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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.