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Clinicopathological conference: hypertension. TAKE HOME MESSAGES. HBP is common and usually symptomatic. Vast majority of cases are primary. Treatment is to reduce stroke (and IHD) risk. Most patients don’t take their medicines. See http://www.hyp.ac.uk/bhs/gl2000.htm. The case.

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clinicopathological conference hypertension take home messages
Clinicopathological conference: hypertension.TAKE HOME MESSAGES
  • HBP is common and usually symptomatic.
  • Vast majority of cases are primary.
  • Treatment is to reduce stroke (and IHD) risk.
  • Most patients don’t take their medicines.
  • See http://www.hyp.ac.uk/bhs/gl2000.htm
the case
The case.
  • A 45 year old man referred for investigation.
  • GP has started a screening programme for hypertension:
    • 200/100 in December
    • 190/96 in January
    • 190/102 in March
  • Asymptomatic
what symptoms did you expect1
What symptoms did you expect?
  • Usually none.
  • Relationship to headache dubious.
  • (Causes of HBP)
  • (Results of HBP)
family history1
Family history
  • Father died of stroke aged 55
  • Mother has had 2 x MI
  • Elder brother has NIDDM
social history1
Social history
  • Unemployed ex car-worker
  • Married with kids at home
  • Smokes 20 per day
  • Drinks ‘a couple of pints per day’.
  • Likes salt
  • No medications
  • No known allergies.
review of systems causes of hbp1
Review of systems: causes of HBP?
  • Urinary
    • Dysuria?
    • Nocturia?
    • Poor stream?
  • (Flushing)
  • (Polydypsia)
review of systems consequences of hbp1
Review of systems: consequences of HBP?
  • Chest pain? (Angina)
  • Dyspnoea/orthopnoea (LVF)
  • Transient neurological syndromes
    • amaurosis fugax
    • transient hemiparesis
    • perturbation of consciousness
review of systems conditions relevant to drugs1
Review of systems: conditions relevant to drugs
  • Airways obstruction: beta blockers
  • Local urinary problems (prostate in men, stress incontinence in women): loop diuretics.
examination1
Examination?
  • The BP today.
  • Consequences of hypertension
  • Other causes of atheroma
  • Causes of hypertension

His BP is 190/100.

consequences
Consequences.
  • Apex beat.
  • Heart sounds.
  • Fundi.
  • (Signs of heart failure)

CLINICAL PICTURES:

fundi

other causes of atheroma1
Other causes of atheroma.
  • Hyperliproteinaemias:
    • Xanthomata
    • Xanthalesmata
    • Corneal arcus

CLINICAL PICTURES:

xanthalesmata etc.

causes 1
Causes #1
  • Endocrine
    • Phaeochromocytoma
    • Cushings
    • Acromegaly
    • Conn’s
  • Metabolic
    • Hypercalcaemia

CLINICAL PICTURES

causes 2
Causes #2
  • Vascular
    • coarctation of the aorta
    • renal artery stenosis
  • Renal
    • polycystic kidneys
    • features of chronic renal failure
    • features of nephrotic syndrome
the case1
The case
  • Nil on REVIEW OF SYSTEMS
  • Nil on EXAMINATION (save a wheezy chest)
what tests do you want
What tests do you want?
  • Urinary
  • Blood
  • Imaging
  • ‘Special’
what tests do you want urine tests
What tests do you want?Urine tests.
  • Dipstick urinalysis
    • Blood and protein: could be a clue to renal pathology
    • Sugar: may be a clue to diabetes mellitus
  • MSSU
    • look for WHITE CELLS as well as organism growth

All normal

what tests do you want blood tests
What tests do you want?Blood tests

Assess renal function: urea and creatinine.

(Assess calcium).

(Assess potassium).

All normal

Fasting blood sugar

Fasting lipids

Cholesterol = 7.2 mmol/L

imaging what do you want to know1
Imaging: what do you want to know?
  • CXR may help you decide about cardiomegaly (but many radiologists think this unnecessary).
  • CXR will allow assessment of his COAD, and will exclude unsuspected cancer.
  • (CXR may pick up coarctation).
imaging what do you want to know2
Imaging: what do you want to know?
  • Renal ultrasound scan
    • helps exclude polycystic disease, RAS and hydronephrosis.
    • But, unless the biochemistry is abnormal, renal U/S is often not needed.

R = 13 cm and L = 9 cm. ?RAS. WHAT NEXT?

renal isotope scan with captopril challenge
Renal isotope scan with captopril challenge
  • Isotope is injected IV and excreted.
  • Scanning allows the rate and extent of excretion of isotope to be determined for each kidney
  • Captopril would reduce perfusion in a kidney with RAS

Our patient’s scan is normal. But, had it shown RAS, what next?

summary so far
Summary so far.
  • Young smoker with + FH.
  • GP has already established sustained HBP.
  • Tests show mild  cholesterol.
  • Life style
  • Drugs
life style
Life style
  • Stop smoking
  • Reduce saturated fat, alcohol, salt.
  • Increase oily fish and vegetables.
  • Exercise.
choice of drug
Choice of drug
  • Little evidence of differences in efficacy
  • Patient needs to understand the aims of treatment…
  • …And the risks.
  • Aim for as few drugs as possible…
  • ...At as low a dose as possible.
thiazides
Thiazides
  • Bendrofluazide
  • Inexpensive, effective.
  • Increase cholesterol and sugar
  • May precipitate gout
  • May cause impotence
ace inhibitor
ACE-inhibitor
  • Captopril, enalapril, ramipril, lisinopril
  • Effective but more expensive.
  • Well tolerated.
  • Contraindicated in the presence of bilateral RAS (rapid worsening of renal function).
calcium channel antagonist
Calcium channel antagonist.
  • Nifedipine, verapamil, nicardipine, diltiazem
  • Effective, more expensive than thiazide.
  • Lots of symptomatic toxicity:
    • constipation
    • flushing
    • ankle swelling
    • (gum hypertrophy)
beta blocker
Beta blocker
  • Atenolol
  • Effective and inexpensive.
  • Contraindicated in:
    • airways obstruction
    • PVD
    • Bradyarrhythmias
    • (Heart failure)
  • Symptomatic adverse effects.
the case2
The case
  • BP remained high on two further outpatient visits.
  • Cholesterol was unaffected by diet (did he stick to it?)
  •  enalapril and simvastatin September 1998.
follow up
Follow up
  • October 1998: still no lifestyle change. BP = 180/100.
  • February 1999: cholesterol now 5.0. Enalapril dose now maximal. BP 170/100.
  • April 1999: BP 160/96. Add thiazide.
  • June 1999: BP 140/92. Cholesterol 6.2. Simvastatin dose increased.
emergency admission july 1999
Emergency admission July 1999
  • 2 hours of tight retrosternal pain associated with:
    • sweating
    • dyspnoea
    • nausea
  • Pale, BP = 110/50. Fine basal crackles.

What diagnosis? What tests?

Briefly, what management?

tests and management
Tests and management.
  • ECG looking for ST segment changes.
  • Troponin-T
  • Chest radiograph.
  • Diamorphine
  • FOLLOW PROTOCOL for streptokinase
  • Monitor
  • Aspirin
further follow up
Further follow up
  • September 1999: no change in lifestyle. 160/94, cholesterol 5.5.
  • November 1999 2 episodes sudden loss vision L eye. Carotid bruit noted.
  • Diagnosis and investigations?
tests
Tests
  • Carotid Doppler studies: 80% occlusion of L carotid artery.
  • Referred for vascular surgery opinion.
  • Continued on aspirin
emergency admission 01 01 01
Emergency admission 01.01.01
  • Sudden onset R hemiparesis.
  • Severe dysphasia
  • Unsafe swallowing
  • Deterioration to GCS 7/15
  • CT shows a large haematoma on L
  • Cardiac arrest.