Name: (78) Zainab Aleid

2014 Jan 30

A 55 year old male is visiting his family physician for blood pressure control. His medical history reveals type 2 diabetes for which he is taking oral glucose lowering medication (metformin 500 mg three times daily). On physical examination BMI is 32 kg/m2 and blood pressure is 154/94 mmHg (repeatedly). Recent laboratory tests show the following: HbA1C 7.8%, serum creatinine 90 µmol/l.

Pathophysiology of high blood pressure in this patient.

Investigations would perform.

BMI is 32 kg/m2 OBESE .• Normal BMI between 18.5–24.9.

HbA1C is 7.8%HIGH ( Diabetes not controlled) .• Normal level for HbA1c is between 20-40µmol/mol (4-5.9%)• For diabetic patient 7%

Indicates for insulin resistance, because not respond for Metformin

which increases body's response to insulin.

Serum creatinine is 90 µmol/l Normal. • Normal range for Creatinine is between 79-118 µmol/L.

Blood pressure is 154/94 mmHg (repeatedly)Mild hypertension (stage 1)

•chronic medical condition characterized by constant elevation of the systolic or diastolic pressure above 140/90 mmHg. For diabetic 130/80 mmHg.

Primary (essential or idiopathic) hypertension:

Elevated BP without an identified cause 90% to 95% of all cases

Secondary hypertension:Because of underlying medical condition.e.g: renal, endocrine,..etc

Insulin resistance (contributing factor) which leads to Primary HTN by:

◦ High insulin concentration stimulates SNS activity and impairs

nitric oxide–mediated vasodilation.

◦ Increased absorbability to sodium (Increased cellular contents in

sodium and calcium).

◦ Caused vascular wall hypertrophy so increase vascular resistance.

◦ Not present in secondary hypertension.

Obesity itself has been directly associated with hypertension.

BMI range 27.5 and above High risk of developing heart disease, high blood pressure, stroke, diabetes.

Possible explanations for this relationship include:

(1) the release of angiotensinogen from adipocytes as substrate for the renin–angiotensin system.(2) Increase blood volume related to increased body mass.(3) increased blood viscosity.

Features for metabolic syndrome:• Obesity BMI>30• Hypertension BP >140/90• Insulin resistance (hyperinsulinemia) • Hyperglycemia

Routine laboratory tests :

CBC

Urine analysis, for protein if there is a microalbuminuria or blood.

Serum potassium, creatinine, calcium, and urea.

Fasting plasma glucose

Lipid profile (HDL and LDL, cholesterol; triglycerides)

ECG

Chest X-Ray

Optional laboratory tests :

Serum uric acid

24 Hrs urinary protein

Creatinine clearance

Echocardiography

Ultrasonography

Thyroid stimulating hormone

JNC 7

&

European Association of Hypertension

Investigations A 55 YO male C\O:

• DM 2 .

• Insulin resistance.

• HbA1C 7.8%.

• BMI>32 kg/m2.

• 154/94 mmHg

Which is Mild HTN. Insulin

resistance

Primary

hypertension

• CBC.

• Urine analysis

• Creatinine.

• Urea, electrolytes .

• Fasting plasma glucose.

• Lipid profile.

• ECG.

• Chest X-Ray.

Look for target-organ damage

Pathogenesis remains unclear&

it has multifactorial atiologies.

Any Qs ?

REFERENCES: Harrison’s Principles of Internal Medicine. 17th ed. New York, NY:

McGraw-Hill; 2008: 1549-1562.

Kumar and Clark's Clinical Medicine, 8th Edition. Pages:777-780.

American Heart Association http://circ.ahajournals.org/content/112/11/1651.full

http://www.whitakerwellness.com/health-concerns/high-blood-pressure-treatment/what-is-insulin-resistance/

http://emedicine.medscape.com/article/1937383-overview

http://www.webmd.com/diabetes/guide/diabetes-causes

JNC 7