Professional Documents
Culture Documents
Claude Bernard, a French scientist, discovered the existence of vascular nerves and reasoned out their role in controlling the diameter of the blood vessels.
Richard Bright:established a co-relation between high blood pressure and kidney disease.
Sir William Gowers highlighted the link between contractions of the arterioles of the retina and increased arterial blood pressure
McLeod described the main factors controlling blood pressure. In 1950s, life insurance companies observed that persons suffering from high blood pressure died earlier than those with lower blood pressure levels.
Thus, a link was established between high blood pressure and mortality rate.
Definition of Hypertension
BP 140/90 mm Hg
Diastolic 90 mm Hg
Category
Optimal
Systolic
<120
and
Diastolic
<80
JNC VII*
Normal
Normal
High Normal Hypertension Stage 1 Stage 2 Stage 3
<130
130-139
and
and/or
<85
85-89
Prehypertension+
120-139/8089
+ Pre-hypertensives patients twice as likely to develop hypertension compared to normal group Lancet 2001;358:1682-1686
Prognosis of Prehypertension
ISH: 160/82 mm Hg
Complications of Hypertension
Cardiovascular Disease
Entire vascular tree
Heart,
Brain,
Kidneys, Eyes,
peripheral
Measurement of BP
Measurement of BP
Measurement of BP
Mercury sphagnomanometer
Korotkoff 1=SBP Korotkoff 5=DBP
Causes of Hypertension
Primary/Essential (80%)
Secondary (20%)
Causes of Hypertension
Primary/Essential (80%)
No identifiable cause Family history later age of onset
Causes of Hypertension
Secondary causes (20%) Renal Chronic kidney disease/failure Glomerulonephritis eg post strep GN
Endocrine Cushings Disease, phaechromocytoma Primary aldosteronism, acromegaly Thyroid or parathyroid disease
Causes of Hypertension
Secondary causes (20%) Cardiac causes Coarctation of Aorta Primary arteritis (Takayasus Disease) Renal stenosis (reno-vascular disease) Drug induced Steriods NSAIDs OCP Others Sleep apnoea
Heart Left ventricular hypertrophy (Cardiomegaly, ECG) Angina, old MI Prior coronary revascularisation Brain Stroke or TIA Kidney Microalbuminuria Chronic kidney failure Eye Retinopathy Peripheral vascular Disease
Smoking
Diabetes Central obesity
Dyslipidaemia
Physical inactivity Microalbuminuria Age Men> 55 , women >65 yrs Family history of premature CVD (men <55 women <65 yrs)
History
Physical examination
20 causes eg Cushings, Heart size, Pulses, coarctation, PAD Renal bruit: renal stenosis Eyes: retinopathy
Magnitude of Hypertension
National Health and Morbidity Survey II, 1996: Prevalence: 32% High normal: 17% Stage 1: 20 % Stage 2: 8 % Stage 3: 4 % -Rule of halves -half not diagnosed -half not treated -half not controlled
48%
50
60
12 mmHg reduction
Treatment of Hypertension
Non-phramacological Pharmacological
Treatment of Hypertension
Non-pharmacological
Lose weight Regular exercise 30 mins three times per week Low salt diet Avoid alcohol Healthy eating
Pharmacological
ACE inhibitors eg lisnopril Calcium channel blockers eg amlodipine Diuretics eg hydrochlorothiazide AIIA ( ARBs: angitensin receptor blocker) eg lorsartan
blockers eg atenolol
(alpha) blockers eg prazosin blockers eg labetalol
Pharmacological
Centrally acting eg methldopa Direct vasodilators eg minoxidil Aldosterone anatgonist: eg aldosterone Renin inhibitors eg aliskerin
Definition: same as adults 140/90 mm Hg Assessment and management is the same Drugs: start low go slow Postural hypotension
Pregnancy induced hypertension Definition: 140/90 mm Hg Korotkoff V as cutoff for Diastolic BP If korotkoff V does not end, then use korotkoff IV Pre-eclampsia and eclampsia
Hypertension in Children
Increasing in prevalence Def: based on age, gender and height Defined as BP >95% for age, gender and height Normative tables for BP for children based on age, sex and height (NCHS: Nat Health Statistics for Growth Chart) Appropriate cuff size Refer to paediatrician
Definition: 140/90 mm Hg adults Associated with increased CVD risk and mortality Proper measurement of BP Assessment of Hypertension:
Cause Target organ damage Associated CVD risk factors
Definition: 140/90 mm Hg adults BP is a continumum Associated with increased CVD risk and mortality Proper measurement of BP Assessment of Hypertension:
Cause Target organ damage Associated CVD risk factors
Reduce BP levels
Case Discussion
Encik Ahmad, 56 retired clerk Comes for running nose BP 148/86 mmHg
Case Discussion
Rested
Case Discussion
What next?
1. 2. 3.
Cause
Target organ damage Associated CVD risk factors
How to do that?
1. 2. 3.
History
Physical examination Investigations
What exactly?
1.
History
Cause
p/h of HT f/h HT p/h of kidney disease, haematuria, kidney stones, ankle oedema, puffiness Drugs eg NSAIDs, steroids Thyroid disease eg thyrotoxicosis
What exactly
1.
History
Target organ damage
Cardiac complications eg chest pain, difficulty in breathing, orthopnoea TIA, strokes, intermittent claudication Kidneys: facial puffiness, ankle oedema, polyuria, nocturia Eyes: visual problems PAD: intermittent claudication
What exactly
1.
History
Associated CVD risk Factors
Coarcatation of aorta
Heart size (LVH) Heart failure Eyes: retinopathy Evidence of kidney disease Peripheral pulses
Obesity, BMI, waist circumference Nicotine stains Xanthomas Evidence of diabetes mellitus
Case Discussion
Encik Ahmad, 56 yr man Non-smoker, no significant p/h otherwise well Not on any drugs no premature CVD Father and one older brother HT
Case Discussion
BMI 25, waist 96 cm Not Cushingnoid No cardiomegaly, no retinopathy, pulses all felt, equal and normal
No renal bruit
No retinopathy
Case Discussion
Tg 1.7 mmol/l total chol 6.2 mmol ldl chol 4.5 mmol
FBS 6.1 mmol/l Renal functions: normal Urine: proteinuria 1+ no cells CXR: no cardiomegaly ECG: No LVH
Essential hypertension Target organ damage: proteinuria Assoc CVD risk: hypercholesterolaemia