HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS
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Transcript of HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS
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HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS
Dr. Zahoor Ali Shaikh
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HYPERTENSION
DEFINITIONHypertension is said to be present
when blood pressure is greater than expected for a person of particular age, sex and race on at least three separate occasions under resting condition whether symptoms are present or not.
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HYPERTENSION
IMPORTANT INFORMATION Elevated arterial BP is major cause of
pre-mature vascular disease leading to cerebrovascular events, ischemic heart disease and peripheral vascular disease.
BP is characteristic of each person. BP varies with age and ethnic
background. BP increases with age.
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HYPERTENSION
Hypertension is one of the commonest chronic condition in the developed countries.
It may be present up to 20-30% of adult population.
In black Africans – hypertension may affect
40-50% of adult population. Hypertension is affecting one billion
people world wide.
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HYPERTENSION
Most common cause for an outpatient visit to the physician.
High BP is associated with high mortality and morbidity.
All adults should have BP measured routinely every 2 years.
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HYPERTENSION
Seated BP should be measured after 5 mins of rest.
In diabetes mellitus, old age – standing BP should be measured to exclude postural hypotension.
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HYPERTENSION
Presentation Patient with mild hypertension is
usually asymptomatic. BP maybe detected on routine
examination. Patient may present with headache,
Epistaxis.
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HYPERTENSION
Presentation may be due to complications of hypertension
Patient may present with breathlessness due to left ventricular failure or cardiac failure.
Patient may present with renal failure.
Patient may present stroke.
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HYPERTENSION
Presentation maybe headache, palpitation, sweating – they occur in paroxysmal attacks, which may point to diagnosis of phaeochromocytoma.
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HYPERTENSION
Malignant hypertension may present with severe headache, visual disturbance, fits, transient loss of consciousness or symptoms of heart failure.
IMPORTANT NOTE Malignant Hypertension if not
controlled, survival less than ONE –TWO YEARS due to CVA, Heart Failure, Chronic Renal Failure
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HYPERTENSION
Examination of patient to look for cause and effects of increase BP
on organs Increased BP maybe only abnormal
sign.Look for underlying cause Cardiac examination may reveal left
ventricular hypertrophy. Signs of cardiac failure maybe there.
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HYPERTENSION
Look for underlying cause Renal artery bruits maybe present
due to renal artery stenosis. Radio femoral delay is present in
Coarctation of aorta. Look at the fundus.
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HYPERTENSION
Fundascopy is essential part of examination in hypertensive patient.
There are four grades of abnormality according to the Keith-Wagener classification.
Grade 1 – Tortuosity of retinal artery (silver wiring)
Grade 2 – Grade 1 + A:V nipping (arteriovenous nipping)
Grade 3 – Grade 2 + flame shaped hemorrhage and soft (cotton wool) exudates
Grade 4 – Grade 3 + papilloedema
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NORMAL FUNDUS
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Fundus of Hypertensive Patient
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HYPERTENSION
Investigations in Hypertension Chest X-ray ECG Echocardiogram Urinalysis Fasting blood glucose and lipids Serum urea, creatinine and
electrolytes
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HYPERTENSION
Further investigations If urea or creatinine are increased
then creatinine clearance should be done.
Renal angiography if renal artery stenosis is suspected.
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HYPERTENSION
Investigations [cont] If serum potassium is low and
Hyperaldosteronism is suspected or Glucocorticoids excess then do
- Aldosterone level - Cortisol level - Renin level
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HYPERTENSION
Investigations [cont] If phaeochromocytoma is suspected
then do - urinary metanephrins - plasma or urinary catecholamines
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HYPERTENSION
Investigations [cont] ECG may show evidence of coronary
artery disease e.g. IHD or left ventricular hypertrophy.
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NORMAL ECG
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ISCHEMIC HEART DISEASE
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HYPERTENSION
Investigations [cont] X-ray chest may show cardiomegly.
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HYPERTENSION
X-ray chest may show Rib notching – which is sign of Coarctation of aorta, if so, do MRI.
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NORMAL X-RAY CHEST
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X-RAY CHEST IN HEART FAILURE
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In Coarctation of the aorta, the dilated LSCA, indentation of coarct and post-stenotic aortic dilation form “3”
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HYPERTENSION
Assessment and Treatment of Hypertension
There are three stages 1. Assessment 2. Non-pharmacological treatment 3. Drug treatment
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HYPERTENSION
1. Assessment Excludes secondary causes of
hypertension. Evaluate target organ damage e.g.
heart, kidney, retina. Look for diabetes mellitus,
hypercholestermia.
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HYPERTENSION
2. Non-pharmacological treatment Reduce weight if over-weight or
obesity Decrease sodium intake in diet Use low-fat diet Exercise Increase fruit and vegetable
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HYPERTENSION
3. Drug treatment Diuretics Beta blockers ACEI (angiotensin converting enzyme
inhibitors) Angiotensin II receptor blocker (ARB) Calcium blockers
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HYPERTENSION
3. Drug treatment (cont) Alpha blockers (cause vasodilatation) Vasodilators (act on smooth muscle
of blood vessel) Sodium nitroprusside – potent
arterial and venous dilator (used intravenously in hypertensive crises)
Centrally acting drugs e.g. methyl dopa – acts on central α2 receptors
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THANK YOU