HypertensionINTRODUCTIONHypertension,isthemostcommondisorderintheworld.Hypertensionisamajorcardiovascularriskfactorthatdirectlycontributestomyocardialinfarction(MI),cerebrovascularaccidents,congestiveheartfailure(CHF),chronickidneydisease,andprematuremortalityanddementia.

INTRODUCTIONSuccessfulreductioninbloodpressure(BP)andothercardiovascularriskfactorscandramaticallyreducetheincidenceofcerebrovascularandcoronarymorbidityandmortality.

“3low”---30.2%aware,24.7%treated,6.1%controlled(inchina)Patientswithnodefinablecausearesidetohaveprimary,essentialhypertension.Morethan90%ofpatientswithhypertensionareessentialhypertension.IndividualsinwhomspecificstructuralorganisresponsibleforhypertensionaredefinedsecondaryhypertensionDEFINITIONANDCLASSIFICATIONDEFINITION:Forthegeneralpopulation,hypertensionisdefinedasasystolicBPof140mmHgorhigherand/oradiastolicBPof90mmHgorhigherIsolatedsystolichypertension(ISH)

isdefinedassystolicBP140mmHgorgreateranddiastolicBPlessthan90mmHg

DEFINITIONANDCLASSIFICATION

Bloodpressure(mmHg)CategorySystolicDiastolicNormal＜120and＜80Highnormal120—139（or）and80—89HypertensionStage1140—159（or）and90—99Stage2160—179（or）and100—109Stage3≥180（or）and≥110Isolatedsystolichypertension(ISH)≥140and＜90WhensystolicanddiastolicBPlevelsfallintodifferentcategories,thehighercategoryshouldbeselectedtoclassifytheindividual?sBPstatus.CAUSESGENETICFACTORSVariationinBPrepresentsthecombinedeffectsofmultiplegenesratherthansinglegenedisorderswithdiscreteseparation.ThegeneticcontributiontoBPvariationrangeisaboutfrom30%to60%.

ENVIRONMENTFACTORS

Diet:highdietarysodiumintake,alcoholintake

Stress,occupation

SmokeCAUSESOTHERFACTORS1.Obesity,physicalinactivity2.Prophylactic:mildandreversible3.SAHS:50%SAHShavehypertension

PATHOGENESIS1.SympatheticNervousSystem(SNS)hyperactivity:

2.Sodiumandwateroverloadingviakinedeys3.Renin-AngiotensinSystem(RAS)hyperactivity4.Defectsiniontransportacrosscellmembranes.5.InsulinResistanse(IR)PATHOLOGYHeart:leftventricularhypertrophy,coronaryarterialdiseaseBrain:cerebralinfarction,hemorrhage

Kidney:renalfailureRetina:hemorrhage

CLINICALMANIFESTATIONANDCOMPLICATIONSSymptomsandsignsMostpatientswithhypertensionhavenospecificsymptomsandareidentifiedonlyinthecourseofaphysicalexamination.Somecomplaintsincludeheadache,dizziness,palpitations,easyfatigability.

murmurComplications1.Malignanthypertension:Apersistentdiastolicpressureexceeding130mmHg,Thepatientsfeelpalpitations,headache,irritability,retinalhemorrhageorpapilledemaandmaydieofrenalfailure,cerebralstrokeorheartfailure.Complications2.Hypertensivecrisis:,headache,nausea,vomiting,palpitations,irritability,symptomsoftargetorgansischemia3.Hypertensiveencephalopathyischaracterizedbyheadache,irritability,alterationsinconsciousness,andothermanifestationsofcentralnervousdysfunction.Complications4.Cerebralinvolvementstroke,transientischemicattacks,hemorrhage5.

Congestiveheartfailure6.Chronicrenalfailure7.AorticdissectionLaboratoryAndOtherTestsLaboratorytestsprovidebaselineinformationformonitoringinpatientswhoaresubsequentlytreatedwithantihypertensivedrugsthatcaninfluencelaboratoryvalues.Laboratoryandothertestsincludeelectrocardiography,urinalysis,bloodglucose,hematocrit,serumpotassium,serumcreatinine,serumcalcium,lipidprofile(high-densitylipoproteincholesterol,low-densitylipoproteincholesterol,totalcholesterolandtriglycerides).DIAGNOSISandDIFFERENTIALDIAGNOSISDIAGNOSISThediagnosisofhypertersionrequiresfindingsofanelevatedaverageBPonatleastthreeofficesvisits,withatleaststandardizedmeasuresofBPmadeateachvisit.EVALUATIONGoalsofEvaluationThegoalsofevaluationofpatientswithhighbloodpressureare:(1)todetectmajorcardiovascularriskfactors,(2)todetecttarget-organdamage,and(3)todetectidentifiablecausesofhypertension.

CardiovascularRiskfactorsinpatientswithHypertension﹥55yearsinmenor﹥65yearsinwomenSmokingOGTT/FGdemageDyslipidemiaTC﹥5.7mmol/LorLDL﹥3.3mmol/LFamilyhistoryofprematurecardiovasculardisease(＜55/65years)AbdominalObesityorBMI﹥28kg/m2hCRP﹥1mg/dlphysicalinactivityThetarget-organdamageincludeasfollows:LeftventricularhypertrophyCarotidatherosclerosisplaqueserumCrelevatedmildly(M115-133umol/L，F(xiàn)107-124umol/L)Microalbuminuria30-300mg/24hComplicationsCoronaryheartdisease:anginaorpriormyocardialinfarction,priorcoronaryrevascularization,heartfailureCerebralinvolvement:stroke,transientischemicattacks,hemorrhagekidneydisease:Diabeteskidneydisease,serumCrelevated﹥133umol/L(M),﹥124umol/L(F)arterialdisease:peripheralarterialdisease,

aorticdissectionPapilledema,hemorrhageMDRiskStratificationIndividualspecificfactorsthatdetermineriskincludethepresenceofotherCVDriskfactorsandthepresenceofinjurytothetargetorgansofhypertensionorclinicalCVDdisease.

StratificationofriskOtherriskfactorsanddiseasehistoryBloodpressure(mmHg)Grade1SBP140—159orDBP90—99Grade2SBP160—179orDBP100—109Grade3SBP≥180orDBP≥110NootherriskfactorsLowMediumHigh1—2riskfactorsMediumMediumVeryHigh≥3riskfactorsorDMorTODHighHighVeryHighACCVeryhighVeryhighVeryhighTREATMENTGoaloftherapyTheultimatepublichealthgoalofantihypertensivetherapyisthereductionofcardiovascularandrenalmorbidityandmortality.

Ingeneral,thegoalistolowerBPtobelow140/90mmHg.Inpatientswithheartfailure,diabetes,orrenaldisease,thegoalistolowerBPtobelow130/80mmHg.InolderpatientswithISH,thegoalistolowersystolicBPtobelow140-150mmHg.AntihypertensivePrinciple

LIFESTLEMODIFICATIONSPHARMACOLOGICTRETMENT

LIFESTLEMODIFICATIONS-----------Criticalandindispensable

Majorlifestylemodificationsinclude:Weightreductioninthoseindividualswhoareoverweightorobese;BMI＜25.Dietarysodiumreduction:＜6gDietrichinpotassiumandcalcium;freshvegetables500g/d;milk500ml/d;Dietarysaturatedfatreduction:＜25%totalcalorie.Nosmoking&Limitalcoholintake.Increaseaerobicexercise(30-60min/d,3-5times/w).Relievestress.Folicacidintake.PHARMACOLOGICTRETMENT

Indicationforpharmacologictherapy1.Patientswithapressurerepeatedly≥160/100mmHgshouldbetreatedunlessspecificcontraindicationsexist.2.Patientswithatheroscleroticvasculardiseaseordiabetesmellitus.Indicationforpharmacologictherapy3.Patientswithprogressiveand/orsustainedhypertensionafter6-monthintervalslifestylemodifications.4.Patientsofhighorveryhighriskstratification.DRUGUESPRINGCIPLELowdose，long-acting，

union，individualized.Classes

Diureticsβ-blockersCalciumChannelBlockers(CCBs)Angiotensin-ConvertingEnzyme(ACE)Inhibitors---ACEIAngiotensin-ReceptorBlockers(ARBs)Diuretics1.Thiazidese.g.hydrochlorothiazideIndications:mildhypertension,asadjunctintreatmentofmoderatetoseverehypertension;Isolatedsystolichypertention;Contraindication:hyperuricemia,primaryaldosteronismDiuretics2.Loop-actinge.g.FurosemideIndications:mildhypertension,asadjunctintreatmentofmoderatetoseverehyper-tension,particularlywithrenalfailure.Contraindication:hyperuricemia,primaryaldosteronismDiuretics3.Potassium-sparinge.g.spironolactone

Indications:hypertensionduetohyperaldosteronism,asadjuncttothiazidetherapyContraindication:renalfailure；hyperkalemiaβ-blockersClassification

PropranololMetoprolol:25-150mgtwicedailyBisoprolol:5-10mg

dailyIndications:mildtoseverehypertension,angina,myocardialinfarction,atrialfibrillationContraindication:congestiveheartfailure(Ⅳdegree),asthma,sicksinussyndrome,2ndor3rddegreeheartblockSideEffects:dizziness,bronchospasm,vomiting,sundenwithdrawlmayprecipitateanginaormyocardialinjuryinpatientswithheartdiseaseCalciumChannelBlockers(CCBs)Classification1.Dihydropyridines:nifidipine;amlodipine;felodipine2.Benzothiazepines:diltiazem;verapamilIndications:mildtomoderatehypertension;ISH;PeripheralvasculardiseaseContraindication:heartfailure;2dor3ddegreeheartblock(Benzothiazepines)Angiotensin-ConvertingEnzyme(ACE)InhibitorsClassification

Captopril:benazepril:enalaprilFosinopril:Indications:mildtoseverehypertension,renalarterystenosis;angina;heartfailure;LVdysfunctionContraindication:renalfailure,bilateralrenalarterystenosis,pregnancy,hyperkalemiaAngiotensin-ReceptorBlockers(ARBs)Classification

LosartanValsartanTelmisartanIndications:mildtoseverehypertension,renalarterystenosis;CoughwithACEinhibitor;Diabetesmellitustype2withproteinuria;Leftventricularhypertrophy(byECG)Contraindication:acuterenalfailure,bilateralrenalarterystenosis,pregnancy,hyperkalemiaCOMBINATIONTHERAPYTheJNC7reportsuggestsinitiationoftherapywithtwodrugs(combinationtherapy)ratherthanasingleagentifBPismorethan20mmHgsystolicor10mmHgdiastolicabovethetreatmentgoal.RESISTANTHYPERTERSION

ResistanthypertensionisthefailuretoreachgoalBPinpatientswhoareadheringtofulldosesofanappropriate3-drugregimenthatincludesadiuretic.Studiessuggestfiveissuestoconsiderwhenevaluatingpatientswithresistanthypertension.Thefiveissuesare1.noncompliancewiththerapy,2.interferingsubstances,3.aninappropriatedrugregimen,4offic