1. http://apps.nccd.cdc.gov/brfss/

5. BLOOD PRESSURE 140 90 Systolic Diastolic

6. NORMAL BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic

7. HIGH BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic Hypertensive

8. NOCTURNAL HIGH BLOOD PRESSURE Ntl High BP Committee. Arch Intern Med 150:2270, 1990 Time of Day (hrs) Blood Pressure (mmHg) Systolic Diastolic Hypertensive

10. AMBULATORY TECHNOLOGY ECG Electrodes Blood Pressure Cuff Microphone Control Box

11. AVERAGE PRESSURES Work 0600-1700 hrs Leisure 1700-2200 hrs Night Time Mean =136 mmHg 2200-0600 hrs Day Time Mean = 139 mmHg 0600 –2200 hrs 24 hour Mean =139 mmHg

12. SLOPE OF MORNING RISE 3:00 am 6:00 am

13. 47% 48%

14. 5177 mmHg hr 9876 mmHg hr AREA UNDER THE CURVE

15. CrestCPS = 10.4 Trough CPS =- 15.3 CrestCPS = 7.55 Trough CPS =- 12.5

16. FOURIER ANALYSIS BP(t) = c 0 + Σ [a j cos(jπt/12)+b j sin(jπt/12)]

17. FOURIER ANALYSIS

18. ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

19. Heart Arterial Vasculature Central Nervous System BARO & CHEMO RECEPTORS  Heart Rate  Contractility  Heart Rate  Contractility Vasoconstriction

20. Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Heart Rate  Contractility  Heart Rate  Contractility Vasoconstriction

21. Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Heart Rate  Contractility  Heart Rate  Contractility Vasodilation

22. Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

23. RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Kidneys Lungs

24. RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Kidneys Lungs Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output

25. RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Lungs Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Decrease blood volume Decrease in renal blood pressure Increase in sympathetic output Renin Angiotensinogin Angiotensin I Kidneys

26. RENIN ANGIOTENSIN Central Nervous System Arterial Vasculature Heart Angiotensin I Kidneys Converting Enzyme Angiotensin II Angiotensin III Lungs

27. RENIN ANGIOTENSIN Central Nervous System Heart Kidneys Angiotensin II Lungs Arterial Vasculature Vasoconstriction

28. RENIN ANGIOTENSIN Central Nervous System Heart Kidneys Angiotensin II Lungs Arterial Vasculature Vasoconstriction  Vegal Tone  Catecholamines  Heart Rate  Contractility  Heart Rate  Contractility

29. RENIN ANGIOTENSIN Central Nervous System Heart Angiotensin II Lungs Arterial Vasculature Aldosterone Kidneys Reabsorb Fluid

30. Renin-Angiotensin CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE Vasoconstriction  Heart Rate  Contractility  Fluid  Heart Rate  Contractility  Fluid

31. ATRIAL NATURETIC FACTOR Heart Central Nervous System Kidneys Arterial Vasculature Vasodilation  Renin  Fluid Loss

32. Heart CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Fluid Loss Vasodilation

33. ANTI-DIURETIC HORMONE Kidneys Pituitary Gland  Fluid Reabsorption

34. Atrial Naturetic Factor CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE  Fluid Reabsorption

35. ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

36. NATURAL HISTORY Genetic Predisposition Salt Stress Transient Changes Low High Stabilizing Factors

37. CategoryFollow-up OptimalRecheck 2 yrs PrehypertensionRecheck in 1 yr Hypertension Stage 1Confirm within 2 months Stage 2 Evaluate or refer within 1 mo >180/>110Evaluate and treat immediately or within 1 week depending on clinical situation and complications CategoryFollow-up OptimalRecheck 2 yrs PrehypertensionRecheck in 1 yr Hypertension Stage 1Confirm within 2 months Stage 2 Evaluate or refer within 1 mo >180/>110Evaluate and treat immediately or within 1 week depending on clinical situation and complications FOLLOW-UP JAMA 289:2534-2573, 2003 Hypertension 42:1206-1252, 2003 Department of Health & Human Services Pub No. 03-5233, 2003 JAMA 289:2534-2573, 2003 Hypertension 42:1206-1252, 2003 Department of Health & Human Services Pub No. 03-5233, 2003

38. TREATMENT: MEDICATIONS DIURETICS ALDOSTERONE-RECEPTOR BLOCKERS  BLOCKERS  1 BLOCKERS  2 AGONISTS ACE INHIBITORS ANGIOTENSIN II ANTAGONISTS (Angiotensin Receptor Blockers-ARB) Ca ++ CHANNEL BLOCKERS VASODILATORS DIURETICS ALDOSTERONE-RECEPTOR BLOCKERS  BLOCKERS  1 BLOCKERS  2 AGONISTS ACE INHIBITORS ANGIOTENSIN II ANTAGONISTS (Angiotensin Receptor Blockers-ARB) Ca ++ CHANNEL BLOCKERS VASODILATORS

40. ANF Central Nervous System Renin-Angiotensin Anti-Diuretic Hormone Baro & Chemo Receptors CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE

41. Lifestyle Modifications TREATMENT ALGORITHM Recheck Blood Pressure At Goal Continue Not at Goal Add Medications Stage of Hypertension Compelling Indications Add Medications Stage of Hypertension Compelling Indications

42. Initial Drug Choices Without Compelling Indications With compelling Indications Stage 1 Thiazide-type Diuretics Consider ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Thiazide-type Diuretics Consider ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Stage 2 Thiazide-type Diuretics With ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers Thiazide-type Diuretics With ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Ca++ Channel Blockers

43. COMPELLING INDICATIONS IndicationDIURBBACEIARBCa ++ AldoANT Heart Failure      Post MI    Hi Risk     Diabetes      Chronic   Kidney Stroke   IndicationDIURBBACEIARBCa ++ AldoANT Heart Failure      Post MI    Hi Risk     Diabetes      Chronic   Kidney Stroke  

44. Adjust dosage if not at Blood Pressure Goal

46. TREATMENT

47. Exercise Effectiveness Whelton, S.P., et al., Annals of Internal Medicine, 2002. 136(7): p. 493-503. Kelley, G.A. and K.S. Kelley, Hypertension, 2000. 35(3): p. 838-843. ResistanceCardiovascular

48. Med Sci Sports Exerc 36:533-553, 2004

49. INTENSITY Fagard & Tipton, Physical Activity, Fitness and Health, p 633-668, 1994. Fagard & Tipton, Physical Activity, Fitness and Health, p 633-668, 1994. Change in Blood Pressure (mmHg)

51. The Interaction of Exercise and Medications? Kelelrman, M.H. et al, JAMA 263:2766-2771, 1990

52. Padilla, MSSE 37:1264-1275, 2005.

59. Accumulation of Four Short Exercise Sessions

60. One Continuous Exercise Session

61. Wallace, et al. J Human Hypertension 13:361-366, 1999  8.3 mm Hg in SBP for 11 hr  6.0 mm Hg in DBP for 4 hr

62. TIME OF DAY FOR EXERCISE Park, S., et al., Journal of Human Hypertension 19: 597-605, 2005

63. TIME OF DAY FOR EXERCISE Park, S., et al., Medicine and Science in Sport and Exercise, in press.

64. Baro receptors Vasopressin Atrial Natriuretic Factor Renin-Angiotensin Central Nervous System

65. Alpha Blockers Ca ++ Channel Blockers ARBs Diuretics β Blockers ACE Inhibitors α 2 agonists Aldosterone Receptor Blockers

66. CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE Renin-Angiotensin Vasopressin Baroreceptors ANF Central Nervous System

67. CARDIAC PERIPHERAL BP = OUTPUT XVASCULAR RESISTANCE DiureticsVasodilators Cardioinhibitory Sympatholytics

68. BP = CARDIAC OUTPUT X VASCULAR RESISTANCE Cardioinhibitory Beta-Blockers Ca ++ Channel Blockers dihydropyridines Ca ++ Channel Blockers Penylkylamines Ca ++ Channel Blockers benzothiazepines