【高血压英文PPT精品课件】 PATHWAYS TO HEART FAILURE IN ARTERIAL HYPERTENSION

Hypertension is often symptom less, so screening is vital - before damage is done. Many surveys continue to show that hypertension remains under diagnosed, undertreated and poorly controlled in the UK
Approximately 25% are due to Reno vascular disease - most frequently atheromatous (e.g. elderly cigarette smokers with peripheral vascular disease) or fibromuscular dysplasia (more common in younger females). Endocrine disease
Secondary hypertension 5% Underlying cause
Causes of Secondary Hypertension
Renal disease
Approximately 75% are from intrinsic renal disease: glomerulonephritis, polyarteritis nodosa, systemic sclerosis, chronic pyelonephritis, or polycystic kidneys.
Hypertension, Introduction.
Hypertension is one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for stroke (ischemic and haemorrhagic), myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension may result in vascular and renal damage that can culminate in a treatment-resistant state.

Renal Salt Reabsorption Intravascular Volume Volume Delivery to Heart Cardiac Output
Vascular compliance
Systemic Vascular Resistance
Essential Hypertension
PKDH1 Gene in Human and Rat
PKD
Ideal Cross
SS
BN Control
F1 Intercross
Distribution of MAP in Male Rats on High Salt
7
BN
6
5
4
3
2
1
0
SS
P0
5
4 3
F1
2
1
0
25
20
15 10
F2
5
0
1. Characteristics of the clinical picture
No model can match the complete clinical picture,
as no single patient reflects the entire clinical spectrum.
•No region consistently demonstrated significant linkage
•Evidence of linkage found in some regions in multiple studies: 1q, 2p, 3p, 6q, 7q, 12q, 15q, 17q, 18q, 19p
Monica Stoll, Anne E. Kwitek-Black, Allen W. Cowley Jr., Eugenie L. Harris, Stephen B. Harrap, José E. Krieger, Morton P. Printz, Abraham P. Provoost, Jean Sassard, and Howard J. Jacob

- Study of the natural history of CVD - Formulation and testing of etiological
hypotheses (risk factors) - Contribution to the development of
cardiovascular prevention programs and the measurement of their effectiveness
EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE
(CVD)
Public Health BETTINA PIKO, M.D., Ph.D.
Types of Cardiovascular Disease
- Coronary heart disease (CHD, ischemic heart disease, heart attack, myocardial infarction, angina pectoris)
- Cerebrovascular disease (stroke, TIA, transient ischemic attack)
- Hypertensive heart disease - Peripheral vascular disease - Heart failure
- Rheumatic heart disease (streptococcal infection)
Parts of Cardiovascular Epidemiology
1., Descriptive epidemiology:
= Describing distribution of cardiovascular disease by means of certain characteristics such as : PERSON (i.e., age, gender, ethnicity) TIME and PLACE

Definitions
Hypertensive Emergency
Acute, rapidly evolving end-organ damage associated with HTN (usu. DBP > 120)
BP should be controlled within hours and requires admission to a critical care setting
Take a good history
History of HTN and previous control Medications with dosage and compliance Illicit drug use, OTC drugs
Diagnosis and Recognition
Physical
Confirm BP in more than one extremity Ensure appropriate cuff size Pulses in all extremities Lung exam—look for pulmonary edema Cardiac—murmurs or gallops, angina, EKG Renal—renal artery bruit, hematuria Neurologic—focal deficits, HA, altered MS Fundoscopic exam—retinopathy, hemorrhage
That is >500,000 Americans per year Correct and quick diagnosis and
management is critical
Mortality rate of up to 90%

Diastolic (mm Hg)
and <80 and <85 or 85-89 or 90-99 or 100- 109 or 110+
4
HTN Treatment Recommendations
• No major risk factors, TOD, CCD: treat stage 1 with lifestyle modification up to 12 months, stages 2&3: add drugs
.CCB’s reduce mortality from AMI.
.ACE inhibitors cause CHF if given during AMI. (They prevent CHF.)
.Neither lidocaine or magnesium are routinely indicated after AMI. They do not reduce mortality.
By the time neurologic manifestations occur, hypertension has reached malignant stage.
9
Fundoscopic Exam
• Retinal hemorrhages • Exudates • Papilledema
. ACE inhibitors reduce mortality in CAD, prolong survival in CHF & post MI LV
dysfunction, preserve renal function in DM
6
Which of the following statement is

Cardiovascular Disease Diabetes
TOTAL
$296 billion $116 billion $412 billion
Estimated Indirect Costs
(disability, work loss, premature mortality)
$152 billion
total cholesterol = 210 ▪ Weight = 230 lbs; BMI = 29 kg/m² ▪ Family history of HTN and diabetes
▪ Age ▪ Race/ethnicity ▪ Gender ▪ Family history
47 African American Male HTN and diabetes
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
▪ Overweight/obesity ▪ Abnormal lipid metab ▪ Hypertension ▪ Smoking ▪ Physical Inactivity ▪ Unhealthy diet
BMI = 29 TC = 210 BP = 146/86 1 pack per day Yes Fast food diet

Small number curable with surgery
Hypertension Pathology
Increased BP inflammation, sclerosis of arteriolar walls narrowing of vessels decreased blood flow to major organs Left ventricular overwork hypertrophy, CHF Nephrosclerosis renal insufficiency, failure
20% of adult population • ~35,000,000 people 25% do not know they are hypertensive Twice as frequent in blacks than in whites 25% of whites and 50% of blacks > 65 y/o
Types
Primary (essential) hypertension Secondary hypertension
Primary Hypertension
85 - 90% of hypertensives Idiopathic More common in blacks or with positive family history Worsened by increased sodium intake, stress, obesity, oral contraceptive use, or tobacco use Cannot be cured
• Commonly used prehospital when targeting BP lowering only especially in AMI

• Symptoms:
Always asymptomatic Symptoms often attributed to hypertension:
headache, tinnitus, dizziness, fainting
slide 10
Clinical Features
• Complications of Hypertension Heart: LVH, CHD,HF Brain: TIA, Stroke Renal: Microalbuminuria, renal dysfunction Ratinopathy
3. Renal Sodium Handling 4. Vascular Remodelling 5. Endothelial Cell Dysfunction 6. Insulin Resistance
slide 4
The pathological changes of small artery
• Ambulatory monitoring can provide:
– readings throughout day during usual activities – readings during sleep to assess nocturnal changes – measures of SBP and DBP load – Exclude white coat or office hypertension
KW II: More marked narrowing and irregularity with arteriovenous nicking (crossing defects)
KW III: Flame-shaped hemorrhages and exudates in addition to above arteriolar changes

False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria.
© Continuing Medical Implementation
…...bridging the care gap
© Continuing Medical Implementation
• RULE OUT SECONDARY AND OFTEN CURABLE CAUSES
– Renal artery stenosis – Hyperaldosteronism – Pheochromocytoma – Coarctation of aorta
Target Organ Damage
Joel Niznick MD FRCPC
© Continuing Medical Implementation
…...bridging the care gap
Diseases Attributable to Hypertension
Coronary heart disease Heart failure
• Neurologic assessment
© Continuing Medical Implementation
…...bridging the care gap
Hypertensive Retinopathy Grade 2
Arteriovenous nicking in association with hypertension Grade 2
…...bridging the care gap
MAU as a Predictor of Morbidity and Mortality