BLOOD PRESSURE

 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 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 higher and 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  RENAL DISEASE : 1. Renal vascular disease. 2. Parenchymal renal disease (glomerulonephritis). 3. Polycystic kidney disease.  ENDOCRINE DISEASE : 1. Pheochromocytoma. 2. cushing’s syndrome. 3. Primary peraldosteronism (conn’s syndrome). 4. Hyperparathyroidism. 5. Thyrotoxicosis. 6. Acromegaly.

 DRUGS : 1. oral contraceptives containing oestrogens. 2. Steroids. 3. 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 hypertension 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

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