HYPERTENSION __Ch. 11

1
LESSON 3

• HYPERTENSION __Ch. 11
• VASCULAR DISEASES __Ch. 12

2
HYPERTENSION
3
Demography of htn

• 50 million have the disease
• 70 aware of it
• Only 50 get treated
• Only 25 have controlled bp
• More common in Afro Americans
• Major cause for end stage renal disease and
• heart failure

4
Assessment and Diagnosis of HTN
5
Assessment and Diagnosis of HTN
6
Physical exam should include

• Vital Stat height, weight, and waist
  circumference
• funduscopic exam (retinopathy) carotid
  auscultation (bruit)
• jugular venous pulsation
• thyroid gland (enlargement)
• cardiac auscultation

• chest auscultation abdominal exam (bruits,
  masses, pulsations)
• exam of lower extremities
• routine labs include urinalysis, complete blood
  count, electrolytes (potassium, calcium),
  creatinine, glucose, fasting lipids, and 12-lead
  electrocardiogram

7
secondary causes of hypertension-suggestive
(clues in parentheses) of

• (1) Pheochromocytoma
• (labile or paroxysmal hypertension
  accompanied by sweats, headaches, and
  palpitations)
• (2) Renovascular disease
• (abdominal bruits)
• (3) APKD-autosomal dominant polycystic kidney
  disease (abdominal or flank masses)
• (4) Cushing's syndrome
• (truncal obesity with purple striae)
• (5) Primary hyperaldosteronism (hypokalemia)

• (6) Hyperparathyroidism (hypercalcemia)
• (7) Renal parenchymal disease (elevated serum
  creatinine, abnormal urinalysis),
• (8) Poor response to drug therapy,
• (9) SBP gt 180 or DBP gt 110 mm Hg, or
• (10) sudden onset of hypertension.

8
JNC VII 2003 recommendations
9
Prehypertension

• gray area of 120139/8089 mm Hg
• a trend away from defining hypertension as a
  simple numerical threshold
• antihypertensive medications be offered to
  persons with prehypertension with compelling
  indications

10
Lifestyle Modifications for Primary Prevention
of Hypertension
11
? DASH Dietary Approaches to Stop Hypertension
12
LOW RISK CANDIDATES
13
COMPELLING CONDITIONS
RECOMMENDED DRUGS
14
PRIMARY HYPERTENSION

• NO IDENTIFIABLE CAUSE (95)
• 30 OF BLACKS/20 OF WHITES
• 25-55 YEAR AGE GROUP
• MULTIFACTORIAL

15
PRIMARY HYPERTENSION CAUSES

• GENETIC
• OBESITY
• SALT INTAKE
• SYMPATHETIC SYSTEM OVERACTIVITY
• ABNORMAL CVS DEVELOPMENT
• RENIN-ANGIOTENSIN ACTIVITY
• ALCOHOL/CIGARETTE/POLYCYTHEMIA

16
Associated causes of hypertension

•   Sleep apnea
• Drug-induced or drug-related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Long-term corticosteroid therapy and
• Cushing's syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

17
RENAL ARTERY STENOSIS

• 1-2 OF HTN PATIENTS
• YOUNGER(lt20 YRS AGE)
• FIBROMUSCULAR HYPERLASIA (flt50)
• LEADS TO EXCESSIVE RENIN RELEASE

18
RENAL ARTERY STENOSIS

• SUSPECT WHEN
• HTN ONSET lt20 YRS AGE OR
• OCCURS AFTER 50
• DRUG RESITANT HTN
• PRESENCE OF EPIGASTRIC OR
• RENAL BRUITS
• PRESENCE OF SIGNIFICANT PERIPHERAL VASCULAR
  DISEASE
• RENAL FUNCTION DETERIORATES AFTER ACEi
  administration

19
RENAL ARTERY STENOSIS

• Tests-
• Radioisotope renography
• duplex us
• MRA/CT ANGIO
• RENAL ARTERIOGRAPHY
• TREATMENT- vascular reconstruction

20
Primary hyperaldosteronism

• Due to excessive aldosterone secretion
• Test-
• check plasma aldosterone levels
• Plasma rennin levels
• Calculate aldosteone/rennin ratio (nomral lt25)
• Cause- Adrenal Adenoma- requires ct/mri scan

21
CUSHINGS SYNDROME

• Glucocorticoid excess
• HTN (75-85) of cases
• Increased Rennin-Angiotensin activity

22
Pheochromocytoma

• 0.1 of all htn patients
• 2/1ooo,ooo incidence
• Hypertensive crisis (BP 300gt)
• Associated with Café au Lait spots and
  neurofibromatosis

23
Other causes for secondary HTN

• Estrogen
• Acromegaly
• Hyperthyroidism
• hypothyroidism
• DRUGS cyclosporine and NSAIDs

24
Complications of HTN

• excess morbidity and mortality related to
  hypertension
• risk doubles for each 6 mm Hg increase in
  diastolic blood

25
Complications of HTN

• Cardiac Complications
• Left Ventricular Hypertrophy congestive heart
  failure
• ventricular arrhythmias
• myocardial ischemia and
• sudden death.

26
Complications of HTN

• Cerebrovascular Disease and Dementia -
  hemorrhagic and ischemic stroke
• higher incidence of subsequent dementia of both
  vascular and Alzheimer types
• markedly reduced by antihypertensive therapy

27
Complications of HTN

• Hypertensive Renal Disease
• renal insufficiency
• hypertensive nephropathy
• more common in blacks
• associated with Diabetes Mellitus
• Benefits with ACEi therapy

28
Complications of HTN

• Aortic dissection
• Increased Atherosclerosis

29
SYMPTOMS OF HTN

• mainly referable to involvement of the target
  organs
• Heart
• Brain
• Kidneys
• Eyes and
• Peripheral arteries.

30
Symptoms of HTN

• Mainly asymptomatic
• Early morning suboccipital pulsating HA
• Hypertensive Encephalopathy Somnolence/confusion/
  Visual/
• Nausea/Vomiting
• (Diastolic BP gt130)

31
Signs of HTN

• Heart Left ventricular enlargement/Hypertrophy
• LAB workup CBC/Urinalysis/FBS/LIPIDS/
• Serum Uric Acid /Electrolytes/Creatinine/
• BUN
• ECG/CXR

32
(No Transcript)
33

34
ECG LV Strain Pattern

• Suggests Advanced disease
• Poor prognosis
• Other Investigations
• Renal US/CT/MRI scans

35
Management Algorithm
36
NON PHARMACOLOGIC THERAPY

• CHANGE LIFESTYLE DASH DIET
• Weight reduction
• Reduced alcohol consumption
• Reduced salt intake
• Gradually increasing activity levels

37
Goals of Treatment

• diabetic patients, CKD, should be lower
• (lt 130/80 mm Hg)
• Others (lt140/90)
• long-term adverse consequences of drug therapy
  ß blockers, Thiazides
• statins can significantly improve outcomes in
  DM/Post MI (total and LDL cholesterol levels of
• lt 194 mg/dL and lt 116 mg/dL )

38
Current Antihypertensive Agents

• Diuretics
• HCTZ (Esidrix, Hydro-Diuril)
• LOOP DIURETICS - Ethacrynic acid (Edecrin)
  Furosemide (Lasix)
• ALDOSTERONE RECEPTOR BLOCKERS  - Amiloride
  (Midamor)
• Spironolactone (Aldactone)
• alone -control blood pressure in 50

39
Side effects of diuretics

• Hypo-K, Hypo-Mg2, Hypo-Ca2, Hypo-Na,
• Hyper-uric acid (gout),  Hyper-glucose,
• Increase LDL cholesterol, Increase
  triglycerides rash, erectile dysfunction.

40
Adrenergic Blocking Agents

• Beta blockers
• decrease the heart rate and cardiac output
• Acebutolol(Sectral)
• Atenolol(Tenormin)
• Metoprolol(Lopressor)
• Pindolol (Visken)
• Propranolol (Inderal)

41
Side effects of Beta Blockers

• exacerbating bronchospasm
• bradycardia or AV block
• precipitating or worsening l vf
• nasal congestion
• Raynaud's phenomenon
• nightmares
• Increase TGL Decrease HDL

42
ACE Inhibitors

• initial medication
• Benazepril (Lotensin)
• Captopril (Capoten)
• Enalapril (Vasotec)

43
RAAS System
44
Side Effects Of ACEi

• Cough
• hypotension
• dizziness
• renal dysfunction
• hyperkalemia
• angioedema
• taste alteration and
• rash
• Contraindicated in pregnancy
• Acute Renal Failure

45
Angiotensin Receptor Blockers ARBs

• Candesartan (Atacand)
• Eprosartan (Teveten)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• do not cause cough

46
The ABCD rule

• B and D may induce more new-onset diabetes
• A ACEi or ARBs
• Bß Blockers
• C CCBs
• D Diuretic (thiazide)

47
BHS Guidelines

• Young Elderly
• (low renin)
• A B C D
• A ACE Inhibitor
• B Beta Blocker
• C Calcium Channel Blocker
• D Diuretic

48
Afro-Americans and HTN

• more likely to become hypertensive and
• more susceptible to the cardiovascular
  complications
• Respond differently to drugs ACEi and ARBs are
  less effective

49
Follow up of HTN patients

• Achieve good control
• Need less frequent visits
• Yearly monitoring of blood lipids and
• an ECG should be repeated at 2- 4 years

50
HTN Crisis (gt220/130)

• requires prompt recognition and aggressive
  management
• blood pressure must be reduced within a few hours
  
• hypertensive encephalopathy
• (headache, irritability, confusion, and
• altered mental status due to cerebrovascular
  spasm)

51
HTN Crisis

• hypertensive nephropathy (hematuria, proteinuria,
  and progressive renal dysfunction )
• intracranial hemorrhage, aortic dissection,
  preeclampsia-eclampsia, pulmonary edema, unstable
  angina, or myocardial infarction

52
initial goal in hypertensive emergencies

• reduce the pressure by no more than 25 (1 or 2
  hours )
• then toward a level of
• 160/100 mm Hg within 26 hours
• Excessive reductions may precipitate coronary,
  cerebral, or renal ischemia

53
a AlphaADRENOCEPTOR BLOCKERS

• Prazosin (Minipress)
• Terazosin (Hytrin)
• Doxazosin (Cardura)
• relax arterial smooth muscle, and reduce blood
  pressure
• no adverse effect on serum lipid levels
• they increase HDL cholesterol
• reduce total cholesterol

54
Pulmonary Heart Disease (Cor Pulmonale)

• Symptoms and signs of chronic bronchitis and
  pulmonary emphysema.
• Elevated jugular venous pressure, parasternal
  lift, edema, hepatomegaly, ascites.
• RV hypertrophy and eventual failure

55
Findings in Cor Pulmonale

• chronic productive
• cough
• exertional dyspnea
• wheezing respirations
• easy fatigability, and weakness
• oxygen saturation is often below 85

56
Cor Pulmonale

• Oxygen
• salt and fluid restriction and
• diuretics
• the average life expectancy is 25 years when CHF
  appears

57
Aneurysms of the Abdominal Aorta

• asymptomatic, detected during a routine physical
  examination or a diagnostic study.
• Severe back or abdominal pain, a pulsatile mass,
  and hypotension indicate rupture
• 90 of abdominal aneurysms originate below the
  renal arteries

58
Aneurysms of the Abdominal Aorta

• 90 of abdominal aneurysms originate below the
  renal arteries
• 58 of men over the age of 65 years
• detection of a prominent aortic pulsation

59
Hypotension Shock
60
Features

• Hypotension,
• tachycardia,
• oliguria,
• altered mental status.
• Peripheral hypoperfusion and
• hypoxia.

61
physiologic response to Shock

• Sympathetic response
• Release of Norepinephrine
• Renin
• ADH
• Glucagon
• Cortisol
• Growth Hormone

62
Causes

• Hypovolemic
• Cardiogenic
• Obstructive- Pneumothorax/
• Pulmonary embolism
• Distributive- pancreatitis
• Septic shock

63
Features of Septic Shock

• fever
• chills
• hypotension
• Hyperglycemia and
• altered mental status
• due to gram-negative bacteremia (E coli,
  Klebsiella, Proteus, and Pseudomonas)

64
Hypotension

• systolic blood pressure of 90 mm Hg or less
• A drop in systolic pressure of more than 1020 mm
  Hg and
• an increase in pulse of more than 15 with
  positional change

65
Treatment General Measures

• Basic life support-(BLS) airway/oxygen/cpr
• Advanced Cardiac Life Support (ACLS)

66
Orthostatic Hypotension

• Vasomotor Syncope
• Elderly
• Diabetics
• greater than normal decline
• (20 mm Hg) in blood pressure immediately upon
  arising from the supine to the standing position

67
VASCULAR DISORDERS
68
Aneurysms of Abdominal Aorta AAA

• Most aortic aneurysms are asymptomatic, detected
  during a routine physical examination or a
  diagnostic study.
• Severe back or abdominal pain, a pulsatile mass,
  and hypotension indicate rupture.
• Concomitant atherosclerotic occlusive disease of
  the lower extremities is present in 25 of
  patients.

69
AAA

• 90 below the level of renal arteries
• Normal aortic diameter 2cms. gt3 cms is aneurysm
• 1951 from 8.7 per 100,000
• 1980 36.5 per 100,000
• Prevalence 5-8 M gt 65
• US screen
• Associated with popliteal artery aneurysms

70
AAA Rupture Signs!

• A RED FLAG needs referral to ER
• Severe back/ abdo/flank pain
• Hypotension
• 90 fatal unless repaired surgically

71
AAA

• Therapy
• Beta blockers
• Surgical excision and graft
• Rupture risk-
• 2 (4-5.5cm)/ 7
• (6-6.9cma0/ 25 (gt7cm)
• Five-year survival after surgical repair is
  6080

72
Peripheral Artery Aneurysms (Popliteal Femoral)

• M gt50
• Associated AAA
• Popliteal most common peripheral
• artery aneurysm
• Arterial thrombus rather than rupture
• needs amputation (30)
• US diagnostic
• Surgery

73
Lower Extremity Occlusive Disease

• 8-12 million affected
• Independent risk factor for CAD
• Intermittent claudication
• M,F (40-55)
• Atherosclerosis, diabetes, HTN
• erectile dysfunction,
• claudication,
• rest pain, and
• gangrene

Triad of bilateral hip and buttock claudication,
erectile dysfunction, and absent femoral pulses
is known as Leriche's syndrome.
74
Tests

• Absent/ diminshed peripheral pulses
• anklebrachial index (ABI) - A normal ratio of
  ankle to brachial systolic blood pressures is
  1.0 less than 0.8 is consistent with
  claudication.
• Rest pain and nonhealing ulcers
• Lipid-lowering medications have been shown to
  produce a 40 risk reduction for new-onset
  claudication or worsening of claudication.
• phosphodiesterase inhibitor, cilostazol (100 mg
  orally twice daily)
• Carnitine
• Ginkgo biloba

75
Acute Limb Ischemia

• embolic, thrombotic, or traumatic.
• six Ps pain, pallor, pulselessness,
• paresthesias, poikilothermia,
• and paralysis.
• Embolic- 90 cardiac
• Heparin and embolectomy
• EMERGENCY!
• Critical time lt6hrs

76
Thromboangiitis Obliterans (Buerger's Disease)

• Cause unknown
• M lt40, smokers, European/Asiatic
• Claudication/ Rest pain
• Necrosis/ ulceration
• Foot arch pain, rest pain, calf pain
• Proximal pulses present / distal pulses absent
• DD ?SLE/ clotting disorders/ ergot ingestion,
  cannabis arteritis
• STOP SMOKING

77
Vasculitis

• fever, malaise, weight loss, elevated white blood
  cell count and sedimentation rate, arthralgias,
  conjunctivitis, or erythema nodosum.
• Drugs- amphetamines, cocaine, hydralazine,
  procainamide
• Infections-hepatitis B, gonococcus, streptococcus

78
Raynaud's Disease Raynaud's Phenomenon

• idiopathic, it is called Raynaud's disease.
• precipitating systemic or regional disorder
  (autoimmune diseases, myeloproliferative
  disorders, multiple myeloma, cryoglobulinemia,
  myxedema, macroglobulinemia, or arterial
  occlusive disease), it is called Raynaud's
  phenomenon
• ? up-regulation of vascular smooth muscle
  2-adrenergic receptors.

79

• Raynaud's disease appears first between ages 15
  and 45, almost always in women.
• A patient with suggestive symptoms that persist
  for over 3 years without evidence of an
  associated disease is given the diagnosis of
  Raynaud's disease.

80
(No Transcript)
81
Varicose Veins

• Dilated, tortuous superficial veins in the lower
  extremities.
• Associated with fatigue, aching discomfort,
  bleeding, or localized pain.
• Edema, pigmentation, and ulceration suggest
  concomitant venous stasis disease.
• Increased frequency after pregnancy.
• ? varicoceles, esophageal varices, and
  hemorrhoids
• Seen in 15 long saphenous veins
• Factors F, pregnancy, family history, prolonged
  standing, and history of phlebitis
• Inherited vein wall or valvular defect

82
Varicose Veins

• Dull, aching heaviness or a feeling of fatigue
  brought on by periods of standing is the most
  common complaint.
• Itching from an associated eczematoid dermatitis
  may occur above the ankle.
• Complications of varicose veins include secondary
  ulceration, bleeding, chronic stasis dermatitis,
  superficial venous thrombosis, and
  thrombophlebitis.

83
Varicose Veins

• Therapy- Non surgical- compression stockings
• Leg elevations/exercises/ Ace wraps
• Surgery- ligations
• 10 recur
• endovenous laser ablation (EVLA)
• ultrasound guided sclerotherapy (UGS)
• varicose vein surgery

84
DVT

• Pain in the calf or thigh, often associated with
  edema. Fifty percent of patients are
  asymptomatic.
• History of congestive heart failure, recent
  surgery, trauma, neoplasia, oral contraceptive
  use, or prolonged inactivity.
• Physical signs unreliable.
• Duplex ultrasound is diagnostic.
• 800,000 new patients/year
• stasis, vascular injury, and hypercoagulability

85
DVT

• 65 recover
• 35 develop post dvt venous insufficiency
• 80 DVT in calf
• Related to surgery 3 show symptoms/ 30 show no
  signs/symptoms
• Contributing factors Prolonged bed rest or
  immobility caused by cardiac failure, stroke,
  ventilatory support, pelvic bone or limb
  fracture, paralysis, extended air travel, or a
  lengthy operative procedure

86
DVT

• Other risk factors-
• advanced age
• type A blood group
• Obesity
• previous thrombosis
• multiparity
• use of oral contraceptives
• inflammatory bowel disease and
• lupus erythematosus
• 50 asymptomatic

• Uncommon causes-
• malignancy
• nephrotic syndrome
• inherited deficiency disorders-
• protein C or S or antithrombin III,
• homocystinuria,
• factor V Leiden mutation, or
• paroxysmal nocturnal hemoglobinuria

87

• Diagnostic tests necessary
• Duplex Doppler US
• Venograms rarely used
• D-dimer test
• Complications of DVT include pulmonary embolism
• Therapy- Heparin and warfarin
• For the first episode of uncomplicated DVT is 36
  months of warfarin to maintain a goal INR of
  2.03.0. After a second episode, warfarin is
  continued indefinitely.

88
Chronic venous insufficiency

• History of phlebitis or leg injury.
• Ankle edema is the earliest sign.
• Late signs are stasis pigmentation, dermatitis,
  subcutaneous induration, varicosities, and
  ulceration.
• incurable but manageable problem.

89
Lymphangitis Lymphadenitis

• Red streak extending from an infected area toward
  enlarged, tender regional lymph nodes.
• Chills, fever, and malaise may be present.
• Streptococcal or staphylococcal infections
• Superficial scratch with cellulitis, an insect
  bite, or an established abscess.
• Red streak extending toward tender, enlarged
  regional lymph nodes is diagnostic.
• WBC elevated
• DD Cat scratch disease (Bartonellosis)
• IV antibiotics otherwise septicemia can happen

90
Lymphedema

• Painless edema of upper or lower extremities.
• Involves the dorsal surfaces of the hands and
  fingers or the feet and toes.
• Developmental or acquired, unilateral or
  bilateral.
• Edema is pitting initially and becomes brawny and
  nonpitting with time.
• Ulceration, varicosities, and stasis pigmentation
  do not occur. There may be episodes of
  lymphangitis and cellulitis.

91
Lymphedema causes

• Congenital
• Familial
• Unilateral (FM 3.51)
• Secondary- Obstruction lymphatics/ Lymphnode
  resection/ Radiation/ Lymphomas/
• No cure
• External compression, leg elevation, massage