2- HYPERTENTION (Modified)

8/6/2019 2- HYPERTENTION (Modified)

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Cardiac

Pathophysiology


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Signs and symptoms1-Chest pain

Characters , Location, Radiation,

Relation to exercise, stages andassociated symptoms

2-Dyspnea, orthopenia, PND,

Pulmonary edema3-Palpitation

4-Diziness


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Evaluation Components

Medical history

Physical examination

Routine laboratory tests

Optional tests


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Medical History

Duration and classification of hypertension.

Patient history of cardiovascular disease.

Family history.Symptoms suggesting causes of

hypertension.

Lifestyle factors - Ethanol intake.Current and previous medications.


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Physical Examination

Blood pressure readings (two or more).Verification in contralateral arm.

Height, weight, and waist circumference.

Funduscopic examination.

Examination of the neck, heart, lungs,

abdomen, and extremities.

Neurological assessment.


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Laboratory Tests Recommended Before

Initiating Therapy

Urinalysis

Complete blood count

Blood chemistry (potassium, sodium,creatinine, and fasting glucose)

Lipid profile (total cholesterol and HDL

cholesterol)

12-lead electrocardiogram


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Optional Tests and Procedures

Creatinine clearance

Microalbuminuria

24-hour urinary protein

Serum calciumSerum uric acid

Fasting triglycerides

LDL cholesterol

Glycosolated hemoglobin


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Investigation

History and examination

Exclude secondary Hypertension

Urea and electrolytes

FBP and ESRECG

Lipid profile

Chest x-ray no longer routinely indicated


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Hypertension

The normal radial artery blood pressures inadults are: Systolic arterial pressure: 100 to

140 mmHg. Diastolic arterial pressure: 60 to

90 mmHg. These pressures are calledNormal blood pressure or (normo-tensive

pressure).

Stage I hypertension: systolic (140-159

mmHg) and/or diastolic (90-99 mmHg).

Stage II hypertension: systolic (160

mmHg) and/or diastolic ( 100 mmHg).


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BP = TPR * CO

Where, BP: blood pressure; TPR: Total peripheral

resistance; CO: cardiac output.Where, CO = SV * HR

; SV: stroke volume; HR: Heart rate.


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Types of hypertension:

In more than 95% of cases a specific

underlying cause of hypertension cause of

hypertension cannot found. Such patients are

said to have (essential hypertension). In realitythe problem is probably multi-factorial.

Hypertension in approximately 40-60% is

explained by genetic factors. Important

environmental factors including high salt intake,

heavy consumption of alcohol, obesity, and

impaired intra-uterine growth.


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About 5% of cases, hypertension shown to

be a consequence of a specific disease orabnormality leading to Na retention and/or

peripheral vasoconstriction (secondary

hypertension).


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The possible causes :

A.Alcohol.

B. Pregnancy:

Gestational hypertension: bloodpressure elevation without protein-uria, that is detected

for first time during mid-pregnancy and return to

normal by 12 week post-partumPre-eclampsia

/eclampsia: pregnancy specific syndrome with elevatedblood pressure that occurs after the first 20 weeks of

pregnancy and accompanied by protein-uria and edema.

C. Renal diseases: Renal vascular disease (renal artery

stenosis)Parenchymal renal disease (glomerulo-nephritis)Polycystic kidney diseases.Most of the

kidney diseases are associated with disorder of rennin-

angiotensin- aldosterome system.


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D. Endocrine diseases:

1.Phaechromocytoma: It is mostly benign tumor of

the adrenal medulla with increase secretion of

epinephrine and nor-epinephrine, so it causes

paroxysmal hypertension but may be persist.

2.Cushing syndrome: elevated level of cortisol has

mineralo-corticoid effect.

3.Primary hyper-aldosteroe-ism (Conn's syndrome).

4.Primary hypo-thyroid-ism: it is associated with

atherosclerosis.

5.Thyrotoxicosis: high thyroid hormone associated

with increase in systolic pressure due to increase

activity of the heart (increase stroke volume and

heart rate) and decrease diastolic pressure due to

vasodilatation.


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E. Drugs: example oral contraceptives

containing estrogen, anabolic steroid,corticosteroids, NSAID, carbenoxolone (is

a licensed drug foroesophageal ulceration

and inflammation, and treatment of oraland perioral lesion), sympathomimetic

agents.


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Complications of hypertension:

A. Blood vessels:

1.In large vessels (>1mm in diameter): the internal elastic

lamina is thickened, smooth muscle hypertrophy, andfibrous tissue deposit. The vessel dilated and become

tortuous and their wall become less complains (less

elastic which means increase resistance).

2.Smaller arteries (


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B. Central nervous system:

Stroke: is common complication of

hypertension and may be due to:cerebral hemorrhage or

infarctionCarotid atheroma and

transient ischemic attacksub-

arachnoid hemorrhage.

Hypertensive encephalopathy: it is rare

condition characterized by high blood

pressure and neurological symptomsincluding transient disturbance of

speech and vision, paraesthesiae,

disorientation.


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C. Heart: left ventricular hypertrophyatrial

fibrillationleft ventricular failure.

D. Kidney: renal disease may result be result of

hypertensive damage to renal vessels. Long

standing hypertension may cause protein-uria,

and progressive renal failure.

E. Retina: hypertensive retino-pathy: long

standing hypertension results in compensatory

thickening of arterial wall, which effectivelyreduces capillary perfusion pressure. With sudden

increase of blood pressure hemorrhage is likely to

occur.


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F.Malignant or accelerating hypertension:

This rare complicate hypertension of any

etiology and is characterized by acceleratedmicro-vascular damage with necrosis in the

wall of small arteries and arterioles (fibrinoid

necrosis) and intra-vascular thromosis. Thediagnosis is based on evidence of high blood

pressure and rapidly progressive end-organ

damage such as retino-pathy, renal failure

and/or hypertensive encephalo-pathy. Leftventricular failure may occur, and if this is

untreated, death occurs within months.


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Prevention

Weight reduction and regularaerobic exercise (e.g., walking):Reducing dietary sugar.

Reducing sodium (salt) in the body

Additional dietary changes beneficial to reducing blood pressure

include the DASH diet (dietary approaches to stop hypertension)

Discontinuing tobacco use

Vasodialators such as niacin.

Limiting alcohol intake

Reducing stress, for example with relaxation therapy,

Increasing omega 3 fatty acids can help lower hypertension. Fishoil is shown to lower blood pressure in hypertensive individuals.

The fish oil may increase sodium and water excretion.


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Treatment

Lifestyle modifications

Lose weight if overweight

Limit alcohol

Increase physical activity Decrease sodium intake

Keep potassium intake at adequate levels

Take in adequate amounts of calcium and magnesium Decrease intake of saturated fat and cholesterol

Stop smoking


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Thiazide diuretics. Diuretics, sometimes

called "water pills," are medications that act on

your kidneys to help your body eliminatesodium and water, reducing blood volume.

Thiazide diuretics are often the first but not

the only choice in high blood pressuremedications. If you're not taking a diuretic and

your blood pressure remains high, talk to your

doctor about adding one or replacing a drugyou currently take with a diuretic.


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Beta blockers. These medications

reduce the workload on your heart andopen your blood vessels, causing your

heart to beat slower and with less force.

When prescribed alone, beta blockers

don't work as well in blacks or in the

elderly but they're effective when

combined with a thiazide diuretic.


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Angiotensin-converting enzyme

(ACE) inhibitors. These medicationshelp relax blood vessels by blocking

the formation of a natural chemical

that narrows blood vessels.


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Calcium channel blockers. These medications

help relax the muscles of your blood vessels.Some slow your heart rate. Calcium channel

blockers may work better for blacks and older

adults than doACE inhibitors or beta blockers

alone.Aword of caution for grapefruit lovers,

though. Grapefruit juice interacts with some

calcium channel blockers, increasing blood levels

of the medication and putting you at higher risk ofside effects. Talk to your doctor or pharmacist if

you're concerned about interactions.


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Central-acting agents. These

medications prevent your brain fromsignaling your nervous system to

increase your heart rate and narrow

your blood vessels.Vasodilators. These medications work

directly on the muscles in the walls of

your arteries, preventing the musclesfrom tightening and your arteries from

narrowing.


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Orthostatic (or postural) hypotension (a fall in

blood pressure of 20/10 mmHg from lying to

standing position):

1.It is an abnormal drop in blood pressure on

assumption of standing position. It is caused by:

1. Reduced blood or fluid volume: as in excessive

use of diuretics, loss of GIT fluid (diarrhea and

vomiting), and loss of fluid in prolong bed rest.

2. Drugs induce hypotension: anti-hypertensive

drugs and psychotropic drugs.

3. Aging: weakness and dizziness on standing are

common complaints of elderly persons. Postprandial

(after meal) blood pressure often decreases in elderly

persons especially after a high-carbohydrate meal.


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4. Bed rest and immobility: Prolonged bed rest

promotes a reduction in plasma volume, a decrease in

venous tone, failure of peripheral vasoconstriction, andweakness of skeletal muscles that support the veins and

assist in returning blood to the heart.

5. Disorder of autonomic nervous system function: The

sympathetic nervous system plays an essential role inadjustment to upright position. Orthostatic hypotension

caused by altered autonomic function is common in

peripheral neuro-pathyies associated with diabetes

mellitus, after injury or disease of spinal cord, or asresult of cerebral vascular accident in which

sympathetic outflow from the brain disrupt and finally

Parkinson disease with autonomic failure.

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2- HYPERTENTION (Modified)