Transcript Target Organ Damage - Continuing Medical Implementation Inc.

Target Organ Damage
Joel Niznick MD FRCPC
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Diseases Attributable to
Hypertension
Stroke
Coronary heart disease
Heart failure
Cerebral hemorrhage
Myocardial infarction
Left ventricular
hypertrophy
Hypertension
Chronic kidney failure
Aortic aneurysm
Retinopathy
Peripheral vascular disease
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Adapted from: Arch Intern Med 1996; 156:1926-1935.
Hypertensive
encephalopathy
All
Vascular
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Initial Assessment
• OVERALL
CARDIOVASCULAR
RISK
–
–
–
–
–
Framingham
Procam
SCORE System
Risk factor counting
Type 2 diabetes
• TARGET ORGAN
DAMAGE
– Physical exam
– Diagnostic testing
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• RULE OUT
SECONDARY AND
OFTEN CURABLE
CAUSES
–
–
–
–
Renal artery stenosis
Hyperaldosteronism
Pheochromocytoma
Coarctation of aorta
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Components of Risk
Stratification
Target Organ Damage/Clinical Cardiovascular Disease
should be assessed by history and physical examination
Brain
Heart
Eyes
Kidneys
Arteries
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Important 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
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Hypertensive Retinopathy
Grade 2
Arteriovenous
nicking in
association with
hypertension
Grade 2
(yellow arrow)
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Hypertensive Retinopathy
Grade 3
• Flame-shaped
hemorrhage in
association with
severe
hypertension
Grade 3 (yellow
arrow)
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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)
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Clinical Signs of LV
Dysfunction
• Hypotension
• Pulsus alternans
• Reduced volume
carotid
• LV apical
enlargement/displace
ment
• Sustained apex - to S2
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• Soft S1
• Paradoxically split S2
• S3 gallop
(not S4 = impaired
LV compliance)
• Mitral regurgitation
• Pulmonary congestion
– rales
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CHS Recommendations
Routine Laboratory Investigations
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
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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
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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?
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Ankle-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
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A 60 year old man with HTN
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An 84 year old woman with
hypertension
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MAU as a Predictor of Morbidity
and Mortality
Retinopathy
LVH
Diabetes
+
MAU
All-cause
mortality
Nephropathy
Non-fatal
cardiovascular
disease
Peripheral/autonom
ic neuropathy
Parving HH. J Hypertens 1996;14 Suppl 2:S89S94.
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Definitions of abnormalities in
albumin excretion
Category
Normal
Microalbuminuria
Clinical
albuminuria
24 hour collection Timed collection
(mg/24h)
(g/min)
Spot collection
(g/mg Cr)
< 30
< 20
< 30
30-299
20-199
30-299
 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.
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Relative Importance of MAU
10.02
10
8
6.52
6
Odds
Ratio
4
3.20
2.32
2
0
Microalbuminuria Smoking
Hypertension Cholesterol
Eastman RC, Keen H. Lancet 1997;350 Suppl 1:29-32.
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Course of Diabetic Nephropathy
Renal failure
2 year survival 50%
1000
ALB
Proteinuria
(µg/min)
Stabilization possible
300
MAU
Reversible
3
0
7-15
Adapted by D. Studney
10-30
Years of Diabetes Mellitus
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