hypertension clinical presentation & investigations

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HYPERTENSION CLINICAL PRESENTATION & INVESTIGATIONS

Dr. Zahoor Ali Shaikh

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HYPERTENSION

DEFINITIONHypertension is said to be present

when blood pressure is greater than expected for a person of particular age, sex and race on at least three separate occasions under resting condition whether symptoms are present or not.

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HYPERTENSION

IMPORTANT INFORMATION Elevated arterial BP is major cause of

pre-mature vascular disease leading to cerebrovascular events, ischemic heart disease and peripheral vascular disease.

BP is characteristic of each person. BP varies with age and ethnic

background. BP increases with age.

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HYPERTENSION

Hypertension is one of the commonest chronic condition in the developed countries.

It may be present up to 20-30% of adult population.

In black Africans – hypertension may affect

40-50% of adult population. Hypertension is affecting one billion

people world wide.

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HYPERTENSION

Most common cause for an outpatient visit to the physician.

High BP is associated with high mortality and morbidity.

All adults should have BP measured routinely every 2 years.

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HYPERTENSION

Seated BP should be measured after 5 mins of rest.

In diabetes mellitus, old age – standing BP should be measured to exclude postural hypotension.

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HYPERTENSION

Presentation Patient with mild hypertension is

usually asymptomatic. BP maybe detected on routine

examination. Patient may present with headache,

Epistaxis.

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HYPERTENSION

Presentation may be due to complications of hypertension

Patient may present with breathlessness due to left ventricular failure or cardiac failure.

Patient may present with renal failure.

Patient may present stroke.

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HYPERTENSION

Presentation maybe headache, palpitation, sweating – they occur in paroxysmal attacks, which may point to diagnosis of phaeochromocytoma.

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HYPERTENSION

Malignant hypertension may present with severe headache, visual disturbance, fits, transient loss of consciousness or symptoms of heart failure.

IMPORTANT NOTE Malignant Hypertension if not

controlled, survival less than ONE –TWO YEARS due to CVA, Heart Failure, Chronic Renal Failure

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HYPERTENSION

Examination of patient to look for cause and effects of increase BP

on organs Increased BP maybe only abnormal

sign.Look for underlying cause Cardiac examination may reveal left

ventricular hypertrophy. Signs of cardiac failure maybe there.

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HYPERTENSION

Look for underlying cause Renal artery bruits maybe present

due to renal artery stenosis. Radio femoral delay is present in

Coarctation of aorta. Look at the fundus.

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HYPERTENSION

Fundascopy is essential part of examination in hypertensive patient.

There are four grades of abnormality according to the Keith-Wagener classification.

Grade 1 – Tortuosity of retinal artery (silver wiring)

Grade 2 – Grade 1 + A:V nipping (arteriovenous nipping)

Grade 3 – Grade 2 + flame shaped hemorrhage and soft (cotton wool) exudates

Grade 4 – Grade 3 + papilloedema

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NORMAL FUNDUS

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Fundus of Hypertensive Patient

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Investigations in Hypertension Chest X-ray ECG Echocardiogram Urinalysis Fasting blood glucose and lipids Serum urea, creatinine and

electrolytes

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Further investigations If urea or creatinine are increased

then creatinine clearance should be done.

Renal angiography if renal artery stenosis is suspected.

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HYPERTENSION

Investigations [cont] If serum potassium is low and

Hyperaldosteronism is suspected or Glucocorticoids excess then do

- Aldosterone level - Cortisol level - Renin level

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HYPERTENSION

Investigations [cont] If phaeochromocytoma is suspected

then do - urinary metanephrins - plasma or urinary catecholamines

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HYPERTENSION

Investigations [cont] ECG may show evidence of coronary

artery disease e.g. IHD or left ventricular hypertrophy.

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NORMAL ECG

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ISCHEMIC HEART DISEASE

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Investigations [cont] X-ray chest may show cardiomegly.

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X-ray chest may show Rib notching – which is sign of Coarctation of aorta, if so, do MRI.

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NORMAL X-RAY CHEST

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X-RAY CHEST IN HEART FAILURE

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In Coarctation of the aorta, the dilated LSCA, indentation of coarct and post-stenotic aortic dilation form “3”

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HYPERTENSION

Assessment and Treatment of Hypertension

There are three stages 1. Assessment 2. Non-pharmacological treatment 3. Drug treatment

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HYPERTENSION

1. Assessment Excludes secondary causes of

hypertension. Evaluate target organ damage e.g.

heart, kidney, retina. Look for diabetes mellitus,

hypercholestermia.

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HYPERTENSION

2. Non-pharmacological treatment Reduce weight if over-weight or

obesity Decrease sodium intake in diet Use low-fat diet Exercise Increase fruit and vegetable

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3. Drug treatment Diuretics Beta blockers ACEI (angiotensin converting enzyme

inhibitors) Angiotensin II receptor blocker (ARB) Calcium blockers

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HYPERTENSION

3. Drug treatment (cont) Alpha blockers (cause vasodilatation) Vasodilators (act on smooth muscle

of blood vessel) Sodium nitroprusside – potent

arterial and venous dilator (used intravenously in hypertensive crises)

Centrally acting drugs e.g. methyl dopa – acts on central α2 receptors

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