Hypertension BP ≥140/90 (WHO/ISH,1993) Isolated systolic hypertension: BP syst ≥ 140 mm Hg, BP diast. < 90 mm Hg

Blood pressure measurement (ESH/ESC 2007)  † Allow the patients to sit for several minutes in a quiet room  † Take at least two measurements  † Use a standard bladder (12–13 cm long and 35 cm wide) but have a larger available for fat arms  † Have the cuff at the heart level  † Use phase I and V (disappearance) Korotkoff sounds to identify systolic and diastolic BP, respectively  † Measure BP in both arms at first visit to detect possible differences due to peripheral vascular disease  † Measure BP after the standing position in elderly subjects, diabetic patients, and in other suspition of postural hypotension

Hypertension – classification  Primary : 90%, per exclusionem  Secondary (10%)  - renal parenchymal  - renovascular  - endocrine : phaeochromocytoma, primary aldosteronism, Cushing´s sy  - coarctation of aorta  - in pregnancy

Hypertension – classification (ESH/ESC 2007, NHLBI 2003)  Optimal : systolic ≤ 120 and, diastolic ≤ 80  Normal 120–129 and/or 80–84 mm Hg  High normal („prehypertension“) 130–139 and/or 85–89  Hypertension ≥ 140/90  Grade 1 hypertension 140–159 and/or 90– 99  Grade 2 hypertension 160–179 and/or 100–109  Grade 3 hypertension ≥ 180 and/or ≥ 110

Routine laboratory tests in hypertension (ESH/ESC 2007, NHLBI 2003)  † Fasting plasma glucose, Serum total cholesterol, Serum LDL-cholesterol, HDL- cholesterol, Fasting serum triglycerides  † Serum potassium, Serum uric acid, Serum creatinine, Estimated creatinine clearance (Cockroft-Gault, MDRD)  † Haemoglobin and haematocrit  † Urinalysis (complemented by microalbuminuria via dipstick, and microscopic examination)  † Electrocardiogram

Recommended tests in hypertension (ESH/ESC 2007, NHLBI 2003)  † Echocardiogram  † Carotid ultrasound  † Quantitative proteinuria (if dipstick test positive)  † Fundoscopy  † Glucose tolerance test (if fasting plasma glucose >5.6 mmol/L)  † Home and 24 h ambulatory BP monitoring

Goals of treatment  † reduction in the long term total risk of CVD  † Treatment of the raised BP  † BP should be reduced to at least below 140/90 mm Hg  † Target BP should be at least 130/80 mm Hg in diabetics and in high risk patients (stroke, MI, renal dysfunction, proteinuria).  † treatment should be initiated before significant cardiovascular damage develops.

Ambulatory 24-h BP monitoring  should be considered when considerable variability of BP is found  marked discrepancy between BP values measured in the office and at home  resistance to drug treatment is suspected  hypotensive episodes are suspected, particularly in elderly and diabetics

Self-measurement of home BP  provides more information on the BP lowering effect of treatment  improves patient’s adherence to treatment regimens  anxiety of the patient  Choice of electron.device (no finger, wrist, yes arm), certification EU (Omron M4, M6, MIT)

Blood pressure thresholds for definition of hypertension  Office or clinic 140/90 mm Hg  Total average 24-hour 125–130/80  Day 130–135/85, Night 120/70  Home 130–135/85

Patients’ follow-up  † Titration to BP control requires frequent visits in order to modify the treatment regimen in relation to BP changes and appearance of side effects.  † Once target BP has been obtained, the frequency of visits can be considerably reduced.  † Patients at low risk or with grade 1 hypertension may be seen every 6 months  † Visits should be more frequent in high or very high risk patients.

Hypertension - prognosis  † ESC SCORE risk ≥ 5%  † DM of 1st type with microalbuminuria, all diabetics of 2nd type  † Family history of premature CV disease (M at age, 55 years; W at age, 65 years)  † Age (M. 55 years; W. 65 years)

Risk factors  † Carotid wall thickening (IMT 0.9 mm) or plaque  † Smoking  † Dyslipidaemia- (TC ≥ 5.0 mmol/l: LDL-C ≥ 3.0 mmol/l - HDL-C: M <1.0 mmol/l, W < 1.2 mmol/l - TG ≥1.7 mmol/l)  † Fasting plasma glucose 5.6–6.9 mmol/L, Microalbuminuria 30–300 mg/24 h  † Abnormal glucose tolerance test  † Abdominal obesity (Waist circumference 102 cm (M), 88 cm (W)

Risk factors  Cerebrovascular disease (ischaemic stroke; cerebral haemorrhage; TIA)  Heart disease: MI; angina; coronary revascularization; heart failure  Renal disease: diabetic nephropathy; renal impairment  Peripheral artery disease  Advanced retinopathy: haemorrhages or exudates, papilloedema

Hypertensive crisis  Life – threatening event with potential failure of important organs (CNS, cardivascular system, kidney)  In severe hypertonics, poor controlled, rebound f.  Emergent, urgent.

Therapy of Hypertensive Crisis  Captopril 12,5-50 mg, furosemide  Nitrates : ISDN 2-10 mg/h., NTG 0,5- 10 mg/h i.v.  Na Nitropruside : 0,3…max.8 μg/kg/min.  Urapidil (Ebrantil) : 25 mg i.v.  Labetalol : bolus i.v mg 1 min., thereafter 1-2 mg/min.  Decrease 20%/h

Hypertension in pregnant women  Alfa-metyldopa, betablockers, dihydropyridin Ca blockers, labetalol  Contraindication : ACE inhibitors, AT1 blockers, diuretics