DISEASE HYPERTENSION

 

HYPERTENSION

Hypertension is defined as sustained rise of systolic blood pressure above 140mmHg and diastolic pressure above 90 mmHg .

# Systolic hypertension 

    Systolic blood pressure 140 or more but diastolic pressure below 90mmHg is called isolated systolic blood pressure .

Cause :

 ⁃ Old age due to atherosclerosis 

 ⁃ Thyrotoxicosis 

 ⁃ Aortic regurgitation 

 ⁃ Exercise 

 ⁃ Emotional stress

Transient hypertension 

            Rise of blood pressure transiently and coming to normal without any treatment .

Causes: 

 • Anxiety 

 • Exercise 

 • Cold

 • Emotional stress 

 • Pheochromocytoma

# White coat hypertension :

      Transient rise in blood pressure mainly in patient with borderline hypertension after seeing doctor wearing white coat .

Etiology of hypertension :

(i ) primary hypertension :

      In about 95% of cases, the cause of hypertension is not known. Such hypertension occurs mainly after 40 years and there is positive family history.

(ii) Secondary hypertension 

       In about 5% of cases , the underlying cause of hypertension is known as secondary hypertension. The commonest cause of secondary hypertension is renal disease.

Causes of secondary hypertension 

  Renal diseases :

 ⁃ Acute glomerulonephritis 

 ⁃ Renal tumor 

 ⁃ Renal artery stenosis 

 ⁃ Chronic pyelonephritis 

 ⁃ Chronic glomerulonephritis

Endocrine cause :

 ⁃ phaeochromocytoma

 ⁃ Conn’s syndrome 

 ⁃ Acromegaly 

 ⁃ Hyperthyroidism 

 ⁃ Hypothyroidism 

Cardiovascular causes : 

 ⁃ co- arctation of aorta 

 ⁃ Takayasu’ s disease 

 ⁃ Polyarteritis 

Drugs : 

 ⁃ oral contraceptive pills 

 ⁃ Steroid eg ., prednisolone , Dexamethasone

 ⁃ Nasal decongestant 

 ⁃ Carbenoxolone 

Chronic Alcohol use 

  Pregnancy : pre - Eclampsia and Eclampsia due to vasospasm .

C/ F

Symptoms: 

 ⁃ Asymptomatic 

 ⁃ Headache 

 ⁃ Polyuria 

 ⁃ Giddiness 

 • symptoms of complications 

 ⁃ Stroke 

 ⁃ Blurred vision 

 ⁃ Angina , myocardial infarction.

 ⁃ Left ventricular failure 

 ⁃ Chronic renal failure.

 • Symptoms of aetiological factors

 ⁃ phaeochromocytoma : 3ps

                                               – palpitation

                                               - perspiration 

                                        - paraxysmal headache 

 ⁃ chronic renal failure:

                                           - Decreased urine 

                                             output 

                                           - Body swelling 

                                           - Anaemia 

Physical examination:

Blood pressure : examine in two arms 

 • Record blood pressure in lying and standing position to see postural hypotension. If there is drop in systolic BP more than 10 mmHg in standing position , it is define as postural hypotension.

Cause of postural hypotension 

 • Bed ridden patient 

 • Hemorrhage 

 • Old age 

 • Drug eg : methyldopa

Chest 

CVS:

 • carotid bruit 

 • Jugular veinou pressure ( jVP)

 • Aortic sound A2 loud 

 • S3 heard of in heart failure 

 • Systolic flow murmur  

Respiratory system 

Look for basal crepitations due to left ventricular failure

Abdomen 

 ⁃ Look for renal bruit in renal artery stenosis 

 ⁃ Palpable finding in polycystic kidney disease le

Face 

 • Swelling of face 

 • Cyanosis and conjunctival congestion 

 • Cushing syndrome: characteristic facies moon face

Limbs 

 ⁃ pulse rate , rhythm, character and volume 

 ⁃ Pedal edema

Complications of hypertension 

 • central nervous system 

 • Heart 

 • Eye : Hypertensive retinopathy 

 • Renal 

Investigations:

For all hypertensive patients :

 ⁃ urine analysis for protein, glucose, blood ,

 ⁃ Blood urea , creatinine

 ⁃ Plasma electrolytes, Hypokalaemic alkalosis 

 ⁃ Blood glucose 

 ⁃ Plasma lipid profiles

 ⁃ Chest X-ray

 • cardiomegaly

 • Pulmonary oedema ( LVG)

 ⁃ 12 lead ECG : left ventricular hypertrophy 

       > ECG finding 

 • sinus rhythm, rate 48/ min

 • Normal axis

 • QRS duration normal , but the R wave height in lead V5 is 30mm and the S wave depth In lead V2 is 25 mm

 • Inverted T waves in lead I, VL, V5 , -v6

 • Ischemic heart disease (IHD)

Treatment 

Components of cardiovascular risk stratification in patients with hypertension.

Major risk factors 

 1. Smoking 🚬 

 2. Dyslipidaemia

 3. Diabetes mellitus 

 4. Age >60

 5. Sex ( male , and postmenopausal women)

 6. Family history of cardiovascular 🫀 diseases 

      ( women < 65 or male < 55 years)

Target organ damage ( TOD)/ Clinical cardiovascular disease (CDC)

 • Heart disease 

 ⁃ Left ventricular hypertrophy

 ⁃ Angina or prior myocardial infarction 

 ⁃ Prior coronary revascularization

 ⁃ Heart failure 

 • Stroke or transient ischaemic 

 • Nephropathy

 • Peripheral arterial disease 

 • Retinopathy

Management of hypertension :

Non pharmacological treatment 

  

Lifestyle modification: • Loose weight if overweight • Limit alcohol intake • Increased aerobic physical activity • Reduce sodium intake to not more than 100 mmol/ Day • Maintain adequate intake of dietary potassium • Maintain adequate intake of dietary calcium and magnesium for general health • Stop smoking Drug therapy Commonly used drug are : 1. Diuretics 2. Beta - blockers 3. Angiotensin conversating enzyme inhibitors 4. Calcium channel blockers . 5. Angiotensin II receptors blockers. Other drugs 1. Directly acting vasodilator ⁃ Hydralazine ⁃ Sodium nitroprusaide ⁃ Minoxidil ⁃ Diazoxide 2. Centrally acting adrenergic receptors ⁃ methyldopa ⁃ Clonidine 3. Alpha adrenergic inhibitors ⁃ prazosin ⁃ Terazosin ⁃ Doxazosin Safe drugs in pregnancy ⁃ Hydralazine ⁃ Methyldopa ⁃ Clonidine ⁃ Metoprolol ⁃ Prazosin Management of hypertensive crisis: (A) parenteral iv.agents ⁃ sodium nitroprusside ( choice of drug) ⁃ Nitroglycerin ⁃ Labetalol ⁃ Esmolol ⁃ Furosemide ⁃ Hydralazine ⁃ Diazoxide Oral agent : A. Nifedipine 10 mg*PO initially may be repeated after 30 minute B. Captropril 12.5-25mg * PO C.clonidine 0.1-0.2mg PO initially then, 0.1 mg every hour up to 0.8 mg