Dr Khulood Alsaraf

Hypertension
Is defined as a sustained diastolic blood pressure greater than 90 mmHg accompanied by an elevated systolic blood pressure (>140 mmHg)

Hypertension
Stage I, mild H.T If D.P is 90-99 mmHg S.P is 140-159 mmHg
If D.P is 100-109 mmHg S.P is 160-179 mmHg If D.P is 110 mmHg or greater S.P is 180 mmHg or greater

Stage II, moderate H.T

Stage III, sever H.T

Hypertension
The aim of therapy is straight forward Reduction of blood pr. to with in normal range. If H.T secondary to a known organic disease, such as renovascular disease or pheochromocytoma , therapy is directed toward correction of the underlying causes.

Hypertension Risk Factors

Etiology of hypertension
Essential hypertension
blood pr. of unknown of origin. 90% of persons with high
Contributing factors including: 1-Family history of hypertension 2-Hyperlipidemia 3-African-American back ground (black-white) 4-Diabetes 5-Obesity 6-Aging 7-Stress 8-excessive smoking and alcohol ingestion

Secondary H.T
disorders

10% , related to renal & endocrine

Hypertension Risk Factors

Hypertension Causes

Hypertension Therapy
1-Diuretics 2-Beta-blockers 3-ACE inhibitors 4-Angiotensin II receptors blockers 5-Ranin inhibitor 6-Calcium-channel blockers 7-Alpha-blockers 8-other
A-alpha-beta adrenoceptors blockers B-centrally-acting adrenergic drugs C-vasodilators

Hypertension Therapy
1-Diuretics
Thiazide diuretics Loop diuretics
Hydrochlorothiazide and chlorthalidone
Furosemide, bumetanide, and torsemide.

Potassium sparing

Amiloride and triamterene spironolactone and eplerenone (Aldosterone receptors antagonists)

Hypertension Therapy
Atenolol Carvedilol Labetalol Metoprolol Nadolol Propranolol

Beta blockers

Hypertension Therapy
ACEIs drugs are:

Captopril , Enalopril , Lisinopril , Ramipril , Moexipril , Quinapril

-Hypertension -Cardiac failure -Following myocardial infarction (especially when there is ventricular dysfunction) -Progressive renal insufficiency

Clinical uses of ACEIs

Adverse effects
-Dry cough -Hypotension -Hyperkalemia -Fever -Altered taste -Rashes

Hypertension Therapy
Angiotensin II receptors Antagonists
Angiotensin type I receptor antagonist are effective as monotherapy in the treatment of hypertension, all of them are competitive antagonists of AgII. Long-acting AT1 receptors antagonists:

(Irbesatan, Candesartan,Telmisartan, Olmesartan, Azilsartan, Eprosartan Losartan,and Valsartan)

More effective than short-acting antagonists: (Losartan, valsartan) at providing 24h control of blood pr. Dont produce dry cough

Hypertension Therapy
Clinical uses
*hypertension : in whom an ACEIs is indicated, but can not tolerate the dry cough
They found that additional enzymes have been identified that are capable of forming AgII from AgI, suggested that inhibition of ACE may not be sufficient for the total elimination of AgII. In contrast, AT1 receptors antagonists are capable of blocking the effects of AgII regardless of enzymatic route of formation

Hypertension Therapy
Renin inhibitors Aliskiren
Selective and direct renin inhibitor, thus, act earlier in the reninAg-Aldosterone system. Can cause cough and angioedema but less often than ACEIs. Can cause diarrhea. Contraindicated during pregnancy.

Hypertension Therapy
Calcium channel blockers
Inhibited the Ca++ component of ionic currents carrried in the cardiac action potential. Free Ca++ causes muscle contractility and peripheral resistance. Ca.Ch.BKs act by antagonizing Ca++ movement (excitation-contraction) coupling in the cardiovascular system.

Ca.Ch.BKs are lack the fluid-accumulating properties

Hypertension Therapy
Classes of Calcium channel blockers
3 classes of different pharmacokinetic properties & clinical indications: 1-Diphenyle alkylamine (Verapamil) Significant effect on both cardiac & vascular smooth muscle

2-Benzothiazepines (Diltiazem)
effect on both cardiac & vascular smooth muscle, but it has less pronounced negative inotropic effect on the heart

Hypertension Therapy
3-Dihydropyridines
first generation : Nifedipine second generation : Amlodipine, Felodipine, Isradipine, Nicardipine, Nimodipine, & Nisoldipine (these 2nd generation differ in pharmacokinetics, approved uses & drug interaction). All of Dihydropyridines have a much greater affinity for vascular Ca-Ch than for Ca-Ch in the heart , thus, more attractive in treating H.T

Clinical uses -Hypertension

-Angina -Supraventricular tachyarrhymias -Migraine headache

Adverse effects : although infrequent but it may include: -constipation, headache, fatigue, and dizziness

Hypertension Therapy
-adrenergic blocking agents
Prazosin, Oxazosin, & terazosin
competitive block of 1 receptors Prazosin used to treat mild to moderate H.T & is prescribed in combination with propranolol or diuretics for additive effects.

and blockers
Labetalol and Carvedilol

Hypertension Therapy
Centrally acting adrenergic drugs

A-Clonidine

: 2 agonist diminishes central adrenergic outflow

Used in treatment of H.T complicated by renal disease Mainly used with diuretics (causes Na & water retention) Main side effects are: Sedation Drying of nasal mucosa

B- -methyl dopa

Hypertension Therapy
vasodilators
-Produce a direct relaxation of vascular smooth muscle

-They decrease total peripheral resistance & thus correct the hemodynamic abnormality that is responsible for the elevated b.p in primary H.T
-Dont inhibit the activity of sympathetic nervous system, there for orthostatic hypotension is not problem. -Most vasodilators relax arterial S.M to greater extent than venous S.M, thus, it may cause further minimizing of postural hypotension

Hypertension Therapy
Hydralazine & minoxidil
: for moderately sever H.T Most common side effects with Hydralazine are:

Edema, tachycardia, palpitation, GI bleeding

Minoxidil : excess hair growth, precipitate anginal attack, &

hyperglycemia

Hypertension Therapy
Hypertensive Emergency
Na+ nitroprusside, labetalol, Fenoldopam and Nicardipine are prescribed for acute hypertensive emergency.
Na+ nitroprusside: acts on the arterial vessels and can cause reflex tachycardia, palpitation, restlessness, agitation, nausea and confusion. Fenoldopam: is a peripheral ddopamin-1 receptor agonist that is given as an intravenous infusion. Nicardipine: calcium channel blocker, can be given as an intravenous infusion.

Hypertension Therapy
Special population
Race and age
AB / CD guidelines
young and white patients starting with ACE inhibitor (A) or blockers (B). older and black patients starting with Ca-Ch-Bk (C) or diuretics (D)