The influence of hypertension on Organs
Galih Gumelar Helath & Therapi - Hypertension can cause damage to various target organs such as brain, heart, kidney, aorta, perifir blood vessels, and retina. Some are cross-sectional studies show that the target organ damage more closely associated with blood pressure measured during ambulatory 24-hour or Blood Preasure (ABP) than blood pressure while in the clinic.
In normal people, blood pressure followed the circadian pattern, which decreased blood pressure at night and has increased in the morning. Similarly, the majority of hypertension, which also follows the normal circadian pattern (dippers). However, hypertension in non-dippers did not decrease blood pressure at night. Incidence of cardiovascular disease and stroke occur more frequently in people with hypertension non-dippers than dippers hypertension. Target organ damage more closely related to severe patients with high blood pressure at night (non-dippers) than patients with blood pressure normally decreases at night (dippers) 7. For example, studies of Verdecchia and colleagues in a prospective cohort terhadap1100 hypertension, reported mortality rates average higher, both in non-dippers and reverse dippers Dipper instead. Yamamoto research results prove that high blood pressure on ambulatory measurement (ABP), particularly high blood pressure at night and a decrease in blood pressure is less at night, will cause adverse effects (increasing the extent of the lesion) in the quiet of ischemic lesions (silent ischemic lesions), and stroke in patients with symptomatic myocardial lakuner9.
In the meantime, the results of Chaturvedi and colleagues proved that ischemic stroke is more common in the morning (between 06.00 to 12.00). According to Chaturvedi, there are some acceptable explanation why the ischemic stroke occurred in the morning:
Circadian pattern of blood pressure. The pattern of blood pressure rise in the morning (the highest increase occurred in the mid-morning until noon). Increased blood pressure causes increased intraplaque hemorrhage, which will aggravate the stenosis of blood vessels having atherosclerosis.
Increased platelet aggregation occurred in the morning.
Blood viscosity peak in the morning.
TPA activity (endogenous tissue plasminogen activator) is very low in the morning. This will change the balance between thrombosis and fibrinolysis that thrombosis become more dominant.
Role of Hypertension in Stroke Pathogenesis
Normal people have a system of autoregulation of cerebral arteries. If the systemic blood pressure increases, cerebral vessels become vasospasme (voasokonstriksi). Conversely, when the systemic blood pressure decreases, the cerebral vessels will be vasodilatation. Thus, blood flow to the brain remains constant. Despite a decline in systemic blood pressure by 50 mmHg, autoregulation of cerebral arteries is still able to maintain blood flow to the brain remained normal. Limits on systemic blood pressure which can still be addressed by autoregulation was 200 mm Hg for systolic and 110-120 mm Hg for diastolic pressure.
When systemic blood pressure increases, cerebral vessels to constrict. Depending on the degree of constriction of the blood pressure increase. If the blood pressure rise high enough for months or years, will cause the muscle layer hialinisasi on cerebral vessels. As a result, the lumen diameter of blood vessels will become permanent. This is dangerous because of cerebral vessels can not constrict dilated or freely to cope with fluctuations of systemic blood pressure. When a decline in systemic blood pressure perfusion pressure to the brain tissue is not adequate. This will result in cerebral ischemia. Conversely, when there is an increase in systemic blood pressure perfusion pressure in the capillary walls are high. As a result, there hiperemia, edema, and possible bleeding on otak13.
In chronic hypertension can occur mikroaneurisma in diameter and 1 mm. Is known as Mikroaneurisma aneurysm of Charcot-Bouchard and mainly occurs in arteria lentikulostriata. On systemic blood pressure spikes, as people angry or pushing, aneurysms can rupture. Chronic hypertension is one of the causes of endothelial dysfunction of blood vessels.
In normal circumstances, endothelial show dualistic function. These properties simultaneously express and release vasoconstrictor substances (angiotensin II, endotelin-I, thromboxane A-2, and superoxide radicals) and vasodilator (prostaglandin and nitric oxide). These factors cause and prevent cell proliferation of smooth muscle cells of blood vessels in a balanced way. The balance between these antagonistic systems in an optimal control function of blood vessel walls. As a result of endothelial dysfunction, vasoconstriction occurs, the cell proliferation of smooth muscle cells of blood vessels, platelet aggregation, adhesion lekosit, and increased permeability to macromolecules, such as lipoprotein, fibrinogen, and imunoglobulin14. This condition will accelerate the occurrence of atherosclerosis. Atherosclerosis is an important role for the occurrence of myocardial stroke.
Blood pressure reduction in Stroke Prevention In Primary and Secondary
Primary stroke prevention is intended for individuals at high risk for stroke, namely by controlling the risk factors of stroke. Risk factors of stroke can be treated or controlled and is proven to reduce the occurrence of stroke is well-hypertension, smoking, diabetes, carotid artery stenosis are asymptomatic, Sickle cell disease, hyperlipidemia, and arterial fibrillation. Other risk factors that could potentially be controlled is obesity, less physical activity, alcohol, hiperhomosisteinemia, drug abuse (cocaine, amphetamines, and heroin), nutrition (diet less vegetables and fruits), oral contraceptives, hiperkoagulabilitas, chronic infections Chalmydia pneumoniae, and hormon15 replacement therapy.
Klugel and colleagues reported that uncontrolled hypertension is present in 78% cases of ischemic stroke and 85% in cases of stroke hemoragik16. Uncontrolled hypertension is very strong relation with stroke akut17. Overviews of a prospective randomized 14 shows that the decrease in blood pressure 5 mm Hg to 6 mm Hg can reduce the occurrence of stroke 42% 18. The research results Systolic Hypertension in the Eldery Program (Shep) shows the incidence of stroke decreased 36% with antihypertensive treatment (klortahalidon or atenolol) in elderly patients with isolated systolic hypertension (isolated systolic hypertension) 19. The risk of stroke will increase two times each 7.5 mmHg increase in diastolic pressure. Antihypertensives may lower the risk of stroke 38% 20.
The results of meta-analysis conducted by Gueyffier showed that lowering blood pressure with antihypertensive drugs can reduce the risk of stroke ulang21. While the research results from POGRESS (perindopril Against recurrent Protection Study) showed that treatment with perindopril in stroke patients with hypertension can significantly reduce the occurrence of re sroke (risk reduction = 28%, 95% Cl = 17% to 38%, P <0.0001)> 20-25% of the blood pressure on average. Indications of hypertension therapy in acute stroke:
If the diastolic blood pressure> 140 mmHg on two readings 5-minute intervals, give the IV natriun nitroprusid (very emergency).
If the systolic blood pressure> 230 mmHg and or diastolic blood pressure of l21-140 mm Hg on two readings 20 minutes intervals, giving 20 mg iv labetolol for 1-2 minutes. Labetolol dose may be repeated every 10-20 minutes until a satisfactory reduction in blood. After the initial dose, given every labetolol be 6-8 hours if necessary (emergency).
If the systolic blood pressure 180-230 mmHg or diastolic blood pressure 105-120 mmHg, emergency therapy should be postponed without any evidence of intracerebral hemorrhage or heart failure the left ventricle. If the blood pressure stayed at two times the measurement interval of 60 minutes, then 200-300 mg given 2-3 times daily labetolol. Labetolol alternative treatment is nifedipin oral 10 mg every 6 hours or captopril 6,25-12,5 mg every 8 hours (urgency).
Systolic pressure <180>
Blood pressure in the acute phase should not be lowered more than 20%. Decrease blood tekananan average no more than 25% and arterial blood pressure on average.
If the systolic blood pressure over 230 mmHg or diastolic pressure over 140 mmHg on two measurements of blood pressure hoses 5 minutes, give sodium nitroprusid or nitroglycerin drip.
When the systolic pressure 180-230 mmHg or diastolic pressure of 105-140 mmHg, or arterial blood pressure an average of 130 mmHg on two measurements of blood pressure hoses 20 minutes, give injections or enalapril labetolol.
When the systolic pressure less than 180 mm Hg and diastolic blood pressure less than 105 mmHg, antihypertensive drug treatment delayed.
Hypertension drugs given to stroke patients is a drug that does not affect cerebral blood flow. Dyker and colleagues reported that administration of perindopril effectively lower blood pressure without disturbing the brain's blood flow in patients with ischemic stroke akut31. Meanwhile, Walter and his colleagues reported that administration of perindopril in patients with ischemic stroke who are not acute, with stenosis or occlusion of moderate to severe carotid artery intema, decrease blood pressure without a decrease in cerebral blood flow.
Galih Gumelar Helath & Therapi - Hypertension can cause damage to various target organs such as brain, heart, kidney, aorta, perifir blood vessels, and retina. Some are cross-sectional studies show that the target organ damage more closely associated with blood pressure measured during ambulatory 24-hour or Blood Preasure (ABP) than blood pressure while in the clinic.
In normal people, blood pressure followed the circadian pattern, which decreased blood pressure at night and has increased in the morning. Similarly, the majority of hypertension, which also follows the normal circadian pattern (dippers). However, hypertension in non-dippers did not decrease blood pressure at night. Incidence of cardiovascular disease and stroke occur more frequently in people with hypertension non-dippers than dippers hypertension. Target organ damage more closely related to severe patients with high blood pressure at night (non-dippers) than patients with blood pressure normally decreases at night (dippers) 7. For example, studies of Verdecchia and colleagues in a prospective cohort terhadap1100 hypertension, reported mortality rates average higher, both in non-dippers and reverse dippers Dipper instead. Yamamoto research results prove that high blood pressure on ambulatory measurement (ABP), particularly high blood pressure at night and a decrease in blood pressure is less at night, will cause adverse effects (increasing the extent of the lesion) in the quiet of ischemic lesions (silent ischemic lesions), and stroke in patients with symptomatic myocardial lakuner9.
In the meantime, the results of Chaturvedi and colleagues proved that ischemic stroke is more common in the morning (between 06.00 to 12.00). According to Chaturvedi, there are some acceptable explanation why the ischemic stroke occurred in the morning:
Circadian pattern of blood pressure. The pattern of blood pressure rise in the morning (the highest increase occurred in the mid-morning until noon). Increased blood pressure causes increased intraplaque hemorrhage, which will aggravate the stenosis of blood vessels having atherosclerosis.
Increased platelet aggregation occurred in the morning.
Blood viscosity peak in the morning.
TPA activity (endogenous tissue plasminogen activator) is very low in the morning. This will change the balance between thrombosis and fibrinolysis that thrombosis become more dominant.
Role of Hypertension in Stroke Pathogenesis
Normal people have a system of autoregulation of cerebral arteries. If the systemic blood pressure increases, cerebral vessels become vasospasme (voasokonstriksi). Conversely, when the systemic blood pressure decreases, the cerebral vessels will be vasodilatation. Thus, blood flow to the brain remains constant. Despite a decline in systemic blood pressure by 50 mmHg, autoregulation of cerebral arteries is still able to maintain blood flow to the brain remained normal. Limits on systemic blood pressure which can still be addressed by autoregulation was 200 mm Hg for systolic and 110-120 mm Hg for diastolic pressure.
When systemic blood pressure increases, cerebral vessels to constrict. Depending on the degree of constriction of the blood pressure increase. If the blood pressure rise high enough for months or years, will cause the muscle layer hialinisasi on cerebral vessels. As a result, the lumen diameter of blood vessels will become permanent. This is dangerous because of cerebral vessels can not constrict dilated or freely to cope with fluctuations of systemic blood pressure. When a decline in systemic blood pressure perfusion pressure to the brain tissue is not adequate. This will result in cerebral ischemia. Conversely, when there is an increase in systemic blood pressure perfusion pressure in the capillary walls are high. As a result, there hiperemia, edema, and possible bleeding on otak13.
In chronic hypertension can occur mikroaneurisma in diameter and 1 mm. Is known as Mikroaneurisma aneurysm of Charcot-Bouchard and mainly occurs in arteria lentikulostriata. On systemic blood pressure spikes, as people angry or pushing, aneurysms can rupture. Chronic hypertension is one of the causes of endothelial dysfunction of blood vessels.
In normal circumstances, endothelial show dualistic function. These properties simultaneously express and release vasoconstrictor substances (angiotensin II, endotelin-I, thromboxane A-2, and superoxide radicals) and vasodilator (prostaglandin and nitric oxide). These factors cause and prevent cell proliferation of smooth muscle cells of blood vessels in a balanced way. The balance between these antagonistic systems in an optimal control function of blood vessel walls. As a result of endothelial dysfunction, vasoconstriction occurs, the cell proliferation of smooth muscle cells of blood vessels, platelet aggregation, adhesion lekosit, and increased permeability to macromolecules, such as lipoprotein, fibrinogen, and imunoglobulin14. This condition will accelerate the occurrence of atherosclerosis. Atherosclerosis is an important role for the occurrence of myocardial stroke.
Blood pressure reduction in Stroke Prevention In Primary and Secondary
Primary stroke prevention is intended for individuals at high risk for stroke, namely by controlling the risk factors of stroke. Risk factors of stroke can be treated or controlled and is proven to reduce the occurrence of stroke is well-hypertension, smoking, diabetes, carotid artery stenosis are asymptomatic, Sickle cell disease, hyperlipidemia, and arterial fibrillation. Other risk factors that could potentially be controlled is obesity, less physical activity, alcohol, hiperhomosisteinemia, drug abuse (cocaine, amphetamines, and heroin), nutrition (diet less vegetables and fruits), oral contraceptives, hiperkoagulabilitas, chronic infections Chalmydia pneumoniae, and hormon15 replacement therapy.
Klugel and colleagues reported that uncontrolled hypertension is present in 78% cases of ischemic stroke and 85% in cases of stroke hemoragik16. Uncontrolled hypertension is very strong relation with stroke akut17. Overviews of a prospective randomized 14 shows that the decrease in blood pressure 5 mm Hg to 6 mm Hg can reduce the occurrence of stroke 42% 18. The research results Systolic Hypertension in the Eldery Program (Shep) shows the incidence of stroke decreased 36% with antihypertensive treatment (klortahalidon or atenolol) in elderly patients with isolated systolic hypertension (isolated systolic hypertension) 19. The risk of stroke will increase two times each 7.5 mmHg increase in diastolic pressure. Antihypertensives may lower the risk of stroke 38% 20.
The results of meta-analysis conducted by Gueyffier showed that lowering blood pressure with antihypertensive drugs can reduce the risk of stroke ulang21. While the research results from POGRESS (perindopril Against recurrent Protection Study) showed that treatment with perindopril in stroke patients with hypertension can significantly reduce the occurrence of re sroke (risk reduction = 28%, 95% Cl = 17% to 38%, P <0.0001)> 20-25% of the blood pressure on average. Indications of hypertension therapy in acute stroke:
If the diastolic blood pressure> 140 mmHg on two readings 5-minute intervals, give the IV natriun nitroprusid (very emergency).
If the systolic blood pressure> 230 mmHg and or diastolic blood pressure of l21-140 mm Hg on two readings 20 minutes intervals, giving 20 mg iv labetolol for 1-2 minutes. Labetolol dose may be repeated every 10-20 minutes until a satisfactory reduction in blood. After the initial dose, given every labetolol be 6-8 hours if necessary (emergency).
If the systolic blood pressure 180-230 mmHg or diastolic blood pressure 105-120 mmHg, emergency therapy should be postponed without any evidence of intracerebral hemorrhage or heart failure the left ventricle. If the blood pressure stayed at two times the measurement interval of 60 minutes, then 200-300 mg given 2-3 times daily labetolol. Labetolol alternative treatment is nifedipin oral 10 mg every 6 hours or captopril 6,25-12,5 mg every 8 hours (urgency).
Systolic pressure <180>
Blood pressure in the acute phase should not be lowered more than 20%. Decrease blood tekananan average no more than 25% and arterial blood pressure on average.
If the systolic blood pressure over 230 mmHg or diastolic pressure over 140 mmHg on two measurements of blood pressure hoses 5 minutes, give sodium nitroprusid or nitroglycerin drip.
When the systolic pressure 180-230 mmHg or diastolic pressure of 105-140 mmHg, or arterial blood pressure an average of 130 mmHg on two measurements of blood pressure hoses 20 minutes, give injections or enalapril labetolol.
When the systolic pressure less than 180 mm Hg and diastolic blood pressure less than 105 mmHg, antihypertensive drug treatment delayed.
Hypertension drugs given to stroke patients is a drug that does not affect cerebral blood flow. Dyker and colleagues reported that administration of perindopril effectively lower blood pressure without disturbing the brain's blood flow in patients with ischemic stroke akut31. Meanwhile, Walter and his colleagues reported that administration of perindopril in patients with ischemic stroke who are not acute, with stenosis or occlusion of moderate to severe carotid artery intema, decrease blood pressure without a decrease in cerebral blood flow.
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