hypertension 2013 diagnostic procedures
TRANSCRIPT
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