Sandbox/22

Hypertension

Suspected hypertension BP > 140/90 mmHg

Blood pressure measurement Before taking the BP ❑ Sit patient quietly in a chair for 5 mins ❑ Avoid caffeine, exercise, smoking at least 30 mins ❑ Ensure appropriate cuff size ❑ Take 2 readings and find the average ❑ Take repeated measurements in patients with arrhythmia ❑ Measure BP at both arms at first visit to detect possible differences ❑ Out-of-office BP Click here for more information regarding blood pressure measurement

Confirmed hypertension

Normotensive

Classify the patient based on the BP reading

White-coat hypertension

SBP 120-139 mmHg DBP - 80-89 mmHg

SBP 149-159 mmHg DBP 90-99 mmHg

SBP >160 mmHg DBP >110 mmHg

Prehypertension

Stage 1 hypertension Proceed to complete diagnostic approach

Stage 2 hypertension Proceed to hypertensive crisis resident survival guide

{{{ }}}

Treatment Lifestyle modification ❑ Weight reduction ❑ Maintain a waist circumference of <40 inches (102cm) for men <35 inches (88cm) for women BMI of ≤25 kg/m2 ❑ Adopt healthy diet ❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins) ❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl) ❑ Limit alcohol consumption ❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky ❑ ≤ 1 drink/day for women ❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day ❑ Patient education ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Complete Diagnostic Approach

Obtain a detailed history: History of present hypertension ❑ Time of first diagnosis ❑ Current and past BP measurements ❑ Current and past antihypertensive medications Identify secondary causes of hypertension: Family history ❑ Chronic kidney disease (suggestive of polycystic kidney disease) ❑ Premature CVD or HTN History of renal disease: ❑ Hematuria ❑ UTI ❑ Analgesic abuse (suggestive of renal parenchymal disease) ❑ Flank pain Medication/substance abuse ❑ Amphetamines ❑ Cocaine ❑ Cyclosporine ❑ Erythropoietin ❑ Liquorice ❑ NSAIDs ❑ Oral contraceptive pills ❑ Steroids History suggestive of pheochromocytoma ❑ Recurrent episodes of sweating, palpitation and hypertension History suggestive of hyperaldosteronism ❑ Muscle weakness and tetany History suggestive of thyroid disease History to assess risk factors ❑ Personal and family history of: ❑ HTN and CVD ❑ Dyslipidemia ❑ Diabetes mellitus ❑ Excessive sodium intake >2.4g per day ❑ Tobacco usage ❑ Obesity ❑ Alcoholism >1.5 drinks/day ❑ Metabolic syndrome ❑ Physical inactivity ❑ Sleep apnea History to assess presence of organ damage/complications ❑ CNS: ❑ Headache ❑ Vertigo ❑ Transient ischemic attack ❑ Stroke ❑ Eyes: ❑ Loss or blurring of vision ❑ Cardiovascular: ❑ History of MI or syncope ❑ Chest pain ❑ Shortness of breath ❑ Pedal edema ❑ Palpitation ❑ Arrhythmia ❑ Pedal edema ❑ Sexual function ❑ Kidneys: ❑ Polyuria ❑ Hematuria ❑ Proteinuria

Examine the patient: General examination: ❑ Calculate BMI ❑ Moon face, truncal obesity, striae (suggestive of cushing disease) ❑ Goitre, exophthalmus, pretibial myxedema (suggestive of graves disease) ❑ Dry skin (suggestive of hypothyroidism) Eyes ❑ Fundoscopy to diagnose retinopathy ❑ Hemorrrhage ❑ Papilledema ❑ Cotton wool spots Neck ❑ Carotid bruits (suggestive of ) ❑ Thyroid gland enlargement (suggestive of hyperthyroidism) Cardiovascular examination ❑ Evidence of long-standing hypertension: ❑ Cardiomegaly ❑ Displaced apex beat (suggestive of enlarged left ventricle) Respiratory examination ❑ Crackles/crepitations/rales Abdominal examination ❑ Bruits over abdominal aorta (suggestive of aortic aneurysm) ❑ Bruits over renal artery (suggestive of renal artery stenosis) ❑ Extremity examination ❑ Absent or diminished femoral pulsation (suggestive of coarctation of aorta) ❑ Bruits over renal artery (suggestive of renal artery stenosis)Hepatomegaly ❑ Pedal edema (suggestive of congestive heart failure) ❑ Delayed return of deep tendon reflexes (suggestive of hypothyroidism) Neurological examination ❑ Findings suggestive of hypertensive encephalopathy ❑ Confusion ❑ Coma ❑ Altered mental status

Order tests: Routine ❑ CBC (rule out anemia) ❑ ❑ ❑ ❑ Electrolytes ❑ ❑ Serum calcium ❑ Serum magnesium ❑ BUN, creatinine ❑ Urinalysis ❑ Fasting blood sugar ❑ Fasting lipid profile ❑ Liver function tests ❑ TSH ❑ Chest X-ray ❑ Cardiomegaly (cardiothoracic ratio >50%) ❑ EKG ❑ 2-D echocardiography with Doppler Additional tests to diagnose specific etiologies: ❑ ANA, rheumatoid factor (for rheumatologic diseases) ❑ Diagnostic tests for hemochromatosis, pheochromocytoma ❑

Does this patient have an identifiable secondary etiology?

Yes

No

Primary hypertension

Secondary hypertension

Proceed to treatment

Underlying Anatomic Abnormalities Causing Heart Failure

Heart failure may result from an abnormality of any one of the anatomical structures of the heart:

• Disorders of the great vessels (e.g. pulmonary hypertension)
• Endocardium
• Myocardium
• Pericardium
• Valvular heart disease or

Systolic versus Diastolic Heart Failure

Patients may be broadly classified as having heart failure with depressed contractility or depressed relaxation

Systolic Dysfunction

The left ventricular ejection fraction is reduced in systolic dysfunction and there is depressed contractility of the heart.

Disastolic Dysfunciton

The left ventricular ejection fraction is preserved in diastolic dysfunction and there is an abnormality in myocardial relaxation or excessive myocardial stiffness. Systolic and diastolic dysfunction commonly occur in conjunction with each other.

Left, Right and Biventricular Failure

Another common method of classifying heart failure is based upon the ventricle involved (left sided versus right sided).

Left Heart Failure

• There is impaired left ventricular function with reduced flow into the aorta.

Right Heart Failure

• There is impaired right ventricular function with reduced flow into the pulmonary artery and lungs.

Biventricular Failure

• The most common cause of right heart failure is left heart failure, and mixed presentations are common, especially when the cardiac septum is involved.

High Output Versus Low Output Failure

Low Output Failure

• The cardiac output is reduced, and the systemic vascular resistance (SVR) is high. In low output failure, there is an inadequate supply of blood flow to meet normal metabolic demands.

High Output Failure

• The cardiac output is increased, and the systemic vascular resistance (SVR) is low. Rather than an inadequate supply of blood flow to meet normal metabolic demands as occurs in low output failure, in high output failure there is an excess requirement for oxygen and nutrients and the demand outstrips what the heart can provide. Causes of high output heart failure include severe anemia, Gram negative septicaemia, beriberi (vitamin B₁/thiamine deficiency), thyrotoxicosis, Paget's disease, arteriovenous fistulae, or arteriovenous malformations.

Causes of Acute or Decompensated Heart Failure

Chronic stable heart failure may easily decompensate. This most commonly results from an intercurrent illness (such as pneumonia), myocardial infarction (a heart attack), arrhythmias, uncontrolled hypertension, or a patient's failure to maintain a fluid restriction, diet, or medication. Other well recognized precipitating factors include anemia and hyperthyroidism which place additional strain on the heart muscle. Excessive fluid or salt intake, and medication that causes fluid retention such as NSAIDs and thiazolidinediones, may also precipitate decompensation.

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Common Causes of Left Sided Heart Failure

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

A 19 year study of 13,000 healthy adults in the United States (the National Health and Nutrition Examination Survey (NHANES I) found the following causes ranked by Population Attributable Risk score:

1. Ischaemic heart disease 62%
2. Cigarette smoking 16%
3. Hypertension (high blood pressure)10%
4. Obesity 8%
5. Diabetes 3%
6. Valvular heart disease 2% (much higher in older populations)

Cardiomyopathies and Inflammatory Diseases

Restrictive Cardiomyopathies

• Alcohol-Induced cardiomyopathy
• Amyloidosis
• Anthracycline induced cardiomyopathy
• Anthracyclines
• Arrhythmogenic right ventricular dysplasia
• Becker's muscular dystrophy
• Cardiac transplant
• Cocaine related cardiomyopathy
• Diabetic cardiomyopathy
• Endocardial fibrosis
• Eosinophilic heart disease
• Hemochromatosis
• Primary (idiopathic)
• Kearns-Sayre syndrome
• Radiation therapy
• Sarcoidosis
• Storage diseases
• Tumor infiltration

Dilated Cardiomyopathies

• Duchenne muscular dystrophy
• Chagas' disease
• Limb-girdle muscular dystrophy
• Mitochondrial myopathy
• Peripartum cardiomyopathy
• Trastuzumab Herceptin-lnduced Cardiomyopathy

Inflammatory Cardiomyopathies

• Bacterial Myocarditis
• Fungal myocarditis
• Giant Cell Myocarditis
• Protozoal Myocarditis: Trypanosomiasis (Chagas Disease)
• Rickettsial Myocarditis
• Sarcoidosis
• Spirochetal Infections
• Viral Myocarditis

Congestive Heart Failure as a Consequence of Valvular Heart Disease

• Acute aortic regurgitation
• Acute mitral regurgitation
• Aortic stenosis with Left Ventricular Systolic Dysfunction
• Chronic aortic regurgitation
• Chronic mitral regurgitation
• Mitral Stenosis

Congestive Hert Failure Secondary to Congenital Heart Disease

A. Causes of Congestive Heart Failure in Adults with Unoperated Congenital Heart Diseases

• Arrhythmia
• Atrial septal defect with mitral regurgitation] secondary to myxomatous mitral valve
• Congenital mitral regurgitation
• Drug abuse, alcohol abuse
• Eisenmenger's syndrome
• Endocarditis
• Fibrocalcific degeneration of abnormal aortic valve
• Pregnancy
• Systemic ventricular dysfunction and/or tricuspid regurgitation in congenitally corrected transposition of the great arteries
• Other degenerative diseases (coronary artery disease, hypertension)

B. Causes of Congestive Heart Failure in Adults with Operated Congenital Heart Diseases

• Arrhythmia
• Endocarditis
• Myocardial dysfunction
• Persistent left-to-right shunt
• Prosthetic valve dysfunction
• Pulmonary vascular disease
• Status post Fontan operation
• Valvular regurgitation
• Other degenerative diseases (coronary artery disease, hypertension)

Right Ventricular Failure

Factors affected right ventricle and to be eliminated during management of congestive heart failure. A. Right ventricular myocardial dysfunction

1. Right ventricular myocardial infarction
2. Dilated cardiomyopathy
3. Right ventricular dysplasia

B. Primary right ventricular pressure overload

1. Left ventricular failure
2. Mitral valve disease
3. Atrial myxoma
4. Pulmonary veno-occlusive disease
5. Cor pulmonale

   • Chronic obstructive pulmonary disease
   • Primary pulmonary hypertension
   • Pulmonary embolism

6. Pulmonic stenosis

   • Supravalvular pulmonic stenosis
   • Valvular pulmonic stenosis
   • Subvalvular pulmonic stenosis

7. Ventricular septal defect
8. Aortopulmonary communication

C. Primary right ventricular volume overload

1. Pulmonic regurgitation
2. Tricuspid regurgitation
3. Atrial septal defect
4. Partial anomalous pulmonary venous return

D. Impediment to right ventricular inflow

1. Tricuspid stenosis
2. Cardiac tamponade
3. Constrictive pericarditis
4. Restrictive cardiomyopathy

Differential Diagnosis of Causes of Heart Failure Segregated by Left and Right Sided Heart Failure

Left Ventricular Failure

Most Common Causes:

• Aortic regurgitation
• Aortic stenosis
• Hypertension
• Mitral regurgitation
• Myocardial ischemia

Expanded List of Causes:

• Atrial fibrillation
• Alcoholism
• Anemia
• Angina
• Aortic regurgitation
• Aortic Stenosis
• Arteriovenous fistula
• Beriberi
• Cardiac aneurysm
• Cardiomyopathy
• Constrictive pericarditis
• Drugs, toxins
• Hypertension
• Hyperthyroidism
• Hypovolemia
• Hypoxia
• Mediastinal tumors
• Mitral Regurgitation
• Myocardial Infarction
• Paget's Disease
• Pancoast's Tumor
• Pericardial effusion
• Pericardial tamponade
• Perimyocarditis
• Protein deficiency
• Restrictive cardiomyopathy
• Rupture of the papillary muscles
• Sepsis
• Superior Vena Cava thrombosis

Right Ventricular Failure

Most Common Causes:

• Cardiomyopathy
• Cor pulmonale
• Diffuse myocarditis
• Left heart failure

Other Causes:

• After left ventricular failure
• After pulmonary resection
• Allergic alveolitis
• Bronchial asthma
• Chronic bronchitis
• Honeycomb lung
• Hyperglobulia
• Emphysema
• Mitral Stenosis
• Right ventricular myocardial infarction
• Pickwickian Syndrome
• Pleural fibrosis
• Pneumoconiosis
• Pulmonary fibrosis
• Pulmonic regurgitation
• Pulmonic stenosis
• Sarcoidosis
• Severe relapsing pulmonary emboli
• Silicosis
• Tachycardia
• Tricuspid insufficiency

Others

• Ascorbic acid deficiency
• Cardiac amyloidosis
• Carnitine deficiency
• Cervical vein stasis of non-cardiac genesis
• Congenital heart disease
• Cyanosis of non-cardiac genesis
• Diabetes Mellitus
• Dyspnea of non-cardiac genesis
• Edema of non-cardiac genesis
• Hemochromatosis
• Pleural effusion of non-cardiac genesis
• Pulmonary edema of non-cardiac genesis
• Thiamine deficiency
• Thyroid disease