Target Organ Damage Joel Niznick MD FRCPC Continuing

Target Organ Damage Joel Niznick MD FRCPC © Continuing Medical Implementation …. . . bridging the care gap

Diseases Attributable to Hypertension Stroke Coronary heart disease Heart failure Cerebral hemorrhage Myocardial infarction Left ventricular hypertrophy Hypertension Chronic kidney failure Aortic aneurysm Retinopathy Peripheral vascular disease © Continuing Medical Implementation Adapted from: Arch Intern Med 1996; 156: 1926 -1935. Hypertensive encephalopathy All Vascular …. . . bridging the care gap

Initial Assessment • OVERALL CARDIOVASCULAR RISK – – – Framingham Procam SCORE System Risk factor counting Type 2 diabetes • TARGET ORGAN DAMAGE – Physical exam – Diagnostic testing © Continuing Medical Implementation • RULE OUT SECONDARY AND OFTEN CURABLE CAUSES – – Renal artery stenosis Hyperaldosteronism Pheochromocytoma Coarctation of aorta …. . . bridging the care gap

Components of Risk Stratification Target Organ Damage/Clinical Cardiovascular Disease should be assessed by history and physical examination Brain Heart Eyes Kidneys Arteries © Continuing Medical Implementation …. . . bridging the care gap

Important Aspects of the Physical Examination in the Hypertensive Patient • Accurate measurement of blood pressure • General appearance: distribution of body fat, skin lesions, muscle strength, alertness • Fundoscopy • Neck: palpation and auscultation of carotids, thyroid • Heart: size, rhythm, sounds • Lungs: rhonchi, rales • Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses • Extremities: peripheral pulses, edema • Neurologic assessment © Continuing Medical Implementation …. . . bridging the care gap

Hypertensive Retinopathy Grade 2 Arteriovenous nicking in association with hypertension Grade 2 (yellow arrow) © Continuing Medical Implementation …. . . bridging the care gap

Hypertensive Retinopathy Grade 3 • Flame-shaped hemorrhage in association with severe hypertension Grade 3 (yellow arrow) © Continuing Medical Implementation …. . . bridging the care gap

Hypertensive Retinopathy Grade 4 • Papilledema from malignant hypertension. There is blurring of the borders of the optic disk with hemorrhages (yellow arrows) and exudates (white arrow) © Continuing Medical Implementation …. . . bridging the care gap

Clinical Signs of LV Dysfunction • Hypotension • Pulsus alternans • Reduced volume carotid • LV apical enlargement/displace ment • Sustained apex - to S 2 © Continuing Medical Implementation • Soft S 1 • Paradoxically split S 2 • S 3 gallop (not S 4 = impaired LV compliance) • Mitral regurgitation • Pulmonary congestion – rales …. . . bridging the care gap

CHS Recommendations Routine Laboratory Investigations Routine laboratory tests for the investigation of all patients with hypertension: 1. Urinalysis 2. Complete blood cell count 3. Blood chemistry (potassium, sodium and creatinine) 4. Fasting glucose 5. Fasting total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides 6. Standard 12 ECG © Continuing Medical Implementation …. . . bridging the care gap

What are the indications for checking the BP in both arms? • The presence of both arms – R/O • • Atherosclerotic obstruction Scalenus anticus syndrome/cervical rib Aortic coarctation above left subclavian Anomalous origin right subclavian artery in aortic coarctation © Continuing Medical Implementation …. . . bridging the care gap

What are the indications for checking BP in the lower extremities? – Hypertensive patient under 40 years of age. – Elderly patient with suspected PVD How do you do it? – Thigh cuff-auscultate over popliteal artery – Large arm cuff around calf (bladder posterior) palpate PT or DP Which is normally higher- arm or leg BP? © Continuing Medical Implementation …. . . bridging the care gap

Ankle-brachial index • Resting and post exercise SBP in ankle and arm. – Normal ABI > 1 – ABI <. 9 has 95% sensitivity for angiographic PVD – ABI 0. 5 - 0. 84 correlates with claudication – ABI < 0. 5 indicates advanced ischaemia © Continuing Medical Implementation …. . . bridging the care gap

A 60 year old man with HTN © Continuing Medical Implementation …. . . bridging the care gap

An 84 year old woman with hypertension © Continuing Medical Implementation …. . . bridging the care gap

MAU as a Predictor of Morbidity and Mortality Retinopathy Diabetes + MAU LVH All-cause mortality Nephropathy Non-fatal cardiovascular disease Peripheral/autonom ic neuropathy Parving HH. J Hypertens 1996; 14 Suppl 2: S 89 S 94. © Continuing Medical Implementation …. . . bridging the care gap

Definitions of abnormalities in albumin excretion Category Normal Microalbuminuria Clinical albuminuria 24 hour collection Timed collection (mg/24 h) ( g/min) Spot collection ( g/mg Cr) < 30 < 20 < 30 30 -299 20 -199 30 -299 300 200 300 Because of variability in urinary albumin excretion, 2 of 3 specimens over 3 -6 should be abnormal before considering diagnostic threshold positive False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria. © Continuing Medical Implementation …. . . bridging the care gap

Relative Importance of MAU 10. 02 10 8 6. 52 6 Odds Ratio 4 3. 20 2. 32 2 0 Microalbuminuria Smoking Hypertension Cholesterol Eastman RC, Keen H. Lancet 1997; 350 Suppl 1: 29 -32. © Continuing Medical Implementation …. . . bridging the care gap

Course of Diabetic Nephropathy Renal failure 2 year survival 50% 1000 ALB Proteinuria (µg/min) Stabilization possible 300 MAU Reversible 30 7 -15 Adapted by D. Studney 10 -30 Years of Diabetes Mellitus © Continuing Medical Implementation …. . . bridging the care gap