What are the initial drugs of choice for HTN?
ACE inhibitors
Angiotensin receptor blocker
Thiazide diuretics
Ca channel blockers
What lifestyle changes should be made for a pt with HTN?
Stop smoking
Blood glucose and lipid control
Healthy diet - less alcohol and Na
Increase physical activity
Which system of hypertensive retinopathy is graded in groups?
Keith-Wegner-Barker
What is KWB group 1 defined as?
Slight narrowing, sclerosis, and tortuosity of the retinal arterioles; mild, asymptomatic HTN
What is KWB group 2 defined as?
Definite narrowing, focal constriction, sclerosis, and AV nicking; BP is higher and sustained; few if any, symptoms referable to BP
What is KWB group 3?
Retinopathy (CWS, arteriosclerosis, hemorrhages)
BP is higher and more sustained
Headaches, vertigo and nervousness
Mild impairment of cardiac, cerebral and renal function
What is KWB group 4?
Neuroretinal edema, including papilledema;
Siegrist streaks, Elscnhig spots
BP persistently elevated
Headaches, asthenia, loss of weight, dyspnea, visual disturbances
Impairment of cardiac, cerebral, and renal function
What is modified Scheie grade 0?
No changes
What is modified Scheie grade 1?
Barely detectable arterial narrowing
What is modified Scheie grade 2?
Obvious arterial narrowing, with focal irregularities
What is modified Scheie grade 3?
Grade 2 plus retinal hemorrhages and/or exudates
What is modified Scheie grade 4?
Grade 3 plus disc swelling
What occurs in the vasoconstrictive sates of HTN?
Generalized narrowing of the retinal arterioles
Decrease in AVR
What is the initial response to increased BP?
Vasoconstriction
What occurs in the sclerotic stage of HTN?
Hyperplasia and thickening of the arteriole walls
Increased ALR
AV crossing changes
What occurs in the exudative stage of HTN?
Autoregulation fails and high BP is transmitted to capillaries
Hemorrhages (flame>blots), CWS, exudates
Optic nerve swelling
What are the symtpoms of hypertensive encephalopathy?
HTN, headaches, nausea, papilledema, accelerated BP
There is a direct relationship between AV nicking / arteriolar narrowing and what?
Increased risk of stroke and heart disease
CWS are really what?
Soft exudates
What is the pathogenesis of hypertensive choroidopathy?
Elevation in systemic BP -> fibrin-platelet obstruction -> obstruction of choroid arteries and choriocapillaries -> necrosis of overlying RPE -> fibrinous exudation
Hypertensive choroidopathy is associated with what?
Moderate and severe HTN retinopathy
T or F the choroid doesn’t autoregulate.
True
What are Elschnig spots?
Choroidal exudation
Changes in the RPE from the non-perfused areas of the choriocapillaris
“moth-eaten appearance”
What is HTN crisis, according to JNC-8?
> 180/>110
Terminal organ damage
What is hypertensive urgency?
> 180/110
May have headaches
No progressive TOD
HTN ret w/o disc edema
What is hypertensive emergency?
>180/110 Progressive/threatening TOD Headaches Shortness of breath Dizziness HTN ret WITH disc edema
What signs/symptoms should be present to call 911 for HTN?
Bilateral disc swelling with headaches
Confusion
Dyspnea
Extremity swelling
What signs/symptoms should be present to send a pt to the ER for HTN?
Bilateral disc swelling
Headaches
Exudates, hemes, CWS (suggest TOD)
What ocular diseases may present secondary to HTN?
Hypertensive retinopathy Retinal vein occlusions Retinal artery occlusions Ocular ischemic syndrome Macroaneurysm CN palsies (III, IV, VI) Sub-conj hemes Anterior ischemic optic neuropathy Hypertensive choroidopathy
What part of the vessel does atherosclerosis affect?
Intimal layer
What happens in atherosclerosis?
Nodular lesions that contain lipid, fibrous tissue, and Ca block it
Plaques are present
What does arteriosclerosis affect?
Smaller arteries
What parts of the arteries are affected in arteriosclerosis?
Intimal and medial layers
What occurs in arteriosclerosis?
Endothelial hyperplasia
Intimal hyalinization
Medial hypertrophy
What are the risk factors for retinal venous occlusion?
Hypertension Increased age Increased LDL DM Blood hyperviscosity POAG Periphlebitis
What causes a vein occlusion?
Thickening of the arterial walls inside the shared adventitia compresses the vein
Turbulence of flow results in endothelial cell damage and thrombotic occlusion
Which needs a large thrombus in a bottleneck location to occlude, CRVO or BRVO?
CRVO
Where are branched retinal vein occlusions the most common?
Superior temporal arcade
What are the 4 risk factors for BRVO?
History of systemic arterial HTN
Cardiovascular disease
Increased body mass index at 20 years of age
History of glaucoma
What signs are commonly seen in BRVO?
Flame hemes
CWS
(vein is missing)