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6. blood pressure - INAYA Medical College

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BLOOD PRESSURE
• The arterial blood pressure reflects the rhythmic ejection
of blood from the left ventricle into the aorta.
• (blood pressure = cardiac output × peripheral vascular
resistance)
• stroke volume (amount of blood that the heart ejects with
each beat .
• heart rate or number of times the heart beats each minute.
• The systolic blood pressure reflects the rhythmic ejection of
•
blood into the aorta, ideally is less than
• 120 mm Hg,
• The diastolic blood pressure is maintained by the energy
• that has been stored in the elastic walls of the aorta during
• Systole, is less than 80 mm Hg.
• The difference between the systolic and diastolic pressure
(approximately 40 mm Hg) is called the pulse pressure.
HYPERTENTION
• DEF : sustained high blood pressure , blood pressure 140/90 ,
at least two reading on separate occasion is considered
hypertension .
• High blood pressure (hypertension) is one of the most
important preventable causes of premature morbidity and
mortality in the world .
• Hypertension is a major risk factor for ischaemic and
haemorrhagic stroke, myocardial infarction, heart failure,
chronic kidney disease, cognitive decline and premature
death.
• The risk associated with increasing blood pressure is
continuous, with each 2 mmHg rise in systolic blood pressure
associated with a 7% increased risk of mortality from
ischaemic heart disease and a 10% increased risk of mortality
from stroke.
• Diastolic pressure is more commonly elevated in people
younger than 50. With ageing, systolic hypertension becomes
a more significant problem, as a result of progressive
stiffening and loss of compliance of larger arteries.
• At least one quarter of adults (and more than half of those
older than 60) have high blood pressure.
CLASSIFICATION OF HT
• Stage 1 hypertension :Clinic blood pressure is 140/90 mmHg
or higherand subsequent ambulatory blood pressure
monitoring (ABPM) daytime average or home blood pressure
monitoring (HBPM) average blood pressure is 135/85 mmHg
or higher.
• Stage 2 hypertension : Clinic blood pressure is 160/100
mmHg or higher and subsequent ABPM daytime average or
HBPM average blood pressure is 150/95 mmHg or higher.
• Severe hypertension : Clinic systolic blood pressure is 180
mmHg or higher or clinic diastolic blood pressure is 110
mmHg or higher.
ETIOLOGY
PRIMARY (ESSENTIAL ) HYPERTENTION
• In about 95% of cases no cause of hypertension can be
identified .
• The onset of essential hypertension is usually between ages
25 and 55 years it is uncommon before age 20 .
CAUSES
• PRECIPITATING FACTORS :
1. Genetic factors .
2. Obesity , lack of exercise .
3. Heavy alcohol intake .
4. Excessive salt intake .
5. Cigarette smoking .
6. Polycythemia .
7. NSAIDs .
8. Low potassium intake .
9. Sympathetic over activity .
10. Insulin resistance .
SECONDARY HYPERTENSION
• In about 5% of cases , cause of hypertension can be
discovered.
• Most of patients are young .
CAUSES
•
1.
2.
3.
•
1.
2.
3.
4.
5.
6.
RENAL DISEASE :
Renal vascular disease .
Parenchymal renal disease (glomerulonephritis) .
Polycystic kidney disease .
ENDOCRINE DISEASE :
Pheochromocytoma .
cushing’s syndrome .
Primary peraldosteronism (conn’s syndrome) .
Hyperparathyroidism .
Thyrotoxicosis .
Acromegaly .
•
1.
2.
3.
•
•
•
DRUGS :
oral contraceptives containing oestrogens .
Steroids .
NSAIDs .
ALCOHOL .
COARCITATION OF THE AORTA .
PRE-ECLAMPSIA .
CLINICAL FEATURES
SYMPTOMS
1. Mostly asymptomatic discovered on routine examination or
when a complication arises .
2. Suboccipital pulsating headache , mainly at morning .
3. Somnolence .
4. Confusion .
5. Visual disturbances .
6. Nausea and vomiting .
signs
1. In majority of patients, high blood pressure may be the only
sign .
2. Features of cause of hypertension .
3. Features of complications .
Complication
CNS
1. STROKE : it results from cerebral hemorrhage or infarction
mostly as a complication of hypertension .
2. HYPERTENSIVE ENCEPHALOPATHY : it is characterized by
severe hypertehsion with neurological symptoms e.g.
transient disturbance of speech or vision, disorientation, fits
and unconsciousness .
3. SUBARACHNOID HEMORRHAGE : it is also more common in
hypertensive patients .
4. MULTI-INFARCT DEMENTIA .
RETINA
• Retinal changes are graded as following :
• GRADE I : tortuosity of the retinal arteries with increased
reflectiveness ( silver wiring ) .
• GRADE II : grade I plus appearance of arteriovenous nipping
produced when thickened retinal arteries pass over the retinal
vein .
• GRADE III : grade II plus flame-shaped hemorrhages and soft
“cotton wool “ exudates due to small infarcts .
• GRADE IV : grade III plus papiloedema ( blurring of the
margins of the optic disc ) .
HEART
• Left ventricular hypertrophy .
• Ischemic heart disease .
• Aortic dissection .
KIDNEYS
• Long standing hypertension may cause nephrosclerosis
(hypertensive nephropathy) that causes proteinuria and
progressive renal failure .
MANAGEMENT
• The clinical management of hypertension is one of the most
common interventions in primary care .
INVESTIGATIONS
•
•
•
•
•
•
•
URINE ANALYSIS : for proteinuria, hematuria and casts .
HEMATOCRIT : polycythemia .
SERUM UREA AND CREATININE : renal failure .
LIPID PROFIL : dyslipdemia .
ECG : left ventricular hypertrophy .
CHEST X-RAY : cardiomegaly , heart failure .
ECO .
TREATMENT
WHO SHOULD BE TREATED
• Patient with mild hypertension without other cardiac risk
factor should be treated non-pharmacologically with
modification of life-style such as regular exercise, low salt
intake
Lifestyle interventions
• Lifestyle advice should be offered initially and then
periodically to people undergoing assessment or treatment
for hypertension .
• Ascertain people’s diet and exercise patterns because a
healthy diet and regular exercise can reduce blood pressure.
• Relaxation therapies can reduce blood pressure .
• Ascertain people’s alcohol consumption and encourage a
reduced intake if they drink excessively .
• Discourage excessive consumption of coffee and other
caffeinerich products.
• Encourage people to keep their dietary sodium intake low .
• Offer advice and help to smokers to stop smoking.
Initiating treatment
• Offer antihypertensive drug treatment to people aged under
80 years with stage 1 hypertension who have one or more of
the following:
1. target organ damage
2. established cardiovascular disease
3. renal disease
4. diabetes
5. a 10-year cardiovascular risk equivalent to 20% or greater.
• Offer antihypertensive drug treatment to people of any age
with stage 2 hypertension .
• For people aged under 40 years with stage 1 hypertension and
no evidence of target organ damage, consider seeking
specialist evaluation of secondary causes of hypertension and
a more detailed assessment of potential target organ damage.
This is because 10-year cardiovascular risk assessments can
underestimate the lifetime risk of cardiovascular events in
these people
THANK YOU .
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