I n t e r n a l M e d i c i n e Chester John C.

Rebojo

Hypertensive SUSTAINED HIGH LEVELS OF CATECHOLAMINES

Receptors downregulated decreasing responsiveness
Cardiovascular Disease
Dr. Ruales Lecture tachyphylaxis
transcribed by: Chester John c. Rebojo
BAROREFLEXES
PRESSURE Mediated by stretch-sensitive sensory nerve endings
CARDIAC OUTPUT x PERIPHERAL RESISTANCE carotid artery & aortic arch effect a decrease
sympathetic outWlow
CARDIAC OUTPUT
STROKE VOLUME x HEART RATE
RENIN-ANGIOTENSIN-ALDOSTERONE (RAAS)
PERIPHERAL RESISTANCE
ANGIOTENSIN II
Vascular Function
VasoCONSTRICTOR
Vascular Structure

ALDOSTERONE
VASCULAR VOLUME
Sodium Retention
Sodium
Chloride
RENIN
Synthesized in juxtoglomerular cells (segment of renal
BLOOD FLOW
Pressure across Vascular Bed/Vascular Resistance
afferent arteriole)

AUTONOMIC NERVOUS SYSTEM STIMULI FOR RENIN SECRETION

Maintains Cardiovascular Homeostasis
Pressure, Volume, and Chemoreceptor Signal MACULA DENSA
NaCI Transport
CATECHOLAMINES
Norepinephrine BARORECEPTOR
Epinephrine pressure or stretch in renal afferent arteriole
Dopamine
BETA 1 Adrenoreceptors of Renin-Secreting Cells
ADRENERGIC NEURONS
Norepinephrine ACTION OF RENIN
Dopamine (Precursor of Noeriphrine)

Cleaves Angiotensinogen to form Angiotensin 1

EPINEPHRINE
ACE (located primarily in the pulmonary circulation)
Adrenal Medulla (when stimulated)
converts Angiotensin I to Angiotensin II, also inactivates
ADRENERGIC RECEPTORS
bradykinin
Alpha (1 and 2)
More occupied & activated by NOREPINEPHRINE than ANGIOTENSIN II
epinephrine
Alpha 1 Receptors Potent vasoconstrictor
Located on POST-SYNAPTIC cells in smooth muscles Stimulate the secretion of Aldosterone in the Adrenal
which elicit vasoconstriction Zona Glomerulosa
Alpha 2 Receptors Potent Mitogen stimulating vascular smooth-muscle cell
Localized on PRE-SYNAPTIC membranes of post- & myocyte growth
ganglionic nerve endings (synthesize Direct cellular action on vessel wall
norepinephrine)
Act as negative feedback controllers ALDOSTERONE
Beta (1 and 2)
More occupied & activated by EPINEPHRINE than Potent mineralocorticoid that increases sodium
epinephrine reabsorption by amiloride-sensitive epithelial sodium
Beta 1 Receptors channels
Myocardium = stimulates rate & strength of cardiac Sodium is exchange for potessium & hydrogen ions
contraction resulting to hypokalemia and alkalosis in increased
Kidney = stimulates Renin release aldosterone secretion
Beta 2 Receptors
Vascular Smooth Muscle = relaxation by
epinephrine resulting in vasodilation

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 I n t e r n a l M e d i c i n e Chester John C. Rebojo

VASCULAR MECHANISMS HYPERTENSION

Vascular radius & compliance of resistance arteries
DEFINITION (Clinical)
Resistance to Wlow varies inversely with the fourth
Level of BP that if treated reduces morbidity & mortaility
power of the radius
Base on average of 2 or more seated readings taken
each of two or more outpatient visits
REMODELLING

HYPERTROPHIC CLASSIFICATION
cell number
NORMAL <120 <80
cell size
deposition of intracellular matrix
PRE- 120-139 80-89
HYPERTENSION
EUTROPHIC
No change in material in the vessel wall STAGE 1 140-159 90-99

PATHOLOGIC CONSEQUENCES
STAGE 2 .=/>160 .=/>100
HEART
Left Ventricular Hypertrophy
ISOLATED .=/>140 <90
Diastolic Dysfunction
SYSTOLIC
CHF
Abnormalities of blood Wlow due to atherosclerosis
CAD & microvascular disease 24-Hour Ambulatory BP
Cardiac Arrhythmias Average Awake =/> 135/85
TESTS Asleep =/>120/75
ECG
Echocardiography (more sensitive for LVH) WHITE COAT HYPERTENSION
Radionuclide angiography OfWice BP level of stage 1 HPN but with average
Cardiac Catherterization ambulatory readings =/> 135/85
Associated with LVH, carotid atherosclerosis, & overall

BRAIN cardiovascular morbidity

Increased risk for developing sustained Hypertension

Infarction (85% of CVA)

CLINICAL DISORDERS
Hemorrhage (Intracerebral or Subarachnoid)
Essential (primary or idiopathic) 80 to 95% of cases
Impaired cognition (dementia)
Secondary HPN
Encephalopathy = failure of autoregulation of cerebral
blood Wlow SYSTOLIC HYPERTENSION with WIDE PULSE
PRESSURE
KIDNEY Vascular Compliance (arteriosclerosis)
CO (AR, thyrotoxicosis, Hyperkinetic Heart Syndrome,
Renal Injury Fever, AV Fistula, PDA)
ESRD
Related more to systolic than diastolic blood pressure SECONDARY CAUSES OF SYSTOLIC & DIASTOLIC HPN
Black than white men Renal
Primarily affect the preglomerular arterioles Renovascular
Early markers = macroalbuminuria or Adrenal
microalbuminuria Aortic Coarctation
Obstructive sleep apnea
PERIPHERAL ARTERIES Pre-eclampsia/eclampsia
Neurogenic
Contributes to pathogenesis Endocrine
Target Organ:
Classic Symptoms = Intermittent Claudication ADRENAL
Evaluated by ankle-brachial index = <0.99 Primary aldosteronism
Cushings syndrome
17 alpha-hydroxylase deWiciency
17 beta-hydroxylase deWiciency
11-hydroxysteroid dehydrogenase deWiciency (licorice)
Pheomchromocytoma

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NEUROGENIC
Psychogenic
Diencephalic Syndrome
Familial Dysuatonomia
Polyneuritis (acute porphyria, lead poisoning)
Acute increased intracranial pressure
Acute spinal cord section

MISCELLANEOUS ENDOCRINE
Hypothyroidism
Hyperthyroidism
Hypercalcemia
Acromegaly

MEDICATIONS CAUSING HYPERTENSION

High-doses estrogens
Adrenal Steroids
Decongestants
Appetite suppresants
Cyclosporine
Tricyclic antidepressants
Monoamine oxidase inhibitors
Erythropoietin, NSAIDS, cocaine

E N D (CJRebojo 2014)

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