© continuing medical implementation …...bridging the care gap target organ damage joel niznick md...

© Continuing Medical Implementation …...bridging the care gap

Target Organ DamageTarget Organ Damage

Joel Niznick MD FRCPC


Diseases Attributable to Hypertension

Diseases Attributable to Hypertension

Hypertension

Heart failureStroke

Coronary heart disease

Myocardial infarction

Left ventricular hypertrophy

Aortic aneurysm

Retinopathy

Peripheral vascular disease

Hypertensive encephalopathy

Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.

AllVascular


Initial AssessmentInitial Assessment

• OVERALL CARDIOVASCULAR RISK– 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


Target Organ Damage/Clinical Cardiovascular Disease should be assessed by history and physical examination

Components of Risk Stratification

Components of Risk Stratification

Brain

HeartKidneys

Eyes

Arteries


Important Aspects of the Physical Examination in the Hypertensive PatientImportant Aspects of the Physical Examination in the Hypertensive Patient

• Accurate measurement of blood pressure• General appearance: distribution of 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


Hypertensive RetinopathyGrade 2


Arteriovenous nicking in association with hypertension Grade 2

(yellow arrow)




• Flame-shaped hemorrhage in association with severe hypertension Grade 3 (yellow arrow)




• Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow)


Clinical Signs of LV Dysfunction

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 congestion

– rales


Routine laboratory tests for the investigation of all patients with hypertension:

1. Urinalysis 2. Complete blood cell count 3. Blood chemistry (potassium, sodium and

creatinine) 4. Fasting glucose 5. Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides 6. Standard 12 ECG

CHS RecommendationsRoutine Laboratory Investigations

CHS RecommendationsRoutine Laboratory Investigations


What are the indications for checking the BP in both arms?

What are the indications for checking the BP in both arms?

• The presence of both arms– R/O

• Atherosclerotic obstruction

• Scalenus anticus syndrome/cervical rib

• Aortic coarctation above left subclavian

• Anomalous origin right subclavian artery in aortic coarctation


What are the indications for checking BP in the lower extremities?

What are the indications for checking BP in the lower extremities?

– Hypertensive patient under 40 years of age.– Elderly patient 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?


Ankle-brachial indexAnkle-brachial index

• Resting and post exercise SBP 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


A 60 year old man with HTNA 60 year old man with HTN


An 84 year old woman with hypertension

An 84 year old woman with hypertension


MAU as a Predictor of Morbidity

and Mortality

MAU as a Predictor of Morbidity

and Mortality

Retinopathy

Diabetes+

MAU

LVH

Non-fatal cardiovascular

diseaseAll-cause mortality

Nephropathy

Peripheral/autonomic neuropathy

Parving HH. J Hypertens 1996;14 Suppl 2:S89-S94.


Definitions of abnormalities in albumin excretion

Definitions of abnormalities in albumin excretion

Category 24 hour collection

(mg/24h)

Timed collection

(g/min)

Spot collection

(g/mg Cr)

Normal < 30 < 20 < 30Microalbuminuria

30-299 20-199 30-299

Clinical albuminuria

300 200 300

Because of variability in urinary albumin excretion, 2 of 3 specimens over

3-6 should be abnormal before considering diagnostic threshold positive

False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria.


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

2.323.20

Relative Importance of MAURelative Importance of MAU


ALB

(µg/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 NephropathyCourse of Diabetic Nephropathy

© continuing medical implementation …...bridging the care gap target organ damage joel niznick md...

Documents

vascular slide

care gap initial assessment

care gap diseases attributable

care gap important aspects

yellow arrow slide

exudates white arrow

renal arteries

severe hypertension