Download Hypertension - Medicine is an art

1-Mais Al-Joulany
2-Eman Al-Zaidi
3-Roaa al Khalifah
4- Reham Ghazal
5- Horyah Al-Ismail
6-Ibtihal Al-Drees
7-Abeer Al-Hatim
8- Fatmah Al-Rojaiy
9- Cady Al-Shammary
•Identify differential diagnosis of a case presented with the
symptoms of lower limb oedema.
•Differentiate between different etiologies of hypertension.
•Discuss briefly between stages of hypertension.
•Enumerate and discuss the importance signs& symptoms in
patients with hypertension.
•Investigate appropriately apatient with hypertension.
•Advice initial management plan for a patient with hypertension according to
recent guidelines (NICE 127).
•Discuss non-drug management of hypertension.
•Identify long term complications of hypertension.
A 50-year-old woman presents to your clinic for routine followup. She has a history of diabetes mellitus and hypertension for ~
20 years. She mentions that she has noted fatigue and increased
swelling in her lower extremities during the past several weeks.
Medications:
- Lisinopril 10 mg p.o. q.i.d.
- NPH insulin 20 units s.c. Q. a.m. and 10 units s.c. q. p.m.
- Regular insulin 5 units s.c. Q. a.m..
On exam she appears to be in no apparent distress. Her height
is153 cm and weight is 100kg.
Blood pressure is 165/98 mmHg, pulse 85/minute and
respirations 20/minute.
Fundoscopic exam reveals diabetic retinopathy. There were no
visible hemorrhages or papilledema.
Cardiac exam was remarkable for an S1, S2 and S4.
Lungs were clear to auscultation and percussion.
Abdomen was obese, non-tender and without masses or bruits.
Lower extremities had good pulses with 3+ pitting edema.
Neurological exam is remarkable for decreased sensation in a
stocking-glove distribution, otherwise intact.
Heart disease is still leading cause of death
Significant morbidity and mortality
- CAD including MI and CHF
- Stroke
- Chronic kidney disease
comprehensive investigations for blood pressure assessment in 35
areas of Saudi Arabia.
Applying the criteria of W.H.O. of blood pressure > 160/95 mmHg as
hypertension
measured systolic and diastolic blood pressure in 14,660 adult Saudis
(6,162 males and 8,498 females)
they found prevalence Among the adults (> 18 years), 5.3% had systolic
hypertension, while 7.9% had diastolic hypertension.
The majority (>75%) of those with hypertension were 40 years of age or
older.
In the age group 40-75 years, they found that a higher prevalence of :
- systolic hypertension : Females > Males (15.7%)
- diastolic hypertension: Males > Females (8.2%)
Out of 65% of people over age 60 diagnosed with
hypertension :
Only 1 in 4 of these individuals are taking adequate
medication
Framingham data suggests that individuals who are
normotensive at age 55 have a 90% lifetime risk of
developing HTN
Common Causes of Leg Edem
Unilateral
Acute
Deep vein
Bilateral
Chronic
Venous
insufficiency
Chronic
Venous
insufficiency
Pulmonary
hypertension
Heart failure
Idiopathic
edema
Lymphoedema
Less Common Causes of Leg Edem
Unilateral
Chronic
Secondary
lymphedema
(tumor, radiation,
surgery, bacterial
infection)
Bilateral
Acute
Bilateral deep vein
thrombosis
Acute worsening of
systemic cause
(heart failure, renal
disease)
Chronic
Renal disease
(nephrotic syndrome,
glomerulonephritis
Liver disease
Diuretic-induced
edema
Preeclampsia
Anemia
A term used to describe high blood pressure.
Blood pressure is a measurement of the force against
the walls of the arteries as the heart pumps
blood through the body.
The risk of morbidity and mortality increases
progressively with increasing systolic and diastolic
blood pressure..
Non- modifiable factors
Advanced
age
Race
especially
those 60 years
and older
Black people.
Genderrelated risk
patterns
Men and
postmenopaus
al women
Fetal factor
& family
history
Babies
born with
low birth
weight get
high BP
Family
history of
hypertensi
on and
CVS
diseases
Modifiable factors
Increase
salt intake
causes increase
blood volume,
increase cardiac
output, increase
peripheral
resistance
Increase
alcohol
consumption
systolic BP is
affected more.
Smoking
Stress
Obesity
increase
sympathetic
activity
lepton hormone
derived from
adipose tissue,
causes increase
sympathetic
activity via
hypothalamus
hypertensive crisis :
(BP >180/120 mm Hg) may be categorized as either
- hypertensive emergency (extreme BP elevation with
acute or progressing target organ damage)
- hypertensive urgency (severe BP elevation without acute
or progressing target organ injury).
- Malignant hypertension when diastolic BP more than
130mmHg. Unless treated, it may lead to death due to
renal failure, heart failure or stroke.
- BP must be measured correctly
- Feet on floor
- Both arms if elevated
- Cuff bladder must circle at least 80% of the arm
- Arm supported at level of heart
- Back supported
- Measure blood pressure in both arms
In clinic:
- IF blood pressure ( 140/90 mmHg ) or higher confirm by
ambulatory blood pressure monitoring (ABPM).
> least 2 measurements/ hr during person’s waking hours
> average value of at least 14 measurements taken to confirm HTN
At home:
Use home blood pressure monitoring (HBPM) to confirm a
diagnosis of hypertension
> blood pressure is recorded twice daily ( morning/evening )
> blood pressure recording continues for at least 4 days, ideally for 7 days
Discard the measurements taken on the first day and use the average
value of all the remaining measurements to confirm a diagnosis of
hypertension.
ABPM
HBPM
Postural hypotension
● In people with symptoms of postural hypotension (falls or postural
dizziness):
− measure blood pressure with the person either supine or
seated
− measure blood pressure again with the person standing for at
least 1 minute prior to measurement.
● If the systolic blood pressure falls by 20 mmHg or more when the
person is standing:
− review medication
− measure subsequent blood pressures with the person
standing
− consider referral to specialist care if symptoms of postural
hypotension persist.
1) Primary (essential) Hypertension:
Has no known cause (idiopathic)
Multi-factorial etiology :
1.Genetic Factors
- Positive Family History
2. Environmental Factors
-Obesity
-Increased Sodium Intake
-Stress
- Increased Alcohol Intake
-95% of hypertensive patient fall into this category.
2) Secondary Hypertension:
Due to an underlying medical condition
Chronic
alcohol abuse
Endocrine
Renal
Cardiovascular
Medications
2) Secondary Hypertension:
Renal:
- Polycystic disease
- Renal artery stenosis
- Renin-producing tumors
- Chronic renal disease
- Renal vasculitis
2) Secondary Hypertension:
Endocrine:
- Adrenocortical hyperfunction (Cushing syndrome,
primary aldosteronism,congenital adrenal hyperplasia)
- Exogenous hormones (glucocorticoids, estrogen)
- Pheochromocytoma
- Hypothyroidism
- Hyperthyroidism
- Pregnancy-induced
2) Secondary Hypertension:
Cardiovascular:
- Coarctation of aorta
- Vasculitis
- Increased intravascular volume
2) Secondary Hypertension:
Medications:
- Steroids
- Oral contraceptives
- Amphetamines and cocaine
- Nonsteroidal anti-inflammatory
- Psychiatric: carbamazepine, lithium and tricyclic
antidepressants
1) Severe headache
2) Fatigue or confusion
3) Vision problems
4) Chest pain
5) Difficulty breathing
6) Irregular heartbeat
7) Hematuria
8) Lower limb edema
Note :
Patients with pheochromocytoma may have a history
of paroxysmal headaches, sweating, tachycardia,
palpitations, and orthostatic hypotension.
Urine stick test for
protein & blood
ECG
Routine
investigation
Fasting blood for (total
&HDL cholesterol
+Glucose )
Serum urea, creatinine
& electrolytic
Optional laboratory tests:
Aortic Coarctation
-
Arm to leg systolic Blood Pressure difference (abnormal if >20 mmHg)
Chest X-Ray (notching of the lower rib borders)
Echocardiogram (Children)
MRI Chest (Adults)
Cushing's Disease
- 24 hour Urine Cortisol
- Late night Salivary cortisol
- Low dose Dexamethasone Suppression Test
Pheochromocytoma
- 24h Urine Metanephrine
- Plasma free metanephrines
X-rays :
- May show cardiomegaly
X-RAY CHEST IN HEART FAILURE
Specialist investigations
● Refer people to specialist care the same day if they have:
− accelerated hypertension (BP > 180/110 mmHg ) with signs of
papilloedema and/or retinal haemorrhage)
− suspected phaeochromocytoma (labile or postural hypotension,
headache, palpitations, pallor and diaphoresis).
● If nedded more investigations for secondary cause of hypertension.
1) Weight reduction (BMI, 18.5 to 24.9 kg/m2)
2) Adoption of the Dietary Approaches to Stop
Hypertension (DASH) eating plan :
- Low content of saturated fat, cholesterol, and total fat
- Focuses on fruits, vegetables, and fat-free or low-fat
dairy products
- Rich in whole grains, fish, poultry, beans, seeds, and nuts
- Contains fewer sweets, added sugars and sugary
beverages, and red meats
- Dietary sodium restriction ideally to 1.5 g/day
•
4) Regular aerobic physical activity.
5) Moderate alcohol consumption (2 or fewer
drinks/day).
6) Smoking cessation
7) Do not offer calcium, magnesium or potassium
supplements as a method of reducing blood pressure
HNT Drugs
thiazide
diuretics
ACE
inhibitors
calcium
antagonists
(CA)
β-blockers
(BB).
angiotensin
receptor
antagonists
(ARB)
*Will lower BP and reduce the complications of
HTN
I) Thiazide diuretics:
● Where to start?
- Hydrochlorothiazide 12.5 mg
- Chlorthalidone 12.5 mg
● How much ?
- Up to 25 mg, unclear benefit beyond that
● Cost? Cheap!
● Side effects -- hypokalemia, glucose intolerance
2) ACE Inhibitors
● Where to start?
- Lisinopril 10 mg QD
- Benazapril 10 mg QD
- Enalapril 5 mg QD
● How much?
- Up to 80 mg (only 40 mg for enalapril)
● Cost -- cheap!
● Side effects -- cough
3) CCBs
● Where to start?
- Amlodipine 5 mg QD
- Diltiazem ER 120 mg QD
- Nifedipine ER 30 mg QD
● How much ?
- Amlodipine 10 mg QD
- Diltiazem ER 540 mg QD
- Nifedipine ER 120 mg QD
● Cost ?
- Amlodipine is generic
- Diltiazem=cheap!
- Nifedipine-less cheap
● Side effects ?
- edema
- constipation
3) Beta Blockers
● Where to start?
- Not with beta blockers
● Why not?
- Possible increase in stroke risk, particularly in
elderly patients
- first-line alternatives in patients who are 60 years and
older, especially for stroke prevention.
3) Beta Blockers
● Where to start?
- Metoprolol 25 mg BID
- Atenolol 25 mg QD
● How much ?
- Up to 100 mg
● Cost -- cheap!
● Side effects -- bradycardia, fatigue, depression
Even More Meds
● ARBs (losartan is generic but still pricey)
● Alpha blockers
● Aldosterone antagonists
ACE inhibitors and ARBs not as effective in African-Americans
Labs: Potassium and Creatinine, maybe sodium
● at initiation of treatment
● 2-4 weeks after starting
● Again after every dose adjustment
● Annually
Heart
Blood
vessels
Kidney
brain
Organs
affected
eyes
1)Atherosclerosis:
formation of fibro fatty lesions in the intimal lining of the large
and medium sized arteries such as aorta and its branches,
coronary arteries and cerebral arteries
2)Stroke or Heart Attack:
If an atherosclerotic plaque breaks off inside the artery, or the
blood vessel ruptures, a blood clot can form within the artery. If
this blocks blood flow to the brain it can lead to a stroke. If it
blocks blood flow to the heart it can result in a heart attack.
3)Aneurysm:
This is when the blood vessels have been weakened to such an extent
that part of the blood vessel wall ‘balloons’ or bulges. The most
common locations for an aneurysm include the main artery that
carries blood from the heart, arteries in the
brain, legs, intestines, and the arteries leading to the spleen
4)Vascular dementia:
High blood pressure can cause the blood vessels that supply your
brain with blood to narrow or become damaged. If the brain is not
supplied with enough oxygen due to stroke, cells in the brain may be
damaged causing adverse effects on a person’s memory, thinking, or
language skills. This condition is called vascular dementia
5) Hypertensive retinopathy :
- Kumar & Clark's Clinical Medicine (Saunders, 2009)
- Davidson's Principles and Practice of Medicine 21st
Edition
- Pharmacotherapy 7th edition McGraw Hill Dipiro
- NICE quick reference HTN
Thanks!!
Have a Nice Day
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