Causes of essential and secondary hypertension and pathophysiology

HYPERTENSION .  

Hypertension is often called the silent killer because it usually has no symptoms until serious complications develop. When symptoms occur, they can vary between individuals depending on factors such as amount of blood pressure, age, underlying cause, medical history, onset of complications and overall health.


PATHOPHYSIOLOGY .

Most systems of secondary hypertension are generally quite clear. However, they are linked to the essential (primary) hypertension is much less understandable. However, it is known that cardiac output is presented at the beginning of the disease, of course, entirely peripheral resistance (TPR) normal, and, over time, decrease cardiac output to normal levels, but increased TPR.

Three theories have been proposed to explain this: the difficulty of the kidneys eliminate sodium and natriuretic factors, such as atrial natriuretic factor is secreted to promote salt excretion with the side effect of an increase in total peripheral resistance. Overactive renin-angiotensin system leads to vasoconstriction and sodium and water. Volume of blood lead to hypertension. Overactive sympathetic nervous system, which increases the stress response.

We also know that high blood pressure is highly heritable and polygenic (caused by more than one gene) and some candidate genes have suggested that the etiology of this work is related to the association condition.

Recently essential hypertension and persistent endothelial damage was popular among researchers in hypertension. However, it is unclear whether the endothelial changes precede the development of hypertension or whether these changes are mainly due to long-term high blood pressure.

CAUSES .

ESSENTIAL HYPERTENSION .

Essential hypertension is the most common type of hypertension that affects 90-95% of hypertensive patients. Although no direct cause is identified, there are many factors such as physical inactivity, stress, visceral obesity, a potassium deficiency (hypokalemia), obesity (more than 85% of cases occur in patients with body mass index greater than saline (sodium) consumption of alcohol sensitivity, and a vitamin D deficiency, which increases the risk of developing hypertension. risk increases with age, inherited some genetic mutations and family history of hypertension. An increase of renin, a hormone secreted by the kidneys, is another risk factor that is overactive sympathetic nervous system.

Insulin resistance, which is part of the syndrome X or metabolic syndrome is also thought to contribute to high blood pressure. The consumption of foods containing high levels of corn syrup may increase the risk of developing hypertension. Recent studies have involved low birth weight a risk factor for essential hypertension in adults.

SECONDARY HYPERTENSION .

Secondary hypertension, by definition of an identifiable cause. This type is important to recognize because it is a different treatment of essential hypertension, treating the underlying cause of blood pressure. Hypertension results of a commitment or an imbalance of the pathophysiological mechanisms such as hormonal regulation of the endocrine system that regulate the volume of blood plasma and cardiac function.

Many conditions increase high blood pressure, some are recognized common secondary causes such as Cushing’s syndrome, a condition where the adrenal glands overproduce the hormone cortisol. In addition, hypertension is caused by other conditions that cause hormonal changes, such as hyperthyroidism, hypothyroidism, and cancer of the adrenal glands.

Other common causes of secondary hypertension include kidney disease, obesity and metabolic disorders, pre-eclampsia during pregnancy, the birth defect known as coarctation of the aorta, and certain prescription and illegal drugs.

Hypertension is a silent killer without sign and symptoms

HYPERTENSION .  

High blood pressure (hypertension) or hypertension is a chronic condition in which blood pressure in the arteries is high. It is the opposite of hypotension. It is classified as primary (essential) or secondary. Approximately 90-95% of cases are classified as primary hypertension, which refers to high blood pressure in which no medical cause can be found.The% balance 5-10 (secondary hypertension) is caused by other conditions affecting the kidneys, arteries, heart or endocrine systems.

Persistent hypertension is one of the risk factors of stroke, myocardial infarction, heart failure and arterial aneurysm, and is a major cause of chronic renal failure . moderately elevated blood pressure leads to shorter life expectancy. Both dietary changes and lifestyle and medications can improve blood pressure control and reduce the risk of complications associated with health.

There are three main types of hypertension. Essential hypertension occurs when the state has no known cause. When hypertension is caused by another condition or disease process, it is called secondary hypertension. When only the number of systolic blood pressure (top row) is high, it is called isolated systolic hypertension, which is common among the elderly.

SIGN AND SYMPTOMS OF HIGH BLOOD PRESSURE .

The uncomplicated hypertension usually occurs without symptoms (silent) and if hypertension has been called the silent killer.It is so named because the disease can progress and eventually develop one or more of the many life-threatening complications of hypertension such as heart attack or stroke. uncomplicated hypertension may be present and remain unnoticed for years or even decades. This happens when there are no symptoms, and pretended not to undergo periodic screening for hypertension.

Some people with uncomplicated hypertension, however, may experience symptoms such as headache, dizziness, shortness of breath, and blurred vision. Symptoms may be a good thing that they can quickly people to seek medical care and to make them compatible with and take drugs. Often, however, a person of first contact, the doctor may be, when there was considerable damage at the end of the body. In many cases personal visits or imported into the doctor or clinic, with a heart attack, stroke, kidney failure or impaired (due to back injury in the retina). Raise public awareness, and often blood pressure screening may help identify patients with undiagnosed high blood pressure before significant complications have developed.

Approximately one in every 100 (1%) of people diagnosed with severe hypertension, high blood pressure (accelerated or malignant hypertension) is their first visit to the doctor. In these patients, diastolic blood pressure (minimum pressure) exceeds 140 mm Hg! People often experience headaches, nausea, visual symptoms, dizziness, and sometimes kidney failure. malignant hypertension is a medical emergency and requires urgent treatment to prevent stroke (brain damage).

Rapid life saving needle technique for cardiovascular diseases -Pericardiocentesis ,Indications ,Procedure and Complications

THERAPEUTIC PROCEDURES FOR HEART DISEASES .

PERICARDIOCENTESIS .

Pericardiocentesis is the will pericardial fluid space around the heart. This article describes the benchmark for the blind or syringe and needle technique is used as a measure of relief for the rapid treatment of cardiac tamponade.

Pericardial space normally contains 15-50 ml of fluid acts as a lubricant between the visceral and parietal layers of pericardium. Several systemic conditions may cause a greater amount of fluid in this space. Blood also can collect in this space after trauma.

The clinical manifestations are highly dependent on the size and rate of accumulation of fluid or blood. The worst outcome is the collapse of the ventricle creates a strong decrease in cardiac output, hypotension and cardiac arrest possible.

Echocardiography provides the use of emergency medical beds to rapidly assess the pericardium and identify the presence of a pericardial effusion. Identification of a pericardial effusion causing the collapse of the right ventricle is the diagnosis of pericardial tamponade and pericardiocentesis mandates immediately.

THERAPEUTIC  INDICATIONS .

The signs are cardiac tamponade, and the need to analyze the fluid that surrounds the heart. cardiac tamponade is a condition in which an accumulation of fluid within the pericardium creates excessive pressure, which then prevents the normal filling of the heart blood. This can be crucial to reducing the amount of blood being pumped to the heart, which can be life threatening. Withdrawal of excess liquid to turn this dangerous process. Examples of liquid analysis would be needed to distinguish whether a pericardial fluid collection due to the spread of infection in cancer, or perhaps an autoimmune condition.

CONTRAINDICATIONS .

In hemodynamically unstable patients, the information, the problems are not the type to make a puncture. The withdrawal of a small amount of pericardial fluid can have a dramatic improvement in the patient's hemodynamic status. Contra-indications: bleeding disorders not corrected.

EVALUATION BEFORE PROCEDURE .

Preoperative transthoracic echocardiographic examination should always be done to limit the scope and location of the fluid. At least 1 cm of liquid flowing freely should be achieved by anterior approach. Chest radiography may be useful to demonstrate changes in the mediastinum, pleural effusions, the position of the diaphragm and the size of pericardial shadow.

Any anatomical abnormality should be carefully observed. Patients with cancer may have undergone surgery and radiotherapy before and after these procedures can move or distort normal anatomical location of the structures.

Patients with lung cancer who underwent resection of a lobe may be a change in the anatomical structures. An enlarged left liver lobe extends beyond the midline may be in the path of a needle pericarial xiphoid to the risk of laceration of the liver. abdominal bloating due to a cause can also change the location of vital structures. If there is concern about the anatomy of the patient, the procedure should be performed with echocardiographic guidance.

PROCEDURE.

Previously, this procedure was cardiac catheterization laboratory, but is now usually performed the procedure room, intensive care unit, or even a nightstand. If the line IV fluids or medications must be given. Medication can be given to prevent vasovagal reflex causes bradycardia (slow heart rate) and hypotension (drop in blood pressure). Increase your site under the sternum (breastbone) is cleaned and local anesthetic is given. pericardiocentesis needle inserted later, are always the pericardium. Electrocardiogram (ECG) leads may be connected to the needle clip to help the correct positioning of the needle. However, ultrasound is often used to position the needle and monitor drainage.

Once the needle reached the pericardium, a guide wire inserted. The needle is removed and replaced by a catheter. This fluid is withdrawn and a catheter placed in containers. Usually this pericardial catheter is the place to continue draining for several hours. Surgical pericardiocentesis may be necessary in severe cases. In this procedure, the liquid is drained through a more invasive procedure, which may require anesthesia.


COMPLICATIONS .

Major complications and skin fluoroscopy guided pericardiocentesis achieved through a catheter after surgery, reviewed and holes surgery.Namely non-cardiac, cardiac arrhythmias, arterial bleeding, pneumothorax, especially for children infected and a major vagal reaction. Pericardiocentesis guided by fluoroscopy approach subxiphoid placement of the catheter is a safe way to get the drainage and surgical and nonsurgical pericardial effusions. accidental perforation of the heart with a needle is a small complication, until the needle goes to the front line of the diaphragm and the right ventricle is made reliable drainage catheter.

Life saving procedures for cardiovascular diseases-Intra-aortic cardiac balloon pump - indications ,contraindications ,complications and physiologic effects

PHYSIOLOGIC EFFECT OF INTRA-AORTIC BALLOON PUMP THERAPY

After proper placement of the IAB in the descending aorta with it `s the tip of the distal aortic arch (below the origin of the left subclavian artery) the balloon is connected to a drive console . The console itself is composed of a tank of gas under pressure, an ECG monitor and record the pressure waves, the timing adjustments for inflation / deflation, the election and battery switches sources backup power. 

The gases used for inflation is either helium or carbon dioxide. The advantage of helium is its lower density and therefore a better rapid diffusion coefficient. Whereas carbon dioxide has increased solubility in blood and therefore reduces the potential impact of gas embolisering after a burst balloon. Inflation and deflation are synchronized with the cardiac cycle of the patient. Inflation in the early results of diastole in the proximal and distal displacement of blood volume in the aorta. Deflation occurs just prior to the onset of systole.

INDICATIONS AND CONTRAINDICATIONS

According to early indications for intraaortic balloon pump has included cardiogenic shock or left ventricle, unstable angina, non-separating a patient from cardiopulmonary bypass and prophylactic applications, including stabilization of preoperative patients with cardiovascular and stabilization of preoperative noncardiac surgical patient. Today, more than the extension of the following: cardiac patients requiring procedural support during coronary angiography and PTCA, or as a bridge to cardiac transplantation. Later in pediatric cardiac patients and patients with stunned myocardium, myocardial contusion, septic shock and drug-induced cardiovascular failure, IABP can save lives.

Intra Aortic Balloon Pump therapy should be considered for use in patients who have the potential recovery of left ventricle, or support patients awaiting a heart transplant. Contra-indications of IABP are relatively rare. There are reports of successful use in patients with aortic insufficiency and in patients with acute trauma of the descending aorta.

COMPLICATIONS

Since the device is placed in the femoral artery and aorta may cause ischemia, and compartment syndrome. The biggest risk is the leg supplied by the femoral artery may be ischemic, but the position of the balloon for distal aortic arch can cause occlusion of the renal artery and kidney failure later. Other complications include cerebral embolism during insertion, infection, dissection of the aorta or iliac artery, perforation of the artery and bleeding in the mediastinum. Mechanical failure of the balloon itself is also a risk involved in vascular surgery to remove in this circumstance. After removing the balloon, there is also a risk of embolic shower "micro clots that have formed on the surface of the ball, and can lead to thrombosis device, myocardial ischemia, hemodynamic decompensation and late pseudoaneurysm.

How could you save life through Intra-aortic balloon pump ( cardiac balloon pump ) Insertion techniques ,triggering ,timing and weaning ?

INSERTION TECHNIQUES

In the early years of IABP - therapy, insertion of the balloon through an incision was made to the femoral. After longitudinal incision in the groin, the femoral arteries were identified and controlled. A vascular graft was then sewn to the femoral artery in one way end-to-side. The balloon was inserted into the artery through the graft and well placed in the thoracic aorta and the graft securely connected to the distal balloon catheter. Finally, the skin incision was closed. 


Remove the ball needs a second operation.

Since 1979, offers a percutaneous placement of ITC through the femoral artery using a modified Seldinger a quick and easy introduction to most situations. After puncturing the femoral artery guide wire in the shape of J is inserted at the aortic arch, then the needle is withdrawn. The arterial puncture side is enlarged by successive placement of a dilator combination 8 to 10.5 Fr / sheath. Only the removal dilator.

Continuing, the balloon is threaded over the guidewire into the descending aorta just below the left subclavian artery. The jacket is slightly pulled back in the thick cuff over the balloon hub, ideally so that the vagina is absent of all light pressure to reduce the risk of ischemic complications of the distal end. Recently, insertion sheathless kits are available. Removal of a percutaneous IAB may be either by surgery or closed technique. There are alternative routes for balloon insertion. In patients with extremely severe peripheral vascular disease or in pediatric patients the ascending aorta or aortic arch may be responsible for inserting the balloon. Other forms of access are subclavian, axillary or iliac artery.

CONTROL OF INTRA-AORTIC BALLOON PUMP .

TRIGGERING .

The optimal effect of counterpulsation, inflation and deflation is timely for the patient's heart. This is done through the use of the ECG signal of the patient, the artery of a patient or extension pump wave. The most common way to start the IAB has come from the R wave of the ECG signal of the patient. Mainly balloon inflation is set to start automatically at the center of the T wave, and remains before the end of the QRS complex. Tachyarrhythmias, pacemaker function and poor ECG signals may cause difficulties in obtaining synchronization when the ECG mode is used. In this case, the waveform of arterial intervention threshold may be used.

TIMING AND WEANING .

It is important that the IAB inflation is happening at the beginning of diastole, marked dicrotic notch in arterial waveform. Deflation, the balloon must take place immediately before the climb blood. Balloon synchronization usually starts in relation to maybe 1:02. This relationship allows for a comparison of the patient's own ventricular beats, and win the set was completed by an ideal time IABP. Errors in timing of IABP may lead to different characteristics of the waveform and a number of different physiological effects.

Right heart bedside catheterization ( swan-ganz ) gives continuous monitoring of cardiac function

THERAPEUTIC PROCEDURES FOR HEART DISEASE .

RIGHT - HEART BEDSIDE CATHETERIZATION ( SWAN - GANZ ) .

Right heart bedside catheterization or Swan-Ganz catheterization include the distance of a catheter in the right side of the heart to obtain diagnostic information on heart and provide a continuous monitoring of cardiac function in critically ill patients. The test can be carried out intensive care clinic for children or a special procedure like cardiac catheterization laboratory. It is sometimes a mild sedative before the procedure. Trained medical catheter should be more toward the right side of the heart through a large vein. Usually in a vein on the right side of the package is used. However, the left side of the neck, on both sides of the groin, and other sites may be used.

Before inserting the catheter, the area used to be cleaned with soap sterile injected under local anesthesia and intravenous (IV) catheter is exported with a needle. Catheter is inserted through the IV and then directly into a vein. Catheter should be in the right atrium (top chamber) and the tricuspid valve cardiac output of right ventricle (lower chamber) through the pulmonary valve and pulmonary artery. Measurements of pulmonary arterial pressure can be measured indirectly by use of the left ventricle. Position of the catheter within the heart or chest X-ray fluoroscopy during the confirmation process and the equipment to read and follow the pressures within the heart. 


During the procedure, the heart rhythm are continuously monitored (ECG).

You may not use any food or liquids for 8 hours before the operation. You may need hospitalization evening procedure. Otherwise, be admitted to the hospital or outpatient procedure in the morning, when the procedure is elective. Critically ill patients, the test can be performed in intensive care. To use the coat and provides access, signed consent process. health care provider to explain the procedure and its risks. A mild sedative is usually given 30 minutes before the procedure.

INTRA-AORTIC BALLON PUMPING .

The pump intra-aortic balloon (IABP) is a mechanical device used to reduce myocardial oxygen demand, while increasing cardiac output. By increasing cardiac output it also increases coronary blood flow and myocardial oxygen supply as well. It consists of a cylindrical polyethylene is in the aorta, approximately 2 cm from the subclavian artery and left counterpulsates. In other words, he actively emptied in systole further blood flow by reducing afterload and breathes actively following in the bloodstream increases diastolic coronary arteries. These measures were the combined result of decreased myocardial oxygen demand and increasing myocardial oxygen supply.

The balloon inflated during the resting phase is a computer-controlled system, which is usually associated with either the ECG or pressure sensor is a distal tip of the catheter, SOME IABPs as Datascope System 98XT, allows asynchronous pumping rate is interest, even if this regulation is rarely used. The computer controls the flow of helium cylinder and then a balloon. Helium is used because of its low viscosity will allow its travel quickly through the long connecting tubes, and lower risk of causing dangerous blood clots should be a rupture of the balloon during use.

The IABP is a polyethylene balloon mounted on a catheter, usually inserted into the aorta via the femoral artery in the leg. The pump is available in a wide range of sizes (2.5 cc to 50 cc) that will fit patients of all ages and sizes. The balloon is guided into the descending aorta, approximately 2 cm of the left subclavian artery. In early diastole, balloon inflated, the improvement of coronary perfusion. In early systole and empty the balloon, the blood ejected from the left ventricle, which increases cardiac output by as much as 40 percent and reduce left ventricular work stroke and myocardial oxygen demand. In this way, indirectly supports the heart balloon.

The IABP is driven by the balloon pump console. Operating profit control is located on a touch pad below the LCD display and can be programmed to produce rates as high as 140 beats per minute. The battery provides energy to the board for a maximum of two hours.

Life saving procedures for heart ( cardiovascular ) diseases Permanent cardiac pacing ( Artificial pacemaker ) medical device to regulate heart beat

THERAPEUTIC PROCEDURES FOR HEART DISEASES .

PERMANENT CARDIAC PACING  (  ARTIFICIAL PACEMAKER  )

A pacemaker (or artificial pacemaker should not be confused with the heart's natural pacemaker) is a medical device which uses electrical impulses delivered by electrodes contacting the heart muscles, to regulate the beating of the heart. The main purpose of a pacemaker is to maintain an adequate heart rate, either because the native heart pacemaker is not fast enough, or there's a block in the system of the heart electrical conduction.


Modern pacemakers are externally programmable and allow the cardiologist to select the optimal stimulation patterns for each patient. Some combine a pacemaker and defibrillator implanted in a single device. Others have multiple electrodes stimulating differing views in the heart of improving the synchronization of the lower chambers of the heart.



Step with the implantable pacemaker with permanent transvenous placement of one or more of the speed of the electrodes inside the chamber or chambers of the heart. This process is repeated a suitable slit a vein in which the wire electrode is inserted along the road, and transferred through the valve from the heart, until it is placed in the room. 


The procedure is to facilitate X-ray that allows a doctor or a cardiologist considered the flow of electrode lead. Once a satisfactory left electrode is fixed to the opposite end of the wire electrode is connected to a pacemaker generator.



The pacemaker generator is a hermetically sealed device containing a power source, usually a lithium battery, a sense amplifier that converts the electrical manifestation of naturally occurring heart beats as detected by electrodes on the logic of computer for pacemaker output circuits and offers the pulse of the stimulation electrodes.



In most cases, the generator is placed below the subcutaneous fat of the chest wall, above the chest muscles and bones. However, the location may vary in each case. The outer casing of a pacemaker is designed so that it is rarely rejected by the body's immune system. It is usually titanium, which is inert in the body. Not everything will be rejected and will be encapsulated by scar tissue in the same way is a piercing.



There are three basic types of permanent pacemakers, are classified with a number of rooms and their basic mechanism of action.



1. A single chamber pacemaker  - This single stimulation lead placed in the heart chamber, or atrium or ventricle.



2.Dual-chamber pacemakers  - Here, two bedrooms, cables laid in the heart. One step leads to the atrium and ventricle step. This type more like the natural heart rate by assisting in the coordination of activities between the heart atria and ventricles.



3. Rate responded with a pacemaker  -  This pacemaker is equipped with sensors that detect changes in physical activity of the patient and automatically adjusts the speed to be completed before the metabolic needs of the organism.



INDICATIONS .



Some indications for permanent pacemakers are relatively certain or unambiguous, while others require considerable expertise and discernment. It is useful to divide the indications for pacemaker implantation into three specific categories or classes, as defined by the ACC / AHA HRS /.

Class I - Conditions that continuous stimulation is definitely beneficial, useful and effective. In such circumstances, the implantation of a pacemaker is considered acceptable and necessary, provided that the situation is not due to a transient cause.



Class IIa   - Conditions for which permanent pacemakers are often used, but there are differences of opinion regarding the need for their deployment. Weight of evidence and opinion is in favor of using pace-maker.



Class IIb -  Conditions for which permanent pacemakers are often used, but there are differences of opinion regarding the need for their addition. Evidence / opinion is in favor of the use of pacemakers.



Class III - Conditions for which there is general agreement that the equipment is not necessary.



These recommendations will serve as guidelines, and there are other clinical factors that may influence the decision to implant a pacemaker. Many indications for pacemaker implantation is based on the presence of symptoms. However, many symptoms such as fatigue or subtle symptoms of heart failure recognized in retrospect, after the installation of a permanent pacemaker.

INSERTION .



Pacemaker patient is placed in general or by simple surgery under local anesthesia or general anesthesia. The patient can give medicine to relax before surgery as well. Antibiotic is usually given to prevent infection. In many cases, a pacemaker inserted in the left shoulder where the incision is made below the collarbone in a solid to create a small pocket where the pacemaker is actually located in the patient. Lead or lead (the amount varies from one type of pacemaker lead) and placed in the heart through a large vein using a fluoroscope to monitor the progress of lead increased. Temporary sewer can be installed and removed the next day. The current intervention may take about an hour.



After surgery, the patient should exercise due diligence in the wound while it heals. There followed a meeting at which the pacemaker is checked by a programmer, you can communicate with the device and allows a health professional to assess the integrity of the system and determine the stimulation parameters such as output voltage. The patient may consider some basic preparation before surgery. The most basic preparation is that people have hair on the chest can remove hair by shaving or using a cream that the operation would lead to the bandages and surveillance equipment aFixed body .



Since the batteries used in pacemakers, the device must be changed, because the batteries lose power. Replacing the device is usually a simpler procedure than the increase in the original, as is usually does not require the guide implanted. The typical replacement requires surgery, the incision is made to remove the existing equipment, cables, remove the current device, the wires are attached to the new device and the device is a new device the patient was replaced.



COMPLICATIONS .



There is  possible complication of dual chamber pacemaker artificial pacemaker mediated tachycardia (PMT), a form of reentrant tachycardia. The MTP is the artificial pacemaker forms the anterograde (atrium to ventricle) is part of the circuit and the atrioventricular (AV) node of the Conservative Party (ventricle to atrium) of the circuit. Treatment usually involves a PMT reprogramming of the pacemaker.