1. © Continuing Medical Implementation …...bridging the care gap Target Organ Damage Joel Niznick MD FRCPC

2. © Continuing Medical Implementation …...bridging the care gap Diseases Attributable to Hypertension Hypertension Heart failure Stroke Coronary heart disease Myocardial infarction Left ventricular hypertrophy Aortic aneurysm Retinopathy Peripheral vascular disease Hypertensive encephalopathy Chronic kidney failure Cerebral hemorrhage Adapted from: Arch Intern Med 1996; 156:1926-1935. All Vascular

3. © Continuing Medical Implementation …...bridging the care gap Initial Assessment OVERALL CARDIOVASCULAR RISK –Framingham –Procam –SCORE System –Risk factor counting –Type 2 diabetes TARGET ORGAN DAMAGE –Physical exam –Diagnostic testing RULE OUT SECONDARY AND OFTEN CURABLE CAUSES –Renal artery stenosis –Hyperaldosteronism –Pheochromocytoma –Coarctation of aorta

4. © Continuing Medical Implementation …...bridging the care gap Identify Target Organ Damage Retinopathy Clinical LVH(S4) ECG-LVH CXR-Cardiomegaly ECHO-LVH/LV Mass/Diastolic Dysfunction Lab-Renal Function/Micro-albuminuria Vascular-bruits/Diminished pulses

5. © Continuing Medical Implementation …...bridging the care gap Target Organ Damage/Clinical Cardiovascular Disease should be assessed by history and physical examination Components of Risk Stratification Brain Heart Kidneys Eyes Arteries

6. © Continuing Medical Implementation …...bridging the care gap 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

7. © Continuing Medical Implementation …...bridging the care gap Hypertensive Retinopathy Grade 2 Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow)

8. © Continuing Medical Implementation …...bridging the care gap Hypertensive Retinopathy Grade 3 Flame-shaped hemorrhage in association with severe hypertension Grade 3 (yellow arrow)

9. © Continuing Medical Implementation …...bridging the care gap 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)

10. © Continuing Medical Implementation …...bridging the care gap Clinical Signs of LV Dysfunction Hypotension Pulsus alternans Reduced volume carotid LV apical enlargement/displace ment Sustained apex - to S2 Soft S1 Paradoxically split S2 S3 gallop (not S4 = impaired LV compliance) Mitral regurgitation Pulmonary congestion –rales

11. © Continuing Medical Implementation …...bridging the care gap Exclude Secondary Causes Renal Artery Stenosis Coarctation of the Aorta Pheochromocytoma Primary Aldosteronism Cushings’s Syndrome Renal Disease Dietary-Sodium Intake/Drugs/ Alcohol/Tobacco

12. © Continuing Medical Implementation …...bridging the care gap 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 CHS Recommendations Routine Laboratory Investigations

13. © Continuing Medical Implementation …...bridging the care gap 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

14. © Continuing Medical Implementation …...bridging the care gap 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?

15. © Continuing Medical Implementation …...bridging the care gap 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

16. © Continuing Medical Implementation …...bridging the care gap A 60 year old man with HTN

17. © Continuing Medical Implementation …...bridging the care gap An 84 year old woman with hypertension

18. © Continuing Medical Implementation …...bridging the care gap MAU as a Predictor of Morbidity and Mortality Retinopathy Diabetes + MAU LVH Non-fatal cardiovascular disease All-cause mortality Nephropathy Peripheral/autonom ic neuropathy Parving HH. J Hypertens 1996;14 Suppl 2:S89- S94.

19. © Continuing Medical Implementation …...bridging the care gap Definitions of abnormalities in albumin excretion Category 24 hour collection (mg/24h) Timed collection (  g/min) Spot collection (  g/mg Cr) Normal < 30< 20< 30 Microalbuminuria 30-29920-19930-299 Clinical albuminuria  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.

20. © Continuing Medical Implementation …...bridging the care gap Eastman RC, Keen H. Lancet 1997;350 Suppl 1:29-32. Microalbuminuria 10 8 6 4 2 0 10.02 SmokingHypertension Odds Ratio 6.52 Cholesterol 2.32 3.20 Relative Importance of MAU

21. © Continuing Medical Implementation …...bridging the care gap ALB (µg/min) 1000 300 3030 Years of Diabetes Mellitus 7-15 10-30 Proteinuria Stabilization possible Renal failure 2 year survival 50% MAU Reversible Adapted by D. Studney Course of Diabetic Nephropathy