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Cardiac complications are the major causes of morbidity and mortality in primary (essential) hypertension, and preventing them is a major goal of therapy Electrocardiographic evidence of left ventricular hypertrophy is found in up to 15% of persons with chronic hypertension For any level of blood pressure, its presence is associated with incremental cardiovascular risk Echocardiographic left ventricular hypertrophy is a powerful predictor of prognosis Left ventricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death Left ventricular diastolic dysfunction, which may present with all of the symptoms and signs of congestive heart failure, is common in patients with long-standing hypertension The occurrence of heart failure is reduced by 50% with antihypertensive therapy Hypertensive left ventricular hypertrophy regresses with therapy and is most closely related to the degree of systolic blood pressure reduction Diuretics have produced equal or greater reductions of left ventricular mass when compared with other drug classes -Blockers are less effective in reducing left ventricular hypertrophy but play a specific role in patients with established coronary artery disease or impaired left ventricular function

FIGURE 4-2

Most Americans with hypertension die of complications of atherosclerosis, but the linkage between hypertension and atherosclerotic cardiovascular disease is not as clear as that with the previously discussed complications Effective antihypertensive therapy is thus less successful in preventing complications of coronary heart disease

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Blacher J et al Large-artery stiffness, hypertension and cardiovascular risk in older patients Nat Clin Pract Cardiovasc Med 2005 Sep;2(9):450 5 [PMID: 16265585] Dielis AW et al The prothrombotic paradox of hypertension: role of the renin-angiotensin and kallikrein-kinin systems Hypertension 2005 Dec;46(6):1236 42 [PMID: 16286563] Izzo JL et al Mechanisms and management of hypertensive heart disease: from left ventricular hypertrophy to heart failure Med Clin North Am 2004 Sep;88(5):1257 71 [PMID: 15331316] Lapu-Bula R et al Diastolic heart failure: the forgotten manifestation of hypertensive heart disease Curr Hypertens Rep 2004 Jun;6(3):164 70 [PMID: 15128466] Luft FC Hypertensive nephrosclerosis: update Curr Opin Nephrol Hypertens 2004 Mar;13(2):147 54 [PMID: 15202608] Persu A et al Recent insights in the development of organ damage caused by hypertension Acta Cardiol 2004 Aug;59 (4):369 81 [PMID: 15368798] Qiu C et al The age-dependent relation of blood pressure to cognitive function and dementia Lancet Neurol 2005 Aug;4 (8):487 99 [PMID: 16033691]

Hypertension is the major predisposing cause of hemorrhagic and ischemic stroke Cerebrovascular complications

The clinical and laboratory findings are mainly referable to involvement of the target organs: heart, brain, kidneys, eyes, and peripheral arteries

Mild to moderate primary (essential) hypertension is largely asymptomatic for many years The most frequent symptom, headache, is also very nonspecific Accelerated hypertension is associated with somnolence, confusion, visual disturbances, and nausea and vomiting (hypertensive encephalopathy) Hypertension in patients with pheochromocytomas that secrete predominantly norepinephrine is usually sustained but may be episodic The typical attack lasts from minutes to hours and is associated with headache, anxiety, palpitation, profuse perspiration, pallor, tremor, and nausea and vomiting Blood pressure is markedly elevated, and angina or acute pulmonary edema may occur In primary aldosteronism, patients may have muscular weakness, polyuria, and nocturia due to hypokalemia; malignant hypertension is rare Chronic hypertension often leads to left ventricular hypertrophy, which can present with exertional and paroxysmal nocturnal dyspnea Cerebral involvement causes stroke due to thrombosis or hemorrhage from microaneurysms of small penetrating intracranial arteries Hypertensive encephalopathy is probably caused by acute capillary congestion and exudation with cerebral edema, which is reversible

proteinuria, and casts, signifying primary renal disease or nephrosclerosis; fasting blood sugar level, since hyperglycemia is noted in diabetes and pheochromocytoma; plasma lipids, as an indicator of atherosclerosis risk and an additional target for therapy; serum uric acid which, if elevated, is a relative contraindication to diuretic therapy; and serum electrolytes Measurement of the plasma aldosterone/renin ratio is indicated to screen for mineralocorticoid excess in hypertensive patients with hypokalemic alkalosis (even if they are taking diuretics), resistant hypertension, or an adrenal incidentaloma

Electrocardiographic criteria are highly specific but not very sensitive for left ventricular hypertrophy The strain pattern of ST T wave changes is a sign of more advanced disease and is associated with a poor prognosis A chest radiograph is not necessary in the workup for uncomplicated hypertension

The IMG (SAP Customizing Implementation Guide) has a menu path for contracts This relates to master contracts, value contracts, and contract data that relates to contract profiles and cancellations In the sales document order entry screen, you can adjust the item s columns width and position by simply dragging their borders You may move columns around For example, if you want the target and order quantity to be adjacent, select one of the column headers and drag the column to the desired position The check partner authorization field is used to determine which partners are authorized to release against a contract Should no check be performed, you may leave the field blank Now that we have been introduced to contracts, let s look at the contract-specific configuration settings on the Define Sales Document Types screen

Although echocardiography has been advocated to determine the need for drug therapy in patients with borderline or mildly elevated pressures, it is unusual to find left ventricular mass readings above the upper 75% confidence limits in the absence of systolic hypertension The primary role of echocardiography should be to evaluate patients with clinical symptoms or signs of cardiac disease

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