Semester 1

Module
CVS
Clinical Aspects of Hypertension

By
Mona Malek Abdel Rehim Ali
Lecturer of Cardiovascular Medicine;
Cardiology Department, Faculty Of Medicine, Mansoura
University
 Objectives
Module CVS

• the prevalence of hypertension

• its importance as a cardiovascular risk

Level 1- Semester 2-

factor.

• Diagnosis for hypertension.

Reference:
 Hypertension
Module CVS

• What is Blood Pressure?

– Pressure created by the heart as it pumps blood
Level 1- Semester 2-

through the arteries and the circulatory system

• What do Blood Pressure Numbers Mean?
– Top number (Systolic)= Pressure while heart is
ejecting (numerator)
– Bottom number (Diastolic)= Pressure while heart
is resting between beats (denominator)

Reference:
 Epidemiology
Module CVS

• Hypertension is an urgent health problem

in Egypt with prevalence rate of 26.3%
Level 1- Semester 2-

among the adult population

• Its incidence increases with aging, around

50% of Egyptians over the age of 60 years
have hypertension

Reference:
 Prevalence of mild hypertension in Egypt
as a result of STEP wise survey 2005
70
60
50
40
Men
30
20 Women
10
0
15-24yrs 25-34yrs 35-44yrs 45-54yrs 55-64yrs

The prevalence of mild hypertension ( SBP ≥ 140 and / or DBP ≥ 90 mmhg

) was 26.7 % with irrelevant differences between males and females
 Prevalence of sever hypertension in Egypt
as a result of STEP wise survey 2005

30
25
20
15 Men
10 Women
5
0
15-24yrs 25-34yrs 35-44yrs 45-54yrs 55-64yrs

The prevalence of sever hypertension ( SBP ≥ 170 and / or DBP ≥ 100 mmhg )
was 6.9 % with irrelevant differences between males and females
 Definition
Module CVS

• The Seventh Joint National Committee

identified hypertension when blood
Level 1- Semester 2-

pressure is ≥ 140/90 .

Reference:
 HTN
Module CVS

• Hypertension is defined as office SBP values >_140

mmHg and/or diastolic BP (DBP) values >_90 mmHg.
Level 1- Semester 2-

Reference:
 Cardiovascular Risk
Module CVS

• 20 mmHg increment in SBP or

• 10 mmHg increment in DBP

Level 1- Semester 2-

• Doubles risk for CVD among 40-70

year olds across entire BP range
(115/75 – 185/115)
Reference:
 Aetiology of Hypertension
• Primary – 90-95% of cases – also termed “essential” of
Module CVS

“idiopathic”

• Secondary – about 5% of cases

– Renal or renovascular disease
Level 1- Semester 2-

– Endocrine disease
• Phaeochomocytoma
• Cusings syndrome
• Conn’s syndrome
• Acromegaly and hypothyroidism
– Coarctation of the aorta
– Iatrogenic
• Hormonal / oral contraceptive
• NSAIDs

Reference:
 Primary hypertension
Module CVS

 About 95% of cases.

 It has no known causes.

 Starts () 35-55 years.

Level 1- Semester 2-

 Family history is usually positive.

 Predisposing factors: Genetic, obesity, stress, salt

sensitivity, smoking.

5/28/2019 12
Reference:
 Risk Factors for Primary
Hypertension
Module CVS

 Age (old)

 Gender (male)

 Race (African-Americans)
Level 1- Semester 2-

 Obesity (abdominal obesity)

 Family history

 Stress

 Sedentary life

 Salt (high)

 Smoking
13
 Alcohol
Reference:
 Secondary hypertension
Module CVS

 About 5% of cases.

 It has known underlying cause.

Level 1- Semester 2-

 Starts before 25 and after 55 years.

 Negative family history.

 Rapidly progressive with early complications.

 Renal, endocrinal, CNS, vascular, iatrogenic.

5/28/2019 14
Reference:
 Target organs affected by
hypertension and
complications of
hypertension
Module CVS

 Kidney: (renal failure)

 Heart: (LVH, heart failure)

 Brain: (stroke or TIA)

Level 1- Semester 2-

 Eye: (hypertensive retinopathy)

 Arteries: (atherosclerosis, aortic dissection)

5/28/2019 15
Reference:
 Symptoms of
hypertension
Module CVS

 Asymtomatic in most cases (Silent Killer).

 May be discovered accidentally.

Level 1- Semester 2-

 Headache (occipital.

 Chest pain.

 Nausea, vomiting, tinnitus, blurring of vision,

epistaxis.

 Symptoms of complications.

5/28/2019 17
Reference:
 Target Organ Damage
 Heart
Module CVS

• Left ventricular hypertrophy

• Angina and ischemic heart disease
• Diastolic dysfunction
• Atrial fibrillation
• Heart failure
Level 1- Semester 2-

 Brain
• Stroke or transient ischemic attack
• Hypertensive encephalopathy
 Chronic kidney disease

 Aortic aneurysm and dissection

 Peripheral arterial disease

 Retinopathy

18
Reference:
 Acute complications of
hypertension
Module CVS

1) Cerebral stroke, hypertensive encephalopathy,

subarachnoid hemorrhage.

2) Acute pulmonary edema, dissecting aneurysm, acute

Level 1- Semester 2-

coronary syndromes.

3) Acute renal failure.

4) Epistaxis.

5/28/2019 19
Reference:
 Investigations of
hypertension
Module CVS

 For etiology: as secondary hypertension.

 For complications:
Level 1- Semester 2-

 Cardiac: ECG, CXR, ECHO.

 Cerebral: CT, MRI brain.
 Renal: urinalysis, renal function, renal imaging.

5/28/2019 20
Reference:
Module CVS

Measurement of BP
Level 1- Semester 2-

5/28/2019 21
Reference:
 Variables that may affect
BP
Module CVS

 Eating

 Emotion
Level 1- Semester 2-

 Exercise

 Exposure to cold

 Empty or full bladder

 Smoking

 Sympathomimetics (cold remedies)

5/28/2019 22
Reference:
 Measurement of BP
Module CVS

• Blood Pressure Measurement

– Sphygmomanometer
– Systolic pressure = pressure when 1st sound is
Level 1- Semester 2-

heard
– Diastolic pressure = pressure when last sound
is heard
• Blood Pressure Cuff Size
– Small – children and small adults
– Average
– Large – overweight and large adults

Reference:
 Measurement of BP
Module CVS
Level 1- Semester 2-

5/28/2019 24
Reference:
 Types of
sphygmomanometers
Module CVS

 Mercury: Gold standard (used for calibration of others).

 Aneroid.

 Automatic (Electronic/Digital).
Level 1- Semester 2-

5/28/2019 25
Reference:
 Measurement of BP
Module CVS

 Rest the patient for five minutes

 In ambulant patients, measurements are normally made with the

patient seated. Either arm can be used.
Level 1- Semester 2-

 Support the patient's arm comfortably at about heart level.

 Apply the cuff to the upper arm with the centre of the bladder over
the brachial artery.

 Palpate the brachial pulse.

 Inflate the cuff until the pulse is impalpable. Note the pressure on
the manometer. This is a rough estimate of SBP.

5/28/2019 26
Reference:
 Measurement of BP
Module CVS

 Now inflate the cuff another 10 mmHg and listen through the
stethoscope over the brachial artery.

 Deflate the cuff slowly until regular sounds are first heard. Note
Level 1- Semester 2-

the reading to the nearest 2 mmHg. This is the systolic pressure.

 Continue to deflate the cuff slowly until the sounds disappear.

 Record the pressure at which the sounds completely disappear as

diastolic pressure. Occasionally muffled sounds persist and do
not disappear, in which case the point of muffling is the best guide
to the diastolic pressure

5/28/2019 27
Reference:
 Treatment of
hypertension
Module CVS

 Non pharmacologic (lifestyle).

 Causal treatment: for secondary
Level 1- Semester 2-

hypertension.
 Pharmacological:
 Associated risk factors.
 Antihypertensive drugs.
 Adjuvant (antiplatelet, statins).

5/28/2019 28
Reference:
 "The Goal is to Get to Goal!”

-PLUS-
Hypertension
Diabetes or Renal Disease

< 130/80 mmHg

< 140/90 mmHg
(best <120/70 mm Hg)
Figure. Algorithm for Treatment of Hypertension