2 nd

Case Analysis
Case
A 45-year-old man, presents at the clinic after having a reading of elevated
blood pressure at a health department screening. His blood pressure is 160/110
and is equal in both arms and legs, he has no other concerns.
He is alert and cooperative but appears to be anxious. The patient reports being
a social drinker and smokes 1 packs of cigarettes a day. He indicates that he
is too busy to exercise. There is a family history of heart disease but no family
history of diabetes.

Physical Examination
T : 37 C, pulse 80x/min, BP 165/110mmHg
BMI 32

Laboratory Studies
General screening test : All within normal ranges
ECG : Left axis deviation

Diagnosis
Essensial Hypertension
Findings

Anamnesis, Physical & Lab Findings

Age: 45
BP: 165/110
BMI 32
ECG : Left axis deviation
Findings

Recommended therapy:
Weight reduction to his ideal level
Low salt diet (< 2 gm/day sodium)
Prudent exercise
Alcohol consumption reduction (< 3 oz whiskey/day)

Medication:
Oral diuretic blocker vasodilator to < 140/90
Problems
Hypertension
JNC Classification: HT stage II (systole 160, diastole 100)
Obesity
BMI : 32 (Class II Obesity)

Social drinker
Smoker 1 packs of cigarettes a day
Esential Hypertension
Alexandra Gabriella
 Hormonal mechanism: Renin-
Angiotensin-Aldosterone System
Prorenin bs jd biomarker baru u/ liat mikro & makrovaskular complication

Laragh, Sealey, & coworkers, 20

 Plasma Renin Activity as a
Clinical Index of RAAS Activity

Alexandra Gabriella
 Clinical Assays
Plasma Renin Activity (PRA) & Plasma
Renin Concentration (PRC) can be
measured

PRA: incubating pts plasma, which

contains angiotensinogen & renin, to
generate Ang I, then measured by
radioimmunoassay

Ang I renin
Clinical Conditions Affecting PRA
BP itself (vol expanded) suppress PRA

however, most puts have normal PRA

nephron heterogeneity : subpopulation of

ischemic nephron renin ec RSNA

nonmodulation concept: defective

feedback regulation of RAAS in kidney &
adrenal gland
 Primary HT w/ Low
Renin
usual finding

vol expansion w/ or w/o mineralocorticoid excess

but majority fail to indicate vol expansion or level
of mineralocorticoids

u/ keeping w/ Normal level of aldosterone (despite of

low renin level) they show lesser rise in
aldosterone secretion on a low-sodium diet

7-year study: low renin HT no strokes/heart attacks;

normal renin 11%, high 14% had 1 stroke/heart
attacks.
Natural History of HT
 Complications of HT

Makrovaskular

PAD, Ao Dissection, Cerebrovascular

Disease, CAD

Mikrovaskular

Renitopathy hypertensive, nephropathy

Retinopathy HT Classification
Funduscopy
Hypertension
Hypertension
Salt sensitivity & Pressure-Natriuresis Phenomenon
In normotensive person: BP renal sodium & renal excretion
fluid volume normal BP (pressure-natriuresis phenomenon)

In hypertensive person:
Salt sensitive low salt diet normotensive
high salt diet hypertensive
Salt resistance low salt diet normotensive
high salt diet normotensive
Salt sensitivity shown in renin plasma concentration
also: pressure-natriuresis resetting (shifted)
Hypertension
Pressure-Natriuresis Phenomenon
Hypertension
Pressure-Natriuresis Resetting
Hypertension
Nocturia
Clinical sign of abnormal pressure-natriuresis and clue to
uncontrolled salt-sensitive hypertension related to aging,
hypertension, blunted/reveres nocturnal dipping pattern in BP
nocturnal urine accounts 53% of urine output in 60 - 80 yo,
in hypertensive due to shifted pressure-natriuresis
fluid retained peripherally during the day leads to central
volume expansion at night nocturia
Hypertension
BP = CO x TPR (age related)
Hypertension Effect on
Organ
Hypertension Effect on
Organ
LVH
Arterial Pressure wall stress LVH ( LV
stiffness diastolic dysfunction LV filling
pressure pulmonary congestion;)
Normal pattern compensation ( Arterial Pressure)
concentric hypertrophy;
In circulating volume eccentric hypertrophy
Hypertension Effect on
Organ
Hypertension Effect on
Organ
Hypertensive Retinopathy
Acute severe hypertension (e.g., uncontrolled and/or
malignant hypertension) burst small retinal vessels
haemorrhages, exudation of plasma lipids & areas of local
infarction;
Chronically elevated blood pressure Papilledema (-), but
vasoconstriction arterial narrowing, medial hypertrophy
thickens the vessel wall, which nicks (indents) crossing
veins.
More severe chronic hypertension arterial sclerosis, an
increased reflection of light through the ophthalmoscope
(termed copper or silver wiring)
Hypertension Crisis
BP or more than 180 in systole and 110 in diastole, with evidence
of organ
damage, such as:
Stroke
Loss consciousness
Memory loss
Heart attack
Damage to the eyes and kidneys
Loss of kidney function
Aortic dissection
Angina (unstable chest pain)
Pulmonary edema (fluid backup in the lungs)
Eclampsia
Obesity
Hypertension & Obesity
Relationship
Hypertension & Obesity
impaired insulindependent transport of glucose into many
tissues (termed insulin resistance)
Possible explanations for this relationship include:
1. The release of angiotensinogen from adipocytes as
substrate for the reninangiotensin system,
2. Augmented blood volume related to increased body
mass, and
3. Increased blood viscosity caused by adipocyte release of
pro-fibrinogen and plasminogen activator inhibitor 1
Hypertension & Obesity
Relationship
Hypertension & Obesity
Relationship
Hypertension & Obesity
Relationship
Hypertension
Management
Hypertension
Management
Recommended therapy:
Weight reduction to his ideal level
Low salt diet (< 2 g/day sodium) BP by a mean 5.4/2.8
mmHg. Additional effect:
Antihypertensive drugs efficacy enhanced
Protective from Diuretic-Induced Potassium Loss (R-A)
Prudent exercise BP is lowered by exercise whether aerobic,
or resistance, even without weight loss
Recommendation: as little as 15 minutes of walking per day
Alcohol consumption reduction (< 3 oz whiskey/day) < 20 -
24 ml of alcohol
Hypertension
Management
Lifestyle Changes:
Reduce or avoid:
Smoking
Obesity
Poor dietary habits (High sodium intake)
Sedentary lifestyle
High alcohol consumption
High stress
Hypertension
Management
Hypertension
Management
Hypertension Management

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Hypertension Management

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Hypertension Management

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Hypertension Management

Angiotensin-Converting Enzyme Inhibitor

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TERIMA KASIH

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