lesson 3 hypertension ch. 11 vascular diseases ch. 12

LESSON 3LESSON 3

HYPERTENSION __Ch. 11HYPERTENSION __Ch. 11VASCULAR DISEASES __Ch. 12VASCULAR DISEASES __Ch. 12

HYPERTENSIONHYPERTENSION

33

Demography of htnDemography of htn

50 million have the disease50 million have the disease70% aware of it70% aware of itOnly 50% get treatedOnly 50% get treatedOnly 25% have controlled bpOnly 25% have controlled bpMore common in Afro AmericansMore common in Afro AmericansMajor cause for end stage renal disease and Major cause for end stage renal disease and

heart heart failurefailure

44

Assessment and Diagnosis of HTNAssessment and Diagnosis of HTN

55

Assessment and Diagnosis of HTNAssessment and Diagnosis of HTN

66

Physical exam should include: Physical exam should include:

Vital Stat: height, weight, Vital Stat: height, weight, and waist circumferenceand waist circumferencefunduscopic exam funduscopic exam (retinopathy); carotid (retinopathy); carotid auscultation (bruit)auscultation (bruit)jugular venous pulsationjugular venous pulsationthyroid gland (enlargement) thyroid gland (enlargement) cardiac auscultationcardiac auscultation

chest auscultation chest auscultation abdominal exam (bruits, abdominal exam (bruits, masses, pulsations) masses, pulsations) exam of lower extremitiesexam of lower extremities routine labs include routine labs include urinalysis, complete blood urinalysis, complete blood count, electrolytes (potassium, count, electrolytes (potassium, calcium), creatinine, glucose, calcium), creatinine, glucose, fasting lipids, and 12-lead fasting lipids, and 12-lead electrocardiogramelectrocardiogram

77

secondary causes of hypertension-secondary causes of hypertension-suggestive (clues in parentheses) of:suggestive (clues in parentheses) of:

(1) (1) PheochromocytomaPheochromocytoma (labile or paroxysmal hypertension (labile or paroxysmal hypertension accompanied by sweats, headaches, accompanied by sweats, headaches, and and palpitations)palpitations)(2) (2) Renovascular diseaseRenovascular disease (abdominal bruits) (abdominal bruits) (3) APKD-autosomal dominant (3) APKD-autosomal dominant polycystic polycystic kidney disease kidney disease (abdominal or flank masses) (abdominal or flank masses) (4) (4) Cushing's syndromeCushing's syndrome

(truncal obesity with purple striae)(truncal obesity with purple striae)(5) (5) Primary hyperaldosteronismPrimary hyperaldosteronism (hypokalemia)(hypokalemia)

(6) H(6) Hyperparathyroidismyperparathyroidism (hypercalcemia) (hypercalcemia) (7) R(7) Renal parenchymal diseaseenal parenchymal disease (elevated serum creatinine, (elevated serum creatinine, abnormal abnormal urinalysis), urinalysis), (8) (8) Poor response to drugPoor response to drug therapy, therapy, (9) SBP > 180 or DBP > 110 mm (9) SBP > 180 or DBP > 110 mm Hg, or Hg, or (10) sudden onset of hypertension.(10) sudden onset of hypertension.

88

JNC VII 2003 recommendationsJNC VII 2003 recommendationsNormal: recheck in 2 years (see Normal: recheck in 2 years (see Comments)Comments)

1. Prehypertension: SBP 120–139 or DBP 80–891. Prehypertension: SBP 120–139 or DBP 80–89

Prehypertension:Prehypertension: recheck in 1 yearrecheck in 1 year

2. Stage 1 hypertension: SBP 140–159 or DBP 90–992. Stage 1 hypertension: SBP 140–159 or DBP 90–99

Stage 1 hypertension:Stage 1 hypertension: confirm within 2 monthsconfirm within 2 months

2 separate office visits)2 separate office visits)

Stage 2 hypertension:Stage 2 hypertension: evaluate evaluate or refer to source of care within 1 or refer to source of care within 1 month (evaluate and treat month (evaluate and treat immediately if BP > 180/110)immediately if BP > 180/110)

4. Perform physical exam and routine labs.4. Perform physical exam and routine labs.aa

3. Stage 2 hypertension: SBP >160 3. Stage 2 hypertension: SBP >160 or DBP>100 (based on average of 2 or DBP>100 (based on average of 2 measurements on different days)measurements on different days)

5. Pursue secondary causes of hypertension.5. Pursue secondary causes of hypertension.bb

6. Treatment goals are for BP < 140/90, unless diabetes or renal 6. Treatment goals are for BP < 140/90, unless diabetes or renal disease present (< 130/80).disease present (< 130/80).

7. Ambulatory BP monitoring is a better (and independent) 7. Ambulatory BP monitoring is a better (and independent) predictor of cardiovascular outcomes compared with office visit predictor of cardiovascular outcomes compared with office visit monitoring; and covered by Medicare when evaluating white-monitoring; and covered by Medicare when evaluating white-coat hypertension.coat hypertension.

99

PrehypertensionPrehypertension

gray area of 120–139/80–89 mm Hggray area of 120–139/80–89 mm Hga trend away from defining hypertension as a a trend away from defining hypertension as a simple numerical threshold simple numerical threshold antihypertensive medications be offered to antihypertensive medications be offered to persons with prehypertension with compelling persons with prehypertension with compelling indicationsindications

1010

Lifestyle Modifications for Lifestyle Modifications for Primary Prevention of HypertensionPrimary Prevention of HypertensionModificationModification RecommendationRecommendation Approximate SBP Approximate SBP

Reduction (Range)Reduction (Range)

Weight reductionWeight reduction Maintain normal body weight (BMI 18.5–24.9 kg/mMaintain normal body weight (BMI 18.5–24.9 kg/m22).).

5–20 mm Hg per 5–20 mm Hg per 10 kg weight loss10 kg weight loss

Adopt DASH Adopt DASH eating planeating plan

Consume diet rich in fruits, vegetables, and low fat dairy products with a Consume diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat.reduced content of saturated and total fat.

8–14 mm Hg8–14 mm Hg

Dietary sodium Dietary sodium reductionreduction

Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g Reduce dietary sodium intake to no more than 100 mmol/day (2.4 g sodium or 6 g sodium chloride).sodium or 6 g sodium chloride).


Physical activityPhysical activity Engage in regular aerobic physical activity such as brisk walking (at least Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day, most days of the week).30 min/day, most days of the week).


Moderation of Moderation of alcohol alcohol consumptionconsumption

Limit consumption to no more than 2 drinks (1 oz or 30 mL ethanol; eg, Limit consumption to no more than 2 drinks (1 oz or 30 mL ethanol; eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey) per day in most men and to no more than 1 drink per day in women and lighter-weight and to no more than 1 drink per day in women and lighter-weight persons.persons.


1111

? DASH: ? DASH: Dietary Approaches to Stop HypertensionDietary Approaches to Stop Hypertension

Type of foodType of food Number of servings Number of servings for 1600 - 3100 for 1600 - 3100

Calorie dietsCalorie diets

Servings on a Servings on a 2000 Calorie 2000 Calorie

dietdiet

Grains and grain products Grains and grain products (include at least 3 whole grain foods each day)(include at least 3 whole grain foods each day) 6 - 126 - 12 7 - 87 - 8

FruitsFruits 4 - 64 - 6 4 - 54 - 5

VegetablesVegetables 4 - 64 - 6 4 - 54 - 5

Low fat or non fat dairy foodsLow fat or non fat dairy foods 2 - 42 - 4 2 - 32 - 3

Lean meats, fish, poultryLean meats, fish, poultry 1.5 - 2.51.5 - 2.5 2 or less2 or less

Nuts, seeds, and legumesNuts, seeds, and legumes 3 - 6 per week3 - 6 per week 4 - 5 per week4 - 5 per week

Fats and sweetsFats and sweets 2 - 42 - 4 limitedlimited

1212

LOW RISK CANDIDATESLOW RISK CANDIDATESModificationModification RecommendationRecommendation Approximate Systolic BP Approximate Systolic BP

Reduction, RangeReduction, Range

Weight reductionWeight reduction Maintain normal body weight (BMI, 18.5–24.9)Maintain normal body weight (BMI, 18.5–24.9) 5–20 mm Hg/10-kg weight 5–20 mm Hg/10-kg weight lossloss

Adopt DASH eating planAdopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of fat dairy products with a reduced content of saturated fat and total fatsaturated fat and total fat


Dietary sodium reductionDietary sodium reduction Reduce dietary sodium intake to no more than 100 Reduce dietary sodium intake to no more than 100 mEq/L (2.4 g sodium or 6 g sodium chloride)mEq/L (2.4 g sodium or 6 g sodium chloride)


Physical activityPhysical activity Engage in regular aerobic physical activity such as Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most brisk walking (at least 30 minutes per day, most days of the week)days of the week)


Moderation of alcohol Moderation of alcohol consumptionconsumption

Limit consumption to no more than two drinks per Limit consumption to no more than two drinks per day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz day (1 oz or 30 mL ethanol [eg, 24 oz beer, 10 oz wine, or 3 oz 80-proof whiskey]) in most men and wine, or 3 oz 80-proof whiskey]) in most men and no more than one drink per day in women and no more than one drink per day in women and lighter-weight personslighter-weight persons


1313

HIGH RISK HIGH RISK CONDITIONSCONDITIONS

DIURETICDIURETIC ββ BLOCKER BLOCKER ACEiACEi ARBARB CCBCCB ALDOSTERONEALDOSTERONE

ANTAGONISTANTAGONIST

HEART FAILUREHEART FAILURE $$ $$ $$ $$ $$

POST POST MYOCARDIAL MYOCARDIAL INFARCTIONINFARCTION

$$ $$ $$

HIGH CAD RISKHIGH CAD RISK $$ $$ $$ $$

DIABETES DIABETES MELLITUSMELLITUS

$$ $$ $$ $$ $$

CRHONIC KIDDNEY CRHONIC KIDDNEY DISEASEDISEASE

$$ $$

REURRENT REURRENT STROKE STROKE PREVENTIONPREVENTION

$$ $$

RECOMMENDED DRUGS

COMPELLING CONDITIONS

1414

PRIMARY HYPERTENSIONPRIMARY HYPERTENSION

NO IDENTIFIABLE CAUSE (95%)NO IDENTIFIABLE CAUSE (95%)30% OF BLACKS/20% OF WHITES30% OF BLACKS/20% OF WHITES25-55 YEAR AGE GROUP25-55 YEAR AGE GROUPMULTIFACTORIALMULTIFACTORIAL

1515

PRIMARY HYPERTENSION: CAUSESPRIMARY HYPERTENSION: CAUSES

GENETICGENETICOBESITYOBESITYSALT INTAKESALT INTAKESYMPATHETIC SYSTEM OVERACTIVITYSYMPATHETIC SYSTEM OVERACTIVITYABNORMAL CVS DEVELOPMENTABNORMAL CVS DEVELOPMENTRENIN-ANGIOTENSIN ACTIVITYRENIN-ANGIOTENSIN ACTIVITYALCOHOL/CIGARETTE/POLYCYTHEMIAALCOHOL/CIGARETTE/POLYCYTHEMIA

1616

Associated causes of hypertensionAssociated causes of hypertension

Sleep apneaSleep apnea Drug-induced or drug-relatedDrug-induced or drug-related Chronic kidney diseaseChronic kidney disease Primary aldosteronismPrimary aldosteronism Renovascular diseaseRenovascular disease Long-term corticosteroid therapy and Long-term corticosteroid therapy and Cushing's syndrome Cushing's syndrome PheochromocytomaPheochromocytoma Coarctation of the aortaCoarctation of the aorta Thyroid or parathyroid diseaseThyroid or parathyroid disease

1717

RENAL ARTERY STENOSISRENAL ARTERY STENOSIS

1-2% OF HTN PATIENTS1-2% OF HTN PATIENTSYOUNGER(<20 YRS AGE)YOUNGER(<20 YRS AGE)FIBROMUSCULAR HYPERLASIA (f<50)FIBROMUSCULAR HYPERLASIA (f<50)LEADS TO EXCESSIVE RENIN RELEASELEADS TO EXCESSIVE RENIN RELEASE

1818


SUSPECT WHEN:SUSPECT WHEN:HTN ONSET <20 YRS AGE OR HTN ONSET <20 YRS AGE OR

OCCURS AFTER 50OCCURS AFTER 50DRUG RESITANT HTNDRUG RESITANT HTNPRESENCE OF EPIGASTRIC OR PRESENCE OF EPIGASTRIC OR

RENAL BRUITSRENAL BRUITSPRESENCE OF SIGNIFICANT PERIPHERAL PRESENCE OF SIGNIFICANT PERIPHERAL VASCULAR DISEASEVASCULAR DISEASERENAL FUNCTION DETERIORATES AFTER ACEi RENAL FUNCTION DETERIORATES AFTER ACEi administrationadministration

1919


Tests-Tests-Radioisotope renographyRadioisotope renographyduplex usduplex usMRA/CT ANGIOMRA/CT ANGIORENAL ARTERIOGRAPHYRENAL ARTERIOGRAPHYTREATMENT- vascular reconstructionTREATMENT- vascular reconstruction

2020

Primary hyperaldosteronismPrimary hyperaldosteronism

Due to excessive aldosterone secretionDue to excessive aldosterone secretionTest-Test-check plasma aldosterone levelscheck plasma aldosterone levelsPlasma rennin levelsPlasma rennin levelsCalculate aldosteone/rennin ratio (nomral <25)Calculate aldosteone/rennin ratio (nomral <25)Cause- Adrenal Adenoma- requires ct/mri scanCause- Adrenal Adenoma- requires ct/mri scan

2121

CUSHING’S SYNDROMECUSHING’S SYNDROME

Glucocorticoid excessGlucocorticoid excessHTN (75-85%) of casesHTN (75-85%) of casesIncreased Rennin-Angiotensin Increased Rennin-Angiotensin activityactivity

2222

PheochromocytomaPheochromocytoma0.1% of all htn patients0.1% of all htn patients2/1ooo,ooo incidence2/1ooo,ooo incidenceHypertensive crisis (BP 300>)Hypertensive crisis (BP 300>)Associated with Café au Lait spots Associated with Café au Lait spots and neurofibromatosisand neurofibromatosis

2323

Other causes for secondary HTNOther causes for secondary HTN

EstrogenEstrogenAcromegalyAcromegalyHyperthyroidismHyperthyroidismhypothyroidism hypothyroidism DRUGS: cyclosporine and NSAIDsDRUGS: cyclosporine and NSAIDs

2424

Complications of HTNComplications of HTN

excess morbidity and mortality related to excess morbidity and mortality related to hypertension hypertension risk doubles for each 6 mm Hg increase in diastolic risk doubles for each 6 mm Hg increase in diastolic blood blood

2525


Cardiac Complications – Cardiac Complications – Left Ventricular Hypertrophy congestive Left Ventricular Hypertrophy congestive

heart failure heart failure ventricular arrhythmiasventricular arrhythmiasmyocardial ischemia and myocardial ischemia and sudden death.sudden death.

2626


Cerebrovascular Disease and Dementia - Cerebrovascular Disease and Dementia - hemorrhagic and ischemic stroke hemorrhagic and ischemic stroke higher incidence of subsequent dementia of both higher incidence of subsequent dementia of both vascular and Alzheimer types vascular and Alzheimer types markedly reduced by antihypertensive therapy markedly reduced by antihypertensive therapy

2727


Hypertensive Renal Disease – Hypertensive Renal Disease – renal insufficiency renal insufficiency hypertensive nephropathy hypertensive nephropathy more common in blacks more common in blacks associated with Diabetes Mellitusassociated with Diabetes MellitusBenefits with ACEi therapyBenefits with ACEi therapy

2828


Aortic dissectionAortic dissectionIncreased AtherosclerosisIncreased Atherosclerosis

2929

SYMPTOMS OF HTNSYMPTOMS OF HTN

mainly referable to involvement of the target organs: mainly referable to involvement of the target organs: HeartHeartBrainBrainKidneysKidneysEyes and Eyes and Peripheral arteries. Peripheral arteries.

3030

Symptoms of HTNSymptoms of HTN

Mainly asymptomaticMainly asymptomaticEarly morning suboccipital pulsating HAEarly morning suboccipital pulsating HAHypertensive Encephalopathy: Hypertensive Encephalopathy: Somnolence/confusion/Visual/Somnolence/confusion/Visual/

Nausea/Vomiting Nausea/Vomiting (Diastolic BP >130)(Diastolic BP >130)

3131

Signs of HTNSigns of HTN

Heart: Left ventricular enlargement/HypertrophyHeart: Left ventricular enlargement/HypertrophyLAB workup: CBC/Urinalysis/FBS/LIPIDS/LAB workup: CBC/Urinalysis/FBS/LIPIDS/

Serum Uric Acid /Electrolytes/Creatinine/Serum Uric Acid /Electrolytes/Creatinine/BUNBUNECG/CXRECG/CXR

3232

Basic Testing in the Hypertensive PatientBasic Testing in the Hypertensive Patient Primary work-up (all patients)Primary work-up (all patients)Urinalysis and sediment reviewUrinalysis and sediment review (identifies possible renal disease or end-organ dysfunction)(identifies possible renal disease or end-organ dysfunction) Basic chemistryBasic chemistry including potassium, fasting glucose, blood urea nitrogen, and including potassium, fasting glucose, blood urea nitrogen, and creatinine (evaluates for renal disease; low or low-normal potassium may be seen in creatinine (evaluates for renal disease; low or low-normal potassium may be seen in hyperaldosteronism; fasting glucose can assess for diabetes)hyperaldosteronism; fasting glucose can assess for diabetes) Complete blood cell countComplete blood cell count (evaluates for polycythemia, which can cause secondary hypertension)(evaluates for polycythemia, which can cause secondary hypertension) Lipid panelLipid panel(risk stratification for patients with dyslipidemia)(risk stratification for patients with dyslipidemia) Electrocardiogram Electrocardiogram (risk stratification in patients with coronary artery disease; evaluate for left ventricular (risk stratification in patients with coronary artery disease; evaluate for left ventricular hypertrophyhypertrophy

3333

Goals of the Initial EvaluationGoals of the Initial Evaluation

1.1.Establish the diagnosis. Establish the diagnosis. 2.2.Staging the disease. If presentStaging the disease. If present, hypertension is staged using , hypertension is staged using the criteria outlined in the JNC 7 consensus statement. This guides the criteria outlined in the JNC 7 consensus statement. This guides immediate management. immediate management. 3.3.Rule out secondary hypertension. Rule out secondary hypertension. 4.4.Identify end-organ effectsIdentify end-organ effects. The initial history, physical . The initial history, physical examination, and laboratory work-up should include investigations that examination, and laboratory work-up should include investigations that will identify common end-organ damage will identify common end-organ damage 5.5.Identify the presence or absence of Identify the presence or absence of other major cardiovascular other major cardiovascular risk factorsrisk factors, in particular those that are modifiable with intervention., in particular those that are modifiable with intervention.

3434

ECG: LV Strain PatternECG: LV Strain Pattern

Suggests Advanced diseaseSuggests Advanced diseasePoor prognosisPoor prognosis

Other Investigations:Other Investigations:Renal US/CT/MRI Renal US/CT/MRI

scansscans

3535

Management AlgorithmManagement Algorithm

3636

NON PHARMACOLOGIC THERAPYNON PHARMACOLOGIC THERAPY

CHANGE LIFESTYLE: DASH DIETCHANGE LIFESTYLE: DASH DIETWeight reductionWeight reductionReduced alcohol consumption Reduced alcohol consumption Reduced salt intakeReduced salt intakeGradually increasing activity levels Gradually increasing activity levels

3737

Goals of TreatmentGoals of Treatment

diabetic patients, CKD, should be lower diabetic patients, CKD, should be lower (< 130/80 mm Hg) (< 130/80 mm Hg)

Others (<140/90)Others (<140/90)long-term adverse consequences of drug therapy – long-term adverse consequences of drug therapy – ββ blockers, blockers, ThiazidesThiazidesstatins can significantly improve outcomes in DM/Post MI (total statins can significantly improve outcomes in DM/Post MI (total and LDL cholesterol levels of and LDL cholesterol levels of < 194 mg/dL and < 116 mg/dL )< 194 mg/dL and < 116 mg/dL )

3838

Current Antihypertensive Agents Current Antihypertensive Agents

Diuretics – Diuretics – HCTZ (Esidrix®, Hydro-Diuril®)HCTZ (Esidrix®, Hydro-Diuril®)LOOP DIURETICS - Ethacrynic acid (Edecrin®) LOOP DIURETICS - Ethacrynic acid (Edecrin®)

Furosemide (Lasix®)Furosemide (Lasix®)ALDOSTERONE RECEPTOR BLOCKERS - ALDOSTERONE RECEPTOR BLOCKERS -

Amiloride (Midamor®)Amiloride (Midamor®)Spironolactone (Aldactone®)Spironolactone (Aldactone®)

alone -control blood pressure in 50% alone -control blood pressure in 50%

3939

Side effects of diureticsSide effects of diuretics

Hypo-K+, Hypo-Mg2+, Hypo-Ca2+, Hypo-Na+, Hypo-K+, Hypo-Mg2+, Hypo-Ca2+, Hypo-Na+, Hyper-uric acid (gout), Hyper-glucose, Hyper-uric acid (gout), Hyper-glucose, Increase LDL cholesterol, Increase triglycerides; Increase LDL cholesterol, Increase triglycerides;

rash, erectile dysfunction. rash, erectile dysfunction.

4040

Adrenergic Blocking Agents Adrenergic Blocking Agents

Beta blockersBeta blockersdecrease the heart rate and cardiac output decrease the heart rate and cardiac output Acebutolol(Sectral®)Acebutolol(Sectral®)Atenolol(Tenormin®)Atenolol(Tenormin®)Metoprolol(Lopressor®)Metoprolol(Lopressor®)Pindolol (Visken®)Pindolol (Visken®)Propranolol (Inderal®)Propranolol (Inderal®)

4141

Side effects of Beta BlockersSide effects of Beta Blockers

exacerbating bronchospasm exacerbating bronchospasm bradycardia or AV block bradycardia or AV block precipitating or worsening l vfprecipitating or worsening l vfnasal congestionnasal congestionRaynaud's phenomenon Raynaud's phenomenon nightmares nightmares Increase TGL Decrease HDLIncrease TGL Decrease HDL

4242

ACE Inhibitors ACE Inhibitors

initial medication initial medication Benazepril (Lotensin®)Benazepril (Lotensin®)Captopril (Capoten®)Captopril (Capoten®)Enalapril (Vasotec®)Enalapril (Vasotec®)

4343

RAAS SystemRAAS System

4444

Side Effects Of ACEiSide Effects Of ACEi

Cough Cough hypotension hypotension dizzinessdizzinessrenal dysfunction renal dysfunction hyperkalemiahyperkalemiaangioedemaangioedemataste alteration and taste alteration and rash rash Contraindicated in pregnancyContraindicated in pregnancy Acute Renal FailureAcute Renal Failure

4545

Angiotensin Receptor Blockers: Angiotensin Receptor Blockers: ARBsARBs

Candesartan (Atacand®)Candesartan (Atacand®)Eprosartan (Teveten®)Eprosartan (Teveten®)Irbesartan (Avapro®)Irbesartan (Avapro®)Losartan (Cozaar®)Losartan (Cozaar®)do not cause cough do not cause cough

4646

The ABCD The ABCD rulerule

B* and D* may induce more new-onset diabetes B* and D* may induce more new-onset diabetes A= ACEi or ARBsA= ACEi or ARBs*B=*B=ββ Blockers BlockersC= CCBsC= CCBs*D= Diuretic*D= Diuretic (thiazide)(thiazide)

4747

BHS GuidelinesBHS Guidelines

YoungYoung ElderlyElderly(low renin)(low renin)

AA BB C C D DAA ACE InhibitorACE InhibitorBB Beta BlockerBeta BlockerCC Calcium Channel BlockerCalcium Channel BlockerD D DiureticDiuretic

4848

Afro-Americans and HTNAfro-Americans and HTN

more likely to become hypertensive and more likely to become hypertensive and more susceptible to the cardiovascular more susceptible to the cardiovascular complicationscomplicationsRespond differently to drugs –ACEi and Respond differently to drugs –ACEi and ARBs are less effectiveARBs are less effective

4949

Follow up of HTN patientsFollow up of HTN patients

Achieve good controlAchieve good controlNeed less frequent visitsNeed less frequent visitsYearly monitoring of blood lipids and Yearly monitoring of blood lipids and an ECG should be repeated at 2- 4 yearsan ECG should be repeated at 2- 4 years

5050

HTN Crisis (>220/130)HTN Crisis (>220/130)

requires prompt recognition and aggressive requires prompt recognition and aggressive managementmanagementblood pressure must be reduced within a few hours blood pressure must be reduced within a few hours hypertensive encephalopathy hypertensive encephalopathy

(headache, irritability, confusion, and (headache, irritability, confusion, and altered mental status due to cerebrovascular altered mental status due to cerebrovascular

spasm) spasm)

5151

HTN CrisisHTN Crisis

hypertensive nephropathy (hematuria, proteinuria, hypertensive nephropathy (hematuria, proteinuria, and progressive renal dysfunction )and progressive renal dysfunction )intracranial hemorrhage, aortic dissection, intracranial hemorrhage, aortic dissection, preeclampsia-eclampsia, pulmonary edema, unstable preeclampsia-eclampsia, pulmonary edema, unstable angina, or myocardial infarction angina, or myocardial infarction

5252

initial goal in hypertensive initial goal in hypertensive emergencies emergencies

reduce the pressure by no more than 25% (1 or 2 hours )reduce the pressure by no more than 25% (1 or 2 hours )then toward a level of then toward a level of

160/100 mm Hg within 2–6 hours160/100 mm Hg within 2–6 hoursExcessive reductions may precipitate coronary, cerebral, or renal Excessive reductions may precipitate coronary, cerebral, or renal ischemia ischemia

5353

αα – Alpha – AlphaADRENOCEPTOR ADRENOCEPTOR BLOCKERSBLOCKERS Prazosin (Minipress®)Prazosin (Minipress®)Terazosin (Hytrin®)Terazosin (Hytrin®)Doxazosin (Cardura®)Doxazosin (Cardura®)relax arterial smooth muscle, and reduce blood pressure relax arterial smooth muscle, and reduce blood pressure no adverse effect on serum lipid levelsno adverse effect on serum lipid levelsthey increase HDL cholesterolthey increase HDL cholesterolreduce total cholesterol reduce total cholesterol

5454

Pulmonary Heart Disease Pulmonary Heart Disease (Cor Pulmonale) (Cor Pulmonale)

Symptoms and signs of chronic bronchitis and pulmonary Symptoms and signs of chronic bronchitis and pulmonary emphysema. emphysema. Elevated jugular venous pressure, parasternal lift, edema, Elevated jugular venous pressure, parasternal lift, edema, hepatomegaly, ascites. hepatomegaly, ascites. RV hypertrophy and eventual failure RV hypertrophy and eventual failure

5555

Findings in Findings in Cor PulmonaleCor Pulmonale

chronic productive chronic productive coughcoughexertional dyspneaexertional dyspneawheezing respirationswheezing respirationseasy fatigability, and weakness easy fatigability, and weakness oxygen saturation is often oxygen saturation is often below 85% below 85%

5656

Cor PulmonaleCor Pulmonale

OxygenOxygensalt and fluid restriction and salt and fluid restriction and diuretics diuretics the average life expectancy is 2–5 years when CHF the average life expectancy is 2–5 years when CHF appearsappears

5757

Aneurysms of the Abdominal Aorta Aneurysms of the Abdominal Aorta

asymptomatic, detected during a routine physical asymptomatic, detected during a routine physical examination or a diagnostic study. examination or a diagnostic study. Severe back or abdominal pain, a pulsatile mass, and Severe back or abdominal pain, a pulsatile mass, and hypotension indicate rupture hypotension indicate rupture 90% of abdominal aneurysms originate below the 90% of abdominal aneurysms originate below the renal arteries renal arteries

5858

Aneurysms of the Abdominal Aorta Aneurysms of the Abdominal Aorta

90% of abdominal aneurysms originate below the 90% of abdominal aneurysms originate below the renal arteriesrenal arteries5–8% of men over the age of 65 years 5–8% of men over the age of 65 years detection of a prominent aortic pulsation detection of a prominent aortic pulsation

Hypotension & ShockHypotension & Shock

6060

FeaturesFeatures

Hypotension, Hypotension, tachycardia, tachycardia, oliguria, oliguria, altered mental status. altered mental status. Peripheral hypoperfusion andPeripheral hypoperfusion and hypoxia. hypoxia.

6161

physiologic response to Shock physiologic response to Shock

Sympathetic responseSympathetic responseRelease of NorepinephrineRelease of NorepinephrineReninReninADHADHGlucagonGlucagonCortisolCortisolGrowth HormoneGrowth Hormone

6262

CausesCauses

HypovolemicHypovolemicCardiogenicCardiogenicObstructive- Pneumothorax/Obstructive- Pneumothorax/

Pulmonary embolismPulmonary embolismDistributive- pancreatitisDistributive- pancreatitisSeptic shockSeptic shock

6363

Features of Septic ShockFeatures of Septic Shock

fever fever chills chills hypotension hypotension Hyperglycemia andHyperglycemia and altered mental status altered mental status due to gram-negative bacteremia: (due to gram-negative bacteremia: (E coli, Klebsiella, E coli, Klebsiella, Proteus,Proteus, and and PseudomonasPseudomonas) )

6464

HypotensionHypotension

systolic blood pressure of 90 mm Hg or less systolic blood pressure of 90 mm Hg or less A drop in systolic pressure of more than 10–20 mm A drop in systolic pressure of more than 10–20 mm Hg and Hg and an increase in pulse of more than 15 with positional an increase in pulse of more than 15 with positional change change

6565

Treatment General MeasuresTreatment General Measures

Basic life support-(BLS) airway/oxygen/cprBasic life support-(BLS) airway/oxygen/cprAdvanced Cardiac Life Support – (ACLS)Advanced Cardiac Life Support – (ACLS)

6666

Orthostatic HypotensionOrthostatic Hypotension

Vasomotor SyncopeVasomotor SyncopeElderlyElderlyDiabeticsDiabeticsgreater than normal decline greater than normal decline (20 mm Hg) in blood pressure immediately upon (20 mm Hg) in blood pressure immediately upon arising from the supine to the standing position arising from the supine to the standing position

VASCULAR DISORDERSVASCULAR DISORDERS

6868

Aneurysms of Abdominal Aorta Aneurysms of Abdominal Aorta AAAAAA

Most aortic aneurysms are asymptomatic, detected Most aortic aneurysms are asymptomatic, detected during a routine physical examination or a diagnostic during a routine physical examination or a diagnostic study.study.Severe back or abdominal pain, a pulsatile mass, and Severe back or abdominal pain, a pulsatile mass, and hypotension indicate rupture. hypotension indicate rupture. Concomitant atherosclerotic occlusive disease of the Concomitant atherosclerotic occlusive disease of the lower extremities is present in 25% of patients.lower extremities is present in 25% of patients.

6969

AAAAAA

90% below the level of renal arteries90% below the level of renal arteriesNormal aortic diameter 2cms. >3 cms is aneurysmNormal aortic diameter 2cms. >3 cms is aneurysm1951 from 8.7 per 100,0001951 from 8.7 per 100,0001980 36.5 per 100,000 1980 36.5 per 100,000 Prevalence 5-8% M > 65Prevalence 5-8% M > 65US screen US screen Associated with popliteal artery aneurysmsAssociated with popliteal artery aneurysms

7070

AAA Rupture Signs!AAA Rupture Signs!

A RED FLAG needs referral to ERA RED FLAG needs referral to ERSevere back/ abdo/flank painSevere back/ abdo/flank painHypotensionHypotension90% fatal unless repaired surgically90% fatal unless repaired surgically

7171

AAAAAA

TherapyTherapyBeta blockersBeta blockersSurgical excision and graftSurgical excision and graftRupture risk- Rupture risk- 2% (4-5.5cm)/ 7% 2% (4-5.5cm)/ 7% (6-6.9cma0/ 25% (>7cm)(6-6.9cma0/ 25% (>7cm)Five-year survival after surgical repair is 60–80% Five-year survival after surgical repair is 60–80%

7272

Peripheral Artery Aneurysms Peripheral Artery Aneurysms (Popliteal & Femoral) (Popliteal & Femoral)

M >50M >50Associated AAAAssociated AAAPopliteal most common peripheral Popliteal most common peripheral

artery aneurysmartery aneurysmArterial thrombus rather than rupture – Arterial thrombus rather than rupture –

needs amputation (30%)needs amputation (30%)US diagnosticUS diagnosticSurgerySurgery

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Lower Extremity Occlusive Lower Extremity Occlusive Disease: Disease:

8-12 million affected8-12 million affectedIndependent risk factor for CADIndependent risk factor for CAD‘‘Intermittent claudication’Intermittent claudication’M,F (40-55)M,F (40-55)Atherosclerosis, diabetes, HTNAtherosclerosis, diabetes, HTNerectile dysfunction, erectile dysfunction, claudication, claudication, rest pain, and rest pain, and gangrene gangrene

Triad of bilateral bilateral hip and buttock hip and buttock claudication, claudication, erectile erectile dysfunction, and dysfunction, and absent femoral absent femoral pulsespulses is known as Leriche's syndrome.

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TestsTests

Absent/ diminshed peripheral pulsesAbsent/ diminshed peripheral pulsesankle–brachial index (ABI) - A normal ratio of ankle to brachial systolic ankle–brachial index (ABI) - A normal ratio of ankle to brachial systolic blood pressures is 1.0; less than 0.8 is consistent with claudication. blood pressures is 1.0; less than 0.8 is consistent with claudication. Rest pain and nonhealing ulcers Rest pain and nonhealing ulcers Lipid-lowering medications have been shown to produce a 40% risk Lipid-lowering medications have been shown to produce a 40% risk reduction for new-onset claudication or worsening of claudication. reduction for new-onset claudication or worsening of claudication. phosphodiesterase inhibitor, cilostazol (100 mg orally twice daily) phosphodiesterase inhibitor, cilostazol (100 mg orally twice daily) CarnitineCarnitineGinkgo bilobaGinkgo biloba

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Acute Limb Ischemia Acute Limb Ischemia

embolic, thrombotic, or traumatic. embolic, thrombotic, or traumatic. six Ps: pain, pallor, pulselessness, six Ps: pain, pallor, pulselessness,

paresthesias, poikilothermia, paresthesias, poikilothermia, and paralysis. and paralysis.

Embolic- 90% cardiacEmbolic- 90% cardiacHeparin and embolectomy Heparin and embolectomy

EMERGENCY!EMERGENCY!Critical time <6hrsCritical time <6hrs

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Thromboangiitis Obliterans Thromboangiitis Obliterans (Buerger's Disease) (Buerger's Disease)

Cause unknownCause unknownM <40, smokers, European/AsiaticM <40, smokers, European/AsiaticClaudication/ Rest painClaudication/ Rest painNecrosis/ ulcerationNecrosis/ ulcerationFoot arch pain, rest pain, calf painFoot arch pain, rest pain, calf painProximal pulses present / distal pulses absentProximal pulses present / distal pulses absentDD: ?SLE/ clotting disorders/ ergot ingestion, cannabis DD: ?SLE/ clotting disorders/ ergot ingestion, cannabis arteritisarteritisSTOP SMOKINGSTOP SMOKING

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VasculitisVasculitis

fever, malaise, weight loss, elevated white blood cell fever, malaise, weight loss, elevated white blood cell count and sedimentation rate, arthralgias, count and sedimentation rate, arthralgias, conjunctivitis, or erythema nodosum. conjunctivitis, or erythema nodosum. Drugs- amphetamines, cocaine, hydralazine, Drugs- amphetamines, cocaine, hydralazine, procainamide procainamide Infections-hepatitis B, gonococcus, streptococcus Infections-hepatitis B, gonococcus, streptococcus

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Raynaud's Disease & Raynaud's Raynaud's Disease & Raynaud's Phenomenon Phenomenon

idiopathic, it is called Raynaud's disease. idiopathic, it is called Raynaud's disease. precipitating systemic or regional disorder (autoimmune precipitating systemic or regional disorder (autoimmune diseases, myeloproliferative disorders, multiple myeloma, diseases, myeloproliferative disorders, multiple myeloma, cryoglobulinemia, myxedema, macroglobulinemia, or arterial cryoglobulinemia, myxedema, macroglobulinemia, or arterial occlusive disease), it is called occlusive disease), it is called Raynaud's phenomenon Raynaud's phenomenon ? ? up-regulation of vascular smooth muscle 2-adrenergic up-regulation of vascular smooth muscle 2-adrenergic receptors. receptors.

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Raynaud's disease appears first between ages 15 Raynaud's disease appears first between ages 15 and 45, almost always in women. and 45, almost always in women. A patient with suggestive symptoms that persist for A patient with suggestive symptoms that persist for over 3 years without evidence of an associated disease over 3 years without evidence of an associated disease is given the diagnosis of Raynaud's disease. is given the diagnosis of Raynaud's disease.

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Varicose Veins Varicose Veins Dilated, tortuous superficial veins in the lower extremities. Dilated, tortuous superficial veins in the lower extremities. Associated with fatigue, aching discomfort, bleeding, or localized pain. Associated with fatigue, aching discomfort, bleeding, or localized pain. Edema, pigmentation, and ulceration suggest concomitant venous Edema, pigmentation, and ulceration suggest concomitant venous stasis disease. stasis disease. Increased frequency after pregnancy. Increased frequency after pregnancy. ? varicoceles, esophageal varices, and hemorrhoids ? varicoceles, esophageal varices, and hemorrhoids Seen in 15% long saphenous veinsSeen in 15% long saphenous veinsFactors: F, pregnancy, family history, prolonged standing, and history Factors: F, pregnancy, family history, prolonged standing, and history of phlebitis of phlebitis Inherited vein wall or valvular defect Inherited vein wall or valvular defect

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Varicose VeinsVaricose Veins

Dull, aching heaviness or a feeling of fatigue brought on by Dull, aching heaviness or a feeling of fatigue brought on by periods of standing is the most common complaint. periods of standing is the most common complaint. Itching from an associated eczematoid dermatitis may occur Itching from an associated eczematoid dermatitis may occur above the ankle. above the ankle. Complications of varicose veins include secondary Complications of varicose veins include secondary ulceration, bleeding, chronic stasis dermatitis, superficial ulceration, bleeding, chronic stasis dermatitis, superficial venous thrombosis, and thrombophlebitis. venous thrombosis, and thrombophlebitis.

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Varicose VeinsVaricose Veins

Therapy- Non surgical- compression stockingsTherapy- Non surgical- compression stockingsLeg elevations/exercises/ Ace wrapsLeg elevations/exercises/ Ace wrapsSurgery- ligationsSurgery- ligations10% recur10% recurendovenous laser ablation (EVLA) endovenous laser ablation (EVLA) ultrasound guided sclerotherapy (UGS) ultrasound guided sclerotherapy (UGS) varicose vein surgery varicose vein surgery

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DVTDVT

Pain in the calf or thigh, often associated with edema. Pain in the calf or thigh, often associated with edema. Fifty percent of patients are asymptomatic. Fifty percent of patients are asymptomatic. History of congestive heart failure, recent surgery, History of congestive heart failure, recent surgery, trauma, neoplasia, oral contraceptive use, or prolonged trauma, neoplasia, oral contraceptive use, or prolonged inactivity. inactivity. Physical signs unreliable. Physical signs unreliable. Duplex ultrasound is diagnostic. Duplex ultrasound is diagnostic. 800,000 new patients/year800,000 new patients/yearstasis, vascular injury, and hypercoagulability stasis, vascular injury, and hypercoagulability

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DVTDVT

65% recover 65% recover 35% develop post dvt venous insufficiency35% develop post dvt venous insufficiency80% DVT in calf80% DVT in calfRelated to surgery 3% show symptoms/ 30% show no Related to surgery 3% show symptoms/ 30% show no signs/symptomssigns/symptomsContributing factors: Prolonged bed rest or immobility Contributing factors: Prolonged bed rest or immobility caused by cardiac failure, stroke, ventilatory support, caused by cardiac failure, stroke, ventilatory support, pelvic bone or limb fracture, paralysis, extended air pelvic bone or limb fracture, paralysis, extended air travel, or a lengthy operative procedure travel, or a lengthy operative procedure

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DVTDVTUncommon causes-Uncommon causes-malignancymalignancynephrotic syndrome nephrotic syndrome inherited deficiency disorders-inherited deficiency disorders-protein C or S or antithrombin III, protein C or S or antithrombin III, homocystinuria, homocystinuria, factor V Leiden mutation, orfactor V Leiden mutation, or paroxysmal nocturnal paroxysmal nocturnal hemoglobinuria hemoglobinuria

Other risk factors- Other risk factors- advanced ageadvanced agetype A blood grouptype A blood groupObesityObesityprevious thrombosisprevious thrombosismultiparitymultiparityuse of oral contraceptivesuse of oral contraceptivesinflammatory bowel disease andinflammatory bowel disease and lupus erythematosus lupus erythematosus 50% asymptomatic 50% asymptomatic

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Diagnostic tests necessary – Diagnostic tests necessary – Duplex Doppler USDuplex Doppler USVenograms rarely usedVenograms rarely usedD-dimer testD-dimer testComplications of DVT include pulmonary embolism Complications of DVT include pulmonary embolism Therapy- Heparin and warfarinTherapy- Heparin and warfarinFor the first episode of uncomplicated DVT is 3–6 For the first episode of uncomplicated DVT is 3–6 months of warfarin to maintain a goal INR of 2.0–3.0. months of warfarin to maintain a goal INR of 2.0–3.0. After a second episode, warfarin is continued After a second episode, warfarin is continued indefinitely.indefinitely.

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Chronic venous insufficiencyChronic venous insufficiency

History of phlebitis or leg injury. History of phlebitis or leg injury. Ankle edema is the earliest sign. Ankle edema is the earliest sign. Late signs are stasis pigmentation, Late signs are stasis pigmentation, dermatitis, subcutaneous induration, dermatitis, subcutaneous induration, varicosities, and ulceration. varicosities, and ulceration. incurable but manageable problem. incurable but manageable problem.

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Lymphangitis & Lymphadenitis Lymphangitis & Lymphadenitis

Red streak extending from an infected area toward enlarged, tender Red streak extending from an infected area toward enlarged, tender regional lymph nodes. regional lymph nodes. Chills, fever, and malaise may be present. Chills, fever, and malaise may be present. Streptococcal or staphylococcal infectionsStreptococcal or staphylococcal infectionsSuperficial scratch with cellulitis, an insect bite, or an established Superficial scratch with cellulitis, an insect bite, or an established abscess. abscess. Red streak extending toward tender, enlarged regional lymph nodes is Red streak extending toward tender, enlarged regional lymph nodes is diagnostic. diagnostic. WBC elevatedWBC elevatedDD Cat scratch disease (Bartonellosis)DD Cat scratch disease (Bartonellosis)IV antibiotics otherwise septicemia can happenIV antibiotics otherwise septicemia can happen

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Lymphedema Lymphedema

Painless edema of upper or lower extremities. Painless edema of upper or lower extremities. Involves the dorsal surfaces of the hands and fingers Involves the dorsal surfaces of the hands and fingers or the feet and toes. or the feet and toes. Developmental or acquired, unilateral or bilateral. Developmental or acquired, unilateral or bilateral. Edema is pitting initially and becomes brawny and Edema is pitting initially and becomes brawny and nonpitting with time. nonpitting with time. Ulceration, varicosities, and stasis pigmentation do not Ulceration, varicosities, and stasis pigmentation do not occur. There may be episodes of lymphangitis and occur. There may be episodes of lymphangitis and cellulitis. cellulitis.

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Lymphedema causesLymphedema causes

CongenitalCongenitalFamilialFamilialUnilateral (F:M 3.5:1)Unilateral (F:M 3.5:1)Secondary- Obstruction lymphatics/ Lymphnode Secondary- Obstruction lymphatics/ Lymphnode resection/ Radiation/ Lymphomas/resection/ Radiation/ Lymphomas/No cureNo cureExternal compression, leg elevation, massageExternal compression, leg elevation, massage

lesson 3 hypertension __ch. 11 vascular diseases __ch. 12

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lesson 3 hypertension ch. 11 vascular diseases ch. 12