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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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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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
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Complete Diagnosis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Underlying Anatomic Abnormalities Causing Heart Failure

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

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

High Output Failure

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.[2] 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.[3]

Differential Diagnosis of the Underlying Causes of Chronic Heart Failure

Common Causes of Left Sided Heart Failure

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:[4]

  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
Dilated Cardiomyopathies
Inflammatory Cardiomyopathies

Congestive Heart Failure as a Consequence of Valvular Heart Disease

Congestive Hert Failure Secondary to Congenital Heart Disease

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

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

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
  6. 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:

Expanded List of Causes:

Right Ventricular Failure

Most Common Causes:

Other Causes:

Others

  1. ↑ Template:DorlandsDict
  2. ↑ Fonarow GC, Abraham WT, Albert NM; et al. (2008). "Factors Identified as Precipitating Hospital Admissions for Heart Failure and Clinical Outcomes: Findings From OPTIMIZE-HF". Arch. Intern. Med. 168 (8): 847–854. doi:10.1001/archinte.168.8.847. PMID 18443260. Unknown parameter |month= ignored (help)
  3. ↑ Nieminen MS, Böhm M, Cowie MR; et al. (2005). "Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology". Eur. Heart J. 26 (4): 384–416. doi:10.1093/eurheartj/ehi044. PMID 15681577. Unknown parameter |month= ignored (help)
  4. ↑ He J; Ogden LG; Bazzano LA; Vupputuri S; et al. (2001). "Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study". Arch. Intern. Med. 161 (7): 996–1002. doi:10.1001/archinte.161.7.996. PMID 11295963.
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