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What is blood pressure?
Why is it important for it to be tightly regulated?
Blood Pressure is a function of cardiac output and peripheral vascular resistance.
If blood pressure is too low then tissues are not adequately perfused
If blood pressure is too high then blood vessels and tissues can be damaged
How is blood pressure regulated?
How does JNC 7 qualify hypertension?
Prehypertension - blood pressure level at which progression to HTN is twice as likely as a blood pressure below 120/80
How does hypertension increase risk of heart disease and stroke?
What are some important epidemiologic factors for hypertension?
28% of US adults have HTN
African Americans - HTN occurs earlier, is usually more severe, has an increased risk of mortality & morbidity from stroke, LVH, CHF, and end stage renal disease compared to caucasian Americans
What are some complications to hypertension?
Remains asymptomatic until late in its course
Coronary heart disease
-1/2 will die of ischemic heart disease or CHF
-1/3 wil die of stroke
Treatment has a dramatic effect on related diseases
How is hypertension classified?
Essential (primary) hypertension
What are some causes of secondary hypertension?
What causes essential hypertension?
95% of hypertensive cases have no identifiable cause
-likely a multifactorial disorder
-due to genetic mutations in blood pressure regulation
-environmental factors (stress, sodium)
What is accelerated or malignant hypertension?
What are some findings?
Clinical syndrome of:
-severe hypertension (Systolic blood pressure >200mm Hg, diastolic blood pressure > 120 mmHg)
-retinal hemorrhages and exudates, with or without papilledema
Can arise in normotensive individuals but usually superimposed on pre-exisiting benign hypertension
What are some pathologic effects of hypertension?
How does hypertension effect the blood vessels?
-results in degeneration of walls of large and medium arteries
Causes changes in small blood vessels
-Hemodynamic stress due to chronic hypertension can result in hyaline arteriolosclerosis
-Changes seen with severe hypertension include hyperplastic arterioloslerosis
What is hyaline arteriosclerosis?
2 left images = normal arteriole
right image = hyaline arteriosclerosis
Result of chronic hypertension
-variable increase in arterial wall thickness
-pink hyaline thickening, narrowed lumens
-due to injury to endothelial cells
-causes leakage of plasma proteins into walls of vessel
-increased smooth muscle cell matrix synthesis due to chronic hemodynamic stress
What is hyperplastic arteriolosclerosis
microvascular change seen in malignant hypertension
-laminated thickening of wall
-smooth muscle cells, thickened basement membranes
-lumen is narrowed
-known as "onion skin lesion"
What is necrotizing arterioloitis?
Microvascular change seen in severe hypertension
-vascular damage causing necrosis of vessel wall
-increased permeability of wall to fibrinogen, proteins
-lumen may be narrowed
-aka fibrinoid necrosis
What is hypertension is a major risk factor for?
Chronic inflammatory and healing process of arterial walls to endothelial injury
What can chronic hypertension result in that is very dangerous?
Abnormal dilation of a portion of blood vessel wall or the heart
Atherosclerosis and hypertension are the most important disorders that predispose aortic aneurysms.
-due to entry of blood into arterial wall & splaying of media
How does hypertension effect the heart?
Can cause heart disease
-most common COD in hypertensive patients
-accelerated atherosclerosis of coronary arteries
Left ventricular hypertrophy and diastolic function
-compensation for increase in pressure
increases stiffness, causes diastolic dysfunction
-can cause pulmonary congestion
-can find heaving impulse on chest palpation and
4th heart sound
strong predictor of cardiac morbidity in patients with HTN
-increased LV mass may not overcome effects of elevated pressure
-deterioration in decompensation may produce
-ischemia from coronary artery disease may contribute
Coronary artery disease
-myocardial ischemia, infarction
-accelerated atherosclerosis (decreased oxygen supply)
-high systolic workload (increased oxygen demand)
-LVH can dilate the LA and cause atrial fibrillation
-other arrhythmias can be PVC, ventricular tachycardia
Left ventricular hypertrophy microscopically
LV hypertrophy - myocardial cells increased in diameter, boxcar rectangular, enlarged, hyperchromatic nuclei
What are the effects of hypertension on the brain?
Important risk factor for strokes
Hemorrhagic CVA's - due to rupture of intracerebral parenchymal vessels
Atherothrombotic CVA's due to atherosclerotic plaque or thrombi disolged from carotids or cerebral arteries
Occlusion of small arteries can cause
- tiny infarcts, almost exclusive in chronic HTN
Hypertensive intracerebral hemorrhage
What causes lacunar infarcts?
Arteriolar sclerosis of deep penetrating arteries and arterioles
that supply the basal ganglia, hemispheric white matter, and brainstem
-image shows arteries typically involved in strokes
Caused by hypertension
occlusion of the vessels and result in infarcts known as lacunar infarcts
Single or multiple cavitary infarcts
, less than 15mm wide
-tissue destruction, lipid-laden macrophages, gliosis seen
clinically silent or produce neurological symptoms:
-motor/sensory deficit, ipsilateral ataxia, others
CT scan usually normal but may show hypodense areas
Lacunary infarcts in caudate and putamen
What is a slit hemorrhage?
Rupture of small penetrating vessels resulting in small hemorrhages
-hemorrhage is eventually reabsorbed and a cavity remains
-tissue destruction, pigment laden macrophages, and gliosis
What is hypertensive encephalopathy?
What does it cause?
Acute hypertensive encephalopathy occurs in
headache, confusion, vomiting, connvulsions and possibly coma
Autopsy may show an
edematous brain with or without transtentorial or tonsillar herniation
May be fibrinoid necrosis of the arterioles on microscopic examination
What is multi-infarct dementia?
What can cause it?
A clinical syndrome including:
Focal neurologic deficits
Stepwise progression of disease due to recurrent strokes
-multiple, bilateral gray and white matter infarcts
Caused by multifocal vascular disease
-cerebral arteriolar sclerosis due to chronic HTN
What is the most common cause of primary brain parenchymal hemorrhage?
Accelerated atherosclerosis of large arteries
Proliferative changes and necrosis
May originate in:
-other brain regions
Acute hemorrhages exhibit extravasation of blood compressing adjacent parenchyma.
Old hemorrhages have cavitations with a surrounding rim of brown discoloration.
What are Charcot-Bouchard microaneurysms?
Very small aneurysms associated with chronic hypertension
-less than 300um in diameter
-common in basal ganglia
Hemorrhage in basal ganglia
Often due to hypertension
How does hypertension affect the kidney?
-renal disease with sclerosis of renal arterioles and small arteries
-associated with aging and can occur without hypertension
-hypertension and diabetes mellitus increase the incidence
-leading cause of renal failure
-fibrinoid necrosis with smooth muscle hypertrophy
-ischemic atrophy of tubules and glomeruli
-renal failure can further contribute to hypertension
Note granularity of the surface of the kidney
Benign hypertension effects in the kidney
Hyaline (pink, amorphous, homogeneous material) accumulates in the wall of small arteries and arterioles, producing the thickening of their walls and the narrowing of the lumens
Causes ischemia -> tubular atrophy, interstitial fibrosis, glomerular alterations
Fibrinoid necrosis - afferent arteriole (left)
Hyperplatic arterioloitis (onion skinning, right)
Malignant hypertension effects on kidney
"Flea bitten" kidney - petechiae!
How does hypertension effect the eyes?
Usually changes are asymptomatic
Symptoms are an
indication of severity and duration of hypertension
Extensive damage can cause vision problems
Severe and acute hypertension may cause:
-rupture of retinal vessels
-exudation of plasma lipids
Papilledema - swelling of optic disc and blurring of margins due to high intracranial pressure
can arise in malignant hypertension
Chronic hypertension can cause:
- medial hypertrophy thickens vessel wall and nicks crossing veins
- arterial sclerosis causes increased reflection of light
& copper wiring
Thickened retinal arterioles are narrowed, tortuous, and where they cross over veins they can be kinked
- they share a common adventitia where they cross
Narrowed lumen diminishes visibility of blood and the arteriole appears orange
-completely obscured vessel reflects a silver color = silver wiring
Cotton wool spots
-Small retinal infarcts and swelling of nerve fiber layer of the retina
-can be caused by hypertension
-deeper in retina than cotton wool spots
-produced by leaky damaged vessel walls
-occur in the superficial (nerve fiber layer) of retina
How do you assess high blood pressure?
Confirm diagnosis with multiple measurements
Rule out secondary causes
Assess severity of disease
Identify additional cardiovascular risk factors
Define isolated systolic, diastolic and mixed systolic/diastolic hypertension!
Isolated systolic hypertension blood pressure is
≥ 140/ <90 mmHg
Isolated diastolic hypertension blood pressure is
<140/ ≥ 90 mmHg
Mixed systolic/diastolic hypertension blood pressure is
≥ 140/ ≥ 90 mm Hg
How does essential hypertension typically present?
Onset 30-50 years
-isolated systolic HTN mainly in elderly
Onset is gradual for most
Patient is often asymptomatic
What is labile hypertension?
Blood pressure that intermittently exceeds normal levels
Labile hypertension often progresses to sustained hypertension
What is "white coat" hypertension?
A form of labile hypertension that persistently exceeds the 140/90mmHg at the doctor's office but not on home measurement
-risk of sustained hypertension
How does secondary hypertension present?
Occurs over a wide age range
Can have abrupt onset and severe magnitude
Usually has a negative family history
How does history help with diagnosing hypertension?
Age of onset
Ask about contributing risk factors including prior renal disease, excess sodium and alcohol, cocaine use, weight gain)
Clues for secondary causes
How do you assess hypertensive patients in a physical exam?
Fundoscopy for AV nicking, hemorrhages, exudates
Peripheral vasculature and carotids for bruits and abnormal pulses
Lungs for signs of heart failure
Heart for left ventricular lift, S3, S4
Neurologic exam for focal deficits
What labs do you use to assess hypertension?
Fasting blood sugar
What determines the cardiovascular risk of a patient with hypertension?
Extent of blood pressure elevation
Presence of cardiovascular risk factors (smoking, diabetes, hypercholesterolemia, gender, family history)
Evidence of target organ damage
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