Primary Eye Carefor The Hypertensive Patient TiffenieHarris,OD,FAAOAssociateProfessorWesternUniversityCollegeofOptometryMember,AmericanSocietyofHypertensionCOPE 31300-SD1高血压英文】PrimaryEyeCareforTheHypertensivePaPrimary Care OptometristPrimary health care providers who examine, diagnose, treat, and manage diseases and disorders of the visual system, the eye, and associated structures as well as diagnose related systemic conditions -AmericanOptometricAssociation,20052高血压英文】PrimaryEyeCareforTheHypertensivePaPrimary Care OptometristPrimary care optometrists have a significant role in the multidisciplinary approach to the management of hypertensive patientsServe as the sole primary eye care provider in more than 3,500 communities3高血压英文】PrimaryEyeCareforTheHypertensivePaObjectivesReview of hypertension and updates on epidemiology Review and update hypertensive retinopathyOptometrists role in the management of hypertensive crises4高血压英文】PrimaryEyeCareforTheHypertensivePaHypertension(HTN)Approximately 65 million people in the US95% are Essential (Primary) HTN, 5% Secondary HTN 29%ofalladults29%ofalladults2% of kids (18yo)7.1 million deaths per year“Silent Killer”Stroke, MI, End-Stage Renal Disease5高血压英文】PrimaryEyeCareforTheHypertensivePa(JNC-7)SeventhReportoftheJointNationalCommitteeonPrevention,Detection,EvaluationandTreatmentofHighBloodPressureNewHypertensionGuidelinesSBP/DSPNormal120/160/100mmHg 6高血压英文】PrimaryEyeCareforTheHypertensivePaWhy2003guidelines?Wasnt 140/90 normal?Patients with “normal” BP still suffered CVDBP and CVD morbidity and mortality begins at 115/757高血压英文】PrimaryEyeCareforTheHypertensivePaJNC-7KeyMessagesBenefits of Early HTN Treatment35% to 40% mean reduction in strokes20% to 25% mean reduction in heart attacksSBP greater risk factor in those 50 Age related HTN is predominantly systolic 8高血压英文】PrimaryEyeCareforTheHypertensivePaJNC-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 BP9高血压英文】PrimaryEyeCareforTheHypertensivePaDiuretics First Line TherapyLowest does to achieve desired goalBest complianceCost effectiveEnhances the effectiveness of other agents10高血压英文】PrimaryEyeCareforTheHypertensivePaJNC-7KeyMessagesHTNTreatmentDiabetics: must have BP control 130/80Chronic Kidney Disease: BP control 55, 65 for women Socioeconomic status: less educated/lower income Hereditary: HTN, DM, Renal Disease, CVDDyslipidemia (low HDLHDL is predominately due to hereditary)15高血压英文】PrimaryEyeCareforTheHypertensivePaRiskFactorsforHTNModifiableObesity apple vs. pearSalt intake -(DASHdiet)(DASHdiet)Smoking and Alcohol consumptionPhysical inactivity (150mins/wk)(150mins/wk)Fatty diets, increase cholesterol(high LDLLDL is predominately diet/exercise related)Stress-work and/or family?MetabolicSyndrome?MetabolicSyndrome?16高血压英文】PrimaryEyeCareforTheHypertensivePaHTN and Metabolic SyndromeAtermusedtodescribetheclusteringofseveraldisordersthatcoexistmorefrequentthanbychanceThepresenceof3ormoreofthefollowingconditions:1.Abdominal obesity - apple vs. pear2.BP 130/853.High triglycerides 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 17高血压英文】PrimaryEyeCareforTheHypertensivePaPrimaryCareOptometristsProactive in patient care and patient educationPerJNC-7:PerJNC-7:“trust in the clinician improves patient motivation and compliance”Co-manage/monitor with PCP, advise when outside guidelines18高血压英文】PrimaryEyeCareforTheHypertensivePaStatusUpdate:ExpectedAvailabilityforPublicReviewandComment:Fall2011Fall2011ExpectedReleaseDate:Spring2012Spring2012Last Updated April 2011JNC8When?19高血压英文】PrimaryEyeCareforTheHypertensivePaJNC-8Whatwillitadd?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 28. Epub ahead of print20高血压英文】PrimaryEyeCareforTheHypertensivePaComprehensiveEyeExaminationPretesting Include in-office BPBlood pressure readings at every comprehensive examination and as needed during a problem focused visit Use the correct cuff size21高血压英文】PrimaryEyeCareforTheHypertensivePaIsBPmeasurementpartofyourdailyroutineinpatientcare?250 OD/250 OMD were surveyedOf those responding: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. J Am Optom Assoc 1994;65(7):512-6.22高血压英文】PrimaryEyeCareforTheHypertensivePaHistory,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?23高血压英文】PrimaryEyeCareforTheHypertensivePaHomeBPMonitoring(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 swelling120Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.38高血压英文】PrimaryEyeCareforTheHypertensivePaBetterCorrelationwithPrognosisGradeofGradeofRetinopathyRetinopathySystemicAssociationsSystemicAssociationsMildModest associations with risk of stroke, heard disease, and deathModerateStrong association with risk of stroke, death from CVDSevere aka “Malignant”Strongest association with stroke, death from CVDWong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310-7.39高血压英文】PrimaryEyeCareforTheHypertensivePaRetinalVasculatureResponseChronicPhaseVasoconstrictivestage:Initial response to increase BP is vasoconstriction Generalized narrowing of the 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 changesCompression, deflection, nicking, bankingHumping of the overlying vein40高血压英文】PrimaryEyeCareforTheHypertensivePaRetinalVasculatureResponseAcceleratedExudativestage:DBP 110When autoregulation fails, the high BP is transmitted directly to the capillariesHemorrhages (flameblots), CWS, hard yellow exudatesOptic nerve swelling*IndicativeoftheseverityofHTNand*IndicativeoftheseverityofHTNandmoststronglyassociatedwithmoststronglyassociatedwithincreasedstrokerisks*increasedstrokerisks*41高血压英文】PrimaryEyeCareforTheHypertensivePaHTNRetinopathyandCardiovascularRisksJNC 7 did not specify the grade/stage of HTN retinopathy ARIC study showed that generalized arteriolar narrowing and AV nicking 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 exudates42高血压英文】PrimaryEyeCareforTheHypertensivePaHTNRetinopathyandCardiovascularRisksBlueMountainEyeStudy found a prevalence of retionpathy in 9.8% of nondiabetic, normotensive patientsAprox 55% of study patients with arterioloar narrowing and AV nicking did not have HTNkeeping in mind this studywaspublishedin1994!43高血压英文】PrimaryEyeCareforTheHypertensivePaArteriolosclerosis or HTN retinopathy?Abnormalitiesoftheretinalvasculaturedemonstratingthe“mild” formofHTNretinopathymayreflectmicrovasculardamageduetohypertensionorarteriolosclerosisorbothPerform Routine BP!44高血压英文】PrimaryEyeCareforTheHypertensivePaMild AVR 1/2A/V crossing “nicking”45高血压英文】PrimaryEyeCareforTheHypertensivePaModerateHTNRetinopathy46高血压英文】PrimaryEyeCareforTheHypertensivePaCotton 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 induced systemic damage to the brain (small vessel ischemic disease in brain)Also associated with DM, SLE, and AIDS47高血压英文】PrimaryEyeCareforTheHypertensivePaDiabeticandHypertensiveImpaired autoregulation alters endothelial cell functionHypothesized that HTN causes increase in VGEF accelerate DRStudies have found that control BP can minimize DRActivation of RAAS in DM HTN (2011)Optometry Nov 2005;76(11):653-656J Clin Hypertens 2011;13(4):224-23748高血压英文】PrimaryEyeCareforTheHypertensivePaSevere(Malignant)HTNRetinopathy49高血压英文】PrimaryEyeCareforTheHypertensivePaHypertensiveChoroidopathyAssociated with Moderate and Severe HTN retinopathyIndicates choroidal vascular sclerosis and ischemia affecting the RPEMost often seen in younger patients with accelerated BP220/120mmHg50高血压英文】PrimaryEyeCareforTheHypertensivePaFollow-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.51高血压英文】PrimaryEyeCareforTheHypertensivePaQuestions52高血压英文】PrimaryEyeCareforTheHypertensivePa