Clinical Aspect of Hypotension PDF

Clinical Aspect of Hypotension Hypertension Normal BP (140 mmHg and/or DBP > 90 mmHg. HTN emergency (crisis): Severe elevation in BP, Complicated by evidence of Impending or Progressive Target/End Organ Dysfunction Pre-hypertension Pre-hypertensive: BP of 120-139 mmHg systolic, 80-89 mmHg dias...

Clinical Aspect of Hypotension Hypertension Normal BP (140 mmHg and/or DBP > 90 mmHg. HTN emergency (crisis): Severe elevation in BP, Complicated by evidence of Impending or Progressive Target/End Organ Dysfunction Pre-hypertension Pre-hypertensive: BP of 120-139 mmHg systolic, 80-89 mmHg diastolic Individuals who are pre-hypertensive are not candidates for drug therapy practice lifestyle modification reduce their risk of developing hypertension. Refractory or resistant hypertension Refractory or resistant hypertension: BP of ≥140/90 mm Hg despite three drugs different classes at maximum approved doses, given at least 1 month to take effect. Malignant Hypertension 1. Acute onset & rapid progression. 2. Very high DBP>120 mmHg with generalized vascular damage. 3. papilloedema. 4. Others: micro-angiopathic hemolytic anemia or Renal faluire. 5. Death occurs rapidly from renal failure, cerebral Hge or HF. 6. Hallmark is fibrinoid necrosis. White coat hypertension White coat HTN: patients whose BP is high >140/90 mmHg in clinic setting, with a normal daytime ambulatory pressure  Clinical Aspect of Hypotension Staging of office BP Measurement of BP Apparatus for BP measurement: 1. Mercury sphygmomanometers (Gold standard ,most common). 2. Aneroid sphygmomanometers. 3. Automatic (Electronic/Digital) 4. Doppler sphygmomanometers. Ambulatory BP monitoring helps in management of patients with: Resistant hypertension. Medication related hypotensive symptoms Stress-related (white coat) increase in blood pressure Circadian rhythm in BP Type of hypertension 1. Isolated systolic HTN: The predominant form of hypertension in the elderly, SBP of 140 mmHg or greater in the presence of a DBP of 90 mmHg or lower. 2. Systolic & Diastolic HTN: ❑ Primary hypertension ❑ Secondary hypertensio  Clinical Aspect of Hypotension Types of hypertension 2. Systolic & Diastolic HTN: ❑ Primary hypertension ❑ Secondary hypertensio Primary hypertension Secondary hypertension About 95% of cases. About 5% of cases. It has no known causes. It has known underlying cause. Starts between 35-55 years. Starts before age 25 years. Family history is usually positive. Negative family history. Rapidly progressive with early complications. Causes : Renal, Endocrinal, CNS, Vascular, Iatrogenic, (most common is renal) 1. Renal Hypertension. 2. Endocrinal Hypertension ❑Parenchymal: Risk Factors: 1. Glomerulonephritis. Non-modifiable factors: 2. Diabetic nephropathy ❑ Age, 3. Pyelonephritis ❑ family history, 4. Polycystic kidney ❑ Ethnicity 5. Analgesic nephropathy Modifiable factors: ❑Renovascular: ❑ Sedentary lifestyle, Renal artery stenosis. ❑ Poor diet (high sodium), 3. Neurogenic causes: Increase Intra Cranial Tension (ICT). ❑ Excessive alcohol consumption, 4. Vascular Conditions: ❑ Smoking, Coarctation of the Aorta: A congenital narrowing of the aorta that increases ❑ Stress, resistance and raises blood pressure above the narrowing. ❑ Obesity 5. Miscellaneous causes: ❑ Toxaemia of pregnancy (pre-eclampsia & eclampsia syndrome) ❑ Drug- induce: 1- Oral contraceptives 2- NSAIDs 3- Sympathomimetics.  Clinical Aspect of Hypotension Clinical picture of HTN Symptoms of Elevated Hypertensive Crisis Target Organ Damage Asymptomatic Phase Blood Pressure Symptoms Symptoms Cardiovascular Symptoms: a) Left ventricular hypertrophy, leading to heart failure. b) Angina or myocardial infarction Neurological Symptoms: 1. Headache: Particularly a) Stroke or transient 1. Severe Headache in the occipital region ischemic attacks (TIAs). 2. Severe Anxiety or (back of the head), often in b) Encephalopathy: Severe Agitation the morning. headache, confusion, 3. Nausea and Vomiting 2. Dizziness or Light seizures, and coma. 4. Confusion or Changes headedness Most patients with in Mental Status 3. Fatigue hypertension don't have 5. Blurred or Double Renal Symptoms: 4. Nose bleeds (Epistaxis) symptoms. It is during Vision a) Proteinuria. edema, and 5. Blurred Vision or Visual this phase that 6. Seizures signs of kidney dysfunction Disturbances: Due to hypertension poses the 7. Shortness of Breath or chronic kidney disease hypertensive retinopathy. greatest risk because 8. Chest Pain or Angina: (CKD). 6. Palpitations damage to organs can May indicate myocardial 7. Tinnitus: Ringing in the occur silently. ischemia or heart attack. ears. Retinal Symptoms: 9. Weakness or 8. Shortness of Breath a) Hypertensive Numbness in Limbs: (Dyspnea) retinopathy: Blurred Could suggest stroke or 9. Chest Pain or Tightness: vision, double vision, or transient ischemic attack Especially if hypertension visual loss. (TIA). has affected the heart b) Hemorrhages or papilledema on retinal examination. Peripheral Vascular Disease: Claudication: Pain in legs or arms due to poor blood flow.  Clinical Aspect of Hypotension Acute complications of Hypertension 1) Cerebral stroke, hypertensive encephalopathy, subarachnoid hemorrhage. 2) Heart complication :Acute pulmonary edema, dissecting aneurysm, acute coronary syndromes. 3) Acute renal failure. 4) Epistaxis (Bleeding per nose ). Investigations of HTN For etiology: as secondary hypertension. For complications: Cardiac: ECG, Chest x ray, ECHO. Cerebral: CT, MRI brain. Renal: urinalysis, renal function, renal imaging. Treatment of HTN The Goal is to Get : ❑ Non pharmacologic (lifestyle). ❑ Causal treatment: for secondary hypertension. ❑ Pharmacological: Associated risk factors. Antihypertensive drugs. DASH diet (Dietary Approaches to Stop Hypertension)  Clinical Aspect of Hypotension Treatment of HTN Antihypertensive Drug Groups 1) Diuretics (thiazides, loop, K-sparing) 2) Beta adrenergic blockers (atenolol) 3) Alpha receptor blockers (prazosin) 4) Central alpha agonists (methyldopa, clonidine) 5) Combined α and β adrenergic blockers (carvedilol) 6) ACE inhibitors (captopril). 7) Angiotension receptor blockers (losartan) 8) Calcium antagonists (amlodipine) 9) Direct vasodilators (hydralazine) Choosing the Antihypertensive Medication: Mild Hypertension: diuretics or ACE inhibitors as first-line therapy. Resistant Hypertension: combination therapy. Specific Populations: Elderly patients: calcium channel blockers or thiazide diuretics. Pregnant women: Methyldopa or labetalol is typically preferred. Rationale for combined therapy: More patient compliance. Lower doses of two or more drugs. Fewer adverse effects. More synergistic effect