⭐⭐ HYPERTENSION ⭐⭐

           ⭐⭐ HYPERTENSION ⭐⭐

1) DEFINITION OF HYPERTENSION :- 

    Blood pressure that is higher than normal is known as Hypertension.

                  ⭐⭐⭐⭐⭐⭐

2) CRITERIA OF HYPERTENSION :-

   (a) Above 60 years - There is

     hypertension if 

     Systolic BP > 150 mm Hg 

     Diastolic BP > 90 mm Hg

   (b) Below 60 years - There is 

     hypertension if 

     Systolic BP > 140 mm Hg

     Diastolic BP > 90 mm Hg

   (c) Above 18 years with diabetes or

    Chronic Kidney Disease - There is 

    hypertension if 

    Systolic BP > 140 mm Hg

    Diastolic BP > 90 mm Hg

⭐ White coat hypertension - BP rises in

hospital. Take readings at home. (Occurs due to anxiety & increased sympathetic response in hospital)

⭐ Isolated ambulatory or masked hypertension - BP is normal at hospital but more at home. Such patients have risk of organ damage.

⭐ Paradoxical hypertension - Paradoxical rise of BP in patients taking antihypertensive drugs. 

In patients with diabetes & hypertension taking Beta blockers, if there is hypoglycemia (due to inhibition of hepatic glucose production by Beta blockers) - Sympathetic response is produced to increase blood glucose & hence BP increases.

                  ⭐⭐⭐⭐⭐⭐

3) CLASSIFICATION OF HYPERTENSION - 

   (a) Primary or Essential hypertension - 

       # In most of the cases.

       # No specific cause.

       # 70 % cases have family history.

   (b) Secondary hypertension - 

       # Less number of cases.

       # Caused due to a disease.

                   ⭐⭐⭐⭐⭐⭐

4) CAUSES OF HYPERTENSION - 

   (a) Pre eclampsia - in pregnancy

   (b) Coarctation of aorta - There is 

   narrowing of aorta which may be due to

   abnormalities during development or 

   genetic cause. This narrowing causes         increase in BP.

               

   (c) Renal diseases - 

        # Chronic pyelonephritis.

        # Glomerulonephritis.

        # Polycystic Kidney Disease.

        # Renal artery Stenosis.

     When kidneys receive less blood flow

     (as in case of renal artery stenosis or

       due to damage to renal vessels in                 renal Infection)

     they release Angiotensin  which leads

     to increase in BP.

     Also, the kidney damage impairs the 

     kidney's ability to filter fluid from the 

     blood leading to increase in fluid 

     volume in the blood, thus causing 

     increase in BP.

   (d) Endocrine diseases -

        (I) Cushing's syndrome - Increased 

        Aldosterone (mineralocorticoid)                    which causes sodium retention &                 increased BP

      (II) Pheochromocytoma  - There is

      increased Adrenaline production which

      leads to increased BP

      (III) Adrenal hyperplasia - Increased 

      secretion of Aldosterone &

      catecholamines.

      (IV) Hyperthyroidism - 

      Other features - diarrhoea, weight loss,

      exophthalmos, increased heart rate,

      heat intolerance, etc.

      (V) Hyperparathyroidism - Increased

      parathyroid hormones cause increase          in blood calcium level which increases        activity of Renin Angiotensin 

      Aldosterone System causing rise in BP.

   (e) Alcohol & drugs - 

        # OC pills.

        # Cyclosporine.

        # Sympathomimetics.

        # Corticosteroids.

    Ask history of this drugs.

   (f) Obstructive sleep apnea - Breathing

   stops during sleep for sometime.

   Sudden drop in oxygen causes RAAS

   activation & increase in BP.

   Causes -

      # Obesity - Excess soft tissue in mouth

      & throat is relaxed during sleep. It can

      cause blocking of airway. 

      # Enlarged tonsils.

      # Tumor in airway.

      # Down's syndrome.

      # Thick neck.

      # Smoking, alcohol & sedatives.

                          ⭐⭐⭐⭐

    ⭐ Causes of isolated systolic                       hypertension ⭐:- 

     (a) Atherosclerosis - cholesterol plaque 

     causes obstruction to blood flow 

     leading to increased blood pressure.

     # Investigations - lipid profile

     (b) Aortic regurgitation - 

      Due to regurgitation, end diastolic 

      volume of left ventricle increases 

      which leads to dilatation of left 

      ventricle and increased stroke volume

      ( Frank starling law) - increased BP

    (c) Coarctation of aorta - explained

      above.

    (d) Hyperthyroidism - explained above

    (e) Patent ductus arteriosus - 

      Normally ductus arteriosus is the 

      communication between pulmonary

      artery and aorta before birth. Blood

      goes from pulmonary artery to aorta

      thus bypassing the non working fetal 

      lungs.

      Persistence of ductus arteriosus after

      birth is called patent ductus arteriosus.

      Too much blood circulating through

      heart's main arteries through PDA can

      lead to pulmonary hypertension.

                    ⭐⭐⭐⭐⭐⭐

5) MEASUREMENT of BP -

#  2 readings per day for 3 days. 

   One reading in sitting or supine position 

   & other in standing position. Reading in

   standing position is taken to check for

   postural hypertension.

 # Person should be seated in chair with

   back resting & arm at heart level. No 

   consumption of tobacco or caffeine 30

   to 45 minutes before checking BP.

# Reading on both arms are taken. One 

   which is high is taken. If difference is

   more than 10 mm Hg, there may be            obstructive lesion of aorta, subclavian         artery.  

 # When the sound of beat is heard 

   (phase I of Korotkoff sound) systolic BP

   is obtained & when sound stops (phase 

   V) diastolic BP is obtained.                       # Auscultatory gap -Sound starts, then 

   disappears in middle, then again starts

   & finally disappears. It is seen in some

   hypertension patients. There may be

   misreading i.e high diastolic BP or low

   Systolic BP depending on the phase 

   heard. To avoid this, palpatory method

   should be done prior to auscultatory

   method.

                   ⭐⭐⭐⭐⭐⭐

6) CLINICAL FEATURES RELATED TO

   HYPERTENSION :-

    (a) Risk factors of Hypertension:-

        # Obesity - atherosclerosis

        # Hyperlipidemia - causes

           atherosclerosis . Check lipid profile

        # smoking - harmful byproducts 

          cause damage to vessel leading to

          hypertension

       # sedentary lifestyle

       # Diabetes - Diabetes may decrease

          the production of nitric oxide 

          ( Vasodilator) thus leading to

          vasoconstriction and raised BP

       # Positive family history

    (b) Clinical features due to hypertension

      itself:-

         (I) Mostly asymptomatic - found on

           examination.

         (II) Acute hypertension - 

            # Transient headache - increased 

           pressure in brain vessels can cause 

           fluid to leak out causing swelling of

           brain. This swelling leads to 

           pressure on brain and headache.

            # polyuria - Nocturnal polyuria .

           At daytime , blood flow to kidney 

           decreases due to vasoconstriction.

           At night, levels of dopamine and

           noradrenaline are lower. This causes

           vasodilation and increased renal 

           blood flow - polyuria.

       (III) Chronic hypertension :-

           Left ventricular hypertrophy - due to 

           increased workload on left ventricle

           to pump against the systemic 

           resistance.

           Heaving apical impulse

      (IV) Enlarged left atrium ( due to

           backpressure on left ventricle and 

           atrium because of systemic arterial

           resistance ) and 4th heart sound 

          ( due to left ventricular hypertrophy)

      (V) Accentuation ( louder) of aortic

          component of 2nd heart sound - 

          forceful shutting of aortic valve at 

          the end of ventricular systole due to

          pumping against systemic

          resistance.

      (VI) Very short early diastolic murmur 

    (c) Clinical features due to diseases

        causing hypertension :-  

       (I) Coarctation of aorta -

          Other symptoms - 

         # Absent leg pulses.

         # Difference in BP between arms &              legs i.e. high BP in arms & low BP in            legs.(narrowing of aorta in                            coarctation is usually located after              arteries branch to the upper body.                Thus , Coarctation can lead to high 

         BP and pulsing of blood in head and

         arms and low BP and weak pulses in

         in legs and lower body)

        # Systolic murmur (due to narrowed               aorta) below scapula.

        # Bounding pulse in arms, carotid.

        # Collaterals around scapula ( due to

            increased BP)

        # systolic murmur over spine

      (II) Renal diseases :- 

          In case of renal cause of                               hypertension,  following symptoms              may accompany

         raised BP -

        # Dysuria i.e. burning micturition.

        # Hematuria.

        # Edema (due to extra fluid and

           sodium in circulation when Kidney is

           unable to filter them)

        # Loin pain.

        # Oliguria

        # UTI.

        # Enlarged kidney - in Polycystic

           Kidney disease.

        # Bruit over lumbar region - renal 

           artery stenosis

        # Fever, backache and recurrent UTI -

           chronic pyelonephritis 

     (III) Endocrine diseases :- 

         # Cushing's syndrome- increased

           levels of glucocorticoid ,

          mineralocorticoid, androgens.

          Other features -  central obesity,

          moon face, hump, stretch marks,

          purple striae,etc.

         # Pheochromocytoma - 

          Other features - Palpitations, 

          headache, panic attacks due to 

          increased catecholamines.

 

         # Adrenal hyperplasia - 

          Other features - Features of                          Cushing's syndrome, palpitations,                panic attacks. Masculine features                due to increased androgens such as            increased facial  & body hair,                         irregular menstrual periods, etc.

         # Hyperthyroidism - 

          Other features - diarrhoea, weight                 loss, exophthalmos, increased                       heart rate, heat intolerance, etc.

      (IV) Alcohol and drug intake:- 

            Ask history for these

       (V) Obstructive sleep apnea - 

           Breathing difficulty during sleep

       (VI) Atherosclerosis -

            # Other features - There may be                     pain in leg on exercising, features                 of stroke, etc.

       (VII) Aortic regurgitation - 

            # Other symptoms - 

             Palpitations - due to regurgitation, 

             end diastolic volume of left

             ventricle increases and hence 

             stroke volume increases due to

             more stretching of ventricle

             ( Frank starling law)

             Pulsations in neck

             Angina - muscle fatigue

             Dyspnea - after ventricular failure

             Syncope

             Signs like - Water hammer pulse, 

             Rosenbach sign, Gerhard sign ,etc

                   ⭐⭐⭐⭐⭐⭐

7) COMPLICATIONS OF HYPERTENSION :-

    (a) Cardiovascular complications :- 

        Occurs due to damage to the vessels

        and chambers of heart because of 

        high blood pressure.

        (I) Coronary artery Disease

        (II) Aortic dissection - tear in the inner

            layer of aorta.

        (III) Aortic aneurysm - abnormal bulge

             or enlargement.

        (IV) Left ventricular failure - as it has 

             to pump against the systemic

             vascular resistance.

        

    (b) Renal complications :- 

        It occurs due because high blood

        pressure causes arteries around the

        kidney to narrow, weaken or harden.

        These damaged arteries are not able

        to deliver enough blood to the kidney.

        Hypertension also causes damage to

        glomeruli due to high blood pressure

        and impairs the ability of filtration.

         (I) Proteinuria

         (II) Progressive renal failure

    (c) Malignant hypertension :- 

        Severe rise in BP, retinal haemorrhage

        and exudates ( due to leakage) ,                    visual disturbances, headache                      (explained above) , vomiting ,renal                damage.

    (d) CNS Complications :-

        (I) Cerebral haemorrhage due to 

             vessel damage.

        (II) Subarachnoid haemorrhage

        (III) Transient ischaemic attack due to

              intracranial atherosclerosis

        (IV) Hypertensive encephalopathy 

        

    (e) Ophthalmic complications :- 

        due to damage to the vessels in retina

        (I) Grade I = Retinal arteriole

          thickening and increase in light                    reflex over arterioles.

        (II) Grade II = Retinal arteriole

          thickening and arteriovenous nipping

        (III) Grade III = Grade II + flame

          shaped haemorrhages and soft 

          exudates.

        (IV) Grade IV = Grade III + 

          papilloedema.

                    ⭐⭐⭐⭐⭐⭐

8) INVESTIGATIONS OF HYPERTENSION:-

    (a) Basic investigations :-

        (I) Blood urea and serum creatinine -

           tell about renal function.

        (II) Urine test for sugar , blood, protein

           and microscopy - Tell about Urinary

           tract infection and renal function

        (III) Fasting and postprandial blood

           sugar - Diabetes mellitus

        (IV) Chest X ray - enlarged heart, 

           dilated vessels

        (V) ECG - left ventricular dysfunction

        (VI) Serum calcium and uric acid 

        (VII) Blood cholesterol and

             triglycerides - atherosclerosis

        (VIII) Serum electrolytes -

             hyperaldosteronism ( sodium 

             retention) , hyperparathyroidism

             ( increased blood calcium) etc.

    (b) Investigations related to causes :-

        (I) Coarctation of aorta

             Investigations - Chest X ray

                                        Echocardiogram

                                        Catheterization

       (II) Renal diseases - 

         Following investigations can be                    carried out - 

         # Renal function tests.

         # Urine examination.

         # USG.

         # CT 

         # IVU - Polycystic kidney

       (III) Endocrine diseases - 

           # Cushing's syndrome-

             Investigations - Urine & blood tests

             of hormone levels, saliva test.

   

           # Pheochromocytoma - 

             Investigations - Plasma                                 Metanephrine testing , 24 hour                     urinary collection of

             catecholamines.

           # Adrenal hyperplasia - 

              Investigations - Blood & urine                        tests for hormones.

           # Hyperthyroidism - 

              Investigations - serum T3 ,T5 , TSH

           # Hyperparathyroidism

              Investigations - Serum Calcium                    level, level of parathyroid                                hormones in blood,

              phosphorus levels, CT, USG, etc.

           # Acromegaly - GH levels and 

              radiography of skull.

 

          # Hyperaldosteronism - Elevated

            aldosterone levels , hypokalemia

             ( Aldosterone causes sodium 

             retention and thus increases BP)

        (IV) Aortic regurgitation :- 

              Investigations :-

              Auscultation 

              Echocardiography

              Coronary angiography

              ECG

              Chest Xray

                   ⭐⭐⭐⭐⭐⭐

9) TREATMENT OF HYPERTENSION :- 

    (a) General measures :- 

        (I) Avoid smoking and alcohol - These

           cause damage to the blood vessels

           and plaque formation.

        (II) Low salt intake - Sodium causes 

            BP to raise.

        (III) Low intake of saturated fats - fats

           promote atherosclerosis

        (IV) Exercise - Exercise increases the

            capacity of heart. Stronger heart 

            can pump more blood with less 

            effort . Hence, force on the arteries

            decreases due to which BP

            decreases

        (V) Relaxation and meditation -

             Stress causes sympathetic fight &

             flight response which causes 

             release of hormones like 

             adrenaline due to which 

             vasoconstriction occurs ,heart rate

             increases and BP increases.

        (VI) Include vegetables and fruits in

             diet - vegetables are rich in nitrates

              (Vasodilator)

    (b) Antihypertensive drugs :- 

        (I) Diuretics -

           # Thiazides - They influence                            carbonic anhydrase and prevent

            reabsorption of sodium bicarbonate

            at PCT and Na+ & Cl- at DCT.

            Drugs - Chlorothiazide

                          Hydrochlorothiazide

                          (Preferable in older 

                          individuals)

          

            # Loop diuretics - Used when more 

            sodium excretion is required. 

            Potassium loss occurs due to

            reduced H+ secretion.

            Drugs - Furosemide, Torasemide.

            

            # Potassium sparing diuretics - 

            Amiloride.

     

            # Aldosterone antagonist -

            Spironolactone.

         (II) Beta blockers - 

             MOA - sympatholytic, deceases 

             heart rate & BP.

             Contraindications - Asthma

                                               COPD

                                               Diabetes

                                               Heart block

            

            Cardioselective Beta 1 blockers-

            Atenolol, Metoprolol - Can be used 

            in asthma, COPD.

   

         (III) alpha + beta blockers - 

          Labetalol, Carvedilol.

   

         (IV) ACE inhibitors -

         MOA - They inhibit ACE. Therefore,

         no formation of Angiotensin II

         leading to vasodilation. There is no

         release of aldosterone.

         Drugs - Captopril, Lisinopril, Enalapril.

 

        (V) Angiotensin Receptor Blockers - 

        MOA - They block 81 receptors.

        Therefore, no action of Angiotensin II.

        Drugs - Losartan, Candesartan.

        (VI) Direct Renin inhibitors- 

        MOA - No activation of RAAS.

        Drugs - Alliskiren.

     

        (VII) Calcium Channel Blockers -

        MOA - Blockage of calcium channels 

        inhibits cardiac muscle contraction.

        Negative inotropic effect.

        Drugs - Verapamil, Diltiazem, 

        Nifedipine, Amlodipine.

       (VIII) Vasodilators - 

        Drugs - Hydralazine, Minoxidil.

        (IX) Alpha blockers -

        Drugs - Prazosin.

        (X) Alpha 2 blockers -

        Drugs - Clonidine.

   

                ⭐⭐⭐⭐⭐⭐⭐⭐⭐