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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Vital signs<br />
suggestive <strong>of</strong> OSAHS. 20 The prevalence <strong>of</strong> sleep apnea in hypertensive populations<br />
ranges between 30 – 40%. Men are 2 to 3 times more likely to be affected than women. 21<br />
Population-based studies have associated OSAHS with cardiovascular<br />
disease, stroke and <strong>hypertension</strong>. In the Sleep Heart Health Study, 6,424 patients<br />
were longitudinally studied with in-home polysomnography. 20 In the highest quartile <strong>of</strong><br />
apnea-hypopnea frequency (>11/hr) the adjusted odds <strong>of</strong> self reported cardiovascular<br />
disease was 1.42 (95% confidence interval, 1.13 – 1.78). 22 The strongest links were to<br />
congestive heart failure and stroke. 21<br />
Strong evidence for an association <strong>of</strong> OSAHS and <strong>hypertension</strong> comes<br />
from the Wisconsin Sleep Cohort Study. Subjects underwent serial in-laboratory<br />
polysomnography. A dose-dependent like between apnea-hypopnea frequency at<br />
baseline and the development <strong>of</strong> <strong>hypertension</strong> was identified. For a baseline apneahypopnea<br />
frequency <strong>of</strong> 15/hr the odds ratio for <strong>hypertension</strong> at 4 years was 2.89<br />
(confidence interval, 1.46 – 5.64). 23<br />
Intermittent hypoxia, negative intrathoracic pressure variations and arousal<br />
characteristics <strong>of</strong> apneas and hypopneas lead to acute increases in BP and the<br />
termination <strong>of</strong> disordered breathing events, evolving into sustained <strong>hypertension</strong> via<br />
chronically heightened sympathetic nervous system activity and arterial baroreceptor<br />
dysfunction. 21<br />
History should focus on breathing disturbances during sleep, unsatisfactory sleep<br />
quality, daytime dysfunction, and OSAHS risk factors. A collateral history should be<br />
obtained from the patient’s bed partner. Reports <strong>of</strong> habitual, socially disruptive snoring<br />
and witnessed apneas terminated by snorts or gasps increase diagnostic accuracy.<br />
Sleepiness, per se, however, lacks diagnostic sensitivity and specificity. 20,21<br />
Physical examination focuses on crani<strong>of</strong>acial and s<strong>of</strong>t tissue conditions<br />
associates with increased upper airway resistance, such as retrognathia, deviated<br />
nasal septum, low-lying s<strong>of</strong>t palate, enlarged uvula, and base <strong>of</strong> tongue. Obesity and<br />
neck circumference over 43cm (17.5inches) correlates with an increased likelihood <strong>of</strong><br />
OSAHS. 20<br />
Treatment <strong>of</strong> OSAHS may, though not invariably, result in improvement <strong>of</strong><br />
<strong>hypertension</strong>. However, treatment <strong>of</strong> sleep apnea does lower cardiovascular risk. 22<br />
164 Hypertension Core Curriculum<br />
Physical Examination 1,4-10,20,21<br />
General appearance<br />
A Retinopathy<br />
B Neck/chest<br />
C Cardiac<br />
i. Inspection <strong>of</strong> precordium<br />
ii. Palpation <strong>of</strong> PMI<br />
iii. First sound<br />
iv. S 3 Gallop<br />
v. S 4 Gallop<br />
vi. Murmurs<br />
D Abdomen<br />
vii. Renal bruits<br />
viii. Bladder distention