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Hypertension (view source)

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'''Hypertension''' is very common and affects multiple organs. Clinically, it is usually classified as primary (idiopathic) and secondary.   
[[Image:Thrombotic microangiopathy - very high mag.jpg|thumb|right|250px|Micrograph of blood vessels in the kidney showing the changes of chronic [[thrombotic microangiopathy]], as may be seen in malignant hypertension.]]
'''Hypertension''', also '''high blood pressure''', is very common and affects multiple organs. Clinically, it is usually classified as primary (idiopathic) and secondary.   


Hypertensive crisis, if untreated, is associated with damage to the brain, heart, eye and kidneys.<ref name=pmid19899722>{{cite journal |author=Janota T |title=[Hypertensive crisis--the present view] |language=Czech |journal=Cas. Lek. Cesk. |volume=148 |issue=8 |pages=370–3 |year=2009 |pmid=19899722 |doi= |url=}}</ref>   
Hypertensive crisis, if untreated, is associated with damage to the [[brain]], [[heart]], [[eye]] and [[kidney]]s.<ref name=pmid19899722>{{cite journal |author=Janota T |title=[Hypertensive crisis--the present view] |language=Czech |journal=Cas. Lek. Cesk. |volume=148 |issue=8 |pages=370–3 |year=2009 |pmid=19899722 |doi= |url=}}</ref>   


Pulmonary hypertension is dealt with separately in the article ''[[pulmonary hypertension]]''.
Pulmonary hypertension is dealt with separately in the article ''[[pulmonary hypertension]]''.
==Classification==
It is classified by etiology.
===Primary===
*Idiopathic.
*Most common.
===Secondary===
Renovascular:
*[[Fibromuscular dysplasia]] of the renal artery
*[[Atherosclerosis]] of the renal artery.
*Compression of renal artery by a tumour.
Endocrine related - tumours:
*[[Juxtaglomerular cell tumour]] - produces renin.
*[[Pheochromocytoma]].
*[[Renal cell carcinoma]].
*[[Adrenal cortical adenoma]] (aldosterone producing) - Conn syndrome.
*[[Adrenal cortical carcinoma]] (aldosterone producing).
*[[Wilms tumour]].
Other endocrine:
*Hyperthyroidism.
Other:
*Renal failure.
*[[Scleroderma]].
*Sleep apnea.
*Drugs - notably [[alcohol]].


==Brain==
==Brain==
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***Apoptotic smooth muscle cell death and collagen deposition.
***Apoptotic smooth muscle cell death and collagen deposition.


Image: [http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Injury_Images/hypertension1w.jpg C-B aneurysm (ucsf.edu)].
Image: [http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Injury_Images/hypertension1w.jpg C-B aneurysm (ucsf.edu)].<ref>URL: [http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Microvascular.html http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Microvascular.html]. Accessed on: 26 November 2010.</ref>
 
===Intracerebral hematoma===
Most common sites:<ref name=pmid10436114>{{cite journal |author=Tanaka A, Ueno Y, Nakayama Y, Takano K, Takebayashi S |title=Small chronic hemorrhages and ischemic lesions in association with spontaneous intracerebral hematomas |journal=Stroke |volume=30 |issue=8 |pages=1637–42 |year=1999 |month=August |pmid=10436114 |doi= |url=}}</ref>
*Subcortex.
*Putamen.
*Pons.
*Thalamus.
*Cerebellum.
 
Notes:
 
*Memory device:
**Ps and the major structures behind 'em: '''p'''utamen + thalamus, '''p'''ons + cerebellum.
*Two papers<ref name=pmid7910073>{{cite journal |author=Hung TP, Chen ST |title=[Cerebral hemorrhage in Taiwan] |language=Chinese |journal=J. Formos. Med. Assoc. |volume=92 Suppl 4 |issue= |pages=S161–8 |year=1993 |month=December |pmid=7910073 |doi= |url=}}</ref><ref name=pmid2204896>{{cite journal |author=Weisberg LA |title=How to identify and manage brain hemorrhage |journal=Postgrad Med |volume=88 |issue=3 |pages=169–75 |year=1990 |month=September |pmid=2204896 |doi= |url=}}</ref> say putamen is #1 and thalamus is #2.
 
===Lacunar infarcts===
====General====
*Common.
*May be located in the putamen.<ref>URL: [http://moon.ouhsc.edu/kfung/jty1/neurotest/Q04-Ans.htm http://moon.ouhsc.edu/kfung/jty1/neurotest/Q04-Ans.htm]. Accessed on: 26 October 2010.</ref>
 
==Hypertension and the eye<ref>URL: [http://health.indiamart.com/eye-care/hypertension-and-eye.html http://health.indiamart.com/eye-care/hypertension-and-eye.html]. Accessed on: 23 September 2010.</ref>==
==Hypertension and the eye<ref>URL: [http://health.indiamart.com/eye-care/hypertension-and-eye.html http://health.indiamart.com/eye-care/hypertension-and-eye.html]. Accessed on: 23 September 2010.</ref>==
{{Main|Eye}}
* Hypertensive retinopathy.
* Hypertensive retinopathy.
* Aneurysms.
* Aneurysms.
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===General===
===General===
*Treated with antihypertensives.
*Treated with antihypertensives.
*Mechanism of death: (ventricular) arrhythmia.<ref name=pmid15860963/>
*Mechanism of death: (ventricular) [[Cardiac arrhythmia|arrhythmia]].<ref name=pmid15860963/>


====Associated pathology<ref name=pmid15860963>{{cite journal |author=Prisant LM |title=Hypertensive heart disease |journal=J Clin Hypertens (Greenwich) |volume=7 |issue=4 |pages=231–8 |year=2005 |month=April |pmid=15860963 |doi= |url=}}</ref>====
====Associated pathology<ref name=pmid15860963>{{cite journal |author=Prisant LM |title=Hypertensive heart disease |journal=J Clin Hypertens (Greenwich) |volume=7 |issue=4 |pages=231–8 |year=2005 |month=April |pmid=15860963 |doi= |url=}}</ref>====
*Left atrial enlargement and atrial fibrillation.
*Left atrial enlargement and [[atrial fibrillation]].


===Gross===
===Gross===
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*In the autopsy context, significant [[valvular heart disease]] should be absent.
*In the autopsy context, significant [[valvular heart disease]] should be absent.
*A heart > ~400 g is considered good enough for the cause of death ''hypertensive heart disease'', if no other significant findings are present.<ref>MSP. 29 September 2010.</ref>
*A heart > ~400 g is considered good enough for the cause of death ''hypertensive heart disease'', if no other significant findings are present.<ref>MSP. 29 September 2010.</ref>
*Right ventricular hypertrophy is commonly seen.<ref name=pmid22392315>{{Cite journal  | last1 = Sant'Anna | first1 = MP. | last2 = Mello | first2 = RJ. | last3 = Montenegro | first3 = LT. | last4 = Araújo | first4 = MM. | title = [Left and right ventricular hypertrophy at autopsy of hypertensive individuals]. | journal = Rev Assoc Med Bras | volume = 58 | issue = 1 | pages = 41-7 | month =  | year =  | doi =  | PMID = 22392315 }}</ref><ref name=pmid18800141>{{Cite journal  | last1 = Cuspidi | first1 = C. | last2 = Valerio | first2 = C. | last3 = Sala | first3 = C. | last4 = Negri | first4 = F. | last5 = Esposito | first5 = A. | last6 = Masaidi | first6 = M. | last7 = Giudici | first7 = V. | last8 = Zanchetti | first8 = A. | last9 = Mancia | first9 = G. | title = Metabolic syndrome and biventricular hypertrophy in essential hypertension. | journal = J Hum Hypertens | volume = 23 | issue = 3 | pages = 168-75 | month = Mar | year = 2009 | doi = 10.1038/jhh.2008.119 | PMID = 18800141 }}</ref>


Gross DDx:
Gross DDx:
*Hypertrophic cardiomyopathy.
*[[Hypertrophic cardiomyopathy]].


===Microscopic===
===Microscopic===
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**Fibrosis of media.
**Fibrosis of media.
*Peirarteriolar fibrosis.
*Peirarteriolar fibrosis.
*Nuclear enlargement (6-7 micrometres).<ref name=pmid16723792>{{Cite journal  | last1 = Koda | first1 = M. | last2 = Takemura | first2 = G. | last3 = Okada | first3 = H. | last4 = Kanoh | first4 = M. | last5 = Maruyama | first5 = R. | last6 = Esaki | first6 = M. | last7 = Li | first7 = Y. | last8 = Miyata | first8 = S. | last9 = Kanamori | first9 = H. | title = Nuclear hypertrophy reflects increased biosynthetic activities in myocytes of human hypertrophic hearts. | journal = Circ J | volume = 70 | issue = 6 | pages = 710-8 | month = Jun | year = 2006 | doi =  | PMID = 16723792 | URL = http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--linkout.jstage.jst.go.jp-logo.gif}}</ref>
**Normal cardiac myocyte nucleus ~4-5 micrometers.<ref name=pmid16723792/>


==Kidney==
==Kidney==
:See: ''[[hyperplastic arteriolosclerosis]]''.
:See: ''[[thrombotic microangiopathy]]''.
===General===
===General===
*May result in renal failure.
*May result in renal failure.
*Hypertension in the kidney may be:
*#Primary, i.e. seen in isolation.
*#Secondary, i.e. it arises due to another kidney disease.
===Gross===
*Granular appearance of the surface.
Note:
*Normal kidneys have a smooth surface.
Image:
*[http://www.sciencephoto.com/media/257407/enlarge Hypertensive kidney (sciencephoto.com)].


===Microscopic===
===Microscopic===
Features:<ref name=pmid9356598>{{cite journal |author=Ono H, Ono Y |title=Nephrosclerosis and hypertension |journal=Med. Clin. North Am. |volume=81 |issue=6 |pages=1273–88 |year=1997 |month=November |pmid=9356598 |doi= |url=}}</ref>
Features:<ref name=pmid9356598>{{cite journal |author=Ono H, Ono Y |title=Nephrosclerosis and hypertension |journal=Med. Clin. North Am. |volume=81 |issue=6 |pages=1273–88 |year=1997 |month=November |pmid=9356598 |doi= |url=}}</ref>
*Fibrinoid necrosis of afferent and interlobular arteries (due to endothelial cell damage).
*[[Fibrinoid necrosis]] of afferent and interlobular arteries (due to endothelial cell damage).


Notes:
Malignant hypertension - characterized by:<ref>{{Ref Klatt|7}}</ref>
*Diabetes mellitus has changes in the afferent and efferent arteriole (see ''[[medical kidney diseases]]'').
*[[Hyperplastic arteriolosclerosis]] - onion skin-like appearance of intima & media with luminal narrowing (chronic change).
 
Note:
*[[Diabetes mellitus]] has changes in the afferent and efferent arteriole (see ''[[medical kidney diseases]]'').
 
==Malignant hypertension==
===General===
*A medical emergency.
 
Defined as either of the following:<ref name=pmid14689106/><ref>{{Cite journal  | last1 = Lenz | first1 = K. | title = [Treating a hypertensive emergency]. | journal = MMW Fortschr Med | volume = 146 | issue = 15 | pages = 42, 44, 46-8 | month = Apr | year = 2004 | doi =  | PMID = 15373020 }}</ref>
# >220 mmHg systolic BP.
# >120 mmHg diastolic BP.
 
Prognosis:
*Depends on the acute rise in blood pressure.<ref name=pmid14689106>{{Cite journal  | last1 = Gegenhuber | first1 = A. | last2 = Lenz | first2 = K. | title = [Hypertensive emergency and urgence]. | journal = Herz | volume = 28 | issue = 8 | pages = 717-24 | month = Dec | year = 2003 | doi = 10.1007/s00059-003-2506-8 | PMID = 14689106 }}</ref>
**Adverse outcomes may arise even when the BP is not at the levels given above.
*Usually better than with [[HUS]].<ref name=pmid18497467>{{Cite journal  | last1 = Zhang | first1 = B. | last2 = Xing | first2 = C. | last3 = Yu | first3 = X. | last4 = Sun | first4 = B. | last5 = Zhao | first5 = X. | last6 = Qian | first6 = J. | title = Renal thrombotic microangiopathies induced by severe hypertension. | journal = Hypertens Res | volume = 31 | issue = 3 | pages = 479-83 | month = Mar | year = 2008 | doi = 10.1291/hypres.31.479 | PMID = 18497467 }}</ref>
 
===Microscopic===
Features:
*See: ''[[thrombotic microangiopathy]]''.
 
Histomorphologic DDx (thrombotic microangiopathy):
*[[HUS]].
*[[TTP]].
*[[DIC]].
*[[Scleroderma]] renal crisis.
*[[ALPA syndrome]].
*Drug reaction, e.g. calcineurin inhibitors.


==See also==
==See also==
*[[Pulmonary hypertension]].
*[[Pulmonary hypertension]].
*[[Portal hypertension]].
*[[Sudden natural death]].
*[[Vascular disease]].
*[[Vascular disease]].
*[[Decidual vasculopathy]] - seen in gestational hypertension.


==References==
==References==
Michael
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