1 hypertension v.v.l.n.s.n.gupta. 2 risk stratification of patients with hypertension blood pressure...
TRANSCRIPT
1
HYPERTENSION
V.V.L.N.S.N.Gupta
2
Risk stratification of patients with hypertension
Blood pressure (mm Hg)
Stage Other risk factors and disease history
Stage 1 Stage 2 Stage 3
SBP 140-159 or DBP 90-99
SBP 160-179 or DBP 100-109
SBP 180 or DBP 110
I No other risk factors Low risk Medium risk High risk
II 1-2 risk factors Medium risk Medium risk Very high risk
3
Risk stratification of patients with hypertension
Blood pressure (mm Hg)
Stage Other risk factors and disease history
Stage 1 Stage 2 Stage 3
SBP 140-159 or DBP 90-99
SBP 160-179 or DBP 100-109
SBP 180 or DBP 110
III 3 or more risk factor or TOD or Diabetes
High risk High risk Very high risk
IV ACC Very high risk Very high risk Very high risk
Risk strata (typical 10 year risk of stroke or myocardial infarction):Low risk = Less than 15%Medium risk = about 15-20%High risk = about 20-30%Very high risk – 30%TOD: Targe Organ DamageACC: Associated clinical condition, including clinical cardiovascular disease or renal disease
4
Risk factors for HTN:
1. Non-modifiable
2. Modifiable
5
Non-modifiable risks:
1. Age
2. Genetic factors
6
Modifiable risks:
1. Obesity
2. Salt intake
• High salt intake (7-8 g/day) increases B.P proportionately
• Low sodium intake lowers B.P
(Due to genetic abnormality of Kidney which makes salt excretion difficult except at raised levels of arterial pressure)
7
Modifiable risks:
3. Other minerals
• Potassium lowers B.P
• Calcium, Cadmium, Magnesium also lowers B.P
8
Modifiable risks:
4. Saturated fats:
• Raise BP
5. Alcohol
• High alcohol intake is associated with increased risk of high B.P
• Alcohol consumption raises Systolic B.P more than Diastolic B.P
• Abstinence brings B.P back to previous level
9
Modifiable risks:
6. Physical activity
• Leads to weight reduction and hence B.P
7. Environmental stress
• Over activity of sympathetic nervous system increase B.P
10
Modifiable risks:
8. Other factors
• Oral contraceptive pills (due to oestrogens)
• Noise
• Vibration, Temperature, Humidity – consistent
11
Modifiable risks:
Smoking: • Nicotine and Carbon monoxide are potent
vasoconstrictors
• Smoking of 2 cigarettes raises SBP & DBP by 16 mm Hg for 20 minutes
12
HTN – 2 MAIN CATEGORIES:
I. Primary (essential) – causes unknown
II. Secondary – due to some cause e.g., Kidney disease, Adrenal gland tumors, Toxemia of pregnancy
13
CAUSES OF HYPERTENSION
SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE
I. Decreased compliance of aorta (arteriosclerosis)
II. Increased stroke volume
14
CAUSES OF HYPERTENSION
SYSTOLIC HYPERTENSION WITH WIDE PULSE PRESSURE
I. Aortic regurgitation
II. Thyrotoxicosis
III. Hyperkinetic heart syndrome
IV. Fever
V. Arteriovenous fistula
VI. Patent ductus arteriosus
15
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
I. Renal
a. Chronic pyelonephritis
b. Acute and chronic glomerulonephritis
c. Polycystic renal disease
16
d. Renovascular stenosis or renal infarction
e. Most other severe renal diseases (arteriolar nephrosclerosis, diabetic nephropathy etc.,)
f. Renin-producing tumors
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
17
II. Endocrine
a. Oral contraceptives
b. Adrenocortical hyper function
1. Cushing’s disease and syndrome
2. Primary hyperaldosteronism
3. Congenital or hereditary adrenogenital syndromes (17-hydroxylase defects)
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
18
c. Pheochromocytoma
d. Myxedema
e. Acromegaly
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
19
III. Neurogenic
A. Psychogenic
B. Diencephalic syndrome
C. Familial dysautonomia (Riley-Day)
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
20
D. Polyneuritis (acute poryphyria, lead poisoning)
E. Increased intracranial pressure (acute)
F. Spinal cord section (acute)
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
21
IV. Miscellaneous
A. Coarctation of aorta
B. Increased intravascular volume (excessive transfusion, polycythemia vera)
C. Plyarteritis nodosa
D. Hypercalcemia
E. Medications, e.g., glucocorticoids, cyclosporine
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
22
V. Unknown etiology
A. Essential hytypertension ( 90% of all cases of hypertension)
B. Toxemia of pregnancy
C. Acute intermittent prophyria
CAUSES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC HYPERTENSION (INCRESED PERIPHERAL VASCULAR
RESISTANCE
23
V. Effects on Heart
1.1. Left Ventricular Hypertrophy
Deterioration of cardiac function
Dilatation & thinning of LV Cavity
Heart failure
EFFECTS OF HTN
24
1. Angina pectoris (due to increased 02 demand of a hypertrophied heart)
2. Ischaemia or Infarction
3. Death due to 1, 2,3
EFFECTS OF HTN
25
B. Neurological effects
Retinal changes
CNS dysfunction
EFFECTS OF HTN
26
Occipital headache especially in morning
Dizziness
Light headache
Vertigo
Tinnitis
EFFECTS OF HTN
27
Dimmed vision
Syncope
Cerebral infarction
Haemorrhage
Encephalopathy
EFFECTS OF HTN
28
Effects on Kidney:
Arteriosclerosis of afferent & efferent glomerular arterioles
Decreased Glomerular filtration rate
Proteinemia
Haematuria (Microspic )
Renal failure
EFFECTS OF HTN
29
EFFECTS OF HTN
D. Blood loss
I. from Kidneys
II. Epistaxis
III. Haemoptysis
IV. Metrorrhagia
30
HTN-SOME FACTS
1) Anti hypertensive treatment is associated with decrease n incidence of
• Stroke by 35-40%
• MI by 20-25%
• Heart failure by 50%
31
HTN-SOME FACTS
2) 5 mm of Hg reduction in DBP can reduce heart disease risk by 21%
3) For every fall of 20 mm Hg SBP & 10 mm Hg DBP, You need one intervention –
• Lifestyle modification or treatment with one drug
32
Three sources of error in recording B.P
A. Observer errors e.g., hearing acuity interpretation of Korotkow sounds
B. Instrumental errors e.g., leaking valve Cuffs that do not encircle the arm
• Small cuff – higher reading
C. Subject errors: e.g., Circumstances of examination
• Physical environment
• Position of the subject
• External stimuli e.g., fear, anxiety
33
Three sources of error in recording B.P
C. Subject errors: e.g., Circumstances of examination
• Physical environment
• Position of the subject
• External stimuli e.g., fear, anxiety
34
WHO Recommendation:
• Sitting position
• Uniform policy – consistently use the same arm for B.P measurement
• Pressure at which the sounds are first heard (Phase I) Systolic pressure
• Near Diastolic B.P, sounds first become muffled (Phase-IV) & then disappear (Phase-V) Phase-V taken as DBP
35
Rule of halves:
• ½ of the HTN patients, aware of this condition
• ½ of these being treated
• ½ of these being treated effectively
36
Investigations:
• Urine for protein
• Blood glucose
• Microscopic urinalysis
• Haematocrit or ESR
• S.Potassium
37
Investigations:
• S.Creatinine and/or BUN
• FBS
• Total Cholesterol
• ECG in all cases
38
TREATMENT:
• General measures:
• Relief of stress
• Dietary management
• Regular aerobic exercise
• Weigh reduction
• Control of other risk factors contributing to development of arteriosclerosis
39
Drug treatment:
1. ACE Inhibitors e.g., Encaplril, Lisinopril, Ramipril
2. Angiotensin I antagonists e.g., Losartan, temisartan, Valsartan
3. Calcium channel Blockers e.g., Nifedipine, Amlodepine
4. Diuretics e.g., Furosemide, Hydrochlorothiazide, Spironolactone
5. Beta Aderenergic Blockers e.g,Atenolol, Metoprolol
40
Drug treatment:
6. Alpha Adrenergic Blockers e.g., Prazosin, Terazocin
7. Central Sympatholytics e.g., Methyldopa
8. Vasodilators
• Arteriolar e.g, Hydralazine, Minoxidil, Diazoxide
• Arteriolar + Venous – e.g., Sodium Nitrtoprusside