Essential hypertension and secondary hypetension Flashcards
Essential hypertension : Definition
Definition
- elevated arterial pressure (sys: >140, diastolic> 90).
Epidemiology
Epidemiology
- > 50%
- prevalence in man
- Highest in Germany
- After 50 years of age, more than 50% have hypertension.
- 20-30% of adult population.
- black Africans among which 40-45% of adults are affected.
Etiology
Etiology
- Genetic
- Diet- high salt, alcohol
- Obesity
- Racial: African American
- Stress.
- Dyslipidemia
- Smoking
- Diabetus mellitus
Pathogenesis
Pathogenesis
1. Abnormal cardiac and peripheral hemodynamics - elevation in cardiac output, total peripheral resistance, or both.
2. Impaired pressure natriuresis - In normal, elevation in blood pressure leads to alteration intrarenal hemodynamics and physical forces results in natriuresis, causes diuresis, decrease total extracellular volume, and fall in blood pressure. In hypertension, kidney fails, natriuresis is impaired.
3. Baroreceptor in carotid arteries and aorta to ―reset‖ higher pressures toward lower blood pressure.
4. Abnormal sodium transport - sympathetic simulation, proliferation of smooth muscle of myocardium and vessels
5. Stimulation of sympathetic nervous system - increase in cardiac output and minute volume
6. Action of renin-angiotensin system – stimulates sympathetic activity, increase in aldosterone production, sodium retention, vasoconstriction, increase in peripheral resistance
7. Deficiency of vasodilator substance
8. Endothelial dysbalance between vasoconstrictor and vasodilator substances
Vasoconstrictors: endothelin, angiotensin II, thromboxane, prostaglandin F and norepinephine Vasodilators: nitrous oxide, postacyin, bradykinin, arial natriuretic peptide and prostaglandin E2 Pressor: SNS, Ag-renin system, Aldosterone, endothelin Counter: Kalikrein-kinin system, Prostaglandin, Prostacyclin E, Baroreflex system
Classification
Classification
- degree, stages and stratification
- Primary (essential) hypertension is hypertension that has no known cause
- Secondary hpt is diagnosable disease and accounts for the remainder of cases of hypertension.
Clinical picture according to stages
Clinical picture according to stages
1. Stage 1
- Head –headache occiput, diffuse or temporal; vertigo
- Heart –tachycardia, extrabeats, pain
2. Stage 2: got changes in organ target (Hypertrophy of LV, changes in heart, microalbunemia fr kidney, hypertrophy- angiopathy from brain, albuminuria, spasm of artery and enlargement of vein in brain)
All previous complaints, plus decreased eyesight due to angiopathy of retina and enlarged left heart border
3. Stage 3: Complication from organ target
- Brain: encephalopathy insult, stroke
- Heart: Ischemic heart disease, M.I, HF
- Kidney: kidney insufficiency, Kidney failure
All stages possible plus paralysis, decreased mental function. Severe Chest pain, arrhythmia. Oedema, pulmonary congestion, peripheral cyanosis, fatigue, weakness. Renal oedema
Investigation
Investigation
1. Obj : measure BP
2. Percussion of heart: enlargement of Left heart borders
3. Aus: systolic murmur at apex, accentuation of S2 above aorta
4. Blood analysis : K, Ca, Na, cholesterol, creatinine, protein, sugar level
5. biochem changes - Na+, K+, Ca2+, cholesterol, creatinine, protein
6. Urine analysis: creatine. Sugar level
7. ECG: LV hypertrophy
8. X ray- LV hypertrophy, heart enlargement
9. Echocardiography
10. Specific tests:
- Brain- rheography (cerebral vessels), encephalography, electroencephalogram
- Kidney- Zimnitsky test, Nichiparenko, US, contrast angiography, contrast urography, biopsy
- Consult neuropathologist, ophthalmologist
- Hormone levels – thyroid, glucocoticoids, cathecolamines
Complications
Complications
1. CNS - Stroke, encephalopathy, Subarachnoid HR, Brain vessels spasm and enlarged veins of brain.
2. Retina:
- Grade 1: Mild arteriolar narrowing
- Grade 2: >marked narrowing + appearance of arterio-venous nipping when thickened retinal aa pass over retina
- Grade 3: grade 2 + flame-shaped HR & soft cotton wool exudates
- Grade 4: G3 + papiloedema
3. Heart: LV hypertrophy, IHD, heart failure, Coronary artery disease
4. Kidney: Proteinuria, renal failure, microalbuminuria
Prophylaxis of complications
- Treatment by pharmalogical & non pharmalogical to maintain the level of arterial Pressure.
- Dietary: low salt, sugar, fat and cholesterol
- Adequate water intake, rest
- Lifestyle: Low stress, no smoking, exercise.
Treatment according to stages & pathogenetic
Treatment according to stages & pathogenetic
To reduce the diastolic blood pressure < 90 mm Hg and the systolic blood pressure <150 mm Hg. Non pharmaco:
- Sodium < 2 g/day. Diet- diet no 10- low sodium, low fat and low water.
- Physical- running and swimming are good. Contraindicated heavy or stressful activities.
- Weight reduction in obese patients
- Limitation of alcohol consumption. no smoking
Medications
Pharmaco According to the stages.
- Stage I: β blockers or diuretics.
- Stage II: β blockers + diuretics
- Stage III: β blockers + diuretics + calcium antagonist
- Stage IV: Diuretics + β blockers + calcium antagonist + ACE inhibitor
1. no risk factor
I - Life-style change only II and III stage - Life style change and medication
2. Have at least 1 risk factor excluding DM
I – life style change only (medication in consideration) II, III – life style change and medication
3. Have DM with / w/o target organ damage and existing heart disease
I, II, III – life style change and medication
According to pathogenesis
- If patient has tachycardia, high systolic, emotional activity- β blockers
- If hyporenin form of hypertension- diuretics
- If high diastolic arterial pressure- calcium channel blockers
- renal (activated renin-Ag activity) – ACE inhibitor : lozartan
Pharmacologic measures.
Pharmacologic measures.
1. Diuretic
- Thiazide diuretics (hydrochlorothiazide, chlorothiazide, metolazone)
- loop diuretics (furosemide, bumetanide, torsem ide, ethacrynic acid).
- Potassium-sparing diuretics (amiloride, triamterene)
- Spironolactone
2. β blockers: Propranolol, nadolol, metoprolol, atenolol, timolol, betaxolol, carteolol, pindolol, carvedilol, acebutolol, and Labetalol
3. Centrally acting adrenergic antagonists: Methyldopa, clonidine, guanabenz, and guanfacine, clofillin
4. Peripherally acting sympathetic antagonist: reserpine and guanethicine.
5. Calcium channel antagonists: dihydropyridines (nifedipine, nicardipine, isradipine, felodipine, nimodipine, amlodipine, nitrendipine), diltiazem, and verapamil
6. Direct vasodilators: l-hydralazine and rhinoxidil
7. ACE inhibitor : Captopril, enalapril, fosinopril, benazepril, quinapril, ramipril, and Eosinopril
8. α blockers (Prazosin)
Prognosis
Prognosis
- If treatment is adequate- prognosis is good
- If development of crisis & no treatment- prognosis is bad
- 1st and 2nd stages, adequate treatment and stop of risk factors, prognosis for life is positive and prognosis for work is good or moderately decreased depending on degree.
- 3rd stage, prognosis for life is moderate and prognosis for work is poor.
Secondary hypertension : Definition
arterial P rises as a symptom of some other disease.
Etiological group of causes
1. Central/ cerebral - trauma, tumors, infection: meningitis, encephalitis, focal ischemic lesions
2. Hemodynamics art HPT
- aortic insufficiency
- artherosclerosis of aorta
- congenital disorders ( coarctation of aorta, AV block, aortic disorder )
- Stenosed carotid and vertebral arteries
3. Drug art HPT
- ephedrine containing drugs
- narcotics
- Coffee, tea (Caffeine containing drugs or food)
- Contraceptives: oestrogen, progesterone containing
- Glucocorticoids
4. Endocrine HPT
- Hyperthyroidism, hypothyroidism
- Acromegaly- Tumor in hypophysis
- Cushing‘s disease/ syndrome – suprarenal tumors
- Conn‘s syndrome – results of tumor wh produce aldosterone
- Pheochromocytoma
5. Renal HPT
- Parenchymal : Glomerulonephritis, Interstitial nephritis, Amyloidosis, Pyelonephritis, polycystosis, Nephrolithiasis, hydronephrosis, TB, tumors, rheumatic disorders: nodulus periarteritis. hypoplastic/dystopic kidney, abnormal renal arteries, Lithiasis
- Renovascular : stenosis, fistules, muscular dysplasia, aneurysm, atherosclerotic, fibromuscular disposing, thromboembolism, congenital disorder of vessels, tumor near vessels, aorta arteritis.
