Hypertension 2013 Diagnostic Procedures

Management of primary Hypertension

1. Diagnostic procedures

March 2013 Prof. G. Hennersdorf DGK ESC SES

Medical Science Tanzania Lectures

Hypertension subsets Primary Hypertension

Dysregulation of neurohormonal (RAS) systems Triggering Target Organ Damage

Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure

Brain Stroke or transient ischemic attack

Kidney: Chronic kidney disease

Peripheral arterial disease Eye

Retinopathy

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension subsets

• Secondary Hypertension– Organ mediated• Renal disorders (parenchymatic, vascular)• Glands (thyroid; adrenal)• Cardiac (aortic regurgitation)• Vessel abnormalities (Aortic coarctation) • Pregnancy (gestation, eclampsia)• Others (drug addiction)

March 2013 Prof. G. Hennersdorf DGK ESC SES

*WHO 2000 ** isolated systolic hypertension

Definition of arterial Hypertension HPT

systolic blood pressure diastolic blood pressure

Normal(diabetic)Age =>80

<140<130150

<90<8090

mild HPTborderline HPT

140-179140-159

90-10490-94

intermediate severe HPT

>=180 >=105

isolated systolic HPT(ISH**)

>=160140-159

<90

and

and/or

and/or

and

March 2013 Prof. G. Hennersdorf DGK ESC SES

Prevalence of arterial hypertension (%)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Prevalence of hypertensive stroke

Subsaharan Africa (Tanzania) 1,6%

Western Countries (US) 1,7%

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• clinical diagnosis• advanced measures• pathways and flowcharts

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Clinical Diagnosis• Advanced Measures• Pathways and Flowcharts

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis: normal changes of BP

March 2013 Prof. G. Hennersdorf DGK ESC SES

Sleeping: BP falls and rises when waking up

Running: BP rises and decreases to normal during recovery phase with positive training effects protecting from hypertension

Alcohol and tobacco misuse, drug addiction: BP rises and triggers hypertension!

Hypertension Diagnosis

• History:– General signs and symptoms should reveal level of risk

and suspicion of TOD*s• Head ache, Dizziness, visus abnormalities, hst. of stroke, hst.

of fainting (syncope) brain damage• Palpitation, Dyspnea, chest pain, nocturnal dysuria, hst. of MI

heart (damage) failure, CAD• Leg pains: Walking, rest pain, peripheral (damage) disease• Family history, physical activity, history of smoking habits,

alcohol abuse• History of medication

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension by itself doesn‘t hurt!

*target organ damage

Hypertension Diagnosis

• Physical examination– Inspection, palpation and auscultation• Chest: lungs and heart (congestion, murmurs, rhythm)• Neurological status: consciousness, motion

abnormalities, reflexes, speech• Peripheral pulses: carotid murmurs, abdominal

murmurs (renal disease?), ankle-brachial-index ABI• Hyperlipidemia: xanthelasm, arcus senilis, ear lobe

creases• Joints: gout

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Physical examination– Measuring blood pressure: necessary at each visit

start, whenever seeing the doctor!

March 2013 Prof. G. Hennersdorf DGK ESC SES

This is the most important examination procedure,

therefore be careful, be skilled, be an expert

Hypertension Diagnosis

• The correct measurement of blood pressure depends on– Patient – Environment– Device– Procedure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• The correct measurement of blood pressure– Patient (first visit) – Environment– Device– Procedure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Silence, Sedation (?)• No coffee, no smoking for at least 60 min.

before reading• Supine position (for at least 10 min.)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• The correct measurement of blood pressure– Patient – Environment– Device– Procedure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Dry, calm, separate (?) room• Avoid fast movements of the personnel• Quiet, warm setting

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• The correct measurement of blood pressure– Patient – Environment– Device– Procedure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Devices for the physician:– Mercury (Hg; best device!)– Aneroid (needs regular calibrations vs. Hg)– Ultrasound (esp. children)– Oscillometry (forearm-wrist devices)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis: mercury device

March 2013 Prof. G. Hennersdorf DGK ESC SES

Scaled mercury manometer

Cuff

Air bulb pumping accessory

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Cuff size: 2/3 of arm length (smaller cuffs result in higher pressures!)

• Cuff position: unclothed arm, tight and strong, deflated• Choose mercury manometer; aneroid devices should be

calibrated against Hg every 6 month!• for children choose smaller cuffs or ultrasound devices

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• The correct measurement of blood pressure– Patient – Environment– Device– Procedure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis: anatomy of brachial auskultation area

March 2013 Prof. G. Hennersdorf DGK ESC SES

membrane area medial,just above the joint (epicondylus medialis)

a.brachialis

Hypertension Diagnosis• Brachial measurement– Inflation quickly 20 mm Hg over expected SBP or as

recognized by palpation of the radial pulse (disappearance)

– Deflation slowly (3 mm Hg /s)– Readings:

first reading both left and right arm, difference not being above 20 mm Hgat least 2 readings from the arm with the higher pressure

– listen to disappearance of Korotkow noise (muffling may occur: take the attenuation point)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis: anatomy of radial palpation area

March 2013 Prof. G. Hennersdorf DGK ESC SES

palpation area

a.radialis

Hypertension Diagnosis

• Radial pulse palpation, if only SBP measurements are needed:– shock or hypotension (if palpable!)– Posture evaluation (syncope diagnosis)– sudden information about systolic blood

pressure

March 2013 Prof. G. Hennersdorf DGK ESC SES

Does NOT replace regular measurements!

Hypertension Diagnosis

March 2013 Prof. G. Hennersdorf DGK ESC SES

Radial blood pressure devices for self measurements:instructions, training and commitment of the patientare necessary. Scheduled repeat calibration!!

Hypertension Diagnosis

• How many doctor‘s readings?– Office visit: at least 3 readings in order to reduce white

coat BPR – At home (self control): at least 5 readings per day with

protocol): • After bedrest,• After breakfast• Late in the morning• late afternoon• Before bed rest

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis:patient commitment

March 2013 Prof. G. Hennersdorf DGK ESC SES

Have a blood pressure protocol booklet ready,when your patient visits office last time.

Ask the patient to use it regularly and carefullyAsk the patient to show at next visit

therapy control Pt. compliance

date time SBP/DBP pulse

remarks-medication

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

Main contents of BP booklet

Hypertension Diagnosis

• Clinical Diagnosis• Devices for measurement• Advanced Measures• Pathways and Flowcharts

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Advanced BP-measures– 24 h monitoring– Telemetry– Exercise (treadmill) Tests

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Advanced BP-measures– 24 h monitoring– Telemetry– Exercise

March 2013 Prof. G. Hennersdorf DGK ESC SES

Blo

od p

ress

ure

Sleep Wake up

High incidence of MACCE

Daytime 7:00 am – 10:00 pm

20 min intervals

During the night 10 pm – 6:00 am 30 min intervals

minimum of measurements

80/24 h

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

24h-BP-Monitoring

Daytime mean < 135/85 mm Hg

Frequency of values over 140/90 mm Hg

20 -25%

Night dipping 10-15%

Total mean <130/80 mm Hg

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

24h-BP-MonitoringNormal values

Recommendations of the german hypertension society

Hypertension Diagnosis

• Advanced BP-measures– 24 h monitoring– Telemetry (mostly investigational,needs

invasive measurement)– Exercise

March 2013 Prof. G. Hennersdorf DGK ESC SES

future use: telemedicineelectronic data transmission by telephone and/or computer

in order to leave the patient not uncontrolledor to give him safety to contact his doctor in case of emergency

Hypertension Diagnosis

• Advanced BP-measures– 24 h monitoring– Telemetry– Exercise

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

March 2013 Prof. G. Hennersdorf DGK ESC SES

Exercise equipment Exercise protocol

Hypertension Diagnosis

• Validation of exercise test concerning BP changes: if– SBP = 200 mm Hg when reaching 100 W level (10

METS), or– no recovery to normal values within 5 min observation

time, or– DBP >= 110 mm Hg at any level (before: do not

perform test, during: stop test!)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Result: exercise hypertension; persistent hypertension

Hypertension Diagnosis

• advanced diagnostic procedures:target organ damage– Heart: Chest Xray, ECG, Ultrasound, MD-CT, MRT– Brain: Carotid Duplex Ultrasound, CT, MRT– Renal: blood tests, urinalysis– Peripheral vessels: arm-ankle-ratio (<=1), retinal

background

March 2013 Prof. G. Hennersdorf DGK ESC SES

Chest Xray: left heart enlargement

March 2013 Prof. G. Hennersdorf DGK ESC SES

Dilated aortic root

Prominent aortic knob

Enlarged (hypertrophic) left ventricle

ECG:Left ventricular hypertrophyLVH

March 2013 Prof. G. Hennersdorf DGK ESC SES

Dgn.: HOCM

Cardiac Ultrasound: LVH

March 2013 Prof. G. Hennersdorf DGK ESC SES

LV AO

LA

PM

PW

IVS

Magnetic resonance imaging: LVH

March 2013 Prof. G. Hennersdorf DGK ESC SES

Retinopathy: hypertension

March 2013 Prof. G. Hennersdorf DGK ESC SES

Crossing phenomenon GUNN

Silver reflecting artery

Target Organ Damage Diagnosis

March 2013 Prof. G. Hennersdorf DGK ESC SES

Ankle Brachial Index ABI

SBP arm-------------------SBP leg (ankle, a. tibialis post.)

Normal value: 120/150 = 0.8Pathological: 120/80 = 1.5

US flow transducer

Peripheral arterial disease

Hypertension Diagnosis: Laboratory tests

• Basic tests:– Blood tests: full blood count, thyroid gland (T3), kidney, liver,

glucose, electrolytes– Urinary test: protein, albumin, sedimentum– Special urinary test. microalbuminuria

• Advanced : – (secondary Hptn.)renine, aldosterone, katecholamines– quantitative urinalysis (quantative albuminuria, clearances, Na+,

Cl-)

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• advanced diagnostic procedures:mainly secondary Hptn.– Hormone assays (thyroid, adrenal, pituitary gl.)– Vascular bed diagnosis (renovascular):• Abdominal CT• Abdominal angiography

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis

• Clinical Diagnosis• Devices for measurement• Advanced Measures• Pathways and Flowcharts

March 2013 Prof. G. Hennersdorf DGK ESC SES

Hypertension Diagnosis: Flow Chart

March 2013 Prof. G. Hennersdorf DGK ESC SES

Persistently raised BP

Target organ damage?

Home BP measurement

24h Monitoring

Continue repeat visits

no

low

normal

History, officereadings

CXR, US, renaltests

patient passportInformation/instruction

Start treatment

consider sec.HPTN

high

yes

abnormal

Hypertension Diagnosis: pathways and networks

patientHospital

admission

Clinic/office

Nurse officeHome care

BP ControlTreatment controlInstructionsScheduling appointments

BP Control, blood teststreatment control

Emergency, First, advanced dgnStart of treatment

OPDvisit

BP Control, blood teststreatment control

Cardiovascular DiseasesHypertension Management

part I

The End

March 2013 Prof. G. Hennersdorf DGK ESC SES