

45.  The coexistence of hypertension in diabetes
is particularly pernicious because of the
strong linkage of the 2 conditions with all
CVD, stroke, progression of renal disease
and diabetic retinopathy.
 The United Kingdom Prospective Diabetes
Study (UKPDS) demonstrated that each 10
mm Hg decrease in SBP was associated with
average reductions in rates of diabetes-
related mortality of 15%; myocardial
infarction, 11%; and the microvascular
complications of retinopathy or
nephropathy, 13%.

46.  CVD is the most common cause of death in
individuals with CKD, and CKD is itself an
independent risk factor for CVD.
 The joint recommendations of the American
Society of Nephrology and the National
Kidney Foundation (NKF) provide useful
guidelines for management of hypertensive
patients with CKD.
 They recommend a goal BP for all CKD
patients of <_130/80 mm Hg and a need
for more than 1 antihypertensive drug to
achieve this goal.

47.  The guidelines indicate that most patients
with CKD should receive an ACEI or an ARB
in combination with a diuretic and that many
will require a loop diuretic( act at the
ascending limb of the loop of Henle in the
kidney) rather than a thiazide.
 In addition, if there is a conflict between the
goals of slowing progression of CKD and
CVD risk reduction, individual decision-
making is recommended, based on risk
stratification.

48.  An associated disease with hypertension
compels not to use a specific
antihypertensive drugs for treatment of
hypertension.
 For example: bronchial asthma with
hypertension is a compelling contraindication
for β blocker.

49.  It is not a curable but a controllable
disease
 Onset is generally at age of 40 or more.
 Has strong association with
atherosclerosis.
 Familial tendency is also known.
 If not treated, it goes on progressing.
 Untreated hypertension can develop
damage to heart, kidney, retina and brain.
 Treatment can prevent these complications.

51.  a) DASH Diet
 b) Weight reduction
 c) Physical activity
 d) All above

52. Ans :

53.  a) Calcium channel blockers
 b) ACEI
 c) ARB
 d) b & c

54. Ans :

55.  a) Calcium channel blockers
 b) ARBs
 c) Non-selective 1 –blockers
 d) None of above