1、 Continuing Medical Implementation .bridging the care gap,Target Organ Damage,Joel Niznick MD FRCPC, Continuing Medical Implementation .bridging the care gap,Diseases Attributable to Hypertension,Hypertension,Heart failure,Stroke,Coronary heart disease,Myocardial infarction,Left ventricular hypertro
2、phy,Aortic aneurysm,Retinopathy,Peripheral vascular disease,Hypertensive encephalopathy,Chronic kidney failure,Cerebral hemorrhage,Adapted from: Arch Intern Med 1996; 156:1926-1935.,All Vascular, Continuing Medical Implementation .bridging the care gap,Initial Assessment,OVERALL CARDIOVASCULAR RISK
3、Framingham Procam SCORE System Risk factor counting Type 2 diabetes TARGET ORGAN DAMAGE Physical exam Diagnostic testing,RULE OUT SECONDARY AND OFTEN CURABLE CAUSES Renal artery stenosis Hyperaldosteronism Pheochromocytoma Coarctation of aorta, Continuing Medical Implementation .bridging the care ga
4、p,Identify Target Organ Damage,Retinopathy Clinical LVH(S4) ECG-LVH CXR-Cardiomegaly ECHO-LVH/LV Mass/Diastolic Dysfunction Lab-Renal Function/Micro-albuminuria Vascular-bruits/Diminished pulses, Continuing Medical Implementation .bridging the care gap,Target Organ Damage/Clinical Cardiovascular Dis
5、easeshould be assessed by history and physical examination,Components of Risk Stratification, Continuing Medical Implementation .bridging the care gap,Important Aspects of the Physical Examination in the Hypertensive Patient,Accurate measurement of blood pressure General appearance: distribution of
6、body fat, skin lesions, muscle strength, alertness Fundoscopy Neck: palpation and auscultation of carotids, thyroid Heart: size, rhythm, sounds Lungs: rhonchi, rales Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses Extremities: peripheral pulses, edema Neurologic assessment
7、, Continuing Medical Implementation .bridging the care gap,Hypertensive Retinopathy Grade 2,Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow), Continuing Medical Implementation .bridging the care gap,Hypertensive Retinopathy Grade 3,Flame-shaped hemorrhage in association
8、with severe hypertension Grade 3 (yellow arrow), Continuing Medical Implementation .bridging the care gap,Hypertensive Retinopathy Grade 4,Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow), Continui
9、ng Medical Implementation .bridging the care gap,Clinical Signs of LV Dysfunction,Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displacement Sustained apex - to S2,Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary co
10、ngestion rales, Continuing Medical Implementation .bridging the care gap,Exclude Secondary Causes,Renal Artery Stenosis Coarctation of the Aorta Pheochromocytoma Primary Aldosteronism Cushingss Syndrome Renal Disease Dietary-Sodium Intake/Drugs/ Alcohol/Tobacco, Continuing Medical Implementation .br
11、idging the care gap,Routine laboratory tests for the investigation of all patients with hypertension: Urinalysis Complete blood cell count Blood chemistry (potassium, sodium and creatinine) Fasting glucose Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein
12、 (LDL) cholesterol, triglycerides Standard 12 ECG,CHS Recommendations Routine Laboratory Investigations, Continuing Medical Implementation .bridging the care gap,What are the indications for checking the BP in both arms?,The presence of both arms R/O Atherosclerotic obstruction Scalenus anticus synd
13、rome/cervical rib Aortic coarctation above left subclavian Anomalous origin right subclavian artery in aortic coarctation, Continuing Medical Implementation .bridging the care gap,What are the indications for checking BP in the lower extremities?,Hypertensive patient under 40 years of age. Elderly p
14、atient with suspected PVD How do you do it? Thigh cuff-auscultate over popliteal artery Large arm cuff around calf (bladder posterior) -palpate PT or DP Which is normally higher- arm or leg BP?, Continuing Medical Implementation .bridging the care gap,Ankle-brachial index,Resting and post exercise S
15、BP in ankle and arm. Normal ABI 1 ABI .9 has 95% sensitivity for angiographic PVD ABI 0.5- 0.84 correlates with claudication ABI 0.5 indicates advanced ischaemia, Continuing Medical Implementation .bridging the care gap,A 60 year old man with HTN, Continuing Medical Implementation .bridging the care
16、 gap,An 84 year old woman with hypertension, Continuing Medical Implementation .bridging the care gap,MAU as a Predictor of Morbidity and Mortality,Diabetes + MAU,Parving HH. J Hypertens 1996;14 Suppl 2:S89-S94., Continuing Medical Implementation .bridging the care gap,Definitions of abnormalities i
17、n albumin excretion, Continuing Medical Implementation .bridging the care gap,Eastman RC, Keen H. Lancet 1997;350 Suppl 1:29-32.,Microalbuminuria,10 8 6 4 2 0,10.02,Smoking,Hypertension,Odds Ratio,6.52,Cholesterol,2.32,3.20,Relative Importance of MAU, Continuing Medical Implementation .bridging the care gap,ALB (g/min),1000,300,30,Years of Diabetes Mellitus,7-15,10-30,Proteinuria Stabilization possible,Renal failure 2 year survival 50%,MAU Reversible,Adapted by D. Studney,Course of Diabetic Nephropathy,
