michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
michigan hypertension core curriculum - State of Michigan
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ecause pressure-related retinopathy occurs at incrementally higher BP levels within the<br />
so-called normal range, not just when BP crosses an arbitrary threshold <strong>of</strong> normalcy. 1<br />
Prevalence rates utilizing photography ranged from 2 to 15 percent for various signs<br />
<strong>of</strong> retinopathy compared to 1 to 2 percents in studies utilizing direct opthalmoscopy. A<br />
higher prevalence <strong>of</strong> retinopathy has been reported amongst African Americans than<br />
among whites, a difference that can be plausibly attributed to their higher incidence,<br />
prevalence, and severity <strong>of</strong> <strong>hypertension</strong> as well as their greater coexistence <strong>of</strong><br />
diabetes. 1<br />
The presence <strong>of</strong> retinal changes in normotensive patients may be a marker<br />
<strong>of</strong> a pre-hypertensive state. 4 There is a clear association <strong>of</strong> hypertensive retinopathy<br />
with stroke. The ARIC (Atherosclerosis Risk In Community), a multisite cohort study,<br />
showed that signs <strong>of</strong> hypertensive retinopathy <strong>of</strong> photographs was associated with a<br />
risk <strong>of</strong> newly diagnosed stroke that was 2 - 4 times higher than in patients without retinal<br />
findings, even the analyses were controlled for <strong>hypertension</strong>, smoking and lipid levels.<br />
The association <strong>of</strong> hypertensive retinopathy with coronary heart disease has, however,<br />
been less robust. 3<br />
Classification <strong>of</strong> Hypertensive Retinopathy 16<br />
Grade <strong>of</strong> Retinopathy Retinal Signs Systemic Associations<br />
None No detectable signs None<br />
Mild Generalized arteriolar narrowing Modest association with risk <strong>of</strong><br />
narrowing, arteriovenous nickingclinical stroke, subclinicalstroke,<br />
opacity (“copper wiring”) <strong>of</strong> coronary heart disease and death<br />
arteriolar wall, or a combination <strong>of</strong> these signs<br />
Malignant Signs <strong>of</strong> moderate retinopathy -Strong association with death<br />
Plus swelling <strong>of</strong> the optic disk,<br />
Identification <strong>of</strong> Secondary Causes <strong>of</strong> Hypertension<br />
There are multiple causes <strong>of</strong> secondary HTN. 8 Listed below are some <strong>of</strong> the more<br />
common etiologies. Please note that the historical and clinical findings suggestive <strong>of</strong> secondary<br />
HTN are neither sensitive nor specific, yet they do significantly inform clinical judgment<br />
regarding the likelihood <strong>of</strong> a given type <strong>of</strong> secondary HTN and therefore the need to pursue this<br />
diagnosis.<br />
Historical and Clinical Findings Suggestive <strong>of</strong> Secondary Hypertension 1,7,8,10<br />
Resistant HTN<br />
HTN and unprovoked hyopkalemia or severe ( 18 inches in men] (sleep apnea)<br />
Onset <strong>of</strong> <strong>hypertension</strong> prior to puberty<br />
Abrupt rise in BP over a previously stable lower level<br />
Onset prior to age 30 with no obesity or family history <strong>of</strong> <strong>hypertension</strong><br />
HTN in a vasculopath (unilateral or bilateral critical renal artery stenosis)<br />
Acute elevation <strong>of</strong> creatinine after initiation <strong>of</strong> ACE or ARB (bilateral critical renal artery<br />
stenosis)<br />
Flash pulmonary edema (bilateral critical renal artery stenosis)<br />
Azotemia (bilateral critical renal artery stenosis causing ischemic nephropathy)<br />
160 Hypertension Core Curriculum