【高血压精品英文课件】高心病 hypertensive heart disease -a brief review

hypertension,1,HYPERTENSIVE HEART DISEASE A Brief Review Joshua M.Crasner, DO,FACC,FACOI,hypertension,2,DEFINITION,the reponse of the left ventricle to increased peripheral resistance due to increased systemic arterial pressure,hypertension,3,JNC-7 Definition of HTN,JAMA 289; 2560-72: 2003,hypertension,4,JNC-6 (old criteria),hypertension,5,TYPES OF HYPERTENSION SYSTOLIC AND DIASTOLIC,Primary(Essential, Idiopathic) Secondary Renal: Acute GN, Diabetic Nephropathy Endocrine: TSH, cortisol, calcium aortic coarctation pregnancy-induced neurologic: tumor, sleep apnea stress: surgery, burns, EtOH withdrawal,S.cell Drugs: decongestants, antidepressants, OCP,hypertension,6,RED FLAGS FOR SECONDARY HYPERTENSION,Abdominal bruit: renal artery stenosis Palps,HA,pallor,perspiration: pheochromocytoma Obesity,moon face,purple striae: Cushings Abd mass: polycystic kidney,hydroneph Obesity,hypersomnolence: OSAS Agitation, sweating: cocaine, ethanol Hypokalemia: hyperaldosteronism Hypercalcemia: hyperparathyroidism,hypertension,7,TYPES OF HYPERTENSION SYSTOLIC,Increased Cardiac Output: aortic regurgitation, PDA/AVF, thyrotoxicosis, Pagets disease Aortic rigidity,hypertension,8,HYPERTENSION WITH AGE,Systolic BP rises continuously with age Diastolic rises up to age 50, then falls Pulse pressure then widens with age Vasan, et al.JAMA, 2002; 287(8):1003-10,hypertension,9,ETIOLOGY HTN,“essential” 90 % Genetics, environment African descent and elderly have low renin; more sensitive to salt and volume non-African/young pts have high renin,hypertension,10,ESSENTIAL HYPERTENSION,Most common HBP( 90 %)-multifactorial increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects structural hypertrophy giving rise to smooth muscle hypercontractility pressure varies throughout the day major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths) leading cause of doctors visit carries prognostic value: 16X increased risk 40 y.o. smokes,hypertension,11,TARGET ORGAN DAMAGE Left Ventricular Hypertrophy,End result of hypertensive heart disease structural adaptation to pressure overload initially adaptive and later pathologic mass 100-130 g/m2,hypertension,12,TARGET ORGAN DAMAGE LEFT VENTRICULAR HYPERTROPHY,Eccentric: isotonic exercise, increased volume load mass/volume ratio low Concentric: isometric exercise, increased pressure load mass/volume ratio high degree does not correlate with blood pressure Prognostic value: sudden cardiac death, ischemia(decreased coronary flow, increased vascular tone, CHF Who? Increases with age 2-3 more times likely in obese athletes African descent higher LV mass response,hypertension,13,TARGET ORGAN DAMAGE LEFT VENTRICULAR DYSFUNCTION,Diastolic dysfunction reduced rate rapid early filling/incr.atrial portion correlates with degree of LVH CHF Systolic dysfunction less common as BP tighter controlled myofibril degeneration/lysis occurs late CHF: will predispose to other causes(CAD, valve),hypertension,14,TARGET ORGAN DAMAGE CORONARY ARTERY DISEASE,HTN accelerates progression of CAD increased oxygen demand increased silent MI/sudden cardiac death/infarct size(33%) ischemia caused by diastolic dysfuntion oxygen demand is different than for epicardial occlusion,hypertension,15,TARGET ORGAN DAMAGE RENAL DISEASE,Increased intraglomerular hypertension loss of concentrating ability nocturia reduced creatinine clearance albuminuria salt and water retention HTN is the leading cause of ESRD nephrosclerosis,hypertension,16,TARGET ORGAN DAMAGE CEREBRO/PERIPHERAL VASCULAR DISEASE,major risk factor for CVA/TIA similar physiology,hypertension,17,DETECTION OF HYPERTENSIVE HEART DISEASE,PHYSICAL EXAM ELECTROCARDIOGRAM 2-D ECHOCARDIOGRAM STRESS TESTING LAB TESTING,hypertension,18,PHYSICAL EXAM,Forceful sustained apical impulse early S4 gallop early S3 gallop later LV dilation: laterally displaced apical impulse,hypertension,19,BP MEASUREMENT,Patient seated/back supported/feet on floor Should rest 5 minutes prior Arm at heart level No recent caffeine, tobacco, cocaine Take medications as directed Cuff size important orthostatics,hypertension,20,ELECTROCARDIOGRAM,All patients should have as baseline no LVH on ECG does not mean no LVH in vivo the presence of LVH suggests target end organ damage.poorer prognosis Left atrial enlargement? Conduction abnormalities,hypertension,21,2D ECHOCARDIOGRAM,Wall thickness chamber size systolic and diastolic function valve pathology,hypertension,22,STRESS TESTING,Detects patients at increased risk silent ischemia/subclinical CAD hypertensive response portends poor prognosis,hypertension,23,LAB TESTING,Urine analysis Chemistry panel Cholesterol CBC Endocrine Drug screen?,hypertension,24,GOALS AT FIRST EVAL.,Diagnose secondary or remediable causes Uncover target organ damage Identify coexisting risk factors that could affect treatment plans,hypertension,25,TREATMENT OF HYPERTENSION,Prevent development/progression of LVH JNC-7: 120/80 optimal reduction of target organ damage: brain, heart, kidney, eyes pharmacologic Lifestyle modifications,hypertension,26,LIFESTYLE MODIFICATION,hypertension,27,PHARMACOLOGIC TREATMENT OF HYPERTENSION,inhibitors of the renin-angiotensin system a must in diabetic, renal, or CAD patients identify co-morbidities (slide 19) ACE inhibitors/A-II blockers Calcium channel blockers Beta blockers diuretics alpha blockers central agents vasodilators,hypertension,28,PHARMACOLOGIC TREATMENT,Heart failure: ACEi, A-II, diuretics, B-blockers Diabetes: ACEi, A-II CAD/post-MI: B-blockers, ACEi, calciu