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Control de la Presión Arterial

Presión arterial = Volúmen Minuto x Resistencia Periférica

HTA =

Aumento

y/o

Contractilidad
FC

Precarga

Aumento

Vasoconstricción

Volúmen Fluidos
Sistema Nervioso
Simpático

Ingreso
Na+

Retención Renal de Na+
Factores
Genéticos
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SRAA

Blood Pressure Control
Blood Pressure = Cardiac Output x Peripheral Resistance

BP =

Decrease

Preload
Fluid Volume
Na+
Intake

and/or

Contractibility
HR
P-Simpathetic
Nervous System

Increase

Vasoconstriction

Simpathetic
Nervous System

Renal Na+ Retention
Genetic
Factors
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RAAS

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www.favaloro.edu.ar

edu.ar Essential Secondary .* * bur b 30 * * 35 Sympathetic Activity and Hypertension 20 NT Essential Secondary 20 NT Lafranchi.favaloro. 1998 www. A et al Blood Press 7 (suppl 3): 40-45.

7 0.6 P-Symp.1 0.3 A 0. 0.edu.0 0 2 4 6 8 10 12 14 16 18 20 22 24 160 140 120 100 Cortisol 80 60 40 20 Insulin 0 0 2 4 6 8 10 12 14 16 Time (h) www.ar 18 20 22 24 .favaloro.5 NA 0.8 0.2 0.P l a s m a C o n c e n t r a t i o n s ( m g / l o rP ml a Us m/ l )a C o n c e n tgr a/ lt)i o n s ( 0.4 0.

60: 801-806 .Variaciones Circadianas e Incidencia de Muerte Súbita Framingham Heart Study Horas del Día www.favaloro.edu.ar Willich. Am J Cardiol 1987.

edu.ar Trombótico -Vol Plasmático bajo -Hto Alto -Procoagulación -Activ Plaquetaria Trombósis . Insulina -Dislipémia -Desrregulación metabólica -Diabetes -Aterosclerosis -Disfunción Endotelia -Ganancia Peso Trófico Hemodinámico Aumento de: -Catecolaminas -Renina/AII -Insulina -Shear Stress y -PA -Hipertrofia Vascular -HVI -Disfunción Endotelial -FC Alta -Vasoconstricción -Rarefacción Arritmia Menor Reserva O2 y Vasodilatadora Isquemia Tisular www.favaloro.Tono Simpático / Tono Parasimpático Metabólico -Resist.

ar Landsberger.Obesidad (-) Termo Génesis (+) Dieta (+) (+) (+) SNS (+) Vasos Vasoconstricción (+) (+) Insulino Resistencia Insulinemia (+) (+) Corazón VM Riñón Reabsorción Na+ AUMENTO DE LA PRESION ARTERIAL www. L: J Hypertension .favaloro. 19: 523-528 . 2001.edu.

Time Frequency Analysis Blood Pressure and HR Beat Series 200 180 160 140 120 100 80 60 40 20 0 480 400 320 240 160 80 0 0 1.000 4.000 2.ar 5.000 7.000 6.edu.000 3.favaloro.000 www.000 .

DS 15 10 5 0 105 115 125 135 145 155 165 PAS (mmHg) www.favaloro.Frecuencia de Distribución (135 Pts) 35 Promedio 30 n= 25 20 + DS .edu.ar 175 185 195 205 .

Children who had lower birth weights tended to have the highest BP values and BP variability. the importance of this variability on further BP rises and/or on vascular damage later in life needs to be assessed in future studies.. 2001.38:389-393. www.BP Variability: Relationship to Birth Weight Empar Lurbe.favaloro. Hypertension.edu.ar . Since that high BP variability is at least partially independent of BP values.

Kristina Björklund:www.ar J Hypertension 2004. .edu.Cardiovascular Event Rate According to SBP Mean SBP: SBPdt Var (ABPM) Tertiles: I: 125. II: 125–138 and III: > 138mmHg and Tertiles: I: 11. II: 11–15 and III: > 15 mmHg).favaloro. 22:1691–1697 .

ar F in a p r e s S D (m m H g ) In HT subjects. the relationship between LVMI and BP variability is independent of the BP values.M a ss In d e x (g 2/m ) 160 140 15 120 100 80 10 115 125 135 145 155 165 175 185 180 M a ss In d e x (g 2/m ) 20 SBP 15 DBP 160 12 140 9 120 6 100 3 0 80 65 75 85 95 105 115 Finapres Blood Pressure (mmHg) www. This is shown by the fact that in either group in which BP was separed in groups of 10mmHg. the higher the standard deviation the higher the LVMI.favaloro.edu. . Hypertensive Subjects F in a p r e s S D (m m H g ) Dependencia del IMVI de la variabilidad de la PA pero no de los valores medios de PA.

Cálculo de la Sensibilidad Barorrefleja 220 Delta IP (mseg) 200 180 160 140 Pendiente = Ganancia = SBR (mseg/mmHg) 120 100 80 4 6 8 10 12 Delta PAM (mmHg) www.ar 14 16 .edu.favaloro.

edu.Baroceptive Heart Rate Control Young and Elderly People Baroceptive Sensitivity and Sequence Number are higher on Younger (open circles) than in Older (closed circles) People Parati et al: J Hypertension 1998.ar . 16(suppl 3): S25-S33 www.favaloro.

favaloro. 1998 www.ar . A et al Blood Press 7 (suppl 3): 40-45.Baroreflex Control of Blood Pressure and Muscle Sympathetic Activity A reduced baroreflex sensitivity was observed dependent of BP values.edu. However. no reduction can be observed in muscle sympathetic activity (MSNA) Lafranchi.

ar .edu.Variabilidad de PA y SBR Pacientes Normotensos BRS (msec/mmHg) www.favaloro.

favaloro.6449.edu. n=41. p<0.005 Variabilidad de PA y SBR SBR ( mseg/mmHg) Pacientes Hipertensos 6 8 10 12 2 www.ar 4 6 8 10 12 .4 4 2 4 r=0.

edu.ar HT .favaloro.m m H g or m sec/m m H g RESULTADOS Blood Pressure Variability and Baroreflex Sensitivity 12 MBP Var Phe Like NTG Like 10 * * 8 * 6 * 4 NT BDL *: P< 0.05 en relación a NT y/o BDL www.

edu.favaloro.000 6.Time Frequency Analysis Blood Pressure and HR Beat Series 200 180 160 140 120 100 80 60 40 20 0 480 400 320 240 160 80 0 0 1.ar 5.000 2.000 3.000 .000 4.000 7.000 www.

2 [Hz] 0.FC [lpm²/Hz] 100 [mmHg²/Hz] 250 80 200 60 150 40 100 20 [Hz] 0 PS 50 [Hz] 0 0 0.2 [l²/Hz] 0.5 PD 0.4 100 0.5 f 0.5 .3 0.ar 0.4 0.4 0.favaloro.1 f 0.1 0.3 0.3 0.edu.3 0.1 0.2 [mmHg²/Hz] 150 VPI 0.1 0.2 f 0.2 f 0.5 0 www.5 0 0.3 0.1 50 [Hz] 0 0 0 0.4 0.4 0.

favaloro.ar .Variabilidad a largo plazo www.edu.

ar . 16(suppl 3): S25-S33 www.edu.favaloro.Broad Band Spectrum (1/f Function) Normotensive Subjects LF HF Parati et al: J Hypertension 1998.

.edu. 2006.Correlation between LF during night and HOMA.ar Perciaccante A: BMC Cardiovasc Disord.favaloro. 6: 19. www.

edu. white squares: controls. LF: Sympathetic.favaloro. Black squares: type 2 diabetes. Perciaccante A: BMC Cardiovasc Disord. 6: 19. HF: P-Sympathetic Activities IFG NGT IGT Ctrl DBT 2 White circles: normal glucose tolerance. 2006. www.Circadian variation of LF/HF in IR subjects.ar . LF/HF: low frequency/high frequency. black triangles: impaired FG. white triangles: impaired glucose tolerance.

Heart rate variability spectral components Heart rate variability spectral components for the three hypertensive groups (HTN) (mean SE).ar . right axis represents the LF/HF ratio scales in normalized units (nu). www. Neumann et al Am J Hypertens 2005. Serina A.favaloro. Left axis pertains to the highfrequency (HF) and low-frequency (LF) power estimates. 18:584–588 .edu.

2001.ar Empar Lurbe. the importance of this variability on further BP rises and/or on vascular damage later in life needs to be assessed in future studies. Hypertension. Since that high BP variability is at least partially independent of BP values.38:389-393.favaloro.edu. www. .BP Variability: Relationship to Birth Weight Children who had lower birth weights tended to have the highest BP values and BP variability.

edu. 4. Aumenta: el daño de órgano blanco (HVI5). Circulation 1994. el Col y TG. Circulation 2000. Am Heart J 1993.ar . 8: Muiesan ML y col. 7 Schwartz PJ y col. 2: Gillman MW y col. Circulation 1992. la agregación plaquetaria. SBR y HR Var son marcadores de mayor riesgo luego del IAM y en la población general3.4. la Ins y el Hto6 y la producción de arritmias7. El aumento de la FC es un marcador de riesgo para morbi. 3: La Rovere y col. 16: 1641-1650 www. J Human Hypertens 1997. la Glu. J Hypertens 1998.Balance simpato-vagal: MorbiMortalidad Cardiovascular El aumento crónico de la actividad simpática se expresa con un aumento de la PA y la FC1. 5: Marcus R y col. MT Lancet 1998. 30: 1267-1273. 85: 177-191. 351: 478-484. 125: 1148-1154. la disminución de la actividad simpática produce una consecuente reversión del daño de órgano blanco (HVI) 8. 102: 1239-1244. 1: Palatini P y col.favaloro. Hypertension 1997. Dekker JM y col. 11(suppl 1): S19-S27.mortalidad coronaria y toda causa de muerte por HTA2. 90: 928-936 6: Palatini P y col. En HTA.

edu.favaloro.www.ar .

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www. b) Compliance alterada con llegada normal de la onda reflejada.ar .La Onda de Presión Arterial Su determinante en la presión sistólica a) Compliance normal con llegada normal de la onda reflejada.favaloro.edu. c) Compliance alterada con llegada precoz de la onda reflejada.

edu.favaloro.www.ar .

favaloro.edu.ar .IôdP.Estructura de la Pared Arterial Mean IMT±SD Mean Diameter±SD Number of points System Iô 2.0 . Paris. France www.

Pm:Mean pressure. T = Time (sec) Cm Dm 1334  2    2 PWV C iso C m Pm  Piso Dm:Mean diameter.  : blood density.favaloro.ar .edu. Piso: 110 mmHg www.CAROTID-FEMORAL PWV AND CAROTID COMPLIANCE 1 L 2 d P h PWV (m/s) =L/T T L = Carotid-Femoral distance (m).

00 NT 3.00 HTpost 1.00 10-4 cm/mmHg 4.ar 140 160 .favaloro.edu.00 2.00 HTpre 0.Compliance Isobárica 5.00 60 80 100 120 PAM (mmHg) www.

31 intercpt=12.06 14 12 10 8 6 4 80 100 120 140 160 180 14 r=0.019 slope=-0.ar 140 160 180 .41 p=<0.edu.05 10 8 6 4 2 0 80 100 120 PAS Diurna (mmHg) www.VOP (m/seg) 18 16 -4 COeff (10 cm/mmHg) Relación PA con Función Arterial r=0.0000 intercpt=1.favaloro.34 12 p=0.19 slope=0.

57 20 p < 0.8 IMT [mm] www.5 0.05 Viscosity index [mmHg.IMT: Compliance and Viscosity Relationship 10 8 R = 0.s/mm] [10 -4 cm/mmHg ] Compliance 25 15 10 5 0 6 R = 0.05 2 0 0.edu.0 1.6 0.4 IMT [mm] 0.ar 1.favaloro.7 0.9 1.2 .60 4 p < 0.1 0.

edu. LVMI Correlation: r = .Indice de Desadaptación e IMVI MI vs.001) 420 360 LVM I 300 240 180 120 60 2 4 6 8 10 MI www.33 (p<0.favaloro. .ar 12 14 16 Regression 95% confid.

01 150 100 M A S S IN D E X 2(g ) /m 50 200 Finapres Day-Time Average y= 0.184*X .828 r = 0.IMVI y PA M A S S IN D E X 2(g ) /m Hypertensive Patients 200 24h Average Office y=0.748 r 0 0.50.0025 150 100 50 100 120 140 160 180 200 100 120 140 Systolic Blood Pressure (mmHg) www.634 r = 0.635*X + 24.01 y= 0.552*X + 40.ar 160 180 200 .199*X .834 r = 0.343 p< 0.favaloro.001 y=1.326 p< 0.edu.270 p< 0.54.325 p< 0.

564*X + 74.edu.150*X + 9.184*X + 11.131 r = 0.IMVI y PA Hypertensive Patients 2 M A SS IN D E X (g/m ) 200 Office 24h Average y=0.616 r = 0.025 y=0.025 Day-Time Average Finapres 150 100 50 2 M A SS IN D E X (g/m ) 200 y=1.996 r = 0.215 p<0.05 150 100 50 60 75 90 105 120 135 60 75 90 105 Diastolic Blood Pressure (mmHg) www.765 r = 0.05 y=1.785*X + 47.ar 120 135 .212 p<0.218 p< 0.favaloro.244 p<0.

edu. This is shown by the fact that in either group in which BP was separed in groups of 10mmHg. the higher the standard deviation the higher the LVMI.M a ss In d e x (g 2/m ) 160 140 15 120 100 80 10 115 125 135 145 155 165 175 185 180 M a ss In d e x (g 2/m ) 20 SBP 15 DBP 160 12 140 9 120 6 100 3 0 80 65 75 85 95 105 115 Finapres Blood Pressure (mmHg) www.favaloro. the relationship between LVMI and BP variability is independent of the BP values.ar F in a p r e s S D (m m H g ) In HT subjects. Hypertensive Subjects F in a p r e s S D (m m H g ) Dependencia del IMVI del la variabilidad de la PA pero no de los valores medios de PA. .

1960 www. JAMA.favaloro.edu. Arritmias) Riñón (IR) Atgeno Plasmatico Aldosterona Na+ retención Renina K+ Pérdida Drawn from Laragh.Riñón e Hipertensión Arterial PA Estrés Oxidativo K+ ACTHVasoconstricció CORTEZA ADRENAL n Vasculotoxicidad Angiotensina IIECA Angiotensina I Cerebro (ACV) Retina (desprendimiento) Corazón (IAM. IC.ar .

ar AT2 .favaloro.Mecanismo de acción de los Bloqueantes de los Receptores de la Angiotensina II (BRA) ANGIOTENSINOGENO CIMASAS INHIBIDOR DE RENINA ANGIOTENSINA I BRADIKININA IECA NO PEPTIDOS ANGIOTENSINA II BRA AT1 www.edu.

www.edu.favaloro.ar .

ar •Vasodilatación •Natriuresis •Diuresis •Acción antiremodelación .Relación entre el SRA y la formación de Óxido Nítrico Angiotensina II Angiotensina I Endopeptidasas Angiotensina (1-7) Receptor AT2 • Acción antiproliferativa •Diferenciación celular •Reparación tisular Bradiquinina Receptor AT (1-7) Receptor BK II ON www.edu.favaloro.

04 www.08 0.12 0.1.ar MHT NMHT .ERPF * 1000 800 600 2 (ml.1.min.1.73m2) 1200 IRVR 0.20 0.favaloro.73m ) # 400 FF 0.24 0.24 0.20 * # 0.edu.04 140 120 100 80 60 0.min.min.73m) (ml.08 0.16 GFR 160 MHT NMHT 2 (mmHg/ml.12 0.16 # ** 0.

L ) 120 Modulators 34.L-1.L-1.4mEq Na+.4mEqNa+.24h U rin ary +NEa xcretion (m E q .ar 120 .mmHg-1 0 95 100 105 110 115 Mean Blood Pressure (mmHg) www.favaloro.mmHg-1 100 80 60 40 20 Non-Modulators 8.edu.

ar 90 95 100 .favaloro.Manejo Renal del Na+ y Obesidad Reducción De Peso Excresión Urinaria de Na+ (mEq/24h) 250 Normal Obesidad 200 150 100 50 0 65 70 75 80 85 PAM (mmHg) www.edu.

favaloro.0 14000 Na Low Na High 12000 10000 8000 ** 6000 ** 4000 2000 Modulators Non-Modulators www.L.Time) 5.0 KKT (UgBK.24h.Incub.Low Na High Na PRA (mmol.ar Modulators Non-Modulators .0 3.5 2.0 2.5 3.5 ** ** 4.edu.h) 4.

ar Non-Modulators .edu.1600 cGMP (ng.24h) High Na+ 1200 1000 800 600 400 * 1000 Low Na+ High Na+ 800 600 400 200 Modulators Non-Modulators Modulators 120 * (Relative Optical Density) + Nitrotyrosine Mass NO3/NO2 (mM) 1400 1200 ** Low Na * + 100 Low Na High Na+ * 80 60 40 20 0 Modulators Non-Modulators www.favaloro.

Beers MH.ar . 3: 125130. Daugherty A et al J Clin Invest 2000. Booz GW. LV = left ventricular. Dahlöf B J Hum Hypertens 1995. 4(suppl 1): 3440. 20(14): 9971008. 105(11): 16051612. Baker KM Heart Fail Rev 1998. Whitehouse Station. Daño de Organo Blanco y Riesgo Cardiovascular Atherosclerosis* Vasoconstriction Vascular hypertrophy Endothelial dysfunction LV hypertrophy Fibrosis Remodeling Apoptosis GFR Proteinuria Aldosterone release Glomerular sclerosis Stroke Hypertension Heart failure MI DEATH Renal failure *preclinical data. 9(suppl 5): S37S44. Berkow R. NJ: Merck Research Laboratories 1999: 16821704. Fyhrquist F et al J Hum Hypertens 1995. MI = myocardial infarction.edu. Anderson S Exp Nephrol 1996. GFR = glomerular filtration rate Adapted from Willenheimer R et al Eur Heart J 1999. 17th ed. 35(2):179188 www. Fogo AB Am J Kidney Dis 2000. 9(suppl 5): S19S24. The Merck Manual of Diagnosis and Therapy.favaloro. eds.HTA.

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