medical topic for help medical student

1. Hypertension
Ahmed jasim jabbar
Wasit university college of medicine
Iraq

2. Definition : defined as systolic BP > 140 mmhg and / or diastolic BP > 90 mmhg on three
separate occasions .
Malignant hypertension : is defined as BP ≥ 200 / 130 mmhg .

3. Types of Hypertension
Primary ( essential or idiopathic ) secondary
95 % 5%
- Alcohol .
- Obesity .
- Renal : Polycystic kidney disease,
glomerulonephritis , Renal artery stenosis , chronic
pyelonephritis .
- Endocrine : Phaeochromocytoma, Cushing’s
syndrome conn’s syndrome , Acromegaly ,
Hyperparathyroidism Primary hypothyroidism ,
Thyrotoxicosis .
- Coarctation of the aorta
- Pregnancy (pre-eclampsia)
- Drugs : Oral contraceptives containing oestrogens,
anabolic steroids, corticosteroids, NSAIDs,
carbenoxolone, sympathomimetic agents

4. How to measure blood pressure

5. History
. Family history
. lifestyle (exercise, salt intake, smoking habit).
. identify those patients with drug- or alcohol-induced hypertension .
. phaeochromocytoma (paroxysmal headache, palpitation and sweating )
. blurred vision .
. Headache , seizures , dizziness.
. nausea , vomiting .
. epistaxis.
. tinnitus .

6. Examination
. Radio-femoral delay (coarctation of the aorta ) .
. enlarged kidneys (polycystic kidney disease), abdominal bruits (renal
artery stenosis).
.Cushing’s syndrome : moon face , buffalo hump .
. central obesity
. Hyperlipidaemia (tendon xanthomas ) .
. Non-specific findings may include left ventricular hypertrophy (apical
heave), accentuation of the aortic component of the second heart sound,
and a fourth heart sound.
. evidence of generalized atheroma or specific complications, such as
aortic aneurysm or peripheral vascular disease.

8. investigation

9. Target Organs
Effects On cardiovascular system
- Ventricular hypertrophy, dysfunction and failure.
- Arrhithymias .
- Coronary artery disease, Acute MI
- Arterial aneurysm, dissection, and rupture.

10. Effects on The Kidneys
- Proteinuria .
- Glomerular sclerosis .
- progressive renal failure by damaging the renal vasculature.
Effects on Nervous System
- Stroke .
- intracerebral and subaracnoid hemorrhage.
- Cerebral atrophy and dementia .

11. Effects on The eye
- Retinopathy, retinal hemorrhages and impaired vision.
- Vitreous hemorrhage, retinal detachment .
- Neuropathy of the nerves leading to extraoccular muscle paralysis and
dysfunction .
Keith- wagner classification of retinopathy :
Stage ( 1 ) : silver wiring .
Stage ( 2 ) : as above , plus arteriovenous nipping .
Stage ( 3 ) : as above , plus flame hemorrhages and cotton wool exudates .
Stage ( 4 ) : as above , plus papilloedema .

12. Stage ( 1 ) : silver wiring

13. Stage ( 2 ) : arteriovenous nipping

14. Stage ( 2 ) : arteriovenous nipping

15. Stage ( 3 ) : Hemorrhages (H), Cotton Wool Spots and Exudats (E)
H

16. Stage ( 4 ) : Stage 3 + Papilledema

17. beetroot juice
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18. Non- pharmacological therapy
- Restricting salt intake .
- Correcting obesity .
- reducing alcohol intake .
- Stop smoking .
- taking regular physical exercise .
- increasing consumption of fruit and
vegetables and low in saturated fat .

19. Pharmacological treatment
Thiazide and other diuretics
1- recommended first line , especially in > 55 years olds or black patients .
2- bendroflumethiazide 2.5 mg daily
cyclopenthiazide 0.5 mg daily
loop diuretics such as :
furosemide (40 mg daily) , bumetanide (1 mg daily)
3- Lasix :Furosemide treats fluid retention (edema) in people with congestive heart
failure, liver disease, or a kidney disorder such as nephrotic syndrome .
- It is type c , Furosemide can pass into breast milk and may harm a nursing baby.
This medication may also slow breast milk production.
-side effect : hearing loss , itching, dark urine , clay-colored stools , nausea and
vomiting , chest pain , stomach pain , headache .

21. ACE inhibitors
enalapril 20 mg daily
ramipril 5–10 mg daily
lisinopril 10–40 mg daily
-inhibit the conversion of angiotensin I to angiotensin II .
-They should be used with particular care in patients with impaired renal
function or renal artery stenosis because they can reduce the filtration
pressure in the glomeruli and precipitate renal failure
- Electrolytes and creatinine should
be checked before and 1–2 weeks after commencing
therapy
- Side-effects include first-dose hypotension, cough, rash,
hyperkalaemia and renal dysfunction.

22. Angiotensin receptor blockers
irbesartan 150–300 mg daily
valsartan 40–160 mg daily
- block the angiotensin type II receptor
and have similar effects to ACE inhibitors.
- they do not cause cough .

23. Calcium channel antagonists
amlodipine 5–10 mg daily
nifedipine 30–90 mg daily
- Recommended first line , especially in > 60 year olds or
black patients .
- Calcium channel blockers prevent calcium from
entering cells of the heart and blood vessel walls,
resulting in lower blood pressure. Calcium channel
blockers, also called calcium antagonists, relax and
widen blood vessels by affecting the muscle cells in
the arterial walls.
-Side-effects include flushing, palpitations and fluid
Retention .
The main side effect of verapamil is constipation.

24. Beta-blockers
atenolol (50–100 mg daily)
Bisoprolol (5–10 mg daily)
Metoprolol (100–200 mg daily)
- Lower myocardial oxygen demand by reducing heart
rate , blood pressure , and myocardial contractitity .
- Beta-blockers should not be withdrawn abruptly as
rebound effects may precipitate dangerous
arrhythmias, worsening angina or MI: the β-blocker
withdrawal syndrome.
- Side effect : bronchospasm ( asthma ) , depression ,
impotence , bradycardia .
- Avoid : heart failure ( pulmonary edema) , systolic BP
< 105 mmhg , heart rate < 65 / min .

25. Labetalol and carvedilol
Labetalol (200 mg–2.4 g daily in divided doses)
and carvedilol (6.25–25 mg twice daily) are
combined β- and α-adrenoceptor antagonist
which are sometimes more effective than pure β-
blockers Labetalol can be used as an infusion in
malignant phase hypertension .

26. Hypertension crisis
Haematuria
Protenuria
Renal failure
AMI , chest pain ( angina ) ,
heart failure
Retinopathy
Encephalopathy
Headache
Irritability
Altered mental status
Dissecting aortic
aneurysm
diastolic ≥130 mmhg

27. Treatment
The aim is to decrease the elevated blood pressure by 25% within 1 hour to protect from end organ
damage Avoid fast lowering of blood pressure as it may precipitate occipital blindness, and precipitate
coronary or renal insufficiency.
1- intravenous sodium nitroprusside (0.3–1.0 μg/kg body weight/min) .
2- Intravenous or intramuscular labetalol (2 mg/min to a maximum of 200 mg) .
3-intravenous glyceryl trinitrate (0.6–1.2 mg/hr) .
4- intramuscular hydralazine (5 or 10 mg aliquots repeated at halfhourly intervals)