Hypertension Flashcards by user 02

What is hypertension?

persistently elevated blood pressure

Repeated measurements showing values of ≥ 140mmHg systolic and ≥ 90mmHg diastolic

(≥ 140/90 mmHg)

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What are the 2 classifications of HTN?

1.Primary/essential/idiopathic

2.secondary

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What is the primary classification?

– No clear underlying cause

-95% of cases

Incidence increases with age
 Increased resistance in the peripheral arteries/arterioles

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What is secondary HTN?

– caused by the presence of another disorder
– e.g. endocrine disorders, kidney disease, medications, tumours
– Accounts for 5% cases

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What is stage 1 HTN?

Clinical blood pressure ≥ 140/90 mmHg

Average ambulatory BP ≥ 135/85 mmHg

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What is stage 2 HTN?

Clinical blood pressure ≥ 160/100 mmHg

Average ambulatory BP ≥ 150/95 mmHg

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What is stage 3 HTN?

Clinical systolic BP ≥180mmHg

or Clinical diastolic BP ≥110 mmHg

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What are the risk factors for HTN?

Family history
Afro-Caribbean race
Diabetes
Hypercholesterolemia
Obesity
Smoking

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If you are at risk of HTN , you are at increased risk of

increased risk of arterial sclerosis and athereresclerosis

which causes increased peripheral resistance

which causes increased bp

Blood vessels constrict to protect the tissues and organs from high pressure (vasoconstriction)

Results in: Decreased blood flow to vital organs and heart working harder to push blood through the narrow vessels

End organ damage: e.g. Heart disease, Heart attack, Stroke, Renal insufficiency, Retinopathy

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What causes Hypertensive choroidopathy

1.Acute rise in blood pressure leads to shut down of the

choriocapillaries – choroidal vascular insufficiency

Lack of blood supply to the choroid and overlying RPE – tissue infarction=
Elschnig Spots, Siegrist Streaks and Exudative Retinal Detachment

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Elschnig spots = small black spots surrounded by yellow haloes

1.RPE changes resulting from non-perfusion of the choriocapillaries (focal choroidal infarcts)

Early stages: yellow demarcated lesions

3.Late stages: central pigment spot within the yellow atrophic area

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Siegrist Streaks

-linear hyperpigmented streaks.

-over choroidal arteries

-Indicates sclerosis / necrosis of the underlying choroidal vessels

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exudative RD
Accumulation of subretinal fluid between the neurosensory retina and RPE

 Increased choroidal vascular permeability interferes with the RPE pumping mechanism – fluid accumulates and pushes the neurosensory retina away

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What is hypertensive retinopathy?

systemic ocular disorder

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why is it important to recognise the signs off hypertensive retinopathy?

Accumulation of subretinal fluid between the neurosensory retina and RPE
 Increased choroidal vascular permeability interferes with the RPE pumping mechanism – fluid accumulates and pushes the neurosensory retina away

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What are the symptoms of hypertensive retinopathy ?

-asymptomatic

Possible history of systemic hypertension (or could be
undiagnosed)

– Evidence of risk factors for hypertension

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What are the signs of hypertensive retinopathy?

signs classified by the Keith-wagener barker system
Vasoconstriction
 Arteriosclerotic changes
 Vascular leakage

Bilateral and symmetrical

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G1 : Arteriolar attenuation

vasoconstriction of retinal arterioles / narrowing of retinal arteries in response to systemic HTN

difficult o view on ophthalmoscopy

Indicator of chronically elevated BP

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Grade 3

focal attenuation and arteriosclerotic changes with retinal vessels

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FOCAL ATTENUATION
Strong indicator that blood pressure is raised
* May be easier to identify than generalised narrowing

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What are the grade 2 arteriosclerotic change?

g1: broadening of arteriolar light reflex

g2: deflection of the veins when crossing the arteries (Salus’ Sign)

g3- ‘ (Bonnet’s sign)
-(Gunn’s sign)

‘copper wiring’ of the retinal arterioles
right angled deflection of veins

g4:‘silver wiring’ of retinal arterioles

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What are the grade 2 arteriosclerotic change?

g1: broadening of arteriolar light reflex

g2: deflection of the veins when crossing the arteries (Salus’ Sign)

g3- ‘ (Bonnet’s sign)
-(Gunn’s sign)

‘copper wiring’ of the retinal arterioles
right angled deflection of veins

g4:‘silver wiring’ of retinal arterioles

atriovenus nipping is also referred as?

Salus’ vs. Bonnet’s vs. Gunn’s Sign

what is the pathogenesis of atriovenus nipping?

At crossing points arteries and veins share a common vascular sheath

– Thickening and hardening of the artery can compress the underlying vein

sales sign= when vein hardens and is pressed down by artery vein deflects

gunns sign= vein thins out on each side as artery crosses over

bonnets sign. vein becomes thicker in one side more than th other as the artery crosses overt

What is the arteriolar light reflex changes?

reflex becomes duller, broader and more diffuse (blood column less visible) Thicker walls and narrower vessel lumen changes nature of the reflex

Why do we get copper wiring?

Wall continues to thicken and lumen gets smaller * Reflection of light reduces – reflex becomes reddish-brown in appearance (copper wiring)

Why do we get silver wiring?

Wall gets thicker still, lumen gets even smaller, blood column is hardly visible * The vessel takes on a ‘silver wiring’ appearance

copper wiring

silver wiring

arteriolar sheathing

What grade is this hypertensive retinopathy?

Grade 2

What are the features of a grade 3 hypertensive retinopathy?

Haemorrhages (flame, blot,microaneuyrsyms) CWS Hard exudates Ischaemic and hypoxic environment * Break down of blood retinal barrier

microaneyrysms Earliest vascular sign * Indicates weakening of the blood vessel wall (pericyte loss)

CWS -indicate ischemia Capillary occlusion leads to interruption of the normal axoplasmic flow within the NFL Accumulation of transported materials in ganglion cell nerve axons we geswolen , fluffy lesions.

hard exudates, yellow/waxy shiny deposits

Difference between diabetic retinopathy and hypertensive retinopathy?

What is grade 4 malignant hypertension?

Optic disc oedema and/or macular star formation

Grade 4 malignant hypertension signs

Optic disc oedema: – Result of choroidal ischaemia and widespread vascular occlusion that occurs in MH – Early indicator Macula star: – Chronic retinal/macula oedema – Accumulation of exudate in Henle’s nerve fibre layer – Can take 1-2 weeks to develop

What ar the symptoms of malignant HTN?

Accelerated high blood pressure – SBP≥200mmHg DBP≥130/140mmHg -high risk to stroke,myocardial infarction, renal or heart failure – 3 year survival rate = 6% -» Decreased/dimmed vision » Headaches » Diplopia » Scotomas » Photopsia

What is the referral for each grade classification of hypertensive retinopathy?

What is the GP management?

Retinal Artery Macroaneurysms  Acquired localised round dilation that balloons over a major retinal artery branch  Superotemporal location most commonly  Strong association with systemic hypertension  Women, 50 and 80 years

Describe the pathogenesis of hypertensive retinopathy -asymptomatic until end stage (malignant

1. systemic HTN--> ret vessels vasoconstict. (G1) 2.atherosclerotic changes within the retinal vessels --> thickening of artery walls(G2) 3. reduces blood flow -- and retinal perfusion is reduced 4. Ischaemic and hypoxic environment to damages (endothelium) 5. blood retinal barrier disrupted, increased vascular permeability 6.Blood and plasma leak out of the blood vessels and into the surrounding retina (Grade 3 and Grade 4)

What is arteriolar sclerosis?

thickening, hardening and loss of elasticity of the walls of small arteries and arterioles - occurs with age, over long period of time

What is atheresclerosis?

narrowing of arteries from a build up of plaque - cholesterol, fatty substances, cellular waste products, calcium and fibrin - large and medium-sized arteries