HTA

Question 1

BLOOD PRESSURE (BP)

Answer 1

The force exerted by the blood against any unit area of the vessel wall
• Standard Units of Pressure: millimeters of mercury (mm Hg)
→ because the mercury manometer has been used since antiquity as the standard reference for measuring pressure

Question 2

BP in the arterial system it is Labile & Varies

Answer 2

1.During the cardiac cycle
‒ Peak (↑) in systole (SBP) and
‒ Fall (↓) to its lowest trough in diastole (DBP)
→ levels that may be measured with the blood pressure cuff, or sphygmomanometer

• With respiration (SBP fall during inspiration)
• Standing SBP should not drop more than 10 mm Hg, and diastolic pressure should remain unchanged or rise slightly, after resting supine

Question 3

PULSE PRESSURE

Answer 3

=The difference between SBP and DBP

Question 4

FACTORS THAT MAY ALTER SYSTOLIC PRESSURE,

DIASTOLIC PRESSURE, OR BOTH

Answer 4

1. Left ventricular stroke volume
2. Ejection velocity
3. Distensibility of the aorta and the large arteries
4. Peripheral vascular resistance, particularly at the arteriolar level
5. Volume of blood in the arterial system

Question 5

Blood pressure levels vary over 24-hour period with:

Answer 5

 Physical activity
 Emotional state
 Other conditions: pain
 Environmental factors: noise, temperature
 Diet: salt
 Tobacco
 Drugs

Question 6

HOW IS BLOOD PRESSURE REGULATED?

Hemodynamic Factors

Answer 6

BP = CO (Cardiac Output) x TPR (Total Peripheral Resistance)
CO = SV (Stroke Volume) x HR (Heart Rate):
SV is determined by:
(1) Cardiac Contractility
(2) the Preload (The venous return to the heart)
(3) the Afterload (The resistance the LV must overcome to eject blood into aorta)

Question 7

BP directly regulated by 4 systems

Answer 7

1. the Heart, which supplies the Pumping pressure
2. the blood vessel Tone, which largely determines systemic Resistance
3. the Kidney, which regulates Intravascular Volume
4. Hormones, which modulate the functions of the other 3 systems

Question 8

Regulation of systemic blood pressure

Answer 8

SLIDE 3

Question 9

How BP levels increases CVD risk

Answer 9

In people between 40–70 yo HTN double the risk of CVD with 20 mm
 SBP or with 10 mm
 DBP

Question 10

Hypertension-Epidemiology

Prevalence

Answer 10

 > 1 in 5 Women & 1 in 4 Men have HTN (reported by WHO)
 > 150 million Europe (central and eastern)
 121.5 mil. adults ≥ 20 y USA (63.1 M; 58.4 F)
 ~ 1,13 billion global prevalence estimated - 2015
 Increases with ageing > 60% older >60 y
 1,5 bill pts. estimated → 2025

Question 11

What is hypertension ?

Answer 11

 A major public health problem
 A major modifiable risk factor for

1. Stroke,
2. Myocardial infarction,
3. Vascular disease, and
4. Chronic kidney disease
    the major Preventable cause of
5. Cardiovascular disease (CVD) and
6. All-cause death

Question 12

HYPERTENSION DEFINITION

Answer 12

Difficult issue because:
- in the overall population BP has a typical bell-shaped curve distribution
- the distinction between Normotension and Hypertension, based on cut-off BP values is Arbitrary (Sir George Pickering)
- The relationship between BP value and related Events (CV and renal)
is Continuous and Progressive without a definite threshold

Question 13

HYPERTENSION DEFINITION

The most used definitions

Answer 13

1. The value from which the long-term risk doubles
2. As stated by Rose (1980): “The operational definition of hypertension is the level at which the benefits… of action exceed those of inaction

Question 14

HYPERTENSION DEFINITION IS ___ BUT

Answer 14

(1)Conventional,
Modifiable and
Perfectible

(2) BUT
“physicians feel more secure when dealing with precise criteria, even if the criteria are basically arbitrary”
 medical practice needs a Delimitation Criteria for
1. Diagnosis and
2. Therapeutic approach

Question 15

CURRENT HTN DEFINITION: 03/2021

based on an average of ≥ 2 careful readings obtained on ≥ 2 occasions

Answer 15

ESC & WHO Definition
Hypertension is defined as OFFICE
SBP values ≥ 140 mmHg
and / or
DBP (diastolic BP ) values ≥ 90 mmHg

Based on evidence from multiple
RCTS that treatment of patients with these BP values is
beneficial

The same classification is used in younger, middleaged, and older people, whereas BP centiles are used in children and teenagers, in whom data from interventional trials are not available.

Question 16

• 2017 ACC/AHA Definition (US) BP categories are:

Answer 16

Normal: Less than 120/80 mm Hg;
Elevated: Systolic between 120-129 and diastolic less than 80;
Stage 1: Systolic between 130-139 or diastolic between 80-89;
Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg

Question 17

Criteria for Hypertension Based on
Office-,
Ambulatory (ABPM)-, and
Home Blood Pressure (HBPM)
Measurement

Answer 17

SBP/DBP, mm Hg
Office BP ≥140 and/or ≥90
ABPM
24-h average ≥130 and/or ≥80
Day time (or awake) average ≥135 and/or ≥85
Night time (or asleep) average ≥120 and/or ≥70
HBPM ≥135 and/or ≥85

Question 18

HTN Classification__1.

According to presumptive etiology

Answer 18

Primary hypertension: 90 to 95% of HTN patients

= Idiopathic: Presumed Environmental and genetic/epigenetic causes
(! NB the term essential hypertension replaced now by primary

Secondary hypertension (or Identifiable causes HTN): 5- 10%

Question 19

HTN Classification __1

According to hemodynamic subtypes

Answer 19

 Systolic hypertension in teenagers and young adults
 Diastolic hypertension in middle age
 Isolated systolic HTN in older adults

Question 20

HTN classification__2.
Classification of Office blood pressurea and
definitions of hypertension gradeb

Answer 20

Category Systolic(mmHg) Diastolic(mmHg)
Optimal <120 and <80
Normal 120–129 and/or 80–84
High normal 130–139 and/or 85–89

Grade 1 hypertension 140–159 and/or 90–99
Grade 2 hypertension 160–179 and/or 100–109
Grade 3 hypertension ≥ 180 and/or ≥ 110
Isolated systolic hypertension(b) ≥ 140 and < 90

Question 21

HTN: other classification__3.

Answer 21

 According to circumstances
‒ White coat hypertension
‒ Masked hypertension

 According to circadian pattern
‒ Dipper (BP decreased at night)
‒ Non-dipper (average night= average day)*
‒ Reverse dipper (BP increases during night time)*
* ↑ mortality, ↑ morbidity risk

Question 22

CONSEQUENCES OF HYPERTENSION

Subclinical Hypertension Mediated Organ Damage

Answer 22

 LVH Electrocardiographic (Sokolow -Lyon >38 mm; Cornell >2440 mm*ms) or
 LVH Echocardiographic (LVMI: Men 125 g/m2, Women ≥ 110 g/m2)
 Carotid wall thickening (IMT > 0.9 mm) or plaque
 Carotid-femoral pulse wave velocity >12 m/s
 Ankle/brachial BP index <0.9
 Slight increase in plasma creatinine
M: 115–133 mmol/l (1.3–1.5 mg/dl); W: 107–124 mmol/l (1.2–1.4 mg/dl)
 Low estimated glomerular filtration rate (<60 ml/min/1.73 m2- MDRD) or creatinine clearance (<60 ml/min-Cockroft Gault formula)
 Microalbuminuria 30–300 mg/24 h or albumin-creatinine ratio: ≥22 (M); or ≥31 (W) mg/g creatinine

Question 23

CONSEQUENCES OF HYPERTENSION

Clinical Hypertension Mediated Organ Damage 1,2

Answer 23

1. Cerebrovascular disease
   - Ischemic stroke
   - Cerebral hemorrhage
   - Transient ischemic attack
   - Lacunar syndrome
   - Cognitive impairment
2. Heart disease
   - LVH- left ventricular hypertrophy
   - Hypertensive heart disease
   - Ischemic heart disease (Angina,
   - Myocardial infarction, Acute coronary syndr.; Coronary revascularization)
   - Atrial fibrillation
   - LV Diastolic and systolic dysfunction; Heart failure

Question 24

CONSEQUENCES OF HYPERTENSION

Clinical Hypertension Mediated Organ Damage 3,4,5

Answer 24

3. Renal disease
   - Proteinuria (>300 mg/24 hr)
   - Hypertensive nephropathy
   (Nephrosclerosis)
   - Chronic kidney disease
4. Vascular complications
   - Peripheral arterial disease &
   - Intermittent claudication
   - Aortic Aneurism & Ao dissection
5. Eye
   - Arterial narrowing
   - Advanced retinopathy
   - Hemorrhages or exudates
   - Papilledema

Question 25

Pathogenesis of the major consequences of HTN

Answer 25

slide 13

Question 26

Diagnostic evaluation

Answer 26

Aims (1) Establishing BP levels: BP measurement (2) Identifying secondary causes of hypertension (3) Evaluating the overall cv risk by searching for  Other associated risk factors  HTN mediated organ damage (HMOD)  Concomitant diseases or accompanying clinical conditions (4) Identify reversible exacerbating factors (5) Document progression The diagnostic procedures: 1. Anamnesis 2. Medical history 3. Physical examination in the setting of HTN, but not only 4. Laboratory and instrumental investigations

Question 27

(1) BP measurement | 4 approaches to BP measurement

Answer 27

1. Conventional office BP 2. Automated office BP 3. Home monitoring 4. Ambulatory BP monitoring All cases  BP should be measured with appropriate technique  Using validated & periodically calibrated devices Home readings taken under varying circumstances AND 24-hr ambulatory recordings may be Preferable and more accurate in Predicting subsequent cardiovascular disease

Question 28

BP measurement: Conditions for the Patient | POSTURE

Answer 28

Sitting pressures are usually adequate for routine follow-up. Patient should sit quietly with back supported for 5 min and arm supported at level of heart Measure BP 1 min & 3 min after standing from a seated position in all patients at the first measurement to exclude orthostatic hypotension. For patients > 65 yr, Diabetic, or receiving Antihypertensive Therapy, check for postural changes (Lying and standing BP) in subsequent visits.

Question 29

BP measurement: Conditions for the Patient | Circumstances

Answer 29

 Quiet, warm setting  The patient should avoid caffeine, exercise, and smoking for at least 30 minutes before measure  No exogenous adrenergic stimulants (e.g., phenylephrine in nasal decongestants or eye drops for pupillary dilation)  Neither the patient nor the observer should talk during the rest period or during the measurement  Remove clothing covering the location of cuff placement  The patient should not be holding his/her arm because isometric exercise will affect the BP levels.

Question 30

BP measurement: Equipment

Answer 30

Cuff size:  Use a standard bladder cuff (12–13 cm wide and 35 cm long) for most patients, but have larger and smaller cuffs available for larger (arm circumference >32 cm) and thinner arms, respectively  The cuff should be positioned at the level of the heart, with the back and arm supported to avoid muscle contraction and isometric exercise- dependant increases in BP  The bladder should encircle and cover 2/3 of the length of the arm; if bladder is too small, false high readings may result ``` Manometer: Auscultatory or Oscillometric  Mercury Sphygmomanometers  Aneroid Sphygmomanometers  Electronic Oscillometric Sphygmomanometers Should be calibrated periodically ``` For infants, use ultrasound equipment, e.g., the Doppler method

Question 31

BP measurement: Technique

Answer 31

* BP cuff should be placed on bare skin | * Shirtsleeves should not be rolled up because this may create a tourniquet effect.

Question 32

BP measurement: Technique | Cuff Placement and Stethoscope

Answer 32

• The observer must first palpate the brachial artery in the ante-cubital fossa and place the center of the bladder length of the cuff (commonly marked on the cuff by the manufacturer) so that it is over the arterial pulsation of the patient’s bare upper arm • The lower end of the cuff should be 2 to 3 cm above the antecubital fossa

Question 33

BP measurement: Performance

Answer 33

1) Inflate the bladder quickly to a pressure 20 mm Hg Above the Systolic, → as recognized by disappearance of the radial pulse 2) Deflate the bladder 2-3 mm Hg every second 3) Record the Korotkoff phase I (appearance) & Korotkoff phase V (disappearance) except in little children, in whom use of phase IV (muffling) may be preferable

Question 34

Korotkoff Phase

Answer 34

If Korotkoff sounds are weak, have the patient raise the arm and open and close the hand 5-10 times, after which the bladder should be inflated quickly  Record heart rate and use pulse palpation to exclude arrhythmia.  Additional measurements may have to be performed in patients with unstable BP values due to arrhythmias, such as in patents with AF, in whom manual auscultatory methods should be used as most automated devices have not been validated for BP measurement in patients with AF (atrial fibrilation)

Question 35

BP measurement: Technique Number of readings Average readings

Answer 35

Number of readings On each occasion,  3 BP measurements should be recorded, 1–2 min apart,  + additional measurements only if the first 2 readings differ by >10 mmHg  BP is recorded as the average of the last two BP readings Average readings:  Use an average of ≥2 readings obtained on ≥2 occasions

Question 36

BP measurement : For Diagnosis

Answer 36

 Whenever possible, the diagnosis should not be made on a single office visit.  Usually 2–3 office visits at 1–4-week intervals (depending on the BP level) are required to confirm the diagnosis of hypertension.  The diagnosis might be made on a single visit, if BP is ≥180/110 mm Hg and there is evidence of cardiovascular disease (CVD)  Orthostatic hypotension is defined as a reduction in SBP of ≥ 20 mmHg or in DBP of ≥ 10 mmHg within 3 min of standing  If possible and available, the diagnosis of HTN should be confirmed by out-of- office BP measurement (ISH 2020) Initially Take pressure in both arms; → if pressure differs, use arm with higher pressure, for further readings If arm pressure is elevated, → take pressure in one leg, particularly in pats. younger than 30 y

Question 37

BP measurement: Recordings

Answer 37

- Note the Pressure, patient Position, which Arm, and cuff Size (e.g., 140/90, seated, right arm, large adult cuff) - Note the time that the most recent BP medication was taken before measurements. Interpretation - Blood pressure of 2–3 office visits ≥140/90 mm Hg indicates hypertension Provide patients their SBP/DBP readings both verbally and in writing.

Question 38

Checklist for Accurate Measurement of BP | Key Steps for Proper BP Measurements

Answer 38

Step 1: Properly prepare the patient. Step 2: Use proper technique for BP measurements. Step 3: Take the proper measurements needed for diagnosis and treatment of elevated BP/hypertension. Step 4: Properly document accurate BP readings. Step 5: Average the readings. Step 6: Provide BP readings to patient.

Question 39

BP Measurement Definitions

Answer 39

BP Measurement Definition SBP : First Korotkoff sound* DBP : Fifth Korotkoff sound* Pulse pressure : SBP minus (-) DBP Mean arterial pressure : DBP plus (+) 1/3 pulse pressure† Mid-BP : Sum of SBP and DBP, divided by 2 †Calculation assumes normal heart rate . BP indicates blood pressure; DBP, diastolic blood pressure; and SBP, systolic blood pressure.

Question 40

Selection Criteria for BP Cuff Size for Measurement of | BP in Adults

Answer 40

Arm Circumference Usual Cuff Size 22–26 cm Small adult 27–34 cm Adult 35–44 cm Large adult 45–52 cm Adult thigh

Question 41

(2) Identifying secondary causes of | hypertension : 1+2+3

Answer 41

``` 1. Renal causes (2.5-6%) [parenchymal &vascular diseases] - Chronic kidney disease - Polycystic kidney disease - Urinary tract obstruction - Renin-producing tumor - Renovascular: Stenoses (Atherosclerotic, Fibromuscular Dysplasia), Embolism, - Vasculitis 2. Vascular causes - Coarctation of aorta - Vasculitis - Collagen vascular disease ``` 3. Hormonal causes - Primary hyperaldosteronism - Cushing syndrome - Pheochromocytoma

Question 42

(2) Identifying secondary causes of | hypertension : 4+5+6

Answer 42

4. Neurogenic causes - Brain tumor - Autonomic dysfunction - Sleep apnea - Intracranial hypertension 5. Drugs and toxins - Alcohol, cocaine, NSAIDS, - Erythropoietin, Adrenergic medications - Decongestants containing ephedrine Herbal remedies containing licorice or ephedrine, nicotine 6. Other causes - Hyper and hypothyroidism - Hypercalcemia, Hyperparathyroidism - Obstructive sleep apnea - Pregnancy-induced hypertension - Acute stress: massive burns, trauma, surgery

Question 43

(3) Evaluating the overall (total) cv risk

Answer 43

What is Risk ? • A cumulative probability of an event, usually expressed as percentage Example: 5 CV events in 100 pts = 5 % risk This is called an Absolute risk & Refers to a specific time period (10 yr) Relative risk (RR) is a ratio of risks Example: 12% risk in hypertensives, 4% risk in normotensives→ RR = 0.12 / 0.04 = 3 “hypertensives have 3 times the risk of normotensives” Lifetime risk is the Absolute Risk of a person for an event during his/her whole remaining life From individual point of view it is probably the most accurate expression of Risk & of Intervention Benefit

Question 44

(3) Evaluating the overall cv risk | by searching for

Answer 44

 Other risk factors & total risk  Hypertension Mediated Organ Damage  Concomitant diseases or accompanying clinical conditions

Question 45

 ATS / CVD risk factors

Answer 45

MAJOR OTHERS MODIFIABLE 1. Dyslipidemia ─ Obesity ─ LDL‐C (CT) ─ Insulin resistance ─  HDL ─ Sedentarism ─ TG ─ Possible/proposed risk factors for ATS • Inflammation (hsPCR,fibrinogen, IL‐6, 2. Hypertension • ↑ Thrombogenic status 3. Diabetes • Homocysteine 4. Smoking • Lipoprotein (a) ─Nontraditional risk Factors NON MODIFIABLE  Rheumatoid arthritis 5. Male Sex ─ Family hyst. of of premature ATS/cvd ─ Age (yr)—men >55; women >65 yr ─ Poverty, low education

Question 46

• Total CV Risk | Most patients have MULTIPLE CV risk factors

Answer 46

OF ALL HYPERTENSIVES 65% have dyslipidaemia 16% have T2 diabetes 45% are obese/overweight OF ALL DYSLIPIDAEMICS 48% have HTN 14% have T2 diabetes 35% are obese/overweight OF ALL T2 DIABETICS 60% have HTN 60% have dyslipidaemia 90% are obese/overweight We need Total Risk Assessment Tools in Clinical Practice And we as have Instruments: Several algorithms and charts - Framingham (US) - SCORE charts (ESC countries) - UKPDS Risk Engine for T2DM, PROCAM, etc

Question 47

Framingham vs SCORE

Answer 47

Framingham - Based on 5000 Americans - Predicts coronary event - Includes nonfatal events - Cannot be adjusted for national variations ``` SCORE -Based on > 200.000 Europeans -Predicts CVD -Restricted to fata events -Can be customized using national mortality statistics ```

Question 48

Cardiovascular risk categories

Answer 48

1. High-risk People with: - Markedly elevated single risk factors, in particular TC >8 mmol/L (>310 mg/dL), LDL-C >4.9 mmol/L (>190 mg/dL), or BP ≥180 / 110 mmHg. - Patients with FH without other major risk factors. - Patients with DM without target organ damage, a with DM duration ≥10 years or another additional risk factor. - Moderate CKD (eGFR 30-59 mL/min/1.73 m2). - A calculated SCORE ≥ 5% and <10% for 10-year risk of fatal CVD. 2. Moderate-risk - Young patients (T1DM < 35 years; T2DM <50 years) with DM duration <10 yrs, without other risk factors. - Calculated SCORE ≥ 1 % and < 5% for 10-year risk of fatal CVD. 3. Low-risk - Calculated SCORE <1% for 10-year risk of fatal CVD.

Question 49

Cardiovascular risk categories

Answer 49

4. Very-high risk People with any of the following: - Documented ASCVD, either Clinical or unequivocal on Imaging. - Documented ASCVD includes previous ACS (MI or unstable angina), stable angina, coronary revascularization (PCI, CABG, and other arterial revascularization procedures), stroke and TIA, and peripheral arterial disease. - Unequivocally documented ASCVD on imaging includes those findings that are known to be predictive of clinical events, such as significant plaque on coronary angiography or CT scan (multivessel coronary disease with two major epicardial arteries having >50% stenosis), or on carotid ultrasound. - DM with target organ damage, a OR at least 3 major risk factors, OR early onset of T1DM of long duration (>20 years). - Severe CKD (eGFR <30 mL/min/1.73 m2). - A calculated SCORE ≥ 10% for 10-year risk of fatal CVD. - FH with ASCVD OR with another major risk factor.

Question 50

Anamnesis Screening of Secondary Causes History, Symptoms & Physical finding

Answer 50

‒ History of known renal disease, abdominal masses, anemia, and Urochrome pigmentation. ‒ History of sweating, labile hypertension, and palpitations (suggests the diagnosis of pheochromocytoma) ‒ History of cold or heat tolerance, sweating, lack of energy, and bradycardia or tachycardia (may indicate hypothyroidism or hyperthyroidism) ‒ History of obstructive sleep apnea ‒ History of weakness (suggests hyperaldosteronism) ‒ Kidney stones (raise the possibility of hyperparathyroidism)

Question 51

ANAMNESIS | Evaluate the Presence of other Risk Factors

Answer 51

1.Hypertension: component of metabolic syndrome (MS) 2. Smoking (cigarettes, chewing tobacco) 3. Hypercholesterolemia or low HDL cholesterol as component of MS 4. Diabetes mellitus: component of Metabolic Syndrome (MS) 5. Obesity (BMI ≥30 kg/m2): component of MS Age >55 y for Men OR > than 65 y for Women: Begins the Increased risk (!Caveat: ATPIII used earlier age cut points to suggest the need for earlier action) 6. Estimated GFR < 60 mL/min 7. Microalbuminuria 8. Family history of premature cardiovascular disease (men < 55 y; women < 65 y) 9. Lack of exercise

Question 52

ANAMNESIS | History taking

Answer 52

- Hypertension - Premature CVD or death - Familial diseases: pheochromocytoma, renal disease, diabetes, gout Working and living condition assessment Eg.: inactivity

Question 53

Anamnesis Duration of the hypertension Prior treatment of the hypertension Intake of agents that may interfere

Answer 53

Duration of the hypertension - Last known normal BP - Baseline values for judging biochemical effects of therapy - Course of the BP Prior treatment of the hypertension Drugs: types, doses, side effects ``` Intake of agents that may interfere Drugs including over-the-counter medications - Nonsteroidal anti-inflammatory drugs - Corticosteroids - Oral contraceptives - Adrenergic medications - Excessive sodium intake ``` Alcohol (>2 drinks/day) Herbal remedies containing licorice or ephedrine The use of illicit drugs, such as cocaine

Question 54

ANAMNESIS Concomitant diseases Pregnancy-induced hypertension Dietary history

Answer 54

``` Weight change Fresh vs. processed foods Sodium intake Saturated fats Source of food preparation Adequate dietary intake of potassium, calcium, and magnesium ```

Question 55

ANAMNESIS Sexual function Features of obstructive sleep apnea

Answer 55

Early morning headaches Daytime somnolence Loud snoring Erratic sleep

Question 56

Anamnesis | Symptoms: Hypertension is the “silent killer”

Answer 56

“an Asymptomatic chronic disorder that, undetected and untreated, silently damages the blood vessels, heart, brain, and kidneys.” Ask for Symptoms of target organ damage 1. Heart : Chest pain, Dyspnea 2. Brain : Headaches, Dizziness 3. Chronic kidney disease : Claudication, cold extremities 4. Peripheral arterial disease : Transient weakness or blindness 5. Retinopathy : Loss of visual acuity

Question 57

SYMPTOMS of HYPERTENSIVE CRISIS* are not specific: Symptoms are secondary to: Acute end-organ damage

Answer 57

 Neurologic: hypertensive encephalopathy, cerebral vascular accident/cerebral infarction, subarachnoid hemorrhage, intracranial hemorrhage  Cardiovascular: myocardial ischemia/infarction, acute left ventricular dysfunction, acute pulmonary edema, aortic dissection, unstable angina  Other: acute renal failure/insufficiency, papilledema / retinopathy, eclampsia, microangiopathic hemolytic anemia  Headaches  Subconjunctival hemorrhage  Epistaxis (Nosebleeds)  Facial flushing  Chest pain  Visual changes, phosphenes  Tinnitus  Hematuria Hypertensive Encephalopathy= Papilledema with the following: Headache, Blurred vision, Confusion, Somnolence, → Coma  Dizziness (generally it is a side effect of some BP medications) Symptoms examples: * Require hospitalization and parenteral drug therapy

Question 58

``` *Terms Definition Hypertensive crises (HTN emergencies) ```

Answer 58

 a heterogeneous group of hypertensive disorders  Charact. by severe HTN + acute TOD (brain, heart, kidney, retina, or blood vessels  BP ≥ 220/130 mm Hg (except women with preeclampsia without preexisting HTN)  * AHA 2018: Systolic over 180 and/or diastolic over 120  require immediate reduction of BP with IV medication .

Question 59

Hypertensive urgency

Answer 59

• severe uncontrolled HTN without evidence of acute TOD • In the absence of Symptoms and Acute Target-organ damage, a patient with a BP of 220/130 mm Hg should be treated with a short-acting oral medication.

Question 60

Severe hypertension

Answer 60

 defined as a BP of 180/110 - 220/130 mm Hg without symptoms or acute target- organ damage, almost always occurs in patients with chronic hypertension who depleted or discontinued their BP medication.  Long-acting oral medication can simply be restarted

Question 61

Physical examination

Answer 61

1. Normal or 2. Abnormalities Secondary to Risk factors OR HMOD Start with BP measurement  Both Arms  Arm & Leg systolic BP measurements: difference >20 mmHg suggests Aortic Coarctation  Check for Orthostatic Hypotension Assess for Obesity & Metabolic Syndrome  Weight, Height, BMI  Waist Circumference

Question 62

``` Physical examination Skin Subcutaneous tissue Head & Eyes Neck Thorax ```

Answer 62

``` Skin  Signs of Cushing's Disease: Striae, Acne Vulgaris, Hirsutism Subcutaneous tissue: edema due to  Heart failure  Renal diseases ``` Head & Eyes  Moon facies suggests Cushing's syndrome  Examination of optic fundi for evidence of HMOD such as papilledema Neck  Auscultation of the suprasternal notch to determine if a bruit suggestive of coarctation is present  Palpation of thyroid gland  Carotid Bruits (HMOD-carotid atherosclerosis)  Neck vein exam (JVD in HF) Thorax  Respiratory Auscultation: congestion rales (if Heart Failure+)

Question 63

Physical examination | Cardiovascular Normal or modified depending on the target organ damage

Answer 63

Inspection: JVD if HF occur as a consequence of longstanding, untreated HTN Palpation: strong ± displaced apical impulse (if cardiomegaly) Percution: ±cardiomegaly (if LVH ± dilation) PMI displaced down to the left Auscultation: ‒ Accentuated S2 Heart Sound in AoValve position ‒ S4 Gallop rhythm (decreased LV compliance, diastolic dysfunction) ‒ S3 Gallop rhythm (LV systolic disfunction) ‒ Tachycardia (compensatory if HF, in pheocromocytoma) ‒ Rhythm disturbances: eg. Irregular heart sounds (if Atrial fibrillation) ‒ Murmurs: eg.: Aortic Insufficiency murmur (if Ao anevrism/ Ao valve disease) Asses together with:  Abnormal EKG or Echocardiogram findings;  Ask for Prior Angiography results

Question 64

``` Physical examination Pulses Lower extremity Abdomen Neurologic ```

Answer 64

Pulses - Asses Pulse Symmetry - A radial femoral delay → (Aortic coarctation) - Peripheral Vascular Disease - Femoral bruits - Femoral pulses: Delayed or absent in Aortic Coarctation Lower extremity: - Hair Loss in men if ischemic Skin lesions secondary to PVD - Leg edema if HF occur Abdomen > Auscultation - Abdominal bruit (suggest renal artery stenosis) > Palpation - Masses, Enlarged/ tender kidneys, Distended urinary bladder, - Abnormal aortic pulsations: Aortic Aneurysm Congestive hepatomegaly if HF present ``` Neurologic Stroke sequelae (Focal neurologic deficits) ```

Question 65

Summary: What is hypertension ?

Answer 65

 A number outside the normal range (Arbitrary value)  A risk factor for target organ damage (myocardium, arteries, brain, kidney, eye)  A sign of a disease (glomerulonephritis, vasculitis, pheochromocytoma)  An homeostasis parameter (depends on other parameters, influences other parameters)  Expression of An altered cellular function  CO ← myocardial cell  TPR ← endothelium, vascular smooth muscle → A complex syndrome overall

Question 66

Benefit of BP reduction in HTN patients

Answer 66

Benefits with antihypertensive therapy:  35-40% Average Reduction in Stroke incidence  20-25% Average Reduction in Myocardial infarction  >50% Average Reduction in Heart failure “In stage 1 HTN (GRD 1 ESC) and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.”