1、LESSON 3,HYPERTENSION _Ch. 11 VASCULAR DISEASES _Ch. 12,HYPERTENSION,3,Demography of htn,50 million have the disease 70% aware of it Only 50% get treated Only 25% have controlled bp More common in Afro Americans Major cause for end stage renal disease and heart failure,4,Assessment and Diagnosis of
2、HTN,5,Assessment and Diagnosis of HTN,6,Physical exam should include:,Vital Stat: height, weight, and waist circumference funduscopic exam (retinopathy); carotid auscultation (bruit) jugular venous pulsation thyroid gland (enlargement) cardiac auscultation,chest auscultation abdominal exam (bruits,
3、masses, pulsations) exam of lower extremitiesroutine labs include urinalysis, complete blood count, electrolytes (potassium, calcium), creatinine, glucose, fasting lipids, and 12-lead electrocardiogram,7,secondary causes of hypertension- suggestive (clues in parentheses) of:,(1) Pheochromocytoma (la
4、bile or paroxysmal hypertension accompanied by sweats, headaches, and palpitations) (2) Renovascular disease (abdominal bruits) (3) APKD-autosomal dominant polycystic kidney disease (abdominal or flank masses) (4) Cushings syndrome (truncal obesity with purple striae) (5) Primary hyperaldosteronism
5、(hypokalemia),(6) Hyperparathyroidism (hypercalcemia) (7) Renal parenchymal disease (elevated serum creatinine, abnormal urinalysis), (8) Poor response to drug therapy, (9) SBP 180 or DBP 110 mm Hg, or (10) sudden onset of hypertension.,8,JNC VII 2003 recommendations,9,Prehypertension,gray area of 1
6、20139/8089 mm Hg a trend away from defining hypertension as a simple numerical threshold antihypertensive medications be offered to persons with prehypertension with compelling indications,10,Lifestyle Modifications for Primary Prevention of Hypertension,11,? DASH: Dietary Approaches to Stop Hyperte
7、nsion,12,LOW RISK CANDIDATES,13,RECOMMENDED DRUGS,COMPELLING CONDITIONS,14,PRIMARY HYPERTENSION,NO IDENTIFIABLE CAUSE (95%) 30% OF BLACKS/20% OF WHITES 25-55 YEAR AGE GROUP MULTIFACTORIAL,15,PRIMARY HYPERTENSION: CAUSES,GENETIC OBESITY SALT INTAKE SYMPATHETIC SYSTEM OVERACTIVITY ABNORMAL CVS DEVELOP
8、MENT RENIN-ANGIOTENSIN ACTIVITY ALCOHOL/CIGARETTE/POLYCYTHEMIA,16,Associated causes of hypertension,Sleep apneaDrug-induced or drug-relatedChronic kidney diseasePrimary aldosteronismRenovascular diseaseLong-term corticosteroid therapy and Cushings syndrome PheochromocytomaCoarctation of the aortaThy
9、roid or parathyroid disease,17,RENAL ARTERY STENOSIS,1-2% OF HTN PATIENTS YOUNGER(20 YRS AGE) FIBROMUSCULAR HYPERLASIA (f50) LEADS TO EXCESSIVE RENIN RELEASE,18,RENAL ARTERY STENOSIS,SUSPECT WHEN: HTN ONSET 20 YRS AGE OR OCCURS AFTER 50 DRUG RESITANT HTN PRESENCE OF EPIGASTRIC OR RENAL BRUITS PRESEN
10、CE OF SIGNIFICANT PERIPHERAL VASCULAR DISEASE RENAL FUNCTION DETERIORATES AFTER ACEi administration,19,RENAL ARTERY STENOSIS,Tests- Radioisotope renography duplex us MRA/CT ANGIO RENAL ARTERIOGRAPHY TREATMENT- vascular reconstruction,20,Primary hyperaldosteronism,Due to excessive aldosterone secreti
11、on Test- check plasma aldosterone levels Plasma rennin levels Calculate aldosteone/rennin ratio (nomral 25) Cause- Adrenal Adenoma- requires ct/mri scan,21,CUSHINGS SYNDROME,Glucocorticoid excess HTN (75-85%) of cases Increased Rennin-Angiotensin activity,22,Pheochromocytoma,0.1% of all htn patients
12、 2/1ooo,ooo incidence Hypertensive crisis (BP 300) Associated with Caf au Lait spots and neurofibromatosis,23,Other causes for secondary HTN,Estrogen Acromegaly Hyperthyroidism hypothyroidism DRUGS: cyclosporine and NSAIDs,24,Complications of HTN,excess morbidity and mortality related to hypertensio
13、n risk doubles for each 6 mm Hg increase in diastolic blood,25,Complications of HTN,Cardiac Complications Left Ventricular Hypertrophy congestive heart failure ventricular arrhythmiasmyocardial ischemia and sudden death.,26,Complications of HTN,Cerebrovascular Disease and Dementia - hemorrhagic and
14、ischemic stroke higher incidence of subsequent dementia of both vascular and Alzheimer types markedly reduced by antihypertensive therapy,27,Complications of HTN,Hypertensive Renal Disease renal insufficiency hypertensive nephropathy more common in blacks associated with Diabetes MellitusBenefits wi
15、th ACEi therapy,28,Complications of HTN,Aortic dissection Increased Atherosclerosis,29,SYMPTOMS OF HTN,mainly referable to involvement of the target organs: Heart Brain Kidneys Eyes and Peripheral arteries.,30,Symptoms of HTN,Mainly asymptomatic Early morning suboccipital pulsating HA Hypertensive E
16、ncephalopathy: Somnolence/confusion/Visual/Nausea/Vomiting (Diastolic BP 130),31,Signs of HTN,Heart: Left ventricular enlargement/Hypertrophy LAB workup: CBC/Urinalysis/FBS/LIPIDS/Serum Uric Acid /Electrolytes/Creatinine/BUNECG/CXR,32,33,34,ECG: LV Strain Pattern,Suggests Advanced diseasePoor progno
17、sis Other Investigations:Renal US/CT/MRI scans,35,Management Algorithm,36,NON PHARMACOLOGIC THERAPY,CHANGE LIFESTYLE: DASH DIET Weight reduction Reduced alcohol consumption Reduced salt intake Gradually increasing activity levels,37,Goals of Treatment,diabetic patients, CKD, should be lower ( 130/80
18、 mm Hg) Others (140/90) long-term adverse consequences of drug therapy blockers, Thiazides statins can significantly improve outcomes in DM/Post MI (total and LDL cholesterol levels of 194 mg/dL and 116 mg/dL ),38,Current Antihypertensive Agents,Diuretics HCTZ (Esidrix, Hydro-Diuril)LOOP DIURETICS -
19、 Ethacrynic acid (Edecrin) Furosemide (Lasix)ALDOSTERONE RECEPTOR BLOCKERS - Amiloride (Midamor)Spironolactone (Aldactone) alone -control blood pressure in 50%,39,Side effects of diuretics,Hypo-K+, Hypo-Mg2+, Hypo-Ca2+, Hypo-Na+, Hyper-uric acid (gout), Hyper-glucose, Increase LDL cholesterol, Incre
20、ase triglycerides; rash, erectile dysfunction.,40,Adrenergic Blocking Agents,Beta blockers decrease the heart rate and cardiac output Acebutolol(Sectral) Atenolol(Tenormin) Metoprolol(Lopressor) Pindolol (Visken) Propranolol (Inderal),41,Side effects of Beta Blockers,exacerbating bronchospasm bradyc
21、ardia or AV block precipitating or worsening l vf nasal congestion Raynauds phenomenon nightmares Increase TGL Decrease HDL,42,ACE Inhibitors,initial medication Benazepril (Lotensin) Captopril (Capoten) Enalapril (Vasotec),43,RAAS System,44,Side Effects Of ACEi,Cough hypotension dizziness renal dysf
22、unction hyperkalemia angioedema taste alteration and rash Contraindicated in pregnancy Acute Renal Failure,45,Angiotensin Receptor Blockers: ARBs,Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) do not cause cough,46,The ABCD rule,B* and D* may induce more new-onset d
23、iabetes A= ACEi or ARBs *B= Blockers C= CCBs *D= Diuretic (thiazide),47,BHS Guidelines,Young Elderly(low renin)A B C D A ACE Inhibitor B Beta Blocker C Calcium Channel Blocker D Diuretic,48,Afro-Americans and HTN,more likely to become hypertensive and more susceptible to the cardiovascular complicat
24、ions Respond differently to drugs ACEi and ARBs are less effective,49,Follow up of HTN patients,Achieve good control Need less frequent visits Yearly monitoring of blood lipids and an ECG should be repeated at 2- 4 years,50,HTN Crisis (220/130),requires prompt recognition and aggressive management b
25、lood pressure must be reduced within a few hours hypertensive encephalopathy (headache, irritability, confusion, and altered mental status due to cerebrovascular spasm),51,HTN Crisis,hypertensive nephropathy (hematuria, proteinuria, and progressive renal dysfunction ) intracranial hemorrhage, aortic
26、 dissection, preeclampsia-eclampsia, pulmonary edema, unstable angina, or myocardial infarction,52,initial goal in hypertensive emergencies,reduce the pressure by no more than 25% (1 or 2 hours ) then toward a level of 160/100 mm Hg within 26 hours Excessive reductions may precipitate coronary, cere
27、bral, or renal ischemia,53, Alpha ADRENOCEPTOR BLOCKERS,Prazosin (Minipress) Terazosin (Hytrin) Doxazosin (Cardura) relax arterial smooth muscle, and reduce blood pressure no adverse effect on serum lipid levels they increase HDL cholesterol reduce total cholesterol,54,Pulmonary Heart Disease (Cor P
28、ulmonale),Symptoms and signs of chronic bronchitis and pulmonary emphysema. Elevated jugular venous pressure, parasternal lift, edema, hepatomegaly, ascites. RV hypertrophy and eventual failure,55,Findings in Cor Pulmonale,chronic productive cough exertional dyspnea wheezing respirations easy fatiga
29、bility, and weakness oxygen saturation is often below 85%,56,Cor Pulmonale,Oxygen salt and fluid restriction and diuretics the average life expectancy is 25 years when CHF appears,57,Aneurysms of the Abdominal Aorta,asymptomatic, detected during a routine physical examination or a diagnostic study.
30、Severe back or abdominal pain, a pulsatile mass, and hypotension indicate rupture 90% of abdominal aneurysms originate below the renal arteries,58,Aneurysms of the Abdominal Aorta,90% of abdominal aneurysms originate below the renal arteries 58% of men over the age of 65 years detection of a promine
31、nt aortic pulsation,Hypotension & Shock,60,Features,Hypotension, tachycardia, oliguria, altered mental status. Peripheral hypoperfusion andhypoxia.,61,physiologic response to Shock,Sympathetic response Release of Norepinephrine Renin ADH Glucagon Cortisol Growth Hormone,62,Causes,Hypovolemic Cardiog
32、enic Obstructive- Pneumothorax/Pulmonary embolism Distributive- pancreatitis Septic shock,63,Features of Septic Shock,fever chills hypotension Hyperglycemia andaltered mental status due to gram-negative bacteremia: (E coli, Klebsiella, Proteus, and Pseudomonas),64,Hypotension,systolic blood pressure
33、 of 90 mm Hg or less A drop in systolic pressure of more than 1020 mm Hg and an increase in pulse of more than 15 with positional change,65,Treatment General Measures,Basic life support-(BLS) airway/oxygen/cpr Advanced Cardiac Life Support (ACLS),66,Orthostatic Hypotension,Vasomotor Syncope Elderly
34、Diabetics greater than normal decline (20 mm Hg) in blood pressure immediately upon arising from the supine to the standing position,VASCULAR DISORDERS,68,Aneurysms of Abdominal Aorta AAA,Most aortic aneurysms are asymptomatic, detected during a routine physical examination or a diagnostic study. Se
35、vere back or abdominal pain, a pulsatile mass, and hypotension indicate rupture. Concomitant atherosclerotic occlusive disease of the lower extremities is present in 25% of patients.,69,AAA,90% below the level of renal arteries Normal aortic diameter 2cms. 3 cms is aneurysm 1951 from 8.7 per 100,000
36、 1980 36.5 per 100,000 Prevalence 5-8% M 65 US screen Associated with popliteal artery aneurysms,70,AAA Rupture Signs!,A RED FLAG needs referral to ER Severe back/ abdo/flank pain Hypotension 90% fatal unless repaired surgically,71,AAA,Therapy Beta blockers Surgical excision and graft Rupture risk-
37、2% (4-5.5cm)/ 7% (6-6.9cma0/ 25% (7cm) Five-year survival after surgical repair is 6080%,72,Peripheral Artery Aneurysms (Popliteal & Femoral),M 50 Associated AAA Popliteal most common peripheral artery aneurysm Arterial thrombus rather than rupture needs amputation (30%) US diagnostic Surgery,73,Low
38、er Extremity Occlusive Disease:,8-12 million affected Independent risk factor for CAD Intermittent claudication M,F (40-55) Atherosclerosis, diabetes, HTN erectile dysfunction, claudication, rest pain, and gangrene,Triad of bilateral hip and buttock claudication, erectile dysfunction, and absent fem
39、oral pulses is known as Leriches syndrome.,74,Tests,Absent/ diminshed peripheral pulses anklebrachial index (ABI) - A normal ratio of ankle to brachial systolic blood pressures is 1.0; less than 0.8 is consistent with claudication. Rest pain and nonhealing ulcers Lipid-lowering medications have been
40、 shown to produce a 40% risk reduction for new-onset claudication or worsening of claudication. phosphodiesterase inhibitor, cilostazol (100 mg orally twice daily) Carnitine Ginkgo biloba,75,Acute Limb Ischemia,embolic, thrombotic, or traumatic. six Ps: pain, pallor, pulselessness, paresthesias, poi
41、kilothermia, and paralysis. Embolic- 90% cardiac Heparin and embolectomy EMERGENCY! Critical time 6hrs,76,Thromboangiitis Obliterans (Buergers Disease),Cause unknown M 40, smokers, European/Asiatic Claudication/ Rest pain Necrosis/ ulceration Foot arch pain, rest pain, calf pain Proximal pulses pres
42、ent / distal pulses absent DD: ?SLE/ clotting disorders/ ergot ingestion, cannabis arteritis STOP SMOKING,77,Vasculitis,fever, malaise, weight loss, elevated white blood cell count and sedimentation rate, arthralgias, conjunctivitis, or erythema nodosum. Drugs- amphetamines, cocaine, hydralazine, pr
43、ocainamide Infections-hepatitis B, gonococcus, streptococcus,78,Raynauds Disease & Raynauds Phenomenon,idiopathic, it is called Raynauds disease. precipitating systemic or regional disorder (autoimmune diseases, myeloproliferative disorders, multiple myeloma, cryoglobulinemia, myxedema, macroglobuli
44、nemia, or arterial occlusive disease), it is called Raynauds phenomenon ? up-regulation of vascular smooth muscle 2-adrenergic receptors.,79,Raynauds disease appears first between ages 15 and 45, almost always in women. A patient with suggestive symptoms that persist for over 3 years without evidenc
45、e of an associated disease is given the diagnosis of Raynauds disease.,80,81,Varicose Veins,Dilated, tortuous superficial veins in the lower extremities. Associated with fatigue, aching discomfort, bleeding, or localized pain. Edema, pigmentation, and ulceration suggest concomitant venous stasis dis
46、ease. Increased frequency after pregnancy. ? varicoceles, esophageal varices, and hemorrhoids Seen in 15% long saphenous veins Factors: F, pregnancy, family history, prolonged standing, and history of phlebitis Inherited vein wall or valvular defect,82,Varicose Veins,Dull, aching heaviness or a feel
47、ing of fatigue brought on by periods of standing is the most common complaint. Itching from an associated eczematoid dermatitis may occur above the ankle. Complications of varicose veins include secondary ulceration, bleeding, chronic stasis dermatitis, superficial venous thrombosis, and thrombophle
48、bitis.,83,Varicose Veins,Therapy- Non surgical- compression stockings Leg elevations/exercises/ Ace wraps Surgery- ligations 10% recur endovenous laser ablation (EVLA) ultrasound guided sclerotherapy (UGS) varicose vein surgery,84,DVT,Pain in the calf or thigh, often associated with edema. Fifty per
49、cent of patients are asymptomatic. History of congestive heart failure, recent surgery, trauma, neoplasia, oral contraceptive use, or prolonged inactivity. Physical signs unreliable. Duplex ultrasound is diagnostic. 800,000 new patients/year stasis, vascular injury, and hypercoagulability,85,DVT,65%
50、 recover 35% develop post dvt venous insufficiency 80% DVT in calf Related to surgery 3% show symptoms/ 30% show no signs/symptoms Contributing factors: Prolonged bed rest or immobility caused by cardiac failure, stroke, ventilatory support, pelvic bone or limb fracture, paralysis, extended air travel, or a lengthy operative procedure,
