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Prognosis





Category: Uncategorized
Source: Disturbances Of The Heart

Janeway [Footnote: Janeway, T. C.: A Clinical Study of Hypertensive
Cardiovascular Disease, Arch. Int. Med., December, 1913, p. 755.]
presented statistics of 458 patients with high blood pressure, 67
percent of whom were men. Of these 458 patients 212 had died, and he
found that the women with high blood pressure lived longer than men
with high blood pressure. They did not seem as likely to have
apoplexy or cardiac failure. About 85 percent of high tension cases
occur between the ages of 40 and 70.

While he believes that a systolic pressure of over 160 mm. is
pathologic, he does not find that any definite prognostic
conclusions can be drawn from the height of the pressure. Of course
the most important concomitant symptoms of high pressure are
cardiac, renal, and cerebral, and the typical headache, as he terms
it, is a symptom of serious import. In considering headache in
persons over 40, we must eliminate the eye headaches produced by the
need of presbyopic glasses or by the need of stronger lenses, as
this need is a frequent cause of headache. Dizziness and vertigo may
occur without headache, and drowsiness, though not so frequent a
symptom as insomnia, often occurs.

Janeway finds that all kinds of apoplectic attacks may occur from
simple transient aphasia to complete hemiplegia, and thirteen of his
patients who had died and thirteen of those living at the time of
this report showed failure of eyesight as an initial symptom of
arterial disease.

Janeway deplores the too frequent diagnosis of neurasthenia in these
patients. This diagnosis probably accounts for the frequency with
which neurasthenics have been said to have high blood pressure.
Patients with high blood pressure may show all kinds of symptoms
simulating neurasthenia, but hypertension is a much better diagnosis
than neurasthenia for such patients, and will lead to more rational
treatment.

Ninety-seven of these patients had hemorrhages somewhere, most
frequently epistaxes, sometimes hemoptysis. Janeway did not find
that purpuric spots on the skin occurred early in the disease in any
of his patients.

Gastro-intestinal disturbances were not much in evidence unless the
kidneys were insufficient. Intermittent claudication in the legs
occasionally occurred. While angina pectoris and edema of the lungs
were not infrequent causes of death in men, it was a rare cause of
death in women. Dyspnea is a frequent symptom, and one for which
many patients seek medical advice.

A constant systolic blood pressure of over 200 shows a probability
that the patient will ultimately die either of uremia or of
apoplexy. Janeway found that those patients who are to die from
cardiac weakness show cardiac symptoms early in their disease. He
found that rapid continuous loss of weight pointed to an early fatal
termination.

Of the 212 patients who had died, seventy-one had shown cardiac
insufficiency at the time of the first examination; twenty-one
showed albumin or casts at that time. Of course it should be
repeatedly emphasized that chronic interstitial nephritis may be in
evidence with either albumin or casts alone, or without either being
present.

Janeway sums up his conclusions by stating that "from the time of
the development of symptoms indicative of cardiovascular or renal
disease, four years will witness the death of half the men and five
years of half the women. By the tenth year half the remainder will
have died, leaving one fourth both of the men and the women who have
lived beyond ten years." The causes of death he would place in the
following order: gradual cardiac failure; uremia; apoplexy; some
complicating acute infection; angina pectoris; accidental causes;
acute edema of the lungs and cachexia. An early occurrence of
myocardial weakness shows a 50 percent probability that death will
be caused by cardiac insufficiency. Heart pains comprise another
important indicator of future cardiac death, perhaps not an angina.
Nocturnal polyuria would indicate a uremic death in about 50 percent
of the patients, and typical headache or cerebral symptoms show the
probability of uremic death in more than 50 percent, and death from
apoplexy in a large number of the other 50 percent As just stated,
rapid loss of weight is a bad symptom.

Janeway [Footnote: Janeway, T. C.: A Study of the Causes of Death in
One Hundred Patients with High Blood Pressure, THE JOURNAL A. M. A.,
Dec. 14, 1912, p. 2106.] has previously reported seven patients with
hypertension who had diabetes. Diabetes generally, on the other
hand, causes a low blood pressure. Patients with this trouble and
with hypertension, and without nephritis, probably have an increased
secretion from the suprarenals.

We may sum up the prognosis in hypertension as follows: Hypertension
alone is not of unfavorable omen; if it is not readily reduced by
ordinary means, it is more serious. If associated with kidney, heart
or liver defect, it is most serious. If there are such serious
conditions as edema, ascites, lung congestion, cyanosis and great
dyspnea, the prognosis is dire.

Obesity being a cause of high blood pressure, it should be treated
more or less energetically, even if the individual does not continue
to add weight.

Stone [Footnote: Stone, W. J.: The Differentiation of Cerebral and
Cardiac Types of Hyperarterial Tension in Vascular Disease, Arch.
Int. Med., November, 1915, p. 775.] believes that the higher the
diastolic pressure the greater danger there is of cerebral death,
while a patient with a very high systolic, but a diastolic pressure
of 100 or lower, is in more danger of cardiac death. He urges a
greater consideration of the pressure pulse in determining the load
of the heart and the great danger from a sustained diastolic
pressure of over 105 as sooner or later bound to cause myocardial
symptoms. This load of the heart is also shown by an increased pulse
rate and increased respiratory efforts. In cardiac failure, as the
systolic pressure falls the diastolic is likely to be increased, and
the pressure pulse thus diminishing, allows insufficient blood to go
to the medullary centers, and death soon occurs. Therefore, in acute
illnesses a sustained pressure pulse gives a better prognosis than a
diminishing pressure pulse. The strenuous measures that should he
used to lower a high diastolic pressure are contraindicated when the
diastolic pressure is already low, even if the systolic pressure 1s
high. If a high systolic pressure begins to fall more or less
rapidly the heart shows fatigue, and should be stimulated by
digitalis or strophanthin.

Rowan [Footnote: Rowan, J. J.: The Practical Application of Blood
Pressure Findings, THE JOURNAL A. M. A., March 18, 1916, p. 873.]
finds that a diastolic reading of 100 mm. or more usually means that
there is a narrowing of the lumen of the vessels, owing to
stimulation of the vasoconstrictors, although it may mean the
existence of a true arterial fibrosis. While a real atheroma
generally causes a reduction in diastolic blood pressure, or at
least but slight increase, he has found in syphilitic cases with
arteriosclerosis a high diastolic pressure. If the blood pressure
cannot be reduced by ordinary measures, arteriosclerosis is probably
present. Several blood pressure examinations must be made, while the
patient is being treated, to establish the diagnosis.

Rowan finds the reading of the pulse pressure to be of great
importance, as this will indicate, sometimes before any other
symptom is present, that the patient is either improving or doing
badly, and it also aids in indicating the proper medicinal
treatment.

In arteriosclerosis the systolic pressure may be high while the
diastolic is low; hence there is a large pressure pulse. If the
heart becomes weak the systolic pressure will drop, and any
improvement caused, especially in aortic regurgitation, is by an
increase of the systolic pressure.

Rowan finds, as has long been recognized, that a conclusion as to
whether or not cerebral hemorrhage will occur cannot be made from
the condition of the radial arteries, as patients with soft radials
may suffer from cerebral hemorrhage, while those "with hard,
sclerosed, pipestem-like arteries may live to a great age and die of
anything rather than apoplexy."

Swan, [Footnote: Swan: Interstate Med. Jour., March, 1915, p. 186.]
has studied the blood pressure in fifty cases of disturbed thyroid,
and finds that functional myocardial tests show that the myocardium
is nearly always disturbed in these patients.

Before taking up the subject of treatment of high blood pressure, it
may be suggested that a high diastolic pressure with a falling
systolic pressure may require vasodilators on the one hand or
cardiac tonics on the other, and sometimes the decision can be made
only by proper tests. In other words, if the diastolic pressure is
lowered the heart will be relieved. On the other hand, if the
diastolic is being raised by an increased venous pressure from a
failing heart, digitalis, strychnin and caffein may be of benefit in
lowering the diastolic as well as raising the systolic. However, if
there is a high systolic and a low diastolic pressure, vasodilators
are often contraindicated.





Next: Treatment

Previous: Symptoms



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