Author: Alan Weder, M.D., 2008 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected]with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
49
Embed
Author: Alan Weder, M.D., 2008 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Author: Alan Weder, M.D., 2008
License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution – Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material.
Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content.
For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use.
Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition.
Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
Citation Keyfor more information see: http://open.umich.edu/wiki/CitationPolicy
Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ
Public Domain – Expired: Works that are no longer protected due to an expired copyright term.
Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105)
Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain.
Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ
Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair.
To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
{ Content the copyright holder, author, or law permits you to use, share and adapt. }
{ Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. }
{ Content Open.Michigan has used under a Fair Use determination. }
Hypertension
M2 Cardiovascular Sequence
Dr. Alan Weder
Fall 2008
Key Points• Hypertension is a disease of blood pressure regulation
• Hypertension is a risk factor for atherosclerosis.
• Blood pressure measurement is important and requires attention to technique.
• Treatment decisions made in the context of overall risk factor burden.
• Secondary forms of hypertension are infrequently encountered and are usually recognized by resistance to treatment and distinctive biochemical features.
Hypertension
= high blood pressure
≠ being “hyper”, anxious
Blood pressure
n
A. Weder
Systolic(upper #)
Diastolic(lower #)
“Normal” is less than 140/90 mmHg
A. Weder
JNC-7* Blood Pressure Classification
<80and<120Normal
80–89 or120–139Prehypertension
90–99 or140–159Stage 1 Hypertension
>100 or>160Stage 2 Hypertension
DBP mmHgSBP mmHgBP Classification
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and treatment of High Blood Pressure JAMA 289:2560, 2003.
Burt et al. Hypertension. 1995;25:305
40% greater relative prevalence in African-Americans
Hypertension: Ethnic Variation (United States)
32.4
23.3 22.6
0
5
10
15
20
25
30
35
African African AmericanAmerican
WhiteWhite HispanicHispanic
Ag
e-ad
just
ed p
reva
len
ce o
f h
yper
ten
sio
n (
%)
Blood pressure regulation
• Hemodynamic (descriptive)
• Sympathetic nervous system (short-term)
• Renal pressure natriuresis (long-term)
Blood pressure regulationHemodynamic
Mean arterial blood pressure = Cardiac output X Peripheral vascular resistance
MAP = C.O. X TPR
See discussion in Lilly hypertension chapter
Blood pressure regulationSympathetic nervous system
Usual Diastolic BP (mm Hg)Usual Diastolic BP (mm Hg)
50-5950-59
60-6960-69
70-7970-79
80-8980-89
Age at risk:Age at risk:
40-4940-49
256256
128128
6464
3232
1616
88
44
22
11
00
8080 9090 100100 1101107070
IHD
Mo
rtal
ity
IHD
Mo
rtal
ity
(flo
atin
g a
bso
lute
ris
k an
d 9
5% C
I)(f
loat
ing
ab
solu
te r
isk
and
95%
CI)
Usual Systolic BP (mm Hg)Usual Systolic BP (mm Hg)
50-5950-59
60-6960-69
70-7970-79
80-8980-89
Age at risk:Age at risk:
40-4940-49
256256
128128
6464
3232
1616
88
44
22
11
00
120120 140140 160160 180180
Components of CVD Risk Stratification in Patients With Hypertension
Major Risk FactorsMajor Risk Factors• SmokingSmoking• DyslipidemiaDyslipidemia• Diabetes MellitusDiabetes Mellitus• Age >60 yearsAge >60 years• Gender (men and postmenopausal women)Gender (men and postmenopausal women)• Family history of early onset Coronary Heart Disease: Family history of early onset Coronary Heart Disease:
– women <65 yearswomen <65 years– men <55 yearsmen <55 years
Source: JNC VI. Arch Intern Med. 1997;157:2413
X HypertensionDiabetesMellitus
Obesity
Hyperlipidemia
The “Metabolic Syndrome” is a Cluster of “Diseases of Civilization”
A. Weder
Rate of CHD in HypertensionRate of CHD in HypertensionAccording to Risk FactorsAccording to Risk Factors
Adapted with permission from Kannel WB. JAMA. 1996;275:1571
1201202202205050––––––
SBP (mm Hg)SBP (mm Hg)Cholesterol (mg/dL)Cholesterol (mg/dL)HDL (mg/dL)HDL (mg/dL)DMDMCigarette smoking Cigarette smoking LVH by ECGLVH by ECG
1601602202205050––––––
1601602592595050––––––
1601602592593535– – ––––
1601602592593535++ – –––
160160259 259 3535++++++
1601602592593535++++++
0
10
20
30
40
50
60
WomenMen
Rat
e (%
)R
ate
(%)
Blood Pressure Measurement
• Patients should be seated with back supported and arm bared and supported at heart level.
• Patients should refrain from smoking or ingesting caffeine for 30 minutes before measurement.
• Measurement should begin after at least 5 minutes of rest.
• Appropriate cuff size and calibrated equipment should be used.
• Both SBP and DBP should be recorded.
• Two or more readings should be averaged.
24-h BP ProfileTypical Medical Student
Time of day
23:00 02:00 06:00 10:00 14:00
Blo
od
pre
ssu
re (
mm
Hg
)
160
140
120
100
80
60
AwakeningSleepAwake Awake
SBP
DBP
A. Weder
Office
Home
120/80 mmHg 110/70 mmHg120/80 mmHg
160/90 mmHg
“White Coat” or “Office” Hypertension
Source Undetermined
Cu
mu
lati
ve I
nci
den
ce (
%)
16
12
10
8
6
4
2
0
14
0 2 4 6 8 10 12
Time (years)
<120/80 mm Hg
120-129/ 80-84 mm Hg
130-139/85-89 mm Hg
Impact of “Normal” BP on CV Disease Risk In Men
Vasan, et al. N Engl J Med. 2001;345:1291-97.
Objectives of the InitialEvaluation of Hypertensives
• To identify other risk factors or disorders that might guide treatment
• To assess presence or absence of target organ damage and cardiovascular disease
• To identify known causes
Evaluation Components
• Medical history
• Physical examination
• Routine laboratory tests
• Optional tests
Medical History• Duration and classification (stage)
• Patient history of cardiovascular disease
• Family history
• Symptoms suggesting causes of hypertension
• Lifestyle factors
• Current and previous medications
0 1 2 3 4 5
1 affected
1 before age 55y
≥2 affected
≥ 2 before age 55y
20-39 y40-49 y
Relative Risk for Hypertension
# of 1o
Relatives Age of hypertensiononset in offspring
Hypertension Runs in Families
Source Undetermined
Physical Examination• Blood pressure readings (two or more).
• Verification in contralateral arm.
• Height, weight, and waist circumference.
• Fundiscopic examination.
• Examination of the neck, heart, lungs, abdomen, and
extremities.
• Neurological assessment.
Objectives of the InitialEvaluation of Hypertensives
• To identify other risk factors or disorders that might guide treatment
• To assess presence or absence of target organ damage and cardiovascular disease
Primary Prevention• Primary prevention offers an opportunity to
interrupt the costly cycle of managing hypertension.
• Lifestyle modifications have been shown to lower blood pressure
• A population-wide approach may reduce morbidity and mortality; trials are lacking.
• Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.
Goal of HypertensionPrevention and Management
• To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by
– Achieving and maintaining SBP < 140 mm Hg and DBP < 90 mm Hg.
– Controlling other cardiovascular risk factors.
Additional Source Informationfor more information see: http://open.umich.edu/wiki/CitationPolicy
Slide 5: A. WederSlide 6: A. WederSlide 7: Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and treatment of High Blood Pressure JAMA 289:2560,
2003.Slide 8: Burt et al. Hypertension. 1995;25:305Slide 11: Source UndeterminedSlide 12: A. WederSlide 14: A. WederSlide 15: A. WederSlide 16: Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.Slide 17: JNC VI. Arch Intern Med. 1997;157:2413Slide 18: A. WederSlide 19: Adapted with permission from Kannel WB. JAMA. 1996;275:1571Slide 20: Slide Modified from Dzau VJ. J Cardiovasc Pharmacol. 1990:15(Suppl 5):S59-S64. Cohn JN. J Hypertens.1998: 16:2117-2124. Glasser SP
et al. Am Heart J. 1996: 131:379-384. Zhuo JL et al. Circulation. 1997: 96:174-182Slide 22: A. WederSlide 23: Source UndeterminedSlide 24: Vasan, et al. N Engl J Med. 2001;345:1291-97.Slide 28: Source UndeterminedSlide 33: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 34: A. WederSlide 35: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 36: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 37: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 38: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 39: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 40: Courtesy of Dr. James Stanley, University of Michigan Division of Vascular SurgerySlide 42: A. WederSlide 43: A. WederSlide 46: Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Illu_adrenal_gland.jpg; Mayo Foundation for Medical Education and Research