update on hypertensive retinopathy dkt. muchai gachago
TRANSCRIPT
Update on Hypertensive Retinopathy
Dkt. Muchai Gachago
Introduction
• First described in the late 1800s• Used to predict risk of stroke, cardiovascular
disease, and even mortalityEpidemiology• HR in 3% to 14% of nondiabetic adults age
≥40.• 10 year cumulative incidence is 16%.
PATHOGENESIS AND PRESENTATION
• spectrum of “retinal vascular signs” caused by elevated blood pressure.
• Autoregulation of the vasculature → breakdown of autoregulation pathways and atherosclerosis
Signs
Signs
Signs
Signs
Signs
Long-term Consequences
• Arteriolosclerosis - irreversible→opacification, compression of venules.
• BRB disruption→“exudative” stage
• “Malignant” stage → optic disc and macular oedema due to raised intracranial pressure.
Keith–Wagener–Barker ClassificationGrade Features
1 Mild generalized retinal arteriolar narrowing
2 Definite focal narrowing and arteriovenous nipping
3 Signs of grade 2 retinopathy plus retinal hemorrhages, exudates, and cotton wool spots
4 Severe grade 3 retinopathy plus papilloedema
-Poor reliability and reproducibility-Grades do not correlate with severity of hypertension-Not sequential in nature-Grades do not correlate with prognosis, cardiovascular events, and mortality.
Simplified ClassificationGrade FeaturesMild( retinal arteriolar signs)
Generalized arteriolar narrowing, focal arteriolar narrowing, arteriovenous nicking, opacity (“copper wiring”) of arteriolar wall, or a combination of these signs
Moderate(retinopathy-like lesions)
Retinal hemorrhages (blot-shaped, dot-shaped, or fiame-shaped), microaneurysms, cotton wool spots, hard exudates, or a combination of these signs
Malignant Signs of moderate retinopathy plus optic disk swelling
-Good reliability and reproducibility.-Predicted the long-term risk of stroke. -Ease of use -Appropriate stratification of cardiovascular risk disease.
Recent Observations• ↑blood pressure →higher frequency of retinopathy signs
• Long-term hypertension → Generalized retinal arteriolar narrowing & AVN. Assoc with ↑BP control in past 10yrs
• Focal arteriolar narrowing and retinopathy lesions related only to concurrently measured blood pressure.
• Assoc between BP and retinal microvascular signs ↓with age
• Smaller retinal arteriolar and larger venular calibers precede clinical stages of hypertension and predict the risk of hypertension in initially normotensive individuals.
RELATIONSHIP WITH TARGET ORGAN DAMAGE
Atherosclerosis Risk in Communities (ARIC) study, subjects with HR:
• ↑ risk of developing incident stroke• Cognitive decline• Cerebral white matter lesions• Cerebral atrophy• Predicted the long-term risk of stroke• Incident stroke (19.3% vs 4.3%) and incident
cerebral infarction (15.5% vs 3.6%)
Kidney and Heart Disease
• ↑Chronic kidney disease (CKD) & microalbuminuria
• Stroke * 7• Heart attack * 4• Coronary artery disease * 3• Peripheral artery disease * 2
CLINICAL MANAGEMENTRetinopathy
GradeSystemic
Associations Management
Mild
Weak associations with stroke, coronary heart disease and cardiovascular mortality
Routine care Closer monitoring
of vascular risk
Moderate
Strong association with stroke, congestive heart failure, renal dysfunction, and cardiovascular mortality
Exclude diabetes Closer monitoring
of vascular risk Possible
indication for hypertension treatment and other risk factors
Malignant Associated with mortality
Urgent hypertension treatment
Hypertensive Choroidopathy
Elschnig Spots: Focal choroidal infarcts
Siegrist Streaks: Fibrinoid necrosis
Exudative RD
Complications
Complications
Complications
Further Reading
• Retinal Physician, Volume: 10 , Issue: November 2013, page(s): 43 – 54...Review Article Reviewing 96 papers on Hypertension and HR.