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Clipping is a handy way to collect and organize the most important slides from a presentation. Normal or optimal blood pressure (BP) is defined as the level above which minimal vascular damage occurs. The role of altered salt excretion by the kidney as a central mechanism in the development of hypertension was proposed by Arthur C.
A detailed history and physical examination is essential for identifying risk factors and stratifying patients to target those who need more aggressive therapy to achieve goal BP.
Careful measurement of BP should be an integral part of any physical examination in a physician's office.
In addition to office BP measurements, 24-hour ambulatory BP monitoring and home BP monitoring are now acceptable methods for evaluating BP more comprehensively on an individual basis.
The recently released National Institute of Health and Clinical Excellence (NICE) guidelines published in the United Kingdom recommend that a diagnosis of primary hypertension should be confirmed with 24-hour ambulatory blood pressure monitoring or home blood pressure monitoring rather than by relying solely on office blood pressure measurement.
Based on 24-hour ambulatory BP monitoring and office BP readings, 4 patterns of BP have been described (Figure 1). Masked hypertension is defined as normal office BP and elevated home BP.10 Its prevalence ranges from 8% in the general population to as much as 20% in hypertensive patients receiving treatment. Patients with white coat hypertension have an elevated office BP and normal home BP measurements.
Normally, there is a diurnal variation in BP, with a 10% to 20% decrease in systolic BP during sleep, which is described as the normal dipping pattern. Several prospective trials have demonstrated that home BP is a better predictor of cardiovascular morbidity and mortality than are office BP measurements. These home BP measurement guidelines recommend that a validated device be used to measure BP at home. Measures of arterial stiffness such as central (aortic) blood pressure and pulse wave velocity (PWV) can now be measured non-invasively in an outpatient setting.
Baseline blood tests are recommended by JNC 7 to identify those individuals at risk for hypertensive events (Table 1).
More extensive testing for identifiable causes is not generally indicated unless blood pressure control is not achieved. Proper technique of BP measurement should be an integral part of the evaluation and management of hypertension. Home blood pressure recording is now recommended as an inexpensive and accurate method of measuring blood pressure.
Patterns of BP based on ambulatory BP monitoring play an important role in altering therapy and outcomes.
Laboratory examination helps in stratifying patients who will need more extensive evaluation and aggressive therapy.
It is clearly recognized that an increasing BP level is associated with a greater risk of heart attack, stroke, and kidney disease. Data from clinical trials published after the release of JNC 7 have provided new information that will likely be addressed in JNC 8.
Educating patients regarding the importance of non-pharmacologic interventions for effective BP control is an important component of reducing cardiovascular risk in the general population. Lifestyle modifications include limiting alcohol intake, increasing physical activity, and reducing sodium intake to <6 g of sodium chloride daily. Weight reduction of as little as 10 to 12 pounds in an obese hypertensive patient can have a considerable effect on elevated BP. Table 4 lists lifestyle modifications for which evidence-based data are available to support BP reductions. The ALLHAT trial was designed to compare antihypertensive therapy using an ACE inhibitor, a dihydropyridine calcium antagonist, and an alpha-adrenergic blocker with treatment with an oral diuretic, chlorthalidone, as the standard of therapy. Trial-design issues subsequently generated significant debate regarding the ALLHAT results, particularly the magnitude of the differences noted. In addition to thiazide diuretics, JNC 7 guidelines also recommend ACE inhibitors, angiotensin receptor blockers (ARBs), beta blockers, and calcium channel blockers as first-line therapy for hypertension. Since the release of JNC 7, new information has emerged in the area of anti-hypertensive therapy. In the Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial, which included hypertensive adults at high risk for cardiovascular events, patients were randomly assigned to receive the ACE inhibitor benazepril plus either the calcium channel blocker amlodipine or the diuretic hydrochlorothiazide.28 There was significant reduction in morbidity and mortality in patients in the benazepril plus calcium channel blocker group compared to conventional diuretic based therapy.
Data from large intervention trials in hypertension clearly demonstrate that patients enrolled in these trials required an average of more than 2 medications for blood pressure control.19,24 It is also true that about two-thirds of patients with hypertension required more than 1 anti-hypertensive medication for BP control. Classification of hypertension is based on BP levels as well as comorbidities such as heart disease, diabetes, and renal disease. Lifestyle intervention should be recommended for patients with prehypertension and all stages of hypertension.
Approximately 5% of patients with hypertension have a secondary etiology that leads to an elevation in blood pressure. Renovascular disease: New onset of uncontrolled hypertension or acute worsening of previously well-controlled hypertension in an older individual could likely be due to renal artery stenosis as a result of atherosclerotic renal artery disease.
Pheochromocytoma: These are chromaffin cell tumors that arise in the adrenal medulla or sympathetic ganglia and cause excess production and secretion of catecholamines. Coarctation of aorta: These patients present with radiofemoral pulse delay and a relatively weaker pulse in the legs compared to arms. Balloon angioplasty in patients with FMD; medical management with ACE inhibitor or ARB in combination with a diuretic for patients with atherosclerotic renal artery disease. Plasma aldosterone renin ratio, salt loading test for confirmation, CT scan of adrenal and adrenal vein sampling for localization. In a patient with adrenal hyperplasia or bilateral functional adrenal adenoma, medical therapy with aldosterone antagonist. In a patient with unilateral functional adenoma, adrenalectomy of the affected adrenal gland. Plasma metanephrines, 24-hour urinary metanephrines and catecholamines, CT, MRI, metaiodobenzylguanidine scan if CT or MRI are not conclusive. Balloon angioplasty in patient with FMD; medical management with ACE inhibitor or ARB in combination with a diuretic for patient with atherosclerotic renal artery disease. A careful history and physical examination of patients with hypertension provides important clues that help in the diagnosis of secondary hypertension. Some forms of secondary hypertension are potentially curable when the underlying pathology is treated.
Resistant hypertension (RH) is defined as blood pressure that remains above goal in spite of the concurrent use of 3 antihypertensive agents of different classes. Recent American Heart Association (AHA) guidelines also include patients who are well controlled but require 4 or more medications as having resistant hypertension.
Resistant hypertension can be thus broadly divided into pseudo-resistant hypertension and true resistant hypertension (Table 8).32 Among patients with pseudo-resistant hypertension, sub-optimal anti-hypertensive therapy has been identified as an important cause leading to uncontrolled hypertension.
Obstructive sleep apnea (OSA) is increasingly being recognized as an important cause for the development of resistant hypertension. Management of resistant hypertension includes a detailed history, accurate BP measurement, recommending lower dietary salt intake, and other lifestyle interventions.
Baroreceptor activation therapy is performed using a Rheos baroreflex hypertension therapy system which is surgically implanted in the subclavicular region. The Symplicity renal denervation system uses a catheter to perform radiofrequency ablation when applied to the lumen of renal arteries through a femoral access. These interventions are not yet FDA approved but hold promise to lower blood pressure in patients with resistant hypertension. Approximately 1% of Americans with hypertension are estimated to be affected by hypertensive crises. Hypertensive emergencies are more common in patients with essential hypertension (20%-30% in Caucasians and 80% in African Americans). Patients with hypertensive emergencies may present with hypertensive encephalopathy, intracerebral hemorrhage, acute myocardial infarction, acute left ventricular failure with pulmonary edema, unstable angina pectoris, dissecting aortic aneurysm, or eclampsia. Underlying history of hypertension is an important factor in patients who develop hypertensive crisis. Triaging patients with hypertensive emergencies early and initiating parenteral antihypertensive therapy helps to limit target organ damage.
Overly rapid lowering of BP to normal levels in patients with hypertensive emergencies should be avoided as it can cause renal, cerebral, and coronary ischemia.
It must be emphasized that accurate measurement of blood pressure is of fundamental importance in management of hypertension. Egan BM, Zhao Y, Axon RN: US trends in prevalence, awareness, treatment, and control of hypertension, 1988-2008. Sarafidis PA, Li S, Chen SC, et al: Hypertension awareness, treatment, and control in chronic kidney disease.
Pickering TG, Davidson KW, Rafey MA, et al: Masked hypertension: are those with normal office but elevated ambulatory blood pressure at risk?
Verdecchia P, Reboldi GP, Angeli F, et al: Short- and long-term incidence of stroke in white-coat hypertension.
Pogue V, Rahman M, Phillips R, et al: Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Beckett NS, Peters R, Fletcher AE, et al: Treatment of hypertension in patients 80 years of age or older.
Appel LJ, Wright JT Jr, Greene T, et al: Intensive blood-pressure control in hypertensive chronic kidney disease.
The ACCORD Study Group: Effects of intensive blood-pressure control in type 2 diabetes mellitus.
Appel LJ, Moore TJ, Obarzanek E, et al: A clinical trial of the effects of dietary patterns on blood pressure.
Julius S, Nesbitt SD, Egan BM, et al: Feasibility of treating prehypertension with an angiotensin-receptor blocker.
PROGRESS Collaborative Group: Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Che Q, Schreiber MJ Jr, Rafey MA: Beta-blockers for hypertension: are they going out of style? Jamerson K, Weber MA, Bakris GL et al: Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. Yusuf S, Teo KK, Pogue J et al: Telmisartan, ramipril, or both in patients at high risk for vascular events. Please, complete the form with your suscription data.If you are a member of the Spanish Society of Cardiology, you can use the same login and password that you use to access the Society's website. Diabetes mellitus, more commonly known as diabetes, is a condition of elevated blood sugar levels (hyperglycaemia) which can affect various organs, including the eyes. Type 1: results from a failure to produce adequate levels of insulin, often presenting in teenage years. Type 2: most common type due to development of a resistance to insulin, usually affects people over the age of 45yrs.
Diabetic retinopathy is the term used when the raised blood sugar damages the retina (image capturing tissue at the back of the eye).
Background retinopathy This is the earliest stage whereby high sugar levels weaken and damage the retinal blood vessels. Pre-proliferative retinopathy Also known now as "non-proliferative retinopathy", there are more advanced signs in the retinal circulation, with visible changes in the blood vessels suggestive of a restricted blood flow to the eye.


Proliferative retinopathy This arises when the damaged retina releases growth chemicals which encourage new retinal blood vessels to grow (retinal neovascularisation). Proliferative diabetic retinopathy right eye with new blood vessels and pale scar tissue extending from the optic nerve above and below.
Another newer approach to treat proliferative retinopathy is to block the chemical messengers which are responsible for the new blood vessel growth. In very advanced cases of proliferative diabetic retinopathy bleeding can occur into the jelly of the eye resulting in sudden loss of vision = vitreous haemorrhage or scar shrinkage from leaking blood vessels can cause a retinal detachment. Diabetic maculopathy The macular is the central part of the retina and is responsible for detailed central vision eg reading, recognising faces. Diabetic maculopathy can occur with any of the stages of retinopathy mentioned above ie background, pre-proliferative or proliferative retinopathy. Checking for diabetic retinopathy has become very much more standardised since the introduction of the NHS Diabetic Eye Screening Programme.
Everyone on a general practitioners database with a diagnosis of diabetes, over the age of 12yrs, is invited to attend annually for retinal screening. Diabetic nerve damage or diabetic neuropathy, as it is more commonly called, is a neuropathic disorder associated with damage of nerves because of high glucose levels in the blood.
Diabetic neuropathy is a symptomatic problem, but in some diabetics with nerve damage, there are no symptoms at all. Diabetic patients often complain of numbness, pain or tingling in their toes, feet, legs, arms, hands, fingers, hips, buttocks, and thighs. Due to diabetic nerve damage, you may develop troubles in digesting food, which further leads to indigestion, nausea, vomiting, feeling fuller even after eating small amount of food, constipation, diarrhea and troubles while swallowing food.
You may also suffer from high heart beat and pain in the chest, which can eventually lead to heart attack.
Due to autonomic neuropathy, diabetic patients may suffer dis-functioning of sexual organs. Diabetic neuropathy can lead to overall weakness in the body, fatigue, and frequent sweating, even when the temperature is cool.
Early detection and treatment is the best way of controlling diabetic nerve disorder and preventing its long-term consequences. There is a continuous, consistent, and independent relationship between elevated BP and risk of cardiovascular events. The metabolic syndrome, with insulin resistance and elevation in insulin levels, leads to increased sympathetic activity and hypertension.
The history should include details of dietary salt intake and should explore lifestyle patterns and social and psychosocial stressors that could potentially affect BP levels.
Because inaccuracies in blood pressure measurement can occur frequently in clinical practice, the following guidelines should be followed when measuring a patient's BP.9 The patient should be seated comfortably with the back supported and the upper arm bared without constrictive clothing. Twenty-four-hour ambulatory BP monitoring is indicated to rule out white-coat hypertension, to uncover apparent drug resistance (office resistance), to better define resistant hypertension, to identify hypotensive symptoms while the patient is being treated with anti-hypertensive medications, to monitor episodic hypertension, and to identify autonomic dysfunction states. Studies done in patients with sustained hypertension for more than 40 years have consistently demonstrated that this condition is closely related to target organ damage and worse cardiac and renal outcomes. Although there are no outcome trials available in patients with masked hypertension, the fact that elevated ambulatory BP is closely related to cardiovascular events implies that its risk profile is similar to that of sustained hypertension.
The prevalence of white coat hypertension has been reported to be 12% to 18% in the general population. Abnormalities in the normal nocturnal dipping pattern of BP have been associated with worse cardiovascular outcomes, even in subjects who are normotensive.12 A 24-hour ambulatory BP measurement remains the only technique to assess the dipping status of patients. Blood pressure measurements using such validated devices should be taken before an office visit, with at least 2 morning and 2 evening readings everyday for 1 week (but discarding the readings of the first day), which gives a total of 12 BP readings over a week, based on which clinical decisions can be made. Preliminary data from clinical studies indicate that these measures of arterial stiffness may provide better prognostic indices and therapeutic targets in hypertensive patients.15,16 Interventional trials that can test the potential value of treating to a predefined central blood pressure goal for a given brachial blood pressure will clarify the utility of these measures in the future clinical management of hypertension.
In addition, laboratory tests can provide clues to the etiology in those with resistant or secondary hypertension (Table 2). In addition, JNC 7 guidelines do recognize and incorporate the importance of increased cardiovascular risk across a broad spectrum of BP values, as well as a high lifetime risk of developing hypertension (Figure 2). The Hypertension in the Very Elderly Trial (HYVET) trial is the first study that clearly demonstrated the benefits of anti-hypertensive therapy in older patients with hypertension.18 In this study, lowering BP in patients with hypertension (mean age of 84 years) lowered the risk of both stroke and all-cause mortality. Appropriate nutritional counseling can encourage a diet with reduced total fat and cholesterol intake, in addition to providing an adequate daily intake of potassium, calcium, and magnesium. The effects of implementing these modifications are both dose dependent and time dependent and could be greater for some patients.
The Framingham study demonstrates that if prehypertension is left untreated, these patients go on to develop hypertension. The alpha-adrenergic blocker arm of this study was discontinued early in the trial because it was observed that patients receiving an alpha-adrenergic blocker as monotherapy demonstrated twice the risk of congestive heart failure when compared with those treated with an oral diuretic. Nevertheless, it was concluded from this trial that diuretic therapy is as effective as a calcium channel blocker or an ACE inhibitor from the standpoint of the primary outcome of the trial, and diuretic therapy is superior for select subgroup analyses. Based on evidence of improved outcomes, JNC 7 has recommended several medications for compelling indications (Tables 5 and 6). Clinical trials like ASCOT and several meta-analyses have demonstrated that a beta-blocker may not be an appropriate first line medication.
Fixed-dose combinations of 2-3 classes of antihypertensive medications are now approved for management of hypertension. In some conditions, hypertension is potentially curable when the underlying cause is treated.
Impaired renal function can worsen blood pressure control by reducing sodium and water excretion, and leading to volume overload and hypertension. In younger women, fibromuscular dysplasia of renal arteries could lead to uncontrolled hypertension. These patients may also complain of muscle cramping and weakness if they develop severe hypokalemia. Patients may present clinically with wide fluctuations in blood pressure, sustained hypertension, or with abrupt paroxysms of hypertension. Recent data suggest that the incidence rate of resistant hypertension is 2% in patients who were newly diagnosed with hypertension and receiving therapy. In the ALLHAT study more than 25% of patients remained on sub-optimal therapy during the course of the study, although their blood pressures were elevated and anti-hypertensive therapy was provided free of cost as part of the study. In this condition, the measured cuff pressure is inappropriately higher than true intra-arterial blood pressure due to excessive arteriosclerosis and arterial stiffness which is common in the elderly. Several studies have reported a strong correlation between obstructive sleep apnea and hypertension.33 Several mechanisms are hypothesized to explain this association, including chronic night time hypoxemia, altered chemoreceptor stimulation, and activation of the sympathetic and renin-angiotensin systems. Food and medications that interfere with hypertension therapy or cause elevation of blood pressure should be discontinued.
The electrodes connected to this device are attached to the carotid body on each side of the neck.
Factors such as renal failure, heart failure, cerebrovascular accidents, and nonadherence to antihypertensive therapy are associated with hypertensive crisis. When evaluating patients with severe hypertension, it is important to distinguish hypertensive urgency from hypertensive emergency as the treatment plan is based on the diagnosis. Although a majority of patients with hypertension remain asymptomatic, a careful early evaluation identifies those with or at risk for target organ damage with left ventricular hypertrophy and microalbuminuria, both of which portend serious future cardiovascular and renal events.
It is also important to identify the modifiable risk factors that can help improve blood pressure control and reduce cardiovascular and renal damage.
It is more common in type 1 compared to type2 diabetes, but overall affects approximately 80% of people with diabetes once they have had the condition for more than 10 years.
Tiny bulges (called microaneurysms) occur in the blood vessel walls which can result in fluid (exudates) or blood (blot haemorrhages) leaking onto the retinal surface. In milder cases no treatment to the eye is required but more frequent monitoring for new blood vessel growth (retinal neovascularisation) is recommended. Although this may initially seem like a helpful solution to improve the blood supply to the retina, the new vessels are thin and fragile. Fluoroscein dye, injected into a vein in the arm, travels to the eye and highlights abnormal blood vessels by leaking out (bright area above and below the optic nerve). In both circumstances specialist vitreo-retinal surgery, usually a vitrectomy, is often required. The term diabetic maculopathy is used when this important area is affected, usually secondary to leaking retinal blood vessels.
Laser photocoagulation is the traditional treatment but anti-VEGF agents and steroids eg: Ozurdex - dexamethasone intravitreal implant, are also proving to be extremely useful.
This aims to reduce the risk of sight loss in people with diabetes by early detection and treatment. Pictures are taken which are looked at by photographers who have been trained to detect the signs of diabetic eye disease.
Anyone with diabetes will automatically be offered an annual screening photograph, often in a mobile unit near their home.
These types of symptoms commonly occur in peripheral neuropathy, which is said to affect toes, feet, legs, arms and hands. Due to this, you may feel weakness or loss of sensation in the muscles of your feet or hands.
Due to weakening of nerves, they may face issues in holding up urine for long periods, may leak urine or face issues in telling when their bladder is full. Men may face erectile dysfunction, while women report vaginal dryness and difficulty in achieving orgasm.
Daryl Norwood Diabetes CasePresentationR.C is a 57-year-old man with Type 2 diabetes first diagnosed two years ago. Daryl Norwood Weight changes should be monitored to assess the need for more aggressive treatments or diet restriction. This was clearly demonstrated in a meta-analysis that included 1,000,000 individuals with no history of vascular disease. Despite the increase in prevalence, recent data from the National Health and Nutrition Examination Survey (NHANES) demonstrate an improvement in blood pressure control (50%) among Americans with hypertension.3 However, the blood pressure control rate remains suboptimal in people who have serious comorbid conditions such as chronic kidney disease.
The remainder of these patients have hypertension caused by renovascular disease, primary aldosteronism, etc. Guyton's hypothesis, there is impaired excretion of sodium ions by tubular epithelial cells in the kidney. In patients with obstructive sleep apnea, activation of the sympathetic and renin angiotensin systems has been defined as a possible mechanism for elevation in BP.
Ophthalmologic assessment and funduscopic examination are simple techniques to identify the severity of disease and target organ damage by grading retinal changes. Twenty-four-hour ambulatory BP monitoring also helps identify abnormal patterns in blood pressure that could remain undetected if a patient is evaluated based on physician office blood pressure measurements alone.
In fact, patients with masked hypertension might have a worse outcome because they are not easily identified and do not receive adequate therapy. Initially, this was thought to be a benign condition, because prospective trials evaluating white coat hypertension have shown less target-organ damage (increased left ventricular mass, carotid media intimal thickness) than that with sustained hypertension. Nocturnal hypertension defines a pattern of BP where BP measured during sleep is higher than that measured when the patient is awake.
Guidelines of the European Society of Hypertension have incorporated measurement of PWV for risk stratification of patients with hypertension.
In an effort to highlight this relationship between elevated BP and cardiovascular disease, a revised classification of hypertension has been provided by JNC 7 (Table 3). In recent years however, large clinical trials performed in patients with kidney disease and diabetes have failed to demonstrate clear benefit with intense blood pressure control.


However, aggressive efforts are needed to ensure optimal adherence to these recommendations.
The Dietary Approaches to Stop Hypertension (DASH) trial has provided substantial data that a diet rich in fruits, nuts, vegetables, and low-fat dairy products and with an emphasis on fish and chicken rather than red meat lowered BP even without weight reduction and was particularly effective in those who also restricted sodium chloride intake.22 Dietary recommendations must be made on an individualized basis and should be well supported with continued educational and counseling efforts. Also, a combination of 2 or more lifestyle modifications can help patients achieve even better results. Current recommendations center on nonpharmacologic interventions, which include lifestyle modifications such as weight reduction, increased physical activity, and reduced dietary salt intake.
The diuretic, calcium antagonist, and angiotensin-converting enzyme (ACE) inhibitor groups were continued to an average follow-up of 4.9 years, at which time no differences were noted among groups with regard to the primary outcome (fatal coronary disease or nonfatal myocardial infarction) or all-cause mortality. A critical look at the trial design suggests a more prudent conclusion that diuretics should be part of all antihypertensive regimens unless they are clearly contraindicated.
These include beta blockers and aldosterone antagonists in patients with cardiac disease, ACE inhibitors and ARBs in patients with chronic kidney disease, and diuretics and calcium channel blockers in patients with isolated systolic hypertension.
These combinations offer superior efficacy as each agent in the combination blocks the counter regulatory system activity triggered by the other.
In the Modification of Diet in Renal Disease (MDRD) study, the prevalence of hypertension increased linearly from 65% to 95% as the glomerular filtration rate declined progressively toward end-stage renal disease.30 Both hypertension and CKD are independently associated with increased cardiovascular mortality and the effect is amplified in CKD patients with hypertension. Significant renal artery stenosis leads to hypoperfusion of the kidney that results in activation of the renin-angiotensin-aldosterone system leading to retention of sodium and water and worsening blood pressure control. In Cushing syndrome, prolonged exposure to endogenous or exogenous cortisol leads to elevated blood pressure.
Elevations in blood pressure may be associated with palpitations, headache, pallor, tremor and diaphoresis. Results from NHANES survey reveal that prevalence of resistant hypertension in US adults is nearly 9%.
In patients who have uncontrolled hypertension despite being on adequate anti-hypertensive therapy, it is important to confirm the diagnosis with home BP monitoring or 24-hour ambulatory BP measurement. The thickened and calcified arteries that result from arteriosclerosis are not compressed adequately during inflation of the blood pressure cuff. Frequent night-time hypoxia and hypercapnia also appear to stimulate aldosterone production independent of plasma renin levels. Early identification of these patients and achieving BP goals could reverse early end-organ damage and improve outcomes in these patients.
Certain classes of medications appear to have a more beneficial effect than others in managing high-risk patients with hypertension leading to the recommendation of compelling indications. Diabetic retinopathy is the commonest cause of severe sight impairment in the UK's working population.
This process often occurs "silently" and the patient is unaware, with no symptoms or change in vision.
Lifestyle changes can be important to reverse the retinal signs eg: balanced diet, regular exercise, blood pressure and blood sugar control. Anti-VEGF drugs eg: Avastin, Lucentis, which are already established treatments for macular degeneration (see AGE RELATED MACULAR DEGENERATION section), are currently being trialled for use in diabetic eye disease.
Another very serious sign of advanced diabetic eye disease is the development of new blood vessels on the iris, at the front of the eye, which results in raised eye pressure = rubeotic glaucoma.
This "waterlogging" can occur silently without there being any symptoms or often the person affected will be aware of reduced vision in the eye.
Although a national initiative the programme is delivered locally in line with set standards and protocols. The result is usually available within 4-6 weeks and if anything significant is detected the patient will be seen by an ophthalmologist in Eastbourne, Bexhill or the Conquest Hospitals. Though diabetics can develop diabetic neuropathy at any time during their life, the risk is said increase as the age or disease progresses. The most common early signs of diabetic nerve damage include numbness or pain in feet and hands, along with tingling.
To maintain salt and water homoeostasis, the body adopts a pressure-natriuresis approach that ultimately leads to an elevation in BP.
The arm should be supported at the level of the heart, and the bladder of the BP cuff should encircle at least 80% of the arm circumference. Clinical studies evaluating cardiovascular outcomes have consistently demonstrated a lower morbidity with white coat hypertension, supporting a more benign course.
In the African American Study of Kidney Disease and Hypertension (AASK), an abnormal dipping pattern was detected in 80% of patients and nocturnal hypertension was found in 40%.13 All of these patients with an abnormal dipping pattern and nocturnal hypertension had hypertension that was apparently well controlled based on office BP readings.
Home blood pressure monitoring provides an inexpensive alternative to 24-hour ambulatory BP monitoring which is not yet widely available. The European Society of Hypertension (ESH) and European Society of Cardiology (ESC) 2009 guidelines have embraced the concept of global cardiovascular risk in recommending that patients be classified not only in relation to grades of hypertension but also in terms of total cardiovascular risk, which represents cumulative risk from the coexistence of multiple factors and target organ damage.17 These guidelines stress that the threshold for hypertension and subsequent drug therapy should remain flexible and should be a function of each patient's individual and total cardiovascular risk.
Lifestyle modifications not only reduce BP but also enhance the efficacy of antihypertensive drugs and decrease cardiovascular risk. However, compared with the diuretic (chlorthalidone) group, the calcium antagonist (amlodipine) group had a significantly higher cumulative incidence of heart failure, and the ACE inhibitor (lisinopril) group had significantly higher incidences of heart failure, stroke, and angina pectoris. Further, there was concern that diuretics might worsen glucose tolerance and insulin resistance.
In addition, single fixed-dose combination improves adherence to medications and BP control. Patients may also present with acute worsening in renal function, asymmetric kidney size, or flash pulmonary edema; a systolic diastolic bruit may be heard over the epigastrium.
In addition, these patients may also present with moon facies, prominent supraclavicular fat pad, buffalo hump, truncal obesity, and purple striae. Patients with resistant hypertension are at a significantly higher risk for cardiovascular events compared to those with non-resistant hypertension. In a Spanish cohort of patients who were defined as having resistant hypertension based on the American Heart Association (AHA) criteria and who underwent 24-hour ambulatory BP measurement, 37.5% patients were found to have white coat hypertension.
Rapid lowering of BP to near normal levels is avoided as it could lead to renal, cerebral and coronary ischemia. Analysis of the data from Framingham Heart study demonstrates that a 2-mmHg reduction in blood pressure would result in 14% reduction in the risk of stroke and transient ischemic attacks, and a 6% reduction in risk of coronary heart disease.
Thus anti-hypertensive therapy should be tailored and personalized based on an individual's health profile. No specific treatment is required but patients are encouraged to be strict with their blood sugar monitoring and control. In severe cases laser treatment is applied to the retina to prevent new blood vessel growth. If yes, then do you have diabetes? If you face any of the above symptoms, then there are fair amount of chances that you are suffering from diabetic nerve damage – a progressive disease that can lead to serious health problems. Moreover, the risk is said to be higher in patients who fail to keep their blood sugar levels under control. Animal studies and studies evaluating Mendelian forms of syndromes that manifest as hypertension and hypotension, such as Bartter's syndrome and Liddle's syndrome, have provided insight into the pathophysiology of hypertension.8 These data confirm that the basic problem in conditions leading to alteration in BP lies in the genetic alteration of sodium transport in renal epithelial cells. Based on these studies, it has been hypothesized that white coat hypertension represents an intermediate risk state between normotension and sustained hypertension.
One of the main drawbacks in home blood pressure measurement when compared to 24-hour ambulatory BP monitoring, is that sleep time blood pressures cannot be recorded and therefore those patients with abnormal dipping pattern in blood pressure and nocturnal hypertension will be missed. Smoking cessation should therefore be strongly encouraged for all patients, and education, counseling, and medication should be provided as needed. There is some evidence from clinical trials suggesting that the addition of an aldosterone antagonist to an existing anti-hypertensive regimen a”€ even in those patients with normal or low aldosterone levels a”€ improves blood pressure levels.
It has been proposed that an acute increase in humoral factors leads to systemic vasoconstriction and increased vascular resistance causing elevation in blood pressure. These patients require monitoring in intensive care units and parenteral anti-hypertensive medications (Table 9). The effective management of hypertension is therefore an important primary health care objective in managing cardiovascular and renal disease. For instance, in patients with hypertension associated with unusual features such as early onset of severe hypertension or clinical features such as palpitations and diaphoresis, further evaluation for secondary hypertension is recommended as these conditions are potentially curable.
Since nerve damage occurs over the years, most of the times, initial symptoms are often minor and go unnoticed.
Several factors including aging, sympathetic overactivity, toxins, and a low nephron number have been proposed as factors that could ultimately damage the renal tubules and alter epithelial cells, resulting in defective sodium excretion.
In patients with OSA and resistant hypertension, treatment with aldosterone antagonists and non-invasive positive pressure ventilatory support (NIPPV) may improve blood pressure control.
In contrast, for patients with hypertensive urgency, blood pressure can be lowered gradually over 24-48 hours. On the other hand, patients with severely elevated hypertension and with evidence of target organ dysfunction or damage need to be triaged early and started on parenteral antihypertensive therapy to lower cardiovascular and renal morbidity and mortality.
If secondary hypertension is suspected it should be thoroughly investigated, as in some instances, such as pheochromocytoma or adrenal adenoma, this may be of curable etiology.
In addition to its contributions to hyperglycemia, alcohol has a negative interaction on the drugs Metformin and Simvastatin that can cause liver toxicities. To achieve adequate control of diabetes, lifestyle modifications are an important part of therapy. Dietary restrictions, increase in physical activity, and gradual weight loss will be more beneficial than taking medication, alone. Body fat distribution, rather than overall adiposity, influences serum lipids and lipoproteins in healthy men independently of age. Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al; INTERHEART Study Investigators. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Globalization, coca-colonization and the chronic disease epidemic: can the doomsday scenario be averted?
Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association.
Toumilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Ilanne-Parikka P, et al; Finnish Diabetes Prevention Study Group. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss.
An Update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease From the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Effects of the cannabinoid-1 receptor blocker rimonabant on weight reduction and cardiovascular risk factors in overweight reduction and cardiovascular risk factors in overweight patients: 1-year experience form the RIO-Europe study. Efficacy and tolerability of rimonabant in overweight or obese patient with type 2 diabetes: a randomised controlled study. Efficacy and safety of the weight-loss drug rimonabant: a meta-analysis of randomised trials. Malmberg K, Ryden L, Wedel H, Birkeland K, Bootsma A, Dickstein K, et al; DIGAMI 2 Investigators. Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity.



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