Hypertension ____عبد الامير Flashcards
……………………
- they found that pt with BP 135/85 they have double risk of CVD
- pt with BP 155/95 they have 4 risk of CVD
- pt with BP 175/105 they have 8 risk of CVD
normal BP ?
LOWER than 120/80
elavated BP?
systolic 120or 129 but diastloic is80-89
hypertension pressure Stage 1 ?
S —(140-159 )
D—-(90-99)
hypertension pressure Stage 2 ?
S _____≥160 mm Hg
D_____≥100 mm Hg
what’re the types of the hypertension ?
1- Essential hypertension: 90 - 95 % means idopathic
2- secondary hypertension: 5 -10 %
a- renal diseases.
b- endocrinal causes.
c- pregnancy related.
d- drugs .
e- coarctation of aorta.
f- others.
what’s the Office BP Measurement ?
_auscultatory method
_seated quietly for 5 minutes in a chair
_feet on the floor,
_arm supported at heart level.
_Appropriate-sized cuff
_At least two measurements should be made
what’re CVD Risk Factors ?
-Hypertension*
-Cigarette smoking
-Obesity* (BMI >30 kg/m2)
-Physical inactivity
-Dyslipidemia*
-Diabetes mellitus*
-Microalbuminuria or estimated GFR <60 ml/min
-Age (older than 55 for men, 65 for women)
-Family history of premature CVD
(men under age 55 or women under age 65)
what’re the presentation of the hypertension ?
1- headache
2- fatigue
3-unsteadness
4-virtigo
what’re the complication of the hypertension TOD ?
TOD IS traget organ damage
1- BRIAN : hemorrhagic & ischemic stroke,SAH,TIA
hypertensive encephalopathy.
2- HEART: CHF , MI , Angina pectoris ,arrhythmias
& dissecting aortic aneurysm.
3- KIDNEY: proteinuria , Azotemia,hematuria& CRF .
4- EYES: retinal hemorrhge , papilledema, CVT & CAT.
hypertension might play an important role in the development of cataract
\+CHF Congestive heart failure \+Subarachnoid hemorrhage (SAH) \+Transient ischemic attack TIA \+Chronic Renal Failure (CRF) \+Cerebral venous thrombosis (CVT) \+Azotemia is a medical condition characterized by abnormally high levels of nitrogen-containing compounds (such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds) in the blood
what’re the secondary causes of the hypertension ?
مهم
1- Renovascular hypertension: severe HT, recurrent flash pulmonary odema& azotemia.
2- primary aldosteronism: polyuria ,unprovoked hypokalemia & generalized weakness.
3- pheochromocytoma : sudden paroxysms , severe HT ,anxiety ,sweating ,orthostatic changes& neurocutaneous lesions .
4- Cushing Syndrom: weight gain , mood changes ,Diabetes , Striae & proximal weakness.
5- Sleep Apnea Syndrome: nocturnal snoring , day time sleepness ,fatigue & poor concentration.
what’s the HYPERTENSIVE CRISIS ?
- when BP is higher than 130
- eyes__Fundoscopy showed hemorrhge ,exudate or papillodema
- heart___ Lt ventricular hypertrophy , congestive heart faliure
- kidney___ Azotemia , oliguria or protienuria
- GIT ___nausia & vomiting
- Hematological —- microangiopathic hemolytic anaemia
microcytic hemolytic anemia
How to approch to pt with hypertension ?
1- history
- about the previous blood pressure how it was and thearby
- search for enviromental , family risk factors
- any symptoms of the target organ as brain heart and perpheral arteries
- search for secondaries causes of HT as renal , drugs or endocrine
2- exam
- signs of secondary hypertension as cushing , pheocytchroma ,polycyctic disease or aortic corrcation
- signs of organs damage
retina , brain , heart , peripheral arteries - evidence of visceral obisty
- body wight , waist circumference , BMI
3- investigation
*Routine Tests
- Electrocardiogram ECG— for the heart
-Urinalysis ——-for the kidney
-Blood glucose, and hematocrit - kidney functions
Serum potassium, creatinine, or the corresponding estimated
GFR, and calcium
- Measurement of urinary albumin excretion or albumin/creatinine ratio
-Lipid profile, after 9- to 12-hour fast, that includes high-density—— to control the lipid
andlow-density lipoprotein cholesterol, and triglycerides
Optional tests
- US abdomen to see if there is polycytic disease
- X-ray
- echo study.
-More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
what’re the investigations of the of HT ?
- Routine Tests
- Electrocardiogram ECG— for the heart
-Urinalysis ——-for the kidney
-Blood glucose, and hematocrit - kidney functions
Serum potassium, creatinine, or the corresponding estimated
GFR, and calcium
- ## Measurement of urinary albumin excretion or albumin/creatinine ratio-Lipid profile, after 9- to 12-hour fast, that includes high-density—— to control the lipid
andlow-density lipoprotein cholesterol, and triglycerides
Optional tests
————————————————————- - US abdomen to see if there is polycytic disease
- X-ray
- echo study.
-More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
what’re the goal treatment of the hypertension ?
_Lifestyle modification
_Pharmacologic treatment
_Classification and management of BP for adults
_Follow up and monitoring
by
Treatment of :-
- All reversible risk factors
- Associated conditions
- Raised BP perse.
what’re the Benefits of Lowering BP?
- Heart failure >50%
- Stroke incidence 40%-35%- Myocardial infarction 20-25%
FUN FACT…
if pt with stage 1 HTN (S130-139 / D 180-189) with additional risk factor of CVD when the blood pressure lower 12 in systole for 10 years
this prevent the death of 1 for every 11
whats the target BP ?
- At least < 140/90 mmHg in all
hypertensives.- Definitely lower values if tolerated. - <130/80 mm Hg in diabetics,CHF & renal diseases
WHAT’RE THE Non-Pharmacological Approach
Life Style Measures ?
Smoking Cessation ↓ Wt ↓ excessive alcohol ↓ Salt intake ↑ Fruits and vegetables. ↓ Saturated and total fat intake
Weight reduction …
5–20mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
If pt with PB S less than 120 and D less than 80
- LIFE STYLE MODIFICATION
- WITH NO DURGS
If pt with PB S 120-129 and D 80-89
PERHYPETTENSIVE
- LIFE STYLE MODIFICATION
- No antihypertensive drug indicated IF THRERE IS NO COMPELING INDICATIONS OTHERWISE GIVE DRUGS FOR THE COMPELLING INDICATION
If pt with PB S 140-159 and D 90-99
stage 1 HTN
- life style modification
-Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.if Without compelling indication
but if With compelling indication
Drug(s) for the compelling indications.‡
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed
+calcium channel blockers
If pt with PB S equal or more 160 and D 100
stage 2 HTN
- life style modification
- Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB) if Without compelling indication
-With compelling indications
Drug(s) for the compelling indications.‡
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed
FUN FACT 2
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80mmHg.
How To Follow-up and Monitoring pt with HTN ?
Patients should return for followup and adjustment of medications until the BP goal is reached.
More frequent visits for stage 2 HTN or with complicating comorbid conditions.
Serum potassium and creatinine monitored 1–2 times per year.
After BP at goal and stable, followup visits at 3- to 6-month intervals.
Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency
of visits.
comorbidity is the presence of one or more additional conditions co-occurring with (that is, concomitant or concurrent with) a primary condition
First question why hypertension is imporant
Target organ damage to brain heart kidney and eyes
what is the new definition of hypertension
Consider hypertension when systolic blood pressure more than 130 mmHg with or without diastolic blood pressure more than 80mmHg
This level before 2 years was normal and hypertension was diagnosed at 140 / 90 mmhg
Because they consider the normal blood pressure when there is a lowest possible level of cardiovascular morbidity and mortality while increase risk at 130/90 mmHg
What is the exact relation of level of blood pressure and CV mortality
They found the increase of systolic blood pressure by 20 and diastolic blood pressure by 10 mmHg will double the mortality
Now you are facing a newly diagnosed patient with hypertension in out patient clinic how can you evalute this patient clinically
1-history
Measure the Bp
Search for family history
Search for secondary
2-Exam
We look for the signs of secondary HTN
Signs for organ damage
And estimated the obsity others risk factor
What point in history you concentrate
amily history , environmental factors and search for the secondary causes of the HTN
Simply the history should include symptoms evaluation and analysis ,assessment for presence of CV risk factors ,any target organ damage from history , family history of hypertension and any clue to secondary causes
Question to هاله محمود what points in examination you must elicit
You must measures blood pressure on both sides and at least twice reading for confirmstion of hypertension ,measure BMI,abdominal circumference, heart examination for TOD ,pulse examination invluding peripheral pulses and abdominal examination
Question to زينب فلاح what you look for in abdominal examination in hypertensive patient
west circumferce BMI
if you find an pulsating central abdominal massMay be aortic aneurysm
Means you have a high risk patient with hypertension need to be treated with antihypertensive medications to prevent rupture of aneurysm
So abdominal examination is so important in evaluation of hypertensive patient looking for TOD and secondary causes
On palpation you should look for any mass specialy renal mass
Question what are routine investigation for newly diagnosed patients with hypertension
1-ECG 2- urine exam 3-blood glucose and hematocrit 4-LFT 5-kidney function test
he ECG showed LVH what is mean to you
Hypertensive crisis
Simply means TOD for heart and this is high risk hypertensive patient
Hypertensive crisis when patient had rapid rise of blood pressure more than 200/110 mmhg
What are the drugs use in hypertensive crisis in emergency care
usually in these situation we need to give parentral antihypertensive drugs specially if there is TOD
Under strict hemodynamic monitoring in ICU
As I.v vadodilators sodium podium nitroprosside, Labetolol , esmolol ,frusemide
Avoid rapid reduction in blood pressure if possible try gradully decrease blood pressure
hat are the antihypertensive drugs used in pregnancy and lactation
Beta blockers as labetolol
- Ca channel blocker as nifedipine
- Centeral acting antiadenergic as methyldopa
- Hydralazine
