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1、Primary Eye Carefor The Hypertensive Patient TiffenieHarris,OD,FAAOAssociateProfessorWesternUniversityCollegeofOptometryMember,AmericanSocietyofHypertensionCOPE 31300-SDPrimary Care OptometristPrimary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual
2、 system, the eye, and associated structures as well as diagnose related systemic conditions -AmericanOptometricAssociation,2005Primary Care OptometristPrimary care optometrists have a significant role in the multidisciplinary approach to the management of hypertensive patientsServe as the sole prima
3、ry eye care provider in more than 3,500 communitiesObjectivesReview of hypertension and updates on epidemiology Review and update hypertensive retinopathyOptometrists role in the management of hypertensive crisesHypertension(HTN)Approximately 65 million people in the US95% are Essential (Primary) HT
4、N, 5% Secondary HTN 29%ofalladults29%ofalladults2% of kids (18yo)7.1 million deaths per year“Silent Killer”Stroke, MI, End-Stage Renal Disease(JNC-7)SeventhReportoftheJointNationalCommitteeonPrevention,Detection,EvaluationandTreatmentofHighBloodPressureNewHypertensionGuidelinesSBP/DSPNormal120/160/1
5、00mmHg Why2003guidelines?Wasnt 140/90 normal?Patients with “normal” BP still suffered CVDBP and CVD morbidity and mortality begins at 115/75JNC-7KeyMessagesBenefits of Early HTN Treatment35% to 40% mean reduction in strokes20% to 25% mean reduction in heart attacksSBP greater risk factor in those 50
6、 Age related HTN is predominantly systolic JNC-7KeyMessagesHTNTreatmentThiazide-typediureticsThiazide-typediureticsshould be initial drug therapy for most, either alone or combined with other drug classesMost patients will require two or more antihypertensive drugs to achieve goal BPDiuretics First
7、Line TherapyLowest does to achieve desired goalBest complianceCost effectiveEnhances the effectiveness of other agentsJNC-7KeyMessagesHTNTreatmentDiabetics: must have BP control 130/80Chronic Kidney Disease: BP control 55, 65 for women Socioeconomic status: less educated/lower income Hereditary: HTN
8、, DM, Renal Disease, CVDDyslipidemia (low HDLHDL is predominately due to hereditary)RiskFactorsforHTNModifiableObesity apple vs. pearSalt intake -(DASHdiet)(DASHdiet)Smoking and Alcohol consumptionPhysical inactivity (150mins/wk)(150mins/wk)Fatty diets, increase cholesterol(high LDLLDL is predominat
9、ely diet/exercise related)Stress-work and/or family?MetabolicSyndrome?MetabolicSyndrome?HTN and Metabolic SyndromeAtermusedtodescribetheclusteringofseveraldisordersthatcoexistmorefrequentthanbychanceThepresenceof3ormoreofthefollowingconditions:1.Abdominal obesity - apple vs. pear2.BP 130/853.High tr
10、iglycerides 1504.HDL 110 - central obesity is also associated with insulininsulinresistanceresistance, , which has been proposed as a factor potentially linking obesity, glucose intolerance, and dyslipidemia to hypertension PrimaryCareOptometristsProactive in patient care and patient educationPerJNC
11、-7:PerJNC-7:“trust in the clinician improves patient motivation and compliance”Co-manage/monitor with PCP, advise when outside guidelinesStatusUpdate:ExpectedAvailabilityforPublicReviewandComment:Fall2011Fall2011ExpectedReleaseDate:Spring2012Spring2012Last Updated April 2011JNC8When?JNC-8Whatwillita
12、dd?Much more evidence based then JNC 7 or 6May address:Combo therapy 1st v. diuretics?BP goals in the elderly: raise it up to 150/80 with compelling factors135/85 for diabetics WITH hypertension*Grossman E, Messerli F. Management of blood pressure in patients with diabetes.Am J Hypertens. 2011 Apr 2
13、8. Epub ahead of printComprehensiveEyeExaminationPretesting Include in-office BPBlood pressure readings at every comprehensive examination and as needed during a problem focused visit Use the correct cuff sizeIsBPmeasurementpartofyourdailyroutineinpatientcare?250 OD/250 OMD were surveyedOf those res
14、ponding:85 % of OD and 87 % of OMD reported that they did routinelyquestionquestiontheir patients about BPOf those owning BP measuring equipment, approximately 20%20%of both professions reported measuring BP not routinelyHarris MG, Gan CM, et al. Blood pressure measurement by eye care practitioners.
15、 J Am Optom Assoc 1994;65(7):512-6.History,History,andmoreHistoryExplore chief complaint and review medical and family histories for assessment of cardiovascular risk factorsReview medications and compliance as well as current and previous BP controlHomemonitoringofBP?HomemonitoringofBP?HomeBPMonito
16、ring(HBPM)?There is convincing evidence accumulated in the last decade on the clinical usefulness of HBPM for the initial diagnosis and long-term follow-up of treated HTN*DaytimeBP140/90willhavelessriskof*DaytimeBP90 and 110 to 120Severe aka “Malignant”Moderate findings in addition to ON swelling120
17、Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.BetterCorrelationwithPrognosisGradeofGradeofRetinopathyRetinopathySystemicAssociationsSystemicAssociationsMildModest associations with risk of stroke, heard disease, and deathModerateStrong association with risk of stroke, d
18、eath from CVDSevere aka “Malignant”Strongest association with stroke, death from CVDWong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.RetinalVasculatureResponseChronicPhaseVasoconstrictivestage:Initial response to increase BP is vasoconstriction Generalized narrowing of the
19、 retinal arteriolesDecrease in the AVR, justnoticeablejustnoticeableNormal is the size of artery to veinScleroticstage:Persistently elevated BP cause hyperplasia and thickening of the arteriole wall Increase in the arterial light reflex (ALR)Normal is 1/3 the width of the arteryAV crossing changesCo
20、mpression, deflection, nicking, bankingHumping of the overlying veinRetinalVasculatureResponseAcceleratedExudativestage:DBP 110When autoregulation fails, the high BP is transmitted directly to the capillariesHemorrhages (flameblots), CWS, hard yellow exudatesOptic nerve swelling*Indicativeofthesever
21、ityofHTNand*IndicativeoftheseverityofHTNandmoststronglyassociatedwithmoststronglyassociatedwithincreasedstrokerisks*increasedstrokerisks*HTNRetinopathyandCardiovascularRisksJNC 7 did not specify the grade/stage of HTN retinopathy ARIC study showed that generalized arteriolar narrowing and AV nicking
22、 have been associated with increase of stroke and heart disease2-3x greater incidence of stroke over 3yr period when HTN retinopathy included CWS, hemes, or exudatesHTNRetinopathyandCardiovascularRisksBlueMountainEyeStudy found a prevalence of retionpathy in 9.8% of nondiabetic, normotensive patient
23、sAprox 55% of study patients with arterioloar narrowing and AV nicking did not have HTNkeeping in mind this studywaspublishedin1994!Arteriolosclerosis or HTN retinopathy?Abnormalitiesoftheretinalvasculaturedemonstratingthe“mild” formofHTNretinopathymayreflectmicrovasculardamageduetohypertensionorart
24、eriolosclerosisorbothPerform Routine BP!Mild AVR 1/2A/V crossing “nicking”ModerateHTNRetinopathyCotton Wool Spots (CWS)Results from ischemic infarction of the NFL bundlesMost commonly within 3-5 DD of the discDetection of CWSCWS is a crucial clinical findingRetinal manifestation of hypertension indu
25、ced systemic damage to the brain (small vessel ischemic disease in brain)Also associated with DM, SLE, and AIDSDiabeticandHypertensiveImpaired autoregulation alters endothelial cell functionHypothesized that HTN causes increase in VGEF accelerate DRStudies have found that control BP can minimize DRA
26、ctivation of RAAS in DM HTN (2011)Optometry Nov 2005;76(11):653-656J Clin Hypertens 2011;13(4):224-237Severe(Malignant)HTNRetinopathyHypertensiveChoroidopathyAssociated with Moderate and Severe HTN retinopathyIndicates choroidal vascular sclerosis and ischemia affecting the RPEMost often seen in you
27、nger patients with accelerated BP220/120mmHgFollow-up Recommendations Retinopathy B/P Follow-up Mild 120/80 RTC x 1- 2 yrs 120-139/80-89 RTC x 1 yr Moderate 140-159/90-99 RTC x 3-6 mos 160-179/100-109 MD in 2-4wks The scheduling of follow-up should be modified by clinical findings, reliable information about past BP, and other cardiovascular risk factors.Questions
