End organ damages of hypertension 2

Weekly Seminar presentation on 21/03/18

1. Clinical F eatures of End O rgan C omplications of Hypertension Dr. Chinedu Ibeh(MBBS; MPH; MWACP)

2. Outline Introduction Hypertensive Cerebrovascular diseases Hypertensive Encephalopathy Cerebrovascular Accidents Ischaemic CVA Haemorrhagic CVA Hypertensive Eye Disease Retinopathy Hypertensive Heart Diseases Left Ventricular Hypertrophy Coronary Artery Disease Cardiac Arrhythmias and Congestive Heart Failure Hypertensive Kidney diseases Benign Nephelosclerosis Malignant Nephelosclerosis

3. Introduction Hypertension is a condition in which the blood vessels have persistently raised pressure. 1 Blood pressure is the product cardiac output and systemic vascular resistance. 1 Hypertensive Urgency  is defined as severely elevated BP with no evidence of target organ damage. 2 Hypertensive Emergency is a condition in which elevated blood pressure (BP) results in target organ damage. 2 End Organ damage usually refers to damage to major organs fed by the circulatory system which can sustain damage due uncontrolled hypertension, hypotension or hypovolemia. 5 World Hypertension Day(May 17; 2018 theme: Know your numbers) .

4. American College of Cardiology 2017 Guideline on Categories of BP in Adults. 6 BP Category SBP DBP Normal <120 mmHg and <80 mmHg Elevated 120–129 mm Hg and <80 mmHg Stage 1 130–139 mm Hg or 80–89 mm Hg Stage 2 ≥140 mm Hg or ≥90 mm Hg

5. Pathophysiology of Hypertension Factors that play a role in the pathogenesis of Hypertension: Genetics Activation of neuro -hormonal systems Sympathetic nervous system Renin-angiotensin-aldosterone system Obesity, Increased salt intake Factors involved in short term and long term regulation of BP for adequate tissue perfusion Cardiac output and circulatory blood volume Vascular caliber , elasticity and reactivity Humoral mediation, Neural stimulation .Complications are largely attributed to the remodeling of the arterial wall, including accelerated atherosclerosis

6. Vision Eye Institute. Hypertensive retinopathy 2017 . Available from https :// visioneyeinstitute.com.au/eyematters/hypertensive-retinopathy/ . [accessed on 19/3/18]

7. Hypertensive Cerebrovascular Disease Hypertensive Encephalopathy Cerebrovascular accidents Haemorrhagic CVA Ischaemic CVA

8. Hypertensive Encephalopathy This is a syndrome consisting of a sudden elevation of arterial pressure usually preceded by severe headache and followed by convulsions, coma or a variety of transitory cerebral phenomena. 3 Symptoms may include Headache Vomiting Trouble with balances confusion Onset is generally sudden Complications include Seizures

9. Cerebrovascular Accident(CVA) CVA is a medical name for stroke. A stroke is a sudden death of some brain cells due to lack of oxygen when blood flow to a part of the brain is impaired either by blockage or rupture of a blood vessel. World stroke day: 29/10 Theme: 1/6 of us will suffer a stroke in our lifetime; we all have good reason to prevent stroke.

10. CVA symptoms Muscular:  difficulty walking, paralysis with weak muscles, problems with coordination, stiff muscles, overactive reflexes, or paralysis of one side of the body Whole body:  balance disorder, fatigue, light-headedness, or vertigo Visual:  blurred vision, double vision, sudden visual loss, or temporary loss of vision in one eye Speech:  difficulty speaking, slurred speech, or speech loss Sensory:  pins and needles or reduced sensation of touch Facial:  muscle weakness or numbness Limbs:  numbness or weakness Also common:  difficulty swallowing, headache, inability to understand, mental confusion, or rapid involuntary eye movement

11. Ischaemic CVA Ischemic stroke occurs when an artery to the brain is blocked.  Ischemic stroke can be divided into two main types:  thrombotic  and  embolic . A thrombotic stroke occurs when diseased cerebral arteries become blocked by blood clot within the brain-responsible for almost 50 percent of all strokes.  An embolic stroke is also caused by a clot within an artery outside the brain itself. This results in near-immediate physical and neurological deficits.

12. Clinical features of Ischaemic stroke History Medical history to identify risk factors for atherosclerotic and cardiac disease: Hypertension, Diabetes mellitus, Tobacco use High cholesterol, History of coronary artery disease, coronary artery bypass, or atrial fibrillation In younger patients, elicit a history of the following: Recent trauma, Coagulopathies Illicit drug use (especially cocaine) Migraines, Oral contraceptive use Nausea , vomiting, headache, and a sudden change in the patient’s level of consciousness are more common in hemorrhagic strokes

13. Clinical features of Ischaemic stroke physical examination Hemiparesis , monoparesis , or (rarely) quadriparesis Hemisensory deficits Monocular or binocular visual loss Visual field deficits Diplopia Dysarthria Facial droop Ataxia Vertigo (rarely in isolation) Aphasia Sudden decrease in the level of consciousness No historical feature distinguishes ischemic from hemorrhagic stroke , .

14. Clinical features of Ischaemic stroke physical examination contd Cranial nerves Motor function Sensory function Cerebellar function Gait Language (expressive and receptive capabilities) Mental status and level of consciousness

15. Hemorrhagic stroke A hemorrhagic stroke is either a brain aneurysm burst or a weakened blood vessel leak. Blood spills into or around the brain and creates swelling and pressure, damaging cells and tissue in the brain. There are two types of hemorrhagic stroke called intracerebal and subarachnoid.

16. Hemorrhagic stroke Intracerebral B lood vessel inside the brain ruptures and leaks blood into surrounding brain tissue. High blood pressure and aging blood vessels are the most common causes of this type of stroke. Sometimes intracerebral hemorrhagic stroke can be caused by an arteriovenous malformation (AVM).

17. Hemorrhagic stroke Subarachnoid This type of stroke involves bleeding in the area between the arachnoid membrane and the pia mater known as th e subarachnoid space. This type of stroke is most often caused by a burst aneurysm. Other causes include: Artero -Venous Malformation Bleeding disorders Head injury Blood thinners

18. Clinical features of Hemorrhagic stroke 1 Generalized symptoms, including nausea, vomiting, and headache, as well as an altered level of consciousness, may indicate increased intracranial pressure and are more common with hemorrhagic strokes and large ischemic strokes. Seizures are more common occurring in 28% of hemorrhagic stroke generally at the onset of the intracerebral hemorrhage or within the first 24 hours..

19. Clinical features of Hemorrhagic stroke 2 Focal symptoms of stroke include the following: Weakness or paresis that may affect a single extremity, one half of the body, or all 4 extremities Facial droop Monocular or binocular blindness Blurred vision or visual field deficits Dysarthria and trouble understanding speech Vertigo or ataxia Aphasia Symptoms of subarachnoid hemorrhage may include the following: Sudden onset of severe headache Signs of meningismus with nuchal rigidity Photophobia and pain with eye movements Nausea and vomiting Syncope - Prolonged or atypical

20. Diagnosing stroke Time is of essence in the diagnosis of stroke. There is urgency to make the diagnosis and determine whether treatment with thrombolytic medications (clot-busting drugs) to “reverse” the stroke is a possibility. The time frame to intervene is narrow and may be as short as 3 to 4 ½ hours after onset of symptoms AHA and ASA recommend that everybody be aware of “FAST “ in recognizing stroke: Face Drooping, Arm Weakness, Speech Difficulty, Time to Call 9-1-1(emergency line 112 for Nigeria) In the emergency department, doctors may perform a more in depth and standardized neurologic examination . .

21. Investigations Radiological tests including CT is used to look for bleeding or masses. CT perfusion scan done to check brain blood supply (perfusion ). An MRI of the brain may be possibly indicated . Blood tests may include a Full blood count SEUCr , FBS , Blood Clotting function with international normalized ratio (INR), prothrombin time (PT) and partial thromboplastin time (PTT). An ECG  may be performed to check the heart's rate and rhythm.

22. Hypertensive retinopathy Hypertensive retinopathy is retinal vascular damage caused by hypertension. Symptoms usually do not develop until late in the disease and include blurred vision or visual field defects. Signs usually develop late in the disease. Funduscopic examination shows arteriolar constriction, arteriovenous nicking, vascular wall changes, flame-shaped hemorrhages, cotton-wool spots, yellow hard exudates, and optic disk edema World sight day: 2 nd Thursday of october (11/10)

23. Hypertensive Heart Diseases(HHD) HHD is a term applied generally to heart diseases that are caused by the direct or indirect effects of elevated BP such as Left Ventricular Hypertrophy Coronary Artery Disease Cardiac Arrhythmias and Congestive Heart Failure World Heart Day: 29/09

24. Left Ventricular Hypertrophy Left ventricular hypertrophy is the enlargement and thickening of the walls of the left ventricle. Left ventricular hypertrophy is more common in people who have uncontrolled high blood pressure

25. Symptoms of Left Ventricular Hypertrophy Left ventricular hypertrophy usually develops gradually. One may experience no signs or symptoms, especially during the early stages of the condition. As left ventricular hypertrophy progresses, you may experience: Shortness of breath Fatigue Chest pain, often after exercising Sensation of rapid Palpitations Dizziness or fainting

26. Coronary Artery Disease(CAD) D evelops when the major blood vessels that supply the heart with blood, oxygen and nutrients (coronary arteries) become damaged or diseased. This is due to deposition of Cholesterol-containing deposits (plaque) in the coronary arteries.

27. Clinical features of CAD Chest pain (angina).   pressure or tightness in the chest usually occurs on the middle or left side of the chest which is generally triggered by physical or emotional stress. this pain may be fleeting or sharp and felt in the neck, arm or back. Shortness of breath.   Heart attack.   A completely blocked coronary artery may cause a heart attack. The classic signs and symptoms of a heart attack include crushing pressure in the chest and pain in the shoulder or arm, sometimes with shortness of breath and sweating.

28. Cardiac Arrhythmia A cardiac arrhythmia is any abnormal heart rate or rhythm. In normal adults, the heart beats regularly at a rate of 60 to 100 beats per minute, and the pulse matches the contractions of the ventricles .  Cardiac arrhythmias sometimes are classified according to their origin as ventricular arrhythmias or supraventricular arrhythmias They also can be classified according to their effect on the heart rate, with bradycardia indicating a heart rate of less than 60 beats per minute and tachycardia indicating a heart rate of more than 100 beats per minute.

29. Clinical features of Cardiac Arrhythmia Asymptomatic Dizziness Fainting Extreme fatigue. Palpitations Lightheadedness Loss of consciousness

30. Congestive Cardiac Failure Congestive heart failure(CHF) is a condition in which the heart's function as a pump is inadequate to meet the body's needs. The symptoms of congestive heart failure vary, but can include: Easy fatiguability Diminished exercise capacity, shortness of breath and swelling (edema).

31. Hypertensive Nephropathy(HN) Hypertensive kidney disease is a medical condition referring to damage to the kidney due to chronic high blood pressure . HN can be divided into two types: benign and malignant. Benign nephrosclerosis is common in individuals over the age of 60 Malignant nephrosclerosis is uncommon and affects 1-5% of individuals with high blood pressure, that have diastolic blood pressure passing 130 mm Hg. World kidney day(8/03); theme: kidneys & women’s health: include, value, empower.

32. Pathogenesis Chronic high blood pressure causes damages to kidney tissue including the small blood vessels, glomeruli , kidney tubules and interstitial tissues. The tissue hardens and thickens which is known as nephrosclerosis . [4]   The narrowing of the blood vessels means less blood is going to the tissue and so less oxygen is reaching the tissue resulting in tissue death (ischemia ).

33. Mechanism of Hypertensive Nephropathy Glomerular ischemia High blood pressure damages the endothelium which leads to a build-up of plaques and eventual renal arteries stenosis with consequent ischemic kidney disease leading to a decrease in t he size of the kidneys. Glomerular hypertension and glomerular hyperfiltration An alternative mechanism of hypertensive nephropathy is prolonged glomerular hypertension and hence glomerular hyperfiltration . As a compensatory mechanism, the unaffected nephrons vasodilate to increase blood flow to the kidney and increase glomerular filtration across undamaged glomeruli .

34. Diagnosis Damage to the glomeruli allows proteins that are usually too large to pass into the nephron  to be filtered. This leads to an elevated concentration of albumin in the urine. Protein in the urine is best identified from a 24-hour urine collection . Haematuria Definitive diagnosis requires morphological examination. Common histological features include Glomerulosclerosis which is either focally or globally and characterized by hardening of the vessel walls ..

35. Finally Thank you for your attention Questions and contributions

36. References WHO. Q&As on hypertension. September 2015. Available from http://www.who.int/features/qa/82/en/ [accessed on 19/3/18] Bisognano JD, Batuman V. Malignant Hypertension. Medscape . Available from https://emedicine.medscape.com/article/241640-overview [accessed on 19/3/18] Finerly JA. Management of hypertensive encephalopathy . Available from https://www.ncbi.nlm.nih.gov/pubmed/721056 [accessed on 19/3/18] Internet Stroke Centre. Ischaemic Stroke. http://www.strokecenter.org/patients/about-stroke/ischemic-stroke/ [accessed on 19/3/18] Prakashkumar K. Kunar J. Biswar TK. Varshil M. Sojib BZ. End Organ Damage in Hypertensive Geriatric Age Group: A cross sectional study. Journal of Medical Research and Innovation. Available from https:// jmri.org.in/jmri/article/view/75 [accessed on 19/3/18 ] Whelton PK, Carey RM, Aronow WS, et al . 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA /ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology. Nov.2016. Available from http://www.onlinejacc.org/content/early/2017/11/04/j.jacc.2017.11.006?_ ga=2.217900830.942552789.1521573549-211035663.1521573549 [accessed on 19/3/18 ]