CASE STUDY B Essential Hypertension Ms. J., aged 48 years, has essential hyperte

Question

CASE STUDY B Essential Hypertension Ms. J., aged 48 years, has essential hypertension, diagnosed 4 years ago. She has not been taking her medication during the past 6 months because she has been feeling fine. Now she has a new job and has been too busy to enjoy her usual swimming and golf. She has decided to have a checkup because she is feeling tired and dyspneic and has had several bouts of dizzi- ness, blurred vision, and epistaxis (nosebleeds) lately. On examination, her blood pressure is found to be 190/120, some rales are present in the lungs, and the retinas of her eyes show some sclerosis and several arteriolar ruptures. The physician orders rest and medication to lower the blood pressure, as well as an appointment with a nutritionist and urinary tests to check kidney function. 1. Describe the pathophysiology of essential hypertension. 2. Explain the possible problems associated with the high diastolic pressure. 3. Explain the significance of the retinal changes. 4. The doctor suspects mild congestive heart failure. Explain how this can develop from hypertension. 5. Give two other possible signs of CHF. 6. List two medications that are helpful in treating hypertension and describe their actions.

Explanation / Answer

1. Essential hypertension is characterized by significant and persistent elevations in arterial pressure. Hypertension is a multifactorial disorder that may involve abnormalities in the functions of the heart pump, the blood vessels, and the kidneys. Short term and long term regulation of arterial pressure is influenced by changes in cardiac function, the peripheral vascular resistance, and the renal control mechanisms of plasma electrolytes and volume. Increases in the heart rate and stroke volume lead to increase in cardiac output that lead to increase in arterial pressure particularly in young individuals. Vascular endothelial cell dysfunction could lead to reduction in endothelium- derived relaxing factor such as nitric oxide, or increased production of contracting factors such as endothelin-1 and thromboxane A2. The decresed vascular relaxation and excessive vasoconstriction lead to significant increase in peripheral vascular resistance and arterial pressure over time, particularly with aging. Alterations in body fluid regulation by the kidneys could lead to salt and water retention, increased plasma volume, and cardiac output. Also, activation of renin-angiotensin system increases the levels of angiotensin II in the plasma, leading to generalized vasoconstriction, or locally in the kidneys, leading to salt and water retention. Individual changes in cardiac, vascular, or renal function seldom occur separately, and if so they may lead to mild or moderate increases in arterial pressure. Combined alterations in cardiac, vascular, and renal functions are more common and are often associated with pathologic increases in arterial pressure and established hypertension.

2. Hypertension is a long term condition in which the blood pressure within the arteries is persistantly elevated. Blood pressure is expressed by 2 measurements- the systolic and diastolic measurements. Systolic blood pressure is the measurement created as the heart contracts during each heartbeat. Diastolic blood pressure is the measurement of blood pressure as the heart relaxes. Having diastolic high blood pressure is a sign that your blood vessels have become less elastic, hardened and scarred. While much emphasis is placed on reducing systolic blood pressure values, elevations in diastolic blood pressure is still significant predictor of life threatening consequences. High diastolic blood pressure was liked to a great risk of abdominal aortic aneurysm. Isolated diastolic hypertension can possibly lead to possible progression of systoilc hypertension, of which is a predictor of diabetes, stroke, and heart failure.

3. The retina is the layer of tissue in the back of your eye. It senses light in to nerve signals and sends to brain for interpretation. When your blood pressure is high, the retina's blood vessel walls may thicken. This may cause your blood vessels to become narrow, which then restricts blood from reaching the retina. Over time, high blood pressure can cause damage to the retina's blood vessels, limit retina's functions, and put pressure on the optic nerve, causing vision problems. You probably won't have any symptoms until the condition has progressed extensively. Possible signs and symptoms include

Reduced vision

Eye swelling

Bursting of a blood vessel

Double vision accompained by headaches

The extent and severity of the retinopathy is generally represented on a scale of 1 to 4. The scale is called keith-wagener-barker classification.

In grade 1 - there is mild narrowing of retinal artery.

In grade 2 - narrowing of artery along with more severe or tighter constrictions of the retinal artery.

In grade 3 - signs of grade 2 but there is also retinal edema, micro-aneurysms, cotton wool spots(fluffy lesions on the retina) and retinal haemorrhages

In grade 4 - has severe signs of grade 3 along with optic disc sweeling called macular edema and papilledema.

4. Heart failure does not mean the heart has stopped working. Rather, it means that the heart's pumping power is weaker than normal or the heart has become less elastic. With heart failure, blood moves through the heart's chambers less effectively and the pressure in the heart increases, making it harder for your heart to deliver oxygen and nutrients to your body. To compensate for reduced pumping power, the heart's chambers respond by stretching to hold more blood. This keeps the blood moving , but over time, the heart muscle walls may weaken and unable to pump as strongly. As a result, the kidneys often respond by causing the body to retain fluid and sodium. The resulting fluid buildup in the arms, legs, ankles, feet, lungs or other organs and is called congestive heart failure. High blood pressure may also bring on heart failure by causing left ventricular hypertrophy, a thickening of the heart muscle that results in less effective muscle relaxation between heartbeats. This makes it difficult for the heart to fill with enough blood to supply the body organs, especially during exercise, leading your body to hold on to fluids and your heart rate increase.

5. Possible signs of CHF are

Shortness of breath - if a person has congestive heart failure, they may have difficulty breathing, especially when he or she is active. When congestive heart failure worsens, fluid backs up into the lungs and interfers with oxygen getting into the blood, causing dyspnea at rest and at night (orthopnea). The individual may awaken at night short of breath and have to sit or stand up to get relief. This condition is known as paroxysmal nocturnal dyspnea. As the fluid buildup in the lungs becomes very severe, a frothy, pink liquid may be coughed out. several pillows are required for comfortable sleep

Fluid retention and swelling- puffy swelling in the legs, feet, ankle may occur particularly at the end of the day or after prolonged sitting. Pitting edema can occur when edeme pressing down on the skin in the puffy areas. The indentation where the finger pressed may be visible for few minutes. Swelling may be severe as to reach up to the hips, scrotum, abdominal wall, and eventually the abdominal cavity (ascites). Daily weight check are necessary in persons with heart failure because the amount of fluid retention is usually reflected by the amount of weight gain and increasing shortness of breath.

6. Medication used in treating hypertension are

ANGIOTENSIN CONVERTING ENZYME INHIBITORS - that inhibit the activity of the enzyme (ACE), which is important for controlling blood pressure. Angiotensin II is a very potent chemical formed in the blood by ACE from angiotensin I. Angiotensin II causes the muscles surrounding blood vessels to contract thus narrowing the vessels and increasing blood pressure. Examples are enalapril, captopril, ramipril.

BETA BLOCKERS - that block norepinephrine and epinephrine from binding to both beta 1 and beta 2 receptors on organs and muscles, including the muscles surrounding blood vessels that cause the blood vessels to narrow and the haert to beat. By blocking the effect of noeepinephrine and epinephrine, beta blockers reduce blood pressure by dilating blood vessels and reducing heart rate. Examples are atenolol, carvedilol, labetalol, metoprolol, propranolol.

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