HIPERTENSION

ARTERIAL

09/06/2014

DEFINICION • La hipertensión arterial (HTA) es una elevación

sostenida de la presión arterial sistólica, diastólica o de ambas que afecta a una parte muy importante de la población adulta, especialmente a los de mayor edad.

• Su importancia reside en el hecho de que, cuanto mas elevadas sean las cifras de presión tanto sistólica como diastólica, más elevadas son la morbilidad y la mortalidad de los individuos.

• The seventh report of Joint National Committee in 2003 on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) described normal blood pressure (BP) in adults as systolic BP, 120 mm Hg and

diastolic ,80 mm Hg.

HTA

PA sistólica (PAS) > 140 mm Hg o PA diastólica (PAD) > 90 mm Hg o ambas.

Prehypertension is defined as: Systolic BP between 120-139 mm Hg or Diastolic between 80-89 mm Hg. Stage 1 hypertension (HTN) is: systolic BP from 140-159 mm Hg or diastolic BP from 90-99 mm Hg. Stage 2 hypertension is: Systolic BP > 160 mm Hg or Diastolic BP > 100 mm Hg

HYPERTENSION

EPIDEMIOLOGIA

• La HTA es el principal factor relacionado con la mortalidad en todo el mundo.

• Las cifras de presión aumentan progresivamente con la edad, por lo que la prevalencia de HTA depende extraordinariamente del segmento etario analizado.

• De muy baja prevalencia en individuos por debajo de los 30 años, dicha prevalencia puede alcanzar hasta el 80% en los mayores de 80 años.

• Todos los grupos étnicos sufren HTA.

PREVALENCE: Based on NHANES data in 2005 to 2008, approximately 68 million (31%) U.S. adults have hypertension and only 31 million (46%) have it well controlled. There are around 1 billion individuals worldwide who meet the criteria for diagnosis of HTN. PEAK PREVALENCE: Males and the elderly

Etiopatogenia

• Factores etiológicos: * Genética (familiares 1° grado) • Factores ambientales: Sedentarismo, mayor ingesta calórica, sal y grasas

saturadas. • Factores patogenéticos • Sistema nervioso simpático: hiperactividad • Sistema renina-angiotensina • Disfunción y lesión endotelial • Cambios estructurales en las arterias: hipertrofia de la

capa media, rigidez de grandes arterias.

CLASIFICACION

- Hipertensión esencial:

No tiene causa específica

- Hipertensión secundaria:

Tiene causa conocida ( 10% )

ETIOLOGY

• Essential (primary) HTN (85%) • Secundary Hypertension (15%): a) Drug induced or drug related (5%) • 1. NSAIDs • 2. Oral contraceptives • 3. Corticosteroids b) Renal HTN (5%) • 1. Renal parenchymal disease (3%) • 2. Renovascular hypertension (RVH) (2%) c) Endocrine (<2%) • 1. Primary aldosteronism (0.5%) • 2. Pheochromocytoma (0.2%) • 3. Cushing’s syndrome and long-term steroid therapy (0.2%) • 4. Hyperparathyroidism or thyroid disease(0.2%) d) Coarctation of the aorta (0.2%)

PHYSICAL FINDINGS & CLINICAL PRESENTATION

• The BP should be measured with an appropriately sized cuff (bladder of the cuff should cover at least two thirds of the circumference of the arm) and in both arms (the higher of the readings being used).

• The BP should be measured twice on each visit, and seperated by at least 1 to 2 min to allow the return of trapped blood. If the values differ, use the higher value.

• Postural BP change should always be recorded in elderly to diagnose postural hypotension and is best assessed by going from the lying to the standing position and should include information on change in heart rate with change in position.

• A diagnosis of HTN may be established if the BP is markedly elevated (180/110 mm Hg) or has evidence of end organ damage; otherwise such a diagnosis should wait until BP is found elevated on at least two occasions measured over a period of 1 wk or more.

• Measure heart rate, height, weight, body mass index, and waist circumference.

PHYSICAL FINDINGS & CLINICAL PRESENTATION

• Examine skin for the presence of cafe-au-lait spots (neurofibromatosis), uremic appearance (renal failure), and violaceous striae (Cushing’s syndrome).

• Perform careful funduscopic examination; check for papilledema, retinal exudates, hemorrhages, arterial narrowing, arteriovenous compression.

• Examine neck for carotid bruits, distended neck veins, and enlarged thyroid gland. • Perform extensive cardiopulmonary examination: check for loud aortic

component of S2, S4, ventricular lift, murmurs, and arrhythmias. • Palpate abdomen for renal masses (pheochromocytoma, polycystic kidneys), and

auscultate for bruit over the aorta and renal arteries. • Examine arterial pulses (dilated or absent femoral pulses and BP greater in upper

extremities than lower extremities suggest aortic coarctation). • Look for truncal obesity (Cushing’s syndrome) and pedal edema (congestive heart

failure [CHF]). • The clinical evaluation should help to determine if the patient has primary or

secondary (possibly reversible) HTN, if there is target organ disease present, and if there are additional cardiovascular risk factors.

• Table 1-174 provides a guide to evaluation of identifiable causes of hypertension.

TRATAMIENTO FARMACOLOGICO 1. BETA-BLOQUEANTES 2. DIURETICOS 3. CALCIO ANTAGONISTAS 4. INHIBIDORES DE LA ECA 5. ARA II 6. INHIBIDORES DE RENINA. 7. BLOQUEADORES ALFA-ADRENERGICOS. 8. ANTAGONISTAS ALFA-CENTRALES. 9. BLOQUEADORES COMBINADOS DE

RECEPTORES ALFA Y BETA ADRENÉRGICOS:

ANTAGONISTAS BETA ADRENERGICOS

ATENOLOL

PROPANOLOL

NADOLOL

TIMOLOL

PINDOLOL

METOPROLOL

ACEBUTOLOL

PRACTOLOL

ESMOLOL

LABETALOL

CARVEDILOL

CELIPROLOL

DIURETICOS

- TIAZIDAS: Hidroclorotiazida, Clortalidona

- DIURETICOS DE ASA: Furosemida, bumetanida

- DIURETICOS AHORRADORES DE K : Amilorida, triamtereno, espironolactona

BLOQUEADORES DE LOS CANALES DEL CALCIO

• Verapamil – diltiazem

• Dihidropiridinas:

• Amlodipino – Nifedipino - Isradipino.

Mecanismo de Acción:

Inhibición del ingreso del Ca intracelular en el músculo liso arterial

INHIBIDORES DE LA EZ CONVERTIDORA DE ANGIOTENSINA

(IECA)

- Captopril

- Enalapril

- Lizinopril

- Quinapril

- Benazepril

- Fosinopril

- Trandolapril

ANTAGONISTAS DE LOS RECEPTORES DE ANGIOTENSINA II

- Losartan

- Valsartan

- Candesartan

- Irbesartan

- Telmisartan

- Eprosartan

SIMPATICOLITICOS DE ACCION

CENTRAL

- METILDOPA

- CLONIDINA

BLOQUEADORES DE LOS RECEPTORES α1

ADRENERGICOS

– PRAZOCIN –TERAZOSINA –DOXAZOCINA