CBL : young hypertension

Case
• Underlying uncontrol hypertension on perindophril 4
mg,exsmoker,multiple episode of SOB
• Problem list :
1)Uncontrol hypertension
2)Multiple episode of SOB with unknown cause
3)Noncompliance to meds
4)Uncontrol diet :oily,salty
5)Exsmoker: chance of relapse due to 8 year smoke
6)Sedentary lifestyle
Investigate causes of Secondary hypertension
1)Renal artery stenosis
• Decrease GFR
• Relationship between RAS &HPT
2)Drug
• Steroid
• NSAIDs:must chronic
• Drug abuse:pil kuda, occupation whether long/short distance lorry driver
3)Nephritic
• Symptom:hematuria,oliguria
4)Hyperthyroid
• Symptom: loss of weight but normal appetite,sweating,tremor,diarhhea,palpitation(most common
symptom),hot intolerance
• PE:hyperthyroid,neck swelling
• Assesment: Grave disease / Multinodular goitre
5)Cushing syndrome
• Symptom: moon facies,truncal obesity,skin
thinning,hirsutism,acne,striae
• Causes: endogenous steroid intake(traditional medicine)

6)Acromegaly
• Symptom: cloth size bigger (short/trouser/shoes),headache
• PE:gigantism

7)Coarctation of aorta
• PE: radial-radial delay
Investigation for young hypertension(find
causes, look for cx)
1)Renal profile
• Creatinine & urea imbalance:CKD
• How electrolyte imbalance lead to causes of hypertension
2)Thyroid function test
• History and PE positive baru order
3)U FEME
• Protein : can be a cause/ a complication of disease
• Blood : nephritic
• Red cell cast: injury to glomerulus
4Doppler ultrasound of kidney
• To see bloodflow in kidney
• Suggest polycystic kidney disease
5)ECG
• To see complication toward heart ( ischemic changes, ventricular hypertrophy,arrhythmias)
6)Fasting lipid and glucose
• Acess overall cardiovascular risk
7)Coarctation of aorta
• Must have positive radial-radial delay
• CXR show dilated aorta/cardiomegaly then do echo/angiogram
Management
1)Prescribe anti hypertension drug(build personal drug based on drug principle)
• “Does age affect drug choice”
• Principle for prescribe:
-high efficacy
-side effect/patient acceptance: drug regime(perindophril OD but captopril TDS),drug interaction,compliance
-cost
• ACEI side effect :angio edema, dry cough mostly in female,postural dizziness(occur in all hypertension but most worried in elderly)
• When prescribe perindophril,patient need to TCA 2 week later to check renal function(potassium and creatinine), also to rule out
renal artery stenosis(absolute CI)
• Calcium channel blocker:amlodipine commonly used, S/E:leg edema,headache
• Number of drug need to be start depend on hpt stage: stage 2 and above use 2 hpt drug
• Beta blocker: atenolol/metaprolol/miso[rolol
• Drug combination has rule
• Tackle compliance : take drug eventhough no symptom
Learning issue
How does adrenal play role
in regulation of BP?
Adrenal cortex
• produces two main groups of corticosteroid
hormonesglucocorticoids and mineralcorticoids+androgens
• The release of glucocorticoids is triggered by
the hypothalamus and pituitary gland
• Mineralcorticoids are mediated by signals triggered by the kidney.
• hypothalamus produces corticotrophin-releasing hormone (CRH),
CRH stimulates the pituitary gland to release adrenal corticotrophic
hormone (ACTH). ACTH alert the adrenal glands to produce
corticosteroid hormones
• Cause kidney to retain sodium and water in response to
stress,increasing blood volume and BP.
Zona glomerulosa
• Produce mineralcorticoid (aldestrone)
• regulation of the concentration of sodium and potassium ions in
urine, sweat, and saliva
• For example, it is released in response to elevated blood K+, low
blood Na+, low blood pressure, or low blood volume. In response,
aldosterone increases the excretion of K+ and the retention of Na+
AND water, which in turn increases blood volume and blood pressure

• Also respond to renin in low blood volume or low blood

pressure,(reninangiotensinogen by
liverangiotensinIangiotensin II convert by ACE in lung)
Angiotensin II has three major functions:
• Initiating vasoconstriction of the arterioles, decreasing blood flow
• Stimulating kidney tubules to reabsorb NaCl and water, increasing
blood volume
• Signaling the adrenal cortex to secrete aldosterone, the effects of
which further contribute to fluid retention, restoring blood pressure
and blood volume
Zona fasciculata
• Produce glucocorticoid (role in glucose metabolism)
• In response to long-term stressors(severe illness), the hypothalamus secretes
CRH, which in turn triggers the release of ACTH by the anterior pituitary. ACTH
triggers the release of the glucocorticoids
• to inhibit tissue building while stimulating the breakdown of stored nutrients to
maintain adequate fuel supplies and downregulation of the immune system,
which inhibits the inflammatory response.
• for example, cortisol promotes the catabolism of glycogen to glucose, the
catabolism of stored triglycerides into fatty acids and glycerol, and the catabolism
of muscle proteins into amino acids. These raw materials can then be used to
synthesize additional glucose and ketones for use as body fuel
• cortisone injections into inflamed joints, prednisone tablets and steroid-based
inhalers used to manage severe asthma, and hydrocortisone creams applied to
relieve itchy skin rashe
Zona reticularis
• The androgens produced in the zona reticularis supplement the
gonadal androgens
• produced in response to ACTH from the anterior pituitary and are
converted in the tissues to testosterone or estrogens
• In post-menopausal women, as the functions of the ovaries decline,
the main source of estrogens becomes the androgens produced by
the zona reticularis
Adrenal medulla
• adrenal medulla releases its hormones in response to acute, short-term stress mediated by the
sympathetic nervous system (SNS).
• medullary tissue is composed of unique postganglionic SNS neurons called chromaffin cells,
which produce the neurotransmitters epinephrine(also called adrenaline) and norepinephrine (or
noradrenaline)
• secretion is controlled by a neural pathway that originates from the hypothalamus directly
• Function:
 They essentially prepare the body for “fight or flight” – ↑HR, ↑BP, ↑blood flow to muscle
 the liver and skeletal muscle cells to convert glycogen into glucose, resulting in increased blood
glucose levels. These hormones increase the heart rate, pulse, and blood pressure to prepare the
body to fight the perceived threat or flee from it.
 vasodilation, further increasing the oxygenation of important organs such as the lungs, brain,
heart, and skeletal muscle
 triggers vasoconstriction to blood vessels serving less essential organs such as the gastrointestinal
tract, kidneys, and skin
Disorder with adrenal gland
1) Cushing disease
• characterized by high blood glucose levels and the accumulation of
lipid deposits on the face and neck. It is caused by hypersecretion of
cortisol
• most common source of Cushing’s disease is a pituitary tumor that
secretes cortisol or ACTH in abnormally high amounts
• In addition to hyperglycemia, chronically elevated glucocorticoids
compromise immunity, resistance to infection, and memory, and can
result in rapid weight gain and hair loss.
2)Addison disease
• hyposecretion of corticosteroids can causes low blood glucose levels
and low blood sodium levels
Antidiuretic hormone
• made by nerve cell at hypothalamus. The nerve cells
transport the hormone down their axons to the pituitary
gland where the hormone is released into the bloodstream.
• helps to control blood pressure by acting on the kidneys and
the blood vessels.
• conserve the fluid volume by reducing the amount of water
passed out in the urine. Thus, more water returns to the
bloodstream, urine concentration rises and water loss is
reduced
• Higher concentrations of ADH cause blood vessels to constrict
(become narrower) and this increases blood pressure.
• A deficiency of body fluid (dehydration) can only be finally
restored by increasing water intake.
Factor for release:
• A decrease in blood volume or low blood pressure, which occurs during dehydration or
a haemorrhage, is detected by sensors (receptors) in the heart and large blood vessels
• concentration of salts in the bloodstream increases, for example as a result of not
drinking enough water on a hot day

Syndrome:
• Syndrome of Inappropriate Anti-Diuretic Hormone secretion (a type of hyponatraemia)
where excess ADH produced
• Diabetes insipidus is a condition where there is decrease in ADH secretion.Diabetes
insipidus is associated with increased thirst and urine production. Urine volume will
increase leading to dehydration and a fall in blood pressure