HYPERTENSION Defenition Hypertension, commonly referred to as "high blood pressure", is a medical condition where the blood pressure is chronically

elevated. Etiology 1. Essential hypertension / primary hypertension Essential hypertension is the term used when no specific medical cause can be found to explain a patient's condition. there are some factors increase #$, lthough it has fre!uently including obesity,insulin been indicated that the causes of essential hypertension are not "nown, but resistance,high alcohol inta"e,high salt inta"e %in salt&sensitive patients', aging, lifestyle,and stress. #etween () * & +,* of people with high blood pressure have primary hypertension. -. .econdary hypertension .econdary hypertension means that the high blood pressure is a result of %i.e. secondary to' another condition, such as "idney disease or certain tumors. #etween 1,* & 1)* of people with high blood have secondary hypertension. Classification #ased on the /01 2 %3he .eventh 4eport of the /oint 0ational 1ommittee on $revention, 5etection, Evaluation, and 3reatment of High #lood $ressure', classfication of hypertension 6 1ategory 0ormal $rehypertension .tage 1 .ystolic #lood $ressure 5iastolic #lood $ressure %mmHg' #elow 1-, 1-, 7 18+ %mild' 19, 7 1)+ %mmHg' #elow (, (, 7 (+ +, 7 ++ 1,,

hypertension .tage - %moderately' 1:, hypertension

Hypertensive urgencies and emergencies 1. Hypertensive urgencies Hypertension is rarely severe enough to cause symptoms. 3hese typically only surface with a systolic blood pressure over 1(, mmHg and/or a diastolic blood pressure over 1-, mmHg. 3hese pressures without signs of end&organ damage %such as renal failure' are termed hypertensive urgensive. 3he blood pressure must be decreased on -9 hours. -. Hypertensive emergencies 3hese typically with a systolic blood pressure over --, mmHg and/or a diastolic blood pressure over 19, mmHg. 3hese pressures with signs of end&organ damage %such as renal failure' or already ongoing. 3he blood pressure must be decreased on 1 hours. Complications ;hile elevated blood pressure alone is not an illness, it often re!uires treatment due to its short& and long&term effects on many organs. 3he ris" is increased for6

1erebrovascular accident %1< s or stro"es' =yocardial infarction %heart attac"' Hypertensive cardiomyopathy %heart failure due to chronically high blood pressure' Hypertensive retinopathy & damage to the retina Hypertensive nephropathy & chronic renal failure due to chronically high blood pressure

Diagnosis

1. namnesis Headache, 0osebleeds, di>>ines, flushed face, fati!ue. .evere or long standing high blood pressure that is untreated %especially emergency hypertension' can produce symptoms because it can damage the brains, eyes, heart, and "idney. -. $hysical Examination High blood pressure 6 blood pressure is measured after a person sits or lies down for ) minutes, especially if the person is older. reading of 19,/+, mmHg or more is considered high, but a diagnosis cannot be based on a single high reading. ?f a person has an initial high reading, blood pressure is measured again during the same visit and then measured twice on at least two other days to ma"e sure that the high blood presure persists. 8. @aboratory examination Aidney damage can be detected by urine and blood test. Brine test can detect early evidence of "idney damage. 3he presence of blood cells and albumin %the most abundant protein in blood' in the urine may indicate such damage. 9. Extensive evaluation E1C D&4ay B.C

Treatment 3he aim of treatment should be blood pressure control to E19,/+, mmHg for most patients, and lower in certain contexts such as diabetes or "idney disease %some medical professionals recommend "eeping levels below 1-,/(, mmHg'. Each added drug may reduce the systolic blood pressure by )&1, mmHg, so often multiple drugs are necessary to achieve blood pressure control.

1ommonly used drugs include6

1E inhibitors such as captopril, enalapril, fosinopril %=onoprilF', lisinopril %GestrilF', !uinapril, ramipril % ltaceF' ngiotensin ?? receptor antagonists6 eg, irbesartan % vaproF', losartan %1o>aarF', valsartan %5iovanF', candesartan % tacandF' lpha bloc"ers such as doxa>osin, pra>osin, or tera>osin #eta bloc"ers such as atenolol, labetalol, metoprolol %@opressorF, 3oprol& D@F' 1alcium channel bloc"ers such as amlodipine %0orvascF', diltia>em, verapamil 5iuretics6 eg, bendroflumethia>ide, chlortalidone, hydrochlorothia>ide %also called H13G' 1ombination products %which usually contain H13G and one other drug'

0on $harmacological treatment 6 .topp smo"ing 5ecrease the over body weight 5ecrease the alchohol consumption $hysical exercise @ow salt inta"e ?ncrease the fruits and vegetable consumption and low fat inta"e

Prognosis Bntreated high blood pressure increase a personHs ris" of developing heart disease %such as heart failure, heart attac", or sudde cardiac death', "idney failure, or stro"e at early age. High blood pressure is the most important ris" factor for stro"e. ?t is also one of the tree most important ris" factors for eart attac" that a person can modify %the other two are smo"ing and high cholesterol levels in the

blood'. 3reatment that lowers high blood pressure greatly decrease the ris" of stro"e and heart failure. .uch treatment may also decrease the ris" of a heart attac", although not as dramatically. ;ithout treatment, fewer than )* of people with malignant hypertension survive for a year.

HYPERTENSI E HE!RT DISE!SE Defenition Hypertensive heart disease is a late complication of hypertension %high blood pressure' in which the heart is affected. Etiology High blood pressure increases the heart's wor"load, and over time, this can cause the heart muscle to thic"en. s the heart pumps against elevated pressure in the blood vessels, the left ventricle becomes enlarged and the amount of blood pumped by the heart each minute %cardiac output' goes down. ;ithout treatment, symptoms of congestive heart failure may develop.

Hipertension

=yocard Ictor

1oroner fctor

@<H

=yocard ischemic

HH5

?H5

Heart failure

"eft ventricular #ypertrop#y $atient with hypertension, 1)&-,* develop to @<H. 3he ris" of @<H is increased -&fold by associated obesity. 3he prevalence of @<H based on E1C findings, which are not a sensitive mar"er at the time of diagnosis of hypertension, is variable. .tudies have shown a direct relationship between the level and duration of elevated #$ and @<H.@<H, defined as an increase in the mass of the left ventricle %@<', is caused by the response of myocytes to various stimuli accompanying elevated #$. =yocyte hypertrophy can occur as a compensatory response to increased afterload. =echanical and neurohormonal

stimuli accompanying hypertension can lead to activation of myocardial cell growth, gene expression %.ome of the genes are given expression primarily in fetal cardiomyocytes.', and, thus, @<H. Complications Heart failure rrhythmias Heart attac" ngina .udden death Diagnosis ;e can diagnosis some one with Hipertensive heart disease if we can detected the @<H %left ventri"el hipertrophy'. @<H can detected by physical examination, E1C, radiologic, echocardiographic. #y echocardiographic, we can find early @<H. Treatment 3he goals of treatment are to reduce blood pressure and control the heart disease. 3reatment of heart disease depends on the conditions that are present. 1ommon medications include diuretics, beta bloc"ers, calcium channel bloc"ers, angiotensin&converting en>yme % 1E' inhibitors, angiotensin ?? receptor antagonists, and direct vasodilators. intravenous dia>oxide or nitroprusside may be prescribed if hypertension is extremely severe and intensive care is necessary. #lood pressure should be chec"ed at regular intervals to monitor the condition. Ire!uent blood pressure measurements performed at home are often recommended for patients who have difficult&to&control high blood pressure. 5iabetes, hyperlipidemia, and other conditions that increase the ris" of heart disease should be carefully controlled. ?n addition to medications, recommended lifestyle changes include weight loss, exercise, and dietary adJustments. 5ietary recommendations include increasing fruits, vegetables, and low&fat dairy

products. $atients may benefit from reducing salt inta"e, .top smo"ing && cigarettes are a maJor cause of hypertension and related heart disease. 4educing excessive alcohol consumption may also help.

C!SE REPORT 2( years old man was admitted to the ?nternal =edicine 5epartement of Ceneral Hospital 5r. chmad =ochtar #u"ittinggi on =arch, -(th -,,( with 6 !namnesis C#ief Complaint Headache and di>>iness since 9 hours ago Present Illness History & & & & & & & & Headache and di>>iness since 9 hours ago 0o blured vision 0o #reathlessness 0o chest pain 0o 1ough 0o nausea, no vomit 0o loss of appetite =ixturation and defecation were normal

Previous Illness History & & & $atient has been "nown as hypertension since - years ago and he has controlled to the hospital since 1 month ago. 5iabetes =ellitus history %&' Heart disease history %&'

$amily Illness History & 0one of his family members got the same illness

Social% Economic% #a&&its and Educational 'ac(ground & 0o smo"ing

PHYSIC!" E)!*IN!TION + ital Sign + , Ceneral ppearance 6 moderately illness & 1onciousness & #lood pressure & $ulse 4ate & 4espiratory rate & 0utrient condition #=? K 12,,( "g/mHead Eye Ears and nose Nec( /<$ 3hyroid Cland C#est "ung ?nspection $alpation $ercussion uscultation Heart ?nspection $alpation ?1. $ercussion 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? 6 simetric movement 6 Iremitus on the left side same with the right side 6 @eft and right is sonor 6 <esiculer, rhonchi %&', whee>ing %&' 6 ) & - cmH-M 6 no enlargement 4egional lymph node 6 no enlargement 6 conJunctiva was not anemic .clera was not icteric 6 normal 6 composmentis cooperative 6 1:,/1,, mmHg 6 (9x/menit 6 -,x/menit 6 #ody weight 6 91 "g #ody length 6 1)) cm L E normal

& #ody 3emperature 6 8:,( ,1

1,

uscultation !&domen ?nspection $alpation $ercussion uscultation 'ac( ?nspection $alpation $ercussion uscultation !nal and -enitalia ;as not examined E.tremities +

6 4eguler rhytm, =1N=-, -N$6 0o enlargement 6 @iver and lien were not palpable 6 thympani 6 $eristaltic sound was normal 6 simetric movement 6 Iremitus on the left side same with the right side $ressure pain at costo vertebrae angle %&/&' 6 @eft and right is sonor 6 <esiculer, rhonchi %&', whee>ing %&'

$hysiological reflex %O/O' $athological reflex %&/&' Edema %&' /or(ing Diagnose Hypertensive Heart 5isease ec. Essensial Hypertension stage T#erapy & & & & #edrest / @ow .alt 5iet ?<I5 4@ -, gtt/1H 1aptopril - x -) mg lpra>olam - x ,,) mg

Suggested E.amination & #BI routine examination

11

& & & & &

1omplete blood examination E1C @ipid profile 4oentgen 3hora" 1onsultation to eye department

$O""O/ 0P *arc# 12t# %1334 / $E <ital .ign 6 C @1 #$ "ung ?nspection $alpation $ercussion uscultation Heart ?nspection $alpation $ercussion 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? ?1. 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line uscultation ECH4 4hytme xis $4 interval 6 2)x/ minute 6 sinus 6 normal 6 normal 6 4eguler rhytm, =1N=-, -N$6 symmetric movement 6 Iremitus on the left side same with the right side 6 @eft and right is sonor 6 <esiculer, rhonchi %&', whee>ing %&' 6 moderate 6 1=1 6 1(,/1,, mmHg $4 44 3 6(, x/minute 6 1(x/minute 6 82o 1 6 headache %O' di>>iness %O'

1-

.3 segment

6 normal

. <- O 4 <: N 8) mm . persistens <) <: ?nterpretation 6 @<H, 4<H, no ischemic "a&oratory findings 'lood + Haemoglobin @eucocyte Eritrocyte count Haematocryte #.4 51 3rombocyte Iasting #lood Clucouse 3otal $rotein & lbumin & Clobulin 3otal #ilirubin & 5irect bilirubin & ?ndirect bilirubin Breum 1reatinine .CM3 .C$3 K 1-,+ g/dl K 21,,/ul K 9,) Juta/ul K 91 vol * K 88/hour K ,/-/9/:)/-)/9 K 122.,,,/mm8 K (, mg/dl

#lood Clucouse - hours $$ K 1:, mg/dl K 2,) g/dl K 8,2 g/dl K 8,( g/dl K ,,(9 mg/dl K ,,12 mg/dl K ,,:2 mg/dl K 91,: mg/dl K 1,- mg/dl K 8: K -1 B/l B/l

.uggested examination 6 33CM 0rinalisis Iisis 1hemistry 6 normal colour 6 protein %&' #ilirubin %&'

18

Brobilin %O' 4eduction %&' .edimen 6 @eu"osit 6 -&8 / big vision Erytrocit 6 -&8 / big vision .ilinder 6 & ;5/ Hypertensive Heart 5isease ec. Essensial Hypertension stage 3herapy 6 continue $O""O/ 0P *arc# 56t# %1337 / 6 headache %O' di>>iness %O' $E <ital .ign 6 C @1 #$ @ung Heart ?nspection $alpation $ercussion 6 moderate 6 1=1 6 -,,/1,, mmHg 6 normal 6 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? ?1. 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line uscultation 6 4eguler rhytm, =1N=-, -N$Consultation to eye department% conclusion + Hypertension fundus was found without retinopaty .ub"apsularis posterior 1atarac M5. ;5/ Hypertensive Heart 5isease ec. Essential Hypertension stage 3herapy 6 & & #edrest / @ow .alt ?nta"e ?<I5 4@ -, gtt/1H $4 44 3 6 (9x/minute 6 -,x/minute 82 1

19

& & &

1aptopril 8 x -) mg lpra>olam - x ,,) mg 1enfresh E5 9x1 gtt M5.

$O""O/ 0P !pr 6st %1334 / $E <ital .ign 6 C @1 #$ "ung ?nspection $alpation $ercussion uscultation Heart ?nspection $alpation $ercussion 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? ?1. 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line uscultation Ro t#ora( .usp. $leural effusion sinistra @<H with congestive pulmonal 55/ position ;5/ Hypertensive Heart 5isease ec. Essential Hypertension stage 3herapy 6 & & #edrest / @ow .alt ?nta"e ?<I5 4@ -, gtt/1H 6 4eguler rhytm, =1N=-, -N$6 symmetric movement 6 Iremitus on the left side same with the right side 6 @eft and right is sonor 6 <esiculer, rhonchi %&', whee>ing %&' 6 moderate 6 1=1 6 1(,/1,, mmHg $4 44 3 6 (,x/minute 6 1(x/minute 8:,( 1 6 Headache %&' 5i>>iness %&'

1)

& & &

1aptopril 8 x -) mg lpra>olam - x ,,) mg 1enfresh E5 9x1 gtt M5.

$O""O/ 0P !pr 1nd %1334 / $E <ital .ign 6 C @1 #$ @ung Heart ?nspection $alpation $ercussion 6 moderate 6 1=1 6 1+,/1,, mmHg 6 normal 6 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? ?1. 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line uscultation 3herapy 6 & & & & & & #edrest / @ow .alt ?nta"e ?<I5 4@ -, gtt/1H 1aptopril 8 x -) mg H13 1x-) mg lpra>olam - x ,,) mg 1enfresh E5 9x1 gtt M5. 6 4eguler rhytm, =1N=-, -N$;5/ Hypertensive Heart 5isease ec. Essential Hypertension stage $4 44 3 62( x/minute 6 -,x/minute 8:,( 1 6 headache %&' 5i>>iness %&'

1:

$O""O/ 0P !pr 5rd %1334 / $E <ital .ign 6 C @1 #$ @ung Heart ?nspection $alpation $ercussion 6 moderate 6 1=1 6 1:,/1,, mmHg 6 normal 6 6 ?ctus was visible 6 ?ctus was palpable one finger lateral at @=1. <? ?1. 6 upper border 6 ?? ?1. @eft border 6 one finger lateral at @=1. <? ?1. 4ight border 6 4ight sternalis line uscultation 3herapy 6 & & & & & & #edrest / @ow .alt ?nta"e ?<I5 4@ -, gtt/1H 1aptopril 8 x -) mg H13 1x-) mg lpra>olam - x ,,) mg 1enfresh E5 9x1 gtt M5. 6 4eguler rhytm, =1N=-, -N$;5/ Hypertensive Heart 5isease ec. Essential Hypertension stage $4 44 3 6 (,x/minute 6 -,x/minute 8:,( 1 6 headache %&' 5i>>iness %&'

12

DISC0SSION 2( years old man patient was admitted to internal medicine department of the chmad =ochtar Hospital, #u"ittinggi on =arch -( th -,,(. #ased on anamnesis, physical examination, laboratory finding, and other examination, we diagnose this patient as hypertensive heart disease ec essential hypertension stage -. Irom anamnesis we found 6 headache and di>>iness since 9 hours ago, 0o blurred vision, no breathlessness, no chest pain, no cough, no nausea, and no vomit. $atient has been "nown as hypertension since - years ago and he has controlled to the hospital since 1 month ago. Irom physical examination we found that blood pressure 1:,/1,, mmHg, and cardiomegaly. Irom E1C we found @<H %O', 4<H %O' and no ischemic. #ut the conclusion of roentgen foto thora" only found @<H and there wasnHt 4<H, and susp. $leural effusion sinistra. ;e had consultation to the eye 5epartment, and the conclusion was Hypertension fundus was found without retinopaty. 3reatment for this patient was bedrest / @ow .alt diet, ?<I5 4@ -, gtt/1H, 1aptopril - x -) mg, and lpra>olam - x ,,) mg. fter consultation to the eye department, they gave advise for us to give 1enfresh 9x1 gtt M5.. ;e increase the dose of captopril become 8x-) mg because on the second day treatment the blood pressure still high %-,,/1,, mmHg'. ;hen the blood pressure still high on the third day, so we give H13 1x-) mg to the patient.

1(

RE$ERENCES $ $5?. #u"u Jar ?lmu $enya"it 5alam. Edisi ?<. /a"arta6 5eprtemen ?lmu $enya"it 5alam , Ia"ultas Aedo"teran Bniversitas ndalas.-,,:. Candelman, Clenn. Hipertensive Heart 5isease. -,,:. ?n http6//www.medlineplus.com. 4ia>, Aamran. Hipertensive http6//www.emedicine.com. Heart 5isease. -,,2. "ses from 6 "ses "ses from from 6 6

High #lood $ressure %Hypertension'. http6//www.medicinenet.com.

-,,2.?n

Hypertension. -,,(. ?n "ses from 6 http6//www.wi"ipedia.com. Hypertensive Heart 5isease. -,,(. "ses from 6 http6//www.drugs.com.

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