Hypertension

Hypertension

1. physiology of Blood pressure

   • How to regulate the mean arterial hypertension
     • Short term regulation (neurological)
       • Baroreceptor reflex
     • Long Term Regulation( hormonal)
       • Renin-angiotensin II- aldosterone system
     • A defect in this mechanism
       • due to
         • decreased sensitivity of the baroreceptors to increases in arterial pressure
         • an increase in the blood pressure set point of the brain stem centers
       • Results in

2. Types

   • Essential or primary
     • no known cause
       • It mainly idiopathic, but genetic , environmental and salt intake may play role
         • old age is most affected
           • good prognosis
   • Secondary
     • specific cause
       • renal, endocrine , cardiovascular and neurological disorders.
         • all age groups are affected
           • bad prognosis
             • A table that summarizes all causes
         • Treating the cause can treat the patient

3. Values of blood pressure and what do they stand for

4. Risk Factors

   • Aging
   • physical inactivity
   • Gender
   • Race
   • Obesity
   • Too much salt (sodium) in diet
   • Too little potassium in diet
   • Drinking too much alcohol.
   • stress
   • smoking
   • family history

5. Asymptomatic for years

   • a symptom appears, it’s usually due to organ failure
     • Except malignant hypertension
       • severe headache
       • nausea
       • vomiting
       • confusion
       • nosebleeds
       • changes in vision

6. Complications

   • 1- Heaving apical impulse
     • Apex beat is forceful and well sustained due to systolic overload of ventricle.
       • This is due to pressure overload of Left ventricle ,force and duration of left ventricular contraction is increased
   • 2- Loud A2
     • Coronary artery disease.
       • due to a high blood pressure damage that affects the arteries that supply blood to the heart muscle.
         • Arteries narrowed by coronary artery disease don't allow blood to flow freely through your arteries
           • loud A2 occurs in systemic hypertension where there is a dilated proximal aorta
   • 3- Audible fourth heart sound
     • Produced during atrial systole due to vibrations that set in the atrial musculature during atrial systole
   • 4-Hypertensive retinopathy
     • When the blood pressure is too high, the retina’s blood vessel walls may thicken.
       • This may cause your blood vessels to become narrow, which then restricts blood from reaching the retina. In some cases, the retina becomes swollen.
         • limit the retina’s function, and put pressure on the optic nerve, causing vision problems.
       • Examined through an Ophthalmoscope
         • cotton wool spots

7. Investigations

   • Full fasting lipid profile
     • screening tool for abnormalities in lipids
       • identify certain genetic diseases, cardiovascular diseases , pancreatitis, and other diseases.
       • Components
         • Total cholesterol
           • measures all of the cholesterol in all the lipoprotein particles.
         • High-density lipoprotein cholesterol (HDL-C)
           • measures the cholesterol in HDL particles
         • Low-density lipoprotein cholesterol (LDL-C)
           • calculates the cholesterol in LDL particles
         • Triglycerides
           • measures all the triglycerides in all the lipoprotein particles
     • it requires a 12-hour fast
     • If it is done after not fasting, the results will be accurate for total cholesterol and HDL, but not LDL or triglyceride levels.
   • Waist-hip ratio
     • simple and useful measure of fat distribution.
       • ratio of the circumference of the waist to that of the hips
         • Associated with Nighttime Blood Pressure Dipping
   • Urinalysis
     • set of screening tests that can detect some common diseases.
       • screen for and/or help diagnose conditions such as a urinary tract infections, kidney disorders, liver problems, diabetes or other metabolic conditions, to name a few.
   • Fundus examination
     • The fundus can be examined by ophthalmoscopy and/or fundus photography
       • Medical signs that can be detected
         • hemorrhages, exudates, cotton wool spots, blood vessel abnormalities (tortuosity, pulsation and new vessels) and pigmentation.

8. Treatment

   • Pharmacological
     • Anti-hypertensives
       • Antiadrenergics (β–blockers)
         • Mechanism of action
         • Adverse side effects
           • Bradycardia, hypotension, fatigue, insomina, and sexual dysfunction
       • Calcium channel blockers
         • effective in treating hypertension in patients with angina or diabetes.
           • High doses can increase myocardial infarction risk
             • due to excessive vasodilation and marked reflex cardiac stimulation
           • Adverse side effects
             • flushing
             • constipation
             • dizziness
             • Headache
             • fatigue
             • Hypotension
       • Angiotensin converting enzyme inhibitors (ACEI)
         • Inhibitors block the angiotensin-converting enzyme, thus preventing the formation of angiotensin II.
           • decreased systemic vascular resistance (afterload), vasodilation, and therefore, decreased blood pressure
         • prevent the breakdown of the vasodilating substance, bradykinin.
       • Angiotensin II Receptor Blockers
         • Allow angiotensin I to be converted to angiotensin II, but block the receptors that receive angiotensin II
         • Block vasoconstriction and release of aldosterone
       • Diuretics
         • Decrease the plasma and extracellular fluid volumes
           • decreased workload of the heart, and decreased blood pressure
       • Direct vasodilators
       • Renin Inhibitors
   • Life style modifications
     • Increased physical activity
     • a reduced salt intake
     • weight loss
     • moderation of alcohol intake
     • increased potassium intake
     • DASH diet
       • emphasizes fruits, vegetables, and low-fat dairy products and is reduced in fat and cholesterol
       • reduced saturated fat, total fat, and cholesterol

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