1. HYPERTENSION

2. Contents [hide] 1 Measurement 1.1 Units 1.2 Noninvasive measurement Palpation methods Auscultatory methods Oscillometric methods 1.3 Invasive measurement 1.4 Home monitoring 2 Classification 3 Normal values 4 Physiology 4.1 Mean arterial pressure 4.2 Pulse pressure 4.3 Vascular resistance 4.4 Vascular pressure wave 4.5 Regulation 5 Pathophysiology 5.1 High arterial pressure 5.2 Low arterial pressure 6 Other sites 6.1 Venous pressure 6.2 Pulmonary pressure 6.3 Fetal blood pressure 7 See also 8 Footnotes 9 External links
WHAT IS BLOOD PRESSURE
Blood pressure is the force with which blood pushes against the artery walls as it travels through the body. Systolic pressure measures cardiac output and refers to the pressure in the arterial system at its highest. Diastolic pressure measures peripheral resistance and refers to arterial pressure at its lowest .Normal blood pressure for an adult is 120/80 (on average).

3. DEFINITION
Defined as a repeatedly elevated blood pressure exceeding 140 over 90 mmHg -- a systolic pressure above 140 with a diastolic pressure above 90.

4. INCIDENCE
It is world wide epidemic with an estimated 690 million people
Increases with age
More prevalent in male.
Higher in African Whites than in whites

5. TYPES
Primary Hypertension: A condition which is characterized by high blood pressure not associated with any identifiable pathological cause
Secondary Hypertension: Secondary hypertension is high blood pressure resulting from an underlying cause such as kidney disease

6. Classification of blood pressure for adults
The following classification of blood pressure applies to adults aged 18 and older. It is based on the average of seated blood pressure readings that were properly measured during 2 or more office visits.
Classification of blood pressure for adults
Category
systolic, mmHg
diastolic, mmHg
Hypotension
< 90
< 60   
Normal
 90 – 119
60 – 79   
Prehypertension
120 – 139
80 – 89  
Stage 1 Hypertension
140 – 159
90 – 99  
Stage 2 Hypertension
≥ 160
≥ 100  

7. White coat hypertension: White coat hypertension is a term used to describe a condition where patients have increased blood pressure readings when measured in a clinical setting such as a doctor's office. Blood pressure readings taken in the home environment while the patient is relaxed are normal. The underlying cause is believed to be tension and anxiety associated with visiting health professionals such as general practitioners.
Isolated systolic hypertension: Often in older adults the first number (the upper or systolic number) is high while the second (the lower or diastolic) number is normal.

8. Malignant hypertension: Malignant hypertension is a condition characterized by very high blood pressure and swelling of the optic nerve. This type of hypertension is more common in people with kidney problems such as narrowed kidney blood vessels. The condition is a medical emergency which can cause organ damage if not treated promptly

9. ETIOLOGY

10. RISK FACTORS Age. Gender. Family history Ethnicity. Stress. Obesity.
NONMODIFIABLE FACTORS
MODIFIABLE FACTORS
Stress.
Obesity.
Lack of vitaminD
Excess intake of salt
Alcoholism
Cigarettesmoking
Diabetes mellitus
Elevated serum lipids
Age.
Gender.
Family history
Ethnicity.

13. CLINICAL MANIFESTATIONS
Severe head ache
Fatigue or confusion
Dizziness
Nausea
Problems with vision
Chest pains
Breathing problems
Irregular heartbeat
Blood in the urine

14. COMPLICATIONS

15. DIAGNOSTIC EVALUATION

16. The medical and family history help the physician determine if the patient has any conditions or disorders that might contribute to or cause the hypertension. A family history of hypertension might suggest a genetic predisposition for hypertension.
The physical exam may include several blood pressure readings at different times and in different positions. The physician uses a stethoscope to listen to sounds made by the heart and blood flowing through the arteries. The pulse, reflexes, and height and weight are checked and recorded. Internal organs are palpated, or felt, to determine if they are enlarged.
Because hypertension can cause damage to the blood vessels in the eyes, the eyes may be checked with a instrument called an ophthalmoscope. The physician will look for thickening, narrowing, or hemorrhages in the blood vessels.
A chest x ray can detect an enlarged heart, other vascular (heart) abnormalities, or lung disease.
An electrocardiogram (ECG) measures the electrical activity of the heart. It can detect if the heart muscle is enlarged and if there is damage to the heart muscle from blocked arteries.
Urine and blood tests may be done to evaluate health and to detect the presence of disorders that might cause hypertension.

17. BLOOD PRESSURE MONITORING
OPTHALMOSCOPE

19. NON PHARMACHOLOGICAL MANAGEMENT
Weight reduction .
Increased physical activity
Limited alcohol consumption
Reduced salt (sodium chloride) intake
Increased potassium intake
Stress reduction technique

20. PHARMACHOLOGICAL MANAGEMENT
Drug classes Commonly used classes of antihypertensive drugs are the
Thiazide diuretics (e.g., bendroflumethiazide)
Beta-blockers (e.g., propranolol, atenolol)
Angiotensin-converting enzyme inhibitors (e.g., captopril, enalapril),
Angiotensin II antagonists (e.g., candesartan, losartan),
Calcium channel blockers (e.g., amlodipine, nifedipine) and alpha-blockers (e.g., doxazosin

21. HYPERTENSIVE CRISIS

22. DEFINITION
Hypertensive crises encompass a spectrum of clinical situations that have in common severely elevated blood pressure (BP), usually higher than 180/110 mm Hg, together with progressive or impending target organ damage.

23. Hypertensive crises affect upward of 500,000 Americans each year.

24. CAUSES Chronic hypertension with acute exacerbation (most common)
Reno vascular hypertension
Parenchymal Renal Disease
Acute glomerulonephritis
Renal Infarction
Vasculitis
Scleroderma Renal Crisis
Drug Ingestion
Tricyclic anti-depressants
Monoamine Oxidase (MAO) Inhibitors
Cocaine
Amphetamines
Anti-hypertensive drug withdrawal or failed compliance
Centrally acting anti-hypertensives (eg. clonidine)
Peripheral alpha blockers (eg. prazosin)
Beta-Blocker acute withdrawal
Pre-eclampsia and Eclampsia
Autonomic hyperactivity
Guillain-Barre Syndrome
Spinal Cord Injury
Pheochromocytoma

26. HYPERTENSIVE URGENCY
Hypertensive Urgency is defined as a clinical setting of severe hypertension  with minimal or no symptoms, where severe elevation of BP are not causing immediate end-organ damage but should be effectively lowered within 24 hours to reduce potential risk to the patient.

27. HYPERTENSIVE EMERGENCY
Hypertensive emergencies are severe elevations in BP, often higher than 220/140 mm Hg, complicated by clinical evidence of progressive target organ dysfunction. These patients require immediate admission and BP reduction (not necessarily to normal ranges) to prevent or limit further target organ damage. Examples include hypertensive encephalopathy, intracranial hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, dissecting aneurysm, acute renal failure, and eclampsia of pregnancy

28. CLINICAL MANIFESTATIONS
Table 1: Clinical Characteristics othe Hypertensive Emergency
CLINICAL MANIFESTATIONS
Blood Pressure (mm Hg)
Funduscopic Findings
Neurologic Status
Cardiac Findings
Renal Symptoms
Gastrointestinal Symptoms
Usually >220/140
Hemorrhages, exudates, papilledema
Headache, confusion, somnolence, stupor, visual loss, seizures, focal neurologic deficits, coma
Prominent apical pulsation, cardiac enlargement, congestive heart failure
Azotemia, proteinuria, oliguria
Nausea, vomiting

31. Severe Hypertension (Urgency) Hypertensive Emergency
Parameter
Asymptomatic
Symptomatic
Hypertensive Emergency
Blood pressure (mm Hg)
>180/110
Usually >220/140
Symptoms
Headache, anxiety; often asymptomatic
Severe headache, shortness of breath
Shortness of breath, chest pain, nocturia, dysarthria, weakness, altered consciousness
Examination
No target organ damage, no clinical cardiovascular disease
Target organ damage; clinical cardiovascular disease present, stable
Encephalopathy, pulmonary edema, renal insufficiency, cerebrovascular accident, cardiac ischemia
Therapy
Observe 1-3 hr; initiate, resume medication; increase dosage of inadequate agent
Observe 3-6 hr; lower BP with short-acting oral agent; adjust current therapy
Baseline laboratory tests; intravenous line; monitor BP; may initiate parenteral therapy in emergency room
Plan
Arrange follow-up within 3-7 days; if no prior evaluation, schedule appointment
Arrange follow-up evaluation in less than 72 hr
Immediate admission to ICU; treat to initial goal BP; additional diagnostic studies

34. Intravenous Drugs: Sodium Nitroprusside
Standard rapidly acting agent effective in many cases
Dose is µg/kg/minute as IV infusion, start with ug/kg/min (about ug/min), then 1- 3 ug/kg/min IV (max:<10 ug/kg/min) (50 mg in 250 ml D5W)
Onset: min ; Duration: min
Adverse effects: hypotension, N&V, apprehension, cyanide (thiocyanate level>10 mg/dl is toxic; >20 mg/dl may be fatal) toxicity convulsion, twitching, psychosis, dizziness, etc.
Nitroprusside has decreased efficacy in renal failure
Toxic levels of cyanide build

35. Nitroglycerin
Highly effective in setting of coronary ischemia, acute coronary syndromes
Dose is 5-100µg/min as IV infusion Nitroglycerin IV infusion start ug/min then may be up to >200 ug/min prn esp. in pts where Na nitroprusside is relatively contraindicated & in pts with ischemic heart disease, impaired renal or hepatic function.
Onset: immediate; Duration:1- 5 min
May cause headache, tachycardia, vomiting, methemoglobinemia
Excellent for titrating blood pressure in setting of coronary ischemia

36. Labetalol (Trandate)
Mixed alpha/beta blocker, excellent for most hypertensive emergencies
Dose is 20-80mg IV bolus every 10 minutes or 0.5-2mg/min infusion IV .Start 20 mg IV, then mg q10 min prn, or start with 0.5 mg/min infusion, then 1- 2 mg/min (may be up to 4 mg/min) IV infusion up to 300 mg/d max.
Onset: min; Duration: 3- 6 h
Adverse effects: hypotension, bradycardia, dizziness, scalp tingling
Avoid in patients with heart block, bradycardia, CHF, severe asthma or bronchospasm
First or second line for eclampsia; excellent in catecholamine surges

37. Enalaprilat Intravenous formulation of enalapril (ACE inhibitor)
Dose is mg q6 hour IV (duration of action ~6 hours)
Onset of action in minutes;  Duration 6 hours or more
Highly variable response; precipitous BP drop in high-renin states, rarely angioedema, hyperkalemia, or acute renal failure.
May be most useful in acute cardiogenic pulmonary edema
Avoid in acute myocardial infarction

38. Diltiazem (Cardizem)
Initial dose 0.25 mg/kg over 2 min, followed by infusion of 0.35 mg/kg at an initial rate of 10 mg/hour
Onset:  3-30 min
Adverse effects: excessive hypotension, flushing; rarely amblyopia

39. Treatment of Hypertensive Emergency
Encephalopathy: Nitroprusside, Labetolol, Diazoxide
Cerebral Infarction: no treatment (hemorrhage control), Nitroprusside, Labetolol
Myocardial Ischemia, Infarction: Nitroglycerine, Labetolol, ß-adrenergic blockers
Acute Pulmonary Edema: Nitroprusside (or Nitroglycerin) and Loop Diuretic
Aortic Dissection: Nitroprusside and ß-adrenergic blockers, Labetolol
Eclampsia: Hydralazine, Labetolol, Diazoxide
Acute Renal Insufficiency: Nitroprusside, Labetolol, Ca antagonists
Funduscopic changes: Nitroprusside, Labetolol, Ca antagonists
Hemolytic Anemia, Microangiopathic: Nitroprusside, Labetolol, Ca antagonists .

41. Check the B.P hourly
Administer the medication
Provide low sodium and caloric diet
Encourage the patient for cessation of smoking.
Check the weight of the patient.
Teach about the stress reduction technique.
Provide health education.

42. In effective therapeutic regimen management related to new diagnosis.
Imbalanced nutrition; more than body requirement related to high sodium and caloric intake.
In effective health maintenance related to lack of regular exercise

43. PREVENTION

44. Know your blood pressure
Cessation of smoking Avoidance of alcoholism
Weight control

45. REGULAR EXERCISE AVOID STRESS
EAT LOW FAT DIET

46. Hypertension is a silent killer disorder
Hypertension is a silent killer disorder.Un treated hypertension lead to hypertensive crisis. It is an emergency. It is prevented by adequate life style modification.

47. THANK YOU