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Hypertension 2013 Diagnostic Procedures

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  • 1. Medical Science Tanzania Lectures Management of primary Hypertension 1. Diagnostic proceduresMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 2. Hypertension subsets  Primary Hypertension  Dysregulation of neurohormonal (RAS) systems  Triggering Target Organ Damage  Heart  Left ventricular hypertrophy  Angina or prior myocardial infarction  Prior coronary revascularization  Heart failure  Brain  Stroke or transient ischemic attack  Kidney:  Chronic kidney disease  Peripheral arterial disease  Eye  RetinopathyMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 3. Hypertension subsets • Secondary Hypertension – Organ mediated • Renal disorders (parenchymatic, vascular) • Glands (thyroid; adrenal) • Cardiac (aortic regurgitation) • Vessel abnormalities (Aortic coarctation) • Pregnancy (gestation, eclampsia) • Others (drug addiction)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 4. Definition of arterial Hypertension HPT systolic blood pressure diastolic blood pressure Normal <140 and <90 (diabetic) <130 <80 Age =>80 150 90 mild HPT 140-179 and/or 90-104 borderline HPT 140-159 90-94 intermediate >=180 >=105 severe HPT and/or isolated systolic >=160 <90 HPT(ISH**) 140-159 and *WHO 2000 ** isolated systolic hypertensionMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 5. Prevalence of arterial hypertension (%) 50 45 40 44 35 30 32 Germany subsaharan Africans 25 26 US 20 Afroamericans 20 15 10 5 0 per cent ageMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 6. Prevalence of hypertensive stroke Subsaharan Africa (Tanzania) 1,6% Western Countries (US) 1,7%March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 7. Hypertension Diagnosis • clinical diagnosis • advanced measures • pathways and flowchartsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 8. Hypertension Diagnosis • Clinical Diagnosis • Advanced Measures • Pathways and FlowchartsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 9. Hypertension Diagnosis: normal changes of BP Sleeping: BP falls and Running: BP rises and Alcohol and tobacco rises when waking up decreases to normal misuse, drug addiction: BP during recovery phase with rises and triggers positive training effects hypertension! protecting from hypertensionMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 10. Hypertension Diagnosis Hypertension by itself doesn‘t hurt! • History: – General signs and symptoms should reveal level of risk and suspicion of TOD*s • Head ache, Dizziness, visus abnormalities, hst. of stroke, hst. of fainting (syncope)  brain damage • Palpitation, Dyspnea, chest pain, nocturnal dysuria, hst. of MI  heart (damage) failure, CAD • Leg pains: Walking, rest pain,  peripheral (damage) disease • Family history, physical activity, history of smoking habits, alcohol abuse • History of medication *target organ damageMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 11. Hypertension Diagnosis• Physical examination – Inspection, palpation and auscultation • Chest: lungs and heart (congestion, murmurs, rhythm) • Neurological status: consciousness, motion abnormalities, reflexes, speech • Peripheral pulses: carotid murmurs, abdominal murmurs (renal disease?), ankle-brachial-index ABI • Hyperlipidemia: xanthelasm, arcus senilis, ear lobe creases • Joints: goutMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 12. Hypertension Diagnosis • Physical examination – Measuring blood pressure: necessary at each visit start, whenever seeing the doctor! This is the most important examination procedure, therefore be careful, be skilled, be an expertMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 13. Hypertension Diagnosis • The correct measurement of blood pressure depends on – Patient – Environment – Device – ProcedureMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 14. Hypertension Diagnosis• The correct measurement of blood pressure – Patient (first visit) – Environment – Device – ProcedureMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 15. Hypertension Diagnosis • Silence, Sedation (?) • No coffee, no smoking for at least 60 min. before reading • Supine position (for at least 10 min.)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 16. Hypertension Diagnosis• The correct measurement of blood pressure – Patient – Environment – Device – ProcedureMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 17. Hypertension Diagnosis • Dry, calm, separate (?) room • Avoid fast movements of the personnel • Quiet, warm settingMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 18. Hypertension Diagnosis• The correct measurement of blood pressure – Patient – Environment – Device – ProcedureMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 19. Hypertension Diagnosis • Devices for the physician: – Mercury (Hg; best device!) – Aneroid (needs regular calibrations vs. Hg) – Ultrasound (esp. children) – Oscillometry (forearm-wrist devices)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 20. Hypertension Diagnosis: mercury device Scaled mercury manometer Cuff Air bulb pumping accessoryMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 21. March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 22. Hypertension Diagnosis • Cuff size: 2/3 of arm length (smaller cuffs result in higher pressures!) • Cuff position: unclothed arm, tight and strong, deflated • Choose mercury manometer; aneroid devices should be calibrated against Hg every 6 month! • for children choose smaller cuffs or ultrasound devicesMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 23. Hypertension Diagnosis• The correct measurement of blood pressure – Patient – Environment – Device – ProcedureMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 24. Hypertension Diagnosis: anatomy of brachial auskultation area a.brachialis membrane area medial,just above the joint (epicondylus medialis)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 25. Hypertension Diagnosis• Brachial measurement – Inflation quickly 20 mm Hg over expected SBP or as recognized by palpation of the radial pulse (disappearance) – Deflation slowly (3 mm Hg /s) – Readings: first reading both left and right arm, difference not being above 20 mm Hg at least 2 readings from the arm with the higher pressure – listen to disappearance of Korotkow noise (muffling may occur: take the attenuation point)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 26. Hypertension Diagnosis: anatomy of radial palpation area a.radialis palpation areaMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 27. Hypertension Diagnosis • Radial pulse palpation, if only SBP measurements are needed: – shock or hypotension (if palpable!) – Posture evaluation (syncope diagnosis) – sudden information about systolic blood pressure Does NOT replace regular measurements!March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 28. Hypertension Diagnosis Radial blood pressure devices for self measurements: instructions, training and commitment of the patient are necessary. Scheduled repeat calibration!!March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 29. Hypertension Diagnosis• How many doctor‘s readings? – Office visit: at least 3 readings in order to reduce white coat BPR – At home (self control): at least 5 readings per day with protocol): • After bedrest, • After breakfast • Late in the morning • late afternoon • Before bed restMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 30. Hypertension Diagnosis:patient commitment Have a blood pressure protocol booklet ready, when your patient visits office last time. Ask the patient to use it regularly and carefully Ask the patient to show at next visit therapy control Pt. complianceMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 31. Hypertension Diagnosis date time SBP/DBP pulse remarks-medication Main contents of BP bookletMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 32. Hypertension Diagnosis • Clinical Diagnosis • Devices for measurement • Advanced Measures • Pathways and FlowchartsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 33. Hypertension Diagnosis • Advanced BP-measures – 24 h monitoring – Telemetry – Exercise (treadmill) TestsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 34. Hypertension Diagnosis • Advanced BP-measures – 24 h monitoring – Telemetry Sleep Wake up – Exercise Blood pressure High incidence of MACCEMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 35. Hypertension Diagnosis 24h-BP-Monitoring Daytime 7:00 am – 10:00 pm 20 min intervalsDuring the night 10 pm – 6:00 am 30 min intervals minimum of 80/24 hmeasurements March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 36. Hypertension Diagnosis 24h-BP-Monitoring Normal values Daytime mean < 135/85 mm HgFrequency of values over 20 -25% 140/90 mm Hg Night dipping 10-15% Total mean <130/80 mm Hg Recommendations of the german hypertension society March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 37. Hypertension Diagnosis • Advanced BP-measures – 24 h monitoring – Telemetry (mostly investigational,needs invasive measurement) – Exercise future use: telemedicine electronic data transmission by telephone and/or computer in order to leave the patient not uncontrolled or to give him safety to contact his doctor in case of emergencyMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 38. Hypertension Diagnosis• Advanced BP-measures – 24 h monitoring – Telemetry – ExerciseMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 39. Hypertension Diagnosis Exercise equipment Exercise protocolMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 40. Hypertension Diagnosis • Validation of exercise test concerning BP changes: if – SBP = 200 mm Hg when reaching 100 W level (10 METS), or – no recovery to normal values within 5 min observation time, or – DBP >= 110 mm Hg at any level (before: do not perform test, during: stop test!)Result: exercise hypertension; persistent hypertensionMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 41. Hypertension Diagnosis• advanced diagnostic procedures: target organ damage – Heart: Chest Xray, ECG, Ultrasound, MD-CT, MRT – Brain: Carotid Duplex Ultrasound, CT, MRT – Renal: blood tests, urinalysis – Peripheral vessels: arm-ankle-ratio (<=1), retinal backgroundMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 42. Chest Xray: left heart enlargement Prominent aortic knob Dilated aortic root Enlarged (hypertrophic) left ventricleMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 43. ECG:Left ventricular hypertrophy LVH Dgn.: HOCMMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 44. Cardiac Ultrasound: LVH IVS LV AO PM PW LAMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 45. Magnetic resonance imaging: LVHMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 46. Retinopathy: hypertension Crossing phenomenon GUNN Silver reflecting arteryMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 47. Target Organ Damage Diagnosis Ankle Brachial Index ABI SBP arm ------------------- SBP leg (ankle, a. tibialis post.) Normal value: 120/150 = 0.8 Pathological: 120/80 = 1.5 Peripheral arterial disease US flow transducerMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 48. Hypertension Diagnosis: Laboratory tests • Basic tests: – Blood tests: full blood count, thyroid gland (T3), kidney, liver, glucose, electrolytes – Urinary test: protein, albumin, sedimentum – Special urinary test. microalbuminuria • Advanced : – (secondary Hptn.)renine, aldosterone, katecholamines – quantitative urinalysis (quantative albuminuria, clearances, Na +, Cl-)March 2013 Prof. G. Hennersdorf DGK ESC SES
  • 49. Hypertension Diagnosis• advanced diagnostic procedures: mainly secondary Hptn. – Hormone assays (thyroid, adrenal, pituitary gl.) – Vascular bed diagnosis (renovascular): • Abdominal CT • Abdominal angiographyMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 50. Hypertension Diagnosis • Clinical Diagnosis • Devices for measurement • Advanced Measures • Pathways and FlowchartsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 51. Hypertension Diagnosis: Flow Chart consider sec.HPTN History, office readings Persistently raised BP yes CXR, US, renal Target organ damage? tests no high patient passport Home BP measurement Start treatment Information/instruction low abnormal 24h Monitoring normal Continue repeat visitsMarch 2013 Prof. G. Hennersdorf DGK ESC SES
  • 52. Hypertension Diagnosis: pathways and networks BP Control, blood tests OPD treatment control visit Hospital Nurse office admission patient Home careEmergency, BP ControlFirst, advanced dgn Treatment controlStart of treatment Instructions Clinic/office Scheduling appointments BP Control, blood tests treatment control
  • 53. Cardiovascular Diseases Hypertension Management part I The EndMarch 2013 Prof. G. Hennersdorf DGK ESC SES

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