STUDY - Technical - New Dacian's Medicine
Hypertension
Translation Draft
Since there is no clear line between normal and increased blood pressure, arbitrary limits have been set to define people at increased risk of developing cardiovascular disease and/ or those who will have a clear benefit after medical treatment. These definitions should take into account not only the value of diastolic pressure but also systolic pressure, age, sex and race.
For example, patients with a diastolic voltage greater than 90 mmHg have a significantly lower morbidity and mortality rate if treated appropriately.
These are therefore patients who have hypertension and should be treated. Systolic blood pressure levels are also important to assess the influence of blood pressure on cardiac morbidity. Men with normal diastolic voltage (<82 mmHg) but high systolic voltage (>158 mmHg) have a cardiovascular mortality rate 2.5 times higher than individuals with a similar diastolic voltage, but whose systolic voltage is normal (<130 mmHg).
A reduction in mortality and morbidity through treatment, especially in the elderly, was shown in these patients. The beneficial effect results mainly from the reduction of the incidence of strokes and is also present in women. Other important factors that alter the influence of blood pressure on the frequency of cardiovascular disease are age, race and sex, with young black men being the most affected by hypertension.
When hypertension is suspected, blood pressure should be measured at least twice, on different occasions, after initial screening. In adults, a diastolic voltage of less than 85 mmHg is considered normal, values between 85 and 89 mmHg are normal at the upper limit, those of 90 to 104 mmHg represent mild hypertension, between 105 and 114 mmHg hypertension is moderate and more than 115 mmHg represent severe hypertension.
When diastolic voltage is below 90 mmHg, a systolic voltage below 140 mmHg is normal, values between 140 and 159 mmHg represent systolic hypertension isolated at the limit and values of 160 mmHg or higher indicate isolated systolic hypertension. Monitoring blood pressure over a period of 12 or 24 hours may provide additional information to patients who are difficult to include in one group or another. However, the normal values for this method and its usefulness in relation to the results of treatment are not commonly known.
Another useful classification of hypertension is carried out in the form of a staging of blood pressure in adults aged 18 or over, which is the most widely used form of classification of tension "values". On the basis of this, optimal blood pressure without cardiovascular risk is considered to be less than 120/ 80 mmHg (however, abnormally low values are required to be clinically evaluated).
Normal voltage is considered to be the lowest 130/ 85 mmHg, the normal limit being between 130-139/ 85-89 mmHg. Above this values it is considered that we are dealing with hypertension (which is "established" only after the average achieved after at least two measurements/ determinations of it at different times of the day, possibly and on different days).
In connection with hypertension we have several stages: stage 1 (mild hypertension) with values between 140-159/ 90-99 mmHg, stage 2 (moderate) with values between 160-179/ 100-109 mmHg, stage 3 (severe) with values between 180-209/ 110-119 mmHg and stage 4 (very severe) with values greater than or equal to 210/ 120 mmHg.
Blood pressure fluctuates in most people, whether normo or hypertensive. Patients considered to have labile hypertension are those who sometimes, but not always, have blood pressure levels above normal. These patients are included in the borderline hypertensive category.
Sustained hypertension can be accelerated or enter a malignant phase, although this development is unusual for treated patients. Although a patient with malignant hypertension frequently has a blood pressure above 200/ 140 mmHg, this condition is defined by the presence of papillary edema, usually accompanied by exudation and retinal hemorrhages, rather than by absolute blood pressure values.
Accelerated hypertension is defined as a recent significant increase, above previous values, in tension, associated with the discovery of vascular lesions, but without papillary edema, when examining the bottom of the eye.
In the evaluation of the hypertensive patient, anamnesis, physical examination and laboratory tests must allow: 1. the discovery of the secondary forms of hypertension that can be corrected, 2. the establishment of a pre-treatment reference state, 3. the evaluation of factors that can influence the type of therapy or can be negatively modified by therapy, 4. determination of damage to the target organs and 5. determination of the presence of other risk factors for arteriosclerotic cardiovascular disease.
Ideally, this assessment should also reveal the basic mechanisms of essential hypertension, especially if this information allows for the establishment of targeted treatment. Unfortunately, at present, this aspect of the evaluation is limited by the lack of knowledge of some of the basic mechanisms, uncertainty as to the correctness of treatment for a distinct category, even if the basic mechanism is known, or the prohibitive cost required to define a group of patients, even if the specific treatment is at hand. However, with the intake of additional information, this last indication of the evaluation of hypertensive patients may become increasingly important.
Most hypertensive patients do not have specific symptoms that can be attributed to increased blood pressure and are identified as such only during physical examination (often accidentally). When symptoms are the ones that bring the patient to the doctor, they are included in three categories.
They are attributed: 1. high blood pressure itself, 2. hypertensive vascular disease and 3. disease in the case of secondary hypertension. Although popularly considered a symptom of high blood pressure, headache is characteristic only for severe hypertension, the most common headache being localized at the occipital level, present in the morning and waking, disappearing spontaneously every few hours. Other symptoms that can be attributed to high blood pressure are vertigo, palpitations, fatigue and impotence.
Symptoms caused by vascular disease include epistaxis, hematuria, blurred vision due to retinal changes, episodes of weakness or vertigo due to transient cerebral ischemia, angina and dyspnea due to heart failure. Pain that occurs in the dissection of the aorta or when an aneurysm ruptures, is an occasional symptom.
Examples of symptoms due to underlying disease in secondary hypertension are polyuria, polydipsia and secondary muscle weakness hypokalemia, in patients with primary or obese hyperaldosteronism, and emotional lability in those with Cushing syndrome. Patients with pheochromocytoma may experience episodes of headache, palpitations, diaphoresis and postural vertigo.
A long family history of hypertension, along with intermittent increases in blood pressure levels in the past, supports the diagnosis of hypertension. Secondary hypertension occurs frequently before 35 or after 55 years. Previous corticosteroid or estrogen treatments have obvious significance.
A history of repeated urinary infections suggests chronic pyelonephritis, although this condition may be asymptomatic (nocturia and polydipsia indicate an endocrine or renal disease, while a flank trauma or an acute painful flank episode may suggest the presence of kidney damage. Weight gain is compatible with Cushing syndrome, and weight loss occurs in the pheochromocytoma).
Several aspects of history can determine whether vascular disease has progressed to a dangerous stage. These include angina, symptoms of brain failure, congestive heart failure and/ or peripheral vascular insufficiency. Other risk factors to be investigated are smoking, diabetes mellitus, dyslipidemia and a family history of premature deaths due to cardiovascular disease.
Finally, certain aspects of the patient's lifestyle, which may contribute to the development of hypertension or influence treatment, such as diet, physical activity, family status, profession and level of education, should be evaluated.
The physical examination begins with the assessment of the general appearance of the patient. For example, are the round face and truncculal obesity characteristic of Cushing syndrome present? Is muscle development of the upper limbs greater than that of the lower limbs, suggesting the coarctation of the aorta?
The next step is to compare blood pressure and pulse to the two upper limbs in orthostatism and clinostatism (for at least 2 minutes). An increase in diastolic pressure when the patient goes from clinostatism to orthostatism most likely occurs in essential hypertension, a decrease in the absence of antihypertensive medication, suggests a secondary form of hypertension. The patient's height and weight must be determined.
Detailed examination of the bottom of the eye is mandatory, as the data provided by it helps to the greatest extent in staging hypertension and establishing the prognosis. A useful guide is the Keith-Wagner-Barker classification of butt changes, the specific changes of each eye butt being required to be recorded and staging.
Palpation and auscultation of carotid arteries to highlight stenosis or occlusions are important, narrowing of the carotid artery may be one of the manifestations of hypertensive vascular disease, but may also suggest the presence of an impairment of the renal arteries, since these lesions may be associated.
When examining the heart and lungs, left ventricular hypertrophy and cardiac decompensation should be sought. Is the left ventricle enlarged? Are heart noises III and IV present? Are there lung rals? Heart noise III and pulmonary rals do not usually occur in uncomplicated hypertension. Their presence suggests ventricular dysfunction.
Examination of the thorax also includes the search for extracardiac blasts and palpable collateral vessels that may occur in aorta coarctations. The most important part of the examination of the abdomen is the hearing of blasts that occur in the stenotic renal arteries.
These blasts due to narrowing of the renal arteries almost always have a diastolic component or can be continuous and are best heard to the right or left of the supraombilical median line or flanks (they are present in many patients with renal artery stenosis due to fibrous dysplasia and in 40-50% of those with a functionally significant stenosis due to arteriosclerosis).
The abdomen should also be palpated in search of an abdominal aneurysm or large kidneys from renal polycystic disease. The femoral pulse should be carefully palpated and, if it is weaker and/ or delayed compared to the radial pulse, the blood pressure of the lower limbs should be measured. Even if the femoral pulse is normal at palpation, the blood pressure of the lower limbs should be measured at least once in patients whose hypertension is discovered before the age of 30.
Finally, limbs should be examined in search of edema or sechelles of an earlier cerebrovascular accident and/ or evidence of intracranial pathology.
As far as laboratory investigations are concerned, there is a lot of controversy as to what investigations should be carried out in hypertensive patients. In general, they concern the extension of investigations in the assessment of a patient for secondary forms of tension or subclasses of essential hypertension.
Basic laboratory examinations to be performed in patients with sustained hypertension are: 1. glucose, blood, urinary proteins, 2. hematocrit, 3. potasemia, 4. serum creatinine and/ or blood urea and 5. Electrocardiogram. In addition may include: 1. microscopic examination of urine, 2. leukocytes, 3. blood plasma glucose, cholesterol and plasma/blood triglycerides, 4. uric acid, phosphates and serum calcium, 5. chest X-ray, possibly echocardiography.
For the evaluation of secondary hypertension, certain special tests, in addition to those presented above, represented by: 1. in renovascular disease: renogram with angiotensin conversion enzyme inhibitor and examination of both kidneys with ultrasound, 2. in feochromotom: determination of creatinine, methanefrines and catecholamines in urine over 24 hours or plasma catecholamines and 3. in Cushing syndrome: nocturnal dexamethasone suppression test or cortisol determination in urine for 24 hours.
Secondary studies should be carried out if: 1. initial assessments suggest a form of secondary hypertension and/ or 2. blood pressure is not controlled after initial treatment. Renal function is assessed by determining the presence of proteins, blood or glucose in the urine and dosing creatinine and/ or plasma urea.
Microscopic urine examination is also helpful. Plasma potassium dosing should be performed both to monitor mineralocorticoid-induced hypertension and to establish a reference level before starting diuretic treatment. Other biochemical determinations are useful, especially since they can be performed as an autonomous series of tests, with a minimum cost to the patient.
For example, blood glucose dosing is useful because diabetes mellitus may be associated with accelerated arteriosclerosis, renal vascular disease and diabetic nephropathy in hypertensive patients, as well as because primary hyperaldosteronism, Cushing syndrome and pheochromocytoma can all be accompanied by hyperglycaemia.
In addition, since antihypertensive treatment with diuretics, for example, may increase blood glucose levels, it is important to establish a reference level. The possibility of hypercalcemia must also be investigated. Determination of serum uric acid is necessary due to the increased incidence of hyperuricemia in patients with renal hypertension and essential because, as with blood glucose, serum levels may increase due to diuretic treatment.
Serum cholesterol, HDL (high density lipoprotein) cholesterol and triglycerides can be dosed to identify other predisposing factors for the development of arteriosclerosis.
In all cases, the electrocardiogram should be performed to allow the assessment of the condition of the heart, especially if left ventricular hypertrophy is present and to establish a reference point. Echocardiography is much more sensitive than electrocardiogram or physical examination in determining the existence of cardiac hypertrophy.
Thus, in some situations, this method may be added to the basic assessment of the hypertensive patient, especially since left ventricular hypertrophy is an independent cardiovascular risk factor and its presence suggests the need for sustained antihypertensive treatment.
In addition, while a substantial increase in blood pressure is often accompanied by the presence of left ventricular hypertrophy, an average increase may not be associated with it. Therefore, the absolute value of blood pressure cannot be used as a substitute marker for the presence or absence of left ventricular hypertrophy.
On the other hand, due to the cost of cardiac ultrasound and uncertainty that the information obtained will alter the therapy, it is not clear whether routine echocardiographic monitoring during treatment is justified. Chest X-rays may also be useful for identifying dilation or elongation of the aorta, as well as costal erosions occurring in the coarctation of the aorta.
Ready for today and, for now, with high blood pressure.
Since there is no clear line between normal and increased blood pressure, arbitrary limits have been set to define people at increased risk of developing cardiovascular disease and/ or those who will have a clear benefit after medical treatment. These definitions should take into account not only the value of diastolic pressure but also systolic pressure, age, sex and race.
For example, patients with a diastolic voltage greater than 90 mmHg have a significantly lower morbidity and mortality rate if treated appropriately.
These are therefore patients who have hypertension and should be treated. Systolic blood pressure levels are also important to assess the influence of blood pressure on cardiac morbidity. Men with normal diastolic voltage (<82 mmHg) but high systolic voltage (>158 mmHg) have a cardiovascular mortality rate 2.5 times higher than individuals with a similar diastolic voltage, but whose systolic voltage is normal (<130 mmHg).
A reduction in mortality and morbidity through treatment, especially in the elderly, was shown in these patients. The beneficial effect results mainly from the reduction of the incidence of strokes and is also present in women. Other important factors that alter the influence of blood pressure on the frequency of cardiovascular disease are age, race and sex, with young black men being the most affected by hypertension.
When hypertension is suspected, blood pressure should be measured at least twice, on different occasions, after initial screening. In adults, a diastolic voltage of less than 85 mmHg is considered normal, values between 85 and 89 mmHg are normal at the upper limit, those of 90 to 104 mmHg represent mild hypertension, between 105 and 114 mmHg hypertension is moderate and more than 115 mmHg represent severe hypertension.
When diastolic voltage is below 90 mmHg, a systolic voltage below 140 mmHg is normal, values between 140 and 159 mmHg represent systolic hypertension isolated at the limit and values of 160 mmHg or higher indicate isolated systolic hypertension. Monitoring blood pressure over a period of 12 or 24 hours may provide additional information to patients who are difficult to include in one group or another. However, the normal values for this method and its usefulness in relation to the results of treatment are not commonly known.
Another useful classification of hypertension is carried out in the form of a staging of blood pressure in adults aged 18 or over, which is the most widely used form of classification of tension "values". On the basis of this, optimal blood pressure without cardiovascular risk is considered to be less than 120/ 80 mmHg (however, abnormally low values are required to be clinically evaluated).
Normal voltage is considered to be the lowest 130/ 85 mmHg, the normal limit being between 130-139/ 85-89 mmHg. Above this values it is considered that we are dealing with hypertension (which is "established" only after the average achieved after at least two measurements/ determinations of it at different times of the day, possibly and on different days).
In connection with hypertension we have several stages: stage 1 (mild hypertension) with values between 140-159/ 90-99 mmHg, stage 2 (moderate) with values between 160-179/ 100-109 mmHg, stage 3 (severe) with values between 180-209/ 110-119 mmHg and stage 4 (very severe) with values greater than or equal to 210/ 120 mmHg.
Blood pressure fluctuates in most people, whether normo or hypertensive. Patients considered to have labile hypertension are those who sometimes, but not always, have blood pressure levels above normal. These patients are included in the borderline hypertensive category.
Sustained hypertension can be accelerated or enter a malignant phase, although this development is unusual for treated patients. Although a patient with malignant hypertension frequently has a blood pressure above 200/ 140 mmHg, this condition is defined by the presence of papillary edema, usually accompanied by exudation and retinal hemorrhages, rather than by absolute blood pressure values.
Accelerated hypertension is defined as a recent significant increase, above previous values, in tension, associated with the discovery of vascular lesions, but without papillary edema, when examining the bottom of the eye.
In the evaluation of the hypertensive patient, anamnesis, physical examination and laboratory tests must allow: 1. the discovery of the secondary forms of hypertension that can be corrected, 2. the establishment of a pre-treatment reference state, 3. the evaluation of factors that can influence the type of therapy or can be negatively modified by therapy, 4. determination of damage to the target organs and 5. determination of the presence of other risk factors for arteriosclerotic cardiovascular disease.
Ideally, this assessment should also reveal the basic mechanisms of essential hypertension, especially if this information allows for the establishment of targeted treatment. Unfortunately, at present, this aspect of the evaluation is limited by the lack of knowledge of some of the basic mechanisms, uncertainty as to the correctness of treatment for a distinct category, even if the basic mechanism is known, or the prohibitive cost required to define a group of patients, even if the specific treatment is at hand. However, with the intake of additional information, this last indication of the evaluation of hypertensive patients may become increasingly important.
Most hypertensive patients do not have specific symptoms that can be attributed to increased blood pressure and are identified as such only during physical examination (often accidentally). When symptoms are the ones that bring the patient to the doctor, they are included in three categories.
They are attributed: 1. high blood pressure itself, 2. hypertensive vascular disease and 3. disease in the case of secondary hypertension. Although popularly considered a symptom of high blood pressure, headache is characteristic only for severe hypertension, the most common headache being localized at the occipital level, present in the morning and waking, disappearing spontaneously every few hours. Other symptoms that can be attributed to high blood pressure are vertigo, palpitations, fatigue and impotence.
Symptoms caused by vascular disease include epistaxis, hematuria, blurred vision due to retinal changes, episodes of weakness or vertigo due to transient cerebral ischemia, angina and dyspnea due to heart failure. Pain that occurs in the dissection of the aorta or when an aneurysm ruptures, is an occasional symptom.
Examples of symptoms due to underlying disease in secondary hypertension are polyuria, polydipsia and secondary muscle weakness hypokalemia, in patients with primary or obese hyperaldosteronism, and emotional lability in those with Cushing syndrome. Patients with pheochromocytoma may experience episodes of headache, palpitations, diaphoresis and postural vertigo.
A long family history of hypertension, along with intermittent increases in blood pressure levels in the past, supports the diagnosis of hypertension. Secondary hypertension occurs frequently before 35 or after 55 years. Previous corticosteroid or estrogen treatments have obvious significance.
A history of repeated urinary infections suggests chronic pyelonephritis, although this condition may be asymptomatic (nocturia and polydipsia indicate an endocrine or renal disease, while a flank trauma or an acute painful flank episode may suggest the presence of kidney damage. Weight gain is compatible with Cushing syndrome, and weight loss occurs in the pheochromocytoma).
Several aspects of history can determine whether vascular disease has progressed to a dangerous stage. These include angina, symptoms of brain failure, congestive heart failure and/ or peripheral vascular insufficiency. Other risk factors to be investigated are smoking, diabetes mellitus, dyslipidemia and a family history of premature deaths due to cardiovascular disease.
Finally, certain aspects of the patient's lifestyle, which may contribute to the development of hypertension or influence treatment, such as diet, physical activity, family status, profession and level of education, should be evaluated.
The physical examination begins with the assessment of the general appearance of the patient. For example, are the round face and truncculal obesity characteristic of Cushing syndrome present? Is muscle development of the upper limbs greater than that of the lower limbs, suggesting the coarctation of the aorta?
The next step is to compare blood pressure and pulse to the two upper limbs in orthostatism and clinostatism (for at least 2 minutes). An increase in diastolic pressure when the patient goes from clinostatism to orthostatism most likely occurs in essential hypertension, a decrease in the absence of antihypertensive medication, suggests a secondary form of hypertension. The patient's height and weight must be determined.
Detailed examination of the bottom of the eye is mandatory, as the data provided by it helps to the greatest extent in staging hypertension and establishing the prognosis. A useful guide is the Keith-Wagner-Barker classification of butt changes, the specific changes of each eye butt being required to be recorded and staging.
Palpation and auscultation of carotid arteries to highlight stenosis or occlusions are important, narrowing of the carotid artery may be one of the manifestations of hypertensive vascular disease, but may also suggest the presence of an impairment of the renal arteries, since these lesions may be associated.
When examining the heart and lungs, left ventricular hypertrophy and cardiac decompensation should be sought. Is the left ventricle enlarged? Are heart noises III and IV present? Are there lung rals? Heart noise III and pulmonary rals do not usually occur in uncomplicated hypertension. Their presence suggests ventricular dysfunction.
Examination of the thorax also includes the search for extracardiac blasts and palpable collateral vessels that may occur in aorta coarctations. The most important part of the examination of the abdomen is the hearing of blasts that occur in the stenotic renal arteries.
These blasts due to narrowing of the renal arteries almost always have a diastolic component or can be continuous and are best heard to the right or left of the supraombilical median line or flanks (they are present in many patients with renal artery stenosis due to fibrous dysplasia and in 40-50% of those with a functionally significant stenosis due to arteriosclerosis).
The abdomen should also be palpated in search of an abdominal aneurysm or large kidneys from renal polycystic disease. The femoral pulse should be carefully palpated and, if it is weaker and/ or delayed compared to the radial pulse, the blood pressure of the lower limbs should be measured. Even if the femoral pulse is normal at palpation, the blood pressure of the lower limbs should be measured at least once in patients whose hypertension is discovered before the age of 30.
Finally, limbs should be examined in search of edema or sechelles of an earlier cerebrovascular accident and/ or evidence of intracranial pathology.
As far as laboratory investigations are concerned, there is a lot of controversy as to what investigations should be carried out in hypertensive patients. In general, they concern the extension of investigations in the assessment of a patient for secondary forms of tension or subclasses of essential hypertension.
Basic laboratory examinations to be performed in patients with sustained hypertension are: 1. glucose, blood, urinary proteins, 2. hematocrit, 3. potasemia, 4. serum creatinine and/ or blood urea and 5. Electrocardiogram. In addition may include: 1. microscopic examination of urine, 2. leukocytes, 3. blood plasma glucose, cholesterol and plasma/blood triglycerides, 4. uric acid, phosphates and serum calcium, 5. chest X-ray, possibly echocardiography.
For the evaluation of secondary hypertension, certain special tests, in addition to those presented above, represented by: 1. in renovascular disease: renogram with angiotensin conversion enzyme inhibitor and examination of both kidneys with ultrasound, 2. in feochromotom: determination of creatinine, methanefrines and catecholamines in urine over 24 hours or plasma catecholamines and 3. in Cushing syndrome: nocturnal dexamethasone suppression test or cortisol determination in urine for 24 hours.
Secondary studies should be carried out if: 1. initial assessments suggest a form of secondary hypertension and/ or 2. blood pressure is not controlled after initial treatment. Renal function is assessed by determining the presence of proteins, blood or glucose in the urine and dosing creatinine and/ or plasma urea.
Microscopic urine examination is also helpful. Plasma potassium dosing should be performed both to monitor mineralocorticoid-induced hypertension and to establish a reference level before starting diuretic treatment. Other biochemical determinations are useful, especially since they can be performed as an autonomous series of tests, with a minimum cost to the patient.
For example, blood glucose dosing is useful because diabetes mellitus may be associated with accelerated arteriosclerosis, renal vascular disease and diabetic nephropathy in hypertensive patients, as well as because primary hyperaldosteronism, Cushing syndrome and pheochromocytoma can all be accompanied by hyperglycaemia.
In addition, since antihypertensive treatment with diuretics, for example, may increase blood glucose levels, it is important to establish a reference level. The possibility of hypercalcemia must also be investigated. Determination of serum uric acid is necessary due to the increased incidence of hyperuricemia in patients with renal hypertension and essential because, as with blood glucose, serum levels may increase due to diuretic treatment.
Serum cholesterol, HDL (high density lipoprotein) cholesterol and triglycerides can be dosed to identify other predisposing factors for the development of arteriosclerosis.
In all cases, the electrocardiogram should be performed to allow the assessment of the condition of the heart, especially if left ventricular hypertrophy is present and to establish a reference point. Echocardiography is much more sensitive than electrocardiogram or physical examination in determining the existence of cardiac hypertrophy.
Thus, in some situations, this method may be added to the basic assessment of the hypertensive patient, especially since left ventricular hypertrophy is an independent cardiovascular risk factor and its presence suggests the need for sustained antihypertensive treatment.
In addition, while a substantial increase in blood pressure is often accompanied by the presence of left ventricular hypertrophy, an average increase may not be associated with it. Therefore, the absolute value of blood pressure cannot be used as a substitute marker for the presence or absence of left ventricular hypertrophy.
On the other hand, due to the cost of cardiac ultrasound and uncertainty that the information obtained will alter the therapy, it is not clear whether routine echocardiographic monitoring during treatment is justified. Chest X-rays may also be useful for identifying dilation or elongation of the aorta, as well as costal erosions occurring in the coarctation of the aorta.
Ready for today and, for now, with high blood pressure.
Lots of health and joy!
Dorin, Merticaru