hypertension is a treatable disease .

1. MEDICINE UPDATE
FOR ALL DOCTORS
HYPERTENSION
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2. DR DINESH MITTAL DR SONALEE MITTAL
DRISHTI EYE HOSP VIJAYNAGAR INDORE

3. Hypertension
• Hypertension is one of the leading causes of the global
burden of disease. Approximately 7.6 million deaths ( 1 3 -
15% of the total) and 92 million disability-adjusted life
years worldwide were attributable to high blood pressure
in 200l . Hypertension doubles the risk of cardiovascular
diseases， including coronary heart disease (CHD)，
congestive heart failure (CHF)， ischemic and
hemorrhagic stroke， renal failure，and peripheral arterial
disease. It often is associated with additional
cardiovascular disease risk factors， and the risk of
cardiovascular disease increases with the total burden of
risk factors. Although antihypertensive therapy reduces
the risks of cardiovascular and renal disease， large
segments of the hypertensive population are either
untreated or inadequately treated .

4. • Cardiac output and peripheral resistance are the
two determinants of arterial pressure. Cardiac
output is determined by stroke volume and heart
rate; stroke volume is related to myocardial
contractility and to the size of the vascular
compartment. Peripheral resistance is determined
by functional and anatomic changes in small
arteries and arterioles

24. HYPERTENSION
• Hypertension is an independent predisposing factor for
heart failure，coronary artery disease， stroke， renal
disease， and peripheral arterial disease .
• Heart disease is the most common cause of death in
hypertensive patients. Hypertensive heart disease is
the result of structural and functional adaptations
leading to left ventricular hypertrophy， CHF，
abnormalities of blood flow due to atherosclerotic
coronary artery disease and microvascular disease，
and cardiac arrhythmias .

25. Pharmacologic Therapy
• Over the past decade, the goals of treatment have
gradually shifted from optimal lowering of blood
pressure, which is taken for granted, to patient’s
overall well being, control of associated risk factors
and protection from future target organ damage.
• Achieve gradual reduction of blood pressure. Use
low doses of antihypertensive drugs to initiate
therapy.

26. Pharmacologic Therapy
• • Five classes of drugs can be recommended as
first line treatment for stage 1-2 hypertension
These include :
• 1) ACE inhibitors,
• 2) angiotensin II receptor blockers,
• 3) calcium channel blockers,
• 4) diuretics and
• 5) newer β-blockers.

31. Hypertensive Retinopathy
• Hypertension affects precapillary arterioles and
capillaries, the anatomical loci of autoregulation and
nonperfusion. An acute hypertensive episode may
produce focal intraretinal periarteriolar transudates
(FIPTs) at the precapillary level. The presence of cotton-
wool spots (sometimes referred to as soft exudates)
indicates ischemia of the retinal nerve fiber layer .
Uncontrolled systemic hypertension leads to
nonperfusion at various retinal levels and to neuronal loss
and related scotomata. Other, more chronic, hypertensive
retinal lesions include microaneurysms, intraretinal
microvascular abnormalities (IRMAs), blot hemorrhages,
lipid exudates (sometimes referred to as hard exudates)
venous beading, and new retinal vessels.

32. Hypertensive Retinopathy
• The relationship between hypertensive vascular changes
and the changes of arteriosclerotic vascular disease is
complex, with wide variation related to duration of
hypertension, severity of dyslipidemia, age, and history of
smoking. Hence, classification of retinal vascular changes
caused strictly by hypertension is difficult, and the often
cited focal arteriolar narrowing and arterial venous
nicking have been shown to have little predictive value for
actual hypertension.

33. Modified Scheie Classification of
Hypertensive Retinopathy

34. COMPLICATIONS OF HYPERTENSION
• Hypertension may be complicated by branch retinal artery
occlusion (BRAO), branch retinal vein occlusion (BRVO),
central retinal vein occlusion (CRVO), and retinal arterial
macroaneurysms . The coexistence of hypertension and
diabetes mellitus results in more severe retinopathy
because precapillary and capillary insults act in
combination.

35. Hypertensive Choroidopathy
• Hypertensive choroidopathy typically occurs in young
patients who experience an episode of acute, severe
hypertension associated with preeclampsia, eclampsia,
pheochromocytoma, or renal hypertension . Lobular
nonperfusion of the choriocapillaris may occur & initially
results in tan, lobule-sized patches that, in time, become
hyperpigmented and surrounded by margins of
hypopigmentation—lesions known as Elschnig spots .
Linear configurations of similar-appearing
hyperpigmentations known as Siegrist streaks follow the
meridional course of choroidal arteries .

38. Hypertensive Optic Neuropathy
• Depending less on the degree than on the chronicity of
the hypertension, hypertensive optic neuropathy has a
variable presentation. Patients with severe hypertension
may have linear peripapillary flame-shaped
hemorrhages, blurring of the disc margins, florid disc
edema with secondary retinal venous stasis, and
macular exudates . The differential diagnosis for
patients with this clinical appearance includes diabetic
papillopathy, radiation papillopathy, CRVO, anterior
ischemic optic neuropathy, and neuroretinitis. Treatment
of systemic arterial hypertension is essential for
reducing or reversing these ocular manifestations of the
disease.

41. THANK
YOU
DR DINESH
DR SONALEE