michigan hypertension core curriculum - State of Michigan

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cause greater disruption of CBF autoregulation than cortical lesions. This disruption of CBF autoregulation can last for weeks. The disruption of autoregulation in the ischemic areas of the brain leads to a dependence of systemic perfusion pressure for blood flow and therefore oxygen delivery into these areas (figure 7). Figure 7. Relation of Systemic Perfusion Pressure to Cerebral Blood Flow On the other hand, excessive blood flow as can occur with very elevated systemic BP can facilitate formation of cerebral edema. Effective cranial perfusion pressure (CPP) is the difference between MAP and intracranial pressure (ICP). A significant proportion of persons with acute stroke have elevated ICP; therefore, the rise in systemic perfusion pressure might also help maintain CBF in the ischemic area of the brain when ICP is elevated. The highest levels of systemic BP appear to be associated with intracranial hematomas. Interestingly, this is also the one stroke subtype where autoregulation of CBF may not be impaired, particularly when the intracranial hematoma is small (< 45 ml). Blood pressure perceptibly falls during the first 4 days after acute stroke and continues to fall spontaneously through 7 - 10 days post-stroke. In one large series of acute stroke patients, the fall in BP by day 10 averaged 20/10 mm Hg. Diurnal variation in BP is abnormal during acute stroke. The normal nocturnal declines in BP, both systolic and diastolic, are markedly attenuated to absent. The therapeutic and clinical implications of the abnormal autoregulation of CBF in acute cerebral ischemia are profound. Though elevated BP is a risk factor for stroke and, in the setting of acute stroke, might facilitate cerebral edema formation, the dependence of CBF in ischemic brain areas on systemic perfusion pressure makes antihypertensive treatment risky. Even moderate reductions in BP might be associated with worsening cerebral ischemia and infarct extension, particularly in the ischemic penumbra (the damaged but still viable brain tissue surrounding the infarct). 36 Hypertension Core Curriculum
Clinical Implications: The clinician must resist the temptation to acutely lower BP in patients presenting with stroke or other manifestations of acute cerebral ischemia or head trauma. This is extremely difficult because clinicians have been conditioned to the fact that elevated BP cases stroke. Therefore when clinicians encounter elevated BP in the setting of stroke there is a strong inclination to acutely lower the BP via pharmacological means. Unless the systolic BP exceeds ~ 230 mm Hg and/or the DBP exceeds ~ 130 mm Hg, the clinician should refrain from intervening with pharmacological agents to acutely lower BP. Blood flow and therefore oxygen delivery into the watershed area (ischemic penumbra) is dependent on systemic perfusion pressure. Also, in ~ 40% of patients with acute stroke, intracranial pressure is increased. Raised intracranial pressure is also an impediment to cerebral blood flow and therefore cerebral oxygen delivery. The major exception to this recommendation of therapeutic restraint is when there are signs of new/ worsening target-organ injury that is likely related to elevated BP (e.g., heart failure, worsening kidney function, etc.). It is wise to keep the BP lower than ~ 185/110 mm Hg when thrombolytic therapy will be utilized in acute stroke patients. NKFM & MDCH 37
Page 1: MICHIGAN HYPERTENSION CORE CURRICUL
Page 4 and 5: April 2010 Dear Colleague: In 2005,
Page 6 and 7: Kevin L. Piggott, MD, MPH, FAAFP Pr
Page 8 and 9: Blood Pressure Measurement........
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Page 12 and 13: of the wrist. Additionally, there i
Page 14 and 15: asis. National guidelines recommend
Page 16 and 17: Post-Test Questions: 1. High BP is
Page 18 and 19: 18 Hypertension Core Curriculum Ess
Page 20 and 21: Masked Hypertension is when the off
Page 22 and 23: TABLE 1. Prevalence of Awareness, T
Page 24 and 25: Blood Pressure, Circulatory Physiol
Page 26 and 27: side of the vascular tree. Arterial
Page 28 and 29: upon the other co-morbidities prese
Page 30 and 31: Table 3. Clinically Available Clues
Page 32 and 33: In the setting of chronic hypertens
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Page 38 and 39: References/Suggested Reading Agabit
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Page 42 and 43: development of essential HTN can se
Page 44 and 45: Figures: Figure 1. Pie-chart with m
Page 46 and 47: Table 2 Table 3 Screening Test for
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Page 52 and 53: side effects particularly well. A h
Page 54 and 55: 14. Gaede P, Vedel P, Larsen N, Jen
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Page 58 and 59: glycemic risk factdors such as hype
Page 60 and 61: . Weight loss c. Weight gain d. A a
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Page 66 and 67: foods and turn out of necessity to
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Page 72 and 73: Incidence and Prevalence The overal
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Page 76 and 77: As a part of the approach to managi
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Page 84 and 85: appear to be related to access to c
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CDC MMWR Feb 24, 2006/55(07); 177-1
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Figure 1; Clinical presentation and
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90 Hypertension Core Curriculum Phe
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ANY patient, who develops paroxysma
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Figure 1: 94 Hypertension Core Curr
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Objectives: 96 Hypertension Core Cu
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Definition Prevalence Clinical Feat
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intake. 4 Figure 1; Ion transport i
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loading with 200 mmoles (4.6 grams)
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Figure 3; Endocrine Society See tex
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INTRODUCTION 106 Hypertension Core
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Renal manifestations. Renal ischemi
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to assess renal dimensions and dupl
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stenosis severity. Patients with no
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ARAS, ischemic nephropathy, and imp
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the goals of minimizing injury to t
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hemodynamically impaired renal arte
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e classified as having “renovascu
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disease of the abdominal aorta and
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Table 1. Contemporary evaluation of
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2. Screening tests for RAS RDU, MRA
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Manifestations of vital organ injur
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Table 6. Clinical evaluation of ren
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Table 9. Assessment of worsening re
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Table 11. New terminology for renal
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References: 1. Murphy TP, Soares G,
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2001;12(6):1235-1241. 40. Subramani
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78. Tami LF, McElderry MW, al-Adli
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142 Hypertension Core Curriculum Pr
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monitored hypertension screening an
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Policy Development: Public health p
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Med Clin North Am. Jan 2004;88(1):2
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mind they will have no problem iden
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Role of Race in the Selection of An
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individuals of any race or ethnicit
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Older Patients Need Elevated Systol
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sister, mother and father. A family
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ecause pressure-related retinopathy
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pulses (lower in the left arm). 4 C
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Vital signs suggestive of OSAHS. 20
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may shed light on underlying medica
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References: patients. 8 However, th
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Objectives: 170 Hypertension Core C
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and evidence that anti-hypertensive
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When subjects are given instruction
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interestingly found only a 6.0/4.6
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pressure: a meta-analysis of random
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isolated systolic hypertension have
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Compelling Indications for Specific
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3.) Beta-blockers, ACE inhibitors,
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treatment levels - albeit though at
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Preparations and Dosage: Oral antih
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Preparations and Dosages: The Oral
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patients with tachy-brady syndrome
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significant proteinuria. Pharmacolo
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the effect found by the ACE inhibit
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and nominally statistically signifi
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sensitive K+-channels in vascular s
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clonidine (Catapres†) 0.1-0.8 mg
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Learning Objectives 204 Hypertensio
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general, the response to beta-block
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Table 2: (JNC VII, 2004) 208 Hypert
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Learning objectives: 210 Hypertensi
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ecently published RCT investigated
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Post-test question: 35y/o male w/ h
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Orthostatic Hypotension Pretest que
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BP. It is important to note that la
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1- Fludrocortisone : a mineralocort
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References: 1. Hiitola P, Enlund H,
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www.neuroanatomy.wisc.edu/.../Image
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Learning objectives: 226 Hypertensi
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controlled BP to have been victimiz
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Treatment of Secondary Causes of Hy
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4-Direct vasodilators (e.g.minoxidi
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Hypertension. Aug 2003;42(2):161-16
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emergency by virtue of the associat
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PATHOPHYSIOLOGY The underlying mech
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trials included a placebo arm. Seve
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an indication for careful and modes
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ACUTE KIDNEY INJURY (AKI) In additi
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Blood Pressure Research Council, an
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[ACE inhibitors (ACEIs), angiotensi
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y sodium restriction or the use of
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44 months 24 , and were also seen i
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• Hypertension in dialysis patien
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GISEN Group (Gruppo Italiano di Stu
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258 Hypertension Core Curriculum
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DEFINITION AND CLASSIFICATION Hyper
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etween adult socioeconomic position
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women treated with atenolol in earl
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Obstet Gynecol. Dec 12 2008. 5. Vol
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able to dissipate the pressure rise
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Use of Dihydropyridine Calcium Anta
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272 Hypertension Core Curriculum Ca
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Case 4 Hypertensive patient with CK
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Case 6 276 Hypertension Core Curric
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year. Sodium restriction and weight
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What may be causing these new sympt
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