Difference between revisions of "Hypertension"

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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 [[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]]''.
 
==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==
Charcot-Bouchard aneurysms:<ref name=pmid16450803>{{cite journal |author=Auer RN, Sutherland GR |title=Primary intracerebral hemorrhage: pathophysiology |journal=Can J Neurol Sci |volume=32 Suppl 2 |issue= |pages=S3–12 |year=2005 |month=December |pmid=16450803 |doi= |url=}}</ref>  
===Charcôt-Bouchard aneurysms===
*[[AKA]] miliary aneurysms.
====General====
*[[Intercerebral hematoma]]s.
*[[AKA]] ''miliary aneurysms'' and ''microaneurysm''.<ref name=pmid17416106>{{cite journal |author=Kojima H, Eguchi H, Mizutani T, Tanaka K, Kikuchi Y, Fukudome N |title=Three-dimensional analysis of pathological characteristics of a microaneurysm |journal=Clin. Neuropathol. |volume=26 |issue=2 |pages=74–9 |year=2007 |pmid=17416106 |doi= |url=}}</ref>
*Associated with [[Intracerebral hemorrhage]]s.
*Classically found in the basal ganglia or the pons.<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: 24 September 2010.</ref>
 
====Microscopic====
Features:<ref name=pmid16450803>{{cite journal |author=Auer RN, Sutherland GR |title=Primary intracerebral hemorrhage: pathophysiology |journal=Can J Neurol Sci |volume=32 Suppl 2 |issue= |pages=S3–12 |year=2005 |month=December |pmid=16450803 |doi= |url=}}</ref>  
*Small aneurysms (~300 micrometers) with a fusiform shape.
*Vessel wall changes:
**Early:
***Proliferation of arteriolar smooth muscle
**Late:
***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)].<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>==
{{Main|Eye}}
* Hypertensive retinopathy.
* Aneurysms.
* Branch retinal vein occlusion (BRVO).
* Vitreous hemorrhage.
 
==Hypertensive heart disease==
===General===
*Treated with antihypertensives.
*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>====
*Left atrial enlargement and [[atrial fibrillation]].
 
===Gross===
Features:<ref name=pmid11151783>{{cite journal |author=Schwartzkopff B, Strauer BE |title=Coronary reserve and arteriolosclerosis in hypertensive heart disease |journal=Z Kardiol |volume=89 Suppl 9 |issue= |pages=IX/132–5 |year=2000 |pmid=11151783 |doi= |url=}}</ref>
*Left ventricular hypertrophy (concentric).
 
Notes:
*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>
*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>


==Eye==
Gross DDx:
*Blindness.
*[[Hypertrophic cardiomyopathy]].


==Heart==
===Microscopic===
*Concentric hypertrophy.
Features:<ref name=pmid11151783/>
*Arteriolosclerosis of intramural coronary arteries and arterioles.
**Fibrosis of media.
*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==
*Renal failure.
:See: ''[[hyperplastic arteriolosclerosis]]''.
:See: ''[[thrombotic microangiopathy]]''.
===General===
*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===
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).
 
Malignant hypertension - characterized by:<ref>{{Ref Klatt|7}}</ref>
*[[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]].
*[[Decidual vasculopathy]] - seen in gestational hypertension.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


==External links==
*[http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Microvascular.html Microvascular disease (ucsf.edu)].
[[Category:Cardiovascular pathology]]
[[Category:Cardiovascular pathology]]

Latest revision as of 07:14, 13 February 2015

Hypertension, also high blood pressure, is very common and affects multiple organs. Clinically, it is usually classified as primary (idiopathic) and secondary.

Micrograph of blood vessels in the kidney showing the changes of chronic thrombotic microangiopathy, as may be seen in malignant hypertension.

Hypertensive crisis, if untreated, is associated with damage to the brain, heart, eye and kidneys.[1]

Pulmonary hypertension is dealt with separately in the article pulmonary hypertension.

Classification

It is classified by etiology.

Primary

  • Idiopathic.
  • Most common.

Secondary

Renovascular:

Endocrine related - tumours:

Other endocrine:

  • Hyperthyroidism.

Other:

Brain

Charcôt-Bouchard aneurysms

General

Microscopic

Features:[4]

  • Small aneurysms (~300 micrometers) with a fusiform shape.
  • Vessel wall changes:
    • Early:
      • Proliferation of arteriolar smooth muscle
    • Late:
      • Apoptotic smooth muscle cell death and collagen deposition.

Image: C-B aneurysm (ucsf.edu).[5]

Intracerebral hematoma

Most common sites:[6]

  • Subcortex.
  • Putamen.
  • Pons.
  • Thalamus.
  • Cerebellum.

Notes:

  • Memory device:
    • Ps and the major structures behind 'em: putamen + thalamus, pons + cerebellum.
  • Two papers[7][8] say putamen is #1 and thalamus is #2.

Lacunar infarcts

General

  • Common.
  • May be located in the putamen.[9]

Hypertension and the eye[10]

Main article: Eye
  • Hypertensive retinopathy.
  • Aneurysms.
  • Branch retinal vein occlusion (BRVO).
  • Vitreous hemorrhage.

Hypertensive heart disease

General

  • Treated with antihypertensives.
  • Mechanism of death: (ventricular) arrhythmia.[11]

Associated pathology[11]

Gross

Features:[12]

  • Left ventricular hypertrophy (concentric).

Notes:

  • 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.[13]
  • Right ventricular hypertrophy is commonly seen.[14][15]

Gross DDx:

Microscopic

Features:[12]

  • Arteriolosclerosis of intramural coronary arteries and arterioles.
    • Fibrosis of media.
  • Peirarteriolar fibrosis.
  • Nuclear enlargement (6-7 micrometres).[16]
    • Normal cardiac myocyte nucleus ~4-5 micrometers.[16]

Kidney

See: hyperplastic arteriolosclerosis.
See: thrombotic microangiopathy.

General

  • May result in renal failure.
  • Hypertension in the kidney may be:
    1. Primary, i.e. seen in isolation.
    2. Secondary, i.e. it arises due to another kidney disease.

Gross

  • Granular appearance of the surface.

Note:

  • Normal kidneys have a smooth surface.

Image:

Microscopic

Features:[17]

  • Fibrinoid necrosis of afferent and interlobular arteries (due to endothelial cell damage).

Malignant hypertension - characterized by:[18]

Note:

Malignant hypertension

General

  • A medical emergency.

Defined as either of the following:[19][20]

  1. >220 mmHg systolic BP.
  2. >120 mmHg diastolic BP.

Prognosis:

  • Depends on the acute rise in blood pressure.[19]
    • Adverse outcomes may arise even when the BP is not at the levels given above.
  • Usually better than with HUS.[21]

Microscopic

Features:

Histomorphologic DDx (thrombotic microangiopathy):

See also

References

  1. ↑ Janota T (2009). "[Hypertensive crisis--the present view]" (in Czech). Cas. Lek. Cesk. 148 (8): 370–3. PMID 19899722.
  2. ↑ Kojima H, Eguchi H, Mizutani T, Tanaka K, Kikuchi Y, Fukudome N (2007). "Three-dimensional analysis of pathological characteristics of a microaneurysm". Clin. Neuropathol. 26 (2): 74–9. PMID 17416106.
  3. ↑ URL: http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Microvascular.html. Accessed on: 24 September 2010.
  4. ↑ Auer RN, Sutherland GR (December 2005). "Primary intracerebral hemorrhage: pathophysiology". Can J Neurol Sci 32 Suppl 2: S3–12. PMID 16450803.
  5. ↑ URL: http://missinglink.ucsf.edu/lm/introductionneuropathology/Response%20_to_Injury/Microvascular.html. Accessed on: 26 November 2010.
  6. ↑ Tanaka A, Ueno Y, Nakayama Y, Takano K, Takebayashi S (August 1999). "Small chronic hemorrhages and ischemic lesions in association with spontaneous intracerebral hematomas". Stroke 30 (8): 1637–42. PMID 10436114.
  7. ↑ Hung TP, Chen ST (December 1993). "[Cerebral hemorrhage in Taiwan]" (in Chinese). J. Formos. Med. Assoc. 92 Suppl 4: S161–8. PMID 7910073.
  8. ↑ Weisberg LA (September 1990). "How to identify and manage brain hemorrhage". Postgrad Med 88 (3): 169–75. PMID 2204896.
  9. ↑ URL: http://moon.ouhsc.edu/kfung/jty1/neurotest/Q04-Ans.htm. Accessed on: 26 October 2010.
  10. ↑ URL: http://health.indiamart.com/eye-care/hypertension-and-eye.html. Accessed on: 23 September 2010.
  11. ↑ 11.0 11.1 Prisant LM (April 2005). "Hypertensive heart disease". J Clin Hypertens (Greenwich) 7 (4): 231–8. PMID 15860963.
  12. ↑ 12.0 12.1 Schwartzkopff B, Strauer BE (2000). "Coronary reserve and arteriolosclerosis in hypertensive heart disease". Z Kardiol 89 Suppl 9: IX/132–5. PMID 11151783.
  13. ↑ MSP. 29 September 2010.
  14. ↑ Sant'Anna, MP.; Mello, RJ.; Montenegro, LT.; Araújo, MM.. "[Left and right ventricular hypertrophy at autopsy of hypertensive individuals].". Rev Assoc Med Bras 58 (1): 41-7. PMID 22392315.
  15. ↑ Cuspidi, C.; Valerio, C.; Sala, C.; Negri, F.; Esposito, A.; Masaidi, M.; Giudici, V.; Zanchetti, A. et al. (Mar 2009). "Metabolic syndrome and biventricular hypertrophy in essential hypertension.". J Hum Hypertens 23 (3): 168-75. doi:10.1038/jhh.2008.119. PMID 18800141.
  16. ↑ 16.0 16.1 Koda, M.; Takemura, G.; Okada, H.; Kanoh, M.; Maruyama, R.; Esaki, M.; Li, Y.; Miyata, S. et al. (Jun 2006). "Nuclear hypertrophy reflects increased biosynthetic activities in myocytes of human hypertrophic hearts.". Circ J 70 (6): 710-8. PMID 16723792.
  17. ↑ Ono H, Ono Y (November 1997). "Nephrosclerosis and hypertension". Med. Clin. North Am. 81 (6): 1273–88. PMID 9356598.
  18. ↑ Klatt, Edward C. (2006). Robbins and Cotran Atlas of Pathology (1st ed.). Saunders. pp. 7. ISBN 978-1416002741.
  19. ↑ 19.0 19.1 Gegenhuber, A.; Lenz, K. (Dec 2003). "[Hypertensive emergency and urgence].". Herz 28 (8): 717-24. doi:10.1007/s00059-003-2506-8. PMID 14689106.
  20. ↑ Lenz, K. (Apr 2004). "[Treating a hypertensive emergency].". MMW Fortschr Med 146 (15): 42, 44, 46-8. PMID 15373020.
  21. ↑ Zhang, B.; Xing, C.; Yu, X.; Sun, B.; Zhao, X.; Qian, J. (Mar 2008). "Renal thrombotic microangiopathies induced by severe hypertension.". Hypertens Res 31 (3): 479-83. doi:10.1291/hypres.31.479. PMID 18497467.

External links

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